ChanBeDu/relevant_section_length · Datasets at Hugging Face

1,162

127,896

6147

Discharge summary

report

Admission Date: [**2114-12-12**] Discharge Date: [**2114-12-14**] Date of Birth: [**2061-3-30**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old right handed man with a history of insulin dependent diabetes, angina, status post angioplasty with three stent placements. Here today for evaluation from neurosurgery service for brain tumor. His neurologic problem began in [**2114-8-27**] when he noted pulsatile tightness. He also experienced poor balance and dizziness. He saw his primary care physician but antibiotics did not help his symptoms. Later in mid [**Month (only) **] he began experiencing mid frontal headaches radiating to the back of his head. The headaches were not positional. He has had pressure in his right ear. He underwent physical therapy and saw an ENT physician. [**Name10 (NameIs) **] reported that he had unremarkable CT of the sinuses and his nasal sinus evaluation showed old scarring. He had a gadolinium enhanced MRI of the brain on [**2114-11-17**] which showed a mass in the right temporal brain. He had a lung and adrenal gland biopsy on [**11-21**]. The lung biopsy was non diagnostic and the adrenal biopsy is still pending. PHYSICAL EXAMINATION: The patient had a blood pressure of 140/80, heart rate 80, respiratory rate 14. Skin had full turgor. HEENT unremarkable. Neck supple, no bruits. Cardiac exam reveals regular rate and rhythm, no murmur or S4. Lungs are clear. Abdomen is soft. Extremities show no clubbing, cyanosis or edema. Neurologically he is awake, alert and oriented times three, there is no left right confusion, calculation is intact. His language is fluent with good comprehension, naming and repetition. Short term memory is [**1-27**] at 0 minutes and [**12-30**] at 5 minutes. Cranial nerve exam, pupils are equal and reactive, 4 mm to 2 mm, extraocular movements are full. Visual fields are full to confrontation. His funduscopic exam reveals sharp disc margins bilaterally with venous pulsations. Face is symmetric. Facial sensation is intact bilaterally. Hearing is intact bilaterally. Tongue is midline. Palate goes up midline. He has no drift. His muscle strength is [**3-31**] in all muscle groups with the exception of his left iliopsoas which is 4+/5. He has normal bulk and tone. His reflexes are 0-1 and symmetric bilaterally. Ankle jerks are absent. Toes are downgoing. Sensation is intact to touch and proprioception. Coordination exam does not reveal any dysmetria and his gait is normal. HOSPITAL COURSE: On [**2113-12-12**] he underwent a right temporal craniotomy for resection of tumor. Post-op his vital signs were stable, he was afebrile, he was awake, alert, extraocular movements intact, tongue midline, mild symmetric, visual fields full to confrontation, no drift. Dressing was removed, his incision was clean, dry and intact. Vital signs have remained stable. Postoperative white count was 37, hematocrit 43.2, sodium 140, potassium 4.6. He is on Depakote 500 mg po tid times one week. For discharge meds, also Decadron to be weaned to 2 mg po bid over 1-2 weeks time, Zantac 150 mg po bid and Percocet 1-2 tabs po q 4 hours. Also Univasc 7.5 mg po q day, Niacin 500 mg po q h.s., Atenolol 50 mg po q day, Actose 45 mg po q day. Patient's vital signs are stable and he was discharged home in stable condition with follow-up in the brain tumor clinic on [**12-24**] at 2 p.m. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2114-12-14**] 10:17 T: [**2114-12-14**] 11:49 JOB#: [**Job Number 24027**]

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Discharge summary

report

Admission Date: [**2155-3-10**] Discharge Date: [**2155-3-18**] Date of Birth: [**2075-11-27**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2880**] Chief Complaint: Pericardial effusion with pulsus paradoxus of 20 Major Surgical or Invasive Procedure: [**First Name3 (LF) **]-guided pericardial fluid drainage Thoracentesis (twice) Placement of pleurex catheter ro right pleural space History of Present Illness: 79yo M with PMHx significant for aortic stenosis s/p AVR (tissue) [**2155-2-17**], COPD, prostate CA (s/p radiation and hormonal therapy [**2150**])who presented from clinic with pericardial effusion found to have pulsus of 20mmHg. . Patient was recently re-admitted for further evaluation of hypotension from his rehab facility. During this recent hospitalization, he received IV fluids. Medications were adjusted, namely lisinopril was discontinued and beta blocker increased for better rate control. An ECHO done during that admission ([**3-3**]) showed a moderate amount of pericardial fluid, mostly overlying the left ventricle and comparatively little fluid over the right ventricular free wall. There was abnormal septal motion which could be due to a conduction abnormality, post-operative state or increased inter ventricular dependence, and an accentuated respiratory variation in mitral inflows but no other evidence of tamponade physiology. He went to see his cardiologist, Dr. [**First Name (STitle) 437**] in clinic today, who repeated echocardiogram and checked a pulsus, which was high at 20mmHg. Per report, the effusion is larger, though it is loculated and will likely require echo-guided pericardiocentesis. . On arrival to the floor, patient endorses no CP/SOB. He says he has had minimal swelling in the lower extremities. He notes some intermittent nausea and poor PO intake over the last week or so. He denies fevers/chills. Has no other complaints. . REVIEW OF SYSTEMS On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: --Aortic stenosis s/p Aortic valve replacement [**2155-1-22**] --Emphysema --probable obstructive sleep apnea --h/o Prostate cancer (s/p radiation and hormonal therapy [**2150**]) --s/p Cholecystectomy [**2141**] --s/p C5-C6 Cervical Disc Surgery [**Hospital1 2025**] [**2115**] --Glaucoma left eye s/p lens implant [**2135**] --Partial gastrectomy for ulcer disease [**2118**] Social History: Retired police officer, married. Currently at a rehab facility, but previously living with his wife at home. -Tobacco history: 50 pack year history of tobacco abuse, quit smoking in [**2134**] -ETOH: < 1 drink/week -Illicit drugs: Denies Family History: Premature coronary artery disease- 87 year old sister recently had aortic valve surgery in [**2153-12-22**]. Nephew passed away from heart failure at the age of 60. Physical Exam: Admission physical exam: VS: T= 98.2 BP= 153/90 HR= 110 RR= 20 O2 sat 98RA; Pulsus paradoxus of 20mmHg GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 9 cm above SC joint. CARDIAC: Heart sounds not muffled. RR, normal S1, S2. No m/r/g. LUNGS: Decreased BS b/l and symmetrically, prolonged expiratory phase ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ DP and PT, 2+ radial b/l . Discharge physical exam: Unchanged from above, except as below Pulsus paradoxus: 5-6mmHg Neck: No JVD Cardiac: RRR, no m/r/g, nl S1/S2 Lungs: CTAB, improved breath sounds at lung bases Pertinent Results: Admission labs: [**2155-3-10**] 05:03PM BLOOD WBC-5.8 RBC-3.52* Hgb-10.1* Hct-30.4* MCV-87 MCH-28.7 MCHC-33.2 RDW-13.5 Plt Ct-329 [**2155-3-10**] 05:03PM BLOOD PT-14.2* PTT-34.6 INR(PT)-1.3* [**2155-3-10**] 05:03PM BLOOD Glucose-129* UreaN-16 Creat-0.9 Na-134 K-3.9 Cl-99 HCO3-28 AnGap-11 [**2155-3-10**] 05:03PM BLOOD Calcium-8.4 Phos-3.8 Mg-1.8 [**2155-3-10**] 05:03PM BLOOD %HbA1c-5.7 eAG-117 Discharge labs: [**2155-3-18**] 07:40AM BLOOD WBC-4.5 RBC-3.45* Hgb-9.3* Hct-30.2* MCV-88 MCH-27.0 MCHC-30.9* RDW-14.6 Plt Ct-264 [**2155-3-18**] 07:40AM BLOOD Glucose-92 UreaN-22* Creat-0.9 Na-138 K-3.9 Cl-105 HCO3-27 AnGap-10 [**2155-3-18**] 07:40AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.3 [**2155-3-11**] 01:54PM BLOOD [**Location (un) 5099**] VIRUS B ANTIBODIES-Negative Imaging: -[**Location (un) **] ([**2155-3-10**]): There is symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is unusually small. with normal free wall contractility. A bioprosthetic aortic valve prosthesis is present. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a moderate to large sized pericardial effusion. The effusion appears circumferential, although it is primarily posterolateral during imaging with the patient in left lateral decubitus position. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Compared with the findings of the prior study (images reviewed) of [**2155-3-3**], the effusion may be slightly larger. -[**Year (4 digits) **] ([**2155-3-11**], post-drainage): There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2155-3-10**], the pericardial effusion has been completely drained. CT CHEST WITH INTRAVENOUS CONTRAST: The thoracic aorta is normal in caliber without dissection. Mild-to-moderate atherosclerotic calcifications are seen throughout its course. The pulmonary arterial vasculature is well visualized to the subsegmental level without filling defect to suggest pulmonary embolism. There is a loculated right pleural effusion, which is predominantly nonhemorrhagic, but a portion of the medial right basilar effusion measures 25-29 [**Doctor Last Name **], compatible with a slightly complex effusion. There is minimal thickening and slight enhancement of the visceral and parietal pleura at the very right lung base, which can be seen in complex effusions, including empyema. A small left pleural effusion is nonhemorrhagic. Adjacent relaxation atelectasis is seen bilaterally. No worrisome nodule or mass is seen. There is upper lobe predominant moderate centrilobular emphysema. Peribronchial wall thickening, predominantly in the right lower lobe with endoluminal narrowing, may be due to acute bronchitis. Secretions are seen in the trachea. A right hilar lymph node conglomerate at the level of the bifurcation of the bronchus intermedius measures 7 x 22 mm (5:55), which may be reactive due to the right complex effusion but followup is recommended. There is no left hilar, mediastinal or axillary lymphadenopathy. The heart is mildly enlarged with a small pericardial effusion and pericardial enhancement. The patient is status post aortic valve replacement. Mild coronary artery calcifications are seen. No nodules are seen in the thyroid gland. The study is not tailored for subdiaphragmatic evaluation. Multiple hypodensities in the liver have the attenuation of simple cysts. Surgical clips are seen at the gastroesophageal junction. BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen. The patient is status post median sternotomy. IMPRESSION: 1. Moderate loculated right pleural effusion with slightly thickened and enhancing visceral and parietal pleura (split pleura sign), which can be seen in complex effusions, including empyema. A small portion is slightly complex and may relate to history of recent hemothorax, but there are no signs of active bleeding. 2. Small, dependent small left pleural effusion. 3. Bilateral relaxation atelectasis. 4. Right hilar lymphadenopathy may be reactive, but follow up with chest CT is recommended in three months to ensure resolution. At that time, right lower lobe bronchial wall thickening may also be reassessed. 5. Small pericardial effusion with enhancing pericardium. Correlate with pericardiocentesis results. An approximately 2 cm portion of the upper lungs was not imaged. This can be reassessed at the time of 3-month followup CT. . [**Doctor Last Name **] ([**2155-3-17**]): The estimated right atrial pressure is 5-10 mmHg. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. There is abnormal septal motion/position. There is no pericardial effusion. Pericardial constriction cannot be excluded. Compared with the prior study (images reviewed) of [**2155-3-13**], no change. Cytology: [**2155-3-13**] Pleural effusion cytology: NEGATIVE FOR MALIGNANT CELLS [**2155-3-12**] Pleural effusion cytology: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells and numerous neutrophils. [**2155-3-11**] Pericardial effusion cytology: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells and lymphocytes. . Microbiology: Time Taken Not Noted Log-In Date/Time: [**2155-3-11**] 12:18 pm FLUID,OTHER PERICARDIAL FLUID. GRAM STAIN (Final [**2155-3-11**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2155-3-14**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2155-3-12**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Time Taken Not Noted Log-In Date/Time: [**2155-3-11**] 12:18 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERICARDIAL FLUID. **FINAL REPORT [**2155-3-16**]** Fluid Culture in Bottles (Final [**2155-3-16**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. STAPHYLOCOCCUS EPIDERMIDIS. SECOND MORPHOLOGY. FINAL SENSITIVITIES. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. 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. PROBABLE MICROCOCCUS SPECIES. Isolated from only one set in the previous five days. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | STAPHYLOCOCCUS EPIDERMIDIS | | CLINDAMYCIN-----------<=0.25 S =>8 R ERYTHROMYCIN----------<=0.25 S =>8 R GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN----------<=0.12 S =>8 R OXACILLIN-------------<=0.25 S =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S 2 S VANCOMYCIN------------ 1 S 1 S Anaerobic Bottle Gram Stain (Final [**2155-3-12**]): GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by [**First Name5 (NamePattern1) 1052**] [**Last Name (NamePattern1) 92069**] @ 12:25 [**2155-3-12**]. Aerobic Bottle Gram Stain (Final [**2155-3-12**]): GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ON [**2155-3-12**]. [**2155-3-11**] 1:54 pm Blood (EBV) Source: Venipuncture. **FINAL REPORT [**2155-3-13**]** [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2155-3-13**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2155-3-13**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2155-3-13**]): NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. In most populations, 90% of adults have been infected at sometime with EBV and will have measurable VCA IgG and EBNA antibodies. Antibodies to EBNA develop 6-8 weeks after primary infection and remain present for life. Presence of VCA IgM antibodies indicates recent primary infection. [**2155-3-12**] 1:51 pm PLEURAL FLUID GRAM STAIN (Final [**2155-3-12**]): 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 [**2155-3-15**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [**2155-3-13**] 6:50 pm PLEURAL FLUID GRAM STAIN (Final [**2155-3-13**]): 4+ (>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 [**2155-3-16**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [**2155-3-16**] 9:00 am BLOOD CULTURE #1. [**Location (un) 5099**] VIRUS B ANTIBODIES: Negative Brief Hospital Course: 79yo M with PMHx significant for aortic stenosis s/p AVR (tissue) [**2155-2-17**], COPD, prostate CA (s/p radiation and hormonal therapy [**2150**]) who presented from clinic with pericardial effusion now s/p pericardiocentesis; also w/ pleural effusion s/p thoracentesis. # Loculated pericardial effusion: Patient presented with a pericardial effusion with pulsus paradoxus of 20; [**Year (4 digits) **] on admission did not show signs of cardiac tamponade. The patient underwent [**Year (4 digits) **]-guided pericardial effusion drainage and a temporary catheter was placed. The patient had a total of 200 cc drained initially, with a total of 375 cc drained while being monitored in the CCU. Output decreased and pericardial drainage catheter was pulled. Cultures and cytology were sent. The patient's cultures grew out Staph epidermidis, a separate coag negative Staph and Micrococcus; however, this was thought to be due to contamination, so antiobitics were not started. EBV serologies were sent and were negative for acute EBV infection. [**Location (un) **] titer was negative. ID was consulted given concern for the low grade fevers and the positive pericardial fluid cultures, they also felt that the positive cultures were contamination and recommended against antibiotics. Cytology was negative for malignant cells. Patient remained hemodynamically stable, repeat pulsus the day after drainage catheter was pulled was 4 mmHg. Patient was transferred back to cardiology floor team. The patient had serial [**Location (un) **]'s through the admission that showed trivial pericardial effusions with no evidence of tamponade. On days of discharge, [**Location (un) **] showed no evdence of pericardial effusion. The etiology of the pericardial effusion is thought to be reactive from his recent aortic valve replacement surgery less than a month prior to this admission. # Pleural effusion: Patient with a right-sided loculated bloody/exudative pleural effusion with eosinophilia, thought to be secondary to instrumentation from aortic valve replacement. Patient underwent a thoracentesis and placement of pleurex catheter. The pleural fluid collected from thoracentesis was negative for malignant cells, and the cultures were also negative. A Chest CT was done to further evaluate pleura to determine if there was pleural pathology that could explain the eosinophilia present in the pleural fluid. Chest CT did not find any plerual-based pathology. Interventional pulmonology placed a pleurex catheter to drain the remaining right-sided pleural effusion, which was removed after approximately 36 hours; the catheter drained a total of 860cc of serosangenous fluid. Pleural fluid collected when the pleurex catheter was placed was also bloody, exudative with eosinophilia. Interventional pulmonary recommended starting ibuprofen 800mg three times daily for 14 days, which he will continue as an outpatient. He has also been placed on omeprazole for 14 days for GI prophylaxis. # Status post aortic valve repair for aortic stenosis: Cardiac surgery following the patient through the hospitalization. The patient's sternal incision was clean, dry, and intact through the admission. He will follow-up with their clinic after discharge # Poor nutrition: Nutrition was consulted during the admission who recommended that the patient's oral intake and weights be monitored. The patient was also given ensures with all meals. # Emphysema: Continue spiriva, advair, albuterol inhaler through the admission. # Code status this admission: DNR/DNI #Transitional issues: -Will continue on ibpurofen (with omeprazole for GI prophylaxis) for 11 more days as an outpatient -Possible constriction noted on last [**Last Name (LF) **], [**First Name3 (LF) **] need follow-up echo within 2 months of discharge -Pt and his VNA were asked to check temperature daily given positive pericardial fluid cx, which were thought to be contaminant, as discussed above -Pt will follow-up with cardiac surgery after discharge regarding recent AVR -Patient will follow-up with pulmonology at the VA after discharge regarding the pleural effusions, this referral will be made by his PCP and he will need a repeat CXR at this appointment Medications on Admission: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H 2. docusate sodium 100 mg [**Hospital1 **] 3. aspirin 81 mg daily 4. magnesium hydroxide 400 mg/5 mL Suspension 30mL Q6H PRN 5. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] 6. simvastatin 40 mg Daily 7. metoprolol tartrate 37.5 mg TID 8. tiotropium bromide 18 mcg Daily 9. alprazolam 0.25 mg PO QHS 10. bisacodyl 10 mg daily PRN 11. albuterol sulfate 90 mcg Q6H PRN 12. fluticasone-salmeterol 250-50 mcg [**Hospital1 **] 13. terazosin 5 mg QHS Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) mL PO every six (6) hours as needed for constipation. 5. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 12. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 13. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 14. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily) for 11 days: Continue to take while on ibuprofen. Disp:*11 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 16. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) for 11 days. Disp:*66 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**First Name8 (NamePattern2) 9485**] [**Last Name (NamePattern1) **] Discharge Diagnosis: Primary diagnosis: Pericardial effusion Right sided pleural effusion Secondary diagnosis: Chronic obstructive pulmonary disease Status post Aortic valve replacement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 92068**], It was a pleasure taking care of you during your hospitalization at [**Hospital1 69**]. You were hospitalizated with a fluid collection around your heart known as a pericardial effusion. You underwent drainage of this collection, there was no fluid around your heart on your most recent heart ultrasound prior to discharge. The fluid culture grew multiple bacteria, which we think was not a true infection after speaking with our infectious disease team. It is important that you call your doctor or return to the emergency room if you have any fevers greater than 100.0F or chills at home. You will also need a repeat ultrasound of the heart 2 months after discharge You were also noted to have a collection of fluid around your right lung, for which you underwent a thoracentesis (drainage of the fluid collection) and had a drain in place to drain the collection, which was removed prior to discharge. The causes of your fluid collection were thought to be due to the recent heart surgery that you had. Take all medications as instructed. Note the following medication changes: START Ibuprofen 800mg three times daily for 11 more days START omeprazole 20mg once daily while on ibuprofen CHANGE metoprolol from 37.5mg to 25mg (1 tablet as opposed to 1.5 tablets) three times daily. Discuss with your PCP if the VA would cover a once a day (extended release) version of this medication. Keep all hospital follow-up appointments. Your up-coming follow-up appointments are listed below. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2155-3-26**] at 9:30 AM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SURGERY When: WEDNESDAY [**2155-3-26**] at 1:30 PM With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**] Building: LM [**Hospital Unit Name **] [**Location (un) 551**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE Address: [**Location (un) 92070**], [**Location (un) **],[**Numeric Identifier 77486**] Phone: [**Telephone/Fax (1) 77350**] ***The office is working on a follow up appointment with the next week. You will be called at home with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above.** As we discussed with you upon discharge, you should follow up with the pulmonary (lung) doctors through the [**Name5 (PTitle) **], and schedule this via your PCP's office. [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]

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Discharge summary

report

Admission Date: [**2103-9-27**] Discharge Date: [**2103-10-30**] Date of Birth: [**2058-7-4**] Sex: M Service: MEDICINE Allergies: Bleomycin / Bactrim Attending:[**First Name3 (LF) 3913**] Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: 45 yo M with a long history of recurrent Hodgkin's lymphoma s/p auto and allogeneic transplant with recurrence on monthly chemotherapy admitted after he presented for scheduled chemotherapy with fevers to 101 in clinic and transferred to the ICU for persistent hypotension after bronchoscopy. . The patient initially presented to clinic on [**2103-9-27**] for scheduled Gemzar, navelbine and decadron therapy. He was found to have a fever to 101. On review of systems at that time the patient did admit to feeling fatigued and generally unwell possibly with a component of pleuritic chest pain and dry cough. CXR at that time revealed an evolving RLL and lingular/LUL infiltrate. He was admitted for further evaluation with CXR and CT chest concerning for evolving pneumonia. The patient was started on Vancomycin, Cefepime and Voriconazole. During his hospital stay, the patient did have relative hypotension as at baseline to the range of sbp 90's with tachycardia to the low 100's. The patient did have individual sbp measurements overnight prior to transfer as low as 80's, reportedly fluid responsive. . The patient was brought to the ICU for elective bronchoscopy. During the procedure, the patient received 1mg midazolam and a bolus of 25mcg of fentanyl. Post-procedure the patient was persistently hypotensive to the range of sbp 78-82 with intact mentation though some complaints of feeling tired and mildly lightheaded. His hypotension was refractory to 1L of NS. The patient was kept in the [**Hospital Unit Name 153**] for further monitoring. . Of note, the patient has a history of multiple episodes of pneumonia in the past most recently with fungal pnuemonia based upon positive galactomannan in [**1-6**]. . ROS: Denies any recent sick contacts. Notes mild pleuritic chest pain and nausea. No emesis, abdominal pain, diarrhea, brbpr, urinary complaints. Past Medical History: Past medical/surgical history: Hodgkin's disease (see below) Hypothyroidism Asthma s/p biliary stent (see below) Hepatitis B core+ . Oncologic history: 1. Diagnosed with stage IIB Hodgkin's lymphoma in 12/99, completed ABVD for four cycles with the last 1 [**1-31**] cycles without bleomycin due to pulmonary toxicity, followed by consolidative mantle radiation therapy. 2. Relapsed in [**10-2**] treated with ICE x2 cycles, high-dose Cytoxan for stem cell mobilization followed by CBV with autologous stem cell transplant on [**2098-1-23**]. 3. Relapsed in [**6-2**] treated with ESHAP x 1 cycle in preparation for allo stem cell transplant, which he underwent on [**2098-8-7**] from a sibling related donor with fludarabine and Cytoxan conditioning. Transplant complicated by liver GVHD confirmed by a biopsy on [**2099-1-11**] treated with prednisone. Also noted to be hepatitis B core antibody positive at that time and began on lamivudine to prevent reactivation. 4. Evidence for recurrent disease and status post a donor lymphocyte infusion on [**2099-7-2**] with a second one on [**2099-9-9**]. 5. Further progression of his disease in [**10-4**] and treated with ESHAP x 2 cycles on [**2099-10-16**] and [**2099-11-17**]. 6. Enrolled on the DC/DLI protocol and received these infusions in mid [**1-3**] with progressive disease particularly in his lung base. 7. Outpatient regimen of Rituxan and gemcitabine with unfortunately progressive symptoms and then followed with two more cycles of ESHAP in [**Month (only) 958**] and [**2100-4-30**] with an excellent response to therapy. 8. Enrolled on an experimental protocol at the [**Company 2860**] involving anti-CTLA-4 antibody with donor lymphocyte infusions support with relatively stable disease. 9. Further progression of his disease over several months with particularly increasing abdominal involvement and treated with another cycle of ESHAP in [**4-5**]. 10. Treated with CEP chemotherapy on [**2101-6-8**] with a donor lymphocyte infusion on [**2101-6-29**] at 1 x 108 T cells per kilogram with marked GVHD of the liver with increased transaminases and bilirubin requiring CellCept and prednisone with eventual resolution. 11. Following discontinuation of his immune suppression and no further GVHD, noted for further progression of his disease, he was treated with CEP chemotherapy on [**2101-12-19**], [**2102-1-31**], and [**2102-3-6**] with a response to treatment. Also requiring periodic thoracenteses of now recurrent pleural effusions. 12. Status post DLI on [**2102-3-29**] at a dose of 1 x 10(8) T cells per kilogram. 13. Presented in [**6-6**] with increased liver function tests and bilirubin with infiltration of the pancreatic head with intrahepatic biliary ductal dilatation. He had a biliary stent placed. This was changed in [**9-6**]. 14. Treated with Day 1,2,3 only of CEP starting on [**2102-6-30**] with evidence for disease response on CT scan from [**2102-7-21**]. 15. Rescanned in [**9-6**] with progression of disease and then received two more cycles of CEP on [**2102-9-7**] and [**2102-10-10**] with CT scan on [**2102-11-8**] with response to therapy. 16. Consideration of another DLI, but developed progression of disease with recurrent hydronephrosis. Treated with another cycle of CEP on [**2102-11-24**]. D8 held due to low counts. During this admission, also had thoracentesis for pleural effusions. 17. Planned evaluation for H-DAC inhibitors at [**Company 2860**]. Social History: Had been working full time as a child psychologist for the [**Location (un) 3915**] public school system, now on disability. He lives in [**Location 1468**]. He has an son, cared for by his ex-wife. [**Name (NI) **] is in a relationship with a woman, who often helps him with logistics of treatment and of activities of daily living. He denies alcohol, smoking, or drug use. Family History: Father had "lymphoma of bone," DM, HTN Physical Exam: Vitals: T: 101 BP: 100/49 P: 120 R: 22 SaO2: 95% General: Awake, alert, NAD, pleasant, appropriate, cooperative. HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in OP Neck: supple, no significant JVD or carotid bruits appreciated Pulmonary: L sided rales up to inferior edge of scapula, CTA on right Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted Extremities: No edema, 2+ radial, DP pulses b/l Lymphatics: No cervical or supraclavicular lymphadenopathy noted Skin: no rashes or lesions noted. . Pertinent Results: [**10-30**] labs: 146 116 51 101 AGap=15 3.1 18 3.4 Ca: 7.5 Mg: 1.6 P: 3.0 ALT: 20 AP: Tbili: 0.2 Alb: AST: 16 LDH: 368 Dbili: TProt: [**Doctor First Name **]: Lip: Source: Line-PICC 93 6.2 7.8 42 D 22.6 N:91 Band:2 L:2 M:4 E:1 Bas:0 Neuts: TOXIC GRANULATION Poiklo: 1+ Ovalocy: 1+ Tear-Dr: OCCASIONAL Plt-Est: Very Low PT: 10.2 PTT: 22.5 INR: 0.8 Source: Line-PICC [**9-27**] labs: 137 101 20 AGap=13 -------------< 94 3.3 26 1.2 Ca: 9.7 Mg: 1.7 P: 3.1 estGFR: 65 / >75 (click for details) ALT: 11 AP: 40 Tbili: 0.3 Alb: 3.7 AST: 16 LDH: 216 Dbili: 0.1 9.9 6.2 >----< 9.9 165 28.9 N:70 Band:0 L:18 M:12 E:0 Bas:0 Anisocy: 1+ Macrocy: 1+ Plt-Est: Normal Gran-Ct: 4660 CT Chest: 1. Overall improving patchy ground-glass opacities within the lungs bilaterally. Slight increased opacities involving anterior right upper and right middle lobes. Findings again suggestive of infection. 2. Unchanged mediastinal mass. 3. Slight decrease in size of right lower lobe mass. 4. Slight decrease in size of incompletely evaluated retroperitoneal lymphadenopathy. 5. Tiny perihepatic ascites. CT Abd: 1. Overall, stable retroperitoneal disease burden. 2. Slight improvement in some regions of consolidation within the lungs, although there is increased ground-glass opacity seen in the upper lobe of both the right and left lungs. This may be secondary in part to regions of improving aeration when compared to prior consolidation, although some regions which appear to have worsening ground-glass opacity may be secondary to atypical infection including processes such as PCP, [**Name10 (NameIs) **] other infectious/inflammatory processes. 3. Unchanged appearance of mediastinal masses. 4. Multiple hypodense foci seen within the spleen and liver. These presumably may be secondary to Hodgkin involvement, and while somewhat more prominent than on prior examination, they do not appear to be new. 5. Moderately severe narrowing of the splenic vein, without total occlusion at this time. In addition, there is moderate-to-severe narrowing of the mid portal vein as well. PATHOLOGY Sigmoid colon biopsy: 1. Diffuse regeneration of the crypts, consistent with a healing process (see note). 2. No viral inclusions, granulomas or tumor seen. 3. Immunostain is negative for CMV with satisfactory control. Renal biopsy, needle: Consistent with "acute tubular necrosis", see note. Bone marrow and core biopsy: 1. Markedly hypocellular marrow with left-shifted myelopoiesis, dysmegakaryopoesis, and mild eosinophilia, see note. 2. No Hodgkin lymphoma seen. Note: Overall the findings are suggestive of acute marrow injury from secondary causes such as medications, toxic/metabolic, immune insult etc. Please correlate with clinical and other laboratory, including cytogenetic findings. Brief Hospital Course: ASSESSMENT: 45-year-old man with a history of Hodgkin's disease status post multiple disease relapses after auto and allo SCT, most recently treated with Gemzar, Navelbine and Decadron on 30 day cycle, who presented with fever to 101 prior to chemotherapy administration. . ## Fever/Pneumonia: CT findings suggested pneumonia as source of fevers. He was initally treated with levoquin, but this was changed to vancomycin cefepime/voriconizole for broader coverage. Beacause of concern for sepsis, the patient was transferred to [**Hospital Unit Name 153**] for bronchoscopy which revealed thick white secretions c/w pna. Small blood in one of BAL samples was likely due to trauma. Following bronchoscopy, the patient's SBP dropped to 60s with Versed so got 500 cc bolus with improvement to 80s-90s. Post bronchoscopy CXR showed slight worsening of RLL infiltrate. Sputum cultures were negative. Pt was started in extended course of Abx. The patient had a repeat bronchoscopy on [**10-8**], with BAL cultures showing just oropharyngial flora and no PCP. [**Name10 (NameIs) **] remained afebrile off antibiotics prior to discharge. Pt continued home salmeterol and albuterol for asthma . ## Hypotension: Pt was noted to be hypotensive during his admission. He had a history of chronic steroid use which had been discontinued. It was felt that his hypotension was possibly due to adrenal insufficiency and he was restarted on stress dose steroids with marked improvement in hemodynamic response. Pt became nauseated and did not take prednisone or other oral meds and was noted to have additional episodes of hypotension [**Date range (1) 3923**]. He was switched to PO prednisone on [**10-27**] and was discharged on prednisone 10 mg daily. - Consider tapering off prednisone as an outpatient. . ## Diarrhea: [**10-9**], pt reported having several loose stools. He was started on flagyl with concern for c. difficile. GI was consulted and the patient was subsequently started on PO vancomycin, however c. dif testing was negative x 3. Flex sig was recommended done on [**10-13**] showing normal mucosa in the sigmoid colon (biopsied). . ## Acute Renal Failure: On [**10-7**], pt was noted to have a non-gap metabolic acidosis with a creatinine of 1.5. He was started on IV fluids with bicarb, however renal function progressively worsened despite hydration. Renal service was consulted. A vanco level was 57. Potentially nephrotoxic medications were held, (including acyclovir). Dialysis was initiated on [**10-12**]. Renal biopsy done on [**10-18**] c/w ATN. He continued on dialysis until [**10-24**] and his HD line was removed on [**10-29**]. Creatinine was stable around 3.4 off dialysis. - Follow electrolytes - Outpatient renal f/u scheduled. . ## Hodgkin's lymphoma: The patient had a history of multiple relapses. He was scheduled to receive Gemzar, Navelbine and Decadron. Treatment was initially on hold given possible infectious issues. However, there was concern that renal failure, diarrhea and rising LDH may be related, however renal and GI biopsies were not consistent with lymphoma. . # Hypotension. Hemodynamically stable; thought to be due to adrenal insufficiency. Pt was on hydrocortisone but switched to Prednisone. Was stable but had additional hypotension on [**10-8**] so was restated on high dose steroids- now on 10 mg methylprednisolone daily. . # HBV core Ab positive. Continue lamivudine therapy. Dosing was adjusted for CrCl. - Readjust dose per renal function. . # FEN: Regular diet. [**10-19**] TPN initiated due to poor PO intake. Stopped [**10-22**]. . # Access: L portocath . # Contact: HCP, [**Name (NI) 3924**] [**Name (NI) 3925**], father of patient, [**Telephone/Fax (1) 3926**]. Medications on Admission: Acyclovir 200 mg q8hrs Albuterol prn Levothyroxine 75 mcg daily Salmeterol 50 mcg [**Hospital1 **] Lamivudine 100 mg daily Lorazepam 1 mg q8hrs prn Oxycodone 10 mg q6hrs prn Prednisone 10 mg daily Olanzapine 2.5 mg qhs prn Multivitamin Discharge Medications: 1. 3 in 1 commode 2. Rolling walker 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Salmeterol 50 mcg/Dose Disk with Device Sig: [**1-31**] Disk with Devices Inhalation Q12H (every 12 hours). 5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Anxiety, insomnia, nausea. Disp:*20 Tablet(s)* Refills:*0* 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation [**Hospital1 **] (2 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every four (4) hours. 11. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 12. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:*120 Capsule(s)* Refills:*0* 13. Methyl Salicylate-Menthol 15-15 % Ointment Sig: One (1) Appl Topical PRN (as needed). 14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Pneumonia, Hodgkin's disease Discharge Condition: Stable Discharge Instructions: You were admitted with fevers, pneumonia, low blood pressure, low platelets, and acute kidney failure. Please follow up in oncology clinic to check your blood cell and platelet counts tomorrow. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**] Phone: [**Telephone/Fax (1) 3237**], extansion # 1 Date: [**2103-10-31**] 2:00 PM Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 60**] Date/Time:[**2103-11-13**] 9:00 AM Provider: [**Name10 (NameIs) **] Phone: [**Telephone/Fax (1) 60**] Date/Time: [**2103-11-6**] 2:30 PM Completed by:[**2103-10-30**]

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Discharge summary

report+addendum

Admission Date: [**2140-6-15**] Discharge Date: [**2140-6-19**] Date of Birth: [**2079-8-15**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 2901**] Chief Complaint: Loss of consciousness Major Surgical or Invasive Procedure: Cardiac catheterization, intubation/extubation History of Present Illness: 60 yo M with PMH of CAD, DM, HTN with h/o prior MI. H/o CHF with refusal of prior Echo. Has reportedly been out of several medications for approximately one month. This morning, he awoke and his caregiver helped him to the bathroom. He started to walk back when he developed a severe cough and returned to the bathroom. He sat on the toilet, becoming acutely SOB and diaphoretic. Per his caregiver, he was mumbling, head tipped back and eyes looking at ceiling. She was concerned for seizure (with h/o seizure) but he did respond to her the whole time. EMS was called. They could not get pulse oximetry, and he was unresponsive so he was intubated in the field. . In the ED, initial vitals were 120, 160/90 with O2 saturation in the 30s. Given 40mg IV Lasix x2. CXR per ED read was concerning for ARDS vs CHF. Femoral line placed and given Vanc/Zosyn for possible PNA. EKG While in ED, sedation and BP problem[**Name (NI) 115**]. [**Name2 (NI) **] was hypertensive upon arrival with SBPs up to the 200s. Started on Nitro gtt that was titrated up to maximum of 2.98 mcg/kg/min and Fentanyl with Versed boluses for sedation, though he was still fighting the ventilator. Given 10mg Vecuronium at 8am due to ventilation issues. Femoral line placed, not sterile. Still struggling on ventilator, started on Propofol. His pressure then dropped rapidly to 80/60s. Stopped both Nitro gtt and Propofol. He was noted to have rising Troponin but had no ischemic changes on ECG, thought to be a possible NSTEMI. Because of a possible heparin allergy, the ED was ordering Argatroban prior to transfer. He was not given Plavix as he had no PO access. He did not get CTA for possible PE because of his Creatinine of 1.7. CT head with prior CVA, no acute hemorrhage. Medications at time of transfer were 5 Versed / 100 Fentanyl bolus with gtts, ASA 600mg PR, low dose Nitro gtt, Argatroban to be started upon arrival in the CCU. He continued to have dysynchronised breathing but O2 sat was 96% on 100 FIO2 with PEEP of 10 and RR 30 x Vt 450. . Per discussion with caregiver and daughter upon arrival to the floor, patient had been well and in his regular state of health until the acute decompensation this morning. No recent cough, fevers, chills, difficulty breathing, chest pain, abdominal pain, diaphoresis or unusual SOB. Caregiver relates today's episode is similar to one that occurred in [**2132**] when he had a CVA and MI and was treated at [**Hospital1 112**]. No sick contacts or recent illness. Had stopped all medications besides Imdur, Metoprolol and ASA in the past month due to not seeing his PCP for over [**Name Initial (PRE) **] year. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Has Diabetes, Dyslipidemia and severe Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: s/p stent in distal LAD -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: CORONARY ARTERY DISEASE [Notes] # s/p mult MIs - Prior care at [**Hospital1 112**], has refused stress and cath. EKG shows previous inferior infarction. # CONGESTIVE HEART FAILURE - exacerbation [**10-12**], refused all workup including echo. # HYPERTENSION - Poorly controlled; on Toprol, lisinopril, Indur and amlodipine prior to reportedly stopping one month prior # INSULIN DEPENDENT DIABETES MELLITUS - Followed at [**Last Name (un) **] but missed appointments. Last A1c [**8-/2139**] 8.8% # HYPERLIPIDEMIA - recently not taking atorvastatin # CHRONIC RENAL FAILURE - Baseline creatinine about 1.6. Presumably from diabetes and HTN. # STROKE - s/p R sided CVA in '[**33**] with expressive aphasia, now wheelchair bound # PSYCH - On zyprexa, has been unable and unwilling to work with any mental health professionals per his doctor in B+W # VIOLENCE - Spoke with PCP at [**Name Initial (PRE) **]+W. Pt. kicked out of practice there as he was violent toward the staff. # TOBACCO ABUSE # H/O Alcohol abuse - Now abstinent, prior DTs and seizure during withdrawal. Social History: He lives with his wife in [**Name (NI) 65536**], MA. He is disabled secondary to stroke. Able to walk short distances at home with walker. Also has electronic wheelchair. -Tobacco history: Prior long, heavy smoking history. Decreased to [**1-13**] cigarettes a day approximately 6-8 years ago when had CVA / MI. -ETOH: Prior long history, quit approximately 6-8 years prior when had CVA / MI -Illicit drugs: None Family History: Noncontributory. Physical Exam: VS: T=98.4 BP=121/76 HR=95 RR=32 on vent O2 sat=94% on vent with RR 32, tidal volume 450ccs, PEEP 10 and FiO2 of 100%. GENERAL: WDWN, lying intubated, grimace to sternal rub. HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink. No xanthalesma. NECK: Thick, intubated, difficult to appreciate JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Distant heart sounds. Tachycardic, regular, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Central rhochi, diffuse crackles worst lower down on anterior exam. No wheezes or rhonchi. ABDOMEN: Soft, slightly distended. No HSM. No abdominal bruits. EXTREMITIES: No femoral bruits. SKIN: Small, dry 2cm ulcer on right big toe. PULSES: Right: Carotid 2+ Femoral 2+ Radial 2+ dopplerable DP and PT [**Name (NI) 2325**]: Carotid 2+ Femoral 2+ Radial 2+ dopplerable DP and PT Pertinent Results: On admission: LABORATORY DATA: 132 96 14 -----------< 356 5.6 17 1.7 . WBC 18.3 Hct 47.9 Plt 506 . CK 146 -> 354 -> 475 CK-MB 36-> 51->59 ->17 ->12 Trop 0.51->0.77->2.31->3.69->4.46 BNP 3793 . ALT 19 AST 45 TBili 0.4 Lipase 54 Lactate 9.6->2.0 . Tox screen negative . 10:39 ABG 7.26/52/54/25 13:00 VBG 7/30/30/51/26 . UA: Negative except Glucose 1000 . CT Head w/o contrast [**2140-6-15**]: 1. No acute intracranial hemorrhage or major vascular territory infarction. 2. Extensive multifocal cystic encephalomalacia, related to chronic infarcts in the left more than right frontoparietal and occipital lobes and right cerebellar hemisphere, with associated ex vacuo dilatation of the left lateral and fourth ventricle, respectively. The overall pattern is suggestive of previous embolic infarction. 3. Chronic microvascular and lacunar infarction. 4. Fluid in the nasal cavity with air-fluid levels in the bilateral sphenoid sinuses may be relate to intubation and supine positioning; clinical correlation recommended. . CXR [**2140-6-15**]: ET tube is approximately 4.5 cm above the carina. There is diffuse bilateral interstitial and airspace opacities. The heart size is top normal. The costophrenic angles are excluded on this study. There is no evidence of pneumothorax. The osseous structures are grossly unremarkable. CXR [**2140-6-19**]: The patient was extubated in the meantime interval with removal of the NG tube tip. The cardiomediastinal silhouette is stable. There is improvement in the left lower lobe retrocardiac opacity consistent with resolution of atelectasis. There is also improvement in the right basal opacity most likely due to decrease in right pleural effusion. Still bibasal opacities are present consistent with atelectasis versus resolving pulmonary edema and should be followed closely for documentation of complete resolution. . ECHO [**2140-6-15**]: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed (LVEF= 20 %) with global hypokinesis and regional akinesis of the inferior and infero-lateral walls. The apex is scarred and dyskinetic. There is no ventricular septal defect. RV with mild global free wall hypokinesis. 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. Trivial mitral regurgitation is seen. 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. . Cardiac Catheterization [**2140-6-15**]: Selective coronary angiography in this right dominant system demonstrated triple vessel disease. The LMCA had no angiographically apparent disease. The LAD was diffusely diseased proximally and in the mid segment and was 100% occluded distally prior to a stent in the distal LAD. There was an 80% stenosis of the origin of the 1st diagonal branch. The distal LCX had a 70% stenosis prior to the termination. OM1 was occluded with right to left collaterals. OM2 was 100% occluded and showed staining which could represent an acute occlusion. The RCA was <50% occluded throughout the vessel. The Mid PDA was 100% occluded. 2. Resting hemodynamics limited to central aortic pressure revealed a pressure of 123/78mmHg. Brief Hospital Course: 59 M with htn, hyperlipidemia, CM, CAD, CHF, CRI, h/o stroke and psychiatric issues presents in respiratory distress. Hospital course by problem is as follows: . # CORONARIES: Patient with history of multiple prior infarctions and rising troponins after diaphoresis and loss of consciousness, but without ECG changes of ischemia, most consistent with NSTEMI. He went for cardiac catheterization and was found to have diffuse three vessel disease with apparent acute occlusion of his distal second obtuse marginal. The lesion was not suitable for intervention and the patient was managed medically with bivalirudin (heparin allergy), Aspirin and Plavix load. He was evaluated by cardiothoracic surgery who felt that he did not have appropriate distal sites for bypass. He was previously prescribed Aspirin, Toprol-XL, Lipitor, Imdur and Lisinopril, though he was only taking ASA, Imdur and Toprol in the last months [**1-11**] not having seen his PCP for over [**Name Initial (PRE) **] year. He was restarted on Aspirin, Metoprolol, Imdur and Lisinopril for blood pressure control and high dose atorvastatin for post-MI lipid control. His Metoprolol was also increased to 400mg daily, which he tolerated well. . # Dyspnea: Most likely due to flash pulmonary edema caused by diastolic dysfunction in the setting of myocardial ischemia. Myocardia ischemia was either due to acute coronary thrombus or hypertensive urgency; pt has had prior multiple admissions for pulmonary edema in the setting of hypertensive urgency due to medication non-compliance. Pneumonia seemed unlikely with the rapid onset of symptoms and lack of cough or fever, although he had a WBC of 18. WBC did trend down steadily to 12.7 prior to discharge. His CXR was most consistent with acute pulmonary edema. Patient was placed on a Lasix drip up to a maximum of 10mg/hr. He was negative 1.5L overnight in the CCU the first night and his fluid overload improved with blood pressure control. He had improved drastically by hospital day two and was -4.5L by the end of his hospital stay. Pt was extubated without any complications on [**2140-6-17**] and was saturating at 98% on room air by the time of discharge. . # Respiratory Failure: Patient arrived in hypoxemic respiratory failure, almost certainly due to acute pulmonary edema in the setting of acutely worsened chronic congestive heart failure. His initial ABG's showed acidosis (pH 7.03) and hypoxemia (pO2 59). There was no evidence of massive PE or infection to explain the large A-a gradient. Initially started on ARDS protocol which was later discontinued [**1-11**] not meeting criteria (Pa)2/FiO2) and clinical picture. Pt tolerated pressure support and eventual extubation on [**2140-6-17**]. Pt continued to have good peripheral perfusion until time of discharge. . # Loss of Consciousness: Unclear etiology for his LOC. Most likely hypoperfusion due to ischemic heart failure due to acute thrombus and hypertensive urgency. Seizure seemed unlikely as patient was speaking throughout. The non-contrast head CT did not show an acute process and he did not have the quick recovery expected for a vagal episode (although he was intubated). Two days after admission, patient was weaned off sedatives and extubated. He gradually returned to his baseline mental status and did not have any further loss of consciousness. . # PUMP: Found to have an EF of 20%, mild LV dilation, global hypokinesis and regional akinesis on echocardiogram. His BNP of 3793 was actually lower than on previous admissions, suggesting that he may not have acutely elevated atrial pressures. Overall, his presentation was concerning for ischemic worsening of already poor systolic function. Pt was diuresed succesfully throughout his day, putting out 4.5L through the duration of his length of stay. . # RHYTHM: Pt was in sinus tachycardia initially. Pt was continued on Metoprolol while in the CCU for prevention of post-MI arrhythmias. His betablocker was titrated up to 400mg daily on [**2140-6-18**], which he tolerated well. Pt will be continued on this upon discharge home. . # DM. Followed by [**Last Name (un) **], with poor compliance, although patient was apparently still taking his insulin at home. Pt was given BS checks QACHS with humalog sliding scale in the CCU. HbA1c was 9.9 on [**2140-6-15**]. . # Hypertension. Pt initially on nitro infusion in ED for management of hypertensive emergency. Pt was normotensive by the time of arrival to CCU. Pt has difficult to control hypertension at baseline. Metoprolol was restarted after cardiac cath, home Imdur was continued. Lisinopril and amlodipine were restarted as well on Friday, [**2140-6-17**]. . # Hyperlipidemia: Unclear level of control, was not taking high-dose statin prior to admission. Pt was restarted on Atorvastatin 80mg Qdaily as Lipid Panel showed: chol 197 TG 120 HDL 33 LDL 140 . # Respiratory Acidosis: Due to hypoventilation in the setting of respiratory failure which improved with ventilation. Final ABG prior to extubation was: 7.45/160/42 . # Anion Gap Metabolic Acidsosis. Pt had lactic acidosis on admission which resolved in CCU and was monitored closely. . # Elevated Troponin: Most likely due to NSTEMI and acute plaque rupture. Repeat cardiac enzyme while in the CCU trended down. CK 17 --> 12, MB 5.6 --> 4.4 . # Leukocytosis: Patient was afebrile throughout his CCU stay and did not report any recent sick contacts per family. Leukocytosis may have been a stress response to NSTEMI, and trended down with time. No antibiotics were given and blood cultures NGTD X2, although pending upon discharge. . # Thrombocytosis: Likely reactive. Was trended with reassuring improvement. . # Hyponatremia: Most likely fluid overload given flash pulmonary edema, poor Lasix compliance and LE edema. Pt was diuresed as above with good effect. Pt resumed home dose of Lasix. . # CRI: Cr near baseline of 1.6, 1.7 on admission. [**Month (only) 116**] have been [**1-11**] poor forward flow given overall clinical picture of decompensated heart failure. Pt was given mucomyst X2 and renally dosed medications to protect renal function post-cath. Creatinine remained stable and was 1.8 upon discharge. . PROPHYLAXIS: -DVT ppx with Bivalirudin [**1-11**] ?heparin allergy -Pain management with Fentanyl gtt -Bowel regimen with colace / senna . CODE: FULL (per daughter); however, on [**2140-6-19**] pt did express clear desire to be DNR ONLY (INTUBATE IF NEEDED). COMM: Partner and [**Name2 (NI) **], at bedside. [**First Name8 (NamePattern2) **] [**Known lastname 2819**] (daughter and [**Name2 (NI) 11752**] of Attorney) [**Telephone/Fax (1) 107670**] [**Location (un) 1439**] (caregiver) [**Telephone/Fax (1) 107671**] Medications on Admission: Amlodipine 10 mg Tablet 1 Tablet(s) by mouth daily (Stopped) Atorvastatin [Lipitor] 80 mg Tablet 1 Tablet(s) by mouth at bedtime (Stopped) Furosemide [Lasix] 20 mg Tablet 3 Tablet(s) by mouth twice a day (Stopped) Insulin Lispro Protam & Lispro [Humalog Mix 75-25] 100 unit/mL (75-25) Suspension 60 units qam, 50 units qpm daily Isosorbide Mononitrate [Imdur] 30 mg Tablet Sustained Release 24 hr 3 Tablet(s) by mouth daily Lisinopril 40 mg Tablet 1 (One) Tablet(s) by mouth once a day (Stopped) Metoprolol Succinate [Toprol XL] 200 mg Tablet Sustained Release 24 hr 1.5 (One and a half) Tablet Sustained Release 24 hr(s) by mouth once a day ZYPREXA 2.5MG Tablet ONE TABLET BY MOUTH AT BEDTIME (Stopped) Aspirin [EC Aspirin] 325 mg Tablet, Delayed Release One Tablet(s) by mouth once a day Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*1* 7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 8. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:*180 Tablet(s)* Refills:*2* 9. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO once a day. Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*1* 10. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Suspension Sig: As directed units Subcutaneous twice a day: 60 units qam, 50 units qpm daily . Discharge Disposition: Home with Service Discharge Diagnosis: Primary: Acute myocardial infarction, acute pulmonary edema, decompensated acute systolic congestive heart failure Secondary: Coronary artery disease, chronic kidney disease, chronic systolic congestive heart failure, history of stroke, diabetes mellitus (insulin dependent) Discharge Condition: Improved. Pt has been afebrile, saturating well w/o ventilation assistance, back to baseline per daughter. Discharge Instructions: You were admitted after having such terrible difficulty breathing that an ambulance was called to your house and you were intubated. You also had a heart attack (myocardial infarction) in this setting. You were evaluated with cardiac catheterization which revealed diffuse heart disease that would not respond well to surgery. You should take your medications every day to help avoid further damage to your heart. The only medication change is that your Metoprolol (Toprol XL) has been increased from 300 mg daily to 400 mg daily. You need to take this new increased dose for better blood pressure control and heart protection. Please take all medications as prescribed. You have been given one month of your Toprol XL at its new, increased daily dose. You need to see your new primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on [**7-11**] to discuss your hospitalization and any other medications you may need. You have an appointment with her currently scheduled for 2:35 pm. Seek medical advice if you develop fever, chills, difficulty breathing, chest pain, increased cough or sputum, nausea, difficulty urinating or any other symptom which is concerning to you. You should weigh yourself every morning and call Dr. [**Last Name (STitle) **] if your weight increases by >3 lbs in one day. You should also stick to a low sodium (2 grams daily) diet and avoid drinking too much fluids (<2 liters a day). Daily weights and diet/drink changes can help preserve your heart function. Followup Instructions: Please keep your appointment with your new primary care physician: [**Name Initial (NameIs) 2169**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4131**], MD Phone:[**Telephone/Fax (1) 250**] [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 516**], [**Hospital1 18**] Date/Time:[**2140-7-11**] at 2:35PM [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 17581**] Admission Date: [**2140-6-15**] Discharge Date: [**2140-6-19**] Date of Birth: [**2079-8-15**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 949**] Addendum: Medication change: Patients insulin was increased from 60 units qAM and 50 units qPM to 70 units qAM, 60 units qPM. The new dosing was what his daughter reported he was actually getting at him, in contrast to what was in OMR Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 950**] MD, [**MD Number(3) 951**] Completed by:[**2140-6-19**]

[ "414.01", "428.0", "410.71", "V58.67", "250.00", "403.90", "518.81", "272.4", "428.23", "585.9", "276.2", "276.1" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "88.52", "88.55", "99.20", "37.22" ]

icd9pcs

[ [ [] ] ]

21372, 21534

9510, 16241

297, 346

18631, 18740

5897, 5897

20315, 21349

4984, 5002

17081, 18269

18332, 18610

16267, 17058

18764, 20292

5017, 5878

3339, 3431

236, 259

374, 3221

5911, 9487

3463, 4534

3243, 3319

4550, 4968

1,406

106,504

5288

Discharge summary

report

Admission Date: [**2134-1-18**] Discharge Date: [**2134-1-19**] Service: MEDICINE Allergies: Valproic Acid Attending:[**First Name3 (LF) 11040**] Chief Complaint: respiratory distress, fever, afib/flutter with rapid ventricular response, hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 85 yo F with Ushers syndrome (deafness, retinitis pigmentosa, vestibular symptoms), [**Hospital **] rehab patient who presented to ED in respiratory distress, fever, afib/flutter with rapid vent response, hypotension. She was found to have multifocal pna on CXR and floridly positive u/a. She was given a dose of ceftaz and vanco. The pateint is DNR/DNI and discussion was had with family to defer aggressive measures. She arrived to [**Hospital Unit Name 153**] in respiratory distress and was given morphine. Per report she was taken off digoxin and changed from verapamil to lopressor yesterday. Past Medical History: # [**Doctor Last Name 21568**] syndrome characterized by deafness, retinitis pigmentosa and vestibular symptoms. # Schizophrenia. # Depression. # Hypertension. # Cerebrovascular accident involving the left sylvan fissure. # Right breast cancer, status post lumpectomy in [**2120**] # h/o pulmonary embolism [**2126**] # atrial fibrillation # Osteoporosis, status post left hip surgery in [**2122**]. # Morbid obesity. # Chronic obstructive pulmonary disease. # Degenerative joint disease with spinal stenosis. # Status post lip cancer and basal cell carcinoma skin cancer. Social History: Retired school teacher. [**Hospital 100**] Rehab resident. Daughter, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11309**], lives in area and is responsible for patient's care. Family History: Noncontributory Physical Exam: Tm 104, BP95/43, HR 80, RR 40, o2sat 97%NRB GENL: ill appearing, appears tachypneic with audible rhonchi HEENT: dry MM CV: RRR Lungs: diffusely rhonchorous Abd: distended, soft, nontender Ext: no edema Pertinent Results: [**2134-1-18**] 02:00AM BLOOD WBC-9.9 RBC-5.25# Hgb-16.7*# Hct-50.7*# MCV-97 MCH-31.8 MCHC-32.9 RDW-14.5 Plt Ct-224 [**2134-1-18**] 02:00AM BLOOD Neuts-72* Bands-15* Lymphs-5* Monos-6 Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 NRBC-1* [**2134-1-18**] 02:00AM BLOOD PT-25.9* PTT-57.8* INR(PT)-2.6* [**2134-1-18**] 02:00AM BLOOD Glucose-175* UreaN-77* Creat-2.8*# Na-151* K-7.5* Cl-111* HCO3-23 AnGap-25* [**2134-1-18**] 02:00AM BLOOD cTropnT-0.17* proBNP-7523* Brief Hospital Course: 85 yo F with h/o [**Doctor Last Name 21568**] syndrome (deafness, retinitis pigmentosa, vestibular symptoms), who presented to ED in respiratory distress, fever, afib/flutter with rapid vent response, hypotension, found to have multifocal pneumonia and UTI and sepsis. # Sepsis: Pt septic and family deferred aggressive measures. Gave morphine to alleviate respiratory distress, lorazepam for agitation, scopolamine for secretions. Daughter at bedside. The pt expired. Medications on Admission: Lopressor 25 mg [**Hospital1 **] Lasix 40 IV Wellbutrin 50 TID Coumadin Albuterol Nebs Atrovent Nebs Morphine 2 mg SL PRN Ativan 0.25 PO Q6 hr PRN Tylenol Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Pt expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "733.00", "486", "362.74", "599.0", "496", "038.9", "389.8", "V12.59", "311", "276.1", "427.31", "V10.83", "V66.7", "721.3", "V10.02", "584.9", "V10.3", "518.81", "295.90", "V12.51", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3208, 3217

2502, 2973

309, 315

3271, 3280

2021, 2479

3336, 3346

1766, 1783

3179, 3185

3238, 3250

2999, 3156

3304, 3313

1798, 2002

183, 271

343, 943

965, 1539

1555, 1750

5,794

139,299

10195

Discharge summary

report

Admission Date: [**2114-11-27**] Discharge Date: [**2115-1-8**] Date of Birth: [**2069-11-17**] Sex: M Service: [**Last Name (un) **] Dictated by:[**Last Name (NamePattern1) 16264**] HISTORY OF PRESENT ILLNESS: The patient is a 45 year old, white male, with a history of insulin dependent diabetes mellitus and end stage renal disease, status post pancreas and kidney transplant [**2112-7-11**]. He presented to [**Hospital1 346**] on [**2114-11-27**] for a cadaveric pancreas transplant for insulin dependent diabetes mellitus. On presentation, the patient reported being in his usual state of health. He denied fevers, chills, nausea, vomiting, stool changes, dysuria, chest pain and shortness of breath. PAST MEDICAL HISTORY: Significant for insulin dependent diabetes mellitus, end stage renal disease, coronary artery disease, status post stent placement [**7-6**], hypertension, congestive heart failure and right leg neuropathy. PAST SURGICAL HISTORY: Significant for pancreas and kidney transplant [**2114-7-12**]. ALLERGIES: The patient reports allergies to Erythromycin and Morphine. REVIEW OF SYSTEMS: The patient denies recent fevers, chills, nausea and vomiting, diarrhea, stool changes, chest pain or shortness of breath. PHYSICAL EXAMINATION: General: The patient is alert, oriented times three and appears comfortable. HEAD, EYES, EARS, NOSE AND THROAT: Pupils are equal, round, and reactive to light and accommodation. Normocephalic. No scleral icterus, jugular venous distention or lymphadenopathy noted. Chest clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm without murmur, click, rub or gallop noted. Abdomen: Appears nondistended, soft, nontender to palpation. Extremities: Bilateral decreased sensation distally. Pulses intact. HOSPITAL COURSE: The patient presented on [**2114-11-27**] for cadaveric pancreas transplant. The patient underwent procedure on [**2114-11-27**]. The patient tolerated the procedure well and was transferred to the monitored bed in the Intensive Care Unit after transplant. The patient's postoperative course was complicated and significant for the following events: The patient appeared to have delayed graft function for several days after his transplant, with elevated amylase, lipase levels and blood sugar levels, requiring insulin drip. Because of this presumed episode of rejection, the patient received ATG from [**11-27**] until [**2114-12-3**]. However, during this time, the patient did remain stable with a possible mild hypersensitivity reaction to the ATG which was controlled well. By [**2114-12-1**], the patient was transferred to the floor in stable condition. On [**2114-12-3**], the patient received a CTA of the abdomen and pelvis for hypotension and hematocrit of 24.3. CTA revealed an edematous pancreas with surrounding fluid. The patient was taken to the operating room and underwent wash-out for a hematoma. During the operation, the pancreas was noted to be viable, without any areas of necrosis. On [**2114-12-3**], the patient did require two units of packed red blood cells for a hematocrit of 24.3. His hematocrit rose to 31.6 after the transfusions. During this time, for the next several days, the patient continued to remain clinically stable; however, his blood sugars did remain elevated, requiring insulin drip. His amylase and lipase began to trend downward. By [**12-5**], his amylase level was 76 and his lipase level was 43. He began to take a regular diet and by [**12-7**], was ambulating well with physical therapy. He was passing flatus and started having bowel movements. However, on [**12-9**], the patient again received a CT of the abdomen and pelvis because of fever spikes up to 103.0. CTA of the abdomen and pelvis demonstrated an ill-defined edematous pancreas again, with loculated fluid collections. However, it did reveal good arterial supply to the pancreas. On [**2114-12-10**], the patient was again taken to the operating room and received wash-out of what appeared to be infected fluid collections, with debridement of some necrosis in the pancreatic tail. The patient again tolerated the procedure well and was transferred to the Intensive Care Unit postoperatively. He remained intubated in the Intensive Care Unit until [**2114-12-12**], at which time he was taken back to the operating room for re- evaluation of possible infected pancreas and peritoneal cavity. At that time, multiple fluid collections were noted; however, none appeared to be grossly infected. The pancreas again was debrided of some necrotic areas. The patient tolerated the procedure well and was transferred back to the unit in stable condition. Since [**12-3**], the patient had been on Zosyn and postoperatively, cultures revealed Klebsiella that was resistant to Zosyn and, therefore, the patient was started on Meropenem on [**2114-12-14**]. Again, postoperatively, the patient generally remained stable in the Intensive Care Unit. He was transferred to the floor on [**2114-12-17**] with wound VAC secured to his abdominal wound. The patient continued to progress on the floor. Physical therapy worked with him to ambulate. His wound VAC was changed on an average of every three days. He began taking p.o. intake. He did continue on total parenteral nutrition from [**2114-12-10**] until [**2114-12-19**]. His wound continued to heal well with each VAC change. On [**2115-1-4**], it was noted that the patient's amylase and lipase had risen dramatically. Amylase was 248 and lipase was 370. He was started on ATG again, which he received times three days from [**1-4**] until [**2115-1-6**], with the initial dose of ATG on [**1-4**]. It appeared that he had a hypersensitivity reaction with some nausea, vomiting and complaints of generalized malaise. His infusion rate was slowed, which seemed to control the symptoms. Before his next two treatments, he would be prophylactically treated before each dose with Benadryl, Tylenol and Prednisone. On [**2115-1-6**], the patient received two units of packed red cells for hematocrit of 25.8. His hematocrit subsequently rose to 30.5 and remained stable until discharge. Throughout the [**Hospital 228**] hospital course, he remained on immunosuppressive therapy including Tacrolimus, Prednisone and MMF. The levels were monitored diligently and the patient's drug dosages were adjusted accordingly on a daily basis. On [**2115-1-8**], with the patient very clinically stable, with blood sugars kept well below 200 without the aide of insulin and with the patient's wound continued to appear well healing on wound VAC, while ambulating and taking in a regular diet well, the patient was discharged home. The patient is to remain on wet to dry dressings with the aide of VNA. DISCHARGE INSTRUCTIONS: The patient is to not lift any objects greater than 10 pounds. He is to keep his wound clean and dry, with wet to dry dressings twice daily. He is not to take baths or soak his wound. He is to seek medical attention immediately if he experiences fevers, chills, nausea, vomiting or abdominal pain or worsening erythema of his wound. DISCHARGE MEDICATIONS: 1. Valganciclovir 450 mg p.o. once daily. 2. Bactrim SS one tablet p.o. daily. 3. Lansoprazole 30 mg p.o. delayed release, once daily. 4. Metoprolol 50 mg two tablets p.o. three times a day. 5. Hydralazine 25 mg one tablet p.o. every six hours. 6. Metoclopramide 10 mg, sig .5 tablet p.o. four times a day a.c. and h.s. 7. Aspirin 325 mg p.o. every day. 8. Plavix 75 mg p.o. every day. 9. Vicodin one to two tablets p.o. every four to six hours as needed. 10. Colace 100 mg p.o. twice a day. 11. Tamsulosin HCL 0.4 mg once daily. 12. Celexa 20 mg two tablets p.o. daily. 13. Fludrocortisone acetate .1 mg tablet four tablets p.o. q a.m. 14. Midodrine 5 mg two tablets p.o. every day. 15. Prednisone 5 mg one tablet p.o. every day. 16. MMF 500 mg two tablets p.o. twice a day. 17. Tacrolimus 1 mg four capsules p.o. twice a day. 18. Nitroglycerin .3 mg sublingual, one tablet prn as needed. 19. Lasix 20 mg .5 tablet p.o. once daily. FOLLOW UP: The patient is to have CBC, chemistry 7, calcium, magnesium, phosphorus, amylase, lipase, urinalysis, Tacrolimus trough drawn every Monday and Thursday and have the results faxed to the Transplant Center. The patient is to follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **] at the [**Hospital Unit Name **], Transplant Center. Telephone number [**Telephone/Fax (1) 30335**]. The patient's discharge condition is good. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern1) 16264**] MEDQUIST36 D: [**2115-1-8**] 23:21:40 T: [**2115-1-9**] 06:30:41 Job#: [**Job Number 33997**]

[ "357.2", "560.1", "V45.82", "250.61", "568.0", "996.86", "552.21", "998.12", "567.2", "250.41", "V42.0", "790.7", "998.59" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.93", "53.61", "54.59", "52.82", "00.93", "96.33", "93.59", "38.91", "54.12", "52.22", "99.15" ]

icd9pcs

[ [ [] ] ]

7211, 8208

1841, 6829

6854, 7188

987, 1125

8220, 8923

1292, 1823

1145, 1269

233, 732

755, 963

68,944

170,602

37351

Discharge summary

report

Admission Date: [**2103-5-22**] Discharge Date: [**2103-6-7**] Date of Birth: [**2046-10-9**] Sex: M Service: NEUROLOGY Allergies: hydromorphone Attending:[**First Name3 (LF) 8850**] Chief Complaint: Transfer for management of pneumonia and all oncology care. Major Surgical or Invasive Procedure: None. History of Present Illness: The patient is a 56-year-old man with history of right temporal lobe glioblastoma, s/p resection and XRT, currently on bevacizumab and dexamethasone followed by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] as outpatient, who was sent to [**Hospital3 417**] hospital from [**Hospital1 15454**] [**Hospital1 **] in [**Location (un) 701**], MA on [**2103-5-19**] with SOB and fevers. CTA revealed posterior consolidations bilaterally most consistent with pneumonia. He was started on imipenem/tigacycline, defervesced, requiring 3-4L of oxygen via nasal cannula. Per ICU attending there, his imaging/presentation did not seem consistent with PCP and serum LDH was normal at 230. He was transfered to [**Hospital1 18**] for further management and since all of his oncology care has been coordinated by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**]. Of note, his nasal swabs at [**Hospital3 417**] tested positive for MRSA and VRE. Upon review of OMR, he was admitted to [**Hospital1 18**] from [**2103-4-13**] to [**2103-4-18**] for AMS and a positive blood culture. He was found to have a UTI had his urinary catheter exchanged on arrival. Urine cultures from [**Year/Month/Day **] was positive for ESBL Klebsiella and pseudomonas resistant to meropenem. Repeat urine culture showed no growth. Blood cultures showed no growth at the time of discharge. Portable chest X-ray showed no evidence of pneumonia. The patient was started on vancomycin, meropenem, and ciprofloxacin, renally dosed. His mental status and clinical condition improved with antibiotics and fluids in the ICU. Vancomycin was discontinued (given patient had only 1 out of 4 bottles positive for coag-positive staph at [**Year/Month/Day **], with negative blood culture here). He was discharged with meropenem/ciprofloxacin for a goal 14 day course to be completed on [**2103-4-26**]. On the floor here, he reports "a lot" of abdominal pain over the past four days and continued pain in both of his legs. He also states that his shortness of breath is improved compared to a few days ago. Review of Systems: (+) Per HPI (-) He denies fever, chills, night sweats, recent weight loss or gain. He denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. He denies chest pain, palpitations, orthopnea, dyspnea on exertion. He denies nausea, vomiting, heartburn, diarrhea, constipation, BRBPR, melena. There is no dysuria, urinary frequency. He denies arthralgias or myalgias. He denies rashes. There is no increasing lower extremity swelling. There is no numbness/tingling or muscle weakness in extremities. There is no feelings of depression or anxiety. All other review of systems negative. Past Medical History: - [**12-21**] developed headaches and leg weakness and CT at [**Hospital1 **] showed right temporal lobe mass. Started on dexamethasone. - Underwent subtotal resection of the R temporal lobe mass by Papavassilious on [**2101-12-30**], path positive for GBM - received intracranial temozolamide chemo-radiation, followed by adjuvant temozolomide (4 cycles) [**2102-1-23**] to [**2102-3-7**] - Ventriculoperitoneal shunt placement [**2102-8-1**] - Procarbazine, CCNU, and Vincristine (PCV) on [**2102-8-23**] and had 1 cycle so far - Hospitalization from [**Date range (3) 84005**], during which time he had: PCP PNA, [**Name Initial (PRE) **]/p PEA arrest and flail chest from compression, PE s/p IVC filter, was previously on lovenox - Discharged to [**Hospital1 **] course c/b C. difficile, ESBL PNA - plan was to treated with bevacizumab but this was delayed due to ICH Per wife has had 3 IC bleeds post craniectomy and as such has meant that anticoagulation was contraindicated - start bevacizumab treatment on [**2103-2-28**] and had 1 cycle so far at 5 mg/kg. - C. difficile: First diagnosed during [**11/2102**] hospitalization with relapse on [**2103-3-26**], for which patient has completed an extended course of po vancomycin on [**2103-5-3**]. - Previous left knee cartilage operation - osteoporosis - epilepsy - PE/bilateral DVTs (s/p IVC filter placement [**11/2102**]) Social History: Semi-retired accountant. He was transfered from [**Year (4 digits) **] but previously at home with wife and children. Mobility at [**Year (4 digits) **] was only standing for a few seconds while holding onto walker. He has no history of tobacco use. He previously drank socially, but without drug use. Family History: His father died had CABG x 3 at age 40, with first MI age 42, and died at age 85 from CAD. His mother is alive with hypertension. He has 4 siblings and one has had recent stent placement for CAD. His 3 children are healthy. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.6 F, blood pressure 139/101, pulse 94, respiration 16, and oxygen saturation 96% on 3L NC; pain [**7-22**] in abdomen. GENERAL: No apparent distress; slow response time to questions, but normal verbal fluency HEENT: No trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CARDIOVASCULAR: Regular rate and rhythm, no murmurs/gallops/rubs PULMONARY: Clear to auscultation bilaterally, but inspirtory effort is poor. He has no rales/crackles/rhonchi ABDOMEN: Soft, non-tender, non-distended; no guarding/rebound EXTREMITIES: No clubbing/cyanosis; 2+ pitting edema L>R, 2+ distal pulses; peripheral IV present NEUROLOGICAL EXAMINATION: His Karnofsky Performance Score is 50. He is awake, alert, and able to follow commands. His language is fluent with good comprehension. Short-term recall is intact. He has moderate psychomotor slowing. Cranial Nerve Examination: His pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full without nystagmus. Visual fields are full to confrontation. His face is symmetric. Facial sensation is intact bilaterally. His hearing is intact bilaterally. His tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: He has postural tremors, but no pronation or drift. He can move his upper extremities with good strength at 4+/5. But in the lower extremities, he has proximal lower extremity weakness at 3/5 on the right and [**2-17**] on the left (this is somewhat limited by low back pain). His muscle tone is normal. His reflexes are 0-1 bilaterally. His ankle jerks are absent. His toes are down. Sensory examination is intact to touch and proprioception. He cannot walk. DISCHARGE PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.5 F, blood pressure 126/82, pulse 65, respiration 18, and oxygen saturation 96% in room air. GENERAL: Middle aged male appearing comfortable, Alert, conversant Place: [**Hospital1 18**] Year: [**2103**] SKIN: Stage II sacral decubitis with dressing in place HEENT: Left sided VP shunt, well healed surgical scar. PERRLA. MMM. CHEST: Right sided porta cath in place with mild erythemia and skin break down surrounding port. CARDIOVASCULAR: RRR S1/S2 normal. no murmurs/gallops/rubs. PULMONARY: Poor inspiratory effort. Clear to ascultation BL. ABDOMEN: Overweight, LUQ mild TTP. BS+, soft, no rebound/guarding, EXTREMITIES: Warm to the touch, BL ecchymoses in upper extremities. L>R peripheral edema to the mid calf. NEUROLOGICAL EXAMINATION: His Karnofsky Performance Score is 50. He is awake, alert, and able to respond to most commands readily. His language is fluent with fair comprehension. Cranial Nerve Examination: His pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full without nystagmus. Visual fields are full to threat. His face is symmetric. Facial sensation is intact bilaterally. His hearing is grossly intact. His tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: He has postural tremors. His motor strength is [**4-17**] at proximal and 4+/5 at distal upper extremities. In the lower extremities, the strength is [**3-17**] at proximal and distal lower extremities. His reflexes are 0-1 bilaterally. His ankle jerks are absent. His toes are down. Sensory examination is intact to pinch. He cannot walk. Pertinent Results: ADMISSION LABS [**2103-5-22**] 10:38PM GLUCOSE-108* UREA N-26* CREAT-0.4* SODIUM-141 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14 [**2103-5-22**] 10:38PM ALT(SGPT)-27 AST(SGOT)-17 LD(LDH)-269* ALK PHOS-109 TOT BILI-0.2 [**2103-5-22**] 10:38PM ALBUMIN-3.1* CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-2.2 [**2103-5-22**] 10:38PM WBC-8.9# RBC-3.81* HGB-12.8* HCT-38.6* MCV-101* MCH-33.6* MCHC-33.2 RDW-16.7* [**2103-5-22**] 10:38PM NEUTS-70 BANDS-0 LYMPHS-8* MONOS-19* EOS-0 BASOS-0 ATYPS-1* METAS-2* MYELOS-0 [**2103-5-22**] 10:38PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-1+ TEARDROP-OCCASIONAL [**2103-5-22**] 10:38PM PLT SMR-LOW PLT COUNT-138* [**2103-5-22**] 10:38PM PT-11.5 PTT-28.8 INR(PT)-1.0 DISCHARGE LABS [**2103-6-7**] 05:47AM BLOOD WBC-6.9 RBC-3.45* Hgb-11.3* Hct-34.5* MCV-100* MCH-32.7* MCHC-32.7 RDW-17.2* Plt Ct-178 [**2103-6-7**] 05:47AM BLOOD Glucose-84 UreaN-12 Creat-0.5 Na-147* K-3.6 Cl-107 HCO3-30 AnGap-14 MICRO [**6-3**] C. diff negative [**5-31**] C. diff negative [**5-29**] CSF gram stain neg FLUID CULTURE (Final [**2103-6-1**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. [**5-29**] BCX x2 Negative [**5-28**] BCX x2 Negative [**5-28**] UCX negative [**5-27**] Bcx Negative [**5-25**] c. diff negative 5/12/2011Sputum: Pneumocystis jirovecii (carinii)-negative [**2103-5-23**] Stool FECAL CULTURE (Final [**2103-5-25**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2103-5-25**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2103-5-24**]): Feces negative for C.difficile toxin A & B by EIA. FECAL CULTURE - R/O E.COLI 0157:H7 (Pending): NEGATIVE FECAL CULTURE - R/O VIBRIO (Pending): NEGATIVE FECAL CULTURE - R/O YERSINIA (Pending): NEGATIVE [**2103-5-23**] URINE CULTURE-negative [**2103-5-22**] Blood Culture, Routine-NEGATIVE CSF: NEGATIVE FOR MALIGNANT CELLS. MRI Head IMPRESSION: Status post right pterional craniotomy for glioblastoma resection. Compared to [**2103-3-26**] MR, there is no suspicous interval change to suggest recurrence, and no evidence of acute pathology. CT HEAD [**2103-5-29**] IMPRESSION: 1. No acute intracranial hemorrhage. 2. The right temporal tumor site and posttreatment changes are better evaluated on the head MRI from [**2103-5-28**]. 3. Stable enlargement of the ventricles. 4. Unchanged air-fluid level in the right sphenoid sinus. EEG [**2103-5-30**] IMPRESSION: This is an abnormal extended routine EEG, due to the presence of continuous 0.5-1 Hz delta slowing seen over the right fronto-temporal region with rare associated sharp discharges (F4/T4). This is consistent with a focal underlying structural lesion with epileptogenic potential. In addition, the presence of a disorganized [**6-19**] Hz theta frequency background is suggestive of a mild diffuse encephalopathy, seen with medication effect, metabolic disturbance, or infection. Brief Hospital Course: [**Known firstname **] [**Known lastname 13013**] is a 56-year-old man with glioblastoma, s/p resection and chemo-irradiation, and most recently on bevacizumab and dexamethasone as well as history of PCP PNA and PE Bilat DVTs admitted to OSH ICU for bilateral PNA. He completed an 8 day course of vancomycin/Zosyn for healthcare assocaited pneumonia. His hospitalization was complicated by confusion related to sedating medications. (1) Pneumonia: Patient initially hypoxic and was on BIPAP on presentation to OSH in the ICU, concern for HAP vs aspiration PNA. OSH imaging suggestive of bibasilar atelectasis and consolidation. He was initially treated with imipenem and tigecycline at OSH. On arrival to [**Hospital1 18**], he was changed to vancomycin and Zosyn for HCAP, he completeed an 8 day course [**2103-5-29**]. Induced sputum was negative for PJP. (2) Seizure Disorder: Patient suffered seizure and cardiac arrest [**11/2102**] and has been on valproic acid since. VPA level 133 prior to transfer from OSH and VPA dose lowered 1750 Q8H->1250 Q8H. After discussion with primary oncologist, VPA dose was returned to 1770 Q8H. Patient developed worsening confusion [**5-26**] and given recently decreased VPA dose, concern was raised for non-convulsive seizures, 20 min EEG was obtained and showed no epileptiform discharges and only diffuse encephalopathy which had been seen on previous EEGs. On [**2103-5-29**], patient had possible convulsive seizure witnessed by shaking of L>R extremities and patient was given 1mg Ativan however shaking had resolved prior to medication administration. Neurological examination was unchanged. Head CT was obtained which was negative for acute hemorrhage. MRI head obtained 10 hours prior to the event (as part of oncologic work up) showed stable GBM. A 24-hour EEG showed epileptiform discharges however the findings were relatively subtle and unlikely to cause convulsive seizure activity. Valproate was lowered to 1250mg Q8H. No further shaking episodes were observed. (3) Altered Mental Status: Patient was noted to be lethargic on [**2103-5-29**], with noted jerking movements of his upper extremities bilaterally. Differential for this included underlying glioblastoma multiforme, question of seizure activity, infection and medications with sedative properties. He underwent lumbar puncture to rule out meningitis, CSF culture was negative and cell count was not suggestive of meningitis. Sedating medications were held, including lorazepam, gabapentin, morphine, oxycodone and diphenhydramine and mental status improved markedly. Methylphenidate was increased. (4) Sepsis: On [**2103-5-29**], patient developed hypothermia and hypotension to SBP 90's. He was bolused with IVNS and pressures returned to 110's. A warming blanket was placed, blood cultures sent and an lumbar puncture was performed as above. Given clinical deterioration, patient was transferred to the ICU for closer monitoring. Infectious workup was negative, pressures stabalized and he was called out to the medical floor. (5) Diarrhea: On admission, patient was having [**1-15**] loose bowel movements daily, and abdominal pain was attributed to enteritis. LFTs and lipase were unrevealing. He was C. diff negative. He appeared distended on [**2103-5-29**] and a plan film of the abdomen showed no evidence of obstruciton or megacolon. Repeat studies for C. diff were negative. Diarrhea is attributed to antibiotic therapy with secondary effect on GI flora. At the time of discharge, stool had become soft. Started loperamide for diarrhea. (6) Gliobastoma/Seizure Disorder: Patient s/p resection with intracranial chemo and s/p VP shunt. Course complicated by intracranial hemorrhage x 3. He is currently on dexamethasone and bevacizumab. He completed C4D1 of bevacizumab while in hospital [**2103-5-31**]. MRI shows stable disease however concern was raised for progression of glioblastoma that cannot be seen on MRI. Dexamethasone tapered to 1mg daily on [**2103-5-26**], and to 0.75mg daily on [**2103-6-5**]. He continued atovaquone and fluconazole PPx. Ritalin was increased to 20mg daily. He received increased AM gabapentin for headaches. Valproate was decreased. He continued carbidopa/levodopa. Plan to taper dexamethasone to 0.5mg daily [**2103-6-12**]. Patient will follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] for bevacizumab treatments. (7) Headahce: Following removal of oxycodone and morphine for pain control, patient complained of intermittant headaches. His neurological examination remained unchanged and there was low suspicion for acute intracranial process. Headahces responded to acetaminophen and, to a limited extent, to Fioricet. After one day of firocet therapy, he again appeared somnolent and fiorcet was discontinued. Headaches were believed to have a component of rebound following withdraw of opiates. His a.m. gabapentin dose was increased 300 to 600mg. Gabapentin 300 Q noon added [**2103-6-7**], could increase to 600 Q noon if headaches worsen. (8) Acute Renal Failure: Patient developed acute renal failure related to vancomycin. Vancomycin was discontinued. Creatinine peaked at 1.5, and returned to baseline after one day. (9) Goals of Care: Given his poor prognosis of glioblastoma, family meeting was held with the wife and code status was changed to DNR/DNI. His wife plans to bring him home after he completes [**Month/Day/Year **] and is arranging for handicap accessable home. (10) History of DVT/PE: This was diagnosed in [**11/2102**] with bilateral PE and patient has IVC filter in place, not systemically anticoagulated due to history of intracranial bleeding x 3. He continued Heparin 5000U SC QID per outpatient oncologists Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] recommendation. He developed oozing at heparin sites and heparin was changed to heparin SC 5000 TID. (11) Macrocytic Anemia: This is likely related to chemotherapeutic agents. B12 and folate were within normal limits. (12) Thrombocytopenia: His platelets trended up form low 100's at OSH likely medication effect from chemotherapeutic agents. HIT was considered unlikely. Platelet count had normalized by the time of discharge. (13) Osteoporosis: This is related to chronic dexamethasone therapy. He has a history of compression fractures. He continued alendronate, vitamin C, calcium and vitamin D. (14) Precautions for: VRE, MRSA, and C. diff. (15) CODE: DNR/DNI changed on [**2103-5-31**]. (16) Contact: [**Name (NI) **], wife [**Name (NI) 553**] [**Name (NI) 13013**] [**Telephone/Fax (1) 84006**]. Medications on Admission: Medication on Transfer alendronate 70mg q week ascorbic acid 1000mg TID Valcium vitamin d 1 tab Carbidopa/levodopa 1 dab daily Methylphenidate 5mg daily Colchicine 0.6mg daily fluconazole 100mg daily furosemide 20mg daily gabapentin 300mg QAM 1200mg QPM Potassium chloride 20meq daily Thiamine 100mg Valproate 1250mg Heparin sub q 500units TID fluticasone 2 sprays Q24 nystatin 500,000 units QID ipratropium 0.5mg UINH Q6H Levalbuterol 1.25mg Q6H Dexamethasone 2mg IV Q6H Pantoprazole 40mg IV daily Acetaminophen 650 Q4h PRN [**Doctor Last Name **]/hydrox/mg hydrox/simethicone 30ml Q4H PRN Guaifenesin 200mg Q6H PRN Mag hydroxide 10mL QHS PRN Docusate 100mg [**Hospital1 **] PRN Ondansetron 4mg Q6H PRN Ibuprofen 400mg Q8H PRN Tramadol 50mg Q4H PRN acetaminophen 650mg PR PRN albuterol sulgate 2.5 mg INH Q4H PRN Ipratropium 0.5mg INH Q4H PRN Pertolatum/zinc oxide 1 appl daily prn miconazole nitrate 1 appl [**Hospital1 **] PRN . Home meds accutane 20 mg 1 capsule [**Hospital1 **] x 3 weeks ([**2103-1-30**]) accutane 40 mg 2 caps po BID x 3 weeks ([**2103-1-30**]) acetylcysteine 20% (200 mg/mL) solution nebs q2hrs prn albuterol sulfate 90 mcg HFA inhaler 90 mcg nasal q4h prn alendronate 70 mg 1 po weekly atovaquone 750 mg/5 ml suspension 10 ml po daily carbidopa-levodopa 25 mg-100 mg 1 tab po BID colchicine 0.6 mg 1 tab po daily dexamethasone 0.75 mg 1 tab po daily esomeprazole magnesium (nexium) 40 mg E.C. 1 cap po daily gabapentin 300 mg 1 cap po qam and 4 qhs heparin 5,000 units/mL cartridge 500 units sub-Q q6 hours ibuprofen 600 mg 1 tab po q8h prn methylphenidate 5 mg 1 tab po qam nystatin 100,000 unit/mL suspensi9on 10 mL po daily ondansetron 4 mg tab 1 po q8h prn potassium chloride 20 mEq ER 1 tab po daily sodium chloride 2.5 mEq/nL parenteral solution 20 mg daily valproic acid 250 mg 7 caps po TIC OTC: acetaminophen 325 mg 2 tabs po q6h prn acetaminophen extra strength 500 mg 2 tabs po qhs prn headache ascorbic acid 500 mg 1 tab po BID calcium carbonate-vitamin D3 500 mg calcium (1,250 mg)-400 unit [**Unit Number **] tab po TID diphenhydramine HCL 25 mg [**1-14**] caps po QHS prn insomnia docusate sodium 100 mg 1 cap po BID multivitamin 1 po daily thiamine HCL 100 mg 1 po daily Discharge Medications: 1. acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) neb Miscellaneous Q2H (every 2 hours) as needed for dyspnea, wheeze. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every Friday). 4. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY (Daily). 5. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QAM. 8. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection Q6H (every 6 hours): DVT Treatment per primary oncologist. 10. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for fever or pain. 11. methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO once a day. 13. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 15. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for headache. 16. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO three times a day. 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation: Hold for loose stools. 18. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 21. valproic acid (as sodium salt) 250 mg/5 mL Syrup Sig: 1250 (1250) mg PO Q8H (every 8 hours). 22. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day). 23. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 24. dexamethasone 1.5 mg Tablet Sig: 0.5 tablets PO DAILY (Daily). 25. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. 26. loperamide 2 mg Tablet Sig: 1-2 Tablets PO four times a day: Hold for constipation. 27. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q 12PM . 28. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary Health Care Associated Pneumonia Toxic metabolic encephalopathy Glioblastoma Multiforme Seizure disorder Acute renal failure Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr [**Known lastname 13013**], As you know, you were transferred from [**Hospital3 417**] Hospital to [**Hospital1 18**] for pneumonia. We treated you with antibiotics and your symptoms improved. Your primary oncologist, Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] noted that you seemed confused and was concerned that you were having a seizure, we performed an EEG which did not show anything to explain the confusion. We held sedating medicaitons and your confusion improved. You were having diarrhea and we checked you for an infectious cause and the tests were negative. We belive that the diarrhea is related to antibiotics and will resolve with time. We recommend that you take Medication changes START Loperamide for diarrhea INCREASE Methylphenidate INCREASE Gabapentin STOP Carbidopa/levodopa STOP sodium chloride STOP Diphenhydramine Followup Instructions: Avastin appointment. Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2103-6-14**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

23538, 23610

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334, 341

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31892+57770

Discharge summary

report+addendum

Admission Date: [**2105-6-10**] Discharge Date: [**2105-6-18**] Date of Birth: [**2077-7-15**] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5667**] Chief Complaint: sarcoma of the scalp Major Surgical or Invasive Procedure: wide excision of scalp lesion, craniotomy with titanium mesh, serratus free flap, STSG History of Present Illness: The patient is a 24-year-old male with a history of having a DFSP that was resected in [**Country 7192**] approximately 1-2 years ago. He has had a prior biopsy at this institution and also a biopsy by myself several weeks ago that proved this to be recurrence to the periosteal layer. It was coordinated with neurosurgery and head and neck surgery to resect this tumor. Past Medical History: none Social History: lives in [**Country 7192**], works as a barber Family History: NC Brief Hospital Course: Patient went to the operating room where he underwent a multi-disciplinary surgery involving ENT, Neurosurg, and Plastic [**Doctor First Name **]. The ENT surgeons first resected the tumor from the patients scalp (full op note to be dictated), the Neurosurgeons then resected part of the cranium and filled in the defect with titanium mesh and methylmethacrylate. Dr. [**First Name (STitle) **] then performed a serratus anterior free flap to the scalp using microsurgical technique to attach the pedicle vessels to the superficial temporal vessels. A STSG was then used to cver the rest of the defect. . Post op the patient was monitored in the PACU, he remained intubated due to the length of the case. He was transferred to the ICU where he was extubated the following day without problem. His flap was monitored hourly by doppler of the venous and arterial anastomosis as well as with a continuous venous doppler that was sutured around the vein. In the ICU it was noted he had a abrasion lesion on his right tricep. It was likely this was from the OR as it was not evident preop, but we were unsure of the etiology. This was dressed with a xeroform and gauze dressing. . The patient was then transferred to the floor. His diet was advanced, his fluids were weaned, and his antibiotics were continued (vanco and gent). On POD 3 he spiked a temp to 101.1 and was pancultured, nothing ever grew. Over the next few days he continued to have low grade temps as well as persistent headaches, eventually we repeated a CT scan. This showed no evidence of hematoma or bleed in the brain. He never had any meningeal signs. Eventually his temperatures normalized and his headaches improved. His penrose and scalp drains were removed prior to discharge. His pain meds were switched to PO, his IV was saline locked, and his venous doppler was clipped at the scalp. Once he was meeting all the criteria for discharge we decided to send him home with VNA services. Medications on Admission: none Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 5 days. Disp:*20 Capsule(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: sarcoma of the scalp Discharge Condition: stable Discharge Instructions: DIET: regular . ACTIVITY: no exercise or heavy lifting. Do not place anything on the head other than the dressing. Be mindful of your head, do not bump it on anything, there is a wire still coming out of the scalp, this will stay in place for weeks as it dissolves on the inside. . DRAINS: you should have your drains emptied daily by the VNA and recorded. . MEDS: cont your home meds, cont the antiobiotics for a total of 10days, cont with your pain meds as needed. . CALL if you experience fevers,chills, increasing headaches, changes in your vision, neck pain, increased drainage from the head or drains. Followup Instructions: please call to schedule a follow up appt with Dr. [**First Name (STitle) **], Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1837**]. Name: [**Known lastname 12331**],[**Known firstname 12332**] Unit No: [**Numeric Identifier 12333**] Admission Date: [**2105-6-10**] Discharge Date: [**2105-6-18**] Date of Birth: [**2077-7-15**] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1165**] Addendum: PATHOLOGY results: 1. Skin, scalp lesion, excision (A-W): -Residual dermatofibrosarcoma protuberans, extending near the deep margin. -Scar and foreign body giant cell reaction consistent with previous biopsy site. 2. Skin, scalp lesion, 3:00 left lateral margin , biopsy (X): No residual dermatofibrosarcoma protuberans seen. 3. Skin, scalp lesion, 6:00 anterior margin , biopsy (Y): No residual dermatofibrosarcoma protuberans seen. 4. Skin, scalp lesion, 9:00 right lateral margin, biopsy (Z): No residual dermatofibrosarcoma protuberans seen. 5. Skin, scalp lesion, 12:00 margin, biopsy (AA): No residual dermatofibrosarcoma protuberans seen. 6. Bone - Pending decalcification results will be reported in an addendum. Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1167**] MD [**MD Number(2) 1168**] Completed by:[**2105-6-18**]

[ "198.89", "784.0", "780.6", "198.5", "173.4" ]

icd9cm

[ [ [] ] ]

[ "86.69", "83.82", "86.4", "01.6", "83.43", "02.05" ]

icd9pcs

[ [ [] ] ]

5555, 5718

959, 2931

335, 424

3539, 3548

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Discharge summary

report

Admission Date: [**2110-12-29**] Discharge Date: [**2111-1-14**] Date of Birth: [**2029-12-7**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: increased abd distention and anemia Major Surgical or Invasive Procedure: End sigmoid colostomy [**2111-1-6**] History of Present Illness: 81 F originally presented in may with complaints of changes in bowel habits. Colonocscopy on [**2110-4-23**] revealed a fungating ulcerating 5 cm mass in the distal rectum 4 cm from anal verge. Bx confirmed melanoma U/S measured the lesion to be 2.3 cm x 5.2 cm and it was hypoechoic and heterogenous with poorly defined borders. The lesion involved the mucosa, submucosa and muscularis. There was suspicion for tumor extension beyond the muscularis layer. The tumor was staged as T3 by EUS criteria. Three lymph nodes were noted in the perirectal region measuring between 2 and 2.2 cm in maximal diameter. This was staged N1 by EUS criteria. she was then started on experiemntal chemo which she recently was taken off of due to an increase in the burden of her disease as the lesion had grown and metastasized now causing bladder outlet obstruction. CT scan on [**11-9**] revelaed Progression of metastatic disease, with increase in size of a left lobe liver lesion and a probable new right lobe liver lesion. Pancreatic lesion grossly stable. Increased size of the presacral mass is causing local mass effect and is the most likely explanation for bladder outlet obstruction. Dr. [**Last Name (STitle) 1120**] had seen the pt in clinic on [**11-5**] and discussed the option of alliative bowel diversion with the patient and her son. At that time both individuals expressed their interest in deferring this option as long as possible. The patient was readmitted on [**12-29**] for anemia and fatigue. Past Medical History: 1. metastatic rectal melanoma, recently off of chemotherapy. 2. Hypertension. 3. Osteoarthritis. 4. Pancreatic cyst consistent with IPMN. Social History: She lives alone, quite active. She is independent in all of her ADLs and IADLs. Physical Exam: Vitals: T 96.2 P 77 BP 141/62 RR 20 O2Sat 97% RA GEN: ill-appearing, NAD HEENT: anicteric sclera, NCAT CV: RRR CHEST: CTAB ABD: softly distended NT no masses Ext: without clubbing or cyanosis with 2+ edema Rectal: guiac pos with large ulcerating mass in posterior midline almost completley obstructing lumen Pertinent Results: [**2110-12-29**] 03:39PM UREA N-46* CREAT-1.6* SODIUM-139 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-22 ANION GAP-14 [**2110-12-29**] 03:39PM ALT(SGPT)-26 AST(SGOT)-72* LD(LDH)-1337* ALK PHOS-218* DIR BILI-0.3 [**2110-12-29**] 03:39PM WBC-9.6 RBC-2.89* HGB-8.0* HCT-27.1* MCV-94 MCH-27.7 MCHC-29.6* RDW-18.7* [**2110-12-29**] 03:39PM PLT COUNT-425 [**2110-12-29**] 03:39PM PT-13.6* PTT-26.3 INR(PT)-1.2* [**2111-1-10**] 05:45AM BLOOD ALT-14 AST-51* LD(LDH)-1491* AlkPhos-175* TotBili-1.8* DirBili-1.3* IndBili-0.5 [**2111-1-12**] 01:06PM BLOOD Type-ART pO2-111* pCO2-30* pH-7.38 calTCO2-18* Base XS--5 [**2111-1-12**] 01:06PM BLOOD Lactate-3.4* [**2110-12-29**] 03:39PM PT-13.6* PTT-26.3 INR(PT)-1.2* [**2110-12-29**] 03:39PM PLT COUNT-425 Brief Hospital Course: 81 yo F with obstructing metastatic melanoma of the rectum s/p chemo presents with worsening abdominal pain, distension, and anemia. She was initially admitted to the OMED service where she was transfused with 2 units of pRBCs. A plain film of the abdomen revealed large amount of ascites but no bowel dilitation. A general surgery consult was made and the patient was recommended for a sigmoid colostomy to divert stool from the rectal obstruction. A CT scan performed before surgery revealed extensive metastatic disease in the liver, omentum, rt adrenal gland, right middle and lower lobes, lumbar spine. Moderate ascites was also noted. The patient remained stable until she went to the OR for a end colostomy on [**2111-1-6**]. Post-operatively, on [**2111-1-7**] she had low urine output and was transferred to the T/SICU after receiving 2L of fluids and 25g albumin. A renal US was perfomed that showed no evidence of obstruction. She continued to require several liters of fluid per day to maintain UOP> 20 cc/hr, and develloped 3+ pitting edema of her LE from the feet to the sacrum. She maitained good UOP until [**2111-1-9**] and was transferred back to the floor. However, on [**1-11**] her UOP dropped to nearly 0 and she was transferred back to the SICU and placed on daily albumin and eventually hetastarch to maintain intravascular volume, but her UOP could not be maintained. At this point, she became increasingly somnolent. On [**1-13**], her family decided to make her comfort measures only, and she stopped receiving fluid replacement. She expired uneventfully on [**1-14**] in the afternoon. Medications on Admission: Medications - Prescription AMYLASE-LIPASE-PROTEASE [CREON 10] - (Prescribed by Other Provider) - Dosage uncertain OXYCODONE-ACETAMINOPHEN [PERCOCET] - (Prescribed by Other Provider) - Dosage uncertain PAROXETINE HCL [PAXIL] - (Prescribed by Other Provider) - 10 mg Tablet - 1 (One) once a day VALSARTAN [DIOVAN] - (Dose adjustment - no new Rx) - 160 mg Tablet - 1 (One) Tablet(s) by mouth once a day Medications - OTC ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) - 500 mg Tablet - 1 (One) Tablet(s) by mouth once a day BISACODYL - (Prescribed by Other Provider) - Dosage uncertain IBUPROFEN - (Prescribed by Other Provider) - Dosage uncertain SENNOSIDES-DOCUSATE SODIUM [SENOKOT-S] - 8.6 mg-50 mg Tablet - 2 Tablet(s) by mouth once daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: death s/p metastatic melanoma Discharge Condition: deceased Discharge Instructions: . Followup Instructions: N/A Completed by:[**2111-1-14**]

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Discharge summary

report+addendum

Admission Date: [**2137-1-2**] Discharge Date: [**2137-1-10**] Date of Birth: [**2091-8-18**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: Elective admission for colloid cyst resection Major Surgical or Invasive Procedure: [**2137-1-2**]: s/p right frontal craniotomy for colloid cyst resection History of Present Illness: Mr [**Known lastname **] is a 45yo gentleman who complains of headaches over the past year. He states that they are 3-4 per week in frequency and are [**5-7**] /10 in intensity but nonspecific in location. They are accompanied by photophobia. He also states that his vision has been becoming worse and he has noted his attention has not been as good. He was evaluated by Dr [**Last Name (STitle) 1906**] who obtained and MRI which reveals a colloid cyst. Past Medical History: DM II headaches HL Social History: married, works as a welder and seasonally as [**Last Name (un) 88046**]. He smokes about [**12-30**] ppd and rarely drinks alcohol. Physical Exam: On Admission: PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs intact Neck: Supple. Lungs: no adventicious sounds Cardiac: RRR Abd: Soft, NT Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-2**] throughout. No pronator drift Sensation: Intact to light touch Coordination: normal on finger-nose-finger, rapid alternating movements ON DISCHARGE: awake alert and oriented x 3, face symmetric, tongue midline, no pronator drift, PERRL, EOMs full without nystagmus, sutures cdi, motor full Pertinent Results: MRI Brain [**2137-1-2**]: IMPRESSIONS: 13 x 13 x 16-mm colloid cyst and associated mild hydrocephalus are unchanged compared to [**2136-10-25**] study from [**Hospital 1474**] Hospital. CTA Head [**2137-1-2**]: IMPRESSIONS: 1. 14 x 14 x 16 mm colloid cyst and associated mild hydrocephalus, without evidence of transependymal migration of CSF, unchanged compared to MRI from [**2136-10-25**]. 2. Intracranial arteries demonstrate conventional anatomy and normal patency. 3. Mild-to-moderate paranasal sinus mucosal thickening without layering fluid. Also, fluid-opacification of the mastoid air cells, bilaterally; correlate clinically. MRI Brain [**2137-1-3**]: IMPRESSIONS: 1. Status post resection of colloid cyst and right frontal craniotomy, with expected postoperative changes including postoperative fluid, blood and gas in the subdural and intraventricular compartments. 2. Slow diffusion along the right frontal resection tract involves the corpus callosum and is of uncertain clinical significance, probably representing postoperative inflammation, although infarction could also have this appearance. CT Head [**2137-1-4**]: 1. No intraparenchymal hemorrhage or large vascular territory infarct 2. Resolution of pneumocephalus. 3. Layering of products within the right occipital [**Doctor Last Name 534**]. CT Head [**1-6**]: 1. Postoperative changes, with residual subgaleal fluid/air collection, pneumocephalus, and right frontal lobe edema along the surgical tract. 2. Decrease in hemorrhage within right occipital [**Doctor Last Name 534**]. Brief Hospital Course: 45M elective admission for colloid cyst, s/p crani for resection, post-op he was admitted to the ICU for close monitoring. He remain intubated because he had no cuff leak, and was placed on a Insulin drip for high glucose levels. On [**1-3**] he was extubated and was slightly confused and disoriented. On the mornign of [**1-4**] he continued to be disoriented and lethargic and a Head CT was obtained which was stable and showed no hydrocephalus. Later in the evening he developed some tachycardia which responded well to medication. On [**1-5**] he was noted to have a large volume of urine output. Endocrine was consulted and felt there was no evidence of DI and that given his normal serum sodium level, no intervention was required. Overnight into [**1-6**] he became agitated and angry and was trying to leave. A Code purple was called and he was given sedative medication to assist in calming him down. A head CT was also done at this time to ensure no interval change had occured The CT was stable. He remaiend stable in the ICU during the day on [**1-6**], but overnight he again became agitated and confused. Again he received Haldol and Ativan, and following this he was much more calm. On the morning of [**1-7**] he was sedated but calm and following commands. The decision was made to transfer him from the ICU to the Step Down Unit, but he would require a sitter. he remained stable and without an episodes of agitation overnight on [**1-7**] into [**1-8**]. On morning rounds he had a sitter at the bedside and there were no reports of issues. His exam and mental status continued to improve and he was deemed fit to be transferred to floor status. On the evenings of [**1-7**] and [**1-8**], he had no issues with psychosis or agitation. He was seen by PT who determined that he was fine to go home with services and 24 hours supervision, which his girlfriend agreed to provied. He was discharged to home on [**2137-1-10**]. Medications on Admission: Metformin 500mg [**Hospital1 **] Albuterol Levemir Combivent Fenofibrate Lisinopril Simvastatin ASA 325 mg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. oxycodone 5 mg Capsule Sig: [**12-30**] Capsules PO every 4-6 hours. Disp:*30 Capsule(s)* Refills:*0* 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. albuterol sulfate Inhalation 7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Take while on the Dexamethasone. Disp:*20 Tablet(s)* Refills:*0* 9. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*0* 10. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q6hours () for 1 days. Disp:*6 Tablet(s)* Refills:*0* 11. dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO q6hours () for 1 days. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**], VNA Discharge Diagnosis: Colloid Cyst Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or [**Known lastname 14073**] 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 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. Followup Instructions: Follow-Up Appointment Instructions ?????? Please return to the office in 10 days (from your date of surgery) for removal of your sutures and a wound check. This appointment can be made with the Physician Assistant or [**Name9 (PRE) **] Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make Please follow-up with Dr. [**Last Name (STitle) **] in 4 weeks with a Head CT w/o contrast. Please call [**Telephone/Fax (1) 3231**] for this appointment. Completed by:[**2137-1-10**] Name: [**Known lastname 4764**],[**Known firstname 33**] Unit No: [**Numeric Identifier 13945**] Admission Date: [**2137-1-2**] Discharge Date: [**2137-1-10**] Date of Birth: [**2091-8-18**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 599**] Addendum: During admission the patient was found to have significant cerebral edema which occured in the fornix resulting in the patients impaired short term memory and emotional issues secondary to his inability to rememebr certain things. This may have contributed to his delayed discharge Discharge Disposition: Home With Service Facility: [**Hospital1 328**], VNA [**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**] Completed by:[**2137-2-25**]

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icd9cm

[ [ [] ] ]

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14035

Discharge summary

report

Admission Date: [**2153-12-31**] Discharge Date: [**2154-1-22**] Date of Birth: [**2101-8-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5123**] Chief Complaint: Knee pain s/p fall Major Surgical or Invasive Procedure: None. History of Present Illness: 52 yo M with morbid obesity, OSA on Bi-PAP, HCV cirrhosis in viral remission, recent admission for H1N1 with superimposed PNA (tx with levaquin), presented with L tibial plateau fracture after a fall at work. While working as an EMT, he was climbing a set of stairs and stepped on a wet piece of sandpaper with his left foot. He slipped and fell backwards down the stairs, striking his left foot followed by his left knee. He heard a cracking sound and immediately had severe pain centered in his right knee. He presented to the [**Hospital1 18**] ED and was found have a Schatzker Type I/II tibial plateau fracture. He was admitted to the orthopedic surgery for planned ORIF. Past Medical History: -Hep C cirrhosis with sustained virologic response, 1 cord of grade 1 varices -Thyroid cancer, status post thyroidectomy -Silent myocardial infarction in [**2142**] (per OMR, patient denies) with normal cardiac cath [**9-/2145**] -Nephrolithiasis -OSA on BiPAP -H/o MVA with chest and abdominal trauma -Deviated septum repair -Inguinal hernia repair as infant - ?COPD Pulmonologist: Dr. [**First Name8 (NamePattern2) 4580**] [**Last Name (NamePattern1) 41892**], [**Location (un) 8545**], MA Social History: Quit smoking ~8/[**2153**]. History of [**2-9**]-1ppd since [**2130**]. Denies EtOH, has remote h/o drug use (cocaine), but no current use, no h/o IVDU. Works as an EMT. He can walk [**Age over 90 **] yds or climb one flight of stairs with groceries before getting SOB. As an EMT, he regularly lifts patients and stretchers. He also performs yard work, including stacking wood. He has no CP at rest or on exertion. Does have chronic ankle edema. Family History: Mother died of congestive heart failure at the age of 51 and maternal grandfather died of a myocardial infarction at age 42. Two brothers with hypertension and increased cholesterol. Physical Exam: VS: T 100.0 126/68 HR 81 RR 22, SpO2 90/RA Gen: Alert, NAD. Morbidly obese. HEENT: Sclerae anicteric. MMM, OP clear. Neck: Excessive soft tissue. No apparent JVD. No carotid bruit. CV: RRR, normal S1, S2. No m/r/g. Chest: Labored breathing intermittently, no accessory muscle use. Decreased BS throughout. No wheezes, rales or rhonchi Abd: Obese, NABS, Soft, NTND. Ext: Trace ankle edema. WWP. 2+ PT pulses. LLE in brace. Wiggles toes. Skin: Venous stasis changes to shin. Neuro: 5/5 strength in upper and distal lower extremities bilaterally, CNs II-XII grossly intact. Pertinent Results: Admission labs [**2153-12-31**]: WBC-7.8 RBC-5.84 Hgb-15.0 Hct-48.7 MCV-83 MCH-25.7* MCHC-30.9* RDW-14.3 Plt Ct-208 Neuts-72.1* Lymphs-21.9 Monos-4.3 Eos-1.3 Baso-0.3 PT-12.8 PTT-24.2 INR(PT)-1.1 GLUCOSE-126* UREA N-14 CREAT-0.9 SODIUM-138 POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-31 ANION GAP-14 . Blood gases: [**2154-1-1**] 05:09PM BLOOD pO2-45* pCO2-73* pH-7.27* calTCO2-35* Base XS-3 [**2154-1-1**] 06:49PM BLOOD Type-ART pO2-44* pCO2-71* pH-7.33* calTCO2-39* Base XS-7 [**2154-1-2**] 09:28AM BLOOD Type-[**Last Name (un) **] pO2-139* pCO2-60* pH-7.37 calTCO2-36* Base XS-7 . ECG [**2153-12-31**]: Sinus rhythm with atrial premature beats, rate 79. Otherwise, probably normal tracing but baseline artifact in the limb leads makes assessment difficult. Since the previous tracing of [**2149-6-20**] atrial ectopy is now present. Otherwise, there is probably no significant change. L Tib/fib x-ray [**2153-12-31**]: IMPRESSION: 1. Suboptimal lateral view of the knee due to multiple overlying external artifacts. 2. Comminuted, displaced proximal fibular fracture, which in part overlies the lateral proximal tibial metaphysis, making likely communited fracture in that region difficult to fully assess. Given proximal fibular fracture, dedicated views of the ankle should be obtained. 3. Possible subtle minimally displaced fracture of the lateral tibial spine. L ankle x-ray [**2153-12-31**]: FINDINGS: AP, oblique, and lateral views of the left ankle were obtained. There is no evidence of acute fracture or dislocation of the left ankle. The ankle mortise and talar domes are intact. Small posterior calcaneal enthesophyte is seen at the Achilles tendon insertion. There is also a small plantar calcaneal spur. Suggestion of lateral ankle soft tissue swelling is noted. IMPRESSION: No evidence of acute fracture or dislocation of the left ankle CT Lower extremity [**2153-12-31**]: 1. Comminuted, mildly displaced proximal fibular fracture. 2. Comminuted fracture of the lateral aspect of the tibial plateau. 3. No definite intra- articular fragment. CXR [**2154-1-2**]: FINDINGS: The lungs are fully expanded and clear with no mass, consolidation, pneumothorax or pleural effusion. Cardiomediastinal silhouette is normal. IMPRESSION: No acute cardiopulmonary findings, no change since [**2149-6-8**]. CT Angiogram - Chest [**2153-3-4**]: The study is limited by the patient's body touching the CT. Further the bolus timing is suboptimal with inadequate opacification of the pulmonary artery. Within this significant limitation there is no large central embolus. No axillary or mediastinal lymph nodes meet CT size criteria for pathologic enlargement. Prevascular nodes measures to 8 mm and a right paratracheal 7 mm. The pulmonary artery measures 3.7 cm, enlarged. There is no concave bowing of the interventricular septum into the left ventricle. The heart is mildly enlarged. There is no pericardial effusion. The esophagus appears normal. There is pronounced mediastinal lipomatosis. There is no pleural effusion, mass, consolidation or pneumothorax. Central airways are patent to the level of subsegmental bronchi. This study is not optimized to evaluate the liver. Within this limitation, the liver, spleen, the visualized right adrenal appears normal. There is no suspicious osteolytic or osteoblastic lesion. IMPRESSION: 1. No evidence of PE, but exam is technically limited and is not diagnostic quality for excluding PE. Consider nuclear medicine V/Q scan or repeat chest CTA study, if clinical suspicion is high. 2. Pulmonary artery diameter suggests possible pulmonary arterial hypertension. Left lower extremity ultrasound [**2154-1-1**]: FINDINGS: Grayscale and color Doppler son[**Name (NI) **] was performed on the left lower extremity. The calf veins are not visualized. The left common femoral, superficial femoral, and popliteal veins are normal in compressibility, augmentation and Doppler waveform. There is no evidence of deep vein thrombosis. IMPRESSION: Calf veins not visualized, and thrombus in these veins cannot be completely excluded. No left lower extremity DVT otherwise visualized. Left Lower Extremity Ultrasound [**2154-1-5**]: Grayscale, color, and Doppler ultrasound was used to evaluate the left common femoral, superficial femoral, popliteal and calf veins. The right common femoral vein was also evaluated. There is suboptimal evaluation of the distal left common femoral vein, although flow is present. There is normal compressibility, flow and augmentation in the remaining venous structures. In the calf, both the posterior tibial and peroneal veins are visualized, and demonstrate normal compressibility. IMPRESSION: No definite left lower extremity DVT. However, due to suboptimal visualization of the distal left SFV, nonocclusive thrombus cannot be definitively excluded. Brief Hospital Course: #. Tibial plateau fracture. Orthopedic surgery was consulted and initially recommended open reduction with internal fixation. After further imaging, it was decided that the patient should be managed non operatively. A brace was placed on the left leg and he was made non weight bearing. Physical therapy was consulted and recommended discharge to a rehab facility. He needs constant encouragement to wear his brace. . #. Lower extremity edema. On arrival to the floor, patient complained of calf pain, and his left calf was noted to be markedly edematous. Lower extremity Doppler ultrasound was performed and did not demonstrate evidence of deep vein thrombosis. He was given lovenox 40 units subcutaneously for DVT prophylaxis and restarted on his home dose of furosemide 40mg PO BID. His leg pain worsened, and his leg was noted to have tense edema and spreading erythema. Pain was initially controlled with IV morphine, and later with oxycodone, and subsequently MS contin, Ibuprofen, and tylenol. A repeat LENI on [**2154-1-5**] was negative for DVT. He was started on vancomycin 1g IV q 12 on [**2154-1-6**] for possible cellulitis. This had to be increased to 1500mg TID [**3-12**] his body habitus and he is currently therapeutic on this. He needs to have his renal function and vancomycin levels checked on Monday. . #. CO2 narcosis. On [**2154-1-1**] and [**2154-1-8**], patient was noted to be somnolent and hypoxic with an oxygen saturation in the low 60s. He also complained of calf and chest pain. An arterial blood gas was found to be 7.25/74/45 and 7.25/90/50 respectively. A CT angiogram was performed which demonstrated no pulmonary embolism. After the study, his mental status returned to baseline. He was placed back on his home Bi-PAP and his overnight opiates were controlled and had no further episodes of altered mental status or hypoxia. This episode was likely CO2 narcosis secondary to obstructive sleep apnea and narcotics with low reserve. He had no further epsiodes of altered mental status or hypoxia. . #. Alkalemic intolerance: On [**1-14**] Dr. [**First Name (STitle) **] and I were called to the bedside because of somnolence and hypoxia. He was found to have oxygen saturations in the high 70's, which came up to the 90's with standing/stimulation. An ABG was checked which showed alkalemia and relatively low [**Name (NI) 41893**] s for him. It was determined that he has a combined central/obstructive sleep apnea and that his drive to breath in his central phase was determined by his acidemia. He was transferred to the unit where he was given acetazolamide x 2 and has thrived. His HCO3 returned to 32 and he was discharged off Lasix. This should be re-evaluated by his PCP. . #. Fever. On [**2154-1-2**], patient had persistent low grade fevers. He has no cough, diarrhea, dysuria or other localizing symptoms. A urinalysis was normal. Final read of chest CTA did not demonstrate any evidence of pulmonary infection, or clot as did LENI's. He defervesced with therapeutic vanc. It was thought that this was likely due to smoldering cellulitis. Medications on Admission: Furosemide 40 mg [**Hospital1 **] Levothyroxine 274 mcg daily Paroxetine 20 mg daily Zolpidem 5 mg HS PRN Pantoprazole 40 mg daily APAP prn MVI 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. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 137 mcg Tablet Sig: Two (2) Tablet PO once a day. 4. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 7. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours): Continue until instructed to stop by your orthopedic surgeon. 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY PRN () as needed for leg pain. Adhesive Patch, Medicated(s) 9. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for Pain: take with food. 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: do not excede 2500mg per day. Tablet(s) 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed for pain. 14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for leg discomfort. Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: Primary: Tibial plateau fracture Secondary: Obstructive Sleep Apnea Hepatitis C Cirrhosis Discharge Condition: Hemodynamically stable and non-weightbearing on left leg. Discharge Instructions: You were admitted after a fall. Orthopedic surgery was consulted and did not feel that surgery was necessary. You pain was controlled with oxycodone. You had an episode of confusion that resolved with supplemental oxygen and Bi-PAP. You were seen by physical therapy who recommended continued physical therapy at rehab. Please note the following changes in your medications: Please START MS Contin 30mg in the morning, 15mg before bed You may also take 1mg of tylenol before bed for pain You may also take 800mg of ibuprofen every 8 hours as needed for pain Please continue taking your other medications as you were before. Please review all changes in your medications with your primary care doctor. If you experience shortness of breath, chest pain, or presistent fever greater than 101 please return to the Emergency Room. You need to have your vancomycin level and renal function labs checked on monday [**1-14**] Followup Instructions: You have follow-up with your primary care physician: [**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) 569**] A. Location: [**Location **] FAMILY PRACTICE Address: [**Location (un) 41894**], [**Location **],[**Numeric Identifier 41895**] Phone: [**0-0-**] Fax: [**Telephone/Fax (1) 41896**] Date/Time:[**2154-1-9**] 11:45AM You have follow-up for your liver disease: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2154-1-25**] 11:00AM Please follow-up with orthopedic surgery. They will perform another set of x-rays at this visit: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2154-1-17**] 11:40 Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 4974**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2154-1-17**] 12:00 Completed by:[**2154-4-11**]

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icd9cm

[ [ [] ] ]

[ "38.93", "93.54" ]

icd9pcs

[ [ [] ] ]

12572, 12613

7706, 10825

335, 343

12747, 12807

2842, 7683

13783, 14749

2050, 2234

11019, 12549

12634, 12726

10851, 10996

12831, 13760

2249, 2823

277, 297

371, 1055

1077, 1571

1587, 2034

72,284

179,787

40135

Discharge summary

report

Admission Date: [**2131-12-11**] Discharge Date: [**2131-12-24**] Date of Birth: [**2047-12-14**] Sex: M Service: CARDIOTHORACIC Allergies: Aldactone Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2131-12-12**] - Mitral valve repair 28 mm [**Doctor Last Name 405**] annuloplasty band History of Present Illness: 83 year old male with increasing dyspnea on exertion with associated abdominal discomfort, lower extremity edema and weight gain. He denies any chest pain. He is found to have moderate to severe mitral regurgitation and coronary artery disease of diagonal vessels. He presents for heparin bridge and surgery. Past Medical History: Coronary artery disease s/p stent LAD [**2128**] Hypertension Hyperlipidemia Spinal Stenosis (ileus s/p surgery for spinal stenosis) Symptomatic bradycardia and Atrial flutter with variable AV block-resolved w/PPM implantation 1/[**2129**]. Procedure complicated by PPM infection w/explant [**3-/2129**] Congestive heart failure Factor V Leiden deficiency Prior left atrial thrombus by TEE [**5-/2129**]-on Coumadin since then s/p PPM [**2-/2130**] c/b retraction of atrial lead. retraction of atrial and ventricular leads w/reinsertion of new leads [**3-/2130**] Bilateral carpal tunnel release Social History: Lives with: wife Occupation: retired minister Tobacco: none ETOH: none Family History: mother had angina, died @ 79 with bleeding ulcer, sister had CABG in her 70s, father died @ 91 old age. Physical Exam: Pulse: 64 Resp: 16 O2 sat: B/P Right: Left: 92/62 Height: 67" Weight: 162 lbs General: NAD, WGWN, appears slightly younger than stated age Skin: Dry [x] intact [x] numerous seborrheic keratoses chest/back well-healed scar of right mini-thoracotomy HEENT: PERRLA [x] EOMI [x] arcus senilis Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur- no murmur appreciated Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [], well-perfused [] venous stasis changes Edema: right- 2+, left- 1+ Varicosities: bilateral R>L, spider veins bilaterally Neuro: Grossly intact Pulses: Femoral Right: 1+ Left: 1+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: Left: NP -edema Radial Right: 2+ Left: 1+ Carotid Bruit no carotid bruit Pertinent Results: Carotid duplex ultrasound: [**2131-12-11**] Right ICA no stenosis. Left ICA no stenosis. [**2131-12-12**] ECHO No spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the left atrial appendage. Moderate to severe spontaneous echo contrast is seen in the body of the right atrium. There is moderate symmetric left ventricular hypertrophy. There is severe global left ventricular hypokinesis (LVEF = 30 %). The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. There are three aortic valve leaflets. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. There is bileaflet restriction with a central MR jet.The left borders of the left atrium are not well visulalized to be measured Post bypass The patient in now s/p Mitral annulopasty with a 28 ring The patient is on a Milrinone drip at 0.5 mcg/kg/min,Nor epi @.05 mcg/kg/min, Epi at 0.1 mcg/kg/min. The cardiac index is 1.9 There is mild residual mitral regurgitation The aorta is similar to prebypass The mean gradient across the mitral valve is 4 mm hg EF on inotropy is 40-45%,with slight improvement in RV function. [**2131-12-11**] Vein Mapping Duplex and color Doppler demonstrate wide patency of the greater saphenous veins bilaterally. Please see digitized images on PACS for formal sequential measurements. Of note is a somewhat varicoid appearance to the right greater saphenous vein containing many large side branches. [**2131-12-24**] 06:50AM BLOOD Hct-33.9* [**2131-12-23**] 06:50AM BLOOD WBC-8.2 RBC-3.97* Hgb-11.9* Hct-35.3* MCV-89 MCH-30.0 MCHC-33.8 RDW-15.8* Plt Ct-259 [**2131-12-11**] 01:10PM BLOOD WBC-8.3 RBC-4.48* Hgb-12.7* Hct-36.9* MCV-82 MCH-28.4 MCHC-34.5 RDW-14.4 Plt Ct-209 [**2131-12-12**] 01:00PM BLOOD WBC-17.4*# RBC-2.76*# Hgb-7.7*# Hct-23.1*# MCV-84 MCH-28.0 MCHC-33.4 RDW-14.4 Plt Ct-150 [**2131-12-24**] 06:50AM BLOOD PT-22.4* PTT-29.2 INR(PT)-2.1* [**2131-12-23**] 06:50AM BLOOD Plt Ct-259 [**2131-12-23**] 06:50AM BLOOD PT-20.5* PTT-28.2 INR(PT)-1.9* [**2131-12-11**] 01:10PM BLOOD Plt Ct-209 [**2131-12-11**] 01:10PM BLOOD PT-13.8* PTT-25.0 INR(PT)-1.2* [**2131-12-24**] 06:50AM BLOOD Glucose-97 UreaN-29* Creat-1.2 Na-136 K-4.3 Cl-96 HCO3-31 AnGap-13 [**2131-12-19**] 12:57PM BLOOD UreaN-34* Creat-1.3* Na-132* K-3.3 Cl-94* [**2131-12-18**] 04:09PM BLOOD UreaN-33* Creat-1.4* Na-134 K-3.1* Cl-96 [**2131-12-11**] 01:10PM BLOOD Glucose-90 UreaN-30* Creat-1.3* Na-139 K-3.8 Cl-97 HCO3-35* AnGap-11 [**2131-12-17**] 03:44AM BLOOD TotBili-1.5 [**2131-12-14**] 03:15AM BLOOD ALT-23 AST-66* LD(LDH)-428* AlkPhos-59 TotBili-2.5* [**2131-12-24**] 06:50AM BLOOD Mg-2.1 [**2131-12-23**] 06:50AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.1 [**2131-12-11**] 01:10PM BLOOD %HbA1c-6.2* eAG-131* Brief Hospital Course: Mr. [**Known lastname 22364**] was admitted to the [**Hospital1 18**] on [**2131-12-11**] for surgical management of his mitral valve disease. As he had been off his coumadin for five days, heparin was started as a bridge to surgery. He was worked-up in the usual preoperative manner. Vein mapping revealed varicosed veins bilaterally right more so then left. A carotid duplex ultrasound showed no significant carotid artery disease. The eectrophysiology service interogated his pacemaker and made the appropriate changes in anticipation of surgery. On [**2131-12-12**], [**Known lastname 22364**] was taken to the operating room where he underwent a mitral valve repair using a 28mm annuloplasty band. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. He remained intubated given his need for pressors and his hemodynamic instability. His pacer was again interoggated and switched back to a DDD at 80. On postoperative day two, he awoke neurologically intact and was extubated. He was slowly weaned off pressors and inotropes, were completing off on post operative day seven. He had been started on low dose ace inhibitor prior to milirone being stopped and placed on carvedilol. He continued to do well and physical therapy worked with him on strength and mobility. He was ready for discharge to rehab ([**Hospital1 10478**] hills)on post operative day twelve. Medications on Admission: Sotalol 40", Bumex 4', MVI, ASA 162', Warfarin 2.5mg Wed/Fri, 5mg otherwise, simvastatin 40', lisinopril 2.5', fish oil, Omeprazole 20' Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours: ATC for 5 days then change to prn pain . 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 9. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation Q6H (every 6 hours) as needed for wheezing. 11. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. white petrolatum-mineral oil Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for lower extremities . 15. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 16. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) gram PO DAILY (Daily). 17. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day for 1 doses: please give 3 mg on [**12-25**] - then check INR mon and wed and fri for 3 weeks and adjust dose based on INR with GOAL INR 2.0-2.5 for atrial fibrillation . (doses 11/29 3mg INR 2.1, [**12-23**] 3mg INR 1.9, [**12-22**] 5mg INR 1.7, [**Date range (1) **] 2.5 mg) Discharge Disposition: Extended Care Facility: [**Hospital1 13316**]Healthcare Center - [**Hospital1 10478**] Discharge Diagnosis: Mitral valve regurgitation s/p MV repair Acute systolic heart failure Coronary artery disease s/p stent LAD [**2128**] Hypertension Hyperlipidemia Spinal Stenosis (ileus s/p surgery for spinal stenosis) Symptomatic bradycardia and Atrial flutter with variable AV block-resolved w/PPM implantation 1/[**2129**]. Procedure complicated by PPM infection w/explant [**3-/2129**] Congestive heart failure Factor V Leiden deficiency Prior left atrial thrombus by TEE [**5-/2129**]-on Coumadin since then Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait with 1 assist Incisional pain managed with tylenol ATC Incisions: Sternal - healing well, no erythema or drainage Edema right +2 left +1 with venous stasis- Right greater than left leg as baseline 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**] Coumadin - please do INR monday, wednesday, and friday for 3 weeks - with goal INR 2.0-2.5 for atrial fibrillation - please adjust dose based on INR **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) **] at [**Hospital1 **] heart center [**Telephone/Fax (2) 6256**] - thrusday [**2132-1-3**] at 9:30 am Cardiologist: Dr [**Last Name (STitle) 20222**] [**Telephone/Fax (1) 6256**] - maralboro office Tuesday [**1-8**] 11:00 Please call to schedule appointments with your Primary Care Dr [**Last Name (STitle) **] in [**4-30**] weeks [**Telephone/Fax (1) 24513**] **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 [**2131-12-26**] Rehab to follow coumadin dosing - INR monday-wednesday-friday then please refer to coumadin clinic [**Hospital1 **] heart center when discharged from rehab ([**Telephone/Fax (1) 6256**]) Completed by:[**2131-12-24**]

[ "V45.82", "V58.61", "424.0", "427.31", "428.21", "414.01", "428.0", "401.9", "289.81", "272.4" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.12" ]

icd9pcs

[ [ [] ] ]

9090, 9179

5592, 7019

300, 392

9720, 9978

2458, 5569

10968, 11907

1458, 1564

7205, 9067

9200, 9699

7045, 7182

10002, 10945

1579, 2439

240, 262

420, 733

755, 1353

1369, 1442

57,775

139,141

21390

Discharge summary

report

Admission Date: [**2125-5-17**] Discharge Date: [**2125-5-24**] Date of Birth: [**2075-7-16**] Sex: M Service: MEDICINE Allergies: Hydrochlorothiazide Attending:[**First Name3 (LF) 4365**] Chief Complaint: altered mental status, electrolyte derangements Major Surgical or Invasive Procedure: None History of Present Illness: This is a 49 year old male with a past history of HTN, bipolar disorder who is transferred to [**Hospital1 18**] from [**Hospital **] hospital for management of multiple electrolyte derangements. He initially called EMS yesterday when he felt confused, and was found to have diffuse ecchymoses and petechiae and to be acutely disoriented. At [**Hospital **] hospital, he was found to be in acute renal failure, profoundly hyponatremic to 108, hyperkalemic, thrombocytopenic, and anemic. He was also noted to have a tiny R apical PTX on CXR which was incidental. He also received a CT head and C spine which confirmed a small apical ptx but was otherwise unremarkable. He was transferred to [**Hospital1 18**] for management of possible TTP. In the [**Hospital1 18**] ED, his initial labs were notable for a normal platelet count, sodium 110, K 4.7, BUN/Cr 72/6.2, elevated LFT's, and an MB fraction greater than 400 (initial CK 7 at [**Hospital1 **], currently pending, but initial value is critically high per stat lab). He was oriented to person/place but doesn't understand what's going on. That being said, he has been calm, with a sitter throughout his ED stay. He has been hemodynamically stable, 75 151/65 100% room air and making good urine (225cc/hr). Getting NS @ 75cc/hr. Renal and heme aware. EKG showed a prolonged QTc without STTWC. Surgery was consulted for the PTX, and recommended monitoring for the ptx. He is transferred to the ICU for multiple electrolyte derangements and altered mental status. . On the floor, he was oriented to p/p/d, however was intermittently not making sense, with hallucinations. He denies recent trauma, falls, ingestions, or medication misuse. He denies any pain, nausea/vomiting/diarrhea, chest pain, palpitations, headache or disordered thinking. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Bipolar Disorder HTN s/p laminectomy Social History: lives alone, parents are HCP's. Denies alcohol or other ingestions. In sales. Family History: unknown at this time Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, but affect strange, ?confusion. no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear. Large abrasion over nose and smaller bruises over forehead with evidence of excoriation. Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, with scattered rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, +rub Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema however diffuse scattered ecchymoses and excoriated abrasions over upper and lower extremities, left chest and right back. No evidence of compartment syndrome. Pertinent Results: [**2125-5-17**] 05:04AM GLUCOSE-66* UREA N-72* CREAT-6.2* SODIUM-110* POTASSIUM-4.7 CHLORIDE-74* TOTAL CO2-19* ANION GAP-22* ALT(SGPT)-584* AST(SGOT)-3568* LD(LDH)-3498* CK(CPK)-[**Numeric Identifier 56496**]* TOT BILI-1.6* DIR BILI-0.7* INDIR BIL-0.9 WBC-12.5* RBC-3.24* HGB-10.8* HCT-29.3* MCV-90 MCH-33.2* MCHC-36.8* RDW-12.6 NEUTS-86.4* LYMPHS-7.6* MONOS-5.7 EOS-0.1 BASOS-0.1 PLT COUNT-175 PT-11.6 PTT-27.2 INR(PT)-1.0 LIPASE-43 CK-MB-484* MB INDX-0.2 cTropnT-0.05* CALCIUM-7.6* HAPTOGLOB-<20* OSMOLAL-259* ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG URINE HOURS-RANDOM UREA N-463 CREAT-64 SODIUM-39 URINE OSMOLAL-364 URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 URINE SPERM-MOD [**2125-5-17**] 08:20AM CALCIUM-7.5* PHOSPHATE-6.7* MAGNESIUM-3.0* [**2125-5-17**] 11:43AM freeCa-0.97* TYPE-[**Last Name (un) **] PH-7.38 CARBAMZPN-<1.0* LITHIUM-LESS THAN 0.2 VALPROATE-<3.0* LACTATE-4.2* Upon Discharge ([**2125-5-24**]) Na 144 K 3.7 Cl 105 HCO3 27 BUN 26 Cr 1.6 Glc 83 ALT 131 AST 114 CPK 2111 WBC 9.7 Hgb 8.9 Hct 26.8 MCV 99 Plt 421 IMAGING ([**2125-5-17**]) Chest XRay: IMPRESSION: Small right apical pneumothorax. No evidence of infiltrate or effusion. ([**2125-5-17**]) Knee XRay: IMPRESSION: No acute fracture. ([**2125-5-21**]) Shoulder XRay: FINDINGS: No acute fractures or dislocations are seen. There is normal osseous mineralization. The visualized left lung apex is clear. ([**2125-5-24**]) Chest XRay: IMPRESSION: Tiny residual pneumothorax of [**5-20**] not visible anymore. Seventh rib fracture in unchanged position. ([**2125-5-24**]) Shoulder MRI: IMPRESSION: 1. No abnormality of the rotator cuff tendons. 2. Pronounced edema in the imaged the supraspinatus, infraspinatus, and teres minor, and deltoid muscles for which the differential is broad including includes myositis from trauma or connective tissue disorder, drugs including statins, and neuropathy involving both the axillary and suprascapular nerves. However, given the clinical history these findings can be seen in the setting of muscle injury related to rhabdomyolysis. Brief Hospital Course: This is a 49 yo M with a history of bipolar disorder on multiple psychiatric medications who presented with confusion, profound hyponatremia, renal failure and rhabdomyolysis. # Altered Mental Status - On admission, the patient had many reasons to be altered, including hyponatremia, uremia, drug or toxin ingestion. Initially, he tremulous and diaphoretic and he required large amounts of valium to control his agitation, without great effect. Per psychiatry recommendations, the patient's was changed to ativan PRN for agitation. However, ativan did not help much with the patient's agitation or hallucinations. With closer nursing monitoring and frequent redirection he became less agitated and required less benzos. Also, the patient's psychiatrist ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) was reached, who could not provide much information other than that he often sometimes showed up to appointments with alcohol on his breath. Over the course of several days, the patient's agitation and hallucinations improved. Psych recommended haldol for agitation instead of ativan while following QTc given borderline prolongation at baseline. Since the night of [**5-19**], the patient has been off of restraints. At the time of discharge, the patient was fully oriented and denied any hallucinations. Physical therapy was also consulted # Acute Renal Failure - It was felt that the patient's acute renal failure was likely ATN secondary to rhabdomyolysis, as he presented with a critically high CK and evidence of myoglobinuria. The underlying etiology of his rhabdomyolysis was unclear, and the differential included alcohol, drugs and toxins infections (including HIV), electrolyte abnormalities (unclear what was the precipitant), endocrinopathies and inflammatory myopathy. NMS was also on the differential, but patient's tone and temperature were normal. The patient had no obvious signs of infection. His increased osm gap raised suspicion for ingestion, but initial basic tox screens were only positive for benzos. His diffuse ecchymoses were throught to be an indication for injury, and recent fall 4 days prior to admission was confirmed with patient's mother. [**Name (NI) **] was started on various IV fluid regimens. Ultimately, he was put on 200 cc NS per hour to raise his sodium, which was changed to 150 cc 1/2 NS per hour if his sodium level began increasing rapidly. After several days of IVF hydration, the patient's CPK levels were trending down and his BUN and creatinine were improving. At time of discharge, the patient was tolerating PO fluids and Creatinine was 1.6. # Hyponatremia - The etiology of the patient's hyponatremia was unclear. Possible precipitants included the patient's HCTZ, misure/overdose of psychiatric medications, and psychogenic polydipsia. Renal felt that it was most likely the latter and that he likely dropped his sodium quickly. He was started on various IV fluid regimens in an attempt to correct his sodium. Ultimately, he was put on 200 cc NS per hour to raise his sodium, which was changed to 150 cc 1/2 NS per hour if his sodium level began increasing rapidly. While on this IVF therapy, the patients sodium levels rose slowly. On [**5-18**], his sodium level did drop slightly, and he was given a dose of 40 mg lasix IV. By [**5-20**], his sodium level had begun to normalize, the patient was taking PO fluids, and on the day of discharge, sodium was 144. . # Bipolar D/o - The patient was on several different psych meds at home, including ambien, cymbalta, lamictal, clonazepam, and geodon. Considering his altered mental status and his profound hyponatremia, all of these psych meds were held on admission. Levels of several psych meds, including lithium, carbamazepine, and valproic acid, were drawn but they were within normal limits. Once the patient's mental status and hyponatremia had improved, psych was consulted for their recommendations for restarting his psych meds. The primary team spoke with inpatient psychiatry as well as the patient's outpatient psych team (Dr. [**Last Name (STitle) **], who agreed that reintroduction of psychiatric meds should occur gradually. At the time of discharge, lamictal, ambien, and cymbalta were being held. Clonazepam 1mg TID still being administered, though goal is to taper the patient off completely. Geodon 20mg Qdaily was restarted while monitoring with EKG for QTc prolongation. The patient did not wish to be admitted to inpatient rehabilitation services, though the psychiatry team felt it necessary as he was deemed unable to care for self. The patient therefore fell under the guidelines for Section 12 and was discharged to rehabilitation. # Pneumothorax - The patient's initial CXR showed a right sided apical pneumothorax. Surgery was consulted and recommended to follow-up with a repeat CXR. The patient had several repeat CXR's which showed improvement and eventually resolution of the pneumothorax. The patient did still complain of rib pain, and incentive spirometry was used as inpatient. . # HTN - At home, the patient took atenolol and HCTZ for his HTN. However, on admission, his atenolol was held due to a low heart rate and his HCTZ was held due to his profound hyponatremia. While in the MICU, hydralazine was used to keep his SBP less than 160. Also, considering the extreme hyponatremia he presented with, it was felt that he should never be restarted on HCTZ, and it was added to his list of allergies. While on the floors, SBP ranged between 140 and 160 when the patient was on metoprolol 25mg PO BID. This dose was uptitrated on the day of discharge to 37.5mg PO BID. The patient should follow up with his PCP for better BP control. . # Other Electrolyte Abnormalities - The patient also required repletion of his potassium, calcium, and magnesium. Care was taken in repleting his electrolytes to not overshoot and make them too high. The patient was consistenly receiving potassium repletion daily and was discharged on 20meq PO of potassium daily. #Physical Activity- Patient was cleared by physical therapists for ADL's. #Poor nutritional intake- Patient had poor oral intake and ensure was added to diet order. It was thought that psychiatric factors played into poor oral intake. Medications on Admission: per pharmacy ([**Last Name (un) 50239**] in [**Location (un) 13011**] - [**Telephone/Fax (1) 56497**]) Cymbalta 40mg po bid Ambien 10mg po qhs lamotrigine 200mg po bid Geodon 20mg po qAM 40mg po qPM Atenolol 50mg daily HCTZ 12.5 mg po daily Klonopin 1mg po qid fluocinonide cream Discharge Medications: Geodon 20mg PO Qdaily Metoprolol 37.5mg PO BID Clonazepam 1mg PO TID Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnoses 1. Acute Renal Failure 2. Altered Mental Status 3. Electrolyte Disturbance with Profound hyponatremia 4. Pneumothorax 5. Rhabdomyolysis Secondary Diagnoses 1. Bipolar Disorder 2. Hypertension 3. Poor nutritional intake Discharge Condition: Vital signs stable, medically clear. Deemed unable to care for self from psychiatric standpoint. Discharge Instructions: You were admitted to the hospital because you were confused and had kidney failure. The reason for your confusion was not entirely clear, but many of your blood tests were abnormal. You were in the intensive care unit for three days until you were transferred to the general medical floors. You received medications to keep you calm until you were thinking clearly. You are currently still taking clonazepam 1mg three times a day. You had kidney failure, which was probably the result of muscle breakdown from pressure on some part of your body for a long period of time. We thought that some injury you might have sustained caused this in light of the bruises on your body when you were admitted. Because of your kidney failure, some of your bloodwork was abnormal. We gave you fluids through an IV and your kidney function improved. You will need to take potassium supplements everyday after you leave the hospital because your potassium levels are still low. When you were admitted, your psychiatric medications were stopped, except for the clonazepam. We are beginning to restart your psychiatric medications gradually after talking to your hospital psychiatric team and with Dr. [**Last Name (STitle) **]. You are leaving on a reduced dose of Geodon at 20mg a day. Your other psychiatric medications will gradually be added back. You are being sent to an inpatient rehabilitation center because your psychiatrists have deemed you unable to care for yourself upon discharge. When you were admitted, you also had a pocket of air between your lung and chest wall called a pneumothorax. This was probably because of an injury you sustained. Before you were discharged, we did an XRay of your chest that showed that this had resolved. You were also admitted with a fracture of one of your ribs on the right side and with swelling of your left shoulder (due to muscle breakdown). These injuries should heal on their own and you should take tylenol as needed every six hours. Do not take more than 4 grams of tylenol in 24 hours. Your blood pressure was also high while you were in the hospital. Your atenolol and hydrochlorothiazide medications were stopped because of your abnormal blood tests and your kidney failure. You were started on metoprolol 37.5 mg twice a day for your blood pressure. Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1968**], for blood pressure control. Please return to the hospital or call Dr. [**Last Name (STitle) 1968**] at [**Telephone/Fax (1) 56498**] if you are feeling confused or have any symptoms that are concerning to you. IMMEDIATELY return to the emergency room or call Dr. [**Last Name (STitle) 1968**], Dr. [**Last Name (STitle) **], or Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 56499**]) if you feel that you want to hurt yourself or somebody else. Followup Instructions: 1. Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**], [**Telephone/Fax (1) 56498**] in [**11-24**] weeks after discharge from the extended care facility. 2. Please follow up with your psychiatrist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (([**Telephone/Fax (1) 56500**]) 3. Please follow up with your psychologist, Dr. [**Last Name (STitle) **] upon discharge from the extended care facility ([**Telephone/Fax (1) 56499**])

[ "276.1", "584.9", "728.88", "401.9", "512.8", "296.80", "285.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12630, 12645

5927, 12206

328, 334

12926, 13025

3540, 5904

15952, 16513

2730, 2752

12536, 12607

12666, 12905

12232, 12513

13049, 15929

2767, 3521

2178, 2558

241, 290

362, 2159

2580, 2619

2635, 2714

5,882

185,301

15799

Discharge summary

report

Admission Date: [**2142-2-8**] Discharge Date: [**2142-3-16**] Date of Birth: [**2082-11-29**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: Mr. [**Known lastname **] is a 59 y.o. man with a hx of End-stage liver disease due to Hepatitis C. He is status post orthotopic liver transplantation on [**2141-9-1**], which has been complicated by acute cellular rejection, treated by converting to Tacrolimus on [**2141-11-8**]. Pt was admitted on [**2142-2-8**] for with acute chronic renal failure, hypoglycemia, decreased MS, lethargy, hypotension, hypothermic, metabolic acidosis, and profound dehydration secondary to severe volume depletion secondary to C. diff. Major Surgical or Invasive Procedure: None post pyloric feeding tube cholangiogram History of Present Illness: 59 y.o. man with a hx of End-stage liver disease due to Hepatitis C. He is status post orthotopic liver transplantation on [**2141-9-1**], which has been complicated by acute cellular rejection, treated by converting to Tacrolimus on [**2141-11-8**].Pt was admitted on [**2142-2-8**] for with acute on chronic renal failure, hypoglycemia, decreased MS, lethargy, hypotension, hypothermic, metabolic acidosis, and profound dehydration secondary to severe volume depletion secondary to C. diff. patient was admitted to SICU for the first 2 weeks intubated for airway protection, and recive iv hydration, nutrition supplementation tru post piloric tube feeding. Past Medical History: End-stage liver disease secondary to Hepatitis C. ERCP and stent of anastomotic stricture [**2141-11-16**] orthotopic liver transplantation [**2141-9-1**] complicated by acute cellular rejection [**2141-11-8**] treated by converting to Tacrolimus. Liver biopsy [**2142-3-1**]-cholestatic liver disease, mild recurrent Hepatitis C Hypertension. History of exploratory laparotomy at the age of 20. IDDM Social History: retired truck driver.Has girlfriend that he is somewhat estranged. She refuses to help care for him at home. history of tobacco Pertinent Results: COMPLETE BLOOD COUNT (BLOOD) DATE WBC 4.0-11.0 K/uL RBC 4.6-6.2 m/uL Hgb 14.0-18.0 g/dL Hct 40-52 % MCV 82-98 fL MCH 27-32 pg MCHC 31-35 % RDW 10.5-15.5 % [**2142-3-12**] 6:07A 5.9 3.67* 10.2* 32.8* 89 27.7 31.1 15.8* [**2142-3-11**] 11:10A 6.8 3.70* 10.4* 32.9* 89 28.1 31.6 15.8* BASIC COAGULATION (PT, PTT, PLT, INR) (BLOOD) DATE PT 11.6-13.6 sec PT [**Name (NI) **] sec PTT 22.0-35.0 sec PTT Mea sec Plt Smr Plt Ct 150-440 K/uL BLEED T 2-8 MINUTES FIBRINO 200-400 MG/DL FSP 0-10 UG/ML INR(PT) MPV 7.2-9.4 fL LPlt PltClmp [**2142-3-12**] 6:07A 225 [**2142-3-12**] 6:07A 12.0 22.8 0.9 [**2142-3-11**] 11:10A 241 RENAL & GLUCOSE (BLOOD) DATE Glucose 70-105 mg/dL UreaN 6-20 mg/dL Creat .5-1.2 mg/dL Na 133-145 mEq/L K 3.3-5.1 mEq/L Cl 96-108 mEq/L HCO3 22-29 mEq/L AnGap [**8-4**] mEq/L [**2142-3-12**] 6:07A 108* 42* 1.5* 133 5.6* 106 18* 15 [**2142-3-11**] 6:22A 128* 42* 1.4* 133 5.9* 105 17* 17 ENZYMES & BILIRUBIN (BLOOD) DATE ALT 0-40 IU/L AST 0-40 IU/L LD(LDH) 94-250 IU/L CK(CPK) 38-174 IU/L AlkPhos 39-117 IU/L Amylase 0-100 IU/L TotBili 0-1.5 mg/dL DirBili 0-.3 mg/dL IndBili mg/dL [**2142-3-12**] 6:07A 200* 129* 1770* 5.2* [**2142-3-11**] 6:22A 201* 134* 1798* 87 5.4* OTHER ENZYMES & BILIRUBINS (BLOOD) DATE HLAP 21-85 IU/L HSAP 6-48 IU/L Lipase 0-60 IU/L LAP 27-59 IU/L GGT [**7-/2098**] IU/L AcdPhos 0-5.4 IU/L ProsFx 0-1.2 IU/L NonPros 0-5.4 IU/L 5'ND [**1-25**] U/L Uncon B MG/DL Delta/D MG/DL Conj [**Hospital1 **] NBil 0-1.5 mg/dL Dlta [**Hospital1 **] MG/DL N-DBil mg/dL N-IBil mg/dL [**2142-3-11**] 6:22A 74* CHEMISTRY (BLOOD) DATE TotProt 6.4-8.3 g/dL Albumin 3.4-4.8 g/dL Globuln [**1-19**] g/dL Calcium 8.4-10.2 mg/dL Phos 2.7-4.5 mg/dL Mg 1.6-2.6 mg/dL UricAcd 3.4-7.0 mg/dL Iron 45-160 ug/dL Cholest 0-199 mg/dL Brief Hospital Course: Mr. [**Known lastname **] is a 59 y. o. man with a HX of End-stage liver disease due to Hepatitis C. He is status post orthotopic liver transplantation on [**2141-9-1**], which has been complicated by acute cellular rejection, treated by converting to Tacrolimus on [**2141-11-8**]. Pt was admitted on [**2142-2-8**] for with acute on chronic renal failure, hypoglycemia, decreased MS, lethargy, hypotension, hypothermic, metabolic acidosis, and profound dehydration secondary to severe volume depletion secondary to C. Diff. Patient at admission received in the ICU intubated for airway protection receiving tube feeding and IVF hydration. Tube cholangiogram on [**2142-2-14**]:Tube cholangiography demonstrated the indwelling bilateral 8 French biliary drainage catheters to be in adequate position. There was no evidence of intrahepatic ductal dilatation with free and rapid passage of contrast into the bowel lumen. Overall, these findings remain unchanged compared to the previous study dated [**2142-1-19**] .Incidental note of blood stained bile with intraluminal clots in the common duct, the cause for which is uncertain. Hepatic enzymes continued to increase with t.bili up to 10.6, ast 60, alt 60, alk phos 1615. A cholangiogram revealed no biliary leak/change. A liver biopsy was performed on [**2142-3-1**]. This demonstrated mild recurrent Hep C and a question of mild acute cellular rejection with 2 out of 10 portal tracts involved. He continued on cellcept 500mg [**Hospital1 **], prednisone 5mg qd and rapamune 5mg qd with rapamune levels in the 5.8 range. On [**2142-3-9**] rapamune level increased to 16.2. The rapamune does was reduced to 4mg po qd. Rapamune levels have been stable with the last level of 10.7 on [**2142-3-15**]. Hepatic enzymes trended down then increased. On day of discharge ast was 121, slt 178, alk phos 1540 and t.bili 4.2. During this stay, after discussing prognosis a decision was reached to re-list for another liver transplant. On the prior hospitalization he had been c.diff positive and was treated for fourteen days. Subsequent stools have been negative x3 for c.difficile. Due to persistent inability to eat, a post pyloric feeding tube was place and tube feedings were initiated and eventually cycled. The tube feeding needed to be stopped over the past day and a half for elevated potassium level of 7.2. This was treated wiht IV insulin, dextrose, bicarb and calcium gluconate, and kayexalate. Potassium dropped to 4.9. On [**2142-3-16**] his potassium level is 5.0. He was started on Marinol 2.5mg [**Hospital1 **] on [**2142-3-15**] to try and increase his appetite. During this stay he has required intermittent sc regular insulin to control blood glucose. Glucoses have ranged from 86 to 183. Due to improvement in nutritional status and correction of acidosis, mental status improved, but was complicated by delusional and paranoid behavior that was different from Mr. [**Known firstname 45467**] baseline. He required a psychiatric consultation and follow up. He was started on IV Haldol 1mg po tid. An attempt was made to switch to zyprexa, but during this time he became more persistent in his attempt to leave the transplant unit. The haldol was restarted and increased to 1mg qid. This dose proved to be just a little too sedating and a new dose of 1.5mg tid was started on [**3-14**] with improvement in alertness. No abnormal movement was detected. On [**2141-3-15**] he spiked a temperature to 101. Urine, blood and sputum were sent. A urinalysis was normal. He was empirically started on ciprofloxacin 500mg [**Hospital1 **]. Since this temperature, he has remained afebrile. Breath sounds were coarse in the lower lobes. A CXR revealed : Nasogastric tube and abdominal drainage tube remain in place. Cardiac and mediastinal contours are within normal limits. Again, note is made of persistent bilateral patchy opacities in the lung, probably representing infectious process in this patient status post liver transplant. Effusion noted. IMPRESSION: Persistent bilateral patchy opacities in the lungs, probably representing persistent infectious process in this patient status post liver transplant. No further studies were done, no change in tubes or biliary anatomy. He has 2 capped PTC/bile drains capped. Insertion sites tend to leak a small amt of bilious drainage. Should this drainage increase, the transplant surgeon should be called. Mr. [**Known lastname **] is ambulatory, but requires monitoring. He has been followed by PT. He did suffer a fall during this admission, but not incurr any injury. A head CT was performed and revealed: CT HEAD W/O CONTRAST [**2142-2-8**] 11:16 AM CT HEAD W/O CONTRAST Reason: Eval for ICH [**Hospital 93**] MEDICAL CONDITION: 59 year old man with altered mental status REASON FOR THIS EXAMINATION: Eval for ICH CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Altered mental status. TECHNIQUE: Head CT without contrast. FINDINGS: There is no intracranial mass effect, hydrocephalous, shift of normally midlined structures, or major vascular territory infarction. The density values of the brain parenchyma is within normal limits. The [**Doctor Last Name 352**] and white differentiation is preserved. The surrounding soft tissue and osseous structures are unremarkable. IMPRESSION: No mass effect or hemorrhage. He is eating small amounts of regular diet. Vital signs have been stable since yesterday's temperature elevation. He is alert and cooperative. Memory is fair for details, namely medications. He will be transfered to the [**Hospital6 13846**] Center and would benefit by placement on the behavioral unit. He should be followed by social service and psychiatry. Blood and urine cultures were pending upon discharge. Labs on [**2142-3-15**] were: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2142-3-16**] 07:07AM 7.2 3.48* 9.8* 30.6* 88 28.3 32.2 15.0 203 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2142-2-18**] 05:19AM 92* 0 6* 0 2 0 0 0 0 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Ovalocy Target [**2142-2-18**] 05:19AM 2+1 1+ 1+ NORMAL 1+ NORMAL OCCASIONAL OCCASIONAL 1 2+ MANUALLY COUNTED BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2142-3-16**] 07:07AM 203 BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2142-3-2**] 07:10AM 518* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2142-3-16**] 07:07AM 86 36* 1.5* 137 5.0 101 23 18 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [**2142-3-16**] 07:07AM 178* 121* 1540* 4.2* OTHER ENZYMES & BILIRUBINS Lipase [**2142-3-11**] 06:22AM 74* Medications on Admission: nystatin 5ml po qid insulin lispro insulin glargine, humulin 44 units qhs sc hydralazine hcl 10mg po metoprolol 100mg po bid celexa 10mg po qd amlodidpine 10mg po qd pansoprazole 30mg qd bactrim ss 1 qd cellcept 500mg po bid prednisone 5mg po qd sirolimus (rapamune) 5mg po qd ursodiol 600mg po qd ritalin 5mg po qd metronidazole 500mg po qid Discharge Medications: 1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): do not give via feeding tube. 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 6. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 12. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 14. Haloperidol 1.5 mg IV TID Discharge Disposition: Extended Care Facility: JMH Discharge Diagnosis: s/p liver transplant [**2141-9-1**] and ptc for biliary strictures with elevated liver function tests Malnutrition Glucose intolerance Paranoia/delusional behavior Encephalopathy hypertension Hepatitis C Metabolic acidosis acute renal failure Hyperkalemia Discharge Condition: stable Discharge Instructions: Call transplant office if any fevers, chills, nausea, vomiting, inability to take medications, increased jaundice, abdominal pain Labs every Monday & Thursday for cbc, chem 10, ast, alt, alk phos, t.bili, albumin, and rapamune trough level. Fax results to [**Hospital1 18**] transplant office [**Telephone/Fax (1) 697**]. Tube feeding cycled Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Where: LM [**Hospital Ward Name **] Bldg Transplant Center, [**2142-3-22**] @ 9:50 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-3-29**] 9:40 Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-4-5**] 9:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-4-12**] 9:40 Completed by:[**2142-3-16**]

[ "584.5", "297.1", "427.31", "572.2", "008.45", "276.5", "403.91", "070.70", "E878.0", "996.82", "276.2", "794.8", "263.9", "250.81", "276.7", "458.9" ]

icd9cm

[ [ [] ] ]

[ "50.11", "99.04", "87.54", "93.90", "96.6", "89.64", "96.72", "96.07", "38.91", "96.04" ]

icd9pcs

[ [ [] ] ]

12330, 12360

4004, 8720

837, 884

12660, 12668

2163, 3981

13058, 13816

11168, 12307

8757, 8800

12381, 12639

10799, 11145

12692, 13035

274, 799

8829, 10773

912, 1573

1595, 1998

2014, 2144

10,750

117,389

1713

Discharge summary

report

Admission Date: [**2195-4-8**] Discharge Date: [**2195-4-17**] Date of Birth: [**2117-9-19**] Sex: M Service: CARDIOTHORACIC Allergies: Zocor Attending:[**First Name3 (LF) 1267**] Chief Complaint: known CAD with unstable angina and severe 3 vessel disease Major Surgical or Invasive Procedure: s/p CABGx3 [**4-10**] LIMA-LAD, SVG-OM, SVG-PDA History of Present Illness: Mr. [**Known lastname 9817**] is a 77 yo with known CAD who had previously refused surgery but had been experiencing increasing episodes of unstable angina. He was refered to Dr. [**Last Name (STitle) **] for operative management Past Medical History: CAD prostate CA with metastatic bone disease OA gout hypercholesterolemiaHTN cataracts Pertinent Results: [**2195-4-17**] 06:25AM BLOOD WBC-4.6 RBC-3.65* Hgb-11.3* Hct-33.2* MCV-91 MCH-30.9 MCHC-34.0 RDW-15.8* Plt Ct-139* [**2195-4-17**] 06:25AM BLOOD Plt Ct-139* [**2195-4-17**] 06:25AM BLOOD UreaN-13 Creat-0.8 K-3.7 Brief Hospital Course: Mr. [**Known lastname 9817**] was admitted from Dr.[**Name (NI) 3502**] office on [**2195-4-8**] with c/o worsening unstable angina. He was taken to surgery with Dr. [**Last Name (STitle) **] on [**4-10**] and underwend CABGx3, LIMA-LAD, SVG-OM, SVG-PDA. He tollerated the procedure well and was transfered to the intensive care unit. Post operatively he was noted to have high chest tube outputs. The decision was made to take the patient back to the operating room for exploration for bleeding. Please see operative notes for full details. He was transfered bact to the intensive care unit in stable conditionOn POD1 he was noted to have collapse of his RUL on CXR and underwent a bronchoscopy to remove secretions. After the procedure, he was weaned and extubated from mechanical ventillation without difficulty. Post operatively, he had mild confusion which slowly resolved and on POD#3, he was transfered from the intensive care unit to the regular floor. His confusion fully cleared by POD#5 and by POD#7 he was cleared by physical therapy and was hemodynamically stable and discharged to home. Medications on Admission: Norvasc 10mg qd atenolol 50mg qd plavix 75mgqd ketoconazole 200mg [**Hospital1 **] hydrocortisone 20mg [**Hospital1 **] nitroglycerin prn percocet prn Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Ketoconazole 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Community VNA of [**Location (un) 6981**] Discharge Diagnosis: CAD s/p CABGx3 post op confusion-resolved prostate CA w/metastatic bone disease hypercholesterolemia HTN Discharge Condition: good Discharge Instructions: you may wash your incisions with mild soap and water do not swim or take a bath for 1 month do not drive for 1 month do not apply lotions, creams, ointments or powders to your incisions do not lift anything heavier than 5 pounds for 3 months Followup Instructions: follow up with Dr. [**First Name (STitle) **] in [**1-25**] weeks follow up with Dr. [**Last Name (STitle) 174**] in [**1-25**] weeks follow up with Dr. [**Last Name (STitle) **] in [**3-27**] weeks Completed by:[**2195-4-17**]

[ "998.12", "E878.2", "414.01", "198.5", "518.0", "274.9", "V10.46", "428.0", "411.1", "272.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "36.12", "34.03", "36.15", "33.22", "39.61" ]

icd9pcs

[ [ [] ] ]

2927, 2999

1009, 2118

330, 382

3148, 3154

772, 986

3444, 3674

2319, 2904

3020, 3127

2144, 2296

3178, 3421

232, 292

410, 642

664, 753

69,011

149,389

16365

Discharge summary

report

Admission Date: [**2156-7-4**] Discharge Date: [**2156-7-15**] Date of Birth: [**2080-11-20**] Sex: F Service: MEDICINE Allergies: Premarin Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: shortness of breath x 1 month, and chest pain for 2-3 days Major Surgical or Invasive Procedure: Right heart catheterization with placement of Swan Ganz catheter History of Present Illness: Ms. [**Known lastname 2470**] is 75F with history of CAD s/p STEMI, CABG in [**12/2155**] (LIMA-LAD, SVG-OM1, SVG Y-graft-diag, SVG-PDA), ischemic cardiomyopathy (EF 20-25%), most recent estimate at 10%, HTN, HLD, s/p fem-[**Doctor Last Name **] [**2-18**] who initially presented with dyspnea on exertion for the last one month and chest pain for 2-3 days prior to presentation. In the ED on [**7-4**], the patient was noted to have EKG in ? a-fib vs. NSR at 94 bpm RBBB with LAFB, and evidence of past anteroseptal MI, without change from prior. A CXR showed mild vascular congestion. An echo was done on [**7-5**] showing LVEF < 20% (approx 10%; Left ventricular cavity dilation with severe global hypokinesis. Right ventricular cavity enlargement with free wall hypokinesis. Mild-moderate aortic regurgitation. Mild mitral regurgitation. Pulmonary artery hypertension. Increased PCWP. Prev study on [**2156-2-11**] showed LVEF 20-25%) While on the [**Hospital1 1516**] service, the patient was initially given lasix boluses, and was later started on a Lasix drip on [**2156-7-5**]. The patient diuresed 914ccs [**2155-7-6**] PM after stopping lasix gtt. Her volume status improved and she had no oxygen requirement. Her Cr bumped to 1.3. However, she still complained of SOB, so RHC with Swan Ganz was performed to assess volume status. The patient tolerated the R heart cath well. Pressures were notable for wedge of 20, RA pressure of 20, and CI 1.5. Given her elevated pressures despite Lasix and in the setting of a creatinine increase and low EF, the patient was transferred to the CCU for initiation of milrinone and IV Lasix. On arrival to the CCU, the patient reports feeling well. She reports that she feels better than when she was first admitted to the hospital. Denies any current shortness of breath (satting 100% on RA), no chest pain. Denies any abdominal pain. Does reports some discomfort at the site of her line placement, reports having some difficulty moving her neck. Of note, while on [**Hospital1 1516**], the patient was also started on amiodarone for her atrial fibrillation. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: - CABG: CABG x4(LIMA->LAD, svg->OM1,svg-Y-graft->diag, svg->pda) [**2156-1-19**] -Atrial Fibrillation 3. OTHER PAST MEDICAL HISTORY: H pylori Back pain Osteopenia Pancreatic cyst AAA s/p endovascular repair [**2151-5-20**] Social History: She exercises three times a week at her adult day center. She is a nonsmoker. She does not drink alcohol or use illicit drugs. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission exam: PHYSICAL EXAM: VS: 36.6 66 81/49 (55) 96% RA 19 CVP 20 PA 48/23 (32) GENERAL: very thin, elderly woman NAD, NT, ND HEENT: NC, AT, EOMI NECK: Right IJ triple lumen. C/D/I. JVP elevated to jaw LUNGS: Speaks in complete sentences, no accessory muscle use, inspiratory rales and dullness to percussion at right > left base, no rales or wheeze, good air movement. HEART: Nl S1 and S2, no murmurs, rubs, or gallops. Sternotomy scar. ABD: Soft, ND/NT, NABS. EXTR: Distal extremities cool to touch feet >> hands. Radial and DP pulses 2+; PTs 1+/thready. No lower extremity edema or cyanosis (toenails painted). NEURO: Alert, oriented x3 EXCEPT year ([**2055**]). Fluent, linear, prompt, moves all 4 spontaneously and without apparent paresis, tremor, or incoordination. The tone is normal Discharge exam: Pertinent Results: [**2156-7-4**] 07:00AM BLOOD WBC-5.8 RBC-4.44 Hgb-14.2 Hct-44.7 MCV-101* MCH-32.0 MCHC-31.8 RDW-15.8* Plt Ct-223 [**2156-7-11**] 10:10AM BLOOD Hgb-11.1* [**2156-7-5**] 07:45PM BLOOD PT-22.1* PTT-32.3 INR(PT)-2.1* [**2156-7-5**] 06:55AM BLOOD Plt Ct-245 [**2156-7-12**] 02:47AM BLOOD Plt Ct-150 [**2156-7-12**] 02:47AM BLOOD PT-15.7* PTT-74.7* INR(PT)-1.5* [**2156-7-4**] 07:00AM BLOOD Glucose-138* UreaN-22* Creat-1.1 Na-136 K-4.0 Cl-98 HCO3-23 AnGap-19 [**2156-7-8**] 05:15PM BLOOD Creat-1.5* Na-136 K-3.7 Cl-98 HCO3-28 AnGap-14 [**2156-7-7**] 07:29AM BLOOD ALT-33 AST-58* AlkPhos-104 TotBili-2.4* [**2156-7-5**] 02:42AM BLOOD CK-MB-2 cTropnT-0.03* [**2156-7-4**] 07:00AM BLOOD cTropnT-0.03* [**2156-7-4**] 07:00AM BLOOD CK-MB-2 [**2156-7-5**] 06:55AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.4 [**2156-7-10**] 05:05AM BLOOD calTIBC-248* VitB12-1327* Folate-GREATER TH Hapto-79 Ferritn-320* TRF-191* [**2156-7-5**] 01:24AM BLOOD %HbA1c-6.4* eAG-137* [**2156-7-6**] 04:00PM BLOOD Digoxin-1.2 [**2156-7-7**] 07:45PM BLOOD Lactate-3.2* calHCO3-24 Cardiovascular Report ECG Study Date of [**2156-7-4**] 6:44:28 AM Atrial fibrillation with a controlled ventricular response. Interpolated ventricular premature contractions. Right bundle-branch block with left anterior fascicular block. Probable prior anteroseptal myocardial infarction. No major change from the previous tracing. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] V. TTE [**2156-7-5**] IMPRESSION: Left ventricular cavity dilation with severe global hypokinesis. Right ventricular cavity enlargement with free wall hypokinesis. Mild-moderate aortic regurgitation. Mild mitral regurgitation. Pulmonary artery hypertension. Increased PCWP. Com;pared with the prior study (images reviewed) of [**2156-2-11**], the false tendon has ruptured and the left ventricular cavity is now larger. Cardiac catheterization [**2156-7-7**] COMMENTS: 1. Limited resting hemodynamics revealed elevated right and left filling pressures. The RVEDP was 14 mmHg. The pulmonary capillary wedge pressure was elevated at 21 mmHg. The cardiac index was notably depressed on 2L supplemental oxygen (with an assumed oxygen consumption) of 1.58 l/min/m2. 2. Right internal jugular swan [**Last Name (un) **] catheter was sutured to the neck for additional pressure measurements during hospitalization. FINAL DIAGNOSIS: 1. Decompensated congestive heart failure with depressed cardiac output. 2. Moderate diastolic heart failure. 3. RIJ VIP swan sutured in place. Cardiac perfusion study [**2156-7-7**] Final Report RADIOPHARMACEUTICAL DATA: 10.1 mCi Tc-[**Age over 90 **]m Sestamibi Rest ([**2156-7-7**]); HISTORY: 75 yo woman with a history of CAD with prior MI and CABG referred for evaluation of chest pain and worsening left ventricular systolic function. Stress imaging was planned but unable to be performed. METHOD: Resting perfusion images were obtained with Tc-[**Age over 90 **]m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. Imaging Protocol: SPECT This study was interpreted using the 17-segment myocardial perfusion model. INTERPRETATION: The image quality is adequate but limited due to soft tissue attenuation and patient motion. Left ventricular cavity size is markedly increased. Resting perfusion images reveal a moderate reduction in photon counts involving the mid anterior wall, mid anteroseptum, the entire distal ventricle and the apex. IMPRESSION: 1. Large, moderate severity resting perfusion defect involving the LAD territory. Brief Hospital Course: Ms. [**Known lastname 2470**] is 75F with history of CAD s/p STEMI, CABG in [**12/2155**] (LIMA-LAD, SVG-OM1, SVG Y-graft-diag, SVG-PDA), ischemic cardiomyopathy (EF 20-25%), most recent estimate at 10% who initially presented with dyspnea on exertion for the last one month and chest pain for 2-3 days prior to presentation. ACUTE ISSUES # DECOMPENSATED ACUTE ON CHRONIC SYSTOLIC HEART FAILURE (EF 10%): Prior to her CCU admission, she was being diuresed while on the cardiology service service. Given her persistent shortness of breath without other signs of heart failure, right heart catheterization was performed and the patient found to have elevated filling pressures. She was transferred to the CCU for initiation of milrinone and Lasix drip. Her milrinone was replaced with dobutamine 5 mcg/kg/min, which was up-titrated to 7mcg/kg/min. Her preload was reduced with Lasix, which was transitioned to torsemide. Her afterload was reduced was increasing doses of captopril, which allowed for reduction of her dobutamine dose to 5 mcg/kg/min. Despite clinical improvement and reduction in subjective shortness of breath, the patient's cardiac index generally ranged between 1.3 and 2.2, although she did have several readings between 2.2 and 2.6. Her CVP was generally between 11 and 17. Her PA diastolic pressures correlated well with her pulmonary capillary wedge pressures and generally remained between 11 and 23. Her pulmonary artery systolic pressures were between 34 and 53, with a general trend towards lower values as she was optimized medically. Although she did complain of some right upper quadrant pain likely related to her poor right heart function (in the setting of unremarkable transaminases), she did not develop peripheral edema. Notably, her weight on admission to the CCU was 56.1kg (down from 58.3kg on [**2156-7-4**]) and her weight on discharge was 57.9 kg Precipitants for this episode remain unclear but include the possibility of dietary indiscretion, new wall motion abnormality [**1-29**] another ischemic event, rapid atrial fibrillation (although pt well controlled in house), or worsening valvular disease (pt with with known MR). Weight on PCP [**Name Initial (PRE) **] ([**2156-5-5**]) was 57.7, ([**2156-6-23**]) was 58.3 kg, admit on [**2156-7-4**] was 56.1 kg. Patient was discharged on the following mediations for her CHF: dobutamine drip, lisinopril 5mg, Dig .125 every other day, torsemide 40mg daily, spironolactone 25 mg daily, imdur 60 mg daily # ATRIAL FIBRILLATION: since CABG 1/[**2155**]. The patient's INR on admission was 2.1. Her coumadin was initially held given the need for catherization and central line placement. On [**7-10**], her coumadin was restarted with a heparin bridge. Her INR at the time of discharge is 1.3. Pt was also on amiodarone for Afib and will continue this medication upon discharge. Because her INR was subtherapeutic we will discharge the patient on warfarin 7.5 mg daily with close follow up. # CAD: On presentation to the hospital, the patient was ruled out with two sets of negative enzymes (MBI negative, mild trop elevation). She denied chest pain at rest and there were no EKG changes from prior studies. Cardiac perfusion study revealed a resting perfusion defect of the LAD territory. Of note, the patient was not stressed during this study. #VAGINAL BLEEDING: While in house pt described some vaginal bleeding which she has had for a couple of weeks. We did a pelvic exam and there was no cervical motion tenderness but there was blood in the vaginal vault. This is concernding for endometrial cancer especially with her age. I discussed this with the patient and told her this should be followed up with her PCP Dr [**Last Name (STitle) **] when she goes home. I called Dr [**Last Name (STitle) **] to fill him in and he is on board with looking into this further when she is discharged. The bigger issue here is of course her decompensated heart failure requiring inotropes however if the patient wishes this should be worked up further. # Hyponatremia: Asymptomatic, mild. Began to develop after Cr normalized s/p easing of diuretic regimen. Likely hypervolemic, though this may manifest in older women with abdominal fullness rather than lower extremity edema. Euvolemic causes such as SIADH are possible but less likely. Her hyponatremia resolved during hospital stay. #Code status: Patient was DNR/DNI at one point during hospitilization and then changed her mind to FULL CODE. This was discussed on [**2156-7-15**] at noon. She is Full Code CHRONIC ISSUES # DM: By history. Not on any medications. A1c 6.4%, indicative of degree of glucose intolerance. # DYSLIPIDEMIA: The patient's statin was continued while in hospital. TRANSITIONAL ISSUES -decompensated CHF: will follow up with cardiologist -Postmenopausal bleeding: concerning for endometrial cancer. Consider having a pelvic u/s and or endometrial biopsy in outpatient setting. Dr [**Last Name (STitle) **] will follow up with this Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Atorvastatin 20 mg PO DAILY 2. Benzonatate 200 mg PO TID:PRN cough 3. Clopidogrel 75 mg PO DAILY 4. Digoxin 0.125 mg PO DAILY 5. Albuterol-Ipratropium [**12-29**] PUFF IH Q4H 6. Losartan Potassium 12.5 mg PO DAILY 7. Torsemide 40 mg PO DAILY 8. Warfarin 2 mg PO DAILY16 9. Aspirin 81 mg PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Metoprolol Succinate XL 12.5 mg PO DAILY 12. Spironolactone 25 mg PO DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Atorvastatin 20 mg PO DAILY RX *atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Digoxin 0.125 mg PO EVERY OTHER DAY RX *digoxin 125 mcg 1 tablet(s) by mouth every other day Disp #*30 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID RX *Colace 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 5. Spironolactone 25 mg PO DAILY RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Benzonatate 200 mg PO TID:PRN cough RX *benzonatate 200 mg 1 capsule(s) by mouth three times a day Disp #*30 Capsule Refills:*0 7. Torsemide 40 mg PO DAILY RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 8. DOBUTamine 5 mcg/kg/min IV DRIP INFUSION RX *dobutamine in D5W 250 mg/250 mL (1 mg/mL) 5 mcg/kg/min Infusion Disp #*12 Bag Refills:*0 9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY RX *Imdur 60 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Lisinopril 5 mg PO DAILY please hold for SBP<100 RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. Sarna Lotion 1 Appl TP QID:PRN itch RX *Anti-Itch 0.5 %-0.5 % Apply as needed prn Disp #*1 Bottle Refills:*0 12. Senna 1 TAB PO BID:PRN constipation RX *senna 8.6 mg 1 capsule by mouth twice a day Disp #*30 Capsule Refills:*0 13. Albuterol-Ipratropium [**12-29**] PUFF IH Q4H RX *Combivent 18 mcg-103 mcg (90 mcg)/actuation 1 inhaler q 4 hrs Disp #*1 Inhaler Refills:*0 14. Amiodarone 200 mg PO BID Afib Duration: 7 Days On [**7-17**], please take just ONE pill a day thereafter. RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 15. Warfarin 7.5 mg PO DAILY16 RX *Coumadin 7.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: VNA Partners [**Name (NI) **] [**Name2 (NI) **]- Central intake Discharge Diagnosis: Primary diagnosis: acute on chronic systolic heart failure exacerbation Secondary diagnosis: Ischemic cardiomyopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname 2470**], It was a pleasure caring for you while you were hospitalized at the [**Hospital1 69**]. You were admitted because of increasing shortness of breath over the month prior to coming to the hospital with a recent onset of exertional chest pain. We found that your heart functioned had worsened, but there was no easily identifiable cause to indicate why- we concluded at the end of your stay that it was disease progression and worsening of your pre-existing heart failure. We gave you medications to remove the excess fluid that was causing you to be short of breath and gave you other medications to help improve your heart function. This required placement of a line through your neck to help us monitor your blood pressure parameters. You were admitted to the cardiac intensive care unit so that we could adjust your medications accordingly and you did well. Several of your medications are new or have changed: START: 1. Amiodarone 200 mg by mouth twice daily until [**2156-7-17**] where you will then take ONE pill a day thereafter 2. Isosorbide mononitrate 60 mg daily 3. Lisinopril 5 mg daily 4. Digoxin 0.125 g EVERY OTHER day. So once every 2 days 5. Warfarin 7.5 mg daily. This is an INCREASE in your dose of 2 mg from before admission. Please make sure the nurses check your INR on Friday [**7-16**] and also when you visit the Nurse practitioner at the cardiology office 6. Torsemide 40 mg daily (increased from 20 mg) 7. Dobumatine drip at 5 mg. You have discussed with the infusion therapy team how to manage this medication You will continue to take your spironolactone 25 mg daily STOP taking these medications 1. Metoprolol 2. Losartan 3. Clopidogrel IN ADDITION: Please weigh yourself immediately after you leave the hospital and then every morning afterwards. Call your physician if your weight increases by more than 3 pounds from your weight after discharge from the hospital. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2156-7-20**] at 1 PM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: TUESDAY [**2156-7-20**] at 2:00 PM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital1 7975**] ST. HLTH CTR-KCSS When: WEDNESDAY [**2156-8-25**] at 12:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7980**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site

[ "401.9", "276.1", "428.0", "724.5", "627.1", "414.01", "414.8", "424.0", "272.4", "577.2", "250.00", "414.02", "427.31", "412", "428.23", "733.90", "785.51" ]

icd9cm

[ [ [] ] ]

[ "88.57", "37.21", "88.52", "89.64", "89.68", "38.93", "37.22", "88.56" ]

icd9pcs

[ [ [] ] ]

15037, 15131

7580, 12582

336, 402

15292, 15292

4005, 6341

17411, 18340

3038, 3154

13148, 15014

15152, 15152

12608, 13125

6358, 7557

15443, 17388

3200, 3968

2650, 2753

3986, 3986

238, 298

430, 2540

15245, 15271

15171, 15224

15307, 15419

2784, 2876

2562, 2630

2892, 3022

26,046

119,753

29993

Discharge summary

report

Admission Date: [**2149-6-14**] Discharge Date: [**2149-6-19**] Date of Birth: [**2103-7-21**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: None History of Present Illness: 45 yo male unrestrained driver, s/p motor vehicle crash vs. tree. + airbag deployment. + LOC. +EtOH. He was taken to an area hospital where he was found to have a subarachnoid hemorrhage and thoracic aortic dissection. He was later transferred to [**Hospital1 18**] for further care. Past Medical History: EtOH cirrhosis HTN Hyperlipidemia Seizures Social History: +EtOH, previously treated at detox facility Family History: Noncontributory Pertinent Results: [**2149-6-14**] 08:15PM GLUCOSE-161* LACTATE-2.8* NA+-150* K+-3.9 CL--111 TCO2-26 [**2149-6-14**] 08:15PM HGB-13.7* calcHCT-41 [**2149-6-14**] 08:00PM UREA N-12 CREAT-0.7 [**2149-6-14**] 08:00PM ASA-NEG ETHANOL-290* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2149-6-14**] 08:00PM WBC-16.4* RBC-4.05* HGB-13.2* HCT-37.4* MCV-92 MCH-32.6* MCHC-35.4* RDW-14.1 [**2149-6-14**] 08:00PM PLT COUNT-301 [**2149-6-14**] 08:00PM PT-14.4* PTT-22.7 INR(PT)-1.3* [**2149-6-14**] 08:00PM FIBRINOGE-224 CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS Reason: eval for change in aortic dissection [**Hospital 93**] MEDICAL CONDITION: 45 year old man s/p mvc with aortic dissection REASON FOR THIS EXAMINATION: eval for change in aortic dissection CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 45-year-old male status post MVC with aortic dissection. Please evaluate for change and/or dissection. COMPARISON: [**2149-6-15**]. TECHNIQUE: MDCT acquired axial imaging from the thoracic inlet to the superior iliac crest before and after the administration of intravenous contrast. Multiplanar reformatted images were obtained and reviewed. CTA CHEST: Focal dissection of the descending aorta is again seen, distal to the origin of the left subclavian artery. Overall appearance of focal dissection is unchanged. Area involving the flap, again measures 17 mm in craniocaudal direction. There has been no propagation of the flap in any direction, and there is no evidence of new flap formation. Small area of intramural hematoma adjacent to the aortic arch has resolved. There is no evidence of stranding within the mediastinum. There is no pericardial effusion. The great vessels are unremarkable. There has been interval resolution of pleural effusions. Lung windows demonstrate no pulmonary nodules or focal consolidations. There is some subsegmental atelectasis in the right lower lobe. Note is made of a separate origin of the left circumflex artery from the aorta, and mild coronary artery atherosclerotic calcification. CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The liver enhances homogeneously, without focal lesion. Again seen around the liver is fluid with increased density, consistent with hemorrhagic ascites. This fluid continues to track around the spleen and down into the right and left paracolic gutters. Overall amount of fluid is probably slightly increased from prior exam. There is evidence of portal hypertension, with prominent splenic varices, and a large recanalized umbilical vein and a prominent umbilical varix, not significantly changed from prior exam. The pancreas and adrenal glands are unremarkable. The spleen has a somewhat lobulated contour, but there is no evidence of splenic injury. The kidneys enhance and excrete contrast symmetrically, and no focal renal lesions are seen. The gallbladder is unremarkable. There is no free intraperitoneal air. Scattered small mesenteric and retroperitoneal lymph nodes are seen, but none meet CT criteria for pathologic enlargement. The stomach and intraabdominal loops of bowel are unremarkable. BONE WINDOWS: No suspicious lytic or sclerotic bony lesions are seen. IMPRESSION: 1. Unchanged appearance of short segment dissection involving the descending aortic arch, just distal to the left subclavian artery. Interval resolution of small intramural aortic hematoma. 2. Interval resolution of pleural effusions. 3. Slight interval increase in intraabdominal free fluid, with high attenuation consistent with hemorrhagic ascites. 4. Unchanged appearance of findings consistent with portal hypertension, including prominent splenic and umbilical vein varices. CT HEAD W/O CONTRAST Reason: eval for interval changes. schedule for 6am please [**Hospital 93**] MEDICAL CONDITION: 45M s/p MVC with known posterior fossa SAH REASON FOR THIS EXAMINATION: eval for interval changes. schedule for 6am please CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 45-year-old man status post MVC, with subarachnoid hemorrhage. Evaluate for interval change. COMPARISON: Study from [**2149-6-14**]. TECHNIQUE: Non-contrast head CT. CT HEAD WITHOUT IV CONTRAST: Again seen is the area of increased density along the right tentorium, which is less distinct and conspicuous in comparison to prior study. No new areas of intracranial hemorrhage are identified. The ventricles are symmetric, and there is no shift of normally midline structures. The [**Doctor Last Name 352**]-white matter differentiation is normal. The soft tissue and osseous structures are unchanged. IMPRESSION: The area of subarachnoid hemorrhage along the right tentorium and posterior to the right temporal lobe is less distinct in comparison to prior study, and likely represents evolving hemorrhage. No new or increasing intracranial hemorrhage is identified. The remainder of the study is stable in comparison to prior exam. Brief Hospital Course: He was admitted to the Trauma Service. Neurosurgery and Vascular Surgery were consulted given his injuries. His subarachnoid hemorrhage was deemed non operative, he was loaded with Dilantin and transferred to the Trauma ICU for closer monitoring. Serial head CT scans were followed and were stable. He will continue on Dilantin for 4 weeks, at which time he will follow up with Dr. [**Last Name (STitle) **], Neurosurgery, for repeat head imaging. Vascular surgery was consulted for the thoracic aortic arch dissection; this injury was non operative; he underwent CTA. He was placed on beta blockade and will follow up in 2 weeks with Dr. [**Last Name (STitle) **] for repeat imaging. He has been instructed to go to the emergency room immediately if her develops any back pain or feelings of dizziness which may indicate a drop in his blood pressure. Social work was also consulted given his history EtOH use; he did express a desire to return to [**Doctor First Name 1191**] for alcohol treatment. Medications on Admission: Atenolol Lexapro Neurontin Naltraxone Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 3. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. Outpatient Lab Work Dilantin level weekly with results to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1669**]. 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: s/p Motor vehicle crash vs. tree Subarachnoid hemorrhage Descending aortic arch Discharge Condition: Stable Discharge Instructions: Return to the Emergency Department if you develop any fevers, chills, headache, dizziness, lightheadedness, chest pain, back pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. Continue with your Dilantin (anti-seizure medication) as prescribed; you will need to have your blood levels monitored and results called into Dr.[**Name (NI) 9034**] office [**Telephone/Fax (1) 1669**]. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **], Vascular Surgery in 2 weeks, call [**Telephone/Fax (1) 1237**]. Inform the officethat you will need a repeat chest CTA for this appointment. Follow up with Dr. [**Last Name (STitle) **], Neurosurgery in 4 weeks. Inform the office that you will need a repeat head CT scan for this appointment. Call [**Telephone/Fax (1) 1669**] for an appointment. Completed by:[**2149-6-19**]

[ "571.2", "E815.0", "345.90", "441.01", "401.9", "303.90", "789.5", "852.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7788, 7794

5773, 6777

337, 344

7917, 7925

836, 1459

8427, 8852

800, 817

6868, 7765

4636, 4679

7815, 7896

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274, 299

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372, 657

679, 723

739, 784

83,300

107,019

7475

Discharge summary

report

Admission Date: [**2180-5-15**] Discharge Date: [**2180-5-31**] Date of Birth: [**2121-5-11**] Sex: M Service: MEDICINE Allergies: Percocet / Tylenol / Warfarin / fentanyl Attending:[**First Name3 (LF) 2145**] Chief Complaint: agitation, AFib with RVR, multifocal PNA Reason for MICU transfer: increased nursing requirement Major Surgical or Invasive Procedure: None History of Present Illness: 59yoM with h/o AFib, asthma, BOOP, DM2, spinal stenosis and chronic back pain and high narcotic requirement at baseline, now s/p L1-2 total laminectomy, fusion of L1-3, reomval of previous instrumentation L3-5 and autograft on [**2180-5-15**]. His post op course has been complicated by HAP, ? aspiration, delirium, and AFib with RVR. Pain management has been following her given high narcotic requirement and difficulty managing post op pain, and post-op he was on a Ketamine gtt. He was having delirium with hallucinations and periods of unresponsiveness, and his chronic pain meds were decreased and started on PRN Zyprexa. He spiked a fever [**5-17**] and CXR showed multifocal PNA, so started on Vancomycin and Ceftazadime for HCAP, went to SICU. BP's have been variable between 200/100 on arrival to TSICU and then noted to be hypotensive to 80/50 which responded well to IVF's and albumin. EKG has been noted to have some ST depressions V3-5 but negative Trops. Hct noted to decrease from 28 on admission to 23 through course, stable thereafter. AFib with RVR has been addressed with uptitration of PO Diltiazem and apparently also with Metoprolol (? -- not noted on transfer from floor). Pt was transferred from TSICU to Medicine floor late pm of [**5-22**] and was switched from Vanc/Ceftaz to Vanc/Zosyn. He triggered on the floor for AFib with RVR, agitation, delirium. Noted to be in pain, turning from left to right, temp noted 100.6 and RVR to 150 but other vitals stable. Dilt ER changed to 60 qid, given 10 mg IV Dilt, given Zyprexa 5mg PO. ROS: On arrival to MICU pt sleeping comfortably, awoken and conversant, and denied any symtpoms, no SOB, CP, abd pain, n/v. Knew where he was and was calm. Past Medical History: HTN CHF ?, pt unsure Hyperlipidemia NIDDM Paroxysmal AFib -- on Dabigatran and ASA 81 daily Sarcoidosis BOOP Asthma Chronic back pain since a fall in [**2150**] s/p L1-L2, L3-L4 fusion and severe spinal stenosis above this; then in [**4-/2180**] s/p L1-2 total laminectomy, fusion of L1-3, reomval of previous instrumentation L3-5 and autograft C-spine fx in [**8-4**] s/p C2-C3 diskectomy Carpal tunnel surgery [**2170**]. Left hip replacement [**2178**]. Social History: Denies tobacco use, rare Etoh. No illicts. On disability. Lives with son (who has a narcotic problem). Ambulates with walker at baseline. Family History: Father with CAD. Mom with parkinson's and breast ca. Physical Exam: PHYSICAL EXAM ON ADMISSION 101.4 102 131/63 17 Large gentleman, sleeping, awoken with voice and calm, conversant, no distress. EOMI, no scleral icterus Difficult to assess JVD CTAB anteriorly, no w/c/r/r, good air movement Irregularly irregular, without gross m/g Obese NT ND, soft abdomen, benign No BLE edema, extrems are warm CN 2-12 grossly intact, no focal neuro deficits noted. Oriented to [**Hospital1 18**], not oriented to date but doesn't answer corrently. Answers some questions correctly, but gets tangential with others, he is redirectable though Back with well healing midline lumbar surgical scar, no purulence or cellulitis PHYSICAL EXAM ON DISCHARGE 97.6, 145/60s, 73, 20, 93% on RA GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT, distended, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), 2+ pitting edema bilaterally SKIN - no rashes or lesions WOUND - nonerythematous induration over anterior aspects of the incision line, mildly tender, rest of incision line clean, intact, morderately tender on palpation over distal portions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**2-29**] in quards and knee on the right, [**3-30**] throughout otherwise, sensation grossly intact throughout, DTRs 2+ and symmetric Pertinent Results: ADMISSION LABS [**2180-5-16**] 04:00AM BLOOD WBC-6.8# RBC-3.19* Hgb-9.7* Hct-28.5* MCV-89 MCH-30.3 MCHC-34.0 RDW-14.0 Plt Ct-115* [**2180-5-23**] 08:32AM BLOOD Neuts-75.7* Lymphs-12.8* Monos-5.7 Eos-5.2* Baso-0.8 [**2180-5-18**] 02:05AM BLOOD Neuts-82.5* Bands-0 Lymphs-11.1* Monos-6.0 Eos-0.2 Baso-0.1 [**2180-5-17**] 10:55AM BLOOD PT-15.1* PTT-27.0 INR(PT)-1.3* [**2180-5-16**] 04:00AM BLOOD Glucose-159* UreaN-17 Creat-0.7 Na-140 K-3.7 Cl-108 HCO3-25 AnGap-11 [**2180-5-19**] 12:30PM BLOOD ALT-71* AST-89* AlkPhos-74 TotBili-0.6 [**2180-5-23**] 09:11PM BLOOD ALT-82* AST-39 LD(LDH)-263* AlkPhos-169* TotBili-0.6 [**2180-5-22**] 01:42AM BLOOD CK-MB-2 cTropnT-<0.01 [**2180-5-22**] 02:01PM BLOOD CK-MB-2 cTropnT-<0.01 [**2180-5-23**] 09:11PM BLOOD CK-MB-3 cTropnT-<0.01 [**2180-5-17**] 10:55AM BLOOD Calcium-7.6* Phos-1.8* Mg-1.9 [**2180-5-24**] 05:38AM BLOOD calTIBC-164* VitB12-747 Folate-14.9 Ferritn-289 TRF-126* [**2180-5-19**] 06:19AM BLOOD Vanco-7.4* [**2180-5-24**] 05:38AM BLOOD Vanco-25.3* [**2180-5-15**] 05:06PM BLOOD Type-ART pO2-166* pCO2-42 pH-7.43 calTCO2-29 Base XS-3 DISCHARGE LABS: [**2180-5-31**] 05:14AM BLOOD WBC-3.1* RBC-2.55* Hgb-7.6* Hct-22.9* MCV-90 MCH-29.9 MCHC-33.3 RDW-15.4 Plt Ct-146* [**2180-5-31**] 05:14AM BLOOD Glucose-115* UreaN-22* Creat-0.8 Na-138 K-3.6 Cl-103 HCO3-29 AnGap-10 [**2180-5-23**] 09:11PM BLOOD ALT-82* AST-39 LD(LDH)-263* AlkPhos-169* TotBili-0.6 [**2180-5-31**] 05:14AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.2 PERTINENT STUDIES: # L-spine ([**5-15**]) Single cross-table lateral demonstrates posterior fusion with rods and pedicle screws as well as retractors. Please refer to operative note for full details. # portable CXR ([**5-18**]) FINDINGS: In comparison with the study of [**5-17**], there is little overall change. There is persistent enlargement of the cardiac silhouette with low lung volumes and evidence of increased pulmonary venous pressure. There may be minimal blunting of the costophrenic angles bilaterally. # portable CXR ([**5-19**]) IMPRESSION: AP chest compared to [**5-17**] and 23: Large scale multifocal consolidation, although accompanied by pulmonary vascular congestion, is quite likely multilobar pneumonia. Moderate right pleural effusion has increased. Heart size is normal. Mediastinum is not widened. Right subclavian line ends in the SVC. No pneumothorax. Dr. [**Last Name (STitle) 27362**] was paged at the time of dictation. # CHEST (PORTABLE AP) Study Date of [**2180-5-23**] 7:16 AM Consolidation at the lung bases, left greater than right, worsened substantially at least on the right side between [**5-18**] and [**5-19**]. Some of that interval change was due to concurrent pulmonary edema which persists, but bibasilar consolidation is improving. At least a small volume of right pleural fluid is present, some still in the major fissure. Heart is top normal size, pulmonary and mediastinal vascular engorgement persists. Right subclavian line ends in the mid SVC. No pneumothorax. # ECHO [**2180-5-24**] The left atrium is elongated. The right atrium is moderately dilated. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal global biventricular systolic function. Mild right ventricular dilation. Technically suboptimal to exclude focal wall motion abnormality. Mild aortic dilation. Biatrial dilation. # Droppler studies ([**5-28**]) FINDINGS: Doppler son[**Name (NI) 1417**] of the bilateral subclavian veins and the right internal jugular, right axillary, right brachial, right basilic and cephalic veins were performed. There is normal compressibility and flow in the subclavian and axillary veins. There are three brachial veins, one of which contains occlusive echogenic thrombus. Nearly occlusive echogenic thrombus is also seen in the distal cephalic vein with minimal flow. IMPRESSION: Deep venous thrombus in a right brachial vein, and superficial thrombosis of a cephalic vein. Brief Hospital Course: Mr. [**Known lastname 27363**] is 59 yo M with a history of A-fib, CHF, DM, spinal stenosis secondary to MVA on chronic narcotics for pain, came in for elective laminectomy for L1-L2 and fusion for L1-L3, and had a complicated post-op course, requring SICU/MICU admission for A-fib with RVR, delirium, hypotension and multifocal peumonia. ACTIVE ISSUES # Orthopedic surgery & routine post-op issues Pt underwent uncomplicated total laminectomy of L1 and L2, fusion L1 to L3, instrumentation L1-L3, removal of previous instrumentation from 3 to 5 and autograft. Patient is mild soft tissue swelling at distal incision site without sign of infection; Dr [**Last Name (STitle) 363**] aware of seroma at time of discharge. OUTPATIENT ISSUES: -- Continue to monitor site -- Ortho follow-up on [**6-5**] -- Continue to wear stabilizing brace with ambulation . # Delirium Patient noted to have display considerable delirum in ICU as well as the floor in the post-operative period. Etiology likely secondary to acute infectious process. Mental status slowly improved with treatment of PNA as well as improved pain control. At time of discharge patient was alert and oriented x3. . # A-fib RVR Patient developed A-fib with RVR post-op. Etiology thought secondary to catocholamine surge post-op, under controlled pain as well as infection. With treatment of pain and infection as well as rate controlled with uptitration of diltazam rates controlled. Prior to discharge patient had converted back to sinus rhythm with rates well controlled on Dilt XR. OUTPATIENT ISSUES: 1. Rate control. Continue with dilt XR 2. Anticoagulation. Patient had previously been on pradexa however due to concern for bleed in the ICU (low HCT) pradexa held. Patient started on Lovenox for treatment of provoked DVT. Will continue Lovenox x1 month (end date [**6-28**]) with plan to transition back to pradexa thereafter for rate control, . # Multifocal pneumonia On post-op day #2, patient developed fever, hypertension and tachycardia. On the subsequently portable CXR, multiple focal consolidations were found, concerning for hospital acquired pneumonia vs aspiration pneumonia. Patient finished a total course of 5 days of vancomycin / ceftriaxone and 3 days of vancomycin / zosyn for complete treatment of HAP. His respiratory status remained stable. Patient continued to spike intermittent low grade fever till he finished his antibiotics course. Prior to discharge patient with stable respiratory rate. . # DVT Patient noted to have upper extremity swelling on [**5-28**]. Upper extremity ultrasound demonstrated deep venous thrombus in a right brachial vein, and superficial thrombosis of a cephalic vein. Patient was started on Lovenox for planned 1month course in treatment of provoked DVT as patient had previously had line in place. OUTPATIENT ISSUES: -- Continue anticoagulation with Lovenox until [**6-29**] for 1month treatment of provoked DVT . # Chronic Pain. Patient with history of chronic pain. Post-operatively the pain team was consulted for assistance in management. At time of discharge patients pain adequately controlled MS [**Last Name (Titles) **] 75mg [**Hospital1 **] with Morphine IR 15-30 Q4hrs for breakthru. . # Lower extremity edema Patient with 1+ lower extremity edema to mid-shins bilaterally. [**5-24**] TTE demonstrated normal global biventricular systolic function, mild right ventricular dilation without appreciable valvular abnl. Though overall study technically suboptimal to exclude focal wall motion abnormality. Patient continued on lasix 40mg PO, diuresising ~1L daily. OUTPATIENT ISSUES: -- Monitor weights, I/O, contact physician/discuss increasing diuretic in advent of weight gain. . # Hypotension. Patient with intermittent episodes of hypotension the ICU. Hypotension likely secondary to infection as well as Afib with RVR. Patient bolused with IV fluid. Infection treated and patient rate controlled. SBPs returned to baseline prior to discharge and patient tolerating all home PO medications. . # Hypertension. Anti-hypertensives held during hypotensive episodes. Restarted on gradually in house. Patient tolerating Imdur, Dilt. amlodipine and benzopril prior to discharge with SBPs 130-150 . # Diabetes. Patient maintained on insulin sliding scale in house. Metformin restarted prior to discharge. . # OSA Patient require CPAP during sleep. . # Dispo: Rehab . # Code: Full Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - (Prescribed by Other Provider) - Dosage uncertain AMLODIPINE-BENAZEPRIL [LOTREL] - (Prescribed by Other Provider) - 10 mg-40 mg Capsule - 1 (One) Capsule(s) by mouth once a day CARBAMAZEPINE [TEGRETOL] - (Prescribed by Other Provider) - 100 mg Tablet, Chewable - 1 (One) Tablet(s) by mouth twice a day CLONIDINE - (Prescribed by Other Provider) - 0.1 mg Tablet - 1 to 2 Tablet(s) by mouth once a day DABIGATRAN ETEXILATE [PRADAXA] - (Prescribed by Other Provider) - 150 mg Capsule - 1 Capsule(s) by mouth twice a day DIAZEPAM [VALIUM] - (Prescribed by Other Provider) - 10 mg Tablet - 1 (One) Tablet(s) by mouth four times a day DILTIAZEM HCL - (Prescribed by Other Provider) - Dosage uncertain EZETIMIBE-SIMVASTATIN [VYTORIN 10-40] - (Prescribed by Other Provider) - 10 mg-40 mg Tablet - 1 (One) Tablet(s) by mouth at bedtime FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - 40 mg Tablet - 1 (One) Tablet(s) by mouth once a day ISOSORBIDE MONONITRATE [IMDUR] - (Prescribed by Other Provider) - 30 mg Tablet Extended Release 24 hr - 1 (One) Tablet(s) by mouth once a day METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 2 (Two) Tablet(s) by mouth in the morning and 1 and [**11-28**] at bedtime OXYMORPHONE [OPANA ER] - (Prescribed by Other Provider) - 40 mg Tablet Extended Release 12 hr - 2 (Two) Tablet(s) by mouth twice a day RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg Tablet - 1 (One) Tablet(s) by mouth at bedtime SUCRALFATE [CARAFATE] - (Prescribed by Other Provider) - 1 gram Tablet - 1 (One) Tablet(s) by mouth at bedtime TERAZOSIN - (Prescribed by Other Provider) - 10 mg Capsule - 1 (One) Capsule(s) by mouth at bedtime TOPIRAMATE - (Prescribed by Other Provider) - 25 mg Capsule, Sprinkle - 2 (Two) Capsule(s) by mouth once a day Medications - OTC ASPIRIN - (OTC) - 81 mg Tablet, Chewable - 1 (One) Tablet(s) by mouth once a day DOCUSATE SODIUM [STOOL SOFTENER] - (Prescribed by Other Provider; OTC) - Dosage uncertain IRON - (Dose adjustment - no new Rx) - 325 mg (65 mg iron) Tablet - 1 (One) Tablet(s) by mouth once a day POTASSIUM - (OTC) - Dosage uncertain Discharge Medications: 1. albuterol sulfate Inhalation 2. Lotrel 10-40 mg Capsule Sig: One (1) Capsule PO once a day. 3. clonidine 0.1 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily). 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) shot Subcutaneous Q12H (every 12 hours). Disp:*14 * Refills:*0* 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. sucralfate 1 gram Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 9. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. potassium Oral 15. diltiazem HCl 360 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 16. topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 17. Orphenadrine Compound Oral 18. metformin 500 mg Tablet Sig: Two (2) Tablet PO qAM. 19. metformin 500 mg Tablet Sig: 1.5 Tablets PO at bedtime. 20. morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 21. morphine 15 mg Tablet Extended Release Sig: Five (5) Tablet Extended Release PO Q12H (every 12 hours). 22. diazepam 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for agitation. 23. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 24. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 25. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. Advair Diskus 100-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation twice a day. Discharge Disposition: Extended Care Facility: Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**]) Discharge Diagnosis: Primary diagnosis Secondary diagnosis Atrial fibrillation Pneumonia Delirium Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 27363**], You came to our hospital for surgery of your spine. The surgery went smoothly, however you did develop some complications post-op that required treatment in an intensive care unit. Briefly, you developed pneumonia, which was treated with antibiotics. Your atrial fibrillation also recurred, which has been successfully controlled by medication. Since your condition has improvement significantly, we think it will be at your best interest to continue your recovery at a rehabilitation facility. Please note that the following of your medications has been changed: -- Please stop taking Carbamazepine -- Please stop taking oxymorphone -- Please stop taking Dabigatran (Pradaxa). You doctor may advise you to restart this medication after finishing 4 weeks of lovenox. -- Please start taking topiramate (Topamax)at 50 mg twice a day (instead of daily) -- Please take Enoxaparin (Lovenox) 110 mg twice a day for 4 weeks -- Please take Morphine SR (MSContin) 75 mg twice a day -- Please take Morphine IR 15-30 mg as needed for pain up to every 4 hours It has been a privilege to take care of you while you are here. We all wish you a speedy recovery. Followup Instructions: Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 **] Address: [**Location (un) **], [**Hospital Ward Name **] 2, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3573**] Appointment: Monday [**6-5**] at 12PM [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2180-5-31**]

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36135+36136

Discharge summary

report+report

Admission Date: [**2113-10-2**] Discharge Date: [**2113-10-7**] Date of Birth: [**2077-9-22**] Sex: F Service: MEDICINE Allergies: Amoxicillin / bees / CT scan dye Attending:[**First Name3 (LF) 2195**] Chief Complaint: wheezing s/p bronchial thermoplasty Major Surgical or Invasive Procedure: bronchial thermoplasty History of Present Illness: 36 yo F with h/o severe persistent asthma, pericarditis, heart murmur, ovarian cysts, C-section x2, enrolled in the PAS study, s/p bronchiothermoplasty of RLL with wheezing post procedure. She has had severe asthma since her first pregnancy leading to several hospitalizations at [**Hospital1 3278**], the last in [**Month (only) **] she was admitted for 2 weeks despite being on maximal inhaled steroids and bronchodilators. She has completed several prednisone tapers after hospital admission, with which she feels jittery and gains weight. On the floor, patient is wheezing and feels very tight. Patient underwent her procedure today and postoperatively in the PACU she had chest pain and shortness of breath. Chest pain was [**9-25**] in severity. She got albuterol and 1g IV tylenol and morphine (total 5 mg) for pain with some relief. Glycopyrole to reduce secretions and prednisone preoperatively. PFTs preop were performed and her 4 hour postop PFTs were 60% of her preop PFTs. Per protocol, if PFTs less than 80% of preoperative values, then the patient requires admission for further evaluation. Past Medical History: Asthma (since childhood) Heart murmur Pericarditis Ovarian cysts C-section X 2 Social History: single mom, lives with her 2 children. Occupation: nanny and administrative director. Smoking history: denies ever. Alcohol: occasional <1 per week. No pets at home Family History: Daughter has asthma, well controlled Physical Exam: Admission exam Vitals: T:98.1 BP:114/59 P:103 R:18 O2:97%RA General: Alert, oriented, difficulty breathing, but not using accessory muscles HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diminished bilaterally on posterior, wheezing bilaterally, no rales or rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Non focal Discharge exam Vitals: T:99.0 BP:140/72 P:86 R:18 O2:99%RA General: Alert, oriented, lying flat asleep HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Air movement increased bilaterally, less wheezing but still some course breath sounds, no rales or rhonchi CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Non focal Pertinent Results: admission labs: [**2113-10-3**] 06:40AM BLOOD WBC-12.3*# RBC-3.34* Hgb-10.8* Hct-32.7* MCV-98 MCH-32.3* MCHC-33.0 RDW-12.8 Plt Ct-230 [**2113-10-3**] 06:40AM BLOOD Glucose-185* UreaN-8 Creat-0.7 Na-139 K-3.4 Cl-103 HCO3-22 AnGap-17 [**2113-10-3**] 03:20PM BLOOD CK(CPK)-68 [**2113-10-3**] 03:20PM BLOOD CK-MB-1 cTropnT-<0.01 [**2113-10-3**] 06:40AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1 ABG: [**2113-10-3**] 02:16PM BLOOD Type-ART pO2-168* pCO2-32* pH-7.46* calTCO2-23 Base XS-0 [**2113-10-3**] 08:43PM BLOOD Type-ART pO2-103 pCO2-36 pH-7.47* calTCO2-27 Base XS-2 [**2113-10-5**] 04:55AM BLOOD Type-ART pO2-92 pCO2-34* pH-7.47* calTCO2-25 Base XS-1 discharge labs: [**2113-10-7**] 05:55AM BLOOD WBC-13.9* RBC-3.46* Hgb-11.1* Hct-34.0* MCV-98 MCH-32.2* MCHC-32.7 RDW-13.3 Plt Ct-264 [**2113-10-7**] 05:55AM BLOOD Plt Ct-264 [**2113-10-7**] 05:55AM BLOOD Glucose-110* UreaN-14 Creat-0.6 Na-141 K-3.2* Cl-104 HCO3-26 AnGap-14 [**2113-10-7**] 05:55AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.3 [**2113-10-6**] 03:58AM BLOOD TSH-0.35 studies: CXR [**10-3**] Heart size and mediastinum are grossly unchanged since the prior study, but there is substantial interval development of perihilar opacities and bibasal consolidations as well as relatively low lung volumes. These findings are concerning for multifocal infection and less likely pulmonary edema. Small amount of pleural effusion cannot be excluded. Current study reveals no evidence of pneumothorax or pneumomediastinum within the limitations of this portable AP radiograph. LENI 1. No evidence of deep vein thrombosis in either leg. 2. Superficial thrombophlebitis seen in the left calf at the site of the patient's tenderness. CXR As compared to the previous radiograph, there is no relevant change. Relatively low lung volumes with parenchymal opacities at both lung bases, right more than left. The extent of the opacity is stable since the previous examination. Moderate cardiomegaly without evidence of pulmonary edema. No larger pleural effusions. No pneumothorax. Brief Hospital Course: This is a 36 yo F with hx of severe asthma who was admitted s/p bronchial thermoplasty for shortness of breath and wheezing. # Shortness of breath: Patient admitted s/p bronchial themoplasty for shortness of breath and wheezing. She was managed with IV steroids, frequent nebulizers, and oxycodone and morphine for pain. Her chest pain was evaluated with ECG and troponins which were negative for ischemic. Overnight she became tachypneic and tachycardic prompting transfer to the MICU for close monitoring. She was given heliox and ativan with improvement of her symptoms. She had a LENI for calf pain which was negative for DVT. She was transferred back to the floor however returned to the MICU due to persistent dyspnea and tachycardia. She was evaluated by ENT who found the patient to have paradoxical vocal fold motion which could be contributing to her symptoms. It was recommended that she start a reflux regimen and follow up with ENT in [**1-16**] weeks. She should also undergo respiratory retraining therapy. She was transitioned to a po prednisone taper regimen and repeat bedside spirometry showed improvement in her respiratory function. She was transferred back to the floor and remained stable overnight. She was discharged with plans to follow up with interventional pulmonary and ENT. # Anxiety: Respiratory distress responded to ativan in MICU. Psychosocial triggers believed to be a significant contributor to vocal cord malfunction and episodes of dyspnea. . TRANSITIONAL ISSUES: - no labs pending at time of discharge - Follow up for PVFM evaluation and respiratory retraining - Follow up with interventional pulmonology as scheduled - patient full code during admission Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea 2. albuterol sulfate *NF* 90 mcg/actuation Inhalation 2 puffs [**Hospital1 **] 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 5. Ipratropium Bromide MDI 1 PUFF IH Q6H 6. Montelukast Sodium 10 mg PO DAILY 7. ValACYclovir 500 mg PO PRN ulcers 8. NuvaRing *NF* (etonogestrel-ethinyl estradiol) 0.12-0.015 mg/24 hr Vaginal monthly Discharge Medications: 1. Montelukast Sodium 10 mg PO DAILY 2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 5. PredniSONE 10 mg PO DAILY Duration: 65 Doses Start: After 20 mg tapered dose. Take 60mg (six 10mg tabs) once per [**Known lastname **] for 3 [**Known lastname **]. Then take 50mg (five 10mg tabs) once per [**Known lastname **] for 3 [**Known lastname **]. Then take 40mg (four 10mg tabs) once [**Known lastname **] per for 3 [**Known lastname **]. Then take 30mg (three 10mg tabs) once [**Known lastname **] per for 3 [**Known lastname **]. Then take 20mg (two 10mg tabs) once [**Known lastname **] per for 3 [**Known lastname **]. Then take 10mg (one 10mg tab) once [**Known lastname **] per for 3 [**Known lastname **]. Then stop. Tapered dose - DOWN RX *prednisone 10 mg [**1-20**] tablet(s) by mouth daily as directed Disp #*65 Tablet Refills:*0 6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea 7. Ipratropium Bromide MDI 1 PUFF IH Q6H 8. NuvaRing *NF* (etonogestrel-ethinyl estradiol) 0.12-0.015 mg/24 hr Vaginal monthly 9. ValACYclovir 500 mg PO PRN ulcers 10. Albuterol Inhaler [**1-16**] PUFF IH Q6H:PRN shortness of breath RX *albuterol sulfate [ProAir HFA] 90 mcg 1-2 puffs inhaled every 4-6 hours Disp #*1 Each Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Asthma, Paradoxical vocal cord movement Secondary diagnosis: Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 81963**], It was a pleasure taking care of your at [**Hospital3 **] Medical Center. You were admitted after your lung procedure because of persistent wheezing and shortness of breath. You were managed with inhalers and medications but required two nights in the ICU for increased monitoring. You were evaluated by the ear, nose and throat experts who found that you have spasms of your vocal cords contributing to your shortness of breath. You improved with continued inhalers and breathing therapy. You should follow up with your pulmonologist as scheduled for futher management of your asthma. You will need to schedule an appointment to see ENT for further evaluation of your vocal cords. Please START taking: - Omeprazole 20mg PO BID - Prednisone taper as follows: 60 mg (6 tablets) for 3 [**Known lastname **] ([**Date range (1) 32271**]) 50 mg (5 tablets) for 3 [**Known lastname **] ([**Date range (1) 32272**]) 40 mg (4 tablets) for 3 [**Known lastname **] ([**Date range (1) 8258**]) Your pulmonologist can discuss how they want to complete your taper at your follow up appointment on [**10-17**]. Please continue taking you home medications as directed. Followup Instructions: Please call ENT at [**Telephone/Fax (1) 41**] to schedule a follow up appointment with Dr. [**Last Name (STitle) **] within 1-2 weeks. Department: PFT When: TUESDAY [**2113-10-17**] at 8:00 AM Department: PULMONARY FUNCTION LAB When: TUESDAY [**2113-10-17**] at 8:00 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2113-10-17**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Completed by:[**2113-10-8**] Admission Date: [**2113-10-9**] Discharge Date: [**2113-10-10**] Date of Birth: [**2077-9-22**] Sex: F Service: MEDICINE Allergies: Amoxicillin / bees / CT scan dye Attending:[**First Name3 (LF) 2145**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 36F with h/o severe persistent asthma, pericarditis, recently discharged after bronchiothermoplasty procedure complicated by asthma exacerbation returns to the ED with worsened dyspnea. She had been home less than 24 hours and felt that her breathing became acutely worse, she took prednisone 60 x1 and rescue inhalers without improvment peak flow measured at home was 300 (typically 350-370), she came into the ED for evaluation. She has had severe asthma since her first pregnancy leading to several hospitalizations at [**Hospital1 3278**], and at [**Hospital1 18**], requiring ICU admission for close monitoring (no intubations). She was admitted to [**Hospital1 18**] [**Date range (1) 81964**] for asthma exacerbation following bronchiothermoplasty of RLL. Her course as compliacted by tachypenia and tachycardia prompting transfer to the MICU for close monitoring. She was given heliox and ativan with improvement of her symptoms. She had a LENI for calf pain which was negative for DVT. She was transferred back to the floor however returned to the MICU due to persistent dyspnea and tachycardia. She was evaluated by ENT who found the patient to have [**Date range (1) 81965**] vocal fold motion which could be contributing to her symptoms. It was recommended that she start a reflux regimen (omeprazole) and follow up with ENT in [**1-16**] weeks. She was discahrged on a prednisone taper (60mg decreasing by 10mg every 3 [**Known lastname **]) with IP and ENT follow up. Initial VS in the ED:97 104 151/85 22 97%. Peak flow was 340. Exam notable for poor air movement and wheezes, occasional "barking cough". Labs notable for WBC 12.6 89% PMN Cr 0.8 UCG negative. Patient was given Albuterol/Ipratropium nebs x3, MethylPREDNISolone 125mg, Lorazepam 1mg IV for anxiety and 1L IVNS. VS prior to transfer: 98.1 84 139/82 20 100% Peak flow repeated at 340. On the floor, she complains of continued sharp right sided chest pain since bronchiothermoplasty pain is made worse by deep inhalation and exhalation. She has been coughing and occasionally bringing up yellow mucous. Temperature at home was 100.1. Review of systems: (+) Sweats, chills (-) Denies recent exposure to dust smoke or allergens. [**Doctor First Name **] headache, sinus tenderness.Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. Past Medical History: Asthma (since childhood) Heart murmur Pericarditis Ovarian cysts C-section X 2 Social History: single mom, lives with her 2 children. Occupation: nanny and administrative director. Smoking history: denies ever. Alcohol: occasional <1 per week. No pets at home Family History: Daughter has asthma, well controlled Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:98.2 BP:148/90 P:86 R: 18 O2:97% RA General: young woman layinig in bed speaking in full sentences, occasional barking cough, in no acute distress HEENT: Sclera anicteric, MMM, Neck: no LAD Lungs: Respiration unlabored. Poor air movement, faint bilateral wheezes. 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, Ext: Warm, no peripheral edema . DISCHARGE PHYSICAL EXAM: Vitals: T98.1 BP 130/83 HR 81 RR 20 SaO2 100% on RA General: NAD, lying in bed getting nebulizer tx. apperas in NAD. HEENT: Sclera anicteric, MMM, Neck: no LAD, no thyromegaly. Lungs: Respiration unlabored. Good air movement. Faint diffuse bilateral wheezes. 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, Ext: Warm, no peripheral edema Pertinent Results: LABS: [**2113-10-9**] 12:05AM BLOOD WBC-12.6* RBC-3.67* Hgb-11.7* Hct-36.1 MCV-99* MCH-32.0 MCHC-32.4 RDW-13.1 Plt Ct-285 [**2113-10-9**] 12:05AM BLOOD Neuts-89.6* Lymphs-8.1* Monos-1.5* Eos-0.7 Baso-0.1 [**2113-10-9**] 12:05AM BLOOD Glucose-173* UreaN-17 Creat-0.8 Na-138 K-4.6 Cl-101 HCO3-22 AnGap-20 [**2113-10-9**] 03:50AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015 [**2113-10-9**] 03:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG . IMAGING: [**2113-10-9**] CXR: Previous pulmonary vascular congestion and right lower lobe consolidation have nearly cleared. Heart size is normal. There is no pleural effusion. Brief Hospital Course: A 36 year old female with PMH severe asthma recently admitted s/p bronchialthermoplasty for asthma exacerbation returns to the hospital with asthma excerbation. ACUTE ISSUES: # Dyspnea: Likely multifactorial. Asthma exacerbation is very common after bronchialthermoplasty (90%) though her peak flow is approximately baseline. Her [**Month/Day/Year 81965**] vocal fold motion also likely contributing along with anxiety. Less likely to be pneumonia, as CXR showed improveds right sided infiltrate which is likely post-procedural edema. Patient received Methylprednisolone IV 125mg in ED along with nebs. Given patient's baseline peak flow is 350-370 and her current peak flow is 340, we restarted her steroid taper at Prednisone 40mg PO. Continued Albuterol, Impratropium nebs, Advair, Flovent. Started Lorazepam for her anxiety. # [**Month/Day/Year **] Vocal Fold Motion: seen on laryngoscopy in prior admission and may contribute to current dyspnea. Continued omeprazole and ranitidine. Will get close follow-up as an outpatient with speech & swallow. # Chest pain: right sided and pleuritic, likely related to inflammation following bronchiothermoplasty and patient's cough. EKG does not show any ischemic change. Pain controlled by oxycodone. TRANSITIONAL ISSUES: - follow up BCx Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Montelukast Sodium 10 mg PO DAILY 2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Omeprazole 40 mg PO DAILY 5. PredniSONE 60 mg PO DAILY Duration: 3 [**Known lastname **] Start [**2113-10-7**] 6. PredniSONE 50 mg PO Daily Duration: 3 [**Known lastname **] Start: After 60 mg tapered dose. 7. PredniSONE 40 mg PO Daily Duration: 3 [**Known lastname **] Start: After 50 mg tapered dose. 8. PredniSONE 30 mg PO Daily Duration: 3 [**Known lastname **] Start: After 40 mg tapered dose. 9. PredniSONE 20 mg PO Daily Duration: 3 [**Known lastname **] Start: After 30 mg tapered dose. 10. PredniSONE 10 mg PO Daily Duration: 3 [**Known lastname **] Start: After 20 mg tapered dose. 11. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea 12. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea 13. NuvaRing *NF* (etonogestrel-ethinyl estradiol) 0.12-0.015 mg/24 hr Vaginal Monthly 14. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation Inhalation 4-6H: PRN Dyspnea 15. ValACYclovir 500 mg PO Q12H take for 3 [**Known lastname **] at the start of outbreak Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY 3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 4. Montelukast Sodium 10 mg PO DAILY 5. Omeprazole 40 mg PO DAILY 6. PredniSONE 40 mg PO DAILY Tapered dose - DOWN 7. Ranitidine 150 mg PO HS 8. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea 9. NuvaRing *NF* (etonogestrel-ethinyl estradiol) 0.12-0.015 mg/24 hr Vaginal Monthly 10. Morphine Sulfate IR 15 mg PO Q6H:PRN Pain RX *morphine 15 mg 1 tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills:*0 RX *morphine 15 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills:*0 11. Lorazepam 0.5 mg PO Q4H:PRN Anxiety RX *lorazepam 0.5 mg 1 tablet(s) by mouth every six (6) hours Disp #*24 Tablet Refills:*0 12. Nystatin Oral Suspension 5 mL PO QID:PRN Thrush RX *nystatin 100,000 unit/mL 5 ml by mouth four times a [**Known lastname **] Disp #*1 Bottle Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Asthma exacerbation [**Known lastname **] focal fold motion. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**First Name4 (NamePattern1) 5930**] [**Known lastname **], It was a pleasure taking care of you at the [**Hospital1 18**]. You presented with shortness of breath. This is likely a combination of an asthma exacerbation and the [**Hospital1 81965**] vocal fold movement. We gave you both steroids intravenously then by mouth. We also gave you nebulizer treatments and your home asthma medications. Your peak flow improved to approximately baseline of 350-370. Please continue the steroid taper as prescribed. Please follow up with the Ear, Nose and Throat doctors regarding your [**Name5 (PTitle) 81965**] vocal fold movement. You have an appointment for Tuesday [**10-10**] at 3:00pm, please call the number below if you need to reschedule. We wish you a speedy recovery. Followup Instructions: Department: SPEECH THERAPY When: TUESDAY [**2113-10-10**] at 03:00 PM With: [**Last Name (LF) **], [**First Name3 (LF) **] Building: Span 106, please enter through the [**Hospital Ward Name 121**] entrance. Campus: West. Please call [**Telephone/Fax (1) 3731**] if you need to reschedule. Department: PULMONARY FUNCTION LAB When: TUESDAY [**2113-10-17**] at 8:00 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2113-10-17**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: OTOLARYNGOLOGY-AUDIOLOGY When: THURSDAY [**2113-10-26**] at 4:00 PM With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], MD [**Telephone/Fax (1) 41**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

[ "E932.0", "478.5", "518.52", "300.00", "493.92", "V58.65", "V70.7", "276.3", "786.05", "790.29", "V14.0" ]

icd9cm

[ [ [] ] ]

[ "31.42", "93.90", "32.27" ]

icd9pcs

[ [ [] ] ]

19558, 19564

15995, 17245

11466, 11472

19669, 19669

15273, 15972

20625, 21992

14210, 14249

18559, 19535

19585, 19648

17309, 18536

19820, 20602

3677, 5040

14289, 14766

17266, 17283

13632, 13908

11419, 11428

11500, 13613

8896, 8906

3030, 3661

19684, 19796

13930, 14011

14027, 14194

14791, 15254

79,174

135,985

42174

Discharge summary

report

Admission Date: [**2200-9-20**] Discharge Date: [**2200-9-27**] Date of Birth: [**2123-4-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 425**] Chief Complaint: ICD Pocket Infection Major Surgical or Invasive Procedure: Device and Lead Removal History of Present Illness: Mr. [**Known lastname **] is a 77 year-old male with BiV ICD (placed in the setting of newly diagnosed CHF and h/o LBBB), paroxysmal AF on coumadin, and CLL who is a direct admit with ICD pocket infection. The patient underwent a generator change in [**7-/2200**] after which he developed cellulitis and a hematoma over the generator site. These resovled and the patient did well until the day prior to admission when he noted pus draining from the ICD pocket and erethyma around the site. Saw his outpatient cardiologist who started cephalexin (3 doses to date) and recommended direct admission. He denies any pain over the site. No subjective fevers or other systemic symptoms. Portal of entry is believed to be small opening in the skin over the defibrilator. . On arrival to [**Hospital1 18**] the patient is in stable condition and without any symptoms. Initial vitals 98.4 114/78 78 20 96%RA. Past Medical History: - CHF diagnosed in [**2196**] - CAD with PCI in [**2196**] - H/o LBBB - CLL diagnosed in [**2192**]; Tx with rituxan and steroids for 4 months - Shingles on head and left eye [**2191**] - [**2147**] detached retina repair - [**2148**] hernia repair - [**2176**] intraocular lens implant - [**2183**] removal of left cheek basal cell carcinoma - [**2194**] laminectomy and discectomy on left Social History: Lives alone in [**Location (un) 7188**]. 4 children and 8 grandchildren. Former executive. Exercises regularly. 80 pack year history but quit 20 years ago. 1-2 drinks/month. No other drug use. Family History: Mother died of Leukemia at 52; father died of CHF at 75. Physical Exam: On Admission: Vitals- 98.4 114/78 78 20 96%RA General- Patient sitting up in chair in NAD HEENT- PERRLA, EOMI, anicteric, MMM, OP clear Neck- Supple, No JVP CV- RRR, S1 and S2, no m/r/g Lung- CTAB, no w/r/r Abdomen- Soft, NT/ND, BSx4 Extremeties- No gross deformity or edema Neuro- Awake, alert and oriented, CN II-XII intact, strength 5/5 throughout Pertinent Results: On Admission: [**2200-9-20**] 11:15AM BLOOD WBC-52.7* RBC-4.66 Hgb-13.6* Hct-41.6 MCV-89 MCH-29.2 MCHC-32.8 RDW-14.4 Plt Ct-96* [**2200-9-20**] 01:55PM BLOOD Neuts-3* Bands-0 Lymphs-89* Monos-2 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-5* [**2200-9-20**] 11:15AM BLOOD PT-22.1* PTT-46.8* INR(PT)-2.0* [**2200-9-20**] 11:15AM BLOOD Glucose-192* UreaN-25* Creat-1.0 Na-141 K-3.9 Cl-103 HCO3-27 AnGap-15 [**2200-9-20**] 11:15AM BLOOD Calcium-9.8 Phos-3.7 Mg-2.1 Studies: . CXR - Transvenous right atrial and left ventricular pacer leads and right ventricular pacer defibrillator leads follow their expected course from the left axillary pacemaker. There is no pneumothorax or pleural effusion. The heart is mildly enlarged, but there is no pulmonary vascular congestion, edema, or pleural effusion. Brief Hospital Course: Mr. [**Known lastname **] is a 77 year-old man who was admitted with a BiV ICD pocket infection. . #. ICD pocket infection - The patient noted pus draining from his ICD pocket on the morning prior to admission. He went to his out-patient cardiologist who diagnosed and ICD pocket infection and started the patient on cephalexin and recommended a direct admission to [**Hospital1 18**]. On arrival to [**Hospital1 18**] on [**2200-9-20**], the patient was noted to have pus draining from his ICD pocket and an area of skin that had been eroded by the device. ID was consulted and blood/wound cultures were taken. On [**2200-9-21**], the patient was started on vancomycina and cefepime. The patient went to the OR for removal of ICD and leads. Intraoperative TEE showed possible small pericardial effusion, which on later TTE was neglible. The patient remained intubated the day of procedure and was transferred to CCU. He was extubated on the morning of POD #1. The patient was started on nafcillin on [**2200-9-23**] once cultures grew MSSA. 4 days later the patient developed [**Last Name (un) **] and nafcillin was stopped due concerns for AIN. IV Cefazolin was started on [**9-25**] and will be complete at home on [**2200-10-6**]. He will be sent home with home with a VNA to monitor recovery from the pocket wound and with infusion services for cefazolin IV 2g q8. The [**Last Name (un) **] was resolving prior to discharge with the creatinine near the patient's baseline. . #. Atrial Fibrillation - The patient has a history of paroxysmal afib for which he is on coumadin. His INR on arrival here was therepeutic at 2.0 and the patient was in sinus rhythym. The coumadin as held pending intervention on [**2200-9-22**]. Given 5mg vitamin K. We helding his ASA and coumadin until five days postoperatively, then restarted prior to discharge. The patient will need to follow up with coumadin clinic for monitoring. . #. CHF - The patient carries a history of CHF for which he received the ICD in [**2196**]. On arrival at [**Hospital1 18**], he appeared euvolemic. His carvedilol, losartan, statin, and furosemide were continued at his home dosing. The patient's ASA was held until POD#5, then restarted. . #. CLL/thrombocytopenia - Mr. [**Known lastname **] carries a history of CLL for which he has received rituxan and steroids in the past. During prior operations he has had significant bleeding and required platelet transfusions. Hematology was consulted and he received 2 units of platelets perioperatively. Medications on Admission: Carvedilol 25mg'' Simvastatin 20mg' Warfarin 5mg Sun-Thurs, 2.5mg Fri-Sat Losartan 50mg' Furosemide 20mg Mon/Wed/Fri Cosopt eye drops 1 drop [**Hospital1 **] in left eye Alphagan 0.1% drops 1 drop [**Hospital1 **] in left eye Lotemax 0.5% drops 1 drop [**Hospital1 **] in left eye Lorazepam 1mg' QHS Lutein 10mg'' Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 2. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for Anxiety. 4. Lotemax 0.5 % Ointment Sig: One (1) Ophthalmic once a day. 5. Cosopt 2-0.5 % Drops Sig: One (1) Ophthalmic [**Hospital1 **] (2 times a day). 6. cefazolin 1 gram Recon Soln Sig: Two (2) 2g Intravenous every eight (8) hours for 9 days. Disp:*54 grams* Refills:*0* 7. Outpatient Lab Work Please obtain a CBC, electrolyte, creatinine and PT/PTT/INR on Thursday, [**2200-10-2**]. Please fax results to [**Telephone/Fax (1) 91467**] (attention to Dr. [**Last Name (STitle) 656**] 8. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 9. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 10. losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. 11. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Primary: ICD Pocket Infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]! You were admitted due to infection of the pocket holding your ICD. In the hospital you were treated with antibiotics and the device was removed in the operating room. You tolerated the procedure well, and we continued your antibiotics after the device was taken out. See below for changes to your home medication regimen: Continue to take cefazolin See below for instructions regarding follow-up care: Followup Instructions: Please set up a follow up appointment with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 5315**]) on Tuesday [**2200-10-1**] . Please set up a follow up appointment with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 3342**]) in two weeks

[ "041.11", "287.5", "996.61", "998.12", "425.4", "423.9", "996.72", "580.9", "204.10", "E930.0", "428.0", "E878.1", "E849.7", "427.31", "414.01", "112.89", "E878.8", "V58.61", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "37.79", "37.77" ]

icd9pcs

[ [ [] ] ]

7100, 7159

3189, 5721

323, 348

7233, 7233

2365, 2365

7875, 8128

1921, 1979

6085, 7077

7180, 7212

5747, 6062

7384, 7852

1994, 1994

263, 285

376, 1279

2379, 3166

7248, 7360

1301, 1693

1709, 1905

23,933

104,301

7539

Discharge summary

report

Admission Date: [**2112-3-21**] Discharge Date: [**2112-4-1**] Date of Birth: [**2039-11-3**] Sex: M Service: MEDICINE Allergies: Penicillins / Morphine Attending:[**First Name3 (LF) 5037**] Chief Complaint: SOB Major Surgical or Invasive Procedure: PICC line placed History of Present Illness: This is a 72 yo M with DMI, HTN, h/o MI, Chronic Kidney Disease s/p LURT [**9-/2105**] from wife, recent diagnosis of adenocarcinoma of lung Stage 1A T1NO (with left upper lobectomy) who presents with SOB over the past week and decreased UO. The pt states that he stopped taking his Lasix 1 week ago due to excessive urination at that time. He has had progressive SOB now over the past 3 days, to now feeling SOB even at rest. He admits to orthopnea, PND, and cough (non-productive). He states that the swelling in his legs has actually improved over the past 2 weeks. . In the ED, the patient's vitals were: BP 130/52 (102-122/31-66) HR 118 (102-115) RR 26 O2 Sat 100% on NRB. He was noted to be anemic with a hct of 18 (Baseline 26-30), but was guaiac negative. BNP was elevated at 7882. He received Lasix 60 mg IV after 1 unit of PRBC. Cr is elevated at 2.9 (baseline 2-2.5). Iron studies and hemolysis labs were ordered per renal recs. CXR was consistent with pulmonary edema. . On ROS, pt denies weight changes, chest pain, palpitations, abdominal pain. He admits to no bowel movement in several days. Past Medical History: 1. Diabetes x25 years 2. hypertension 3. cholesterolemia 4. myocardial infarction in [**2104**] 5. severe osteoarthritis effecting the hips, shoulders, knees 6. spinal stenosis bothering his back 7. chronic kidney disease s/p living related renal transplant in [**9-/2105**] with a graft from his wife 8. peripheral vascular disease s/p bilateral lower extremity revascularizations and bilateral toe amputations. 9. left upper lobectomy for an asymptomatic newly defined left upper lobe pulmonary nodule seen at the time of revision of lower extremity bypass graft back in [**2111-9-27**]. Path revealed poorly differentiated adenocarcinoma, 0/5 lymph nodes positive. His postoperative course was complicated by urinary retention and a subsequent readmission with urosepsis. He was staged as T1 N0, stage 1A, without need for further treatment. 10. Diastolic Heart Dysfunction: Echo [**1-3**]: There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated athe sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). 11. Klebsiella bacteremia, UTI and sepsis [**2-3**] Social History: Smoked cigarettes until [**2083**]. No ETOH. He lives at home. Retired, but was previously a truck driver. Family History: Significant for lung cancer in the patient's father who developed this at age 75, but subsequently died of a stroke. Physical Exam: Vitals: BP 136/37 HR 95 RR 26 Sat 100% NRB-->ABG: 7.41/37/112 GEN: obese caucasian male sitting at 60 degrees in bed with respiratory accessory muscle use and paradoxical abdominal wall movements with breathing HEENT: pupils constricted, conjunctivae anicteric/noninjected but pale, MMM NECK: JVP at mandible with +HJR CV: distant heart sounds, regular rhythm, no m/r/g LUNGS: rales at bilateral lung bases R>L, poor air movement AB: soft, nontender, mildly distended and protuberant, paradoxical abdominal wall movements with breathing EXTREM: 2+ pitting edema in BL LE up to the knees, BL toe amputations (all 10 toes amputated), 1+ radial pulses bilaterally SKIN: chronic venous insufficiency changes in the BL LE NEURO: alert and oriented, moving all 4 extremities Pertinent Results: Studies: [**2112-3-21**] EKG: EKG: sinus tachnycardia, nl axis, TWI and 1mm ST depressions in V5-6, [**Street Address(2) 4793**] elevation in V2, TWI in lateral and inferior leads-->all old from [**1-3**] . [**2112-3-21**] CXR: IMPRESSION: Moderate bilateral pulmonary edema, with more focal consolidative process involving the right lower lobe, likely representing areas of alveolar pulmonary edema. Cardiogenic versus renal etiology is not completely clear; recommend correlation with clinical history and labs to clarify the etiology. . [**2112-3-22**] Renal transplant ultrasound: IMPRESSION: Normal renal transplant ultrasound. . [**2112-3-22**] CXR: FINDINGS: A portable upright chest radiograph shows diffuse alveolar edema, right greater than left, with some sparing of the left upper lobe. Top normal heart size and mild central pulmonary vascular congestion. Compared to yesterday's study, there may be slightly more focal consolidation at the right base. PICC line placed via the right upper extremity is seen with the tip at the level of the mid superior vena cava. . [**2112-3-23**] CXR: PORTABLE CHEST: Comparison to a day prior reveals persistent alveolar edema again with some sparing of the left upper lobe. Heart size and pulmonary vascular congestion appears unchanged. Although more focal consolidation at the right base is less evident on today's film, this may simply be due to patient rotation. Evaluation of the apices are limited by head positioning. Worsening of small pleural effusions is noted bilaterally. A right sided PIC catheter is unchanged in position. . [**2112-3-24**] CXR: Compared to prior studies from [**3-22**] and 28th, there has been interval improvement in now mild interstitial pulmonary edema. Right lower lobe consolidation has also improved. Cardiomediastinal contour is unchanged. There is blunting of the posterior CP angles likely small pleural effusions. Right PICC line tip is in the SVC. . [**2112-3-22**] ECHO: LVEF 60% Conclusions: The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. 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 borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2112-1-27**], tissue Doppler analysis was included in the current study with evidence of elevated LV filling pressure. . EGD: Grade 1 esophagitis in the lower third of the esophagus . Colonoscopy: 1. Diverticulosis of the sigmoid colon 2. Polyps in the cecum (polypectomy) 3. Polyp in the descending colon (polypectomy) Brief Hospital Course: Mr. [**Known lastname 27548**] is a 72 year old male with DMI, HTN, h/o MI, ESRD s/p LURT [**9-/2105**] from wife, recent diagnosis of adenocarcinoma of lungs Stage 1A T1NO (with left upper lobectomy) who presented with SOB most consistent with pulmonary edema. . #Shortness of Breath/Hypoxia: The patient had pulmonary edema likely in the setting of diastolic dysfunction exacerbated by self-discontinuation of lasix (pt. self d/c'd because he was "tired of urinating all the time"). Additionally, he was tachycardic on admission and has known diastolic dysfunction which likely also played a role. BNP was 7000 on admission. Another likely contributor to his dyspnea was his anemia, as below. There were no signs of PNA clinically, and serial CXR showed improvement of pulmonary edema. He was initially admitted to the ICU and required a NRB to keep his oxygen saturation greater than 90%. He was placed on a nitro gtt to decrease his preload. He had an ECHO which showed grade II diastolic dysfunction and a LVEF of >60%. He was given metoprolol with a goal HR in the 60s and SBP in the 120s. His respiratory status improved markedly with diuresis and cardiac rate control and he will be discharged to rehab maintaining oxygen saturations on room air. He is back on his home dose of 80mg PO lasix daily to which he has been putting out well. . #Acute on Chronic Renal Insufficiency: His baseline creatinine is 1.9 to 2.9, with a recent trend upward from 1.9 (max 3.6 during this hospitalization). He is s/p living related donor renal transplant in [**2105**] and is on sirolimus, cellcept, and prednisone. This was likely multifactorial in the setting of decompensated CHF and worsening anemia. FeUrea was consistent w/ pre-renal cause. Renal transplant US was normal without evidence of obstruction. Per renal recommendations his immunosuppression meds were originally decreased as his sirolimus level was 9 on admission (goal [**5-2**] as he is 7 years out from transplant). His sirolimus was changed from 3mg daily to 2mg. He will, however, be discharged on 3mg sirolimus daily as his level trended down during his stay. This should be followed qweekly at rehab until follow up with renal. His cellcept was changed from 500mg TID to 250mg [**Hospital1 **] and he was continued on prednisone 5mg daily. Given his acute on chronic renal failure and anemia (discussed further below), an SPEP and UPEP were sent, both of which were negative. His renal function continued to improve during his stay with continued diuresis and PRBC transfusions and creatinine on discharge was 1.7. His prophylactic bactrim was held during his stay secondary to his worsened renal function, but should be reinitiated upon follow up as long as his renal function remains stable. . #Anemia: His HCT was 18 on admission from a previous baseline of 26-30. His chronic anemia likely from CKD and chronic inflammation, but acute exacerbation was not initially clear. During his hospital stay, he required a total of 6units of prbcs. He was consistently guaiac negative although reports several weeks prior to admission he had a large grossly bloody BM, but none since. EGD and colonoscopy were performed which did not reveal a source of bleed. GI recommended small bowel follow through prior to pill endoscopy, but patient could not tolerate original study due to hip pain and then refused repeat prior to discharge. His reticulocyte count was appropriately elevated, making marrow suppression unlikely. Iron studies revealed significantly low iron and he was repleted with IV iron. A serum TTG was sent to rule out celiac disease. He will be discharged on PO iron supplementation. Hemolysis labs were not suggestive of active hemolysis. He will be discharged on erythropoeitin in addition to iron supplementation. His hematocrit should be followed at rehab. He should follow up as scheduled with hematology and iron studies should be rechecked in [**2-28**] weeks. Hematocrit on discharge was 29.3. . #DM: He was admitted on 100 Units NPH [**Hospital1 **]. His insulin requirement, however, was significantly lower while inpatient, however, appears now to be consistently increasing. He will be discharged on 34Units qam and 36Units qhs, but this will need to be adjusted. . # UTI: Urine cultures on admission grew Klebsiella sensitive to ciprofloxacin. He has a history of BPH and high PVRs as well as a history of recurrent UTIs and bacteremia. He is followed by urology as an outpatient. His foley was removed here and he has been voiding without difficulty without elevated PVRs. A recent urine culture grwe enterococcus sensitive to vanco, ampicillin (pt. allergic to PCN), nitrofurantoin (contraindicated in pt's w/ crcl <60). He will need to be continued on vancomycin for a 10 day course. Vancomycin levels should be followed at rehab to ensure therapeutic levels. He is to complete his course of ciprofloxacin for klebsiella on [**2112-4-4**]. . #CAD: On admission, he was found to be tachycardic. Cardiac enzymes were felt to be secondary to tachycardia in the setting of severe anemia. He had no EKG changes consistent with acute ischemia nor symptoms of chest pain. He was continued on metoprolol for improved rate control, aspirin, and lipitor. . #Grade 1 Esophagitis: Asymptomatic, but found on endoscopy performed in the setting of his anemia. H. pylori antibody was sent which will need to be followed up. He was started on a PPI to be taken twice daily for 1 week and then once daily thereafter. . #Hyperlipidemia: He was continued on his home dose statin. . #PPX: SC Heparin until increasingly ambulatory with physical therapy. . #Access: PICC line placed during this hospitalization. . #CODE: FULL Medications on Admission: Trimethoprim-Sulfamethoxazole 160-800 mg Tablet daiy Prednisone 5 mg daily Doxazosin 4 mg qhs Lasix 80 mg daily Norvasc 5 mg daily Metoprolol 100 mg [**Hospital1 **] Gabapentin 100 mg twice daily Sirolimus 3 mg qhs Mycophenolate Mofetil 500 mg three times daily NPH insulin 100 units [**Hospital1 **] Tamsulosin 0.4 mg Capsule, Sust. Release 24HR daily Lipitor 60 mg daily Niaspan 500 mg Tablet Sustained Release qhs Colace ASA 81 mg daily Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours). 9. Atorvastatin 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Niaspan 500 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO at bedtime. 14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 15. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous once a day for 10 days. 16. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**]) units Injection QMOWEFR (Monday -Wednesday-Friday). 17. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 5 days. 19. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: Following the completion of twice daily dosing (in 5 days). 20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 34 units qam, 36 units qhs Subcutaneous daily. 21. Humalog 100 unit/mL Solution Sig: sliding scale as directed Subcutaneous daily. 22. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 23. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: Primary: Diastolic congestive hear failure Urinary tract infection Acute on chronic renal failure Anemia Diabetes mellitus . Secondary: Coronary artery disease Hypertension Hypercholesterolemia Lung adenocarcinoma Discharge Condition: Stable maintaining oxygen saturation on room air. Hematocrit stable. Discharge Instructions: Please call your doctor or return to the emergency room if you develop worsening shortness of breath, lower extremity swelling, chest pain, fevers, chills, pain/discomfort with urination, blood in your stool or any other symptoms that concern you. . Please follow up with your appointments as outlined below. . Please complete your course of antibiotics as prescribed. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] on Monday [**4-18**] at 2pm. . Please follow up with Dr. [**First Name (STitle) 805**] on [**4-26**] at 1:30pm. . Please follow up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2112-4-20**] 1:00pm (Hematology/Oncology) . Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14116**] on [**7-1**] at 3:30pm at [**Last Name (un) **] Diabetes Center. . Please call Dr.[**Name (NI) 825**] office in order to arrange for urologic follow up ([**Telephone/Fax (1) 7707**]. . Appointments scheduled prior to this admission: 1. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2112-4-7**] 10:00 2. Provider: [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**0-0-**] Date/Time:[**2112-4-7**] 3:30 [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]

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icd9cm

[ [ [] ] ]

[ "38.93", "45.42", "45.13" ]

icd9pcs

[ [ [] ] ]

15613, 15688

7280, 13017

286, 304

15946, 16017

3943, 7257

16434, 17468

3019, 3138

13508, 15590

15709, 15925

13043, 13485

16041, 16411

3153, 3924

243, 248

332, 1442

1464, 2878

2894, 3003

18,105

198,383

24001

Discharge summary

report

Admission Date: [**2160-5-16**] Discharge Date: [**2160-7-6**] Date of Birth: [**2083-3-27**] Sex: F Service: SURGERY Allergies: Codeine / Heparin Agents Attending:[**First Name3 (LF) 3223**] Chief Complaint: pancolitis, sepsis, MS changes Major Surgical or Invasive Procedure: subtotal colectomy & end colostomy [**5-18**] History of Present Illness: 77F known UC x 1yr who developed recalcitrant UC following a fall in early [**Month (only) 547**]. She presented to [**Hospital1 **] on [**5-16**] with pancolitis in severe sepsis & was admitted to the MICU service. Her condition was not responding to maximal medical therapy--with continued fevers, mental status changes, and worrisome runs of ventricular tachycardia--she was brought to the OR on [**5-18**] by Dr [**Last Name (STitle) 519**] & received a subtotal colectomy with end ileostomy. Please refer to the previosuly dictated op note for the details of this procedure. Past Medical History: peptic ulcer disease arthritis hypertension hysterectomy ulcerative colitis multiinfarct dementia Social History: patient is a nonsmoker and lives alone, she is a widow Family History: noncontributory Physical Exam: GEN-ill appearing woman HEENT-anicteric, flushed skin, oral mucosa dry, neck supple CV-rrr, no r/m/g resp-expiratory wheezes, no accessory muscle use [**Last Name (un) 103**]-no bowel sounds, generalized tenderness ext-3+ pitting edema, DP 1+ bilaterally Pertinent Results: [**2160-5-16**] 08:02PM GLUCOSE-125* UREA N-23* CREAT-0.3* SODIUM-147* POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-34* ANION GAP-10 [**2160-5-16**] 08:02PM ALT(SGPT)-97* AST(SGOT)-73* ALK PHOS-87 TOT BILI-4.2* [**2160-5-16**] 08:02PM ALBUMIN-2.1* CALCIUM-8.0* PHOSPHATE-2.1* MAGNESIUM-1.6 [**2160-5-16**] 08:02PM WBC-3.1* RBC-3.08* HGB-9.8* HCT-29.0* MCV-94 MCH-31.9 MCHC-33.9 RDW-18.5* [**2160-5-16**] 08:02PM NEUTS-57 BANDS-25* LYMPHS-15* MONOS-0 EOS-3 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* [**2160-5-16**] 08:02PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL OVALOCYT-2+ SCHISTOCY-2+ TEARDROP-2+ BITE-2+ [**2160-5-16**] 08:02PM PLT SMR-LOW PLT COUNT-123* [**2160-5-16**] 08:02PM PT-16.4* PTT-31.7 INR(PT)-1.7 (at discharge) [**2160-7-4**] 07:15AM BLOOD WBC-6.6 RBC-3.57* Hgb-11.1* Hct-33.9* MCV-95 MCH-31.1 MCHC-32.8 RDW-17.6* Plt Ct-322 [**2160-7-1**] 12:00PM URINE Blood-SM Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2160-7-4**] 07:15AM BLOOD Plt Ct-322 [**2160-6-25**] 04:17AM BLOOD PT-12.4 PTT-25.0 INR(PT)-1.0 Brief Hospital Course: She had a prolonged SICU course following this surgery, which is summarized below in an organ system based approach. Neurologic: Despite waking soon after extubation in the first week postop, she developed increasing lethargy for the next several weeks. Neurology was consulted, and both radiographic imaging & EEG were negative for pathology. Her lethargy was ultimately attributed to poor clearance of sedating medications and she finally perked up about three weeks after surgery. Zoloft was empirically started for depression, with some benefit. Neurontin was started for pain control. Following placement of her transgastric jejunostomy tube on [**6-2**] the patient did require intermittent subcutaneous morphine and vicodin. Her mental status was markedly improved following transfer to the floor. WIth minimization of sedating medications she is alert and oriented. Cardiac: She received perioperative beta blockade after her initial dependence on vasopressors was weaned. Her preop runs of ventricular tachycardia persisted for a couple days postop but eventually subsided. About 1 week postop, she developed atrial fibrillation which responded to amiodarone. Cardiology was consulted and anticoagulation was decided against after she reverted to normal sinus rhythm by POD14. She remains on amiodarone and lopressor. She remained in normal sinus rhythm from the time of her transfer to the floor on [**2160-6-30**]. Respiratory: Her mental status led to a difficulty weaning off the ventilator & in fact, she required re-intubation due to tachypnea & poor clearance of secretions. Once extubated a 2nd time, she avoided reintubation with frequent nebs, suctioning & chest PT. By the time of discharge, she has saturations of 96-100% on nasal cannula. She did require frequent chest PT and nebulizer treatments as well as encouragement to breathe deeply. FEN: She was about 20 kg over her dry weight (70kg) during this admission. She received diuresis with lasix & diamox, with good effect. Nutritionally, she was sustained periop with TPN & transitioned to tube feeds once her ostomy was functional. Following removal of her dobhoff tube, a swallow consult was obtained. The swallow specialists recommended the following: "begin a po diet, but with modified solid textures to reduce the work of chewing. Thin liquids are recommended, as they appear no different than nectar thick liquids, and only very trace aspiration occurs." However, per the nutrition service the patients caloric intake was insufficient to meet her nutritional needs. Thus a transgastric jejunostomy tube was placed on [**2160-6-2**] by interventional radiology. In consultation with the nutrition service the patient was rapidly advanced to her goal nutritional support of 65ccs/hour of Promote with fiber. GI: She receives a PPI for GI prophylaxis. She tolerated tube feeds via a dobhoff tube & her ostomy is functional. Her voluminous ostomy output is controlled with banana flakes TID. She had a slight amount of drainage from her abdominal wound in her 2nd postop week, during several staples were removed. This is healing well at the time of discharge with wet to dry packings. Her ostomy consistently appeared pink and the patient was getting routine ostomy care from the enterostomal nurse at the time of discharge. HEME: She had blood loss anemia & anemia of chronic disease requiring multiple RBC transfusions. She developed severe sepsis about POD14, during which time her WBC count dropped to neutropenic levels & she was treated with neupogen at the suggestion of the heme onc team. She also developed heparin-induced thrombocytopenia, for which her heparin was DC'd & she was continued on daily aspirin. The primary surgical team decided against an IVC filter. At the time of discharge her only blood thinner was aspirin. ID: She develop pseudomonal & fungal pneumonia, bacteremia, urinary tract infections, sepsis & septic shock. The ID team consulted on the case. She was successfully treated with meropenem & fluconazole prior to discharge. At the time of discharge the patient was noted to have a recurrent pseudomonas urinary tract infection resistant to levofloxacin thus the patient was discharged on a course of meropenem. Her foley catheter was to be d/c'ed on arrival to [**Hospital6 13314**]. ENDO: Her diabetes was being managed initally with an insulin drip and at the time of discharge a sliding scale. However, her blood sugars rarely required insulin coverage at the time of discharge. Hypoadrenalism was treated early in the [**Hospital 228**] hospital course with hydrocortisone. The patient also was noted to have sick euthyroid syndrome. DISPO: full code Medications on Admission: protonix 40 atenolol 25 Ca carbonate with vitamin D colazoal 1500 TID mercaptopurine 100 QD hydrocortisone enema 100 PR QD vicodin allergy:novocaine Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. 3. Insulin Regular Human 100 unit/mL Solution Sig: see sliding scale see slding scale Injection ASDIR (AS DIRECTED). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed. nebulizer 6. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Erythromycin 5 mg/g Ointment Sig: 0.5 Ophthalmic QID (4 times a day). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) NEB Inhalation Q4H (every 4 hours) as needed. 12. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO PRN (as needed) as needed for PRN K< 4. 15. Meropenem 1 g Recon Soln Sig: One (1) 1000 mg Intravenous every eight (8) hours for 5 days. Disp:*15 * Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: peptic ulcer disease arthritis hypertension hysterectomy fulminant ulcerative colitis multiinfarct dementia atrial fibrillation sepsis neutropenia respiratory failure requiring intubation pneumonia postop atelectasis hypokalemia hypomagnesemia hypocalcemia heparin induced thrombocytopenia blood loss anemia anemia of chronic disease fungal UTI & pneumonia wound infection pseudomonas urinary tract infection poor po intake Discharge Condition: good Discharge Instructions: contact with fevers > 101, increasing abdominal pain or vomiting, or if you have any questions/concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 519**] in one week. Call ([**Telephone/Fax (1) 5323**] for appointment and directions. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2160-7-6**]

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icd9cm

[ [ [] ] ]

[ "93.90", "51.22", "96.6", "96.72", "99.15", "46.21", "00.14", "46.32", "38.93", "45.73", "99.04" ]

icd9pcs

[ [ [] ] ]

9001, 9075

2634, 7347

314, 362

9542, 9548

1489, 2611

9701, 9988

1182, 1199

7547, 8978

9096, 9521

7373, 7524

9572, 9678

1214, 1470

244, 276

390, 973

995, 1094

1110, 1166

23,599

105,879

15584

Discharge summary

report

Admission Date: [**2119-11-16**] Discharge Date: [**2119-12-5**] Date of Birth: [**2048-8-27**] Sex: F Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This is a 71-year-old female patient with a known history of aortic stenosis reports recent increase in dyspnea on exertion over the past month. She was admitted to the [**Hospital1 69**] for cardiac catheterization prior to undergoing a scheduled aortic valve replacement. Patient at that time denied history of syncope or chest pain. Cardiac catheterization performed on [**2119-11-16**] revealed a right dominant system with single vessel coronary artery disease, severe aortic stenosis with a calculated aortic valve area of 0.86 cm squared and a mean gradient of 33 mm Hg, left ventricular ejection fraction estimated at 58%, and a left ventricular end diastolic pressure of 24. PAST MEDICAL HISTORY: Patient has a history of supraventricular tachycardia which was treated with atenolol, known aortic stenosis, spastic colon. The patient describes a history of scarlet fever as a child, arthritis of both knees, history of renal calculus, significant hearing loss, cataract surgery, status post D&C, status post bilateral knee replacements, bilateral appendectomies, status post tonsillectomy. ALLERGIES: The patient states allergies to Biaxin. MEDICATIONS ON ADMISSION TO THE HOSPITAL: Atenolol 25 mg po q day, cholestyramine 4 mg po q day, Fosamax 70 mg once a week. She also took nitroglycerin sublingual prn, Percocet prn, Compazine prn, and Serax prn. SOCIAL HISTORY: The patient is retired, former 40 pack year smoker, quit 10 years ago. Denies alcohol intake and she is recently widowed. FAMILY HISTORY: Is significant for a mother who died of complications related to a CVA. Father died of complications related to a CVA. PHYSICAL EXAMINATION ON ADMISSION TO THE HOSPITAL: Temperature 97.3, blood pressure 128/52, pulse 62 and regular, on room air oxygen saturation is 95% and respiratory rate of 20. Neurologically, the patient is alert and oriented with no apparent deficits. HEENT were unremarkable. Pulmonary examination: Lungs were clear to auscultation bilaterally. Coronary examination was regular, rate, and rhythm with a systolic murmur evident. Abdomen was soft, obese, and nontender with positive bowel sounds. Her extremities were warm and well perfused. Patient was taken to the operating room on [**2119-11-17**] where she underwent a minimally invasive aortic valve replacement with a 21 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. Please refer to operative report for details of surgical procedure and operative event. Postoperatively, the patient was transported from the operating room to the Cardiac Surgery Recovery Unit on intravenous amiodarone, intravenous Levophed, and IV propofol drips. She was initially atrially placed via her temporary epicardial wires. Patient was initiated on insulin drip for hyperglycemia at that time. On the night of her surgical day, [**11-17**] into the morning of [**11-18**], the patient was noted to have questionable seizure activity. Patient's anesthesia drugs were reversed and she was noted to have increased jerky-type movements. Emergency neurologic consult was obtained. The patient spiked a fever to 102 at that time, and otherwise remained hemodynamically stable. On the morning of [**11-18**], Neurology consult was obtained. Patient was started on Dilantin for witnessed seizure activity. She was felt to have had partial complex seizures at that time. She had a stable cardiac rhythm at that time and her epicardial wires were discontinued to facilitate emergent MRI scan to evaluate the etiology of her seizure activity. The MRI from later that morning was suspicious for an acute right middle cerebral artery infarct with a small left hemisphere infarct stressed to embolic events. Patient was then initiated on a Heparin drip. She was also pancultured for fever and increasing white blood cell counts. These cultures other than a positive urine culture for E. coli ultimately were negative. Patient was placed on ceftriaxone empirically pending results of a culture which was sent at that time. Patient was transfused to maintain a hematocrit of approximately 30%. She also was placed on intravenous Levophed to keep her systolic blood pressure greater than 130 mm Hg to optimize cerebral perfusion at the recommendation of the Neurology staff. She remained hemodynamically stable, although febrile at times with full ventilator support and no seizure activity noted. The patient continued to be febrile for the next 24 hours or so, and remained on empiric antibiotics pending results of cultures. A repeat CT scan on [**11-19**] showed no hemorrhage with no evidence of shift and some, mild edema in the right frontal lobe area. On [**11-20**], patient remains on IV amiodarone drip, although no other vasoactive drips were continued at that time. She remained on some insulin intermittently to treat hyperglycemia. She had some atrial fibrillation also on that day for which she received an additional bolus of IV amiodarone. An electroencephalogram was done at that time which was consistent with mild encephalopathy, however, no focus seen for seizure activity. There are also no clear periods of wakefulness noted at that time. On the following day, [**11-21**], the patient continued with ventilator weaning. Required minimal ventilator support, but it was felt inappropriate to extubate her at that time due to patient's inability to protect her airway. She was maintained on Dilantin to prevent further seizure activity and her electrolytes were being repleted. She also had some intermittent bursts of atrial fibrillation at that time with rates between the 80s and 120s with ventricular rates. On [**11-22**], the patient showed some signs of wakefulness. She began to nod her head in response to questions asked, although she was noted to have left arm weakness at that time. Patient was started on tube feeds which she was tolerating well and appeared to be waking up appropriately. Patient at that time later on that day began to follow one-step commands. Repeat head CT scan also on the [**11-22**] revealed evolution of multiple small right frontal and parietal infarcts. Chest x-ray at that time revealed a left lower lobe collapse and some left pleural effusion. The following day on the [**11-23**], patient continued with burst of atrial fibrillation treated with intravenous Lopressor and continued on the intravenous amiodarone. Chest x-ray showed a persistent left lower lobe collapse with some effusion. On [**11-24**], the patient was much brighter mentally. She was much more interactive with people's surrounding her. She was moving both of her legs. She was moving her right arm freely and moving her left arm, although with less vigor than her right arm. Her tube feeds were held, and later morning of [**11-24**], the patient was extubated successfully. On [**11-25**], physical therapy became involved with her care. Her intravenous central line has been discontinued and sent for culture which ultimately turned out to be negative, and her ceftriaxone was discontinued since the only positive culture from the previous fever spike was urine, which had been adequately treated. On [**11-26**], the patient had intermittent periods of confusion, however, was overall very interactive with her caregivers. [**Name (NI) **] chest x-ray showed a continued left pleural effusion for which a chest tube was placed. She remained at this time in normal sinus rhythm. The following day, [**11-27**], she continued with physical therapy. She was noted to have a large raised area at the superior aspect of her sternal incision with no erythema and she had some serous drainage on the superior aspect of her incision. Patient also underwent a bedside swallowing evaluation by the Speech and Swallowing therapist to evaluate safety of airway protection and risk of aspiration. It was felt that she visually did at least fairly well by her bedside evaluation and a modified barium swallow is recommended to be followed up on. Patient's white blood cell count at this time rose to 22,000 and she was again pancultured. She was begun empirically on Vancomycin IV and levofloxacin via nasogastric tube at that time due to increasing white blood cell count. Also Gastroenterology consult was obtained for possible placement of a PEG if she were unsuccessful with her barium swallow which was scheduled for the following day. On [**11-28**], the patient did undergo a modified barium swallow, which she passed well, and she was at a low risk for aspiration. She was then supervised. She also began to have very large amounts of diarrhea over the next 24-48 hours. Patient has a history of "spastic colon", and however, stated that this was much more significant than her baseline. Her white blood cell count had come down minimally to 20.8 thousand, however, she had a fever of 101.7. She was resumed on her cholestyramine and the Gastroenterology service was reconsulted on [**11-29**] due to increasing diarrhea. Three Clostridium difficile specimens were sent and were all negative, as well as subsequent stool cultures which also came back negative. Neurologically the patient had been waking up significantly on a daily basis. She was much more bright and interactive. She had some left arm weakness, but otherwise was moving her other three extremities fairly well. She was begun on Coumadin at the recommendation of the Neurology Service for her stroke as well as for her history of multiple postoperative episodes of atrial fibrillation. The following day, [**2119-11-30**], the patient continued to remain stable hemodynamically. Remained in normal sinus rhythm. White blood cell counts were slowly coming down to 16.9 thousand and all subsequent cultures came back positive. She continued to have some sternal drainage with moderate amounts of erythema around the drainage area and just superior to the top of her sternal wound incision. Over the next 48 hours, the patient remained stable. Her white blood cell count has been slowly decreasing. She remains alert and oriented. Her diarrhea has subsided. Her IV Heparin drip for anticoagulation was discontinued because her INR had become therapeutic with Coumadin dosing, and she remains stable today on [**2119-12-4**] and is ready to be discharged to rehabilitation facility to continue with physical therapy and increasing mobility. Patient's status today on [**2119-12-4**] is as follows: temperature 99.4. Patient is in normal sinus rhythm at 82/minute, her blood pressure is 110/54, her oxygen saturation on a 2 liter per minute nasal cannula is 96% with a respiratory rate of 23/minute. Most laboratory values are from today, [**12-4**] which revealed a white blood cell count of 13.0 thousand, hematocrit of 32.3, platelet count of 480. PT of 20.6, INR of 2.8. Sodium of 143, potassium 3.9, chloride of 106, CO2 20, BUN 14, creatinine 0.7, glucose 99. Physical examination: Neurologically, the patient is awake, alert, and interactive with some left arm weakness. Cardiovascularly, patient remains in normal sinus rhythm, regular S1, S2 with no murmur noted. Her respiratory examination is stable. Her lungs are clear to auscultation bilaterally. Her sternum is stable with a small amount of serous drainage at the top area of her wound. Erythema is significantly decreasing on the Vancomycin and levofloxacin. Patient remains on a cardiac diet with aspiration precautions. The patient is scheduled to have a PICC line placed today in the Interventional Radiology Department so that she may continue to receive her Vancomycin for another five days. Most recent Vancomycin levels revealed a trough of 6.8 and a peak of 18.1. Most recent Dilantin level is 8.6 on [**2119-11-29**]. DISCHARGE MEDICATIONS: Amiodarone 400 mg po q day, Dilantin 300 mg po bid, metoprolol 75 mg po bid, aspirin 81 mg po q day, cholestyramine 4 grams po q day, psyllium one packet po q day, pantoprazole 40 mg po q day, acetaminophen 650 mg po q4h prn, miconazole powder 2% topically qid prn, Vancomycin 1 gram IV q12 hours x5 more days. Her last dose should be on [**2119-12-10**] morning dose. Levofloxacin 500 mg po q day x5 more days, also to end on [**2119-12-10**]. Patient is on a sliding scale of regular insulin coverage for a glucose of 150-200 she should receive 3 units subQ, blood glucose of 200-250 6 units subQ, and a glucose of 250-300 9 units subQ. The patient is also on daily Coumadin. She received 1 mg on [**Month (only) **] and 1 mg on [**12-4**]. Her INR should be between 2 and 2.5 as a goal for her stroke as well as atrial fibrillation. The recommendation of the Neurology Service, is to continue anticoagulation for at least 6-8 weeks. The patient is to followup with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] at area code ([**Telephone/Fax (1) 1504**] upon discharge from rehabilitation facility. Please contact our service at that number for any surgical-related questions for Mrs. [**Known lastname **]. The patient is also to followup with her primary care cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in [**Hospital1 1474**], [**State 350**] at telephone number ([**Telephone/Fax (1) 16005**]. She should follow up with him regarding continued amiodarone dosing and also for anticoagulation followup. She is to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], attending neurologist here upon discharge from rehabilitation facility and her telephone number is ([**Telephone/Fax (1) 15319**]. Discharge diagnosis is aortic stenosis status post aortic valve replacement, postoperative atrial fibrillation, cerebrovascular accident with seizure activity, pleural effusion, urinary tract infection. DISCHARGE STATUS: Stable. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2119-12-4**] 15:42 T: [**2119-12-4**] 16:12 JOB#: [**Job Number 45069**]

[ "997.02", "780.39", "511.9", "424.1", "599.0", "997.3", "427.31" ]

icd9cm

[ [ [] ] ]

[ "37.23", "35.21", "88.53", "39.61", "88.56" ]

icd9pcs

[ [ [] ] ]

1715, 11131

11990, 14274

11154, 11966

185, 871

894, 1557

1574, 1698

74,459

108,621

42948

Discharge summary

report

Admission Date: [**2110-12-7**] Discharge Date: [**2110-12-9**] Date of Birth: [**2046-1-8**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: none History of Present Illness: 64 yo M s/p MVA. The patient states that he was shopping with his wife, they got back to the car and then he passed out and hit a parked car. He denies any chest pain, difficulties breathing, nausea or vomiting prior to this incident. He denies any urinary or bowel incontinence and did not have a similar episode in the past. +EtOH (237 on admission). In the ER the patient received 500ml NS, no meds per report or documented in chart. Of note, the patient states that he was stung by a bee yesterday for which he took benadryl at home and then went to ER at OSH where he was observed for 2.5 hours. He did not get an epinephrine injection. Past Medical History: PMH: ?CRI, HTN, HLD, "thyroid dz",?aortic aneurysm PSH: "gum surgery" Physical Exam: 99.4 67 110/64 15 96%2L NAD/AAO RRR CTA b/l SNDNT no peripheral edema Pertinent Results: [**2110-12-7**] 05:18PM BLOOD WBC-7.8 RBC-4.38* Hgb-14.0 Hct-42.4 MCV-97 MCH-32.0 MCHC-33.1 RDW-13.1 Plt Ct-275 [**2110-12-7**] 10:01PM BLOOD WBC-9.4 RBC-4.23* Hgb-13.6* Hct-40.9 MCV-97 MCH-32.1* MCHC-33.2 RDW-13.1 Plt Ct-239 [**2110-12-8**] 06:19AM BLOOD WBC-7.4 RBC-3.80* Hgb-12.2* Hct-37.2* MCV-98 MCH-32.0 MCHC-32.8 RDW-13.2 Plt Ct-221 [**2110-12-7**] 05:18PM BLOOD UreaN-26* Creat-2.1* [**2110-12-7**] 10:01PM BLOOD Glucose-126* UreaN-23* Creat-1.5* Na-140 K-3.6 Cl-102 HCO3-25 AnGap-17 [**2110-12-8**] 06:19AM BLOOD Glucose-156* UreaN-19 Creat-1.1 Na-137 K-3.9 Cl-103 HCO3-26 AnGap-12 [**2110-12-7**] 05:18PM BLOOD ASA-NEG Ethanol-237* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: He was admitted to the trauma ICU from the ED for pain control and respiratory monitoring related to his rib fractures. he was placed on CIWA protocol given his +blood alcohol level at time of admission. He remained in the ICU for approximately 24 hours and once determined that his pain was controlled prn morphine he was transferred to the regular nursing unit. Once on the nursing unit he was transitioned to oral narcotics for which he reported adequate relief. He was given a bowel regimen as well. Social work was consulted for assessment re; his +blood alcohol level. At time of discharge his pain is adequately controlled, he is tolerating a regular diet and ambulating independently. He will follow up in [**1-25**] weeks in [**Hospital 2536**] clinic for repeat chest xray imaging. Medications on Admission: ASA, thyroid medicine, antihypertensive, statin Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Advil 200 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 5. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 6. senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: s/p Motor vehicle crash Bilateral rib fractures [**2-28**] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * Your injury caused rib fractures on both sides of your chest which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). Followup Instructions: Follow up in [**1-25**] weeks in [**Hospital 2536**] clinic call [**Telephone/Fax (1) 600**] for an appointment. You will need a standing end expiraotry chest xray before this appointment. Completed by:[**2110-12-9**]

[ "E812.0", "E849.5", "305.01", "807.04", "403.90", "401.9", "585.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3414, 3420

1916, 2714

321, 327

3522, 3522

1202, 1893

5136, 5355

2812, 3391

3441, 3501

2740, 2789

3672, 5113

1108, 1183

274, 283

355, 1000

3537, 3648

1022, 1093

18,209

129,206

28466

Discharge summary

report

Admission Date: [**2150-3-23**] Discharge Date: [**2150-5-5**] Date of Birth: [**2099-2-20**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 64**] Chief Complaint: Chronic Osteo Left Hip Major Surgical or Invasive Procedure: [**2150-3-26**]: Left hip disarticulation [**2150-3-28**]: I&D with VAC placement [**2150-3-30**]: Revision hip disarticulation, I&D, VAC placement [**2150-4-1**]: I&D left hip with primary closure and surface VAC placement [**2150-4-3**]: VAC change [**2150-4-7**]: I&D left hip with VAC change [**2150-4-13**]: I&D left hip with VAC change [**2150-4-16**]: I&D left hip with stump closure and VAC change [**2150-4-21**]: VAC d/c'd [**2150-4-25**]: PICC "fell out" [**2150-4-27**]: PICC placed in angio History of Present Illness: Mr. [**Known lastname 17811**] is a 51 year old man with history of severe OA s/p bilateral THR in [**2145**] complicated by recurrent MSSA infections of the left hip s/p extensive wash out, girdlestone revision, and removal of retained cement by Dr. [**Last Name (STitle) **] in [**10-10**]. He now presents with worsening left hip pain and swelling. Past Medical History: -osteoarthritis: status post bilateral total hip arthroplasty, with left hip prosthesis removed in [**2149-1-5**] (MSSA) -seizure disorder -hypertension -substance abuse -hepatitis C -erectile dysfunction -urinary retention Social History: Patient lives with girlfriend and two children. History of IVDU and currently endorses smoking [**3-8**] cigarettes per day. Denies alcohol. Played college and semiprofessional football. Nonambulatory at baseline. Family History: Noncontributory. Physical Exam: Physical Exam: T 97.0 P 80 BP 122/78 R 18 SaO2 96% RA Gen - nad HEENT - no scleral icterus Lungs - clear Heart - RRR Abd - Soft, NT, ND, BS+ Extrem - Left hip with well healed scar, moderate swelling, warmth and fluctuance over left hip, tender to palpation, left foot and ankle with swelling 2+ DP/PT pulses bilaterally Brief Hospital Course: Mr. [**Known lastname 17811**] presented to the [**Hospital1 18**] and was admitted on [**2150-3-23**] with worsening left hip pain and swelling. He stated that he had noted some drainage of brown fluid from his left hip. He also reports fevers, chills, and night sweats prior to presenting the to hospital. Given his debilitating pain and chronic osteomyelitis he was recommended to have a hip disarticulation vs. amputation as possible treatment options. Mr. [**Known lastname 17811**] was in favor of this agreement given his current degree of debilitation as well as the severity of his pain. On [**2150-3-26**] he was prepped and consented and taken to the operating room for a left hip disarticulation. He was again taken to the operating room on [**2150-3-28**] for and I&D with VAC placement. On [**2150-3-29**] he was transfused with 2 units of packed red blood cells due to post operative anemia. On [**2150-3-30**] he was again taken to the operating room for a revision of the left hip disarticulation with Incision and drainage with VAC placement. On [**2150-4-1**] he was again taken to the operating room for an I&D of the left hip with primary closure and surface VAC placement. Also on [**2150-4-1**] he was transferred to the ICU fordyspnea and possible seziure. He was started on Ciproflox per infectious disease. On [**2150-4-2**] he was seen by neurology and started on Keppra for seziures. He was also transferred out of the ICU and started on Vancomycin and cefepime. On [**2150-4-3**] he had his VAC changed at the bedside he was also transfused with 2 units of packed red due to post operative anemia. On [**2150-4-7**] he returned to the operaing room for an I&D with VAC change. On [**2150-4-13**] he again went to the operating room for an I&D with VAC change also per infectious disease his cefpime was stopped and oral cipro was started. On [**2150-4-16**] he was again taken to the operating room for and I&D with stump closure and VAC change. On [**2150-4-20**] he was seen by renal for question of acute renal failure. He was diagnosed with acute interstitial nephritis most likley due to Cipro. He was placed on ceftriaxone for antibiotic coverage. He was also seen by renal due to urinary retention. It was believed that is was a result of narcotic use. He should follow up with urology for prostate exam. Throughout his hospital stay he was seen by physical and occupational therapy to improve his strength and mobility. His surgical staples were removed and his sutures should be removed on [**2150-5-16**]. He will continue with vancomycin for a total of 6 weeks. This may be revised by infectious disease. Mr. [**Known lastname 17811**] has been doing his own wound care to the left groin. He has continued to clean the site with the commercial wound cleanser, applying the DuoDerm wound gel to the wound and covering it with dry gauze. The yellow slough is thinner and there is more pink granulation tissue. He is to continue with this care on a daily basis.He is being discharged today in stable condition. Medications on Admission: Medications: Lisinopril 40mg daily Hydrochlorothiazide 25 mg daily Tramadol 50 mg tid PRN Nifedipine 90 mg SR daily Atenolol 100 mg daily Percocet 1-2 tabs q 4-6 hours PRN Methadone 40 mg [**Hospital1 **] Senna PRN Colace 100 mg [**Hospital1 **] Protonix 40mg daily Elavil 50mg po qhs Discharge Medications: 1. Outpatient Lab Work Please draw weekly CBC with diff, BUN, Cr, Vanco trough, and Chem 7 and fax to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 432**] Please draw first set of labs on [**2150-5-1**] 2. PICC Care PICC Care per protocol 3. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) 1000mg Intravenous Q 12H (Every 12 Hours) for 4 weeks: Total length of treatment to be determined by infectious disease. 4. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) 1gm Intravenous Q24H (every 24 hours) for 4 weeks: Total lenght of treatment to be determined by infectious disease. 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 weeks: Total length of treatment to be determined by infectious disease. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Hold for heartrate less than 60 or SBP less than 110. 7. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO BID (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Nifedipine 30 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO DAILY (Daily): Hold for SBP less than 90. 11. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. 13. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 14. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 16. Sodium Chloride 1 g Tablet Sig: Two (2) Tablet PO TID (3 times a day). 17. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 18. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 19. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 20. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30mg syringe Subcutaneous Q12H (every 12 hours) for 4 weeks. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Left hip osteomyilitis Post operative anemia Discharge Condition: Stable Discharge Instructions: Continue to ambulate as instructed Continue your antibiotics as directed If you notice any increased redness, drainage, or swelling, or if you have a temperature greater than 101.5 please call the office or come to the emergency department. Physical Therapy: Activity: Activity as tolerated Treatments Frequency: Stump: Dry dressing daily or as needed for comfort or drainage. Site: left groin Type: Exfoliating rash/skin reaction Comment: please evaluate frequently and clean with soap and water, make sure dry when done Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment. Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the Infectious Disease clinic on [**2150-5-18**] at 9:00am. Call the office at [**Telephone/Fax (1) 457**] to confirm your appointment. Please schedule an appointment with urology for a prostate and urinary exam. Please call [**Telephone/Fax (1) 164**] to schedule that appointment. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2150-5-19**] 9:30 Completed by:[**2150-5-5**]

[ "719.45", "788.20", "682.2", "041.04", "041.11", "711.05", "730.15", "E930.8", "998.59", "440.22", "733.42", "V02.59", "305.1", "E879.8", "070.70", "580.89", "349.82", "731.3", "998.6", "401.9", "V09.0" ]

icd9cm

[ [ [] ] ]

[ "84.18", "99.04", "83.32", "86.22", "38.93", "93.59" ]

icd9pcs

[ [ [] ] ]

7741, 7814

2107, 5177

339, 845

7903, 7912

8491, 9170

1728, 1746

5512, 7718

7835, 7882

5203, 5489

7936, 8179

1776, 2084

8197, 8231

8253, 8468

277, 301

873, 1229

1251, 1478

1494, 1712

26,893

111,476

51012

Discharge summary

report

Admission Date: [**2177-5-16**] Discharge Date: [**2177-5-18**] Date of Birth: [**2119-11-24**] Sex: F Service: MEDICINE Allergies: Ampicillin / Codeine / Penicillins / Amoxicillin / Risperidone / Lisinopril Attending:[**First Name3 (LF) 358**] Chief Complaint: DKA, manic episode Major Surgical or Invasive Procedure: none History of Present Illness: 57F h/o insulin-dependent DM2, CAD, CKD, syncope, Bipolar disorder presented with AMS. The patient states that she had been walking home, and the police picked her up and had her go to the hospital in an ambulance. Per report, the patient was agressive, yelling at cars, throwing a doll towards passing vehicles when she was picked up by the police and had her brought to the hospital. The patient states she did not take her insulin last night, but reports otherwise being compliant with her medications. She reports taking her psych medications. On arrival to the ED, the patient was agitated and aggressive, requiring chemical and physical restraints. Vital signs: HR 90-100 and SBP 140s (of note, BP varies depending on location -- check on forearm rather than upper arm). Labs were drawn, notable for WBC 11.8 with 77% polys but no bands, glucose 586, AG 18, Cre 2.4, CK 715, CKMB 5, TnT 0.02, lactate 3.3. Concern for DKA, and given 2L NS bolus, then 500cc/hr and started on insulin gtt at 7 U/hr. U/A sent after IVF as UOP poor was negative including ketones. CXR and ECG unremarkable. Serum and urine tox screens negative. Believe psych-induced medication noncompliance, possibly due to [**Last Name (LF) **], [**First Name3 (LF) **] discussed case with psychiatry consult who deferred evaluation until acute medical condition resolved. Admitted to [**Hospital Unit Name 153**] for DKA treatment. Past Medical History: 1. Diabetes mellitus, type 2 2. Bipolar disorder 3. Hypercholesterolemia 4. Hypertension 5. Dystonia 6. Syncope (?vasovagal or volume depletion) 7. Chronic kidney injury (Cre 1.5 baseline) Past Surgical History: 1. Status post total abdominal hysterectomy/right salpingo-oophorectomy for benign fibroids. Status post laparoscopy for ovarian cyst. 2. Status post cholecystectomy. 3. Status post hernia repair. 4. Status post tonsillectomy. Social History: Divorced in [**2163**] after 11 years of marriage. Lives alone and worked as a nursing assistant, but is now on disability. Smoked cigarettes for five years, but quit in [**2163**]. Endorses a history of alcohol use of about one six pack per week, also quit that in [**2163**]. Denies illicit drug use. Family History: Non-contributory Physical Exam: AF, VSS, on room air Gen: obese female, NAD HEENT: sclera anicteric, op clear, neck supple CV: RRR, no murmurs Lungs: CTA bilaterally Abd: obese. well healed surgical scar. normal BS Ext: trace edema Neuro: alert, orient, nonfocal Pertinent Results: Admission LABS: ------------- [**2177-5-16**] 01:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2177-5-16**] 01:55AM WBC-11.8*# RBC-4.56 HGB-11.8* HCT-37.8 MCV-83 MCH-26.0* MCHC-31.3 RDW-14.0 [**2177-5-16**] 01:55AM NEUTS-77.0* LYMPHS-19.7 MONOS-2.9 EOS-0.1 BASOS-0.2 [**2177-5-16**] 01:55AM PLT COUNT-431# [**2177-5-16**] 01:55AM GLUCOSE-586* UREA N-27* CREAT-2.4* SODIUM-130* POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-18* ANION GAP-23 [**2177-5-16**] 03:20AM CK-MB-5 cTropnT-0.02* [**2177-5-16**] 03:20AM CK(CPK)-714* [**2177-5-16**] 03:20AM GLUCOSE-533* UREA N-28* CREAT-2.6* SODIUM-131* POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-18* ANION GAP-23* [**2177-5-16**] 03:59AM LACTATE-3.3* [**2177-5-16**] 04:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2177-5-16**] 04:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG Reports: ------- [**2177-5-16**]- HEAD CT- CT OF THE HEAD WITHOUT CONTRAST: There is no intracranial mass lesion, hydrocephalus, shift of normally midline structures, major vascular territorial infarct, or intracranial hemorrhage. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Prominence of the sulci and ventricles likely consistent with mild cerebral atrophy. Hypodensities within the periventricular white matter likely represent chronic microvascular ischemic changes. The osseous and soft tissue structures are unremarkable. The visualized paranasal sinuses are clear. IMPRESSION: No acute intracranial process. [**2177-5-16**] CXR- FINDINGS: Portable AP view of the chest in upright position. The cardiomediastinal silhouette is normal. The lungs are clear. There is no pneumothorax or pleural effusion. The pulmonary vasculature is normal. The osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. [**2177-5-16**] EKG- Sinus tachycardia. There are non-diagnostic Q waves in the inferior leads. Compared to the previous tracing non-diagnostic Q waves are new and the rate is faster. ======================================== Discharge Labs: [**2177-5-18**] 06:05AM BLOOD WBC-8.1 RBC-4.02* Hgb-10.8* Hct-32.7* MCV-81* MCH-26.9* MCHC-33.0 RDW-14.3 Plt Ct-323 [**2177-5-18**] 06:05AM BLOOD Glucose-123* UreaN-20 Creat-1.6* Na-139 K-4.8 Cl-106 HCO3-23 AnGap-15 [**2177-5-17**] 07:05AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.7 Brief Hospital Course: 57F h/o insulin-dependent DM2, CAD, CKD, syncope, Bipolar disorder presents with AMS, DKA. # DKA: Although less common, occurs in DM2 especially given her insulin dependence. Urine ketones may have been masked by hydration. Likely precipitating factor was medication non-compliance due to psychiatric disorder. No infectious sourse identified. Blood cultures no growth to date on transfer. She initially received IV insuling gtt in the [**Hospital Unit Name 153**], and resumed her outpatient insulin regimen with Lantus 30 units qhs and oral glyburide, glitazone on transfer to the floor. This worked well. Her electrolytes were stable, and anion gap closed. Her aspirin, statin were continued, [**Last Name (un) **] restarted one day prior to transfer to psychiatry. # AMS: Possibly due to manic episode, complicated by DKA. Psychiatry consulted and recommended inpatient psychiatric hospitalization. She was discharged to [**Hospital1 **] 4 after medical clearance. # Acute renal failure: Cre 2.4 on admission increased from baseline 1.5, likely pre-renal due to osmotic diuresis and poor PO intake. Improved to baseline with hydration. [**Last Name (un) **] resumed one day prior to discharge. # Hypertension: Stable. #. Contact: [**Name (NI) **] [**Name (NI) 76796**] [**Name (NI) 4223**] [**Telephone/Fax (1) 105973**] Medications on Admission: 1. Candesartan 16 mg PO BID. 2. Atorvastatin 20 mg PO DAILY. 3. Ziprasidone HCl 20 mg PO BID. 4. Glyburide 5 mg PO BID. 5. Pioglitazone 45 mg PO DAILY. 6. Lantus 30 units QHS Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Pioglitazone 15 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime. 10. Ziprasidone HCl 20 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 11. Candesartan 16 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Humalog Please give qAC, qHS. If BG<60, give juice/crackers. BG 60-120, give nothing. BG 121-150 give 2 units. BG 151-200 give 4 units. BG 201-250 give 6 units. BG 251-300 give 8 units. BG 301-350 give 10 units. BG 351-400 give 12 units. If blood glucose greater than 400, please [**Name8 (MD) 138**] MD. Discharge Disposition: Extended Care Facility: [**Hospital1 18**] -[**Hospital1 **] 4 - [**Hospital Ward Name 517**] (West Contact) Discharge Diagnosis: 1. diabetc ketoacidosis 2. bipolar disorder, [**Hospital Ward Name **] 3. chronic kidney disease, stage III 4. coronary artery disease Discharge Condition: manic, Section XII, transferring to inpatient psychiatry, medically cleared. Discharge Instructions: You were admitted to the hospital for diabetic ketoacidosis. This improved with IV insulin and remained stable on your previous medications. You will be discharge to inpatient psychiatry. Please take all your medications as prescribed. Call your primary physician with glucose >400, changes in your mood, chest pain, fever greater than 101. Followup Instructions: Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2177-6-3**] 8:30 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2177-8-5**] 10:00 Please arrange an appointment with [**Company 191**], urgent care at [**Telephone/Fax (1) 250**] prior to discharge home for hospital follow up.

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Discharge summary

report+addendum

Admission Date: [**2118-2-27**] Discharge Date: [**2118-3-15**] Date of Birth: [**2042-2-7**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Latex Attending:[**Doctor First Name 3298**] Chief Complaint: Right subdural hematoma Major Surgical or Invasive Procedure: AV fistula graft partial resection Left IJ line placement History of Present Illness: Patient is a 76 year old female with end stage renal disease who was at [**Hospital3 **] following a mechanical fall at home where she reportedly struck her head on the right side. She was admitted on [**2118-2-22**] and had been undergoing dialysis. On [**2-27**] while undergoing dialysis she had an episode where she was observed to begin twitching on the left side of her face and was transiently unresponsive. The entire seizure lasted approximately 2 minutes and she was not aware of the episode. She states she has never had an episode like this or has ever been told that she has had one that she was unaware of. Following the episode she underwent a noncontrast CT scan of the head which showed a right sided subdural hematoma measuring 10mm at it;s thickest and producing no measurable midline shift. Neurologically she returned to her baseline following a post-ictal period. After reviewing the CT scan it was determined that she would be transferred to [**Hospital1 18**] for further evaluation. Prior to transfer she received 2 units of FFP, platelets, and vitamin K. Of note, she was found to have MSSA bacteremia while at [**Hospital3 **] with a presumed fistula cellulitis. She had been using a right arm fistula and a left IJ dialysis line was placed as well. Subsequently she had the left IJ line discontinued and a femoral catheter was placed. Upon arrival she has no complaints and verbalizes well her reasoning for transfer. She denies headaches, nausea, vomiting, dizziness, weakness, numbness, tingling, changes in vision, hearing, or speech, or changes in bowel habits. MEDICINE ACCEPT NOTE: Ms. [**Known lastname 33522**] is a 76yo F with history of ESRD on HD, DVT with IVC filter and OA s/p R knee replacement who presented to [**Hospital3 10960**] after a mechanical fall, had seizure like activity during HD on [**2-27**] and was found to have small subdural hematoma on CT, erythema around her AV graft and blood cultures on [**2-22**] +for MSSA. Ms. [**Known lastname 33522**] was admited to OSH following a mechanical fall at home where she reportedly struck her head on the right side. She was admitted on [**2118-2-22**] and had been undergoing dialysis. On [**2-27**] while undergoing dialysis she had an episode where she was observed to begin twitching on the left side of her face and was transiently unresponsive. The entire seizure lasted approximately 2 minutes and she was not aware of the episode. She states she has never had an episode like this or has ever been told that she has had one that she was unaware of. Following the episode she underwent a noncontrast CT scan of the head which showed a right sided subdural hematoma measuring 10mm at its thickest and producing no measurable midline shift. Neurologically she returned to her baseline following a post-ictal period. After reviewing the CT scan it was determined that she would be transferred to [**Hospital1 18**] for further evaluation. She has had 2 subsequent CT scans that showed that the bleed is stable and does not require intervention. Patient is followed by Neurology who did bedside EEG monitoring and saw no seizures. Though she was initially on anti-seizure meds (Keppra/Dilantin), they were dc'd 2/13 days ago and pt still remains seizure free. While at OSH, she was found to have a DVT in the R brachial vein, and [**4-20**] blood cultures on [**2-22**] grew MSSA. She received vancomycin for this until narrowing to cefazolin on [**2-25**] after cx data returned. Given her presumed infected AV graft, she had a L IJ HD line placed on [**2-25**] but this stopped functioning, and R femoral HD line was placed on [**2-26**]. On [**2-28**], her R femoral HD line was removed and L IJ HD line was placed. The patient had a TTE on [**2-26**] at OSH which did not show any vegetations but was remarkable for mild to moderate MR [**First Name (Titles) **] [**Last Name (Titles) **]. ID is following. She was transitioned to Vancomycin per HD protocol. TEE was obtained [**3-2**] and ruled out endocarditis. Currently, patient feels "much better." She denies any pain at fistula site. No sob, no chest pain, no abdominal pain, no cough, no headache, no dysuria. Does report constipation, last BM 4 days ago. Past Medical History: ESRD on HD tuesday/thursday/saturday afib GI bleeds gastric bypass DVT with IVC filter sarcoidosis Social History: lives at home with husband, no ETOH or tobacco Family History: non contributory Physical Exam: PHYSICAL EXAM: VS - Tc 99.8 Tm 100.2 BP 118-158/33-57 HR 82-99 RR 19 O2-sat %95RA GENERAL - NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, irregularly irregular, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs); left hand with splint and swelling s/p fall at home; R AV fistula non erythematous, non tender, +bruit SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly, muscle strength 5/5 throughout, sensation grossly intact throughout DISCHARGE PHYSICAL EXAM: VS: Temp 97.4, BP 178/78, HR 99, RR 20, O2 96% on RA GEN: A&OX3, NAD HEENT: PERRL, MMM, OP clear NECK: supple, no LAD, JVD not visulized LUNG: CTA bilaterally, no r/rh/w HEART: RRR, no m/r/g EXT: non pitting edema in LUE SKIN: bruise over L knee with dressings, incision over R forearm, 1 cm skin tear over L forearm Pertinent Results: ADMISSION LABS [**2118-2-28**] 12:14AM BLOOD WBC-8.7 RBC-2.08*# Hgb-6.7*# Hct-20.9*# MCV-100* MCH-32.2* MCHC-32.1 RDW-15.0 Plt Ct-394 [**2118-2-28**] 12:14AM BLOOD PT-11.1 PTT-22.1* INR(PT)-1.0 [**2118-2-28**] 12:14AM BLOOD Glucose-104* UreaN-82* Creat-6.7*# Na-133 K-4.3 Cl-88* HCO3-28 AnGap-21* [**2118-2-28**] 12:14AM BLOOD ALT-6 AST-34 LD(LDH)-386* AlkPhos-79 Amylase-98 TotBili-0.4 [**2118-2-28**] 12:14AM BLOOD Albumin-3.3* Calcium-7.2* Phos-4.7* Mg-2.2 [**2118-2-28**] 08:00PM BLOOD calTIBC-198* VitB12-1367* Folate-GREATER TH Ferritn-1584* TRF-152* [**2118-2-28**] 12:14AM BLOOD Phenyto-<0.6* DISCHARGE LABS [**2118-3-15**] 07:00AM BLOOD WBC-10.4 RBC-2.66* Hgb-8.3* Hct-26.3* MCV-99* MCH-31.4 MCHC-31.6 RDW-17.5* Plt Ct-516* [**2118-3-15**] 07:00AM BLOOD PT-25.2* INR(PT)-2.4* [**2118-3-15**] 07:00AM BLOOD Glucose-64* UreaN-38* Creat-4.3* Na-139 K-3.9 Cl-98 HCO3-29 AnGap-16 [**2118-3-15**] 07:00AM BLOOD Calcium-9.1 Phos-1.2* Mg-2.3 PERTINENT LABS [**2118-3-6**] 06:16AM BLOOD ESR-50* [**2118-3-1**] 02:34PM BLOOD Ret Aut-1.9 [**2118-3-9**] 10:50AM BLOOD Albumin-3.0* Mg-2.1 [**2118-3-1**] 02:34PM BLOOD calTIBC-200* Ferritn-1643* TRF-154* [**2118-3-1**] 02:34PM BLOOD PTH-198* [**2118-3-6**] 06:16AM BLOOD CRP-195.9* [**2118-3-14**] 07:40AM BLOOD Phenyto-7.3* [**2118-3-11**] 11:00AM BLOOD Phenyto-8.0* [**2118-3-9**] 12:35PM BLOOD Phenyto-8.8* MICROBIOLOGY Blood culture [**2-28**] X2, [**3-1**] X2, [**3-2**] X2, 2/17X1, 2/19X1 - no growth AV graft - MSSA Catheter tips [**2-28**] and [**3-2**] - no growth Radiology Report CT HEAD W/O CONTRAST Study Date of [**2118-2-28**] 3:16 AM IMPRESSION: Right-sided subdural hematoma measuring up to 11 mm in maximal thickness. Prior images are not available for comparison at the time of report. No significant shift of midline structures. WRIST(3 + VIEWS) LEFT Study Date of [**2118-2-28**] 3:44 PM FINDINGS: Three views show no evidence of fracture or dislocation. There is some soft tissue swelling dorsally at the wrist level. There is calcification in vascular structures about the wrist. Degenerative change is seen in the first CMC and triscaphe joints. CHEST PORT. LINE PLACEMENT Study Date of [**2118-2-28**] 11:07 AM IMPRESSION: AP chest compared to most recent prior chest radiographs currently available, from [**2108-7-10**]: Left supraclavicular dual-channel central venous line ends in the left brachiocephalic vein close to its junction with the right brachiocephalic vein. There is no mediastinal widening, pleural effusion, or pneumothorax. Heart size is top normal, but pulmonary vasculature is engorged. Band-like areas of opacity in both lungs are mostly atelectasis. Although there is no mediastinal vascular engorgement, the other findings suggest patient is on the verge of cardiac decompensation. . [**2-28**] EEG: IMPRESSION: This is an abnormal continuous ICU monitoring study because of asymmetric background with further slowing over the right hemisphere. This finding is indicative of diffuse cortical and subcortical dysfunction in the right hemisphere. Background is also slightly slow over the left hemisphere indicative of a mild diffuse encephalopathy. In addition, there are frequent right central and temporal sharp waves consistent with a potential epileptogenic focus in this region. There is one verbal event report and two pushbutton activations in this file, all due to activity discontinuation, eye closure, or low amplitude shaking of the left arm with no electrographic seizures on EEG. The latter episode is suspicious for focal motor seizures which may not have an electrographic correlate. Note is made of irregular heart rate with occasional wide complex premature beats. [**3-1**] EEG: IMPRESSION: This is an abnormal continuous ICU monitoring study because of diffuse background slowing consistent with a mild to moderate encephalopathy with non-specific etiology. A few brief clinical events are detected throughout the recording showing mainly myoclonic jerking of the left arm and rarely of the right arm with no correlating electrographic seizure. These episodes most likely represent focal motor seizures. Compared to the prior day's recording, there is an increase in the number of clinical events; however, EEG is not changed. [**3-1**] Right Upper extremity doppler ultrasound: IMPRESSION: Patent right upper extremity AV graft with elevated velocities at the venous anastomosis suggesting significant stenosis. [**3-1**] CT head noncontrast: IMPRESSION: 1. Stable subdural hematoma layering over the right cerebral convexity, measuring up to 11 mm in maximal thickness, with no change in degree of mass effect. 2. No new foci of hemorrhage or shift of normally-midline structures. [**3-2**] TEE: IMPRESSION: No evidence of valvular vegetations or abscess seen. The ascending aorta is moderately dilated. Mild to moderate aortic regurgitation is seen. Mild anterioir leaflet MVP with mild MR. [**3-2**] CTA w/ & w/o contrast 1. No definite evidence of mass, infarct or septic embolus, though this examination would be expected to have low sensitivity to the last of these. If clinical concern persists, this could be further evaluated with an MRI (if feasible), as suggested previously. 2. Unchanged appearance of right frontal convexity subdural hematoma, without significant mass effect. 3. Normal cerebral vasculature without steno-occlusive disease, dissection, or aneurysm larger than 3 mm. [**3-7**] CT head w/o contrast IMPRESSION: Unchanged right frontoparietal subdural hematoma without increase in mass effect or new hemorrhage. [**3-10**] US guided HD line placement IMPRESSION: 1. Uncomplicated placement of a 19-cm tip-to-cuff tunneled dialysis line with the distal tip at the right atrium. The line is ready to use. 2. Occlusive new thrombus in the left internal jugular. 3. Chronic [**Last Name (un) **]-occlusive disease of the right internal jugular. [**3-12**] CT head w/o contrast: 1. Interval evolution of subacute on chronic subdural hematoma overlying the right cerebral hemisphere, not significantly changed in size compared to CT from [**2118-3-7**]. 2. Persistent mild leftward shift of normally midline structures, not significantly changed. No central herniation. 3. No acute large vascular territorial infarction. [**3-14**] CT head w/o contrast 1. No change in subacute on chronic subdural hematoma overlying the right cerebral hemisphere. 2. No new hemorrhage. Brief Hospital Course: Ms. [**Known lastname 33522**] is a 76yo F with history of ESRD on HD, DVT with IVC filter and OA s/p R knee replacement who presented to [**Hospital3 10960**] after a mechanical fall, had seizure like activity during HD on [**2-27**] and was found to have small subdural hematoma on CT, as well as erythema around her AV graft and blood cultures on [**2-22**] positive for MSSA, presumably from graft infection. Her hospital course was c/b several nonocclusive thrombi (see below) and occasional witnessed seizure activity. ACTIVE ISSUES: # Subdural hematoma: Patient had a 10mm subdural hematoma s/p mechanical fall c/b seizure activity at OSH. Her SDH was considered to be stable on repeat CTs during admission; while a small herniation and increase in size of the SDH was observed on one CT head, this was considered to be due to different slices being taken. Her neurological exam remained unchanged throughout admission other than during and after her seizure episodes (see below). Neurology and neurosurgery both stated that heparin would be OK from their standpoint for her b/l arm and Right IJ clots at a goal PTT 40-60 (see below). The patient was guaiac negative [**3-11**]. The heparin was started on [**3-11**], and a head CT once her goal PTT was reached was stable. Coumadin was started on [**3-12**] and we recommend to continue to three months. Her goal INR should be 2.0-2.5 given the history of complications. Her INR on discharge day was 2.4. # Seizures: Her seizures were likely [**2-17**] her SDH; while an EEG did not show seizure activity, on [**3-9**] she had a witnessed seizure with L face and arm involvement (some R arm movement) lasting about 3.5 min, broke on its own before ativan 2mg given. She had postictal confusion, a slight L facial droop and slightly slurred speech. The seizures were unlikely to be uremic or electrolyte-related in etiology, and pt has no seizure Hx. She was dilantin loaded on 2/22am and maintained on dilantin thereafter. She was maintained on fall, aspiration, and seizure precautions. Neurology recs regarding her seizures were as follows: if seizes for >5 min, give Ativan 1mg. However, if self-resolved, give another 300mg IV Dilantin and holding off on using Ativan. # nonocclusive thrombi: she was found to have nonocclusive thrombi in her b/l brachial veins and R IJ, which were visualized on US from [**3-6**]. After her condition stabilized and she did not have active seizures, anticoagulation with heparin bridge to coumadin was commenced as described above. Her goal INR should be 2.0-2.5 given the history of complications. Her INR on discharge day was 2.4. # MSSA bacteremia: Patient had 4/4 bottles +MSSA at OSH on [**2-22**]. Source presumed to most likely be infection of AV graft that was removed on [**3-3**]. TEE on [**3-2**] ruled out endocarditis. CT head did not show e/o septic emboli. We continued cefazolin at HD sessions per ID recs, for a 6-week course (d1 = [**2-22**]). The pt had low-grade fevers on [**2025-3-3**], and a leukocytosis of 19 on [**3-6**]; at that time, her CXR was unremarkable, but a US of graft site saw fluid collection and nonocclussive clots. She defervesced and remained stable for the remainder of admission. F/u blood cultures did not show any growth. # ESRD on HD s/p RUE AV fistula: Gets dialysis T,Th,Sat. Pt likely had infection of AV graft, and transplant surgery resected a portion of her graft. She received a temporary line on 2/17am, then had a tunneled IJ line placed on [**3-10**]. She continued to receive dialysis. Her last session was on the day of discharge. # Anemia: Pt's Hct on [**3-9**] was 21.8, down from 24.2 on [**3-8**]. Pt required 2U RBC's for Hct 19.3 upon admission. Renal transfused 1U RBC's at HD on [**3-10**] and gave one dose of Epo. Her post transfusion Hct was satisfactory and appropriately bumpted at 27. Renal service recommended Epo to be given at HD sessions. CHRONIC ISSUES: # HTN: continued metoprolol # HLD: continued home atorvastatin TRANSITIONS OF CARE: -Pt need cefazolin for AV-fistula related bacteremia. Recommended dosing regimen: 2 g Cefazolin iv during dialysis on Monday and Wednesday, 3 g Cefazolin iv during dialysis on Friday. The last dose should be on [**4-6**]. -Pt need anticoagulation for three months. Goal INR should be 2.0-2.5 given the subdural hematoma and prior history of RP bleed on coumadin -Due to seizures, patient can NOT drive for at least six months (earliest she could drive would be approximately [**2118-9-17**]. -Per neurology recommendations: if pt has seizures: if seizure lasts 5 min, give Ativan 1mg. However, if self-resolved, give 300mg IV Dilantin and hold off on using Ativan. Medications on Admission: Aspirin 325mg PO qd Atorvastatin 40 mg PO qd Calcitriol Colace Lorazepam p.r.n. Metoprolol 50mg PO qd Discharge Medications: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 6. warfarin 2 mg Tablet Sig: One (1) Tablet PO [**Last Name (LF) **],[**First Name3 (LF) **],Sat for 3 months. 7. warfarin 1 mg Tablet Sig: One (1) Tablet PO Mon,Wed,[**Last Name (LF) **],[**First Name3 (LF) **] for 3 months. 8. Outpatient Lab Work INR, every other day until INR stable at range 2-2.5 9. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 10. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 14. cefazolin 1 gram Recon Soln Sig: Two (2) gram Intravenous [**Last Name (LF) 33523**], [**First Name3 (LF) **] for 3 weeks: Please give during dialysis on Monday and Tuesday. 15. cefazolin 1 gram Recon Soln Sig: Three (3) gram Intravenous qFri for 3 weeks: Please give during dialysis on Friday. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Subdural Hematoma Seizures MSSA bacteremia Renal Failure Hypocalcemia Acute anemia Venous thrombosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 33522**], It was a privilege to provide care for you here at the [**Hospital1 1535**]. You were transferred here after you had a seizure and a new brain bleed as well as bacteria in your blood. You were evaluated by the neurosurgeons who felt that you did not need surgery. You did have seizures while you were admitted, and you were evaluated by the neurologists as well. On discharge, you should follow up with Dr. [**Last Name (STitle) **] and have a CAT scan before the appointment as scheduled below. The blood in your bacteria was thought to be from an infection of your AV fistula graft. You went to the operating room and part of the graft was removed. (You will follow up with transplant surgery in [**3-20**] weeks to decide when you can have a new one placed). We treated the infection with IV antibiotics which you will continue on discharge to complete a 6 week course. In the mean time, you will have dialysis through the tunneled line. In addition, we also found that you have a venous thrombosis in your neck veins. We started you on anticoagulation and you tolerated coumadin well in the hospital. You will continue the treatment and have your coumadin level checked periodically. We have made the following changes to your medications: NEW: -Cefazolin (for infection) -Phenytoin (to prevent seizures) -Senna (for constipation) -Warfarin (for venous thrombosis) CHANGED: None STOPPED: -Aspirin It was a pleasure taking care of you, we wish you all the best! Followup Instructions: Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Apartment Address(1) 33524**], [**Hospital1 **],[**Numeric Identifier 4293**] Phone: [**Telephone/Fax (1) 26774**] **Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge.** Department: TRANSPLANT CENTER When: MONDAY [**2118-3-21**] at 8:30 AM With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2118-3-22**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2118-4-12**] at 10:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: RADIOLOGY When: TUESDAY [**2118-4-26**] at 10:00 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: TUESDAY [**2118-4-26**] at 11:00 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Known lastname 5871**],[**Known firstname 5872**] E. Unit No: [**Numeric Identifier 5873**] Admission Date: [**2118-2-27**] Discharge Date: [**2118-3-15**] Date of Birth: [**2042-2-7**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Latex Attending:[**Doctor First Name 3492**] Addendum: Pt need surveilence OPAT labs while on iv Cefazolin. The [**Hospital 5874**] was called on [**2-/2035**], and lab orders for weekly CBC, LFT, BUN, Cr were faxed over. The lab results were instructed to be returned to ID department at [**Hospital1 8**]. I also included lab orders for INR check. The instructions were verbally communicated to [**Doctor First Name 769**] at the rehab facility who confirmed the receipt of fax orders. Discharge Disposition: Extended Care Facility: [**Hospital6 3465**] - [**Location (un) 824**] [**Name6 (MD) **] [**Name8 (MD) 3493**] MD [**MD Number(2) 3494**] Completed by:[**2118-3-16**]

[ "V12.55", "564.00", "453.82", "784.51", "E888.9", "348.30", "E879.1", "852.21", "427.31", "041.11", "V45.86", "790.7", "275.41", "403.91", "453.76", "V43.65", "453.86", "345.50", "585.6", "V45.11", "842.00", "996.62", "135" ]

icd9cm

[ [ [] ] ]

[ "39.43", "39.95", "88.72", "38.95" ]

icd9pcs

[ [ [] ] ]

23609, 23807

12519, 13045

325, 385

19096, 19096

6071, 12496

20819, 23586

4853, 4871

17377, 18856

18972, 19075

17251, 17354

19279, 20542

4901, 5709

20571, 20796

261, 287

13060, 16450

413, 4649

19111, 19255

16553, 17225

16467, 16532

4671, 4772

4788, 4837

5734, 6052

27,973

105,962

445

Discharge summary

report

Admission Date: [**2157-9-26**] Discharge Date: [**2157-10-3**] Date of Birth: [**2092-5-20**] Sex: M Service: CARDIOTHORACIC Allergies: Thiopental Sodium Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2157-9-26**] Coronary Artery Bypass Graft x 5 (LIMA to LAD, SVG to Diag, SVG to OM1 to OM2, SVG to PDA) History of Present Illness: 65 y/o male with PMH of CAD s/p MI in [**2147**] and [**2152**]. Recently c/o DOE and underwent an ETT which showed a perfusion defect. Underwent Cardiac cath which revealed severe three vessel disease and referred for surgical intervention. Past Medical History: Myocardial Infarction [**2147**]/[**2152**], Hypertension, Hypercholesterolemia, Diabetes, Mellitus, Obesity, h/o Bladder cancer Social History: Active smoker with approx. 1.5ppd x 40yrs. Denies ETOH use. Family History: Father with MI in 80's, Brother with MI at 67. Physical Exam: VS: 58 14 160/90 Gen: WDWN male in NAD Skin: w/d, mult. nevi on torso HEENT: NCAT, EOMI, PERRL, OP benign with poor dentitian Neck: Supple, FROM, -carotid bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, trace edema Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**2157-9-26**] Echo: PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with thinning and dyskinesis of the basilar inferrior and inferolateral walls.. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45%). The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of Mild (1+) mitral regurgitation is seen. POSTBYPASS: LV systolic function is marginally improved (LVEF-45-50%) Previous wall motion abnormalities persist. RV systolic function remains normal. Study is otehrwise unchanged from prebypass. [**2157-9-26**] 12:24PM BLOOD WBC-15.5*# RBC-3.46*# Hgb-11.0*# Hct-30.7*# MCV-89 MCH-31.7 MCHC-35.7* RDW-13.9 Plt Ct-144* [**2157-9-28**] 06:35AM BLOOD WBC-11.9* RBC-3.36* Hgb-10.1* Hct-29.0* MCV-86 MCH-30.0 MCHC-34.7 RDW-14.1 Plt Ct-111* [**2157-9-26**] 12:24PM BLOOD PT-13.6* PTT-25.1 INR(PT)-1.2* [**2157-9-27**] 03:09AM BLOOD PT-12.3 PTT-27.7 INR(PT)-1.1 [**2157-9-26**] 01:48PM BLOOD UreaN-15 Creat-1.2 Cl-108 HCO3-28 [**2157-9-29**] 11:30AM BLOOD Glucose-211* UreaN-17 Creat-1.0 Na-135 K-4.4 Cl-97 HCO3-33* AnGap-9 Brief Hospital Course: Mr. [**Known lastname **] was a same day admit after undergoing all pre-operative work-up as an outpatient. On the day of admission he was brought directly to the operating room where he underwent coronary artery bypass grafting to five vessels. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Later on operative day one, he was weaned from sedation, awoke neurologically intact and extubated. He was then transferred to the step down unit for further recovery. Mr. [**Known lastname **] was gently diuresed towards his preoperative weight. He remained stable post-operatively and worked with physical therapy for assistance with his postoperative strength and mobility. Beta blockers were increased for heart rate and blood pressure control. He developed atrial fibrillation which was treated with an increase in his beta blockade. He progressed well and was discharged home with VNA services on [**2157-10-3**]. He will follow-up with Dr. [**Last Name (STitle) 1290**], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Aspirin 325mg qd, Lisinopril 20mg qd, Metformin 500mg [**Hospital1 **], Toprol XL 100mg qd, Lipitor 80mg qd Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 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:*1* 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 7. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*1* 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. Disp:*60 Capsule, Sustained Release(s)* Refills:*2* 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 PMH: Myocardial Infarction [**2147**]/[**2152**], Hypertension, Hypercholesterolemia, Diabetes, Mellitus, Obesity, h/o Bladder cancer Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. Do not lift more than 10 lbs. for 2 months. Do not drive for 4 weeks. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office with sternal drainage, temps.>101.5 [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] in 4 weeks Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**2-12**] weeks Dr. [**Last Name (STitle) 3314**] in [**1-11**] weeks Completed by:[**2157-10-4**]

[ "250.00", "412", "333.94", "997.5", "414.8", "401.9", "V10.05", "272.0", "414.01", "788.20", "518.0", "424.0", "997.3", "278.00" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5429, 5463

2820, 3955

304, 412

5701, 5707

1301, 2797

928, 976

4113, 5406

5484, 5680

3981, 4090

5731, 6014

6065, 6265

991, 1282

245, 266

440, 683

705, 835

851, 912

31,139

199,202

50236

Discharge summary

report

Admission Date: [**2178-5-28**] Discharge Date: [**2178-5-30**] Date of Birth: [**2117-10-18**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[**First Name3 (LF) 5790**] Chief Complaint: restaging Major Surgical or Invasive Procedure: R VATS and pleural bx [**2178-5-28**] History of Present Illness: 60M w/ RLL sq cell CA stage IIIa (T3N2), s/p chemo (carboplatin/taxol) [**2-3**] - + concurrent radiation (4500cGy) who presented for restaging. Denies weight loss, hemoptysis. However, he had significant right sided effusion w/ FDG avidity on recent PET, concerning for pleural disease. Past Medical History: 1. CAD: s/p PCI to LAD in [**8-31**], PCI to distal RCA in [**2168**] at OSH, followed by Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], last pMIBI in [**2-1**] with no new perf. defect 2. Squamous cell ca of larynx: dx [**2-1**] by biopsy, involving epiglottis, local lymphatic vasc. invasion, began XRT on [**2176-3-11**] (Dr. [**Last Name (STitle) 3929**], undergoing eval for chemo at DF (Dr. [**Last Name (STitle) 17315**] 3. Hypertension 4. H/o NSVT: postcath in [**2168**], EP study with only 8sec inducible VT 5. OSA: previously on CPAP 6. Hypercholesterolemia Social History: Tobacco: 50-pack-year history, quit '[**75**]. ETOH: occasionally asbestos exposure in the past. Does not use other drugs. married, has three children former truck driver and lives in [**Location 86**]. Family History: Mother had [**Name2 (NI) 499**] cancer and died of bowel rupture at age 65. Father died in his 80's of [**Last Name **] problem. MGM with 'heart disease'. He has three healthy children. Physical Exam: AVSS AAOx3 NAD obese no cervical LN RR S1 S2 decreased BS on Right 2+ edema Pertinent Results: [**Last Name 88689**] Frozen Section - sq cell CA Pleural fluid - no malignant cells Brief Hospital Course: [**Last Name 88689**] frozen section of pariental pleura returned positive for carcinoma. Three liter of bloody effusion was removed. Findings were discussed w/ his wife [**Name (NI) **] and options of [**Name (NI) 31382**] catheter or pleurodesis were discussed. His wife wanted to wait. Pt required brief ICU admission for poor oxygenation postop, likely contributed by underlying CA, postop fluid mobilization after removal of pleural effusion, obesity and anesthesia. His O2 requirement improved by end of POD#1 and came out of ICU then. Chest tube was placed on water seal POD#1 and removed POD#2 w/o complication. There was minimal right pleural effusion on post-pull CXR. Pt was discharged home on POD#2, w/ SpO2 94-95% RA. He is to resume all home meds, including lasix. Medications on Admission: atenolol 50', baclofen 10"', lasix 40', ativan 1q2-3prn n/v, GI cocktail (maalox, benadryl, 2%lido) 15ml, compazine 10q4-6, protonix 40', zocor 20', [**Last Name (LF) 104768**], [**First Name3 (LF) **] 325', colace, MVI, senna Discharge Medications: 1. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:*30 Tablet Sustained Release 12 hr(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. Disp:*30 tabs* Refills:*2* 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: RLL sq cell CA, stage IIIb pleural disease, despite chemo/XRT htxn CAD Discharge Condition: stable Discharge Instructions: If you have fever, chills, wound redness, please call the office ASAP Followup Instructions: Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] Date/Time:[**2178-6-9**] 3:00 Please call Dr [**Last Name (STitle) **] for appt Completed by:[**2178-5-30**]

[ "V45.82", "V16.3", "V10.21", "327.23", "272.0", "197.2", "V15.84", "530.81", "278.00", "401.9", "414.01", "530.10", "V15.82", "252.00", "V10.79", "162.5" ]

icd9cm

[ [ [] ] ]

[ "34.20" ]

icd9pcs

[ [ [] ] ]

3818, 3824

1908, 2690

285, 325

3940, 3949

1799, 1885

4067, 4264

1500, 1687

2967, 3795

3845, 3919

2716, 2944

3973, 4044

1702, 1780

236, 247

353, 643

665, 1263

1279, 1484

7,706

125,764

9965

Discharge summary

report

Admission Date: [**2161-6-13**] Discharge Date: [**2161-6-17**] Date of Birth: [**2103-1-21**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old man with an extensive cardiac history who was admitted on [**6-11**] to an outside hospital with complaint of left testicular pain. Ultrasound showed epididymitis as well as edema. The patient was febrile and had increased white blood cell count with bandemia. A urine culture was positive with pan sensitive E-coli. Repeat ultrasound on [**6-13**] showed severe epididymitis with a question of possible orchitis on the left as well as a question of a 1 cm abscess on the tail of the epididymis raising the question of Fournier's gangrene. There was also a thickening on the right suggesting a mild right epididymitis. The patient had been on intravenous Kefzol since [**6-11**]. He was transferred to [**Hospital1 346**] for surgical management. He had a left orchiectomy with a Penrose drain placed on [**2161-6-13**] and was admitted to the Medicine Service for further management. PAST MEDICAL HISTORY: 1. Coronary artery disease with an myocardial infarction 18 years ago. 2. Coronary artery bypass graft [**2143**] with a left internal mammary coronary artery to left anterior descending coronary artery. 3. Hypertension. 4. Cerebrovascular accident in [**2158**]. 5. Chronic obstructive pulmonary disease. 6. Dilated cardiomyopathy with an ejection fraction of less then 20% based on an echocardiogram from [**2161-4-15**]. 7. Alcohol abuse. 8. Biventricular pacemaker/ICD placed for symptomatic bradycardia. 9. 2+ mitral regurgitation. 10. Benign prostatic hypertrophy status post TMT one year ago at an outside hospital. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Coumadin 2 mg q.h.s. and 3 mg on Mondays. 2. Lasix 40 mg q.d. 3. Lipitor 10 mg. 4. Sertraline 50 mg q.d. 5. Toprol XL 50 mg q.d. 6. Percocet prn. 7. Accupril 10 mg q.d. 8. Folate 1 mg q.d. SOCIAL HISTORY: The patient has a history of alcohol abuse. He now drinks three glasses of wine a day. He lives with his wife. [**Name (NI) **] quit smoking three months ago. He use to smoke two packs per day. PHYSICAL EXAMINATION: Temperature 100.4 with a blood pressure of 121/66. Heart rate of 80. Respiratory rate 21. Oxygenation of 99% on 2 liters. Generally he was drowsy, but arousable, pleasant and in no acute distress. Pupils are equal, round and reactive to light. Extraocular movements intact. Mucous membranes are moist and pink. Oropharynx was intact. Neck was supple with no JVD. His lungs are clear to auscultation bilaterally with no wheezes. The ICD site was nontender. His heart was regular rate and rhythm with no murmurs, rubs or gallops. His lungs were clear to auscultation. His abdomen was soft, nontender, nondistended. His extremities showed no edema. His genitourinary examination showed a left scrotum with a dressing in place and a Foley. His skin showed no rashes and on neurological examination he was alert, oriented with a nonfocal examination. LABORATORY STUDIES: White blood cell count 17.0 with 84% polys, 9% lymphocytes, 5% monocytes, 2% eosinophils. His hematocrit was 35, platelets 193, INR 1.8 with a PT of 16.3, sodium 138, potassium 3.8, chloride 101, bicarb 25, BUN 12, creatinine 1.1 and a glucose of 91. Urinalysis showed 21 to 50 white blood cells, no bacteria. No yeast. Urine culture was pending at the time. HOSPITAL COURSE: The patient was admitted to the Medicine Service for observation. He was started on ................ 5 grams intravenous q 8 hours for treatment for his infection postoperatively. The Penrose drain was gradually removed by urology over the next two days without complications. The patient's Foley was removed on postoperative day number two without problems and the patient was able to urinate well. The patient's white blood cell count decreased on antibiotic therapy from initially 7.0 to 9.7 on the day of discharge. The patient remained afebrile while in house and the antibiotics were changed to po Levofloxacin for a fourteen day course following the day of discharge. The patient's Coumadin was restarted on postoperative day number two given the patient's severe apical akinesis and low ejection fraction. The electrophysiology service was also consulted while the patient was in house as there had been a discussion of revising the wiring of his ICD. It was decided to not undertake this while the patient was in house given the possible infection of the device and the patient was instructed to follow up with the electrophysiology service toward the end of [**Month (only) 116**]. The patient overall continued to do well and was discharged to home in good condition on [**2161-6-17**]. DISCHARGE STATUS: Full code. DISCHARGE MEDICATIONS: 1. Toprol XL 50 mg po q.d. 2. Quinapril 10 mg po q.d. 3. Lasix 40 mg q.d. 4. Sertraline 15 mg q.d. 5. Percocet prn for postop pain. 6. Coumadin 2 mg po q.h.s., 3 mg q Monday. 7. Lipitor 20 mg po q.d. 8. Folic acid 1 mg po q.d. 9. Multivitamin one capsule q.d. 10. Levofloxacin 500 mg po q.d. for 14 days. DISCHARGE DIAGNOSES: 1. Left epididymitis with possible orchitis status post left orchiectomy. 2. See past medical history. FOLLOW UP INSTRUCTIONS: The patient is to follow up with Dr. [**Last Name (STitle) 365**] of urology on [**2161-7-1**] as well as with the electrophysiology service on [**2161-7-3**]. [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 21**], M.D. [**MD Number(1) 31683**] Dictated By:[**Last Name (NamePattern1) 423**] MEDQUIST36 D: [**2161-6-18**] 11:25 T: [**2161-6-22**] 09:48 JOB#: [**Job Number 33367**]

[ "604.0", "401.9", "790.7", "496", "425.4", "V45.81", "414.01", "412", "041.4" ]

icd9cm

[ [ [] ] ]

[ "62.3" ]

icd9pcs

[ [ [] ] ]

5186, 5755

4849, 5165

3488, 4826

2223, 3470

156, 1078

1100, 1985

2002, 2200

53,372

156,773

2253

Discharge summary

report

Admission Date: [**2171-5-6**] Discharge Date: [**2171-5-8**] Date of Birth: [**2087-8-4**] Sex: F Service: MEDICINE Allergies: Ibuprofen Attending:[**First Name3 (LF) 6701**] Chief Complaint: hypoxemia/hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 83 yo with h/o afib, gib, ischemic colitis, CHF just discharged from MICU to [**Hospital 100**] Rehab MACU on [**5-2**] readmitted with hypoxemiz and hypotension. This is the third admission this month for Ms. [**Known lastname **]. Please review past discharge summary for details, but briefly she had GI bleed from AVMs, dabigatran stopped, readmitted with ischemic colitis, managed conservatively. She was relatively hypotensive during her last admission. She was always very clear about her wishes to avoid invasive measures including central lines. At rehab, she was noted to be hypoxemic. CXR with e/o CHF. Started on lasix gtt. Difficulty with hypotension. Also had right calf pain and dvt ruled out by ultrasound. She was admitted here for work-up. In emergency department, was started on dopamine for hypotension. On arrival, discussed with patient and niece at bedside. She stated she wanted to be made comfortable. She stated that she did not want medicine to raise her blood pressure and was made CMO. Patient was transferred to [**Hospital Ward Name 121**] 7 from the MICU accompanied by her niece, and palliative care physicians (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from [**Hospital1 778**], Dr. [**First Name8 (NamePattern2) 11894**] [**Last Name (NamePattern1) 406**]) were consulted. Per palliative care recommendations, was placed given intravenous and sublingual morphine, 5% lidocaine patch, acetaminophen, scopolamine patch and SL Levsin for comfort. Vital signs were held for comfort. She was monitored regularly for pain and shortness of breath, which were treated with the above medications. She was declared deceased at 13:47 on [**2171-5-8**]. Primary cause of death was CHF secondary to sepsis, with incident causes of GIB, mesenteric ischemia, ischemic colitis, CAD, atrial fibrillation, thyroid cancer. Primary care physician (Dr. [**Last Name (STitle) 11895**] was notified of admission. Past Medical History: * Coronary artery disease with MIs (?X3 in [**2119**]) * Hypertension * Atrial fibrillation: on digoxin in the past, now on dabigatran started ~[**2-/2171**] * Hyperlipidemia * Osteoarthritis * Cholecystectomy + ERCP in [**2163**] * Partial hysterectomy * Thyroid cancer s/p thyroidectomy and parathyroidectomy Social History: Worked at [**Location (un) 8599**]Hospital as nursing aide in the Alcoholics Unit for years. Retired, lives in retirement community. [**12-9**] glasses of wine/month (social), denies illicits. Remote history of tobacco (quit over 40 years ago). Has refused to ever have colonoscopy. Family History: Father had an MI in his 50s and died of renal cancer. Mother had an MI in her 40s. No family history of sudden cardiac death. Daughter died at 54 years old of liver cancer, brother died at 77 years old (4 years ago) of gastric cancer. No other family history of malignancies, IBD, celiac disease, blood dyscrasias. Physical Exam: VS: Not recorded GENERAL: Obese elderly woman in no acute distress, drowsy but responsive, unable to state why in hospital, says she's at [**Hospital1 2025**], cannot recall date. HEENT: NC/AT, sclerae anicteric, MMM, OP clear. NECK: Supple, no JVD. HEART: RRR, no MRG, nl S1-S2. LUNGS: Diffuse rhonchi, no r/wh, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, obese, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. SKIN: No rashes or lesions. LYMPH: No cervical LAD. Pertinent Results: ADMISSION LABS: . [**2171-5-6**] 03:45PM BLOOD WBC-9.0 RBC-4.29 Hgb-13.0 Hct-40.0 MCV-93 MCH-30.2 MCHC-32.4 RDW-16.5* Plt Ct-281 [**2171-5-6**] 03:45PM BLOOD Neuts-78* Bands-0 Lymphs-14* Monos-7 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2171-5-6**] 03:45PM BLOOD Glucose-132* UreaN-35* Creat-1.6* Na-142 K-5.1 Cl-109* HCO3-26 AnGap-12 [**2171-5-6**] 03:45PM BLOOD proBNP-7656* Brief Hospital Course: 87 year-old woman with history of gastrointestinal bleed, atrial fibrillation, heart failure, ischemic colitis admitted from [**Hospital 100**] rehab with heart failure and hypotension. She has consistently expressed a desire to avoid invasive measures and states clearly that she would like to be made comfortable and is okay with the possibility of death. Her niece is at bedside and confirms that this is consistent with her wishes throughout. She was made comfort measures only and transferred to the floor with her niece (health care proxy), where palliative care was consulted. She was made comfortable with intravenous and sublingual morphine, 5% lidocaine patch, scopolamine patch, acetaminophen, and sublingual levsin. She was monitored regularly for pain and shortness of breath, with the above medications titrated to effect. She was declared deceased at 13:47 [**2171-5-8**]. Her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], was notified. Autopsy was declined as patient is donating her body to medical science. Medications on Admission: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO twice a day. 3. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 6 days: Course to be complete [**2171-5-8**]. 4. ciprofloxacin 400 mg/40 mL Solution Sig: Four Hundred (400) mg Intravenous once a day for 6 days: Course to be complete [**2171-5-8**]. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 7. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual PRN as needed for chest pain: Please take 1 tab as needed for chest pain. 1 tab every 5 minutes, for up to 3 tabs in 15 min. . 8. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis Congestive Heart Failure Sepsis Mesenteric Ischemia Discharge Condition: Deceased. Discharge Instructions: You were admitted with low oxygen levels and hypotension. You were made comfortable and passed away Followup Instructions: None. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**] Completed by:[**2171-5-9**]

[ "401.9", "428.0", "412", "557.1", "995.91", "427.31", "428.33", "272.4", "V10.87", "414.01", "038.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6297, 6306

4208, 5276

290, 296

6420, 6431

3808, 3808

6579, 6736

2936, 3255

6267, 6274

6327, 6399

5302, 6244

6455, 6556

3270, 3789

228, 252

324, 2283

3824, 4185

2305, 2619

2635, 2920

27,608

120,703

34742

Discharge summary

report

Admission Date: [**2164-8-18**] Discharge Date: [**2164-9-7**] Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3645**] Chief Complaint: Cord Compression, Lumbar Compression Fracture, Aspiration Pneumonia Major Surgical or Invasive Procedure: [**2164-8-29**] Flexible bronchoscopy [**2164-8-21**] PROCEDURE: 1. Open treatment of L1 burst fracture with spinal cord compromise and spinal cord injury. 2. Posterior arthrodesis, T10-L3. 3. Posterior segmental instrumentation T10-L3. 4. Posterior spinal decompression with laminectomy, bilateral medial facetectomy, foraminotomy of L1. 5. Far lateral transpedicular decompression of L1, bilaterally. 6. Bilateral laminotomies of T12 with medial facetectomy at T12-L1. 7. Open biopsy of L1 vertebral body and right-sided pedicle. 8. Application of local allograft and autograft, as well as BMP II. [**2164-8-19**] PROCEDURE: Flexible bronchoscopy. History of Present Illness: 86 year old Male sent from [**Hospital6 **] for urgent management of spinal cord compression due to L1 vertebral burst fracture, and orthospine requested medical co-management. Patient also with Left mainstem aspiration of food, virtually obstructing the bronchus. Patient initially presented to OSH after falling backwards while brushing his teeth, presumed to be retropulsion due to his parkinson's disease. Patient did not lose consciousness. Patient reports marked pain at lumbar area post-fall, but was able to ambulate. Over the next week his pain progressed to the point he could no longer ambulate. Over the next 3 weeks he was bed bound. He was seen at a hospital in [**Doctor First Name 5256**], and an x-ray showed a L1 fracture of undeterminate age. He returned to [**State 350**], and was sent by his PCP to [**Hospital3 **]. While there he was noted with hypoxic, and imaging there was consistent with an aspiration pneumonia, and he was started on vancomycin/Zosyn. A CT of his back, along with MRI demonstrated a communuted fracture of L1 with cord-compression. He is transferred for possible surgical repair. Of note, he suffered an NSTEMI in [**5-10**], which was medically managed. At OSH, he did not have leukocytosis, but on arrival here it had progressed to 17 on arrival here. He was afebrile at the OSH as well. Past Medical History: Parkinson's Disease Atrial Fibrillation on Coumadin CAD/NSTEMI [**5-10**] BPH Osteoarthritis Osteoporosis COPD Social History: Currently married, lives at [**Location 25868**] with his wife. Three children do not live in the area. Previously an [**University/College **] professor in political science. Denies smoking, EtOH, and illicits Family History: Non-Contributory Physical Exam: ROS: GEN: - fevers, - Chills, + 40lb Weight Loss/3 months EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, + Incontinence Urinary SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, + Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: VSS: 98.3, 140/62, 81, 18, 97.2% GEN: cachexia Pain: [**10-12**] HEENT: EOMI, MMM, - OP Lesions PUL: Left Base absent BS, otherwise clear COR: Irregular, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE, pulses 2+ NEURO: CAOx3, resting tremor, intermittant spasm LLE, no rectal tone, babinski downward going, exam limited by pain DERM: Sacral Decubitus Ulcer Brief Hospital Course: #. Cord Compression due to L1 burst fracture secondary to traumatic mechanical fall: On admission, the patient complained of excruciating pain in his back and legs. On exam, he was able to wiggle his toes, but unable to lift his legs from a supine position without substantial pain. He also had decreased light touch sensation in the lower extremities bilaterally. Imaging from OSH showed an L1 burst fracture. He was placed on bedrest, and his pain was controlled with dilaudid. Ortho/spine was consulted and recommended surgical decompression for stabilization of the spine. On HD3, he underwent T10-L3 decompression. . #. Aspiration Pneumonia, Dysphagia, Leukocytosis: On admission, the patient was afebrile, but had an elevated white blood cell count of 17. OSH imaging showed material in the left mainstem bronchus and left lower lobe collapse, likely due to aspiration. He was made NPO and started on IV cefepime and flagyl. Pulmonary was consulted, and on HD2, he was transferred to the MICU for bronchoscopic removal of foreign material in the left mainstem bronchus. Gram stain and culture of the material was sent. Gram stain returned 2+ gram positive rods and 1+ yeast. Culture returned positive for yeast. An NG tube was placed, and he was restarted on all essential medications prior to surgery. . #. Parkinson's Disease: On admission, the patient was made NPO for aspiration risk and sinemet was held. An NG tube was placed on HD2; neurology was consulted and recommended restarting sinemet, which was resumed at his home dose. . #. Severe Malnutrition: On admission, the patient, per the daughter's report, had lost upwards of 40 pounds over the last three months. Nutrition was consulted, and an NG tube was placed. Tube feeds were started, though they were periodically held, as he was NPO after midnight prior to surgery. Speech and swallow consult was deferred until he was post-op. . #. CAD, NSTEMI in [**5-10**], atrial fibrillation: On admission, the patient was NPO for aspiration risk. He was rate controlled on IV metoprolol, titrated up to goal HR of 60-70. An NG tube was placed and he was restarted on metoprolol and statin. Aspirin and coumadin were held prior to surgery. . #. Sacral Decubitus Ulcer Stage 1: On admission, the patient had stage I sacral decubitus ulcers on the bony surfaces of his back, likely worsened by poor nutrition. Wound care was consulted and recommended dressings for the ulcers, an air mattress to relieve pressure, and frequent rolls. . Full Code, although family considering change to DNR/DNI. Daughter concerned that he may not have a truly meaningful recovery, although is aware that even from a comfort standpoint the surgery may be helpful. . On [**9-7**] decision was made to make patient CMO status. Pt was extubated and sunsequently developed agonal respirations, with bradycardia and hypotension. Pt soon passed. TOD 23:47. Immediate cause of death: Cardiopulmonary arrest. Chief cause of death: Respiratory Failure. Family does not wish for autopsy. Condolences from the orthopedics team expressed to family for their loss. Medications on Admission: Aspirin 81 mg PO daily MVI 1 TAB daily Detrol 4 mg PO daily Colace 200 mg PO qHS Proscar 5 mg PO daily Flomax 0.4 mg PO qHS Senna 8.6 mg PO qHS PRN Sinemet 25/100 [**1-4**] TAB PO at noon Sinemet 25/100 mg PO BID Metoprolol XL 25 mg PO daily Vitamin C 500 mg PO daily Coumadin 5 mg PO MW, 2.5 mg PO TRFSS Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A, patient passed away Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "81.05", "84.52", "03.09", "81.63", "77.49", "33.24", "96.6", "96.08", "96.04", "96.72", "96.05", "38.93" ]

icd9pcs

[ [ [] ] ]

7194, 7203

3711, 6811

333, 1013

7271, 7280

7333, 7340

2759, 2777

7166, 7171

7224, 7250

6837, 7143

7304, 7310

3329, 3688

226, 295

1041, 2381

2403, 2515

2531, 2743

1,847

155,576

15418+56644

Discharge summary

report+addendum

Admission Date: [**2148-8-25**] Discharge Date: [**2148-9-27**] Date of Birth: [**2103-10-3**] Sex: F Service: [**Company 191**]/MED HISTORY OF PRESENT ILLNESS: This is a 44 year old female with a relatively complicated course who was transferred from an outside hospital to [**Hospital1 69**] for further management. Originally she was being conservatively treated for cholecystitis in [**2148-7-11**]. She then underwent a laparoscopic cholecystectomy on [**2148-8-22**], at [**Hospital6 3105**]. Her postoperative course was complicated by respiratory distress, hypoxia, decreased urine output, increased serum creatinine, increased abdominal pain and serum markers consistent with pancreatitis. An abdominal CT scan at that point was concerning for retained stone in the common bile duct with questionable cystitis. She was then intubated and subsequently sent to the [**Hospital1 69**] for further management on [**8-29**]. Upon arrival to our institution, the patient underwent an endoscopic retrogram cholangiopancreatography which revealed coffee ground emesis in the stomach and a large extravasation of contrast in the cystic duct suggestive of a postoperative bile leak. A biliary stent was placed and Interventional Radiology placed a drain in her peritoneal cavity. The patient was started on TPN for nutritional support as well as broad spectrum antibiotics. She had a prolonged Intensive Care Unit course, mostly due to difficulty with extubation. She was extubated on one occasion about two weeks into her stay but required reintubation fairly soon. She remained very difficult to extubate which continued to be the case until [**9-19**]. At that point she was extubated and transferred to the Medical Floor. Upon transfer to the Medical Floor, the patient was comfortable with no complaints. She was awake and alert and conversant although slightly confused. She complained of no abdominal pain, no chest pain, no shortness of breath. The only complaint was of dry mouth. PAST MEDICAL HISTORY: 1. Gunshot wound to the head resulting in blindness in the right eye. 2. Hepatitis C. 3. Diabetes mellitus. MEDICATIONS UPON TRANSFER: 1. Protonix. 2. Subcutaneous heparin. 3. Lasix. ALLERGIES: To Demerol. SOCIAL HISTORY: She smokes cigarettes but no alcohol or intravenous drug use. FAMILY HISTORY: Significant for diabetes mellitus in her mother. PHYSICAL EXAMINATION: Upon transfer to the medical floor, temperature 99.0 F.; blood pressure 130/64; heart rate 100; respiratory rate 24; 97% on three liters. In general, comfortable, minimally conversant but appropriate woman. Mucous membranes were moist. Neck: No lymphadenopathy, no jugular venous distention. Respiratory with poor air movement but no frank crackles. Cardiovascular: Tachycardic S1, S2, with no murmurs, rubs or gallops. Abdomen is soft and nondistended, with hypoactive bowel sounds and diffuse tenderness in the left lower and right lower quadrant. There is no rebound, no guarding, no masses. There is no liver edge and no spleen tip. Extremities reveal no edema and two plus pulses. LABORATORY: Upon transfer from the Medical Intensive Care Unit included an unremarkable Chem-7; albumin 1.9, 30. BRIEF HOSPITAL COURSE: 1. CARDIOVASCULAR: The patient remained relatively stable from a cardiovascular standpoint. During her Medical Intensive Care Unit course she had become significantly volume overloaded and upon transfer to the regular floor she initially was receiving Lasix 20 mg intravenously twice a day. She continued to diurese relatively well to the point that she was almost two liters negative. At this point, her Lasix was discontinued and she was allowed to auto-diurese which she continued to do for the hospital course. On an occasional episode, she was tachycardic, which was probably due to her depletion of effective intravascular volume. This was treated by frequent boluses of normal saline. 2. PULMONARY: Upon extubation, the patient did very well from a Pulmonary standpoint. She was only on nasal cannula for a few days originally and this was easily weaned to room air over the next four or five days. She had no complaints whatsoever of shortness of breath, chest pain or cough. 3. GASTROINTESTINAL: The patient had occasional complaints of abdominal pain but her abdominal examination remained completely unremarkable. Additionally, her enzymes revealed no evidence for worsening pancreatitis or hepatobiliary process. Of note, soon after transfer to the medical floor, it was found that the patient had a collection of pus in one of the trochanter sites from the open cholecystectomy. An abdominal CT scan was obtained which showed an enclosed loculated focus of pus consistent with a superficial abscess with no tracking or communication of fistula to the abdominal organs. Surgery was consulted and they incised and drained the area. They were convinced that this was a superficial lesion which was adequately drained. She is receiving a two day course of Keflex post drainage. Given the fact that the patient was intubated for over 30 days, a Speech and Swallow consultation was obtained. We were unable to obtain a video swallow secondary to patient's body habitus. Nevertheless, the Speech and Swallow Service felt that she was aspirating a mild to moderate degree with thin liquids; therefore, she is on a diet of thick nectar pureed type foods which can be switched to thins upon reassessment from Speech and Swallow. 4. INFECTIOUS DISEASE: The patient was found to have a urinary tract infection which was treated with Ciprofloxacin 250 twice a day for three days. She remained otherwise asymptomatic from an Infectious Disease standpoint with only fevers to 99.0 and 100.0 F., in the context of a urinary tract infection and the above mentioned superficial wound abscess. 5. ENDOCRINE: Diabetes mellitus type 2 remained relatively stable during hospital stay with well controlled sugars covered with a regular insulin sliding scale. 6. RENAL: BUN and creatinine remained within normal limits. She was occasionally hypokalemic requiring repletion of potassium. In general, her renal function remained excellent during her hospital stay with no complications. CONDITION AT DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Status post cholecystectomy. 2. Status post bile leak. 3. Acute pancreatitis. DISCHARGE DISPOSITION: To a Rehabilitation facility. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. q. day. 2. Nystatin 5 cc p.o. four times a day swish and swallow. 3. Miconazole powder four times a day to affected areas. 4. Natural tears one drop o.u. q. four p.r.n. 5. Albuterol Metered-Dose Inhaler, two puffs twice a day. 6. Tylenol 650 p.o. q. six p.r.n. 7. Regular insulin sliding scale. 8. Ativan 1 mg p.o. p.r.n. 9. Heparin 5000 units subcutaneously twice a day. 10. Keflex 500 mg p.o. twice a day. 11. Magnesium oxide 400 mg p.o. q. day. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Name8 (MD) 5094**] MEDQUIST36 D: [**2148-9-26**] 14:23 T: [**2148-9-26**] 16:01 JOB#: [**Job Number 44727**] Name: [**Known lastname 2717**], [**Known firstname **] Unit No: [**Numeric Identifier 8202**] Admission Date: Discharge Date: [**2148-9-30**] Date of Birth: [**2103-10-3**] Sex: F Service: ADDENDUM: This addendum will cover the [**Hospital 1325**] hospital course from [**2148-9-27**] until [**2148-9-30**], her date of discharge. Over the weekend, the patient was comfortable with no complaints. She remained awake, alert, and conversant, although slightly confused. She complained of no abdominal pain, chest pain, or shortness of breath. The patient was followed by Surgery for a collection of pus in one of the trochanter sites from the open cholecystectomy. She continued on her course of Keflex post drainage. She was discharged on medications listed in the above discharge summary. [**Doctor Last Name **] [**Name6 (MD) 909**] [**Name8 (MD) **], M.D. [**MD Number(1) 348**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2149-4-3**] 05:52 T: [**2149-4-6**] 17:46 JOB#: [**Job Number **]

[ "507.1", "567.8", "996.62", "577.0", "997.4", "682.2", "584.9", "599.0", "518.5" ]

icd9cm

[ [ [] ] ]

[ "96.72", "34.04", "96.6", "86.04", "33.24", "51.87", "88.72", "96.04", "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

6451, 6482

3275, 6295

2363, 2413

6341, 6426

6505, 8336

2436, 3252

6311, 6320

183, 2027

2049, 2266

2283, 2346

12,115

155,451

3487+3488

Discharge summary

report+report

Admission Date: [**2110-7-28**] Discharge Date: [**2110-8-11**] Service: MEDICINE/[**Location (un) 259**] FIRM HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old Russian-speaking male, with a history of atrial fibrillation, no anticoagulation per patient's wishes, peripheral vascular disease, hypertension, chronic renal insufficiency, who was admitted to [**Hospital6 256**] with progressive, diffuse lower abdominal pain. The patient has a history of C. difficile colitis on [**7-1**] following completion of a course of clindamycin for lower extremity cellulitis. The patient was treated with Flagyl 500 tid and ciprofloxacin for persistent cellulitis and superimposed C. difficile colitis. The patient continued having diarrhea which was nonbloody, nonmucoid, one to two times a day. The patient denies any fevers or chills, but complains of nausea, decreased po intake and dyspnea which has been the patient's baseline. In the ED, the patient was seen by vascular surgery, since the patient is status post SMA stent placement. The patient's abdominal CAT scan showed severe pancolitis, no evidence of toxic megacolon, consistent with Clostridium difficile infection. There was no concern for ongoing mesenteric ischemia. In the ED, the patient received ampicillin, Flagyl and IV vancomycin. PHYSICAL EXAM: Temperature 97.6, pulse 106, blood pressure 123/87, respirations 16, 94% on 3 liters. Generally, an elderly, anxious appearing gentleman in bed in no apparent distress. HEENT - pupils equal, round and reactive to light and accommodation. Extraocular muscles were intact. A hoarse voice. Smooth tongue. Neck - no jugulovenous distention. Pulmonary - coarse breath sounds, bilateral wheezing in all fields. Cardiovascular - irregularly irregular, distant heart sounds. Abdomen - positive bowel sounds, distended but soft, diffusely tender to palpation mostly bilateral lower quadrant, no hepatosplenomegaly, no rebound, positive guarding. Extremities - [**2-17**]+ lower extremity edema, superficial erythema, left lower extremity more than right lower extremity, no purulence or open wounds. Bilateral DP and PT pulses not palpable. LABS: White count 38.7, hematocrit 36.3, platelets 345, sodium 131, potassium 3.4, chloride 97, bicarb 21, BUN 36, creatinine 2.1, platelets 80, calcium 8.3, phosphorus 3.7, magnesium 1.6, lactate 0.8. Negative stool, blood and urine cultures. Chest x-ray - right lung base linear atelectasis. HOSPITAL COURSE - 1) CLOSTRIDIUM DIFFICILE PANCOLITIS WITH RESPONSE TO PO FLAGYL AS OUTPATIENT: The patient was started on po vancomycin. Given dilaudid for pain control. The patient was put on isolation precautions for C. difficile colitis with positive C. difficile toxin. The patient was closely monitored for signs of toxic megacolon by serial abdominal exam and daily KUBs. The next day, the patient's white blood cell count increased to 40 with 12% bands. The patient was started on IV Flagyl, and the following day was given a trial of IVIG with interval improvement in white count and metabolic acidosis. The patient was put on bowel rest and was decompressed with a nasogastric tube for one day, and with rectal tube for the duration of three days with interval improvement in colonic distention as evidenced by clinical exam and radiographic confirmation. Subsequently, the patient's IV Flagyl was stopped, and the patient continued on po vancomycin. The patient was started on clear liquids which were to be advanced slowly to small amounts of solids. The patient was followed this admission by surgical, infectious disease and gastroenterology consults. 2) RESPIRATORY STATUS WITH OBJECTIVE DYSPNEA: During the hospitalization, the patient had complained objectively of severe dyspnea. However, the patient's oxygenation had remained normal, and ABG analysis showed no hypocarbia or hypoxia. It was presumed that the patient likely had emphysema and this was chronic progression of his chronic lung disease. However, there was no evidence of CO2 trapping. There were no infiltrates on chest x-ray, and chest CT was performed which showed moderate bilateral pleural effusions. The patient had undergone right-sided thoracentesis with ultrasound guidance with removal of 500 cc of clear transudate. This was attributed to likely mild congestive heart failure in light of interval decrease of ejection fraction, as was found during this admission by echocardiogram, which showed an ejection fraction of 40% which was an interval decrease from more than 55% in [**2106**]. Of note, the patient's cardiac enzymes were cycled and were negative. Therefore, the patient's dyspnea was thought to be at least partially cardiac, and the patient was given a trial of lasix for the treatment of presumed CHF. The patient was also rate controlled for atrial fibrillation with diltiazem. He required several IV pushes of diltiazem, but his rate was controlled well on diltiazem 180 mg po qd. 3) RENAL FAILURE: The patient's renal failure had mostly a prerenal component and creatinine returned to a baseline of 1.6 with IV hydration. Subsequently, the patient remained uvolemic, and his creatinine was followed closely when the patient was started on lasix for congestive heart failure. 4) ATRIAL FIBRILLATION: Per patient wishes, the patient has not been anticoagulated with Coumadin. The patient has a history of longstanding atrial fibrillation and presented with atrial fibrillation with rapid ventricular response on Lopressor. The patient's Lopressor dose was increased, but subsequently Lopressor was changed to a calcium channel blocker which controlled the patient's heart rate in the range of 60s-70s. 5) HYPERTENSION: The patient was continued on hydralazine, as well as diltiazem and lasix. 6) HISTORY OF CELLULITIS: The patient presented with resolved cellulitis and no antibiotics targeting cellulitis were continued in light of current Clostridium difficile superinfection. 7) NUTRITION: The patient was put on bowel rest in light of severe dilation of transverse colon. The patient was started on TPN, and at the same time was slowly advanced to a clear liquid diet. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**] Dictated By:[**Name8 (MD) 16035**] MEDQUIST36 D: [**2110-8-11**] 01:04 T: [**2110-8-11**] 08:49 JOB#: [**Job Number 16036**] Admission Date: [**2110-7-28**] Discharge Date: [**2110-9-10**] Service: MICU-ORANG Previous discharge summary completed through period of [**8-11**]. HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old Russian-only speaking male with a history of atrial fibrillation who refused anticoagulation therapy, hypertension, chronic obstructive pulmonary disease, chronic renal insufficiency and peripheral vascular disease who was admitted on [**7-28**] to the Medical Service at [**Hospital1 346**] with Clostridium difficile colitis. The patient had previously failed outpatient course of Flagyl and was admitted with GI an Surgery follow up. He was treated with a 20 day course of p.o. vancomycin, an eight day course of intravenous Flagyl and IVIG with slow resolution of his GI symptoms. On hospital day 15 patient was found to be unresponsive with a witnessed tonic-clonic seizure activity. He was transferred to the MICU with close neurologic follow up. He had no past history of seizure disorder and then extensive workup that followed did not reveal any obvious cause. He had a negative CT and MR of his head, a negative EEG and a lumbar puncture was not performed. The patient's course in the SICU was complicated by a respiratory decompensation that was felt to be secondary to his underlying chronic obstructive pulmonary disease with the addition of a presumed aspiration pneumonia versus pneumonitis. The patient was transferred back to the floor on [**8-18**] with a post transfer course significant for continued abdominal pain and some distended loops of bowel on a KUB possibly secondary to an ileus as well as shortness of breath with a left lower lobe infiltrate. He was given a ten day course of levofloxacin for presumed aspiration pneumonia with the last dose on [**8-23**]. He received multiple bedside swallow evaluations and a video swallow study which showed aspiration to all consistencies. The patient was transferred from the floor to the Medical Intensive Care Unit on [**8-26**] for respiratory decompensation with rate going into the 40's and oxygen saturations decreasing into the 80's despite good suctioning. He was electively intubated at that point for respiratory distress. PAST MEDICAL HISTORY: Includes atrial fibrillation with previous refusals to take anticoagulation medicines, hypertension, peripheral vascular disease status post a right _____ artery stent, osteoarthritis, chronic renal insufficiency, benign prostatic hypertrophy and he is status post an SMA stent. He also has congestive heart failure with a past ejection fraction on echocardiogram noted at 30-40%, a right inguinal hernia, status post left inguinal hernia repair, status post right total hip replacement and status post recent Clostridium difficile colitis and new onset seizure disorder. SOCIAL HISTORY: This is a Russian-speaking only male who lives with his wife. Denies alcohol use and quit tobacco some 30 years ago. MEDICATIONS ON TRANSFER TO MICU ON 12TH: Diltiazem 90 t.i.d., Dilantin 400 q. day, simethicone, Reglan 10 q.i.d., viscous lidocaine as needed, Atrovent and albuterol nebs q. 4h., insulin sliding scale, Hydralazine 10 q. 6h. and Lasix 40 b.i.d., guaifenesin p.r.n., Nystatin Swish 'n Swallow, Flovent and an aspirin 325 q. day. ALLERGIES: Include penicillin and Demerol, reactions unknown. PHYSICAL EXAMINATION: On initial presentation on the 12th to the MICU Service, he was 100 degrees Fahrenheit with a heart rate of 121, blood pressure of 91/52, respiratory rate of 23 and satting 99%. His ventilations settings were AC tidal volume of 600 by a rate of 12, FiO2 of 50% and a PEEP of 5. He was intubated and sedated with low frequency jerking motions in his upper extremities bilaterally. He had dry mucus membranes and no jugular venous distention. He had some decreased breath sounds at the bases, left more than right. His heart sounds were distant and no murmurs were appreciated at the time. He had a soft belly with no guarding or rigidity. He had positive bowel sounds and some questionable mild distention. He had no lower extremity edema. LABORATORY ON 12TH: Notable for a high white count at 19.4. He had a hematocrit of 28.7 which was consistent with his previous anemia. He had a platelet count of 302,000. His BMP was sodium of 145, potassium of 3.3, chloride of 113, bicarb of 19, BUN and creatinine of 68 and 2.2 and a glucose of 133. The patient has a baseline creatinine of about 2 from his chronic renal insufficiency. The patient had an albumin of 2.2, a calcium of 7.5, magnesium of 1.5 and phosphorus of 4.6. Patient had a recent gas of 7.3, 39 and 400 with a lactate of 4.5. He has been persistent blood culture negative and was Clostridium difficile negative at the time of transfer, his last positive Clostridium difficile was on [**7-29**]. MEDICAL INTENSIVE CARE UNIT COURSE: 1. Infectious Disease: The patient's initial presentation was for Clostridium difficile colitis. His symptoms appeared to resolve with antibiotic therapy. Abdominal CT on [**8-28**] showed no radiographic evidence of colitis, including no obstruction, wall thickening or pneumatosis. The abdominal CT was remarkable only for a large left renal cyst and a calcification in the spleen which was probable a granuloma. The patient has remained Clostridium difficile toxin negative in his stool and had a repeat CT after the placement of PEG tube performed on [**9-8**] which also showed an unremarkable abdomen with no sign of colitis. The patient has consistently failed swallow studies and has shown to be an aspiration risk. He did develop pneumonia while here at [**Hospital1 69**] which by BAL was shown to be methicillin-resistant Staphylococcus aureus. The patient completed a 14 day course of vancomycin for MRSA pneumonia with resolution of white count and fevers. On [**9-8**] CT scan of abdomen changes were seen at the bases of the lungs including a pleural effusion, larger on the left than right, and a few small cavitary lung lesions, consistent with a Staph pneumonia. Clinical team felt these cavitations were the result of the pneumonia, not representing septic emboli. However, to be certain, a transesophageal echocardiogram was performed which showed no evidence of vegetations on the [**9-9**]. The patient had a similarly negative TE performed on the [**8-29**]. The patient is on day four of seven of levofloxacin for Gram negative rods that were found in an [**9-6**] sputum sample. This likely represents a super infection in tracheobronchitis for which a one week course of levofloxacin should be sufficient. 2. Respiratory status: The patient has been intubated since here in the Medical Intensive Care Unit. He had a trach placed on [**9-4**]. The latest RSBI study was 160. His negative inspiratory force was low at 15. This indicates some respiratory muscle weakness and indicates that he may be difficult to wean from the ventilator. Currently he is on pressure support and CPAP with a pressure of 10, a PEEP of 5, an FiO2 of 0.4 and tidal volumes ranging from 4 to 500. This allows him to keep a stable sat in the high 90's. 3. Neurologic: The patient has new onset seizure disorder that developed during this hospitalization. He had a generalized tonic-clonic seizure that was noted on the floor. Subsequent workup was negative for cause. He has been maintained on Dilantin since that episode with some trouble achieving therapeutic dose. He has required several 500 mg boluses to reach a higher level. Recommend re-checking the level of Dilantin, in addition, possibly with a free Dilantin level in one to three days to see if dose needs to be adjusted. Currently he is taking 100 Dilantin suspension t.i.d. as a maintenance dose. His albumin has been low and Dilantin level needs to be adjusted accordingly. 4. Hematology: The patient did receive transfusion of two units of packed red blood cells earlier in his hospital stay. Currently he is maintained at a relatively stable hematocrit in the upper 20's. He was placed on Epogen at 8000 units three times a week on a Monday, Wednesday, Friday schedule for his chronic renal insufficiency. 5. Renal: The patient has evidence of a renal tubular acidosis and has been taking Bicitra with a good response in his bicarb. Would recommend continuing Bicitra. 6. Fluids, Electrolytes and Nutrition and GI: Patient currently tolerating tube feeds well with low to no residuals. Patient is I more than O, positive more than 19 liters for his stay since early [**Month (only) 205**]. Diuresis has had mixed results. Small doses of Lasix in the range of 20 IV did initially produce diuresis, but we have had diminishing returns on Lasix dosing. The patient has peripheral edema and is clearly third spacing some fluid. This is likely due to his hypoalbuminemia and low oncotic pressure. His fluid status will need to be monitored at the rehab unit. 7. Cardiovascular: The patient has a history of atrial fibrillation but has previously refused anticoagulation therapy. He was placed on diltiazem 30 mg q.i.d. for rate control with a lowering of his rate from the 110's into the 100's. Additional improvement can probably be made with rate control. He has previously taken as much as 180 of diltiazem per day and his blood pressures have held well on that dosing. 8. Physical therapy: The patient will likely need intensive physical therapy in order to regain strength. 9. Skin: The patient has some decubitus ulcers that have been treated with Duoderm dressing changes at least once a day. He also has some skin breakdown of his upper extremities possibly secondary to third space fluid overload. They leak serous fluid and do not appear infected but have been put on Adaptic or Vaseline dressing changes p.r.n. DISCHARGE MEDICATIONS: 1. Diltiazem 30 mg p.o. q.i.d. 2. Levofloxacin on day four of seven 250 mg p.o. q. 24h. 3. Phenytoin suspension 100 p.o. q. 8h. via PEG. 4. Nystatin Swish 'n Swallow. 5. Haldol 1 mg q. 4h. p.r.n. for agitation. 6. Epogen 8000 units three times a week on a Monday, Wednesday, Friday schedule. 7. Miconazole powder 2% as needed. 8. Insulin sliding scale regular. 9. Sodium citrate citric acid 30 mL q.i.d. 10. Albuterol and Atrovent nebs as needed. 11. Fluticasone 110 mcg two puffs b.i.d. 12. Heparin 5000 subcu q. 12h. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: The patient will be going to [**Hospital **] Rehabilitation. DISCHARGE DIAGNOSES: Include: 1. History of Clostridium difficile colitis now resolved. 2. Likely tracheobronchitis with Gram negative rods. 3. Methicillin-resistant Staphylococcus aureus pneumonia with completed vancomycin course. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 16037**] MEDQUIST36 D: [**2110-9-10**] 11:15 T: [**2110-9-10**] 11:18 JOB#: [**Job Number 16038**]

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icd9cm

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icd9pcs

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40712+40713

Discharge summary

report+report

Admission Date: [**2115-7-17**] Discharge Date: [**2115-7-22**] Date of Birth: [**2056-2-1**] Sex: F Service: PSYCHIATRY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 12693**] Chief Complaint: "I'm going to die ..you'll die of old age I just gave you MRSA because I just shook your hand." Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 59 yo cauc. female with reported hx of bipolar do discharged fom [**Hospital **] Hospital psych unit yeserday brought to the ED by her husband and twin sister as she continues delusional.The patient is psychotic, manic and has thoughts that she and other people are dying and believes she is the last Catholic alive. Her husband reports that she was discharged from [**Hospital **] Hospital yesterday after a 3 week admission but she continues psychotic, not sleeping,and arguementative and refusing to take her medications .He said she is continously hungry , is an insulin dependent diabetic and last night she ate a huge piece of cheesecake. This morning he said "she laid down on the kitchen floor and refused to get up and said " I'm dying."He said that she has not slept all night and that he has been up with her as she is a flight risk.He said before her most recent hospitalization to Norwooed she cut a hole in the screen door, crawled out and ran and hid under [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].He said she threw her suiticase in the [**Doctor Last Name 6641**] and continually tried to run away and he had to watch her 24 hrs a day. Her husband [**Name (NI) 68655**] that she was referred to a Dr. [**Last Name (STitle) **] in [**Location (un) 3320**] after she was discharged but was told that she could not have an appointment with him until she was seen by a therapist for 2-3 times. The patient has hx of bipolar do first daignosed and hospitalized 24 years ago and was admitted to [**Hospital3 15986**] twice and has been apparently relatively stable unitl this past [**Name (NI) **] and has reportedly had 2 admisssions to [**Hospital **] Hospital. Recent stressors are her brother in law her twin sister's husband died in [**Name (NI) 404**] and [**Month (only) 958**] is the anniversary of her son's death. Past Medical History: * [**Hospital **] Hospital discharged [**2115-7-15**] after a [**2-7**] week admission where she was admitted from [**Hospital3 3583**] ED manic * [**Hospital3 15986**] twice 23 years ago manic and diagnosed with bipolar do * no hx of SA or SIB * [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) **] CNS, @ Southeast Psychiatric [**First Name9 (NamePattern2) 89027**] [**Location (un) 5110**], MA * Dr. [**Last Name (STitle) 39602**] in [**Location (un) 3320**] has not seen yet was referred to him after she was dischzrged from [**Hospital **] Hospital PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES, OR OTHER NEUROLOGIC ILLNESS): * PCP [**Last Name (NamePattern4) **].[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5311**] ([**Telephone/Fax (1) 89028**]} * IDDM hx of insulin pump not connected * Crohn's Disease Social History: alcohol: reported hx of abuse many years ago, sober 9 years denies hx of w/d sz or balckouts drugs: denies illicits tob: denies caffeine: drinks a pot of coffee a day SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.): The patient was born and grewup in [**Location (un) 6691**],MA. and has an identical twin sister and a younger brother was from an intact family and no hx of abuse.Her [**Last Name (un) 89029**] died at age 59 and her father has [**Name (NI) 2481**] and lives in a nsg home. She graduated from [**Hospital **].[**Location (un) 5169**] with a degree in Mathematics was working until this past [**Month (only) 116**] for an insurance company as a Customer Survey Representative. She is married and had 2 children, her dtr is 23 and works @ [**Hospital1 18**] in accounting and her son died at age 20 in a car fire in [**2106**] while sitting in his car in the driveway of their home.He was reportedly working with some type of electrical equipment and the car caught on fire and he died of smoke inhalation. Family History: paternal cousin with psychiatric illness father and paternal uncle with [**Name (NI) 2481**] maernal grandfather with mental illness Physical Exam: PE: General: Thin woman in no distress. Frequently getting up out of chair during interview, lots of fidgeting. HEENT: head normocephalic & atraumatic, PERRL, EOMI, no lymphadenopathy, no thyromegaly Lungs: Clear to auscultation; no crackles or wheezes. CV: Regular rate and rhythm; no murmurs/rubs/gallops Abdomen: Soft, nontender, nondistended Extremities: No clubbing, edema or cyanosis. Skin: Warm and dry, no rash or significant lesions. Neuropsychiatric Examination: *VS: BP: 155/76 HR: 94 temp: 97.9 resp: 16 O2 sat: 100% height: 61" weight: 113.6 lbs Neurological: *station and gait: gait wnl, but when asked if she is ever unstable immediatly demonstrated with a self-corrected stumble *tone and strength: wnl cranial nerves: PERRL, EOMI, face motor & sensation intact & symmetric, hearing grossly intact & symmetric to finger rub, symmetric palate raise, symmetric shoulder shrug, tongue midline. abnormal movements: frequent fidgeting *Appearance & behavior: unkempt hair, dressed in hospital gown and wearing bright pink socks with black sandals. Nursing had given her dinner in the exam room because she had a low CBG [**Location (un) 1131**]; she frequently got up to fidget with the food and ate very fast and enthusiastically with mouth open. Cooperative, good eye contact. *Mood and Affect: "stable" & "a little bit happy"; affect labile, ranging from tearfulness to happy, occasionally irritable *Thought process: tangential, occasionally loose *Thought Content: delusional content as described in HPI; denies SI, HI, and hallucinations *Judgment and Insight: poor Cognition: *Attention, *orientation, and executive function: fully oriented to place, date, time, and season; thought it was Tuesday when it is Wednesday. *Memory: [**3-7**] registration, [**3-7**] short-term Calculations: did serial 7's starting at 30 down to -6, with one mistake (23-7=15) Abstraction: initially interpreted "apple doesn't fall far from the tree" literally, but able to accurately interpreted with the prompt that it is a saying about people. Accurately interpreted "birds of a feather." Comparisons: pear & [**Location (un) 2452**] are both fruit *Speech: rapid, articulate, occasionally bordering on pressured Pertinent Results: [**2115-7-16**] 01:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2115-7-16**] 01:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.026 [**2115-7-16**] 01:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2115-7-16**] 01:20PM URINE HOURS-RANDOM [**2115-7-16**] 01:55PM PLT COUNT-271 [**2115-7-16**] 01:55PM NEUTS-78.0* LYMPHS-14.0* MONOS-6.4 EOS-0.6 BASOS-1.0 [**2115-7-16**] 01:55PM WBC-6.5 RBC-3.37* HGB-11.2* HCT-31.1* MCV-92 MCH-33.3* MCHC-36.1* RDW-12.8 [**2115-7-16**] 01:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2115-7-16**] 01:55PM estGFR-Using this [**2115-7-16**] 01:55PM GLUCOSE-357* UREA N-27* CREAT-0.8 SODIUM-131* POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-25 ANION GAP-16 [**2115-7-17**] 01:00PM GLUCOSE-509* UREA N-14 CREAT-0.7 SODIUM-132* POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-30 ANION GAP-14 [**2115-7-17**] 01:18PM freeCa-1.17 [**2115-7-17**] 01:18PM GLUCOSE-458* LACTATE-2.2* NA+-131* K+-4.8 CL--90* TCO2-30 [**2115-7-17**] 01:18PM PH-7.38 COMMENTS-GREEN TOP [**2115-7-17**] 04:21PM freeCa-1.03* [**2115-7-17**] 04:21PM GLUCOSE-300* LACTATE-3.6* NA+-133* K+-3.6 CL--103 TCO2-23 [**2115-7-17**] 04:21PM PH-7.39 [**2115-7-17**] 05:30PM PLT COUNT-260 [**2115-7-17**] 05:30PM NEUTS-80.6* LYMPHS-14.2* MONOS-4.2 EOS-0.7 BASOS-0.4 [**2115-7-17**] 05:30PM WBC-6.3 RBC-3.20* HGB-10.5* HCT-29.8* MCV-93 MCH-32.8* MCHC-35.1* RDW-12.7 [**2115-7-17**] 05:30PM CALCIUM-8.6 PHOSPHATE-2.5* MAGNESIUM-1.7 [**2115-7-17**] 05:30PM GLUCOSE-228* UREA N-12 CREAT-0.5 SODIUM-133 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-27 ANION GAP-11 [**2115-7-17**] 05:35PM GLUCOSE-217* LACTATE-2.3* Brief Hospital Course: #Bipolar: Per her family, Mrs. [**Known lastname 9464**] was successfully treated with tegretol as an outpatient for 20 years prior to her recent decompensation. After being admitted to [**Hospital **] Hospital for mania the patient was transitioned from tegretol to zyprexa and risperdal, out of concern that tegretol was causing hyponatremia. While at [**Hospital1 18**] during this hospitalization the patient was started on lithium for mania. Her level was 0.6 on a dose of 300mg [**Hospital1 **], so her dose was increased to 300mg TID. She was also transitioned from zyprexa 10mg daily to ziprasidone 80mg qhs, as this option is a more weight-neutral atypical antipsychotic. She demonstrated some improvement in her symptoms, including improvement of her pressured speech and impulsivity. However she persistently had delusions of death and traveling through time. She also frequently lay on the floor, reporting she was either having seizures or dying. In looking through old records the patient has exhibited this behavior throughout each of her hospitalizations. She responds well to 2mg PO ativan and re-direction into bed. #Diabetes: The patient demonstrated very labile blood sugars throughout this hospitalization. Her sugars were frequently elevated in the 300s - 400s, however she frequently over-corrected into the 30s - 50s overnight. [**Last Name (un) **] has been following the patient and adjusting her insulin, however she remains difficult to control. Of note the patient has an insulin pump which she is not currently using. According to her family her blood sugar was well-controlled prior to her hospitalizations at [**Location (un) **] when she was started on Zyprexa. #Autonomic instability: On the day of transfer ([**2115-7-22**]) the patient had some autonomic instability which was initially concerning for NMS, as she had received 3 doses of Geodon over the weekend. She demonstrated tachycardia (128) and muscle rigidity this morning, with some concern of rising temperature (99.7 up from 98.5). The patient was given 2mg PO ativan and a 1 liter bolus of normal saline. She had labs sent which demonstrated a WBC of 12 without bands, and a CK of 85. This decreased our suspicion for NMS but the patient was placed on constant observation and we continued frequent vital sign checks. The patient's vital signs improved to temp 96.3 and HR 91 in the early afternoon. However, she later demonstrated somnolence and had a fingerstick which showed a blood sugar of 20. The patient was given glucagon but her blood sugar continued to drop to 18, then 14. A code was called on the patient. The ICU team came to evaluate the patient and found her to be hypotensive with blood pressure in the 90s/50s. She was given D50 for her low blood sugar and her sugar rose to the 200s. The patient was given another 1L bolus of NS and the decision was made to transfer her to the ICU for ongoing monitoring, with likely transfer to the medicine service after acute stabilization. #Hypertension: The patient was continued on her outpatient regimen of metoprolol 50, amlodipine 5 and irbesartan 300mg daily. #Alzheimer's: The patient was continued on her Aricept. According to her husband she has never had formal neuropsych testing. We will plan to order a neuropsych consult after she returns to [**Hospital1 **] 4. We will also obtain a head CT at that time, unless she has a head CT as part of her workup while on medicine. #Legal: The patient signed a CV which was accepted by the house officer on [**Hospital1 **] 4. She remained her voluntarily #Safety: The patient frequently had to be placed on 5 minute checks or constant observation for behavioral problems, including eating other patients' food and lying on the floor complaining of seizures. She will be on "constant observation" while on medicine to try to prevent behavioral problems. Medications on Admission: * Xanax .5mg qid * Zyprexa 5mg [**Hospital1 **] * Aricept 5mg @hs * Avapro 300mg qd * Toprol XL 50mg extended release 24hr * Glucophage 1,000mg [**Hospital1 **] * Zocor 10mg qd * Vit D 1000 unit qd * lantus 100 unit/ML s.c. 24u solutions @ 2100 * Novolog unknown strengthI * Norvasc 5mg qd Discharge Medications: Ziprasidone Hydrochloride 40 mg PO/NG QAM [**7-22**] @ 1550 View Lithium Carbonate 300 mg PO TID [**7-22**] @ 1550 View Lorazepam 2 mg PO/NG ONCE Duration: 1 Doses [**7-22**] @ 1043 View Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose [**7-20**] @ 0908 Ziprasidone Hydrochloride 80 mg PO/NG HS [**7-18**] @ 1712 View Avapro *NF* (irbesartan) 300 mg Oral daily Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. [**7-17**] @ 2122 View Alprazolam 0.5 mg PO QID:PRN anxiety, agitation [**7-17**] @ 2122 View Amlodipine 5 mg PO DAILY [**7-17**] @ 2122 View Donepezil 5 mg PO HS [**7-17**] @ 2122 View Metoprolol Succinate XL 50 mg PO DAILY [**7-17**] @ 2122 View Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol [**7-17**] @ 2051 View Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol [**7-17**] @ 2051 View Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO Q4H:PRN acid reflux [**7-17**] @ 2051 View Milk of Magnesia 30 ml PO Q8H:PRN constipation [**7-17**] @ 2051 View Acetaminophen 650 mg PO Q4H:PRN pain, fever [**7-17**] @ 2051 View Discharge Disposition: Extended Care Facility: [**Hospital1 18**] CC7 Discharge Diagnosis: II- defer III - NIDDM, htn IV - family tensions, acute hospitalizaiton, recent d/c from psychiatric unit, failure to comply with medications V-28 Discharge Condition: Unstable - being discharged to medicine CC7 for stabilization of blood sugars and blood pressure Discharge Instructions: -Please call psychiatry consult service ([**7-/7896**]) to have psychiatry continue to follow this patient -Please have [**Last Name (un) **] continue to follow the patient. They are aware she has been transferred -Please have patient return to psychiatry when medically stable Followup Instructions: No follow up appointments scheduled at this point Admission Date: [**2115-7-22**] Discharge Date: [**2115-7-25**] Date of Birth: [**2056-2-1**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2181**] Chief Complaint: hypotension, hypoglycemia Major Surgical or Invasive Procedure: n/a History of Present Illness: This is a 59 y/o F with history of T1DM, Hypertension, Bipolar disorder who was admitted to acute psychiatric [**Hospital1 **] for acute manic episode. Patient was recently admitted to OSH Psych [**Hospital1 **] where she was treated for 3 weeks. Upon discharge home, she continue display manic behavior and was brought back to [**Hospital1 18**] ED for further evaluation. . In [**Hospital1 18**] ED, patient displayed frank manic behavior and was admitted to [**Hospital1 **] 4 for further evaluation and treatment. While on the inpatient psych team, pt continued to display manic behavior and was noted to run up and down hallways eating her floormates food. Patient was noted to have labile blood sugars. Hyperglycemia was thought to be [**2-6**] olanzapine and changed to zisperidone. Of note because of her manic behavior, patient was placed in the "quiet room." . On day of transfer, pt was noted to be tachycardic to 100s and hypertensive. Patient was given 500cc IV bolus for tachycardia. She received a total of 25 units of insulin today. At approximately 330pm, pt was assessed in "quiet room," and was noted to somnolent and unresponsive. Code was called. FS taken at that time was noted to be 14. Patient was given PO glucagon and 1 amp of D50 was given. Patient remained confused and somnolent. BP was noted to be in SBPs 80s/40s with cool/clammy extremities. 1L of NS was given and patient SBPs responded to 100s. Pts mental status was improved and patient was transported to ICU for further monitoring. . On the MICU, patient was reported feeling very well. She noted that during initial event, patient left confused and felt faint. She denied CP, SOB, N, V. Had similar events in past that she stated was [**2-6**] "low blood sugar." Past Medical History: - Diabetes Mellitus Type 1 - HTN - celiac disease - bipolar dx Social History: former drinker sober for last 9 yr, denies tobacco and IVD. She is married, one daughter, son passed away in '[**06**] from accident. Family History: non-contributory Physical Exam: Admission Physical Exam: Vitals: 96.1 107/59 63 13 100%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: cool extremitites, 2+ pulses, no clubbing, cyanosis or edema Transfer Physical Exam: Vitals: T-97.5 110-163/70-86 HR-72-80 RR-18 99-100%RA General: Alert, oriented, generalized intermittent shaking HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: wwp, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2115-7-22**] 11:58AM BLOOD WBC-12.2*# RBC-3.69* Hgb-12.0 Hct-34.3* MCV-93 MCH-32.7* MCHC-35.1* RDW-12.8 Plt Ct-372 [**2115-7-22**] 11:58AM BLOOD Neuts-91.4* Lymphs-5.1* Monos-3.0 Eos-0.2 Baso-0.3 [**2115-7-22**] 04:32PM BLOOD Glucose-172* UreaN-17 Creat-0.8 Na-131* K-3.8 Cl-99 HCO3-26 AnGap-10 [**2115-7-22**] 11:58AM BLOOD ALT-32 AST-26 LD(LDH)-250 CK(CPK)-85 AlkPhos-89 TotBili-0.3 [**2115-7-22**] 04:32PM BLOOD Lithium-0.7 [**2115-7-23**] 04:03AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.0 [**2115-7-22**] 04:32PM GLUCOSE-172* UREA N-17 CREAT-0.8 SODIUM-131* POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-26 ANION GAP-10 [**2115-7-22**] 04:32PM LD(LDH)-227 CK(CPK)-182 [**2115-7-22**] 04:32PM CK-MB-8 cTropnT-<0.01 [**2115-7-22**] 04:32PM CALCIUM-8.7 [**2115-7-22**] 04:32PM LITHIUM-0.7 [**2115-7-22**] 04:32PM WBC-8.5 RBC-3.11* HGB-10.1* HCT-28.5* MCV-92 MCH-32.5* MCHC-35.4* RDW-12.8 [**2115-7-22**] 04:32PM NEUTS-83.1* LYMPHS-11.4* MONOS-4.6 EOS-0.5 BASOS-0.4 [**2115-7-22**] 04:32PM PLT COUNT-274 [**2115-7-22**] 11:58AM ALT(SGPT)-32 AST(SGOT)-26 LD(LDH)-250 CK(CPK)-85 ALK PHOS-89 TOT BILI-0.3 [**2115-7-22**] 11:58AM WBC-12.2*# RBC-3.69* HGB-12.0 HCT-34.3* MCV-93 MCH-32.7* MCHC-35.1* RDW-12.8 [**2115-7-22**] 11:58AM NEUTS-91.4* LYMPHS-5.1* MONOS-3.0 EOS-0.2 BASOS-0.3 [**2115-7-22**] 11:58AM PLT COUNT-372 [**2115-7-22**] 06:35AM UREA N-11 CREAT-0.6 [**2115-7-22**] 06:35AM TSH-2.9 [**2115-7-22**] 06:35AM LITHIUM-0.6 Brief Hospital Course: 59 y/o F with type 1 DM, HTN and bipolar disease presented to MICU after hypoglycemic episode (BS=14) with hypotension(90/50's), transfered to [**Hospital1 **] bed on [**2115-7-23**], now stable for transfer to inpatient psychiatry. . # HYPOTENSION: Episode Occured in setting of hypoglycemia likely related to concurrent vagal episode. No evidence of sepsis or ongoing infectious symptoms. EKG and cardiac enzymes were normal. Patient remained hemodynamically stable while in MICU and after when monitored on floor for 48 hours. Oral antihypertensives were initially held with plan to re-initiate prior to discharge. The amlodipine was started on [**2115-7-25**]. # HYPOGLYCEMIA/LABILE BLOOD SUGARS: Patient withi history of type 1 diabetes that was historically treated with insulin pump. However given psychiatric disorder, insulin pump was discontinued. Since the discontinuation of pump, patient's blood sugars have been labile. [**Last Name (un) **] was initially consulted while patient was on psych [**Hospital1 **]. On day of unresponsive episode, patient's FS was 14, which recovered with oral glucagon and ampule of D50. This occured because of aggressive sliding scale in setting of reduced PO. Glargine was reduced and RISS was reduced with better control of fingersticks. She has ranged from 186 to 281 over the past 24 hours. Currently the patient is taking 16units of Glargine QHS and on an ISS based on post-prandial blood glucose levels. [**Last Name (un) **] is following the patient and will continue to follow her to provide recommendations moving forward. They recommend that when she goes back to psychiatry that she will need close supervision and assistance at meal time to make sure that she eats her meals. Her premeal insulin should then be dosed AFTER the meal. If she eats 50% of her meal or less then her short acting meal insulin should be cut in half. . # MANIA: Patient floridly manic and intermittently agitated. Pt was being stabilized on lithium and geodon for mania, which has improved but not resolved. Psychiatry continued to follow her on the medicine floor. . # HYPONATREMIA: Patient stable hyponatremia that was thought to be [**2-6**] tegretol. Her sodium was monitored and remained stable. . # TREMOR: Patient developed intermittent upper extremity tremor with mild rigidity. This was thought to be due to extra-pyramyidal side effect from her anti-psychotic medications. She is currently being uptitrated to benztropine 1mg [**Hospital1 **], currently at 0.5mg [**Hospital1 **]. These shakes could also be from a conversion disorder after her hypoglycemic episode. Of note, she only shakes when medical professional are present, and does not shake when observed from a far. . Medications on Admission: Medications (on transfer from MICU) Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Docusate Sodium 100 mg PO BID Heparin 5000 UNIT SC TID Insulin SC (per Insulin Flowsheet), Sliding Scale & Fixed Dose Ziprasidone Hydrochloride 40 mg PO/NG QAM Lithium Carbonate 300 mg PO TID Ziprasidone Hydrochloride 80 mg PO/NG HS Alprazolam 0.5 mg PO QID:PRN anxiety, agitation Donepezil 5 mg PO HS Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO Q4H:PRN acid reflux Milk of Magnesia 30 ml PO Q8H:PRN constipation Acetaminophen 650 mg PO Q4H:PRN pain, fever Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 3. donepezil 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. ziprasidone HCl 40 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 8. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for anxiety, agitation. 9. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 10. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: Thirty (30) ML PO Q4H (every 4 hours) as needed for acid reflux. 11. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 12. benztropine 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. insulin glargine 100 unit/mL Solution Sig: One (1) 16 Subcutaneous at bedtime. 16. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: Please see attached sliding scale . 17. dextrose 50% in water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Intensive care unit Discharge Diagnosis: bipolar I Diabetes Mellitus type 1 Hypertension episode of hypoglycemia Discharge Condition: stable Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 18**] ICU for manic episodes. You had a hypoglycemic episode. Your insulin was reduced. Your blood sugars remained stable. You were followed by [**Last Name (un) **] Diabetes Specialists. You are being transferred to inpatient psychiatry for futher management of your mania. Followup Instructions: Please follow up with [**Last Name (un) **] Diabetes and your primary care physician at discharge from inpatient psychiatry

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

24807, 24870

19730, 22459

15085, 15090

24986, 24993

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21,551

155,460

10203

Discharge summary

report

Admission Date: [**2159-10-27**] Discharge Date: [**2159-11-10**] Service: VSURG Allergies: Codeine / Percodan Attending:[**First Name3 (LF) 4748**] Chief Complaint: AAA, symptomatic Major Surgical or Invasive Procedure: AAA repair with ABF graft,exploration right femoral artery with dacron patch repair [**2159-11-1**] History of Present Illness: 83y/o female with known AAA but increased in size , now with back pain. CT c/w 5.5cmAAA with 2.2cm thrombus. Compressing right ureter with resulting hypdronephrosis. UA c/w UTI began on Iv levoquin. Patient transfered from [**Location (un) **] [**Hospital1 **] [**First Name (Titles) **] [**Hospital 34026**] [**Hospital 9688**] Medical Center.Transfered to us for further evaluation. Past Medical History: Aortic valve disease s/p AVR coronary artey disease s/p CABG"S asthma hypertension osteo arthritis Social History: unknown Family History: unknown Physical Exam: Vital signs: 99.4-89-22 182/87 Oxygen saturation 96% General: alert oriented x3, no acute distress HEENT: neck supple no JVD, no carotid bruits Lungs: clear to auscultation Heart: regular rate rythms, no mumur ABD: soft nontender. Back tenderness @ L1-2 Neuro : grossly intact. Pertinent Results: [**2159-10-27**] 07:55PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2159-10-27**] 07:55PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR [**2159-10-27**] 07:55PM URINE RBC-0-2 WBC-[**7-5**]* BACTERIA-MOD YEAST-NONE EPI-0 [**2159-10-27**] 06:43PM URINE COLOR-Straw APPEAR-SlHazy SP [**Last Name (un) 155**]-1.021 [**2159-10-27**] 06:43PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-TR [**2159-10-27**] 06:43PM URINE RBC-0-2 WBC-[**3-30**] BACTERIA-MOD YEAST-NONE EPI-0-2 RENAL EPI-0-2 Brief Hospital Course: [**2159-10-27**] admitted to vascular service.Hypetension controlled with esmolol drip and pain controlled. Seen by cardology placed at very high risk. Patient made aware of the consequencs of ruptured AAA if not surgically treated with open procedure. Patient could have a encovascular stenting but only with Zenith device which is not avaible here or at [**Hospital1 2025**]. admitteing urine with UTI. Placed on levofloxcin [**2159-10-28**] CT of abdomen and pelvis obtained with 5mm cuts. Reviewed by Dr. [**Last Name (STitle) **] recommendations open repair at this time. Episode of SOB secondary to betablockade resolved with nebulizer treatment.and solumedrol IV which was converted to predisone 40mgm daily,norvasc 5mgm started. [**2159-10-30**] patient's predisone discontinued secondary to CHF. atrovent and albuteral Nebs. continued and diuresis with lasix continued. [**2159-10-31**] diuresed effectively. Blood pressure well controlled.DNR?DNI converted to full code per patient's wishes right IJ line placed. [**2159-11-1**] DOS: aaa resection with ABF graft and exploration of right femorla artery and paatch closure.Required four units PRBC and two FFP intraoperatively. Transfered to SICU for continued care stable and intubated from PACU. [**2159-11-2**] POD#1 Epidural placed intraoperatively for analgesic control.remained in SICU [**2159-11-3**] POD# 2 extubated.Loose stools x4 [**2159-11-4**] POD#3 contiued to diuresis [**2159-11-5**] POD#4 right subclavian placed. epidural catheter discontinued patient converted to oral analgesics.started on clears and tolerating 10/12-13/04 POD#[**5-31**] afebrile .Wounds clean dry and intact .Diet advanced . Bowel regiment began. ambulation to chair began. Seen by physical thearphy and rehabilitation short term recommended prior to d/c to home. [**2159-11-8**] POD#7 awaiting rehab screening and bed . [**2159-11-9**] POD#8 mild abdominal pain and tenderness that completely resolved with Bowel Movement. Bed available tomarrow at rehab facility. [**2159-11-10**] POD#9 scheduled to leave to rehab in AM. Medications on Admission: detrol ASA plavix combivent lasix lipitor atenolol Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 6. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed. 7. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 9. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two (2) Packet PO BID (2 times a day). 12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for CONSTIPATION. 14. Furosemide 20 mg IV Q8H 15. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection every six (6) hours: regular insulin scale q6h: glucoses <140-no insulin glucoses 141-160/2u glucoses 161-180/4u glucoses 181-200/6u glucoses 201-240/8u glucoses 241-260/10u glucoses 261-280/12u glucoses 281-300/14u glucoses > 300 notify Md. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: AAA s//p repair Discharge Condition: stable Discharge Instructions: [**Name8 (MD) 138**] Md [**First Name (Titles) **] [**Last Name (Titles) 26520**] fever, chills or wound changes of redness or drainage Followup Instructions: f/up with [**Doctor Last Name 1391**] 2 weeks. call for appointment. [**Telephone/Fax (1) 1393**] Completed by:[**2159-11-9**]

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icd9cm

[ [ [] ] ]

[ "99.07", "39.25", "39.57", "89.64", "38.08", "99.04", "99.00" ]

icd9pcs

[ [ [] ] ]

5619, 5705

1903, 3981

242, 345

5764, 5772

1246, 1880

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186, 204

373, 759

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897, 906

66,730

140,651

36888

Discharge summary

report

Admission Date: [**2152-6-7**] Discharge Date: [**2152-6-22**] Date of Birth: [**2079-5-29**] Sex: M Service: CARDIOTHORACIC Allergies: Phenergan / Levaquin / Keflex Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2152-6-9**] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending, with vein grafts to obtuse marginal and posterior descending artery History of Present Illness: Mr. [**Known lastname **] is a 73 year old male with known coronary artery disease and aortic stenosis. Three months ago presented to another hospital with chest pain and was ruled out for ischemia by pharmacologic myoview, and was discharged. On [**6-1**] he developed heaviness in chest that radiated to his back during dinner. He took ultram and it decreased the pain, however he woke in the middle of the night feeling dizzy and increased heaviness in chest and called 911. He was worked up at outside hospital, ruled in for non st elevation myocardial infarction troponin 2.21 CK 499 and underwent cardiac catherization that revealed coronary artery disease. He was transferred for surgical evaluation. Past Medical History: Obstructive sleep apnea (uses CPAP) Osteoarthritis Prostate cancer s/p seed implantation Coronary artery disease s/p angioplasty [**2137**] Hypertension Hyperlipidemia Mild aortic stenosis Atrial Fibrillation (new) Restless leg syndrome Esophageal dilitation - [**2152-1-27**] Kidney stones Pneumonia [**2148**] Gastroesophageal reflux disease Past Surgical History: Multiple rotator cuff surgeries - right and left Cholecystectomy Bilateral Knee surgery Social History: Occupation: retired - inspector telephone co Last Dental Exam - 2 months ago (Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5279**] - VA) Lives with spouse in [**Name2 (NI) **] and [**State **] - [**State **] visiting family Race caucasian Tobacco: denies ETOH: 2 drinks day - vodka/wine Family History: Mother - deceased 69 myocardial infarction. Father valvular disease deceased 82. Physical Exam: Pulse:62 Resp: 18 O2 sat: 97 RA B/P Right: 107/71 Left: Height: Weight: General: Skin: Dry [x] intact [x] patchs of eczema above nose HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] no lymphadenopathy Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [**1-14**] systoic ejection murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] obese Extremities: Warm [x], well-perfused [x] Edema +1 pitting LE Varicosities: None [X] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +1 Left: +1 PT [**Name (NI) 167**]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: no bruit Left: bruit vs murmur Pertinent Results: [**2152-6-7**] Echo: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. [**2152-6-7**] Carotid: Right ICA stenosis <40%. Left ICA stenosis <40%. [**2152-6-7**] Chest CT Scan: Right hilar prominence on chest radiographs is due to enlargement of pulmonary arteries, the right and left are each 3.2 cm, although the main pulmonary artery is normal caliber. Atherosclerotic calcification is present in the left anterior descending and proximal circumflex branches, and at multiple locations in the right coronary artery and posterior descending branch, but not in the ascending aorta. Moderately extensive dystrophic calcification is also present in the aortic valve and mitral annulus. The former is more likely to be hemodynamically significant. [**2152-6-7**] Head CT Scan: No evidence of hemorrhage, edema, mass effect, or acute vascular territorial infarction. Ventricles and sulci demonstrate minimal prominence, which may be sequela of age-related parenchymal atrophy. There are periventricular white matter hypodensities, predominantly in the posterior centrum semiovale (2:19), likely the sequela of small vessel microvascular infarcts. The osseous structures appear intact. There is evidence for prior ethmoid sinus surgery. Otherwise, the paranasal sinuses and mastoid air cells are clear. [**2152-6-7**] 01:20PM BLOOD WBC-6.7 RBC-3.98* Hgb-13.0* Hct-37.9* MCV-95 MCH-32.5* MCHC-34.2 RDW-13.5 Plt Ct-214 [**2152-6-10**] 02:33AM BLOOD WBC-10.2 RBC-3.03* Hgb-10.0* Hct-28.7* MCV-95 MCH-33.1* MCHC-35.0 RDW-13.7 Plt Ct-158 [**2152-6-19**] 05:02AM BLOOD WBC-11.5* RBC-3.13* Hgb-9.7* Hct-29.8* MCV-95 MCH-30.9 MCHC-32.5 RDW-15.6* Plt Ct-471* [**2152-6-7**] 01:20PM BLOOD PT-12.3 PTT-23.1 INR(PT)-1.0 [**2152-6-17**] 01:06PM BLOOD PT-59.1* INR(PT)-6.7* [**2152-6-19**] 06:30AM BLOOD PT-20.2* PTT-30.3 INR(PT)-1.9* [**2152-6-7**] 01:20PM BLOOD Glucose-84 UreaN-20 Creat-1.4* Na-140 K-4.1 Cl-102 HCO3-30 AnGap-12 [**2152-6-10**] 02:33AM BLOOD Glucose-95 UreaN-21* Creat-1.6* Na-137 K-5.1 Cl-107 HCO3-23 AnGap-12 [**2152-6-19**] 05:02AM BLOOD Glucose-100 UreaN-19 Creat-1.6* Na-135 K-4.2 Cl-98 HCO3-28 AnGap-13 [**2152-6-7**] 01:20PM BLOOD ALT-65* AST-42* LD(LDH)-223 AlkPhos-55 Amylase-68 TotBili-0.6 [**2152-6-19**] 05:02AM BLOOD ALT-20 AST-21 LD(LDH)-261* AlkPhos-46 TotBili-0.6 [**2152-6-19**] 05:02AM BLOOD Albumin-3.4 Calcium-8.8 Phos-4.1 Mg-2.3 [**2152-6-21**] 04:54AM BLOOD WBC-11.0 RBC-3.05* Hgb-9.5* Hct-29.2* MCV-96 MCH-31.1 MCHC-32.6 RDW-15.8* Plt Ct-511* [**2152-6-22**] 05:08AM BLOOD PT-28.2* INR(PT)-2.8* [**2152-6-21**] 04:54AM BLOOD Glucose-86 UreaN-25* Creat-1.8* Na-136 K-4.3 Cl-99 HCO3-26 AnGap-15 Brief Hospital Course: Mr. [**Known lastname **] was admitted to cardiac surgery and underwent extensive preoperative evaluation including echocardiogram, and carotid ultrasound along with chest and head CT scans - please see result section for details. He remained pain free on medical therapy and was eventually cleared for surgery. On [**6-9**], Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting surgery. For surgical details, please see dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring in stable condition. On postoperative day one, extubation was not performed secondary to agitation, hypertension and tachypnea. Agitation was attributed to alcohol withdrawal. He concomitantly experienced fevers for which pan-cultures were obtained. On postoperative day two, successful extubation was performed. He experienced rapid atrial fibrillation and was started on Amiodarone. Eventually was started on Coumadin. He converted to sinus rhythm and remained in sinus until discharge. On postoperative day four, he transferred to the SDU. Blood cultures grew both yeast and gram-negative rods. Infectious disease was consulted and he was treated with both Fluconazole and Zosyn. In addition he was getting Vancomycin for hospital-acquired pneumonia. On post-op day five PICC line was placed for presumed long-term antibiotic therapy. [**Last Name (un) **] was consulted on post-op day seven for new-onset diabetes management (patient told in past he was pre-diabetic). He was maintained on sliding scale insulin as needed and discharged on Januvia [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. He will follow up with PCP for diabetes screening. The patient was discharged home on POD 13 with home care IV antibiotics and appropriate follow up instructions. Medications on Admission: Medications at home: Aciphex 20 mg daily Aspirin 81 mg daily Diltiazem 240 mg daily Lipitor 40 mg daily Micardis/HCTZ 40/12.5 mg daily Mirapex 1 mg daily Tricor 145 mg daily Multivitamin daily Flonase 0.4 mg daily Zetia 10 mg daily Miralex [**12-10**] capfuls daily as needed for constipation Vitamin d [**Numeric Identifier 1871**] IU once weekly Domperidone Elcon intermittently for eczema Discharge Medications: 1. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 2 weeks: through [**2152-7-4**]. Disp:*42 * Refills:*0* 2. Rabeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 6. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. Pramipexole 1 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*2* 8. 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:*2* 9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO daily (). 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 12 days: last dose is [**2152-7-4**]. Disp:*24 Tablet(s)* Refills:*0* 16. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID PRN () as needed for anxiety. Disp:*20 Tablet(s)* Refills:*0* 19. Sitagliptin 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Hypertension Dyslipidemia Mild Aortic Stenosis Atrial Fibrillation Obstructive sleep apnea (uses CPAP) Prostate caner s/p seed implantation Osteoarthritis Restless leg syndrome Esophageal dilatation Kidney stones Gastroesophageal reflux disease Pneumonia [**2148**] s/p Multiple rotator cuff sugeries - right and left s/p Cholecystectomy s/p Bilateral knee surgery Discharge Condition: Stable Discharge Instructions: 1)No driving for one month 2)No lifting more than 10 lbs for at least 10 weeks from the date of surgery 3)Please shower daily. Wash surgical incisions with soap and water only. 4)Do not apply lotions, creams or ointments to any surgical incision. 5)Please call cardiac surgeon immediately if you experience fever, excessive weight gain and/or signs of a wound infection(erythema, drainage, etc...). Office number is [**Telephone/Fax (1) 170**]. 6)Call with any additional questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) **] in [**3-12**] weeks, call for appt Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 2603**] or Dr. [**First Name (STitle) 12795**] in [**1-11**] weeks, call for appt Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5279**] in [**1-11**] weeks, call for appt [**Hospital Ward Name 121**] 6 for wound check in 2 weeks Completed by:[**2152-6-22**]

[ "272.0", "V45.79", "V10.46", "401.9", "424.1", "427.32", "518.5", "410.71", "427.31", "038.49", "333.94", "112.5", "V13.01", "997.31", "530.81", "414.01", "999.31", "276.6", "E878.1", "327.23", "715.90" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.12", "96.71", "39.61" ]

icd9pcs

[ [ [] ] ]

10341, 10390

6034, 7868

306, 507

10859, 10867

2916, 6011

11410, 11810

2069, 2151

8310, 10318

10411, 10838

7894, 7894

10891, 11387

7915, 8287

1640, 1729

2166, 2897

256, 268

535, 1250

1272, 1617

1745, 2053

712

108,413

13140

Discharge summary

report

Admission Date: [**2155-11-1**] Discharge Date: [**2155-11-9**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9554**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Cath x 2 with stenting History of Present Illness: 85y/o M w/ h/o CAD s/p CABG, HTN, Hypercholesterolemia, remote tobacco history who was in USOH PTA. He had been hospitalized for a pneumonia ~6 weeks ago, treated and sent home on 2L oxygen. One month ago he was able to walk up a flight of stairs (12 steps) without any dificulty or DOE. Up until one week ago he started noticing that he could not walk up the full flight of stairs, he would stop at 6 steps [**12-30**] SOB and abdominal pressure/tightness. 2.5 days ago he could only go up 4 stairs prior to symptoms starting, he also noticed that he developed a pressure around his waist that waxed and waned in intensity. This morning, he quickly became sob with minimal exertion lasting 30min before recovering his breath. He dressed himself, washed and shaved and was readily out of breath, developed pressure around his waist that was worse than before [**9-7**] non radiating, no LH/dizziness/N/V. He gave himself oxygen which helped ease both the abdominal tightness and SOB. He called EMS who found him to have a P: 84, BP: 170/80, R: 24, O2 84% on 2L then switched to NRB iwth O2 95%, they gave him lasix 40mg and 2 baby asa and was taken to [**Name (NI) 1474**] Hospital. There he was noted to be in florid heart failure, given NTG, Morpine 2mg+2mg, lasix 40mg, started on NTG drip, 2 baby asa, lovenox 80mg sc, mucomyst 600mg iv, lopressor 2.5mg, and started on Tirofiban. Hct was 46.4, wbc 13.2, BUN 46, Cr 2.3, CK 67, TropI 0.5. He was subsequently transferred to [**Hospital1 18**] for cardiac catherization. Upon arrival to floor patients face was dark red/almost purple, c/o severe abdominal pressure, non radiating, acutely sob, no LH/Dizziness, no N/V. He was tachypneic on NRB with sats in the high 80's/low 90's, JVD ~14cm, heart RRR, lungs with crackles from bases to [**12-31**] of lung field. He was given 80mg iv lasix, 2mg of morphine, started on heparin iv, then given additional 100mg of iv lasix. CXR with pulmonary congestion/edema, sats improved to the low 90's and no longer was desating with conversation. ABG's showed 7.39/34/48-> 7.34/39/63-->7.37/39/76. He diuresed 2L total after 180mg of lasix and was no longer in distress, abdominal pain resolved after 10min on floor. Patient still on NRB. ROS: no cough, no PND, no orthopnea, no edema, no N/V/F/CH, no pleuritic chest pain, Past Medical History: PMH: 1. Parkinsons 2. CAD s/p CABG, CHF diastolic dysfunction EF 60-65% 3. PPM [**12-30**] afib 4. HTN 5. hypercholesterolemia 6. peripheral neuropathy 7. Cardiomegaly on CXR and effusion 8. Pulm nodules on CT: 2, 2mm in the LUL Social History: SOH: remote tobacco: used to smoke 1ppd with 1-2 cigars, then switched to pipe. quit 21yrs ago, no etoh. Married lives with wife no ivdu Family History: FMH: had one brother that died from MI at age 35, two other brothers that died at ages 66 and 80 from MI. Brother that died at 80 died after shovelling snow, immediate death. Physical Exam: GEN: moderate distress upon arrival, face dark red, c/o sob and abdominal pressure, tachypneic HEENT: EOMI, PERRL, mmdry, o/p clear, Neck: JVD ~14cm, supple, ?bruit in the left carotid CV: RRR, paced, no m/r/g, surgical scar appreciated PULM: crackles [**12-31**] lung field b/l, mild exp wheezes in the lower bases, no rhonchi, good inspiratory and expiratory efforts ABD: soft, round, NABS, NT/ND, no hepatic tenderness, no HM, no HJR, no massess, no pulsatile masses appreciated. Groin: bruits appreciated in both groins, pulses palpable Ext: 1+ edema to BK b/l, no c/c, DP/PT both palpable, ext warm and perfused Neuro: grossly intact, CN II-XII grossly intact Pertinent Results: [**2155-11-1**] 05:42PM TYPE-ART TEMP-36.3 RATES-/24 O2-100 PO2-76* PCO2-39 PH-7.37 TOTAL CO2-23 BASE XS--2 AADO2-615 REQ O2-98 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA [**2155-11-1**] 05:42PM O2 SAT-96 [**2155-11-1**] 03:10PM TYPE-ART PO2-63* PCO2-39 PH-7.34* TOTAL CO2-22 BASE XS--4 INTUBATED-NOT INTUBA [**2155-11-1**] 03:10PM HGB-14.4 calcHCT-43 O2 SAT-92 CARBOXYHB-0.5 MET HGB-0.8 [**2155-11-1**] 02:59PM GLUCOSE-124* UREA N-48* CREAT-2.3* SODIUM-141 POTASSIUM-5.2* TOTAL CO2-20* [**2155-11-1**] 02:59PM ALT(SGPT)-14 AST(SGOT)-19 CK(CPK)-58 ALK PHOS-85 TOT BILI-1.0 [**2155-11-1**] 02:59PM CK-MB-NotDone cTropnT-0.07* [**2155-11-1**] 02:59PM ALBUMIN-4.2 CALCIUM-8.9 PHOSPHATE-3.8 MAGNESIUM-2.1 [**2155-11-1**] 02:59PM WBC-12.2* RBC-4.70 HGB-14.7 HCT-43.2 MCV-92 MCH-31.2 MCHC-34.0 RDW-14.2 [**2155-11-1**] 02:59PM PLT COUNT-201 [**2155-11-1**] 02:59PM PT-15.0* PTT-139* INR(PT)-1.4 [**2155-11-1**] 02:47PM TYPE-ART TEMP-35.0 O2-100 PO2-48* PCO2-34* PH-7.39 TOTAL CO2-21 BASE XS--3 AADO2-648 REQ O2-100 INTUBATED-NOT INTUBA [**2155-11-1**] 02:47PM HGB-14.4 calcHCT-43 O2 SAT-89 CARBOXYHB-0.3 MET HGB-0.9 [**11-3**] Echo 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. There is moderate pulmonary artery systolic hypertension. [**11-4**] Stress MIBI 1) Moderate, reversible inferior and inferolateral wall perfusion defect. 2) Slight hypokinesis of the lateral wall with calculated ejection fraction of 46%. [**11-5**] Cath 1. Selective coronary angiograpy of this right dominant system revealed multi-vessel disease. The LMCA contained mild, diffuse disease. The LAD was occluded mid vessel and filled via SVG-D. The LCX was occluded proximally. The RCA had diffuse disease up to as much as 80% stenosed. 2. Vein graft imaging revealed patent LIMA-LAD without significant disease. The SVG-RPL was totally occluded. The SVG-D1 had 70-80% lesions proximally. 3. Resting hemodynamics revealed a severely elevated mean PCPW of 22mmHg. The Cardiac Index by the Fick method was 2.3 l/min/m2. 4. Successful stenting of the SVG to RPL with distal to proximal overlapping Cypher DESs (3.0x33, 3.0x33, and 3.5x23) (See PTCA comments). [**11-7**] Cath 1. Selective angiography of the recently stented SVG to the RPL revealed widely patent stents. The SVG to the LAD had a 80% proximal stenosis. 2. Successful stenting of the proximal segment of the SVG to the LAD with a 3.5x18mm Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] with a 4.5x12mm Quantum MAverick at 20 atms using Filterwire EZ RX for distal protection (See PTCA comments). Brief Hospital Course: 85y/o M with CAD s/p CABG, diastolic heart failure, HTN, hypercholesterolemia, p/w 2 day history of USA and acute pulmonary edema. 1. CV: History c/w UA progressing to ACS. CAD: Patient arrived on Tirofiban [**12-30**] his ARF and NTG gtt. We started patient on heparin, asprin full dose, metoprolol, holding acei, started lipitor. NTG gtt titrated to relieve pain. Once initially stabalized the pt had no chest pain for the entire admission. Once resp status stabalize pt sent for a stress MIBI which demonsrated a reversible inf/inf-lat perfusion defecit with HK of the lat wall. He was sent to cath where the pt was found to have multi vessel disease. The SVG-RPL was stented with overlapping stents. He was brought back for repeat cath and stenting of the SVG-LAD. With both caths the pt was prehyd with Na Bicarb and mucomyst. His groin cath sites did not have evidence of eccymoses or bleeding. He had a small hematoma on the R which was stable. He also has been hemodynamically stable throughout the admission. The pt will be sent out on ASA, plavix, ACEI, lipitor, and B Blocker. Pump: supposed EF of 60-65% with diastolic heart failure, patient presently in acute heart failure and hypoxic. Nitro gtt was given for afterload reduction and lasix for diuresis. Given morphine here, one dose for pain releif and pulm vasculature dilation. The patient was oxygenating well but requiring a non-rebreathing mask at 100%. When the mask was taken off the pt would desat to the 80's immediately. He was diuresed with lasix requiring 100mg iv mult time to put out about 2 liters. He was started on natrecor and sent to the CCU for further diuresis with close supervision. The diuresis was successful at relieving the patient's respiratory distress but his Cr. did rise. The pt was then free from shortness of breath from the remainder of the hospitalization. Rhythm: on telemetry, paced. Medications on Admission: 1. adalat 60mg once a day (nifedipine) 2. atenolol 50mg twice a day 3. avapro 150mg once a day (ibesartan) 4. proscar .05mg once a day 5. finesteride 20mg once a day 6. furosemide 20mg once a day 7. stalebo 100mg qid (parkinsons) 8. Neurontin 300mg qid Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 4. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2* 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab Sublingual as needed as needed for chest pain: PLease take for chest pain. If not releived by 3 tabs then go to emergency room. Disp:*30 tabs* Refills:*0* 8. Neurontin 300 mg Capsule Sig: One (1) Capsule PO four times a day. 9. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Stalevo 100 25-100-200 mg Tablet Sig: One (1) Tablet PO four times a day. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Unstable Angina Diastolic CHF CAD Parkinson's Disease HTN Chronic Renal Failure Discharge Condition: Stable Discharge Instructions: Please take all medications as instructed on discharge paperwork. You will be given sublingual nitroglycerin tabs. If pain does not resolve after 3 tabs then call you primary doctor or go to the emergency room. I you have shortness of breath, dizziness, fainting, palpitations, chest pain at rest or chest pain that does not immediately respond to the nitro please call you doctor or go to the emergency room. Followup Instructions: Please follow up with Dr [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3183**]) with in 2 weeks. [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]

[ "593.9", "414.02", "414.01", "401.9", "428.30", "332.0", "272.0", "428.0", "584.9", "410.71", "599.7" ]

icd9cm

[ [ [] ] ]

[ "37.23", "88.56", "36.01", "99.20", "99.19", "99.10", "00.13", "37.22", "36.07" ]

icd9pcs

[ [ [] ] ]

10365, 10420

6948, 8854

273, 306

10544, 10552

3954, 6925

11012, 11283

3077, 3253

9158, 10342

10441, 10523

8880, 9135

10576, 10989

3268, 3935

223, 235

334, 2654

2676, 2907

2923, 3061

23,039

109,327

5635

Discharge summary

report

Admission Date: [**2205-5-13**] Discharge Date: [**2205-5-17**] Date of Birth: [**2143-8-20**] Sex: M Service: MEDICINE Allergies: Vancomycin / Nsaids / Iodine / Versed / Ativan / Haldol Attending:[**First Name3 (LF) 1666**] Chief Complaint: diarrhea and fever Major Surgical or Invasive Procedure: none History of Present Illness: 61 year old male with a h/o DM1 and ESRD on HD, recent C. Diff colitis x 2 who finished flagyl approximately 9 days ago and presented with fevers and increasing diarrhea. Per wife's report, one day PTA he had a recurrence of diarrhea, similar to previous episodes of c. diff. He also had a temp to 100.3. Diarrhea increased on the night prior to admision and he was febrile to 102 the following morning. Pt thinks he has had more diarrhea in the past week. Describes ~4 BMs/day, loose, non-bloody and without mucous. Denies abd pain, N/V or chills. . Of note, during last admission,the patient had PNA and pleural eff with dialysis cath infection. Currently denies SOB, cough, dysuria, nasal congestion, ST. . In the ED VS were T: 101, HR: 110, BP: 171/68 and CBC showed a left shift. He received tylenol, flagyl and levaquin. . Upon arrival to the floor a decision was made to start the patient on PO vancomycin for presumed c.diff recurrence. Pt has a h/o anaphylaxis to IV [**Last Name (LF) 22572**], [**First Name3 (LF) **] allergy was contact[**Name (NI) **]. Their recommendation was that the pt receive small doses of vancomycin with monitoring in the ICU. He received sucessfully vancomycin PO desensitization. . ROS: Per his wife, [**Name (NI) **], when the patient feels extremely ill he becomes extremely stiff and non-responsive. She also states he "dissociates" with reality. He has a history of hallucinating when extremely ill. He also has trouble with his vision when his blood pressure gets below 150. He has a long standing history of extremely labile blood pressure. Rest of ROS as above. Past Medical History: Past Medical History: 1. DM I for 45 yrs, complicated by triopathy 2. ESRD on HD T/Th/Sa 3. Tunneled cath infections 4. UGIB [**2-16**] PUD 5. VSE septic shoulder 6. Osteomyelitis 7. Left BKA 8. HTN 9. Gastroparesis 10. Depression 11. Right femoral dorsalis pedis graft - [**2198-3-15**] 12. H/o gangrenous cholecystitis Social History: Lives in [**Location 701**] with wife [**Name (NI) **] [**Name (NI) 10653**] (Home: [**Telephone/Fax (1) 22469**], cell: [**Telephone/Fax (1) 22470**]). No EtOH. Former remote smoker. Used to work in retail 14 yrs ago. Family History: Noncontributory. Physical Exam: Admission: VS: Temp: 97.7 BP: 135/61 HR: 107 RR: 15 O2 sat: 97% on 2L Nc GEN: pleasant, comfortable, NAD, AOx3 HEENT: pupils equal and round, anicteric, MMM, op without lesions RESP:decreased sounds at the RLB and dullness to percussion on that side, rhonchi in LLL that cleared with cough CV: tachy with reg rhythm, S1 and S2 wnl, 1/6 systolic murmur loudest LUSB ABD: normoactive BS, soft, NT, ND EXT: s/p L BKA. RLE without edema. R foot with out clear lesions/ulcers, s/p multiple skin grafts to base of foot. 1+ DP pulse SKIN: no jaundice NEURO: AAOx3. Moves all ext spontaneously. . Admission: VS: Temp: 98.4 BP: 144/61 HR: 107 RR: 18 O2 sat: 98% RA GEN: pleasant, comfortable, NAD, AOx3 HEENT: pupils equal and round, anicteric, MMM, op without lesions RESP:decreased sounds at the RLB and dullness to percussion on that side, rhonchi in LLL that cleared with cough CV: tachy with reg rhythm, S1 and S2 wnl, 1/6 systolic murmur loudest LUSB ABD: normoactive BS, soft, NT, ND EXT: s/p L BKA. RLE without edema. R foot with out clear lesions/ulcers, s/p multiple skin grafts to base of foot. 1+ DP pulse SKIN: no jaundice NEURO: AAOx3. Moves all ext spontaneously. Pertinent Results: CXR [**5-13**]: There is marked interval worsening of the right pleural effusion with right fissural fluid noted. Mild improvement in left pleural effusion is noted. There is bibasilar atelectasis, worse at the right lung base. Remainder of the lungs are clear without evidence of vascular congestion. Moderate kyphotic deformity of the thoracic spine is noted. Severe degenerative changes in the right shoulder with osseous demineralization. . EKG: sinus tachycardia, low voltages w/TWF in I,II,III, AVR, AVL, AVF (stable compared to prior). No STE or depressions. . Micro: Stool: C.diff positive Blood Cx; negative . CT HEAD WITHOUT CONTRAST: No intracranial hemorrhage, mass effect, shift of normally midline structures, or major vascular territorial infarct is apparent. There is again noted a prominence of the ventricular system and sulci consistent with central age-related atrophy, and periventriular white matter hypodensities idnicating chronic small vessel angiopathy. There are marked calcifications of the cavernous portions of the internal carotid arteries and vertebral arteries bilaterally. There is markedly increased mucosal thickening in the left maxillary sinus, now filling the sinus almost completely. No fluid level is seen in the visualized portion. The remainder of the paranasal sinuses and the right mastoid air cells are clear. There is new fluid in the mastoid air cells on the left. IMPRESSION: 1. No evidence of intracranial hemorrhage or mass effect. 2. New fluid in the left mastoid air cells and near-complete opacification of the left maxillary sinus. Particularly, the mastoid air cell fluid is concerning for an infectious process . CBC [**2205-5-13**] 08:05AM BLOOD WBC-9.1 RBC-3.82* Hgb-12.4* Hct-37.8* MCV-99* MCH-32.6* MCHC-32.9 RDW-17.8* Plt Ct-268 [**2205-5-14**] 04:26AM BLOOD WBC-5.0 RBC-3.51* Hgb-11.3* Hct-34.3* MCV-98 MCH-32.1* MCHC-32.8 RDW-17.1* Plt Ct-208 [**2205-5-15**] 05:03AM BLOOD WBC-5.4 RBC-3.32* Hgb-10.9* Hct-33.2* MCV-100* MCH-32.9* MCHC-32.9 RDW-17.3* Plt Ct-193 [**2205-5-16**] 07:15AM BLOOD WBC-6.6 RBC-3.57* Hgb-11.4* Hct-35.6* MCV-100* MCH-31.9 MCHC-32.0 RDW-16.8* Plt Ct-235 [**2205-5-17**] 06:30AM BLOOD WBC-6.1 RBC-3.52* Hgb-11.3* Hct-35.3* MCV-100* MCH-32.0 MCHC-31.9 RDW-16.3* Plt Ct-263 [**2205-5-13**] 08:05AM BLOOD Neuts-87* Bands-1 Lymphs-5* Monos-5 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 . Chem 10 [**2205-5-13**] 08:05AM BLOOD Glucose-221* UreaN-24* Creat-5.0* Na-140 K-5.0 Cl-96 HCO3-31 AnGap-18 [**2205-5-14**] 04:26AM BLOOD Glucose-96 UreaN-30* Creat-5.5* Na-142 K-5.5* Cl-100 HCO3-30 AnGap-18 [**2205-5-15**] 05:03AM BLOOD Glucose-144* UreaN-17 Creat-3.9*# Na-140 K-3.3 Cl-100 HCO3-29 AnGap-14 [**2205-5-16**] 07:15AM BLOOD Glucose-95 UreaN-23* Creat-5.3*# Na-143 K-3.7 Cl-103 HCO3-28 AnGap-16 [**2205-5-16**] 10:00PM BLOOD Glucose-300* UreaN-13 Creat-3.2*# Na-144 K-5.0 Cl-108 HCO3-23 AnGap-18 [**2205-5-17**] 06:30AM BLOOD Glucose-162* UreaN-15 Creat-3.7* Na-144 K-4.4 Cl-111* HCO3-25 AnGap-12 [**2205-5-13**] 08:05AM BLOOD ALT-21 AST-32 LD(LDH)-330* AlkPhos-170* TotBili-0.6 [**2205-5-14**] 04:26AM BLOOD Calcium-9.0 Phos-5.9*# Mg-2.1 [**2205-5-15**] 05:03AM BLOOD Calcium-8.5 Phos-3.9# Mg-1.8 [**2205-5-16**] 07:15AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0 [**2205-5-16**] 10:00PM BLOOD Calcium-9.4 Phos-3.1 Mg-1.9 [**2205-5-17**] 06:30AM BLOOD Calcium-9.4 Phos-2.7 Mg-2.2 [**2205-5-13**] 10:58PM BLOOD pH-7.46* Comment-PLEURAL FL [**2205-5-13**] 08:17AM BLOOD Lactate-1.8 Brief Hospital Course: 61 year old male with extensive PMHx who re-presents with recurrent C. Diff after recently completing a course of Flagyl. . # C. difficle colitis: Pt has had several recurrences of c. diff in the past month (+ toxin assay on [**4-20**] and [**4-12**]) and had recurrent diarrhea and fevers last night. Pt was initially started on flagyl. C. diff returned positive. As pt has failed flagyl before, he was transferred to ICU for monitoring during po vanc desensitization. He underwent po vanc desensitization protocol per pharmacy without issues. His diarrhea improved. He was discharged on a prolonged PO Vanc taper. . # Fevers: This is most likely [**2-16**] to c. diff as above. Pt also recently had a PNA and line infection, both of which are possibilities. CXR shows increased R pleural effusion, but no definite infiltrate. Pt underwent thoracentesis on [**5-13**], which transudative processes, ?[**2-16**] recent pneumonia. Pleural fluid was sent for culture and did not grow any organism. Pt is HD dependent and makes no urine. WBC 9.1 but with left shift and pt currently afebrile. Lacate 1.8 and pressures were stable. . . #ESRD on HD: Patient continued HD on T/Th/Sat schedule. . #Type I DM: Per his wife, the patient has very brittle diabetes with highly variable fingersticks. He was continued on his home doses of insulin and his NPH sliding scale. . #HTN: The patient has extremely labile BP and often goes over 200. The patient has vision changes when blood pressure is below 150. Systolic goal was 150-180. He was continued on labetolol, minoxidil, lisinopril, and nifedipine at home doses. He had several episodes of hypertension to SBP 220 which improved with IV hydralazine. On one occaison, he BP [**Month (only) **] to 150 and the pt had mental status changes. CT head was negative. His blood pressure recovered to his normal range SBp 160-180 and his mental status improved. . #Depression: He was continued on sertraline. . Medications on Admission: Home medications (per wife): Lisinopril 80 mg QHS Nifedipine 60 mg QHS Minoxidil 2.5 mg QHS Labetolol 200 mg [**Hospital1 **] (only if SBP is greater than 150). AM dose held on dialysis days Nephrocaps daily Zoloft 100 mg daily Benadryl 25 mg daily NPH 8 units in AM, 4 units in PM Regular sliding scale . Medications on transfer: Lisinopril 80 mg PO HS Minoxidil 2.5 mg PO QHS DiphenhydrAMINE 25 mg PO HS:PRN insomnia NIFEdipine CR 60 mg PO DAILY Heparin 5000 UNIT SC TID Nephrocaps 1 CAP PO DAILY Insulin SC Sliding Scale & Fixed Dose Pantoprazole 40 mg PO Q24H Labetalol 200 mg PO QHS Sertraline 100 mg PO DAILY Labetalol 200 mg PO QAM Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 3. Labetalol 200 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)) as needed for only if SBP>150. 4. Labetalol 200 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 6. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Benadryl 25 mg Capsule Sig: One (1) Capsule PO once a day. 8. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day. 9. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as directed below Subcutaneous once a day: 8 unit in am, 4 units in pm. 10. Vancomycin 125 mg Capsule Sig: as directed taper Capsule PO Q6H (every 6 hours) for 52 doses: see additional instructions for taper. Disp:*52 Capsule(s)* Refills:*0* 11. Vancomycin Taper week 1: 1 tablet every 6 hours week 2: 1 tablet every 12 hours week 3: 1 tablet daily week 4: 1 tablet every other day week 5: 1 tablet every 3 days week 6: 1 tablet every 3 days Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Recurrent C.diff colitis Discharge Condition: improved Discharge Instructions: You were diagnosed with recurrent clostridium difficile colitis. You have failed flagyl and therefore underwent successfull oral Vancomycin densensitization in the ICU. You will to take oral Vancomycin for 6 weeks on a tapering shedule as follows: week 1: 1 tablet every 6 hours week 2: 1 tablet every 12 hours week 3: 1 tablet daily week 4: 1 tablet every other day week 5: 1 tablet every 3 days week 6: 1 tablet every 3 days . If your diarrhea worsens, you have abd pain, fever or chills, please return to the hospital Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] (PCP)[**Telephone/Fax (1) 22468**] Thursday [**2208-5-22**]:00 am. Please call to reschedule if this time is inconvient. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]

[ "511.9", "311", "V07.1", "585.6", "008.45", "403.01", "250.43" ]

icd9cm

[ [ [] ] ]

[ "99.12", "34.91", "39.95" ]

icd9pcs

[ [ [] ] ]

11099, 11150

7279, 9237

335, 341

11219, 11229

3802, 7256

11798, 12121

2578, 2596

9927, 11076

11171, 11198

9263, 9569

11253, 11775

2611, 3783

277, 297

369, 1979

9594, 9904

2023, 2324

2340, 2562

12,521

133,800

18607+18608

Discharge summary

report+report

Admission Date: [**2119-7-26**] Discharge Date: [**2092-3-31**] Date of Birth: [**2057-7-16**] Sex: F Service: [**Company 191**] [**Hospital Ward Name **] DISCHARGE DATE: Unknown right now. HISTORY OF PRESENT ILLNESS: This is a 61-year-old female transferred from [**Hospital3 3765**] on [**7-26**] for acute pancreatitis. The patient was admitted on [**7-16**] for right upper quadrant pain and found to have a common bile duct dilated to 10 mm with increased liver function tests. The patient had an ERCP at [**Hospital1 **] on the 16th, and developed post-ERCP pancreatitis within hours. The patient was hydrated and also developed some atelectasis while on her PCA pain medicine. A CT scan on [**7-23**], which showed extensive pancreatitis at the head with phlegmonous changes, fluid, stranding in the abdomen and pelvis. No necrosis or localized collections, and the tail and the body of the pancreas were normal. Patient has a past history of deep venous thromboses, migraines, total abdominal hysterectomy with bilateral salpingo-oophorectomy, irritable bowel syndrome, rheumatic fever. The patient was transferred to [**Hospital1 190**] for further workup. The patient was initially admitted to the VICU and was started on TPN and imipenem as per previous hospitalizations. Tube feeds were attempted secondary to the patient's abdominal pain, and distended abdomen with tube feeds were stopped and the patient was continued on TPN. The patient's hematocrit drifted downward, and the patient received 2 units of blood. The patient has been guaiac negative throughout her VICU course. The patient received 2 units of blood. The patient was volume depleted and hydrated to keep central venous pressure of about 12 to 13 mm Hg. The patient was treated for pancreatitis and atelectasis with imipenem and the patient's white blood cell count trended downwards from admission initially of about 32,000. Patient's pain was controlled on a Morphine PCA, and the patient was transferred to the floor. The patient felt okay. Upon arrival, she felt some pain in the upper abdomen area and in the back, and also complained of headaches. The patient had migraine headaches for which she had taken propanolol prophylaxis daily and had been off her po medicines since her pancreatitis. She also noted some increasing sweats and hot flashes, so she has been off her estrogen. She also notes some difficulty breathing, but no cough or sputum, and occasionally admitted with some palpitations, but no chest pain and no changes on Telemetry. She denied any dysuria, nausea, vomiting, melena, or bright red blood per rectum. The patient was transferred to the floor still on TPN and was planned to restart tube feeds if could advance nasojejunal tube past ligament of Treitz to prevent further pancreatic stimulation. Patient was encouraged to use an incentive spirometer to help prevent atelectasis, and encouraged to get out of bed more to prevent, although was limited due to fatigue. Patient's vital signs on admission to the floor were temperature 99.6, pulse 100, blood pressure 150/100, respiratory rate 22, and O2 is 93% on room air. In general, she is alert, awake, oriented. In no acute distress with a tube in her nose and a central internal jugular central line. HEENT is anicteric. Pink conjunctivae. Clear oropharynx. Moist mucous membranes. Chest: Lungs with good air movement, no rales or rhonchi, and diffuse crackles bilaterally. Cardiovascular: Regular, tachycardic, no murmurs. Abdomen is soft, positive bowel sounds, slightly distended and slightly tender to both ribs, right upper and left upper quadrants. Extremities were warm and dry with trace pitting tibial edema bilaterally. No cyanosis or clubbing. HOSPITAL COURSE: Patient was admitted to the SICU and was continued on her TPN with hydration. Tube feeds were attempted, but were unsuccessful due to placement of the tube prior to the ligament of Treitz, which increased pancreatic stimulation. The tube was then advanced with Interventional Radiology assistance past the ligament of Treitz into the jejunum, but patient then complained of some nausea and vomiting, and subsequently the tube was pulled, and her nausea and vomiting resolved. Patient was continued on TPN through her central venous access. Following that, the patient attempted to get a PICC line access so she can get TPN, and we could pull the central line. Essentially, the PICC line was placed in the right arm, but became phlebitic and was pulled, and reattempted in the left arm. Patient's central line tip grew positive for coag-negative Staph, and the patient was started on a seven day treatment of Vancomycin. Patient's imipenem was stopped on arrival to the floor as patient had no evidence of abscess or necrotizing pancreatitis. Patient tolerated that well, and had no symptoms. Patient's white count improved over the course of her stay and pain continued to improve over the course of her stay. Patient also started to ambulate more and sit-up in the chair and was switched off the PCA to prn Dilaudid which patient developed an allergic rash to and was switched back to meperidine. Patient tolerated that well without any further reactions. Patient then developed increasing shortness of breath and fluid overload. Her bilateral lower extremities had [**2-2**]+ pitting edema. Patient was overly well hydrated secondary to the pancreatitis, and was keeping the fluid. The patient responded to 20 mg of IV Lasix doses as needed, and improved her breathing and symptoms dramatically. The patient was continued to encourage to use incentive spirometry, and increased usage as her fluid overload status improved. An echocardiogram performed showed that she had good left ventricular ejection fraction greater than 55%, but did show mild-to-moderate mitral regurgitation with mild-to-moderate pulmonary artery systolic hypertension consistent with the patient's fluid overload status. Secondary to the fluid overload status, patient and in addition to having stopped her propanolol because of itch, because patient was NPO. Patient developed some tachycardia which responded to the diuresis, and when the patient was tolerating NPO, the patient was restarted on hydralazine 25 mg four times a day, for hypertension during her hospitalization, and propanolol which was titrated up to 60 mg 3x a day. The patient responded well with improved blood pressure control and improved heart rate. Patient was scheduled for a cholecystectomy secondary to the gallstone causing her pancreatitis to prevent further episodes. The patient was eventually restarted on clears. She tolerated sips of clears well for the first two days, had some abdominal tenderness after the sips, but otherwise was doing fine. Patient was advanced to a full clear liquid diet, and tolerated that fine too. Then the patient was made NPO at midnight for her procedure as she was planned for cholecystectomy. Patient's pain was well controlled on a miperidole po prn basis with IV doses for breakthrough. Patient's migraines were also well controlled with propanolol po which was switched to IV for surgery and occasionally had breakthroughs which were also controlled well with meperidine. The patient was also on Heparin for prophylaxis through her TPN and then her TPN once her PICC line was pulled due to an infected sore site. Patient was continued on a proton-pump inhibitor for some increasing gastroesophageal reflux disease symptoms, which seemed to be improved on the pantoprazole. The patient was also started on Benadryl around-the-clock for the rash secondary to her Dilaudid allergy, and then the patient was started on a preoperative workup for her cholecystectomy. The patient had a chest x-ray, electrocardiogram, laboratories drawn, and all were within normal limits, and surgery was planned for the 10th. Secondary to the need for an open cholecystectomy, the patient will be transferred to the [**Hospital Ward Name 517**] under Surgery team to have an open cholecystectomy on the 11th. The patient is aware as is the family, and so is the Surgery team. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Name8 (MD) 264**] MEDQUIST36 D: [**2119-8-10**] 10:45 T: [**2119-8-14**] 05:40 JOB#: [**Job Number 51091**] Admission Date: [**2119-7-26**] Discharge Date: [**2119-8-14**] Date of Birth: [**2057-7-16**] Sex: F Service: GOLD SURGERY HISTORY OF PRESENT ILLNESS: This is a 61-year-old female, who was transferred from [**Hospital3 3765**] with a diagnosis of acute pancreatitis, who was admitted to [**Hospital1 **] on [**7-16**] with a right upper quadrant pain. Ultrasound found a common bile duct dilated to 10 mm, and elevated LFTs with normal lipase. ERCP on [**7-17**] at [**Hospital1 **] showed a sphincter of Oddi dysfunction and biliary sludge throughout the distal common bile duct. Sphincterectomy was performed and 15 mm balloon catheter was used to extract the sludge and stone particles. There was a good drainage after the procedure, and the patient was hydrated aggressively, but developed a post ERCP pancreatitis within hours. Patient was placed on Morphine PCA. Patient also developed atelectasis on [**7-19**] due to poor inspiratory effort from pain in the abdomen. The patient was transferred to the [**Hospital1 **] Intensive Care Unit. The patient was aggressively treated for hypovolemia. Patient also received Lasix to treat the fluid overload. Patient had elevated white blood cell count throughout and she had a CT scan of the abdomen on [**7-23**] that showed extensive pancreatitis and phlegmon changes with any necrosis. Patient's white blood cell count rose to 35,000 on [**7-25**], and a repeat CT scan was done which showed no difference compared to previous scan. CVP was measured 6 to 8 throughout her hospital course and the patient remained afebrile. Patient and family requested transfer to [**Hospital1 1444**] for further evaluation and workup. Upon arrival, patient stated that her pain has improved since previous day and the distention has not changed since the admission. Denied any fever or chills. PAST MEDICAL HISTORY: 1. History of deep venous thromboses. 2. History of migraines. 3. Total abdominal hysterectomy/bilateral salpingo-oophorectomy. 4. Irritable bowel syndrome. ALLERGIES: 1. Aspirin. 2. Quinine. MEDICATIONS ON TRANSFER: 1. SSRI. 2. Imipenem. 3. Famotidine. 4. SubQ Heparin. 5. Morphine PCA. 6. TPN. 7. Ativan q hs. 8. Inderal 20 [**Hospital1 **]. 9. Potassium sliding scale. 10. Lasix [**Hospital1 **]. MEDICATIONS AT HOME: 1. Hormone replacement therapy. 2. Propanolol 20 [**Hospital1 **] for migraines. PHYSICAL EXAMINATION: Vital signs: Temperature 98.8, heart rate 118 regular, blood pressure 137/51, sating 99% on 3 liters nasal cannula. Lungs were clear to auscultation bilaterally. Her heart was tachycardic, regular rhythm, no murmurs or bruits were appreciated. Her abdominal examination was tense, but no rebound or guarding, no bowel sounds, distended. Examination of the extremities showed no edema. LABORATORIES: On admission, the patient's white blood cell count was 32.4, hematocrit was 25.4, platelets 327. Sodium 133, potassium 3.7, chloride 99, bicarb 26, BUN 16, creatinine 0.5, glucose 107. PT 13.6, PTT 28.5, INR 1.2, albumin 2.0, calcium 7.5, magnesium 1.7, phosphorus 3.9. ALT 57, AST 62, alkaline phosphatase 159, total bilirubin 1.2, LDH 351, amylase 105, lipase 132. ELECTROCARDIOGRAM: Showed a sinus tachycardia at 124, normal axis without any acute ST-T wave changes. HOSPITAL COURSE: On [**7-27**], patient was kept NPO with IV fluids and TPN. Surgery Service was consulted and she did not need any acute surgical interventions and planned to do a laparoscopic cholecystectomy when the patient was medically stable. Continue the pain control and start on nutrition for feeding tube. A CT scan of the abdomen on [**7-27**] showed diffuse peripancreatic mesenteric inflammatory changes consistent with acute pancreatitis. There was no necrosis or fluid collection as well as bibasilar atelectasis. Patient was continued on a course of NPO, TPN, IV fluids, and imipenem. Patient continued to improve in the SICU setting. The patient had a pyloric tube placed. Patient continued to be tachycardic and hypertensive. Patient was treated with propanolol, continue to monitor that. Patient's abdominal pain has somewhat improved, but continued a course of her treatment for pancreatitis. On [**7-30**], patient's abdominal pain had improved. In terms of her acute pancreatitis, there was no major changes. Management was continued NPO, TPN, and IV fluids. She was beta blocked to treat her tachycardia and hypertension. Her symptoms markedly improved, and the patient was transferred to the floor on [**2119-7-30**]. Patient's pancreatitis continued to be treated with keeping the patient NPO, providing nutrients through TPN, and treating her pain with pain medication. On [**8-1**], the patient's pancreatitis was treated continuously with keeping the patient NPO and TPN. Patient's tube feeds was not started because she had increase in abdominal distention. Patient's IV fluids were increased and patient's continual hypertension was treated with hydralazine. On [**8-3**], the patient's abdominal pain improved and she denied shortness of breath or chest pain. She continued to have blood pressure of 150s/80s and heart rate of 120s. Patient's IV fluids were kept at 150 cc/hour maintenance to treat hypovolemia. Patient's migraine headache was treated while on her antihypertensive medication, hydralazine dose was increased. Patient continued on TPN and tube feeds were not started because the patient had a bout of emesis. Patient's heart rate increased to 140s. Patient was given O2 and chest x-ray, and there was a workup for pulmonary embolus. The CT scan was done in order to rule out the pulmonary embolus showed that it was negative. There was no signs of pulmonary emboli in the lungs. On [**8-4**], the patient's breathing improved significantly. Patient's CT scan of abdomen showed no significant change from the previous CT scan. LFTs and enzyme markers were much improved. She remained to have white blood cell count of 17,000. Chest x-ray for the shortness of breath showed bilateral pleural effusions. Thus her shortness of breath might have been associated with fluid overload. Patient's IV fluids were decreased to prevent fluid overload. Patient had PICC line inserted, and her central line was removed. Culture of the central line tip showed a Staph epi, and the patient was treated with Vancomycin. Patient continued to do well on [**8-5**], a trial of clears did not help. Her tube feeds were removed the previous day. Patient's oxygenation improved and she remained hypertensive and tachycardic throughout. Patient's pressures were treated with propanolol. Electrocardiogram did not show any signs of ischemia. Patient received some Lasix due to prevent fluid overload on [**8-6**]. The patient's pancreatitis continued to improve. On [**8-7**], patient continued to improve. Patient's propanolol was increased to control continued hypertension. Patient received an echocardiogram to assess her function. Echocardiogram showed [**2-2**]+ mitral regurgitation, ejection fraction within normal limits, and mild-to-moderate pulmonary hypertension. Patient's pancreatitis continued to improve throughout. Patient was preoped on the [**8-9**] and planned to have an operation to remove the gallbladder. Patient on the [**8-11**] had laparoscopic cholecystectomy and patient was transferred to the Surgery Service. Patient tolerated the procedure very well. After the operation, the patient's pain was controlled with Morphine as needed. Patient's blood pressure was controlled with Lopressor had she received regular diet and activities as tolerated on postoperative day one, [**8-12**]. The patient was HEP locked, encouraged to ambulate, and be out of bed. Patient's pain medication was changed as she did not tolerate Morphine very well. Subsequently on postoperative day #2, patient continued to improve. Her pain medication was changed to po Dilaudid which seems to have improved her pain management. Her significant laboratory value was that potassium was 2.7 which was repleted, and the patient was tolerating a regular diet. On [**8-14**], patient's pain was well controlled on po pain medications. She was ambulating, eating regular diet, was able to urinate on her own, and without any difficulties. She remained afebrile and had stable vitals. She was discharged to home. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Status post laparoscopic cholecystectomy. 2. Post ERCP pancreatitis. 3. Migraine headaches. 4. Status post total abdominal hysterectomy/bilateral salpingo-oophorectomy. 5. History of deep venous thrombosis. 6. Irritable bowel syndrome. DISCHARGE MEDICATIONS: 1. Propanolol 30 mg po bid. 2. Hydromorphone 2 mg 1-2 tablets every six hours as needed for pain. 3. Colace 100 mg po bid as needed for constipation. 4. Senna 8.6 mg twice a day as needed for constipation. FOLLOW-UP PLANS: Please follow up with Dr.[**Name (NI) 1863**] office for an appointment, and please follow up with primary care doctor, Dr. [**Last Name (STitle) **] with adjustment for the blood pressure. Dr. [**Last Name (STitle) **] was updated on her situation and he is aware of the blood pressure medications that patient left the hospital on. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Last Name (NamePattern1) 3118**] MEDQUIST36 D: [**2119-8-15**] 10:56 T: [**2119-8-22**] 07:25 JOB#: [**Job Number 51092**]

[ "518.0", "574.40", "E878.8", "276.6", "276.5", "577.0", "996.62", "997.4", "E849.7" ]

icd9cm

[ [ [] ] ]

[ "38.93", "51.23", "99.15" ]

icd9pcs

[ [ [] ] ]

16861, 17101

17124, 17331

11740, 16808

10735, 10817

10840, 11722

17349, 17960

8591, 10289

10530, 10714

10311, 10505

16833, 16840

70,329

165,392

46165

Discharge summary

report

Admission Date: [**2162-11-22**] Discharge Date: [**2162-12-1**] Date of Birth: [**2096-7-11**] Sex: M Service: CARDIOTHORACIC Allergies: Antihistamines - 1st Generation Classif. Attending:[**First Name3 (LF) 165**] Chief Complaint: crescendo angina Major Surgical or Invasive Procedure: coronary artery bypass grafts x 3 (LIMA-LAD,SV-DG,SV-OM) [**11-26**] left heart catheterization, coronary angiography History of Present Illness: Increasing angina in setting of known coronary artery disease, admitted for catheterization. Past Medical History: s/p rotator cuff repair s/p inguinal hernia repair s/p coronary stent hypertension hyperlipidemia benign prostatic hypertrophy Social History: Denies any significant smoking history. Drinks 20 beers per week, last drink two nights before admission, no history of withdrawal. No IVDA. Lives alone and works as a HVAC repairman at [**University/College **] Family History: No family history of CAD Father with DM Brother with melanoma Physical Exam: Discharge exam: general: very well appearing, fit male in NAD- looking younger than stated years. VS: 98.1, 101/69, 71SR, 20, 94% HEENT: unremarkable Chest: sternal incision C/D/I. Sternum stable. Lungs CTA bilat. COR; RRR S1, S2 ABD; soft, round, NT, +BS Extrem: Trace LE edema bilat. left EVH site healing well. 2 small open blisters near EVH sites. Neuro: alert and oriented x3. Pertinent Results: [**2162-11-22**] 08:50PM GLUCOSE-179* UREA N-15 CREAT-1.0 SODIUM-136 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15 [**2162-11-22**] 08:50PM ALT(SGPT)-56* AST(SGOT)-35 LD(LDH)-213 ALK PHOS-90 TOT BILI-0.8 [**2162-11-22**] 08:50PM ALBUMIN-4.4 [**2162-11-22**] 08:50PM %HbA1c-5.9 [**Known lastname 98178**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 98179**] (Complete) Done [**2162-11-26**] at 9:05:27 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2096-7-11**] Age (years): 66 M Hgt (in): 70 BP (mm Hg): 112/78 Wgt (lb): 180 HR (bpm): 67 BSA (m2): 2.00 m2 Indication: Intraoperative TEE for CABG procedure. Aortic valve disease. Left ventricular function. Mitral valve disease. Preoperative assessment. Right ventricular function. ICD-9 Codes: 786.51, 440.0, 414.8, 424.1, 424.0 Test Information Date/Time: [**2162-11-26**] at 09:05 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW-:01 Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.4 cm Left Ventricle - Fractional Shortening: 0.38 >= 0.29 Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Ascending: *3.5 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 10 mm Hg < 20 mm Hg Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal regional LV systolic function. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions Prebypass 1. No atrial septal defect is seen by 2D or color Doppler. 2. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7. There is no pericardial effusion. 8. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2162-11-26**] at 830 am. Post bypass 1. Patient is in sinus rhythm and receiving an infusion of phenylephrine. 2. Biventricular systolic function is unchanged. 3. Aorta is intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2162-11-29**] 13:36 Radiology Report CHEST (PA & LAT) Study Date of [**2162-11-29**] 3:18 PM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2162-11-29**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 98180**] Reason: interval chnage [**Hospital 93**] MEDICAL CONDITION: 66 year old man with removal of pleural and mediastinal tubes, and pacing wires REASON FOR THIS EXAMINATION: interval chnage Final Report INDICATION: 66-year-old man with removal of pleural and mediastinal tubes. PA AND LATERAL CHEST RADIOGRAPHS: All the lines and tubes have been removed. The lung volumes are low with mild basilar atelectasis. There is no evidence to suggest pneumonia or pulmonary edema. There is no pneumothorax. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**] DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: MON [**2162-11-29**] 7:15 PM Brief Hospital Course: Mr. [**Known lastname **] is a 66 year old gentleman who was transferred to [**First Name9 (NamePattern2) 98181**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for cardiac catheterization due to an abnormal stress test. The catheterization revealed multi-vessel coronary artery disease. After a plavix washout he was taken to the operating room and underwent a triple coronary artery bypass on [**2162-11-26**]. This procedure was performed by Dr. [**Last Name (STitle) **]. The patient tolerated the procedure well and was transferred to the surgical intensive care uit in critical but stable condition. He was extubated and weaned from his pressors on post-operative day one. On the following day he was seen in consultation by physical therapy. He was transferred to the surgical step down floor. His chest tubes and epicardial wires were removed. On [**2166-11-29**] pt developed rapid afib w/ rate 180- responded to IV lopressor and amiodarone bolus 150mg x2. Pt converted to SR later that evening and remained in NSR on po amiodarone. By POD# 5 he was ready for discharge to home w/ VNA services. Medications on Admission: ASA 325mg/D Plavix 75mg/D Lisinopril 10mg/D Toprol XL 25mg/D Lipitor 80mg/D Niaspan 100mg/D Discharge Medications: 1. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO once a day. Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*0* 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Niacin 1,000 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO at bedtime. 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 6 days: then 2 tabs daily for 7days then one tablet daily until instructed to stop. Disp:*72 Tablet(s)* Refills:*0* 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 7 days. Disp:*14 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts s/p coronary stents hypertension hyperlipidemia benign prostatic hypertrophy s/p herniorraphy s/p rotator cuff repair Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotion, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any weight gain greater than 2 pounds a day or 5 pounds a week report any fever greater than 100.5 take all medications as directed Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) [**Hospital 409**] clinic in 2 weeks Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4469**] in [**11-19**] weeks ([**Telephone/Fax (1) 4475**]) [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2162-12-1**]

[ "427.31", "411.1", "285.9", "V15.82", "V45.82", "414.01", "272.0", "412", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "36.12", "39.61", "36.15", "88.56" ]

icd9pcs

[ [ [] ] ]

9427, 9485

6713, 7900

324, 444

9705, 9712

1446, 5911

10115, 10504

966, 1029

8043, 9404

5951, 6031

9506, 9684

7926, 8020

9736, 10092

1044, 1044

1060, 1427

268, 286

6063, 6690

472, 566

588, 717

733, 950

40,269

149,166

52752

Discharge summary

report

Admission Date: [**2146-9-15**] Discharge Date: [**2146-9-20**] Date of Birth: [**2075-7-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3977**] Chief Complaint: Fevers Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 174**] is a 71 year old man with a history notable for hypertrophic non-obstructive cardiomyopathy, Afib, and Stage IIB squamous cell lung cancer on chemo, s/p VATS RLL lobectomy [**2146-7-25**], now C1D10 cisplatin/taxotere adjuvant chemotherapy, who presents from heme/onc clinic with febrile neutropenia, tachycardia, and hypotension. The patient had his first dose of adjuvant chemo on [**9-6**] and felt well until Saturday [**9-10**]. Then, he began to experience nausea, fatigue, poor appetite, and diarrhea. He also felt dizzy and lightheaded occasionally. He denied vomiting or bloody stools. His wife takes his temperature at home and it had never been abolve 98.6. He presented today to his oncologist's office for a routine visit, where he was found to be neutropenic (WBC 1.6, N:7%) and febrile to 100.8. He was also tachycardic to the 130s. He was referred to [**Hospital1 18**] ED for further management. In the ED, initial VS were: 100.8 131 133/82 16 98%. His EKG showed rapid Afib. He had a CXR that showed a RLL opacity, consistent with mucoid impaction. He was given vamcomycin and cefepime. He was given tylenol 1g PO. For Afib, he was given 4L NS, diltiazem 10mg IV, metoprolol 50mg PO, and digoxin IV 0.5mg x1, 0.25mg Q6H x2 doses, but were unable to break his rapid Afib. His BP was as low as 89/76 and his HR was as high as 170. On arrival to the MICU, patient's VS: 98.2 84 95/60 17 95%/RA. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Hypertrophic Obstructive Cardiomyopathy (Cardiol Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**]) HTN CHF (EF 55%) Bicuspid AV Mild AS ([**Location (un) 109**] 1.7 cm2) Dilated ascending aorta Cholecystectomy Hypercholesterolemia Pneumonia ([**2139**]) Left leg claudication Left inguinal hernia repair ([**2142**]) Colonic polyps (proximal descending colon; distal sigmoid colon; [**2138**] colonoscopy) Right rotator cuff injury Atrial fibrillation ([**5-/2146**]) s/p DCCV [**2146-6-16**] Right lung nodule Social History: He previously worked at Polaroid. He is now also retired from bartending and delivering car parts. He has 4 children - 2 sons (both live in [**Name (NI) 108**]) and 2 daughters (live locally). He continues to refrain from smoking (80 pack years; quit [**2143**]). He has beer on the weekends. Denies drugs. Wife recently underwent surgery for brain aneurysm. Family History: His parents are both deceased (father - unknown; mother 85; colon cancer). He has two brothers (64 - CAD, obesity; 72 - CAD, CVA). He has 4 children - 42, 46 year old sons - one with prior melanoma; 47 and 49 year-old daughters. Physical Exam: ADMISSION EXAM: Vitals: 98.2 84 95/60 17 95%/RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic murmur at RUSB, no extra heart sounds. JVP 10-12 cm, +HJR. Lungs: Rales on left 1/3 up, absent breath sounds R base. Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred. Pertinent Results: ADMISSION LABS [**2146-9-15**] 09:40AM BLOOD WBC-1.6*# RBC-4.74 Hgb-13.6* Hct-39.5* MCV-83 MCH-28.6 MCHC-34.3 RDW-14.2 Plt Ct-206 [**2146-9-15**] 09:40AM BLOOD Neuts-7* Bands-1 Lymphs-64* Monos-24* Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0 [**2146-9-15**] 09:40AM BLOOD UreaN-19 Creat-0.9 Na-132* K-4.7 Cl-98 HCO3-29 AnGap-10 [**2146-9-15**] 09:40AM BLOOD ALT-27 AST-19 CK(CPK)-46* AlkPhos-61 TotBili-0.3 [**2146-9-15**] 09:40AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9 Cholest-165 [**2146-9-15**] 09:40AM BLOOD Triglyc-204* HDL-37 CHOL/HD-4.5 LDLcalc-87 [**2146-9-15**] 01:54PM BLOOD Lactate-1.8 CXR [**2146-9-15**]: FINDINGS: Frontal and lateral views of the chest were obtained. The heart is of top normal size with stable cardiomediastinal contours. The right lung base linear opacity is similar to multiple prior examinations, compatible with chronic mucoid impaction. Known right lower lobe nodule is not clearly visualized on this exam. Small right pleural effusion is present, similar to prior. No radiopaque foreign body. Multilevel thoracic spine degenerative changes. IMPRESSION: Right lower lung linear opacity, similar to prior and likely reflects chronic mucoid impaction. Small right pleural effusion is also similar to prior. DISCHARGE LABS [**2146-9-20**] 07:20AM BLOOD WBC-34.1* RBC-4.04* Hgb-11.6* Hct-34.6* MCV-86 MCH-28.9 MCHC-33.6 RDW-15.7* Plt Ct-196 [**2146-9-19**] 08:05AM BLOOD UreaN-6 Creat-0.8 Na-139 K-3.7 Cl-104 HCO3-26 AnGap-13 [**2146-9-20**] 07:20AM BLOOD UreaN-10 Creat-0.9 [**2146-9-19**] 04:00PM BLOOD CK(CPK)-47 [**2146-9-18**] 07:00AM BLOOD ALT-19 AST-21 AlkPhos-100 TotBili-0.2 [**2146-9-19**] 08:05AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.0 Brief Hospital Course: 71 year old man with hypertrophic cardiomyopathy, AFib, squamous cell lung cancer on adjuvant chemo C1D15 on day of discharge, cis/docetaxel who presented with febrile neutropenia, Afib with RVR, and hypotension. . At time of discharge, pt was clinically stable with resolution of neutropenia. He had a dose of Neulasta at time of admission. He remains in sinus rhythm, with adjustments to his medications this admission. Other details below: . # Afib with RVR: - The patient has a history of Afib s/p DCCV in [**5-/2146**] and is on disopyramide for rhythm control and metoprolol for rate control. Fever and neutropenia likely precipitating factors. Metoprolol has been held. Dig loaded initially. No role for cardioversion unless pt is hemodynamcially unstable. - Med changes per discussion with cardiology: - [**9-18**] - stopped digoxin 0.25mg daily. Metoprolol changed to long acting 50 mg po daily. Stopped heparin gtt and started back on outpt [**Month/Year (2) **]. - Change to longacting diltiazem. - Continue disopyramide. (see discharge meds for regimen) In sinus rhythm with this regimen. - telemetry; reviewed EKG with cardiology, who reports no acute issues with EKG findings. . # Hypotension: resolved with IVF and rate control; maybe associated with infection. . # Febrile neutropenia: Resolved [**2146-9-17**]. - [**2146-9-18**] WBC 19, leukocytosis now - Patient received outpt Neulasta on [**2146-9-15**]. - Likely urinary source with e coli (essentially pan-sensitive) in urine. Blood cultures no growth to date. Patient has had ANC of 112 initially. - Had cefepime 2g q8h (started [**2146-9-16**], had 5 day course); Will change to cefpodoxime to continue additional 3 days of therapy. - vancomycin started [**9-16**], stopped [**9-19**] to tailor therapy. - unlikely cxr findings are PNA. Post VATS CXR shows RLL field opacity, likely associated with resection. Exam has been normal thus far. Monitor closely. . # Hyponatremia: Resolved due to hypovolemia. . # Squamous cell lung cancer: Cycle 1 of adjuvant chemo. When stable will start C2 in [**1-24**] weeks as outpatient. . # Hypertrophic cardiomyopathy: Stable. Followed cards recs. . # Hyperlipidemia - continue pravastatin Patient will follow up with oncology and cardiology as instructed. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**]. 1. [**Name2 (NI) 62055**] Etexilate 150 mg PO BID 2. Disopyramide CR 240 mg PO Q12H 3. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety 4. Metoprolol Succinate XL 50 mg PO Q12H 5. Pravastatin 80 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Ondansetron 4-8 mg PO Q8H:PRN nausea 8. Prochlorperazine 5-10 mg PO Q6H:PRN nausea Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 3 Days RX *cefpodoxime 200 mg 1 tablet(s) by mouth q12 h Disp #*6 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY 3. [**Name2 (NI) 62055**] Etexilate 150 mg PO BID 4. Disopyramide CR 200 mg PO Q12H RX *disopyramide [Norpace CR] 100 mg 2 capsule(s) by mouth twice a day Disp #*120 Capsule Refills:*1 5. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety 6. Pravastatin 80 mg PO DAILY 7. Diltiazem Extended-Release 120 mg PO DAILY RX *diltiazem HCl 120 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*1 8. Ondansetron 4-8 mg PO Q8H:PRN nausea 9. Prochlorperazine 5-10 mg PO Q6H:PRN nausea 10. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Atrial Fibrillation with RVR Neutropenic Fever Urinary Tract Infection Hypotension Hyponatremia Squamous Cell Lung Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted due to infection from having a low immune system due to the chemotherapy for lung cancer. You also had complications of a rapid heart rate due to atrial fibrillation. A urine source of infection was discovered and you were treated with appropriate IV antibiotics, and you will complete an additional 3 day course of oral antibiotics while at home. Your heart rate was also very fast and needed aggressive intervention with multiple medications. You had a brief stay in the ICU. The heart doctors helped in your management and you are now on a good regimen that controls your heart rate. It is in SINUS RHYTHM. You will go home for recovery with close follow up with your outpatient providers. TRANSITION ISSUES: 1. Start taking antibiotics either tonite or tomorrow morning and finish taking pills. 2. Need to discuss with your cardiologist about HEART MEDICATION management. 3. Follow up with your ONCOLOGIST for further care. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2146-9-27**] at 9:30 AM With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD (And Dr [**Last Name (STitle) **] [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2146-9-27**] at 11:00 AM With: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN [**Telephone/Fax (1) 9644**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage CARDIOLOGY Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**] Department: [**Hospital **] MEDICAL GROUP When: WEDNESDAY [**2146-9-28**] at 10:45 AM With: DR. [**First Name (STitle) 569**] PASTOR [**Telephone/Fax (1) 133**] Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**] Campus: OFF CAMPUS Best Parking: On Street Parking Department: CARDIAC SERVICES When: THURSDAY [**2147-1-12**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *The office has sent Dr. [**Last Name (STitle) 696**] an email seeing if they can get you a sooner appointment. The office has also put you on cancellation list, they will contact you at home if a sooner appointment becomes available. If you have any questions or concerns please call the office.

[ "458.9", "V15.82", "272.4", "447.71", "428.0", "162.5", "599.0", "276.1", "041.49", "746.4", "428.32", "V12.72", "276.52", "425.11", "443.9", "424.1", "E933.1", "V87.41", "288.00", "427.31", "780.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9361, 9367

5812, 8087

310, 316

9533, 9533

4112, 5789

10656, 12300

3184, 3416

8578, 9338

9388, 9512

8113, 8555

9684, 10633

3431, 4093

1810, 2230

264, 272

344, 1791

9548, 9660

2252, 2787

2803, 3168

5,228

160,414

923+55244

Discharge summary

report+addendum

Admission Date: [**2178-10-16**] Discharge Date: Service: CHIEF COMPLAINT: Back pain. HISTORY OF PRESENT ILLNESS: The patient had been experiencing intermittent back pain over the past week who has a well known history of osteoarthritis of the spine. He was given Percocet for pain control without improvement in his symptomatology. He was seen in the Emergency Room on [**2178-10-16**] and at that time because of increasing pain and drop in his hematocrit from 30.0 to 20.6. The patient denies any chest pain or short of breath. He is admitted for urgent repair of a ruptured abdominal aortic aneurysm 8 cm in size. PAST MEDICAL HISTORY: Osteoarthritis, T-spine compression fracture. PAST SURGICAL HISTORY: Right inguinal hernia repair. Vertebral steroid injections. The patient is a previous smoker. MEDICATIONS: 1. Zantac. 2. Fosamax. 3. Iron. 4. Percocet. The patient is not allergic to any foods or drugs. Does have a history of asbestos exposure. PHYSICAL EXAMINATION: Shows vital signs 96.1, 142/86, 90, 18, room air sat was 96% Head, eyes, ears, nose and throat exam is unremarkable. There are no carotid bruits. Lungs are clear to auscultation. Heart is regular rate and rhythm. Abdomen is distended with bowel sounds, is nontender. There is no bruits. Extremities have palpable femoral pulses bilaterally without distal dorsalis pedis bilaterally. The rectal exam was guaiac negative. LABS: Hematocrit of 20.6 with a white count of 16.5, BUN 42, creatinine 1.7. Potassium 4.7. Urinalysis was positive for nitrates. Chest x-ray showed bilateral pleural effusions with pleural plaques, the right greater than the left. Electrocardiogram was without acute changes. Normal sinus rhythm. The patient was taken to the operating room and underwent abdominal aortic aneurysm repair. He was then transfused 12 units of packed red blood cells and also received 5 units of FFP and two units of platelets intraoperatively. He remained intubated, was transferred to the SICU for continued monitoring and care. His SICU course was prolonged and complicated by respiratory failure. He had multiple blood cultures drawn and urine cultures obtained because of failure to wean. His sputum cultures were on [**10-21**] negative. His urine culture on [**10-18**] and [**10-16**] were negative. He underwent a bronchoscopy on [**10-23**] with Endotracheal tube change at that time. There were no blockages seen, vocal cords were normal and there was mild bronchial edema on the mucosa, endotracheal bronchial tree. The right IJ cortise was converted to a central line on [**10-25**] and required left subclavian line placement later that day. The patient remained intubated, chest x-ray remained unremarkable except for the bilateral pleural effusions and some basilar atelectasis. The patient was finally extubated on [**2178-10-28**]. Physical therapy was requested for evaluation. During this period in SICU the patient required TPN and tube feed support. On [**2178-10-30**] the patient passed flatus and had a bowel movement. He was then at that time transferred to MICU for continued monitoring and care. On [**11-5**] the left subclavian line was changed to left IJ. He was begun on p.o.'s and diet advanced as tolerated. The TPN and tube feeds were discontinued after caloric intake was evaluated. On [**2178-11-8**] the patient became tachypneic and tachycardiac. Electrocardiogram was without acute ischemic changes. A chest x-ray was unchanged. The chest CT was negative for pulmonary embolism. Abdominal CT showed distended gallbladder. His liver function tests were elevated with an ALT of 94, AST 81, Alk phos 293, total bili 6.9, Lipase 73, amylase 106, lactate was 1.8, blood gases 7.38, 31, 99 and 13 with an elevated white count of 33.0 with a T-max of 102.6. The patient required re-intubation and transfer to the SICU. Gastrointestinal was consulted. An ultrasound of the gallbladder was obtained and needle aspirate was done. The patient was empirically begun on Unasyn. The cultures of the blood, urine, sputum and gallbladder were no growth. The Infectious Disease was consulted at this time. He was empirically started on Unasyn, Vancomycin and Flagyl. CK and Troponin levels were obtained and they were flat. On [**11-10**] the patient was extubated without incident and the right subclavian line was changed. Cultures were sent to the line, at this point of the dictation are no growth but not finalized. Vancomycin was discontinued. Oxacillin was begun on [**2178-11-11**] 2 grams q 6 hours for suspected line sepsis. The Nasogastric tube was removed. His diet was advanced as tolerated on [**2178-11-12**]. PICC line was placed and the central line was discontinued. He received two units of packed cells for hematocrit. Oxacillin was started for the enterococcus which was 10,000 to 100,000 organisms in his urine culture and sensitivity on [**2178-11-8**]. The transfusion was for a hematocrit of 26.7, he received two units. His post transfusion crit was 33.3. The patient continued to do well. Physical therapy continued to work with the patient. Recommended rehabilitation and case management was requested to screen the patient appropriate facilities. At the time of discharge the patient's wounds were clean, dry and intact. He was medically stable. DISCHARGE MEDICATION: 1. Albuterol multidose inhaler puffs two q 4 hours. 2. Insulin sliding scale, glucose of less than 60 no insulin, glucoses 131 to 151 one unit, 151 to 200 two units, 201 to 250 4 units, 251 to 300 6 units, 301 to 350 8 units, 351 to 400 10 units, greater than 400 12 units and call. 3. Heparin subcutaneously b.i.d. 4. Boost with meals. 5. Vioxx 25 mg q day. 6. Lasix 20 mg q day. 7. Lopressor 37.5 mg b.i.d. 8. Albuterol, Atrovent nebulizer treatments q 4 hours p.r.n. 9. Oxacillin 2 grams intravenous q 4 hours for a total of two weeks. FOLLOW-UP: Patient should be seen by Dr. [**Last Name (STitle) **] in two weeks post discharge. DISCHARGE DIAGNOSIS: 1. Ruptured abdominal aortic aneurysm with repair. 2. Metabolic acidosis, etiology undetermined, corrected. 3. Respiratory failure requiring prolonged intubation, extubated, stable. 4. Blood loss anemia, transfused, corrected. 5. Enterococcus urinary tract infection treated. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2178-11-15**] 16:59 T: [**2178-11-15**] 16:57 JOB#: [**Job Number 6224**] Name: [**Known lastname 753**], [**Known firstname 77**] Unit No: [**Numeric Identifier 754**] Admission Date: [**2178-10-16**] Discharge Date: Date of Birth: [**2088-12-17**] Sex: M Service: DISCHARGE DIAGNOSIS: Staphylococcus coag positive septicemia, treated. [**Known firstname 77**] [**Last Name (NamePattern1) 237**], M.D. [**MD Number(1) 238**] Dictated By:[**Last Name (NamePattern1) 145**] MEDQUIST36 D: [**2178-11-15**] 17:17 T: [**2178-11-18**] 09:33 JOB#: [**Job Number 755**]

[ "721.90", "038.19", "530.81", "276.2", "599.0", "518.81", "996.62", "441.3", "285.1" ]

icd9cm

[ [ [] ] ]

[ "38.44", "99.15", "96.04", "54.91", "96.71", "33.23", "45.24", "38.93" ]

icd9pcs

[ [ [] ] ]

6909, 7223

730, 984

1007, 6055

86, 98

127, 636

659, 706

13,302

100,797

22849

Discharge summary

report

Admission Date: [**2116-6-2**] Discharge Date: [**2116-7-25**] Date of Birth: [**2076-9-30**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Iodine Attending:[**First Name3 (LF) 2297**] Chief Complaint: Here for allogeneic transplant for refractory multiple myeloma Major Surgical or Invasive Procedure: central line placement and removal chemotherapy with cytoxan and busulfan allogeneic bome marrow transplant PICC line placement VATS/pleurodeisis History of Present Illness: 39 yo male with multiple myeloma diagnosed in [**2114**] He was initially treated with Decadron alone and then began treatment with thalidomide and dexamethasone, which was started in 09/[**2114**]. He also underwent radiation therapy to the sacral area in 11/[**2114**]. His course was complicated by a DVT and PE at the time of his diagnosis, and he was on anticoagulation particularly while receiving thalidomide and Decadron. He was noted for a very good response to his treatment with a repeat bone marrow biopsy in [**2115-3-19**] showing 5% plasma cells as well as marked improvement in his lesion in the sacral area. In [**Month (only) 547**]/05, he was noted to have a drop in his white blood count, and repeat bone marrow biopsy showed increasing plasma cells with 20% involvement. His IgG level had also increased with a concern for more refractory disease. He received a cycle of DVD chemotherapy on [**2115-4-25**]. Following this therapy, he had increasing pain with increasing IgG levels and SPEP with a poor response to therapy, he was switched to treatment with Velcade and Decadron. He was given four cycles of this therapy. A repeat bone marrow aspirate and biopsy revealed CD138 staining of plasma cells for approximately 10% of the cellularity. His IgG level had decreased to a low of 1680. His SPEP had also decreased to 1100 mg/dL of the total protein. He then received high-dose Cytoxan on [**2115-7-25**] in preparation for stem cell mobilization with his stem cell collections completed during the week of [**2115-8-5**]. He then was admitted on [**2115-8-23**] for high-dose chemotherapy with melphalan followed by stem cell transplant. Followup evaluation of his disease at 2 months post-transplant at the end of [**10/2115**] showed approximately 10% involvement by plasma cells by CD138 staining. This was essentially stable, and he was continued to be monitored. His IgG level had decreased to 1314 following his transplant. On [**2116-1-19**], pt has increasing pain in the left groin area. An x-ray of the area did not show any evidence for fracture or lesion. He did undergo an MRI as well, which showed a lesion near the groin area with no pathologic fracture. He received radiation therapy to this area. Also in this setting, his IgG level had now increased to almost 4 g. He underwent a bone marrow aspirate and biopsy by his local oncologist, Dr. [**Last Name (STitle) 59071**], which revealed extensive relapsed disease with plasma cell myeloma accounting for 80-90% of the core biopsy specimen. As a result of this, it was felt that Mr. [**Known lastname 40270**] required more systemic therapy in addition to continuing the radiation therapy to the groin area, he was started Velcade with Decadron [**2116-3-2**]. He had been requiring increasing platelet transfusion support prior to beginning Velcade as well as during the course of Velcade with a platelet count less than 20,000 as well as red blood cell transfusion support, his IgG level had increased to 7 g with his SPEP now representing 50% or 4900 mg/dL of the total protein. He was started on more aggressive chemotherapy with D-PACE on [**2116-3-4**]. Within one week, he was noted for an increase of his IgG to over 6 g. As he clearly had an agressive refractory myeloma, he is being admitted for with a myeloablative transplant with cytoxan and busulfan conditioning. Mr. [**Known lastname 40270**] is being admitted today to begin his allogeniec transplant. Past Medical History: 1. Multiple myeloma as described above. 2. History of DVT and PE while receiving thalidomide, status post 6 months of anticoagulation. 3. Recent pneumonia treated with a 14-day course of Levofloxacin in 02/[**2116**]. Social History: Mr. [**Known lastname 40270**] previously worked as a florist but is currently unemployed. He does coach a girls basketball team and tries to keep active although since his most recent admission, he has not been keeping up with this. He denies any history of tobacco or alcohol use. He is married with a very supportive wife and has two young children, ages 4 and 1-year-old. Family History: Mr. [**Known lastname 40270**] has no hematologic malignancies in his family. There is type 2 diabetes in the family with elevated cholesterol. His mother died of a cerebrovascular accident. He has a brother and sister, both of whom have been HLA typed and do not match him. He currently has a non-related [**9-27**] HLA match Physical Exam: Admission: VS: T 97.6 BP108/65 HR110 O2sat97%RA Gen: young AA male lying in bed in flat affect HEENT: anicteric sclera, MMM, OP clear Neck: Supple. No LAD. Cardio: RRR, nl S1 S2, no m/r/g Lungs: CTAB no RRW Abd: soft, NT, ND +BS, no hepatosplenomegaly Ext: 2+pulses. No edema. . Neuro: A&Ox 3 Back: no point tenderness to palpation Pertinent Results: . [**6-2**] CXR: Slight improvement in the multiple patchy opacities which may be consistent with improving multifocal pneumonia . [**6-2**] Line placement 1: Successful placement of a 7-French triple lumen central line through the left internal jugular vein with the tip in the superior vena cava. The line is ready for use . [**6-2**] Line Placement 2: Successful placement of a 29 cm cuff-to-tip 10 French double- lumen tunneled [**Doctor Last Name 3075**] catheter with the tip in the superior vena cava. The line is ready for use. . [**6-2**] ECHO: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2116-5-22**], left ventricular systolic function now appears slightly more vigorous. . [**6-2**] ECG: Sinus tachycardia. Normal ECG except for rate . [**6-8**] CXR: Stable appearance of multiple airspace opacities within the bilateral lungs which may represent multifocal pneumonia . [**6-8**] ECG: Sinus tachycardia. Diffuse ST-T changes are nonspecific . [**6-8**] Transfusion reaction investigation: Mr [**Known lastname 40270**] had diffuse trunk and arm pain, tachycardia, mild hypertension and difficulty breathing while undergoing a transfusion of compatible red cells. Although there are a few laboratory parameters that are suspicious for hemolysis (mildy elevated LDH), other labs (negative DAT, normal haptoglobin) are not supportive of hemolysis, nor is his clinical picture. We feel that this reaction is an atypical non-hemolytic transfusion reaction that does not have a clear underlying cause. At this time we do not recommend changes in transfusion practice in this patient except careful monitoring during future transfusions. . [**6-9**] ECG: Sinus rhythm. Non-specific diffuse T wave changes. Compared to the previous tracing of [**2116-6-2**] no significant diagnostic change. . [**6-11**] US Liver: No evidence of liver, gallbladder, or biliary tree pathology to explain the patient's symptoms. Tiny 2 mm polyp or non-shadowing stone in the gallbladder lumen. Small bilateral pleural effusions. . [**6-12**] CXR: The bilateral central venous lines are in stable position. There is no pneumothorax. There is persistent left lower lobe opacity presumably atelectasis which appears slightly increased with the medial diaphragm obscured. No new areas of consolidation or effusion are identified. . [**6-13**] CT CAP: 1. Interval development of large left and smaller right pleural effusions. A new focal area of consolidation is seen at the left lung base which may represent atelectasis or possible pneumonia. 2. Resolving multifocal areas of peribronchovascular nodular opacification. 3. Progressive areas of soft tissue density in the paraspinal, pleural/extrapleural bases and left pelvis. Multifocal skeletal lesions are relatively unchanged and most severe at T11 with associated wedge compression fracture and in the left scapula. 4. No radiographic findings to explain the patient's abdominal pain. . [**2116-6-14**] ECHO: 1. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 2. Compared with the prior study (images reviewed) of [**2116-6-2**], there is no significant change. [**2116-6-18**] Transthoracic Echocardiogram: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. There is a small pericardial effusion. The effusion appears loculated around the right atrial free wall. There are no echocardiographic signs of cardiac tamponade, although there is brief right atrial diastolic invagination. Compared with the findings of the prior study (images reviewed) of [**2116-6-14**], the loculated pericardial effusion appears somewhat larger. [**2116-6-17**] CXR:IMPRESSION: Markedly increased right pleural effusion, compared to the prior study, worrisome for hemothorax in this patient with recent thoracentesis if it was on the right side. Edema in the right lung. Opacity in right lower lobe, which may be due to atelectasis, however, the evaluation is somewhat limited on this portable exam. [**2116-6-18**]: CT CHEST BEFORE AND AFTER CONTRAST: IMPRESSION: 1. Large pleural fluid accumulation in the right hemithorax, with findings suggestive of clot in the inferior aspect. No definite extravasating vessel identified. Stable appearance of left pleural effusion. 2. No pulmonary embolism. 3. Otherwise, no significant interval change since examination of [**2116-6-13**] [**2116-6-19**]: CHEST AP: IMPRESSION: Stable pulmonary edema. Tiny right apical pneumothorax. Worsening left lower lobe consolidation, which could represent atelectasis or pneumonia. [**2116-6-19**]: RIGHT UPPER QUADRANT ULTRASOUND: IMPRESSION: Unremarkable abdominal ultrasound. Normal liver Doppler vascular examination. [**2116-6-22**]: CXR - Interstitial edema has cleared though pulmonary vascular redistribution persists. Left lower lobe has been consolidated since at least [**6-18**] and could be either persistent atelectatic or infected. Right pleural tube still in place, but there is no pneumothorax or appreciable right pleural effusion. Tip of the left PIC catheter projects over the SVC. Heart size top normal, midline. [**2116-6-28**] Right Upper extremity ultrasound: IMPRESSION: No evidence of left upper extremity DVT. [**2116-6-28**] CXR: FINDINGS: Comparison is made to prior study from [**2116-6-23**]. The right apical pneumothorax is no longer visualized. The heart size is upper limits of normal and unchanged. There is a persistent left retrocardiac opacity and bilateral pleural effusion, which are stable. There is no overt pulmonary edema. [**2116-7-1**] CXR UPRIGHT AP VIEW OF THE CHEST: A left PICC is present with tip in the distal SVC. The heart is normal in size. The mediastinal and hilar contours are normal. The lungs are clear, and there are no pleural effusions or pneumothorax. Pulmonary vascularity is normal. The osseous structures are unremarkable. . [**7-2**] ECHO: Conclusions: 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 4. There is moderate pulmonary artery systolic hypertension. 5.There is a small pericardial effusion with fibrin deposits on the surface of the heart. 6. Compared with the prior study (images reviewed) of [**2116-6-18**], there is no significant change. . [**7-2**] EEG: IMPRESSION: Abnormal portable EEG due to the slow and disorganized background and bursts of generalized slowing. These findings indicate a widespread encephalopathic condition affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. There were no areas of persistent focal slowing, and there were no epileptiform features. . [**7-4**] DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [**Known lastname 40270**] has a clinically significant red cell alloantibody, anti-S. S is a member of the MNS blood group system. Anti-S can cause hemolytic transfusion reactions. In the future he should receive S negative red cells for transfusion. He is also restricted to irradiated and leukoreduced red cells. . [**7-15**] RUQ U/S IMPRESSION: No son[**Name (NI) 493**] abnormalities in the right upper quadrant. . [**7-20**] MRI of C-spine and T-spine: CONCLUSION: T11 vertebral body collapse, unchanged since [**3-22**], [**2116**]. C5-6 disc protrusion to the right with indentation on the spinal cord and occlusion of the neural foramen. No evidence of epidural abscess. . [**7-21**] CT Chest w/o contrast: IMPRESSION: 1. Persistent small right pneumothorax, as seen on an earlier radiograph of the same day. 2. Improvement in bilateral pleural effusions, with small residual left effusion. 3. Improved aeration of the right lung since the prior CT, although the entire right lung remains involved with heterogeneous consolidations. 4. Worsening consolidations throughout the left lung. 5. Similar prominent soft tissue densities in the left pelvic side wall, probably lymphadenopathy. Brief Hospital Course: Mr [**Known lastname 40270**] was admitted for a MUD allogeneic BMT with Cytoxan and Busulfan conditioning. He was treated according to the transplant protocal. He was transfused to keep his hct>25 and plt>10. He had one suspected transfusion reaction to pRBCs, and an investigation was performed. He received additional units of pRBCs without further reaction. After the allogeneic BMT, he had febrile neutropenia. On [**6-7**] blood cultures grew MRSA. He was started on Vancomycin, Cefepime and then Caspofungin was added. He was persistently febrile to 104-105 degrees. He had a chest x-ray and CT scan that demonstrated bilateral pleural effusions, left greater than right. He was diuresed with some decrease in effusion size, although left sided effusion was still large. On [**6-18**], given the persistent, high fevers, and consolidation within the left pleural effusion, there was a concern for empyema. Interventional Pulmonary was contact[**Name (NI) **]. Platelets were transfused to keep > 50 prior to procedure. They attempted thoracentesis on left, but were unable to drain any fluid despite being able to visualize fluid on ultrasound. Ultrasound was performed on the right side and effusion was seen. Thoracentesis was performed on the right side and very small amount of fluid was drained. Approximately 10 hours after the procedure, patient noted severe substernal chest pain, difficulty breathing. He was tachycardic to 130's. Pain responded to iv morphine. A chest x-ray was performed and demonstrated new right pleural effusion. His hematocrit had decreased to 15 (approx 8 point decrease) and concern for hemothorax. The medical ICU team was contact[**Name (NI) **]. [**Name2 (NI) **] was transferred to the ICU. A contrast CT Chest/Abdomen/Pelvis was performed. Given concern for contrast administration in patient with Multiple Myeloma, he was given 4 doses of mucomyst immediately following the CT scans. Thoracics was contact[**Name (NI) **] and placed a chest tube on [**6-18**] on the right which drained bloody fluid. Patient was feeling much better after the chest tube was placed. His LFTS were noted to be increasing, and especially his Bilirubin (direct bilirubinemia). There was a concern for [**Last Name (un) **]-occlusive disease. His weight had not been increasing, though. An ultrasound with dopplers was performed on [**6-20**] and was normal with normal blood flow. His LFTs started trending down and chest tube output was decreasing. He was transferred back to oncology floors on [**6-21**]. Chest tube was removed by Thoracics surgery on [**6-22**]. He continued to have serosanguinous drainage from chest tube site while he was neutropenic, but this stopped when his blood counts started rising. On [**7-1**], patient was noted to be diaphoretic and complained of not feeling well. In the afternoon he underwent a sharp decline in mental status, becoming confused and then increasingly somnolent. An ABG on the BMT floor showed hypercarbia (ABG: 7.27/58/89/28) with stable vital signs and a PE notable for poor respiratory excursion. He was given 125mg Solumedrol and 1U plts/1U blood were transfused. When the ICU team arrived the pt was noted to be stuporous. Pt was given 0.8mg Narcan-- > became more alert for a couple of minutes and then again lapsed obtunded state, had tonic clonic sz activity, and was noted to have LOC, disconjugated gaze and bowel incontinence. He was intubated on floor for airway protection and transferred back to the ICU. . In the [**Hospital Unit Name 153**], patient was noted to be in hypercarbic resp failure as above. His vent settings were titrated as needed to maintain normal pCO2. His MS appeared to have improved. His seizure/MS changes as above were thought due to his hypercarbia and no AEDs were initiated as per the neurology c/s service. It was felt that his hypercarbic resp failure was due to DAH, and he received He was noted to develop ARF with his Cr rising to 2.0 from 1.0 over the span of a few days. It was thought that this was likely iatrogenic in nature rather than prerenal azotemia as he was fluid overloaded on exam, with nml vital signs and urine lytes c/w ATN. His acyclovir was held and his CSA dose was decreased to prevent further nephrotoxicity. He was steadily weaned from the vent until [**7-8**] am when he was noted to have a sudden increase in oxygen requirement. He was bronched ([**7-8**]) and was noted to have progressive bloody return on BAL, concerning for recurrent diffuse alveolar hemorrhage. He continued to intermittently spike and was pan-cultured. . From [**2116-7-22**] to [**2116-7-25**], Mr. [**Known lastname 59072**] mental status deteriorated such that he was no longer awake and responsive. His oxygen requirements continued to go up such that he was on 100% FiO2 and was satting in the low 90s and was persistently tachypneic in the 30s-40s. He also continued to spike fevers of unknown origin and had rising Cr. On the night of [**7-25**], in light of increasing oxygen requirements/decreasing sats and upon consultation with the BMT team and his wife, the decision was made to withdraw life support due to dismal prognosis and his wife's feeling that he had fought and suffered long enough. He died at 2359 on [**2116-7-25**]. . Fever & neutropenia: While in the ICU, the patient was continued on Vancomycin and Meropenem given his prior MRSA bacteremia and neutropenic fever. His Caspofungin was initially changed to Ambisome but given his rise in creatinine, he was switched back to Caspofungin and then back to Ambisome once his Bili and AST/ALT began to rise. Two thansthoracic echocardiograms were performed looking for valvular vegetations but none seen. He was maintained on his Acyclovir ppx until his creatinine rose to 1.8, and this was held. . Back pain: Mr [**Known lastname 40270**] has chronic back pain secondary to his myeloma. He was continued on MSSR, with a dose increase to 60 [**Hospital1 **], and covered for breakthrough pain with prn MSIR. . Peripheral neuropathy: He was usually on Neurontin and B6, but these were held for high dose chemotherapy given unknown durg-drug interactions with high dose chemotherapy. . FEN: He was on a neutropenic, cardiac diet, with prn repletion of electrolytes and IVF per protocol. TPN was started on [**2116-6-27**] given poor po intake, low albumin. . PPX: he was on a PPI and a bowel regimen. . FULL CODE *** Of note, he has a bactrim allergy, so he will need to have pentamidine as PCP [**Name Initial (PRE) 1102**]. Medications on Admission: Lexapro has been dicontinued Neurontin 400 mg t.i.d. B6 vitamin 50 mg daily MS Contin 15 mg b.i.d. MSIR 15 to 30 mg q.4-6h. p.r.n. Protonix 40 mg daily acyclovir 400 mg t.i.d. aerosolized pentamidine q. monthly last given on [**2116-5-28**] Discharge Disposition: Home with Service Discharge Diagnosis: Multiple Myeloma MRSA bacteremia bilateral pleural effusions Hemothorax Discharge Condition: Death Discharge Instructions: None Followup Instructions: None

[ "285.1", "511.8", "041.04", "512.1", "038.9", "782.4", "510.9", "428.0", "203.00", "V58.65", "780.6", "518.84", "284.8", "792.0", "780.39", "786.3", "482.39", "995.92", "585.9", "584.9", "356.9" ]

icd9cm

[ [ [] ] ]

[ "34.04", "99.05", "34.51", "34.91", "99.25", "00.14", "41.03", "96.05", "96.72", "38.93", "99.28", "33.24", "99.04", "96.6", "00.92", "96.04", "99.15", "31.1", "03.31" ]

icd9pcs

[ [ [] ] ]

21624, 21643

14765, 21333

352, 499

21759, 21766

5368, 14742

21819, 21826

4669, 5000

21664, 21738

21359, 21601

21790, 21796

5015, 5349

250, 314

527, 4016

4038, 4257

4273, 4653

1,769

147,591

48104

Discharge summary

report

Admission Date: [**2107-3-28**] Discharge Date: [**2107-4-5**] Service: BLUE GENERAL SURGERY HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old independent female in good health who has had intermittent self limited right upper quadrant pain for several weeks prior to admission which became severe on [**2107-3-18**]. The patient was referred by her primary care physician to Dr. [**Last Name (STitle) **] on [**3-24**] and an ultrasound showed a distended gallbladder with 2.5 cm stone and sludge. The patient afterwards continued to have nagging right upper quadrant pain until 5 p.m. on the night of admission when she developed severe right upper quadrant pain after eating a low fat dinner. She has not had any nausea or vomiting. She did not have any fevers or chills. There has been no change in her bowel habits, no dysuria, no hematuria, no small bowel obstruction, no chest pain and she presented to [**Hospital6 1760**] Emergency Room for further evaluation. PAST MEDICAL HISTORY: 1. Cholelithiasis 2. Multi-nodule goiter 3. Hypothyroidism 4. Osteoporosis 5. Glaucoma 6. Mild left ventricular hypertrophy 7. Lactose intolerance 8. History of deep venous thrombosis in [**2094**] which was treated with Coumadin PAST SURGICAL HISTORY: 1. Status post subtotal thyroidectomy 2. Status post tonsillectomy ADMISSION MEDICATIONS: 1. Aspirin 81 mg po qd 2. Betagen 0.5% each eye [**Hospital1 **] 3. Fosamax 70 mg po q week 4. Motrin prn 5. Levothyroxine 150 mcg po qd 6. Vitamins A, C, D, E and zinc 7. Glucosamine ALLERGIES: QUESTION OF SULFA ALLERGY, BUT HAS CODEINE ALLERGY WHICH CAUSES NAUSEA AND VOMITING. SOCIAL HISTORY: Denies any ETOH use. Denies tobacco use. PHYSICAL EXAM: VITAL SIGNS: The patient is [**Age over 90 **].5??????, 90, 100/74, 20, 96% on room air. GENERAL: She is alert and oriented, following commands. HEAD, EARS, EYES, NOSE AND THROAT: She has no cervical lymphadenopathy. Pupils are equal and reactive to light. Tongue is midline. CHEST: Clear to auscultation bilaterally. HEART: Regular rate and rhythm with a 2/6 systolic murmur. ABDOMEN: Soft. She has guarding in the right upper quadrant, positive [**Doctor Last Name 515**] sign, mild tympany, minimum distention. EXTREMITIES: Warm. She has bilateral spider veins and right varicosity, palpable popliteal and dorsal pedis. NEUROLOGIC: Intact. ADMISSION LABORATORIES: White count 12.2, hematocrit 38.1, platelets 534. Sodium 133, potassium 5.0, chloride 94, bicarbonate 25, BUN 15, creatinine 0.5, glucose 168. Her PT was 12.4. PTT was 26.8. INR was 1.1. Her ALT was 32. AST was 26. Alkaline phosphatase was 148. Total bilirubin was 0.5 and amylase was 69. ADMISSION RADIOLOGIC STUDIES: Ultrasound showed 2.5 cm gallstone at its neck with positive wall thickening, no fluid, no wall gas and a 0.7 cm common bile duct with a positive son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. Abdominal x-ray showed stool throughout with gas in the rectum. HOSPITAL COURSE: The patient was admitted to the surgery service. She was placed on intravenous antibiotics made of ampicillin, Flagyl, ceftriaxone. She was made NPO and she was observed overnight. On hospital day #2, she was afebrile. She continued to have right upper quadrant tenderness with no rebound and it was decided that her white count had increased to 20 and because exam had not significantly improved, she was taken to the Operating Room where she underwent diagnostic laparoscopy. The laparoscopy showed gangrenous gallbladder. She underwent an exploratory laparotomy, cholecystotomy tube placement and drainage of suprahepatic abscess. She tolerated the procedure well. There were two JP drains placed. She received 1500 cc of intravenous fluids, had minimal estimated blood loss and only urine output of 100 cc. She was continued on ampicillin, Flagyl and ceftriaxone and cultures were taken from the Operating Room. The cultures resulted in growing Staphylococcus aureus coagulase positive. She was covered with vancomycin, Levaquin and Flagyl and no sensitivities returned. She was switched to levofloxacin and Flagyl which we will leave on po regimen for several weeks. Her postoperative course is significant for patient becoming tachycardic on postoperative day #2. Urine output remained approximately 20 to 40 cc per hour. She was resuscitated with fluids, but continued to have episodes of sinus tachycardia. Her electrolytes were checked and repleted. Her hematocrit was found to be 26.7 down from an admission of 38. She was transfused with 2 units of blood and she was started on intravenous Lopressor for beta blockade. With the tachycardia continuing through postoperative day #3, it was decided to transfer the patient to the Intensive Care Unit for central venous pressure monitoring. When she entered the unit, a central line was placed and using the CVP she was optimally fluid resuscitated. Her urine outputs increased appropriately. Her heart rate decreased appropriately. She was continued on the intravenous Lopressor and her antibiotic. On postoperative day #4, when she was stable, she was discharged from the Intensive Care Unit and back to the floor, hence from when she has continued to be stable. She is continuing Lopressor 25 mg po bid. Heart rate remained sinus and in the 80s and her electrolytes have been corrected. Postoperative day #6, the output from the JP drains had been minimal to 20 and 5 respectively for the last 24 hours and has been serous in character. The cholecystostomy tube drainage has been consistent at approximately 500 cc of bilious drainage. The JP drains were discontinued on postoperative day #6. The cholecystostomy tube will remain for an undetermined length of time which will be discussed with Dr. [**Last Name (STitle) **]. Her white count has been decreased to 14. She is currently on po levofloxacin and po Flagyl which she is tolerating. She is tolerating her low fat, no wheat, no glutin diet. She is voiding without any problem and she has been positive for flatus and bowel movements. She has been evaluated by physical therapy and has been ambulating, though she will require a short course of rehabilitation due to the fact that she does live independently. Though she has family support, she currently lives alone. She is now stable and ready for discharge to rehabilitation and will follow up with Dr. [**Last Name (STitle) **] in approximately six weeks wherein she will have evaluation of her cholecystostomy tube and question removal at that time. In addition, during the patient's cardiac evaluation, she had a set of cardiac enzymes sent in which her creatinine kinase was 191 and 141 respectively. Her troponin Is were 1.3 and 0.8 respectively. Her electrocardiogram showed no changes and it was determined that the patient most likely did not have any cardiac event during her episode of tachycardia. DISCHARGE DIAGNOSES: 1. Status post exploratory laparoscopy and laparotomy with cholecystostomy tube placement and drainage of suprahepatic abscess. 2. Hypothyroidism 3. Osteoporosis 4. Glaucoma 5. History of deep venous thrombosis in [**2094**]. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg po qd 2. Betagen 0.25% drops in each eye [**Hospital1 **] 3. Fosamax 70 mg po q week 4. Motrin 400 mg prn 5. Levothyroxine 150 mcg po qd 6. Levofloxacin 500 mg po qd x2 weeks 7. Flagyl 500 mg po tid x2 weeks 8. Percocet 5/325 1 to 2 po q4h prn DISCHARGE CONDITION: Stable FOLLOW UP: The patient will make an appointment with Dr.[**Name (NI) 41561**] office for follow up in approximately six weeks. She will go to rehabilitation and they will be able to remove the staples at rehabilitation and will continue with appropriate drain care for the cholecystostomy tube. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2107-4-5**] 09:52 T: [**2107-4-5**] 10:02 JOB#: [**Job Number 101430**]

[ "574.00", "572.0", "567.2", "427.89", "997.1", "575.5", "V64.4", "041.11" ]

icd9cm

[ [ [] ] ]

[ "50.0", "51.21", "51.04" ]

icd9pcs

[ [ [] ] ]

7512, 7520

6965, 7197

7220, 7490

3027, 6944

1373, 1663

1280, 1350

1738, 3009

7532, 8095

134, 996

1018, 1257

1680, 1723

50,760

197,380

2134

Discharge summary

report

Admission Date: [**2141-4-13**] Discharge Date: [**2141-4-18**] Date of Birth: [**2079-8-6**] Sex: M Service: MEDICINE Allergies: Iron Attending:[**First Name3 (LF) 5037**] Chief Complaint: n/v, abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 61 year old male w/ a PMH notable for CKD (baseline Cr ~1.8-2) s/p renal transplant ([**2135**]) c/b CMV Viremia, DM2 (insulin managed), pancreatitis, HCV, gastroparesis, esophagitis who presents w/ nausea, vomiting and abdominal pain. . Patient reports having abdominal pain that started around 2:30am, in the mid-epigastric area. He took 2 percocet but became nauseous and had an episode of [**Doctor Last Name 352**]-liquid emesis. In the morning of admission, he attempted to take his anti-hypertensive medications but had another episode of non-biliary, non-bloody emesis. He also had an episode of loose stools in the AM. He has not been able to take his immunosuppressants. He denies ETOH consumption, fevers, chills, BRBPR, melena, dysuria, and hematuria. . In the ED, initial VS were: T 99.8, HR 78, BP 190/68, RR 16, O2 100%. On exam patient was tender in the RUQ and epigastrium. While in the ED, he acutely desated to 80s on RA, improved to high 90s on 5L nc. He was hypertensive to 170s-190s. UA was notable for proteinuria and trace blood (neg nit/leuk/bact), hct 34.4, wbc 9.6 (84% pmn), plt 142, bun/cr 29/1.7 (baseline), alt/ast 22/30, ap 83, tbili 0.5, lipase 58, lactate 2.3->2.9, blood gas (likely venous) 7.32/48/22; CXR R>L opacity; KUB no obstruction. He recieved zofran, reglan, morphine, 2LIVF, and vanco/zosyn for ?aspiration PNA. . On arrival to the MICU, he complains of [**11-8**] mid-epigastric pain, but denies shortness of breath. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. ESRD s/p Renal Transplant [**6-/2135**] (baseline Cre 1.8-2.5) - complicated by CMV Viremia 2. Erectile Dysfunction 3. Hx of detached retina - [**2132**], surgically repaired 4. h/o infected sebaceous cyst 5. Pancreatitis -chronic - admitted in [**2140**] for pancreatitis 6. Diabetes Mellitus Type II - on Insulin 7. h/o Knee arthritis 8. h/o Hepatitis C - followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11455**] ([**Hospital1 2177**]) 9. Hypertension - controlled on metoprolol 10. Osteoarthritis 11. Esophagitis - EGD in [**2140**] w/ esophagitis, received 1 unit pRBC on that admission Social History: Lives alone in apartment on [**Location (un) **] avenue. On disability, not currently working. EtOH: Last drink 15 yeasr ago although previously reported ETOH intake in setting of admissions for pancreatitis in [**2139-7-30**]. Drugs: Denies illicits. Tobacco: 1pack per week for 7-10 years, quit in 90s. Family History: Mother - Type 2 Diabetes Mellitus, hypertension, passed away from "old age" Father - Type 2 Diabetes Mellitus, passed away from "old age". Also has h/o alcoholism Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, ttp at mid-epigastric area w/o guarding or rebound, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, LUE fistual with good thrill. Neuro: 5/5 strength in upper and lower extremities, EOMI, PERRL, tongue midline, down going toes, A&Ox3 Pertinent Results: [**2141-4-13**] 12:15PM BLOOD WBC-9.6# RBC-4.61 Hgb-10.2* Hct-34.4* MCV-75* MCH-22.1* MCHC-29.6* RDW-15.3 Plt Ct-142* [**2141-4-13**] 12:15PM BLOOD Neuts-84.5* Lymphs-9.2* Monos-5.4 Eos-0.4 Baso-0.6 [**2141-4-13**] 12:15PM BLOOD Glucose-157* UreaN-29* Creat-1.7* Na-141 K-4.7 Cl-106 HCO3-22 AnGap-18 [**2141-4-13**] 12:15PM BLOOD ALT-22 AST-30 CK(CPK)-64 AlkPhos-83 TotBili-0.5 [**2141-4-13**] 12:15PM BLOOD Lipase-58 [**2141-4-13**] 12:15PM BLOOD CK-MB-2 cTropnT-<0.01 [**2141-4-13**] 12:15PM BLOOD Albumin-4.8 [**2141-4-13**] 09:07PM BLOOD Type-ART pO2-63* pCO2-36 pH-7.43 calTCO2-25 Base XS-0 [**2141-4-13**] 09:07PM BLOOD Lactate-1.2 Na-138 K-5.0 [**2141-4-13**] 12:19PM BLOOD Lactate-2.3* [**2141-4-13**] 04:50PM BLOOD Lactate-2.9* KUB [**2141-4-13**]: The bowel gas pattern is unremarkable. There are no dilated loops of large or small bowel or air-fluid levels. The stomach is nondistended. There is no evidence for free air. Patchy vascular calcifications are associated with each kidney. There is slight rightward convex curvature centered along the thoracolumbar junction. IMPRESSION: No evidence for obstruction or free air. CXR [**2141-4-13**]: Single portable view of the chest is compared to previous exam from [**2140-9-14**]. There are predominantly perihilar parenchymal opacities, right greater than left likely dur to pulmonary edema. Mild blunting is seen at the left costophrenic angle which is new from prior. Cardiac silhouette is within normal limits. Osseous and soft tissue structures are unremarkable. IMPRESSION: Mild pulmonary edema, tiny left plerual effusion. Brief Hospital Course: Primary Reason for Hospitalization: 61 year old male w/ a PMH notable for CKD (baseline Cr ~1.8-2) s/p renal transplant ([**2135**]) c/b CMV Viremia, DM2, pancreatitis, HCV who presents w/ nausea, vomiting and abdominal pain. Active Issues: # Nausea, vomiting, abdominal pain: Ddx - gastroparesis, esophagitis, infectious (given small episode of loose stools). Lipase was wnl. Mild lactate elevation initially gave concern for ischemic colitis, however he was not hypotensive. Given his rapid improvement, it was felt he most likely had viral gastroenteritis in addition to his chronic gastroparesis. He improved with IVF and dilaudid/zofran and bowel rest. # Hypoxia: Transient, weaned to 2L within hours of admission. Etiology unclear. [**Name2 (NI) 227**] immunosuppressed status as well as hypoxia, there was some concern for CAP, thus was started on ceftriaxone/levofloxacin, however these were discontinued after his O2 requirement resolved due to low clinical suspicion. # Hypertensive Urgency. Likely due to acute GI illness and inability to tolerate home PO regimen. He was transiently treated with IV metoprolol and hydralazine and transitioned to home regimen of norvasc and metoprolol PO on HD 1 with SBPs in 130-160s. Chronic Issues: # CKD s/p renal transplant: UA w/ proteinuria, and cr at baseline. Restarted on home regimen of immunosuppression with decreased dose of cell cept 500mg [**Hospital1 **]. Transitional Issues: -Medication changes: His home cellcept was decreased to 500mg [**Hospital1 **], his home reglan was increased to 10mg TID. He was started on PO zofran and compazine prn nausea. -He is scheduled to f/u with his PCP [**Name Initial (PRE) 176**] 1 week of discharge -Code status: Full Medications on Admission: mycophenolate mofetil 500 mg Tablet Sig: 1.5 Tablets PO BID prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO QAM tacrolimus 1 mg Capsule Sig: One (1) Capsule PO QPM. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). metoprolol succinate 50 mg Tablet Extended Release 24 hr DAILY simvastatin 10 mg PO QPM omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **] oxycodone-acetaminophen 5-325 mg PO Q6H (every 6 hours) as needed for Pain. Lantus 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous at bedtime. Humalog 100 unit/mL Solution Sig: Five (5) units Subcutaneous prior to meals. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Discharge Medications: 1. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 2. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 3. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO QPM (once a day (in the evening)). 4. prednisone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 8. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 9. Lantus 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous once a day. 10. Humalog 100 unit/mL Solution Sig: Per sliding scale prior to hospitalization Subcutaneous four times a day. 11. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 12. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:*30 Tablet(s)* Refills:*1* 14. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: Nausea and vomiting Gastroparesis Diabetes Mellitus Secondary Diagnosis: Chronic kidney disease status post renal transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted with nausea, vomiting, and abdominal pain. You initially went to the ICU due to low oxygen levels in your blood and high blood pressure, which improved when your nausea and vomiting improved. It was felt that your nausea and vomiting was likely related to gastroparesis, although you may have had a viral illness as well. CHANGES to your medications: DECREASE mycophenolate mofetil to 500mg by mouth twice daily INCREASE reglan to 10mg by mouth three times daily ADD compazine 10mg by mouth every 6 hours as needed for nausea ADD zofran 4-8mg by mouth every 8 hours as needed for nausea Followup Instructions: We have scheduled an appointment for you to follow up at the [**Hospital1 2177**] primary care clinic on [**2141-4-25**] at 10:00AM. [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]

[ "250.60", "585.9", "403.90", "276.2", "536.3", "V42.0", "518.4", "577.1", "070.70", "V58.67" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9585, 9594

5669, 5896

284, 290

9783, 9783

4049, 5646

10655, 10891

3243, 3408

8189, 9562

9615, 9615

7430, 8166

9934, 10366

3423, 4030

7120, 7121

10395, 10632

1810, 2258

7141, 7404

225, 246

5912, 6910

318, 1791

9708, 9762

9634, 9687

9798, 9910

6927, 7099

2280, 2905

2921, 3227

25,767

169,218

14630

Discharge summary

report

Admission Date: [**2157-5-29**] Discharge Date: [**2157-6-4**] Date of Birth: [**2088-4-8**] Sex: F Service: Cardiac Intensive Care Unit HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old female with no prior known coronary artery disease who presents with substernal chest pain, diaphoresis, dyspnea and left arm numbness for two hours. She initially presented to [**Hospital 1562**] Hospital where an EKG was performed and showed an inferior posterior myocardial infarction. She was given IV Lopressor, Aspirin, Nitroglycerin, started on Heparin and thrombolysis with TNK. ?????? hour after receiving TNK the patient continued to have persistent chest pain as well as [**Known lastname **] elevations in the inferior leads with [**Known lastname **] depressions in the anterior leads. She then developed nausea, a sudden increase in her chest pain and junctional bradycardia with her heart rate only 30 beats per minute and an episode of hypotension. She received 0.5 mg of Atropine in intravenous fluids with good response. She was transferred to [**Hospital1 190**] via Med Flight for cardiac catheterization. The cardiac catheterization showed mild luminal irregularities in the LAD and left circumflex arteries and there were severe focal 96% mid right coronary artery narrowing in a segment of 60% narrowing. This was stented with a 3.5 by 18 mm stent with timi III flow resulting. The right heart cath showed elevated filling pressures. Specifically, the RVADP was 21, the pulmonary capillary wedge pressure was 21, mean right atrial pressure was 18, pulmonary artery pressure was 42/25. 20 mg of Lasix was given intravenously. An LV gram showed an EF of 55-60% with rather severe inferior hypokinesis or akinesis. PAST MEDICAL HISTORY: Asthma, COPD, back pain and hypercholesterolemia. ALLERGIES: No known drug allergies. MEDICATIONS: Theophylline, Fosamax, Advair which is Serevent plus Fluticasone and Atrovent. FAMILY HISTORY: No early coronary artery disease although her father had a CABG at age 77. SOCIAL HISTORY: She quit tobacco 10 years ago. No alcohol. Her PCP is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1193**], [**Telephone/Fax (1) 43120**]. She is followed by a pulmonologist. PHYSICAL EXAMINATION: Vital signs on admission, temperature 95.9, pulse 81, blood pressure 98/37, respirations 15, oxygen saturation 93% on four liters and her exam in general, she is an alert, pale female in no acute distress. HEENT: Pupils are equal, round, and reactive to light, extraocular movements intact, anicteric sclera, mucus membranes moist. Neck, JVP was not seen. There is no lymphadenopathy. Chest, prolonged expiratory phase with end expiratory wheeze. Cardiovascular, normal S1 and S2, regular rate and rhythm, no murmurs, no S3 or S4. Abdomen soft, nontender, non distended, positive bowel sounds. Extremities, no clubbing, cyanosis or edema, 2+ dorsalis pedis pulses bilaterally. Neuro, alert and oriented times three, cranial nerves II through XII intact. Upper extremity strength was full, lower extremities, not tested secondary to recent cardiac catheterization. Groin, no hematoma, there is a pressure dressing in place. LABORATORY DATA: On admission, sodium 140, potassium 3.8, chloride 101, CO2 28, BUN 17, creatinine 0.6 and glucose 126, calcium 9.9, CK 59, troponin I was less than 0.1, Theophylline was 7.0 with normal range being [**10-2**]. CBC, white cells 3.5 with a differential of 74% neutrophils, 17% lymphs, 6% monos, 2% eosinophils. Hematocrit was 45, platelet count 262,000, INR 1.0, PTT 21.9, PT 12.0. EKG at 11:40 a.m. at [**Hospital 1562**] Hospital showed normal sinus rhythm at 64 with 1-[**Known lastname 1766**] elevations in leads 2, 3 and AVF, there are [**Known lastname **] depressions in leads V1 through V3, there is T wave inversion in lead AVL after lytic was given. There was no prelytic EKG. After cardiac catheterization at [**Hospital1 346**], additional EKG showed normal sinus rhythm at 83 with 1 mm Q wave in leads 2, 3 and AVF, complete resolution of the [**Known lastname 43121**] changes in the lateral and anteroseptal leads. IMPRESSION: This is a 69-year-old female with hypercholesterolemia, history of tobacco abuse, COPD but no known prior CAD who presents with an inferior posterior myocardial infarction involving both the LV and the RV. She was lysed at the outside hospital with TNK, developed junctional bradycardia and hypotension that responded to Atropine and had persistent EKG changes and chest pain despite [**Last Name (LF) 43122**], [**First Name3 (LF) **] she was transferred to our hospital for emergent cardiac catheterization where she received a stent to her right coronary artery. HOSPITAL COURSE: 1. Cardiac: Following the stent placement she had complete resolution of her chest pain. We gave her Aspirin, Plavix and Lipitor and initiated Lopressor at 25 mg po bid. Because of the elevated filling pressure suggesting right ventricular involvement, we obtained an echocardiogram which showed an ejection fraction of 40-50% which was mildly depressed. This is secondary to hypokinesis of the posterior wall. Additionally, the right ventricular systolic function was also depressed. There was mild mitral regurgitation. If her blood pressure tolerates, she will be started on an ACE inhibitor as an outpatient. 2. Pulmonary: The patient was noted to have worsening pulmonary function and oxygenation during her stay in the CCU. Initially she had evidence of pulmonary edema which was treated effectively with diuresis. However, her pulmonary status did not significantly improve. She had diffusely decreased breath sounds. Chest x-ray only showed bibasilar atelectasis. The clinical picture was most consistent with mild COPD exacerbation. She improved with Prednisone, nebulizers and Flovent. Theophylline was restarted, as she had been on this at home. 3. GI: The patient had a lot of nausea post procedure, lasting almost three days. This was treated successfully with Ondansetron. Constipation was managed with a typical bowel regimen. 4. Prophylaxis: Heparin was given subcutaneously for DVT prophylaxis. Pantoprazole was given for GI prophylaxis. DISCHARGE MEDICATIONS: Aspirin 325 mg po q d, Plavix 75 mg po q d for one month, Lipitor 10 mg po q d, Lopressor 25 mg po q d, Theophylline 300 mg po bid, Albuterol nebulizer/MDI, Atrovent nebulizer/MDI, Flovent 110 mcg two puffs inhaled [**Hospital1 **], Prednisone taper 40 mg po q d, then 20 mg po q d, then 10 mg po q d, then 5 mg po q d for two days, then discontinue. DISCHARGE STATUS: To rehabilitation for physical therapy. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSIS: 1. Posterior/inferior myocardial infarction with RV and LV involvement. 2. Status post stent to the RCA. 3. Mild COPD exacerbation. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Name8 (MD) 2734**] MEDQUIST36 D: [**2157-6-29**] 11:26 T: [**2157-7-3**] 20:15 JOB#: [**Job Number **]

[ "564.00", "E879.0", "458.2", "428.0", "414.01", "272.4", "410.31", "491.21" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.23", "36.01", "88.47", "88.53", "36.06", "88.48" ]

icd9pcs

[ [ [] ] ]

6748, 6755

1980, 2056

6314, 6726

6776, 7197

4808, 6290

2325, 4791

183, 1757

1780, 1963

2073, 2302

80,861

109,056

49895

Discharge summary

report

Admission Date: [**2147-10-24**] Discharge Date: [**2147-11-5**] Date of Birth: [**2097-3-5**] Sex: M Service: EMERGENCY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2565**] Chief Complaint: anorexia, hypotension Major Surgical or Invasive Procedure: paracentesis, central line placement (right internal jugular vein), arterial line placement, intubation History of Present Illness: . 50 yo M with EtOH abuse, liver disfunction and hx of fatty liver, presented to the ED after several days of n/v, lightheadedness and syncopal episodes. . Pt. reports being in USOH until ~ 2.5 wks ago, when he noted upon awakening difficulty tolerating PO, nausea and emesis and subsequent lightheadeness. Sx would improve by late afternoon when he would be able to take PO. In additino, noted easy bruising over the past few months (in ED reported last drink 6days ago). He reports drinking 6-10d/night usually, however, 2wks ago, quit given he could not keep anything down. He did not seek medical attention, but did call PCP's office on [**10-11**] and reported several fainting episodes. He was advise to come in for an evaluation but did not do so. . Over the past 3 days, his n/v and dizziness became constant. He could not keep anything down other than clear liquids and had multiple fainting episodes with falling. ~ 1.5wks ago noticed his eyes and skin became yellow. Denies confusion or changes in sleep. . He reports having had long standing liver problems, per OSH records from [**Name (NI) 270**] hospital there is a discussion re: alcoholic hepatitis and alcohol dependence in [**Month (only) 404**] and [**2144-12-25**]. [**2145-1-4**] notable for AST 115, ALT 191, total bili 1.3, direct bili 0.6, total cholesterol 248, HDL 70, triglycerides 92. CBC with a hemoglobin of 16.0, hematocrit 45, MCV 107, B12 671, TSH 0.9. Most recent [**Hospital1 18**] labs [**4-2**] notable for Tbili of 2, negative HepB serologies, negative HIV, HCV, and transaminitis of AST/ALT 254/106. . In the ED ini vs were: T98 P91 BP113/57 R15 O2 97% ra. Initial BP en route was repoted to be in 80s systolic, but pt. has been in 110s while in the ED for the rest of the stay. He received 40meQ of IV K in NS 1L, 2g of Mg IV, and 1.5L of NS. Underwent Liver US (see below) but did not have a location of ascites that could be tapped safely. Had guiac positive yellow stool. . On the floor, VS 98.4 100/72 104 16 95% RA. Pt. did not feel lightheaded and had no complaints. . Review of systems: (+) Per HPI, abdominal bloating. Denied hemoptysis, melena, bloody BMs, or abdominal pain. No fevers but had chills, night sweats. . Signif weight loss. Otherwise negative in detail. Past Medical History: EtOH Abuse Fatty liver HTN Urethritis Allergic rhinitis Gout Social History: The patient is an IT manager for [**Company 25186**]. Lately, he has been working seven days a week and many nights as well. He has been on his current job for approximately three and a half years and he is looking for other work because of the level of stress. There is also a great deal of concern about people losing their jobs. He is divorced, has one child, and has been divorced for approximately a year. No tobacco. [**Doctor First Name **] currently drinks on average six drinks nightly after work and at times more. Recently on his golfing trip he was drinking up to 12 drinks per day. He used to drink mostly beer, but lately his drink of choice is vodka tonic. He notes that his work is extremely stressful and this is his way for relaxing and coping with his work. He notes that he has had an alcohol use problem for some time and at times in the past and has been able to decrease his alcohol consumption to one or zero drinks. He has attended AA meetings in the past, but generally "falls off the wagon". He gets tired of going and talking about alcohol all the time. He has previously used other strategies to deal with stress, including walking. All of his friends currently also drink alcohol and he notes that they have been drinking more recently as well also. No drug use. Exercise: He used to work at a gym, but has not been exercising recently due to his schedule. Diet: The patient states his diet and has not been good lately. There was a period a couple of months back when he noticed that he was recently not eating anything at all and he began to feel lousy. Within the last month, he has made a concerted effort to try to eat three meals a day. Family History: Paternal grandfather died of lung cancer. Maternal grandfather also died of cancer, had emphysema. Bother grandfathers were alcoholics. Maternal and paternal grandmothers lived into their 90s. His parents are both alive at 73 and in good health except for his father has some eye problems. [**Name (NI) **] family history of liver disease or autoimmune disease. Physical Exam: Vitals: 98.4 100/72 104 16 95% RA. General: Alert, oriented, no acute distress, but ill appearing. HEENT: Icteric sclera, dMM, oropharynx clear. Neck: supple, no LAD Lungs: Clear to auscultation bilaterally CV: Regular rate, normal S1 + S2, hyperdynamic Abdomen: soft, distended, + fluid wave, NT, bowel sounds present, no rebound tenderness or guarding, hard liver, no splenomegaly Ext: Warm, well perfused, atrophic, 2+ pulses, no edema MSK: Bruising on his back, spider angiomas. Neuro: MOYb intact, no asterixis, some tremor, no piloerection. Pertinent Results: [**Known lastname **],[**Known firstname **] [**Medical Record Number 104241**] M 50 [**2097-3-5**] Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2147-10-24**] 8:08 PM [**Last Name (LF) **],[**First Name3 (LF) **] EU [**2147-10-24**] 8:08 PM LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL Clip # [**Clip Number (Radiology) 104242**] Reason: eval for portal venous thrombosis [**Hospital 93**] MEDICAL CONDITION: 50 year old man with liver failure REASON FOR THIS EXAMINATION: eval for portal venous thrombosis Wet Read: NATg TUE [**2147-10-24**] 9:50 PM Echogenic liver with GB wall thickening stones/polyps. Normal CBD, GB wall thickening likely related to hepatitis . Normal arterial, portal and hepatic venous waveforms throughout with recanalization of the umbilical artery. Ascites. Final Report CLINICAL INFORMATION: 50-year-old male with liver failure. TECHNIQUE AND FINDINGS: Grayscale and color Doppler son[**Name (NI) 493**] images were obtained of the right upper quadrant, demonstrating an echogenic liver. There is gallbladder wall thickening, but the gallbladder does not appear distended. Small, subcentimeter, gallbladder polyps are again seen without significant change. Two small, subcentimeter rouneded structures in the gallbadder, similar in appearance to polyps, but demonstrating shadowing, may be due to stones. The common bile duct is normal in caliber. There is no definite intrahepatic biliary ductal dilatation. There is normal hepatopetal portal venous flow and arterial flow. The hepatic veins are patent and demonstrate normal direction of flow. There is recanalization seen of the umbilical vein. Ascites is present. The spleen is enlarged, measuring 14.6 cm in length. The pancreas is not well seen due to overlying bowel gas. IMPRESSION: 1. Echogenic liver consistent with fatty infiltration. Other forms of liver disease including fibrosis/cirrhosis cannot be excluded on this study. 2. Gallbladder wall thickening, polyps, and possible stones, though the common bile duct is normal in caliber and the gallbladder is not distended, with a convex contour seen anteriorly. These findings are more likely related to hepatitis and not acute cholecystitis. 2. Patent hepatic vasculature. 3. Ascites, recanalization of the umbilical vein, and splenomegaly suggest portal hypertension. [**2147-10-26**] 02:36PM BLOOD Glucose-116* Lactate-4.8* Na-126* K-3.6 Cl-102 [**2147-10-24**] 07:50PM BLOOD ALT-57* AST-326* LD(LDH)-237 CK(CPK)-49 AlkPhos-165* TotBili-29.8* DirBili-19.8* IndBili-10.0 [**2147-11-4**] 02:35AM BLOOD TotBili-31.0* [**2147-11-4**] 02:35AM BLOOD WBC-21.2* RBC-2.45* Hgb-10.1* Hct-29.0* MCV-119* MCH-41.1* MCHC-34.7 RDW-21.9* Plt Ct-102* [**2147-10-26**] 2:37 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2147-10-29**]** Blood Culture, Routine (Final [**2147-10-29**]): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Anaerobic Bottle Gram Stain (Final [**2147-10-27**]): REPORTED BY PHONE TO DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] PAGER# [**Serial Number 104243**] @ 0627 ON [**2147-10-27**]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final [**2147-10-27**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Brief Hospital Course: 50 yo M with EtOH abuse, liver disfunction and hx of fatty liver (and now cirrhosis) presented to the ED after several days of n/v, lightheadedness and syncopal episodes with massive hyperbilirubinemia and synthetic dysfunction. . # Alcoholic hepatitis: On admission, MELD of 28, discriminant fx of 70. Pt did not have any evidence of infection on admission (ascitic fluid negative for SBP) and portal vein blood flow appeared normal. On the floor the pt was started on pentoxyfilline. On [**10-25**] the pt had an IR-guided paracentesis that he tolerated well and 580cc was removed. # ICU Course, MSSA Bacteremia, Hypoxia, Liver failure: On [**10-26**] the pt was noted to be acutely confused, with HR in 140's, RR 40's, temp 98.1. Pt acknowledged that he had last had a drink on [**10-22**] or [**10-23**]. Pt was given ativan IV and transferred to the ICU for further rx of presumed alcohol withdrawal. On [**2147-10-27**] pt was intubated due to high requirement for benzodiazepines and worsening evidence of sepsis. The pt was noted to have positive blood cultures and was started on Vanc/Zosyn and TTE did not show evidence of vegetation. Pt was also started on pressors. On [**10-27**] radiology was unable to perform US guided paracentesisi d/t too little fluid. On [**10-28**] the pt was started on tubee feeds and blood cultures grew MSSA and the pt was started on Nafcillin 2g q4. CT abdomen that day also showed enterocolitis. On [**10-29**] it was felt that pt had an ileus, so TF were stopped. On [**11-1**] TEE was negative for endocarditis. On [**11-2**] bronchoscopy was performed given worsening secretions from NG tube. No obvius pneumonia identified - started vancomycin. Due to continueing volume overload, and minimal urine output with 20mg/hr lasix drip, Metolazone was added. On [**11-3**] a family meeting was held to discuss the pt's very poor prognosis. The family did not want to "pull the plug," as other members of their family have gone on to lead productive lives after doctors have told [**Name5 (PTitle) **] that they would soon die. Overnight [**Date range (1) 101286**] the pt required increasing amounts of pressors due to plummeting blood pressures. The pt also became more difficult to oxygenate. On [**11-4**] a family meeting was held again and the decision was made to not escalate care. On [**11-5**] the patient's family asked to change goals of care to be more comfort-oriented. The patient was continued on sedation and the patient soon expired. Medications on Admission: ALLOPURINOL - 100 mg daily INDOMETHACIN - 50 mg three times a day as needed for gout flares Discharge Disposition: Expired Discharge Diagnosis: Expired. Discharge Condition: Expired. Discharge Instructions: Expired. Followup Instructions: Expired.

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icd9cm

[ [ [] ] ]

[ "33.24", "38.93", "54.91", "99.15", "96.72", "96.04", "94.62" ]

icd9pcs

[ [ [] ] ]

12359, 12368

9717, 12216

327, 432

12420, 12430

5467, 5886

12487, 12498

4520, 4883

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2545, 2729

266, 289

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2829, 4504

6,345

199,217

29244+57630

Discharge summary

report+addendum

Admission Date: [**2190-2-15**] Discharge Date: [**2190-2-18**] Service: VSU CHIEF COMPLAINT: Carotid artery stenosis of the right carotid artery with restenosis. HISTORY OF PRESENT ILLNESS: This is a patient who known carotid artery disease who has undergone bilateral carotid endarterectomies who presents with restenosis of the right internal carotid artery by MRA. The patient was referred to Dr. [**Last Name (STitle) 1391**] and is now admitted for elective redo right carotid endarterectomy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Medications are aspirin 81 mg daily, atenolol 50 mg daily, Lipitor 40 mg daily, multivitamin tablets, Avandia 2 mg daily, Coumadin 2.5 mg daily (this was discontinued 1 week prior to elective surgical date), Tricor 145 mg at bedtime. PAST MEDICAL HISTORY: Illnesses include carotid artery disease status; post bilateral carotid endarterectomies; left subclavian stenosis by MRA; right subclavian stenosis by MRA; left subclavian steal; history of GI bleed, transfused, remote; history of ischemic heart disease; status post myocardial infarction in [**2169**] with stable angina; history of osteoporosis; history of type 2 diabetes with retinopathy and nephropathy; history of renal artery stenosis; status post right renal artery stenting with a nonfunctioning left kidney and chronic renal insufficiency; history of urinary tract infection, treated in [**2189-5-9**]; history of breast carcinoma; status post mastectomy in [**2158**]; history of glaucoma; history of hyperlipidemia, on a statin; history of tobacco use, discontinued in [**2169**]; postoperative hypotension requiring vasopressor support secondary to nitrate use; status post hysterectomy, remote. PHYSICAL EXAMINATION: Systolic blood pressure on the left arm is 121/73, pulse is 69, O2 saturation 95% on room air. General appearance reveals a very pleasant, forgetful, female who is accompanied by son and grandson. [**Name (NI) 4459**] exam is unremarkable except for brisk carotid bruits bilaterally with well-healed endarterectomy skin incisions. Lungs are rales posteriorly at the bases 1/4 up. Heart is a regular rhythm with a 4/6 systolic ejection murmur at the right upper sternal border. Abdominal exam is unremarkable, without bruits. Extremities are without edema. Skin is warm and dry. Neurological exam is remarkable for left eye ptosis. HOSPITAL COURSE: The patient was admitted to the preoperative holding area on [**2190-2-15**]. She underwent a right carotid endarterectomy with Dacron patch. She was transferred to the PACU in stable condition, neurologically intact. The patient required a Neo-Synephrine drip for hypotension. The patient could not be weaned from the Neo- Synephrine IV fluid boluses as blood pressure was refractory to IV fluid resuscitation. The patient was transferred to the SICU for continued vasopressor support. Hypotension was associated with garbled speech, which did resolve. The patient remained in the unit until [**2190-2-17**]; when her Imdur was discontinued, and she was able to be weaned off her Neo-Synephrine. After reviewing the medication list, since there were 2 conflicting medication lists, it was noted that the patient was no longer on Imdur. The patient continued to do well. DISCHARGE STATUS: She was discharged to home neurologically intact and stable on [**2190-2-18**]. DISCHARGE DIAGNOSES: Restenosis of the right carotid artery; history of carotid artery disease; status post bilateral carotid endarterectomies; history of subclavian steal; history of right subclavian stenosis by MR; history of gastrointestinal bleed, transfused, remote; history of ischemic heart disease with myocardial infarction in [**2169**] with stable angina; history of osteoporosis; history of type 2 diabetes with retinopathy and nephropathy; history of renal artery stenosis with right renal artery stenting with a nonfunctional left kidney and chronic renal insufficiency; history of urinary tract infection, treated in [**2189-5-9**]; history of breast carcinoma; status post mastectomy in [**2158**]; history of glaucoma; history of hyperlipidemia, on statin; history of tobacco use, discontinued in [**2169**]; postoperative hypotension requiring vasopressor support secondary to nitrate use. DISCHARGE FOLLOWUP: The patient should follow up with Dr. [**Last Name (STitle) 1391**] as directed. MAJOR SURGICAL PROCEDURES: A right carotid endarterectomy with Dacron patch angioplasty. MEDICATIONS ON DISCHARGE: Include aspirin 81 mg daily, rosiglitazone 2 mg daily, atorvastatin 40 mg daily, fenofibrate micronize 145-mg tablets 1 daily, Protonix 40 mg daily. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2190-2-18**] 09:37:12 T: [**2190-2-18**] 10:41:19 Job#: [**Job Number 70306**] Name: [**Known lastname 11919**],[**Known firstname 1049**] M Unit No: [**Numeric Identifier 11920**] Admission Date: [**2190-2-15**] Discharge Date: [**2190-2-19**] Date of Birth: [**2103-1-20**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 231**] Addendum: [**2190-2-19**] d/c to rehab stable. Discharge Disposition: Extended Care Facility: NORTHEAST REHABLITATION [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2190-2-19**]

[ "362.01", "733.00", "583.81", "458.29", "403.90", "433.10", "585.9", "272.4", "250.40", "250.50" ]

icd9cm

[ [ [] ] ]

[ "38.12", "00.40" ]

icd9pcs

[ [ [] ] ]

5397, 5604

3416, 4304

4525, 5374

580, 815

2422, 3394

1772, 2404

107, 177

4325, 4498

206, 553

838, 1749

73,479

139,984

28907

Discharge summary

report

Admission Date: [**2136-5-29**] Discharge Date: [**2136-5-31**] Date of Birth: [**2072-6-1**] Sex: M Service: MEDICINE Allergies: Bactrim / Augmentin Attending:[**First Name3 (LF) 2641**] Chief Complaint: Leg weakness, increased somnolence Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [**Known lastname 69742**] is a 63 year-old with h/o CAD, CVA, OSA, asthma, and dementia BIBA from home with worsening dyspnea, dizziness, and confusion. Patient was at home today when he had a near-fall [**1-5**] bilateral leg weakness. He feet like he was "wobbling on his feet." Patient was walking out of the bathroom and he felt like his legs were very weak and he felt dizzy. He fell onto the bed and couldn't support his weight. As per his wife, he looked pale, was having difficulty breathing, and his speech seemed garbled and he looked "out of it." His wife checked his FS, which was 115. He has had similar episodes in the past, but no recent episodes over the past six months. He was admitted in [**12/2135**] and [**1-/2136**] with similar presentations where his altered mental status improved without intervention and etiology was not identified. In the ED, initial VS were: 96.7 50 117/51 18 98% 4L. Patient had normal head CT. He had CXR that was concerning to ED for pneumonia (although read by radiology as no pneumonia). He received 0.2 of narcan since he takes tramadol at home. His mental status did not improve with this. Patient received levofloxacin for pneumonia. He had ABG given confusion, which was 7.3/58/100. He was started on BiPAP given the primary respiratory acidosis and pneumoia and was admitted to the MICU because of the BiPAP. Of note, he had a repeat ABG prior to transfer that was unchanged. On arrival to the MICU, patient feels better. His weakness and altered mental status have resolved. Patient does not recall the episode, but knows only what his wife told him. He denies weakness, confusion, difficulty speaking or swallowing, changes in vision, numbness, tingling. He denies cough, dyspnea, fevers, or chills. He feels back to baseline. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -CAD -DM -HLD -HTN -prior strokes (right lentiform and corona radiata strokes) -OSA -prostate CA s/p radical prostatectomy -GERD -asthma -major depressive disorder/PTSD with transient SI -s/p L knee arthroscopic surgery to repair torn meniscus -follwed by Dr. [**Last Name (STitle) 8012**] in Cog Behavior clinic for short term memory disturbance. Unclear dx -anterior ischemic optic neuropathy -s/p prostar suture (medicated closure device) to right groin in femoral artery. - PTSD Social History: Mr. [**Known lastname 69742**] is married with 4 children and lives with his wife in [**Name (NI) 10059**] (two children nearby, two in [**State 12000**]). He is a retired world reknowned oral pathologist and did extensive forensic dentistry work for the CIA, FBI, and military. He was also Professor and Chairman at the School of Dental Medicine at [**Hospital1 69743**] until [**2128**]. He is world renowned in his field. He is a nonsmoker and denies any alcohol or drug use. Family History: Notable for fatal sudden MI in his mother at age 43. Father died at age 51 of metastatic lung cancer. Paternal grandfather had malignant HTN and died of a CVA at age 62. Maternal GM with angina in her 40s. Also has 3 primary family members with [**Name (NI) 2481**] disease (pt had genetic testing for this that was negative). Physical Exam: ADMISSION EXAM General: Alert, oriented, conversant, speaking very slowly, but speaks clearly, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Slightly bradycardiac, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: obese, soft, non-tender, non-distended, bowel sounds present GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, pt with b/l ankle braces and a left knee brace Neuro: CNII-XII intact, 5/5 strength upper extremity, [**4-7**] strenght in RLE, 4/5 strength in LLE quad, hamstring, gastroc, grossly normal sensation, toes downgoing b/l, gait deferred, finger-to-nose intact (but slow) DISCHARGE EXAM General: Alert, oriented, appropriate. No signs of sedation or abnormal speech HEENT: ncat, mmm, eomi, sclera anicteric, conjunctiva pink Neck: supple, no clad, no thyromegaly CV: normal s1 and s2, rrr, no m/g/r, PMI non-displaced Resp: good aeration, CTAB, no w/r/r Abd: obese, soft, normoactive bs, nd/nt/no r/g GU: no foley Ext: wwp, 2+ peripheral pulses, no e/c/c Neuro: CN II-XII grossly intact, 5/5 strength, [**1-7**] reflexes, normal sensation, no focal deficits Skin: no lesions or rashes Pertinent Results: ADMITTING LABS: [**2136-5-29**] 11:30AM BLOOD WBC-8.3 RBC-4.90 Hgb-14.0 Hct-42.4 MCV-87 MCH-28.6 MCHC-33.1 RDW-15.0 Plt Ct-174 [**2136-5-29**] 11:30AM BLOOD Neuts-66.0 Lymphs-25.2 Monos-4.5 Eos-3.6 Baso-0.7 [**2136-5-29**] 11:30AM BLOOD PT-10.5 PTT-34.2 INR(PT)-1.0 [**2136-5-29**] 11:30AM BLOOD Glucose-118* UreaN-31* Creat-1.5* Na-141 K-4.4 Cl-106 HCO3-28 AnGap-11 [**2136-5-29**] 11:30AM BLOOD ALT-19 AST-15 AlkPhos-70 TotBili-0.3 [**2136-5-29**] 11:30AM BLOOD Albumin-4.1 Calcium-9.9 Phos-3.8 Mg-2.2 [**2136-5-29**] 11:52AM BLOOD Lactate-1.2 DISCHARGE LABS: CBC: 6.6, 15.3/46.9, 206 BMP: 143 104 17 104 4.2 31 1.1 PERTINENT MICRO/PATH: [**2135-1-17**] 4:35 pm URINE Site: CLEAN CATCH **FINAL REPORT [**2135-1-18**]** URINE CULTURE (Final [**2135-1-18**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. PERTINENT IMAGING: CT Head ([**2136-5-29**]): FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or large territorial infarction. The ventricles and sulci are mildly prominent, compatible with age-related volume loss. The basal cisterns appear patent and there is preservation of [**Doctor Last Name 352**]-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, middle ear cavities are clear. The bilateral ocular lenses have been replaced. IMPRESSION: No intracranial hemorrhage or mass effect. CXR ([**2136-5-29**]) - FINDINGS: Single supine AP view of the chest is compared to previous exam from [**2136-3-5**] and [**2136-1-6**]. Low lung volumes are seen. This is likely accounting for apparent pulmonary bronchovascular congestion and increased interstitial markings. Cardiomediastinal silhouette is unchanged. Osseous and soft tissue structures are unremarkable. IMPRESSION: No definite acute cardiopulmonary process based on the portable supine chest x-ray. Brief Hospital Course: 63 year-old man with history of CAD, OSA, asthma, and dementia presenting with somnolence, weakness, found to have respiratory acidosis, transferred to ICU for BiPAP, then called out to the floo on NC. # Acute on Chronic Respiratory Acidosis: Etiology unclear. Acidosis had resolved and patient was off BiPAP by the time he arrived in the MICU. Patient with history of asthma, but no evidence of asthma exacerbation as patient has no wheezing, no dyspnea. # Confusion: Unclear etiology, but quickly resolved. Possibly [**1-5**] hypercabia, but it was also possible that somnolence caused the hypercarbia. Also possibly secondary to medication side effect as patient has some sedating medications (klonipin, tramadol). Of note, patient has had similar episodes in the past without a clear etiology determined. All sedating medications were held upon admission, and they were gradually added on, first at lower doses. By discharge, pt was able to take all of his home medications for pain/sleep but we sent him home on half dose of klonipin. He was also urged to follow up with neurology to investigate a possible cause for his confusion and weakness (see below). # Leg weakness: Again, etiology unclear, but spontaneously resolved. Neurologic exam consistent with prior baseline (strenth documented in previous neurology note is consistent with my examination today). The patient was visited by PT and ordered for home PT services to help improve his strength and coordination. # CKD: Patient with creatinine of 1.5, baseline fluctuates but has ranged 1.1 - 1.9 during recent admissions. # H/O CVA: Continued clopidogrel 75 mg daily. # Hypertension: Normotensive on arrival. Continued lisinopril, amlodipine, prazosin, imdur. Held atenolol given bradycardia on arrival. Also, held lasix - restarted day before discharge per patient's request and continued to be normotensive. # Asthma: Continued fluticasone-salmeterol and albuterol nebs. # Diabetes Mellitus: Continued home insulin regimen. # Dementia: Continued home memantine. # Hypothyroidism: Continued home levothyroxine. # Hyperlipidemia: Continued home rosuvastatin. # RLS: Continued home pramipexole. # Depression/Anxiety/PTSD: Pristiq initially held on arrival given non-formulary. Klonopin dose was decreased on arrival given altered mental status. # Allergic rhinitis: Continued home fluticasone nasal spray. # Pain: Continued home tramadol. Medications on Admission: lisinopril 10 mg daily furosemide 20 mg daily levothyroxine 25 mcg daily prazosin 2 mg qHS rosuvastatin 20 mg daily fluticasone-salmeterol 500-50 mcg 1 puff [**Hospital1 **] clopidogrel 75 mg daily atenolol 100 mg daily amlodipine 10 mg daily pramipexole 0.375 mg qHS memantine 10 mg [**Hospital1 **] imdur 120 mg daily nitroglycerin 0.4 mg SL PRN Pristiq 150 mg daily tramadol 100 mg daily insulin aspart 10 units at lunch insulin glargine 50 units qHS diclofenac sodium 1 % Gel apply to knees as needed for pain Seroquel 50 mg qHS fluticasone 50 mcg daily clonazepam 1 mg TID Lyrica Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. Clonazepam 0.5 mg PO TID 4. Clopidogrel 75 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] 6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 7. Furosemide 20 mg PO DAILY 8. Glargine 50 Units Bedtime aspart 10 Units Lunch 9. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY 10. Levothyroxine Sodium 25 mcg PO DAILY 11. Lisinopril 10 mg PO DAILY 12. MEMAntine *NF* 10 mg Oral [**Hospital1 **] Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 13. pramipexole *NF* 0.375 mg Oral qHS Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 14. Prazosin 2 mg PO QHS 15. Pregabalin 200 mg PO DAILY 16. Pristiq *NF* (desvenlafaxine) 150 Oral daily Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 17. TraMADOL (Ultram) 50 mg PO BID:PRN pain 18. Rosuvastatin Calcium 20 mg PO DAILY 19. Quetiapine Fumarate 50 mg PO HS 20. Insulin Aspart 22units at breakfast Aspart 12units at lunch Aspart 30units at dinner Glargine 50units at bedtime Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: PRIMARY: weakness confusion hypoglycemia respiratory acidosis SECONDARY: dementia falls 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 because of an episode of weakness. Due to your fall at home last week, you have been minimally active, so this episode might have been related to muscle weakening. In addition, your wife was concerned that you were confused; this might have been related to some of the medications you were on. We adjusted some of your medications and observed you; your confusion has resolved. Note that when you first came to the ED you were noted to have some slowed breathing and abnormal blood gas values so you were admitted to the medical ICU. This resolved with non-invasive ventilation and some diuresis (using medications to dry out the lungs). In addition, the lower dose of sedating medications can cause this kind of breathing abnormality. In addition, here you had some hypoglycemic episodes without symptoms, which is dangerous. Please change your insulin regimen to the one outlined below. Check your fingerstick in the AM and also with meals; if you have values >200 or <80 please contact your PCP. Please continue to follow up with your Primary Care doctor, especially with regards to your sleep apnea, as you might benefit from an outpatient sleep study and a positive-airway-pressure mask. You were evaluated by Physical Therapy who felt that you were safe to be discharged home with services. We made the following changes to your medications: -DECREASE Clonazepam dose -DECREASE Tramadol dose -CHANGE Insulin regimen to: Aspart 22units at breakfast Aspart 12units at lunch Aspart 30units at dinner Glargine 50units at bedtime Followup Instructions: Department: COGNITIVE NEUROLOGY UNIT When: MONDAY [**2136-6-4**] at 12:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Location: [**Location (un) 2274**] Primary Care Address: [**University/College 2899**], [**Location (un) **],[**Numeric Identifier 2900**] Phone: [**Telephone/Fax (1) 2115**] Appt: Monday, [**6-4**] at 2:20pm ***This appontment will take the place of tomorrows appt. The appt previously scheduled appt for [**Last Name (LF) 2974**], [**6-1**] has been cancelled. Completed by:[**2136-6-2**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11721, 11796

7283, 9709

314, 321

11929, 11929

5275, 5823

13696, 14520

3629, 3957

10344, 11698

11817, 11908

9735, 10321

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318

Discharge summary

report

Admission Date: [**2136-1-25**] Discharge Date: [**2136-2-3**] Service: MEDICINE Allergies: Nitroglycerin Attending:[**First Name3 (LF) 30**] Chief Complaint: palpitations, chest pain, abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **]y/o Russian speaking F with CAD, severe AS, HTN, and atrial fibrillation presenting with chest pain, SOB, palpatations, and abdominal pain. She was in her USOH until the past week per the daughter and this includes intermittant chest pain and palpatations. Over the past week, however, she has complained of dull transient upper abdominal pain especially with food and more frequent episodes of chest pain and palpatations. Her chest pain can occur either with exertion (walks at home with a cane or walker) or at rest. She denies any recent fevers, chills, sick contacts, N/V, diarrhea, weakness, paresthesias, visual/auditory changes, dysuria, rash, or mental status changes. She has mild orthopnea and DOE, both of which are baseline, but has been mildly more SOB this week. . In the ED she was found to be in Afib w/ RVR up to the 130s and received 10mg IV diltiazem x 3 and given 30mg PO diltiazem. A RUQ ultrasound revealed dilated biliary and pancreatic ducts and her pain was controlled with IV morphine 0.5mg x 2. ERCP was contact[**Name (NI) **] and plan to take the patient for an exam in the AM. . On the floor, the patient remained tachycardic and she remained tachypneic. The MICU was called to evaluate the patient for possible admission given her high nursing needs. On evaluation, the patient "felt better" and denied any chest pain. Her abdominal pain was mild and she denied nausea. Past Medical History: 1. ? Coronary Artery Disease (no cath on record) 2. Aortic stenosis (AV 0.7cm2 in [**3-1**]) 3. Atrial fibrillation 4. Sinus node dysfunction s/p pacer 5. Hypertension 6. Dyslipidemia 7. Asthma 8. Chronic dizziness/Headache NOS 9. Hypothyroidism 10. Hyponatremia 11. Anemia 12. Cholelithiasis 13. Glaucoma . Social History: Russian speaking only. She has 2 daughters in their 60s and grandchildren. Lives with her daughter [**Name (NI) 2951**]. She finished college and is widowed. She is a nonsmoker, nondrinker and denies ilicit drug use. Family History: non-contributory Physical Exam: vitals: 96.3 BP 168/86 HR 107 RR 40 95%4L General: Frail, ill appearing in resp distress HEENT: Dry MM CV: Irreg, tachy Nml S1, S2, 2/6 SEM at LUSB Lungs: expiratory wheezing on upper lung fields, no crackles Abdomen: Soft, mildly distended, diffuse tenderness to palpation, mild guarding or rebound, diminished BS Ext: no peripheral edema Neuro: A&O x3 per daughter, no focal deficits, follows commands appropriately Pertinent Results: [**2136-1-25**] 12:00PM WBC-7.7 RBC-3.91* HGB-11.3* HCT-33.3* MCV-85 MCH-28.8 MCHC-33.8 RDW-13.9 [**2136-1-25**] 12:00PM NEUTS-72.2* LYMPHS-21.4 MONOS-3.9 EOS-2.1 BASOS-0.4 [**2136-1-25**] 12:00PM PLT COUNT-288 [**2136-1-25**] 12:00PM PT-11.5 PTT-26.7 INR(PT)-1.0 [**2136-1-25**] 12:00PM GLUCOSE-99 UREA N-18 CREAT-1.2* SODIUM-130* POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-23 ANION GAP-14 [**2136-1-25**] 12:00PM ALT(SGPT)-17 AST(SGOT)-27 LD(LDH)-181 CK(CPK)-63 ALK PHOS-137* AMYLASE-53 TOT BILI-0.3 [**2136-1-25**] 12:00PM LIPASE-18 [**2136-1-25**] 12:00PM cTropnT-0.04* [**2136-1-25**] 06:40PM CK(CPK)-63 [**2136-1-25**] 06:40PM cTropnT-0.05* [**2136-1-25**] 06:40PM CK-MB-NotDone [**2136-1-31**] Chest Xray - The heart size is moderately enlarged but stable. The ascending aorta is very tortuous, unchanged. There is no significant change in perihilar interstitial opacities suggesting mild pulmonary edema associated by bilateral pleural effusions, small to moderate. . [**2136-1-25**] U/S liver: Dilated intra- and extra-hepatic biliary ducts, common bile duct, and pancreatic duct. Tiny hyperechoic focus in the distal common bile duct, suggesting obstructing stone versus extrinsic compression. Single enlarged lymph node in the porta hepatis. Single non-mobile, non-obstructing gallbladder stone. No evidence of acute cholecystitis. Brief Hospital Course: Mrs. [**Known lastname 2952**] is a [**Age over 90 **] yo F with PMH of CAD, HTN, Afib, s/p pacemaker, severe AS who presents with abdominal pain, rapid Afib, and chest pain. . 1)Atrial fibrillation with RVR: She has history of atrial fibrillation, not previously treated with anticoagulation, controlled prior with amiodarone and amlodipine. She presented in rapid atrial fibrillation with associated tachypnea requiring transfer to the MICU. She was seen by the cardiology consult team and she was treated with diltiazem and continued on amiodarone. In addition, she was started on coumadin, with a heparin bridge, per cardiology recommendations. She was not cardioverted during this admission, but will follow up in one month as an outpatient to further address whether cardioversion is indicated. She did well and was converted to long acting diltiazem prior to discharge and continued on outpatient regimen of amiodarone 100mg every other day. She will follow up with Dr. [**Last Name (STitle) 1911**] as an outpatient. . 2)Chest pain/CAD: she has h/o stable angina at home, on aspirin/statin/acei/ntg. Episode of increased chest pain w/ palpatations likely represents demand myocardial ischemia in the setting of RVR, cardiac enzymes and slight troponin leak also consistent with this. Her rate was controlled and her chest pain resolved. She was continued on statin and aspirin. . 3)Abdominal Pain: Initially there was concern for possible CBD stone and biliary obstruction based on patients symptoms and ultrasound. She was evaluated by the ERCP fellow, however no intervention was undertaken given patients acute cardiac issues. Her abdominal pain resolved and she had no LFT abnormalities or concerns for cholangitis. Given underlying medical issues, intervention was deferred given symptom resolution. She will follow up as an outpatient, as she did have gall bladder stone on ultrasound. . 3)Asthma -pt with 20-30 year h/o asthma, although no h/o smoking, living with a smoker or other exposures. She has been treated for acute infection and COPD flare since admission. She completed a course of azithromycin and ceftriaxone during her admission. She was also treated with prednisone taper of 30mgx3 days ([**Date range (1) 2953**]), 20mg x3days([**Date range (1) 2954**]), 10mg x3 ([**Date range (1) 2955**])days then stop. She was also continued on inhaled agents including fluticasone and salmeterol as well as prn atrovent nebulizers. Albuterol nebulizers were held because of her tachycardia. . 4)Aortic stenosis: severe AS (<0.8cm2) and moderate LVH on ECHO, h/o chronic dizziness but no syncopal episodes at home recently. . 5)Hypertension: normotensive currently on regimen of dilt and amio. Her lisinopril 10mg daily was held during admission because of sbp <120. . 6)Dyslipidemia: continue lipitor . 7)Chronic renal failure: approximately baseline currently, with Cr 1. . 8)Hypothyroidism: continue synthroid (TSH checked on admission, wnl) . 9)Glaucoma: continue timolol 10) FEN: nectar thick liquids, soft diet per speech and swallow evaluation. 11)Code status: No CPR; Intubation OK (confirmed with daughter [**Name (NI) 2956**] [**2136-2-1**]) 12)Communication: [**First Name9 (NamePattern2) 2957**] [**Doctor First Name 2951**]=HCP, home [**Telephone/Fax (1) 2958**] cell [**Telephone/Fax (1) 2959**]; Neice ([**Doctor First Name **]-speaks English) [**Telephone/Fax (1) 2960**] cell Medications on Admission: -amiodarone 100mg every other day -amlodipine 5mg daily -asa 81mg daily -atorvastating 20mg daily -fioricet prn -Flovent -Serovent [**Hospital1 **] -lidocaine patch -lisinopril 10mg daily -lorazepam 1mg qhs -omeprazole 20mg [**Hospital1 **] -albuterol prn -levothyroxine 50mcg daily Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Fluticasone 50 mcg/Actuation Spray, Suspension [**Hospital1 **]: Two (2) Spray Nasal DAILY (Daily). 4. Salmeterol 50 mcg/Dose Disk with Device [**Hospital1 **]: One (1) INH Inhalation Q12H (every 12 hours). 5. Levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Timolol Maleate 0.25 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 7. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 8. Lorazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime) as needed. 9. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Neb Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 10. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: as directed according to sliding scale Subcutaneous ASDIR (AS DIRECTED) for 1 weeks: while on prednisone. 11. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H (every 8 hours) as needed. 12. Olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed. 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 14. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). 15. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at bedtime). 16. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily) for 3 days: [**Date range (1) 2954**]. 17. Prednisone 10 mg Tablet [**Date range (1) **]: One (1) Tablet PO DAILY (Daily) for 3 days: [**Date range (1) 2955**]. 18. Nystatin 100,000 unit/mL Suspension [**Date range (1) **]: Five (5) ML PO QID (4 times a day). 19. Amiodarone 200 mg Tablet [**Date range (1) **]: 0.5 Tablet PO QOD (). 20. Aspirin 81 mg Tablet, Chewable [**Date range (1) **]: One (1) Tablet, Chewable PO DAILY (Daily). 21. Acetaminophen 325 mg Tablet [**Date range (1) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 22. Diltiazem HCl 180 mg Capsule, Sustained Release [**Date range (1) **]: Two (2) Capsule, Sustained Release PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: Atrial fibrillation with RVR COPD exacerbation Pneumonia-community acquired Cholelithiasis . Severe Aortic Stenosis s/p pacemaker HTN Hyperlipidemia Asthma Chronic dizziness Hypothyroidism Hyponatremia Anemia Cholelithiasis Glaucoma Discharge Condition: fair Discharge Instructions: You were admitted to the hospital because you were having belly pain, chest pain and palpitations. You were found to be in rapid atrial fibrillation, a fast irregular heart rate. You were treated with a medication called diltiazem and continued on your amiodarone. You were also started on a blood thinner, coumadin, to decrease your risk of complications from atrial fibrillation such as stroke. Your amlodipine was stopped. You will be taking diltiazem instead. You also had an ultrasound to evaluate your abdominal pain. You had a gall stone in your gallbladder and some dilation of your bile ducts. You did not require any intervention to remove the stones as your pain resolved and your blood work was normal. You should follow up with the gastroenterologists as an outpatient. You were also treated for a pneumonia and asthma flare during your admission. You completed antibiotics before discharge and were on a tapering dose of prednisone. You were discharged to rehab to increase your strength before going home. Please call your doctor or return to the emergency department if you develop any concerning symptoms including chest pain, difficulty breathing, palpitations or rapid heart rate. Followup Instructions: You will be contact[**Name (NI) **] by Dr. [**Last Name (STitle) 1911**] for an appointment to follow up in cardiology clinic for your atrial fibrillation. . You have an appointment to follow up in the gastroenterology clinic with Dr. [**Last Name (STitle) **] on [**2-28**] at 1:40. The clinic is located in the [**Hospital Unit Name **], [**Location (un) 453**]. . Please call Dr. [**Last Name (STitle) 2961**] and schedule an appointment to follow up within one to two weeks of discharge from rehab.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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259, 265

10732, 10739

2769, 4129

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41003

Discharge summary

report

Admission Date: [**2107-7-15**] Discharge Date: [**2107-7-19**] Date of Birth: [**2056-12-27**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5790**] Chief Complaint: Right mainstem bronchus mass Major Surgical or Invasive Procedure: Right pneumonectomy History of Present Illness: Ms. [**Known lastname 1005**] is a 50 year old female with a large right hilar mass. She underwent a bronchoscopy on [**2107-6-8**] with pathology revealing a squamous cell carcinoma and negative level 7 and 10R lymph nodes. She subsequently underwent a cervical mediastinoscopy on [**6-28**] with pathology negative for malignancy at levels 2R & L, 4R & L, and 7. She presented in clinic for follow up after her [**Hospital Unit Name **] and for further operative planning. Since the operation she reports doing well with minimal pain and no drainage from the wound. She is still taking percocet 1-2 times per day. She elected to undergo operative resection of this mass. Past Medical History: Squamous Cell Carcinoma of the lung Bronchitis Asthma Oral surgery in [**2107**] Social History: Tobacco history 37 years at 1.5 packs per day, he quit in 2/[**2107**]. She drinks alcohol 2-3x/month and uses cocaine occasionally. Lives with her mother. Family History: Sister with breast cancer at age 38, father with diabetes milletus Physical Exam: VS: T: 98.3 HR: 84 SR BP: 98/60 Sats: 96% RA Gen: No acute distress CV: RRR, nl S1 and S2 Resp: CTAB GI: abd soft, NT, ND Incision: R thoracotomy site clean dry intact, margins well approximated, no erythema Neuro: awake, alert oriented. walking in halls independently Pertinent Results: [**2107-7-15**] WBC-19.7*# RBC-4.19* HGB-10.8* HCT-32.9* MCV-79* MCH-25.8* MCHC-32.8 RDW-14.7 [**2107-7-15**] GLUCOSE-158* UREA N-13 CREAT-0.7 SODIUM-139 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16 [**2107-7-17**] WBC-10.5 RBC-3.58* Hgb-8.9* Hct-27.7* MCV-77* MCH-24.9* MCHC-32.1 RDW-14.5 Plt Ct-570* [**2107-7-17**] Glucose-135* UreaN-12 Creat-0.6 Na-137 K-4.5 Cl-100 HCO3-28 CXR: [**2107-7-18**]: Right hydropneumothorax shows an air-fluid level that is gradually increasing in height compared with prior examinations after accounting for difference in techniques. Subcutaneous emphysema unchanged from prior exam. The mediastinum is displaced to the right status post pneumonectomy. Lung in the left side is clear with no signs of pleural effusion or pneumothorax. Brief Hospital Course: Ms. [**Known lastname 1005**] presented for pneumonectomy to remove the mass in her right hilar region. Neuro: She was transferred directly to ICU from the OR. An epidural was placed for pain control. She was given Ativan for sleep. She was extubated on POD 0. CV: She tolerated the procedure well and was hemodynamically stable throughout. On POD 2 she was noted to be mildly tachycardic and so she was started on metoprolol 25mg TID, which was effective. She was discharged on toprol 50 mg daily Pulm: A chest tube was placed and was placed immediately on water seal. She was transferred to the unit intubated but was extubated soon after arriving on POD 0 and by POD 1 was on 2lNC with good oxygen saturation. Her chest tube was pulled on POD 1 after having minimal output. She was weaned to room air without difficulty and maintained good oxygen saturation throughout. Her chest x-rays showed minimal mediastinal shift and progressive filing of her right chest cavity. GI: She was transitioned from clears to fulls to regualr diet by POD 3 and tolerated POs well. GU: A foley was placed in the OR and was kept in until the epidural was taken out on POD 2. She voided after foley was removed. Heme: She had minimal blood loss in the OR and had a stable Hct. ID: She was afebrile and had an initial leukocytosis thought to be from the operation that normalized. FEN: She was quickly transitioned to POs. Pain: her pain was well controlled with oxycodone and acetaminophen. Dispo: She was seen by physical therapy who recommended home. She will follow-up with Dr. [**Last Name (STitle) 5795**] as an outpatient. Medications on Admission: Ativan Percocet Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*70 Tablet(s)* Refills:*0* 3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain: take with food and water. Disp:*90 Tablet(s)* Refills:*0* 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Large right hilar mass, Stage IIB lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or chest pain -Incision develops drainage Daily weights: -Keep a log. Call with 3-4 pound weight gain -Monitor fluid intake. Pain: -Acetaminophen 650 every 6 hours as needed for pain -Oxycodone 5-10 mg every 4-6 hours as needed for pain -Ibuprofen 600 mg every 8 hours as needed for pain. Take with food and water -No driving while taking narcotics -Take stool softners with narcotics Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed -No lifting greater than 10 pounds until seen -Walk 4-5 times a day for 5-10 minutes increase to a Goal of 30 minutes daily Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**] on [**2107-8-2**] at 2:00PM Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your appointment Completed by:[**2107-7-19**]

[ "338.18", "493.90", "V15.82", "162.2" ]

icd9cm

[ [ [] ] ]

[ "33.24", "40.3", "32.59", "03.90" ]

icd9pcs

[ [ [] ] ]

4951, 4957

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340, 362

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390, 1071

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1191, 1348

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182,202

24546

Discharge summary

report

Admission Date: [**2180-6-21**] Discharge Date: [**2180-6-24**] Date of Birth: [**2154-8-4**] Sex: F Service: UROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 11304**] Chief Complaint: Abdominal pain/further management of ureteral stone Major Surgical or Invasive Procedure: - Extubation done by ICU team (previously intubated by Anesthesia in OR [**6-22**]) History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE Date: [**2180-6-21**] Time: 02:10 The patient is a 25F with a h/o asthma who p/w right sided abdominal/flank pain that has been persistant since last night. She describes the pain as constant and not worsened with urination, but worse with movement. She also reports nausea with three episodes of vomitting. She denies f/c, dysuria, diaphoresis, cp, sob. She initially presented to [**Hospital3 **] where she had a CT scan, which was positive for a 6 mm proximal ureteral stone. Her pain was not controlled despite multiple doses of IV Dilaudid. She also had nausea with vomitting, which was treated with IV Zofran. She also received IV benadryl for anxiety. She was transferred here to [**Hospital1 18**] for further pain control, possible urological intervention and since her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2472**], is here. She endorses diarrhea on Sunday and Monday and a 60 lb weight loss in the past ~three months, which she attributes to stress from studying for the MA bar exam. In ER: VS: 98.8 106 140/90 18 100% RA OSH Studies: WBC: 17.1 87% neutrophils, no bands, HCT: 42.0, PLT: 357 137 | 102 | 10 --------------- 3.6 | 19 | 1.4 ua: 2+ LE, 10 WBC, B-HCG: neg Fluids given: 1L NS Meds given: toradol 30 mg, hydromorphone 2mg IV (received 4 of dilaudid at OSH), tamsulosin 0.4 mg, ondansetron 2mg Consults called: Urology: Conservative management admit for pain control Review of Systems: (+) Per HPI (-) Denies night sweats, recent weight gain. Denies visual changes, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. Denies chest pain, palpitations, orthopnea, dyspnea on exertion. Denies shortness of breath, cough or wheezes. Denies heartburn, constipation, BRBPR, melena. Denies arthralgias or myalgias. Denies rashes. No increasing lower extremity swelling. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: PMH: asthma, migraines, idiopathic intracranial hypertension, h/o HSP, anxiety, ADHD PSH: right forearm ORIF, chole Social History: SH: nonsmoker, non-drinker, no drug use; Completed law school and is currently studying for her MA bar exam. Family History: Not relevant to presentation of ureteral stone. Physical Exam: VS: 98.0 177/87 77 20 97%RA; [**6-11**] RLQ/R flank pain GEN: No apparent distress HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: Clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, tender to palpation in RLQ, no R flank pain; non-distended; no guarding/rebound; obese EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: Alert and oriented to person, place and situation; CN II-XII intact, [**4-6**] motor function globally DERM: no lesions appreciated ICU Discharge PE: VS: T 100.1 HR 80 BP 132/48 O2Sat 97% 2L NC General: Patient is laying in bed in pain (right sided radiating to back) on 2L nasal cannula, breathing comfortably HEENT: Sclera anicteric LUNGS: Clear to auscultation bilaterally with no added sounds CVS: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs or gallops GI: Obese, soft, tender to palpation on right side with bowel sounds present; no rebound tenderness or guarding, no organomegaly GU: Foley in place EXT: Warm, well-perfused with no clubbing, cyanosis or edema; 2+ pulses NEURO: Alert and oriented to person, place and situation; gross neurological exam normal DERM: No lesions appreicated Pertinent Results: OSH Labs, prior to admission: WBC: 17.1 87% neutrophils, no bands HCT: 42.0 PLT: 357 137 | 102 | 10 --------------- 3.6 | 19 | 1.4 glucose: 146 u/a: bland Relevant Labs: [**2180-6-21**] 12:39AM GLUCOSE-104* UREA N-7 CREAT-1.6* SODIUM-138 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17 [**2180-6-21**] 12:39AM ALT(SGPT)-38 AST(SGOT)-23 ALK PHOS-69 TOT BILI-0.8 [**2180-6-21**] 12:39AM LIPASE-11 [**2180-6-21**] 12:39AM ALBUMIN-4.2 CALCIUM-9.0 [**2180-6-21**] 12:39AM WBC-13.7*# RBC-4.45 HGB-13.5 HCT-37.4 MCV-84 MCH-30.4 MCHC-36.1* RDW-14.4 [**2180-6-21**] 12:39AM PLT COUNT-301 [**2180-6-22**] 03:27PM BLOOD WBC-8.0 RBC-3.64* Hgb-10.8* Hct-30.9* MCV-85 MCH-29.7 MCHC-35.0 RDW-13.5 Plt Ct-181 [**2180-6-21**] 05:05AM BLOOD Neuts-89.3* Lymphs-6.5* Monos-3.3 Eos-0.7 Baso-0.3 [**2180-6-22**] 03:27PM BLOOD Glucose-103* UreaN-9 Creat-1.5* Na-138 K-3.4 Cl-107 HCO3-22 AnGap-12 [**2180-6-22**] 03:27PM BLOOD Calcium-7.8* Phos-1.9* Mg-1.5* [**2180-6-22**] 01:00AM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-TR [**2180-6-22**] 01:00AM URINE RBC-3* WBC-18* Bacteri-FEW Yeast-NONE Epi-24 Micro: [**6-21**]: Blood cultures --> Gram stain showed gram negative rods, preliminary culture showed Proteus Imaging: [**6-22**]: Chest X-ray --> IMPRESSION: No evidence of acute cardiopulmonary disease. Brief Hospital Course: Initial Urology Course: 25F h/o asthma p/w right sided abdominal/flank pain and found to have a 6mm proximal ureteral stone, ARF and leukocytosis at OSH 1. Ureteral stone: Likely cause of n/v and leukocytosis. Seen by Urology who recommends conservative management at this time. - IVF - Tamsulosin 0.4 mg - IV hydromorphone prn pain - IV ondansetron 4 mg q8h prn n/v 2. Leukocytosis: Likely reactive. U/A mostly bland. Will hold ABx for now given lack of bands/fever/comorbidities with a low threshold for starting Unasyn if spikes. - F/u Bcx x 2 3. Acute renal failure: Worsening sCrt compared to OSH. Evidence of post-obstructive etiology. DDX includes prerenal causes from urinary frequency. Urology has seen her in the ED did not think a surgical intervention for ureteral stone was indicated. Will following kidney function and electrolytes closely. - Renally dose medications - F/U FENA 4. Asthma: Stable. - Albuterol/atrovent NEBs q6h prn sob/wheeze 5. Anxiety: - Diazepam 5 mg po renally dosed prn anxiety 6. ADHD: Stable. Will hold dextroamphetamine/amphetamine (Adderal) for now given worsening renal function. - Restart Adderal once renal fuction improves. 7. Migraine: Stable. She has not been taking her topiramate prophylaxis for the past few months. . FEN: NPO for now and ADAT (given nausea w/ vomitting) . Access: PIV . Prophylaxis: Pneumoboots for VTE prophylaxis. . Precautions: None . Communication: Patient . Dispo: Pending clinical improvement . CODE: Full MICU Course 25 yo woman, with PMH asthma and obesity, with sepsis secondary to infected ureteral stone s/p ureteral stenting, admitted to ICU for management of urosepsis, as well as extubation and post-procedural monitoring. 1. Sepsis: [**1-5**] to UTI given Proteus growing in blood. Symptoms improved after stent placed. Narrowed to cipro once Proteus sensitivities came back. CXR negative for intrapulmonary process. 2. Ureteral stone: Right obstructing stone s/p stent placement and drainage. Pain control was initially with morphine then changed to dilauded .25 mg Q3. Will need eventual stone removal with urology. 3. Hypoxia: Thought to be secondary to splinting due to pain from right-sided pain; chronic asthma may also have played some part. Patient is currently on 2L nasal cannula. Chest x-rays were performed (see 1. Sepsis) and patient was given asthma meds. Incentive spirometer should be considered once patient's pain has decreased significantly. 4. Acute kidney injury: Appeared to be a combination of pre-renal (FeNA<1, high urine Osm) and obstructive pattern. Creatinine decreased over length of stay in ICU, most likely secondary to aggressive fluid rehydration after stent placement and drainage. Medications were renally dosed. 5. Headache/migraine: Patient has a history of migraines relieved by Tramadol x2. The patient was admitted to Dr.[**Name (NI) 11306**] Urology service following stent placement [**6-22**]. Please see operative note for further details. She tolerated the procudure well but was left intubated due to concern for development of sepsis and transferred to the ICU. She remained stable and was extubated later that day. She transferred to the floor on [**6-23**]. Pain, nausea, vomiting improved steadily following the procedure. She remained afebrile. At discharge, patient's pain well controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. She will be discharged with a total 14d course of antibiotics. She was given explicit instructions to call Dr. [**Last Name (STitle) 3748**] for follow-up and stent removal. Medications on Admission: albuterol sulfate 90 mcg HFA 2 puffs(s) inhaled q 4-6 hr prn tramadol 50 mg 1 Tablet by mouth twice a day as needed for headache dextroamphetamine/amphetamine XR [Adderall XR] 15 mg po BID dextroamphetamine/amphetamine [Adderall] 20 mg po BID * OTCs * ascorbic acid 500 mg one tab po daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 5. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Advair Diskus 250-50 mcg/dose Disk with Device Sig: Two (2) PUFFS Inhalation once a day. 7. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) PUFFS Inhalation four times a day as needed for shortness of breath or wheezing. 8. multivitamin Oral 9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 10. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: POSTOPERATIVE DIAGNOSIS: Right ureteral stone with infection. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Resume all of your pre-admission/ home medications, unless otherwise noted. Please avoid Aspirin unless otherwise advised. -No vigorous physical activity for 2 weeks. -Expect to see occasional blood in your urine and to experience urgency and frequency over the next month. -You may have already passed your kidney stones OR they may still be in the process of passing. -You may experience some pain associated with spasm of your ureter. This is normal. Take IBUPROFEN as directed and take the narcotic pain medication as prescribed if additional pain relief is needed. -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthrough pain >4. Replace Tylenol with narcotic pain medication. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -Make sure you drink plenty of fluids to help keep yourself hydrated and facilitate passage of stone fragments. -You may shower and bathe normally. -Do not drive or drink alcohol while taking narcotics or operate dangerous machinery -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative -If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Followup Instructions: Call Dr.[**Name (NI) 11306**] office ([**Telephone/Fax (1) 8791**] for follow-up in 10 days AND if you have any questions; there is an indwelling ureteral stent that MUST be removed or exchanged in the near future. It is VERY IMPORTANT that you follow-up with Dr. [**Last Name (STitle) 3748**] as advised. Completed by:[**2180-6-24**]

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icd9cm

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41214

Discharge summary

report

Admission Date: [**2137-3-1**] Discharge Date: [**2137-3-5**] Date of Birth: [**2069-3-17**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (un) 85086**] Chief Complaint: pain w/ swallowing Major Surgical or Invasive Procedure: None History of Present Illness: This patient is a 67 year old male with PMH of prostate cancer with metastatis to spine, shoulder, and sternum undergoing radiation (last [**2137-2-25**] from nose of face down to sternum) who presented to [**Hospital 4199**] hospital with throat pain, painful swallowing and feeling like his throat was closing. He has been having this problem for the past 7 days or so and was being treated nystatin and fluconazole for thrush. He has been having difficulty handling his own secretions and now upper lip swelling for past 24hours. Evaluated at OSH ED and felt to be stridorous. He was given methylprednisolone, magic mouthwash, ativan at outside hospital. This improved his symptoms but still having mouth and chest discomfort. He had a CT scan of the neck at OSH showing esophagitis but not read as having laryngeal edema. He was admitted to [**Hospital Unit Name 153**] given concern for airway obstruction. VS prior to transfer: Tmax of 101.1, Tcurrent 98.9, 88, 122/73, 98% 4L NC . In the ED at [**Hospital1 18**] initial vs were: 98, 92, 112/64 19 96% 4/l . Patient was given viscous lidocaine, benadryl, methylprednsinone 125mg, famotidine, zofran, oxycodone liquid, ativan, scopolamine patch, and maalox. . In the [**Hospital Unit Name 153**], feels that throat pain and swallowing improved and no SOB. No stridor on exam. The OSH CT neck was reviewed with radiology here who also felt that no evidence of laryngeal edema but did note esophagitis. He was continued on methylprednisone with plan for five day course. He was given fluconazole IV given difficulty taking PO for the esophagitis. He also reported new cough, sputum production and given that had been febrile (OSH ED?) was emperically started on antibiotics (cefepime, vanc, azithro) for HCAP. Of note he was treated in [**Month (only) 956**] for pneumonia at [**Hospital1 2025**]. He also reported unilateral leg pain. LE u/s was obtained which showed non-obstructive thrombus in peroneal vein. He was started on heparin IV. Of note, radiology evaluated CT neck there was question of recanulated thrombus in pulmonary vasculature on right. He is transferred out of [**Hospital Unit Name 153**] given clinical improvement. Vitals are afebrile today, 99.1 85 96/56 (BP runs low 100s) 23 97%2L. Past Medical History: Prostate cancer with spinal, sternal and shoulder mets Dilated CMP PNA treated at [**Hospital1 2025**] [**2137-2-15**] HLD Herniorrhaphy anemia Baseline Hct around 32 Social History: Lives with wife, son, brother in law and sister in law in [**Name (NI) 2251**]. - Tobacco: None - Alcohol: Quit 3 yrs ago, never heavy drinker - Illicits: Denies Family History: No history of cancer Physical Exam: ADMISSION PHYSICAL EXAM: General: Alert, oriented, no acute distress, breathing comfortably, speaking in full sentences HEENT: Sclera anicteric, MMM, oropharynx with significant erythema and whitish exudate, some scabs but no active bleeding. Lips significantly edematous and ulcerated. No stridor. Neck: supple, JVP elevated to ears bilaterally, no LAD Lungs: Decreased breath sounds and crackles in RLL, otherwise clear CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic murmur Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, 1+ edema of the R calf. Pertinent Results: LABS ON ADMISSION: [**2137-3-1**] 11:52AM BLOOD WBC-3.4* RBC-4.09* Hgb-10.2* Hct-31.2* MCV-76* MCH-25.1* MCHC-32.8 RDW-14.6 Plt Ct-221 [**2137-3-1**] 11:52AM BLOOD Neuts-75* Bands-0 Lymphs-12* Monos-13* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2137-3-1**] 11:52AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 15924**] [**2137-3-2**] 06:39AM BLOOD PT-15.8* PTT-38.0* INR(PT)-1.4* [**2137-3-1**] 11:52AM BLOOD Glucose-132* UreaN-13 Creat-0.8 Na-132* K-4.4 Cl-96 HCO3-27 AnGap-13 [**2137-3-1**] 11:52AM BLOOD cTropnT-<0.01 [**2137-3-2**] 06:39AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.6 [**2137-3-1**] 11:52AM BLOOD calTIBC-391 VitB12-315 Folate-8.3 Ferritn-47 TRF-301 [**2137-3-1**] 11:52AM BLOOD TSH-0.29 [**2137-3-2**] 06:39AM BLOOD Digoxin-0.5* DISCHARGE: [**2137-3-5**] 07:40AM BLOOD WBC-6.0 RBC-4.39* Hgb-10.6* Hct-34.6* MCV-79* MCH-24.2* MCHC-30.7* RDW-16.0* Plt Ct-202 [**2137-3-5**] 07:40AM BLOOD Glucose-107* UreaN-21* Creat-0.8 Na-131* K-4.1 Cl-96 HCO3-26 AnGap-13 [**2137-3-5**] 07:40AM BLOOD Calcium-7.9* Phos-2.0* Mg-2.9* LEUS [**2137-2-28**]: FINDINGS: Thre is normal compressibility, flow, and augmentation of bilateral common femoral, bilateral superficial femoral, bilateral popliteal and the left calf veins. There is a non-occlusive thrombus involving one of the right peroneal veins. IMPRESSION: Thrombosis of a right peroneal vein. Brief Hospital Course: 67M with PMH metastatic prostate ca presented initially to the [**Hospital Unit Name 153**] for concern over airway swelling in the setting of recent radiation. ACTIVE ISSUES: #CONCERN FOR LARYNGEAL EDEMA: Patient reported throat closing and initial exam with concern for stridor but over the first forty-eight hours symptoms improved and not stridorous on exam, CT without evidence of laryngeal edema. Radiation induced edema considered, angioedema considered as patient on [**Last Name (un) **]. - Pt was initially treated overnight in the [**Hospital Unit Name 153**] with IV methylprednisolone - After transfer to the floor, his steroid regimen was switched to PO prednisone and then tapered to off by [**3-4**] - Difficulty with handling secretions thought to be more related to oropharyngeal candidiasis combined with likely radiation mucositis . #ESOPHAGITIS / MUCOSITIS: Patient with throat pain with swallowing with evidence on imaging of esopagitis. Exam with white patches on oropharyx concerning for [**Female First Name (un) **]. Suspect radiation induced esophagitis, [**Female First Name (un) **] esophagitis or likely both - pt was placed on fluconazole and treated symptomatically with liquid pain relief and maalox -advanced diet to soft mechanical, well tolerated with over 1.5L of intake for each of the two days leading up to his discharge #PERONEAL VEIN THROMBOSIS: Patient reporting leg pain and swelling found to have non-occlusive distal vein thrombosis. Given hypercoagulability secondary to cancer and symptomatic plan to treat for 3months. Initially treated with heparin gtt, and sent out on fragmin shots (ease of once daily dosing). . #PRODUCTIVE COUGH: Patient with fever to 101.1 in the OSH emergency department also with productive cough for several days concerning for pneumonia. - No infiltrate seen on CXR - Given recent hospitalization, thought reasonable to treat for HCAP - Initially treated with IV vanc/cefepime and then transitioned to oral levaquin for a course of 8 days - viral swab cultures negative. #METASTATIC PROSTATE CANCER: PSA increasing on anti-androgen therapy over past several months, concern that becoming refractory - outpt zometa will be discussed, deferred to outpt Atrius oncologist Medications on Admission: 1. oxycodone ER 10 mg 12 hr Tab Oral 1 Tablet Extended Release 12 hr(s) Twice Daily 2. Percocet 5 mg-325 mg Tab Oral1-2 Tablet(s) Every 4-6 hrs 3. ranitidine 150 mg Tab Oral1 Tablet(s) Once Daily, at bedtime 4. gabapentin 300 mg Tab Oral 1 Tablet(s) QHS 5. digoxin 125 mcg Tab Oral 1 Tablet(s) Once Daily 6. furosemide 40 mg Tab Oral 2 Tablet(s) Once Daily 7. omeprazole 40 mg Cap, Delayed Release Oral 1 Capsule, Delayed Release(E.C.)(s) Twice Daily 8. metoprolol succinate ER 25 mg 24 hr Tab Oral1 Tablet Extended Release 24 hr(s) Once Daily 9. irbesartan 75 mg Tab Oral 1 Tablet(s) Once Daily 10. nilutamide 150 mg Tab Oral 1 Tablet(s) Once Daily 11. Tramadol 50-100mg TID Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Fragmin 18,000 unit/0.72 mL Syringe Sig: One (1) shot Subcutaneous once a day: Until told to stop by coumadin clinic. Disp:*30 0* Refills:*2* 3. tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 4. nilutamide 150 mg Tablet Sig: One (1) Tablet PO once a day. 5. irbesartan 75 mg Tablet Sig: One (1) Tablet PO once a day. 6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at bedtime as needed for insomnia. 8. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO at bedtime. 9. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 11 days. Disp:*11 Tablet(s)* Refills:*0* 11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:*1 Tablet(s)* Refills:*0* 12. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 13. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet in water PO DAILY (Daily) as needed for constipation. Disp:*20 packets* Refills:*0* 15. oxycodone 5 mg/5 mL Solution Sig: Five (5) ML PO Q4H (every 4 hours) as needed for pain: [**Street Address(1) 87025**], DRINK ALCOHOL, OR OPERATE HEAVY MACHINERY WITH THIS MEDICATION. Disp:*300 ML* Refills:*0* 16. lidocaine HCl 2 % Solution Sig: One (1) swish Mucous membrane QID (4 times a day) as needed for pain. Disp:*20 cups* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Esophagitis Oral Candidiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [**Known lastname 89783**], You were admitted to the [**Hospital1 18**] with the complaint of throat pain after your recent radiation treatment. We were able to make your pain better with liquid medications. We also gave you antibiotics for a possible pneumonia, as well as for a fungal infection in your mouth and upper throat. These are common complications for patients in your situation to have and should get better over time with medicine. Take all medications as prescribed. Try to avoid hard, solid foods or sharp foods like crackers or chips that could cause you more pain in your throat. Medications: Added: Fluconazole (for 11 days), Levaquin (for one more day), Carafate, miralax, Magic Mouthwash, fragmin injections, coumadin. Take the fragmin injections only until the coumadin clinic tells you to do so. You will need to have your INR checked as an outpatient so we can manage your coumadin levels. Changed: Oxycodone (now liquid) Removed: furosemide Followup Instructions: You will have a follow up appointment scheduled by your Atrius team. They will call you with your appointment.

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

9951, 10008

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354, 2625

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101,077

32136

Discharge summary

report

Admission Date: [**2157-8-1**] Discharge Date: [**2157-8-5**] Date of Birth: [**2088-4-2**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: arm pain Major Surgical or Invasive Procedure: s/p CABGx3(LIMA->LAD, SVG->Diag,SVG to OM) [**2157-8-1**] History of Present Illness: 69 yo male with history of arm pain and abnormal ETT with a hypotensive response to exercise. Referred for cath which showed LAD and CX disease. Then referred for CABG. Past Medical History: HTN elev. chol. polio ( no residual) PSH: tonsillectomy, LIH repair Social History: retired analyst lives with wife rare ETOH never used tobacco Family History: non-contrib. Physical Exam: 180 cm 78 kg HR 52 RR 18 145/75 98% RA sat. lying flat after cath, NAD skin/HEENT unremarkable neck supple, full ROM, no carotid bruits CTAB RRR, no murmur sift, NT, ND, + BS extrems wwarm, no edema or varicosities noted neuro grossly intact 2+ bil. fem/DP/PT/radials Pertinent Results: [**2157-8-4**] 05:55AM BLOOD WBC-12.1* RBC-3.64* Hgb-10.6* Hct-30.5* MCV-84 MCH-29.0 MCHC-34.5 RDW-13.9 Plt Ct-156 [**2157-8-5**] 06:25AM BLOOD Hct-30.9* [**2157-8-4**] 05:55AM BLOOD Plt Ct-156 [**2157-8-4**] 05:55AM BLOOD UreaN-22* Creat-1.1 K-4.1 [**2157-8-5**] 06:25AM BLOOD K-4.7 [**2157-8-2**] 03:06AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9 [**2157-8-2**] 03:06AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75197**] (Complete) Done [**2157-8-1**] at 11:31:06 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2088-4-2**] Age (years): 69 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Intraoperative TEE for CABG ICD-9 Codes: 440.0, 518.82, 424.1 Test Information Date/Time: [**2157-8-1**] at 11:31 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW4-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.2 cm <= 5.2 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm Aorta - Ascending: 3.0 cm <= 3.4 cm Aorta - Arch: 2.6 cm <= 3.0 cm Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm Aortic Valve - LVOT diam: 2.0 cm Findings LEFT ATRIUM: Mild LA enlargement. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Significant PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE CPB The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Mild-moderate pulmonic regurgitation is seen. POST CPB Normal biventricular systolic function. No changes form pre-CPB study. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician RADIOLOGY Final Report CHEST (PA & LAT) [**2157-8-3**] 9:42 AM CHEST (PA & LAT) Reason: evaluate left apical ptx [**Hospital 93**] MEDICAL CONDITION: 69 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate left apical ptx HISTORY: A 69-year-old male status post CABG. Evaluate left apical pneumothorax. COMPARISON: Radiograph [**2157-7-27**]. TWO VIEWS OF THE CHEST: The small left apical pneumothorax is not changed. Bilateral pleural plaques are extensive but not changed. The cardiac and mediastinal contour is normal. The bony thorax is normal. IMPRESSION: Persistent small left apical pneumothorax. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name 3900**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: WED [**2157-8-3**] 8:32 PM ?????? [**2152**] CareGroup Brief Hospital Course: Admitted [**8-1**] and underwent cabg x3 with Dr. [**Last Name (STitle) **]. Transferred to the CVICU in stable condition on a titrated propofol drip.Extubated later that afternoon and transferred to the floor on POD #1 to begin increasing his activity level. Beta blockade titrated and gently diuresed toward his peroperative weight. Chest tubes and pacing wires removed without incident.Cleared for discharge to home with services on POD #4. Pt. is to make all followup appts. as per discharge instructions. Medications on Admission: atenolol 25 mg daily plavix 600 mg (SINGLE DOSE 9/11) ASA 325 mg daily norvasc 5 mg daily MVI daily Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) 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 x3 HTN ^chol. polio Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Call our office with sternal drainage, temp>101.5 Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 17025**] for 1-2 weeks. See dr. [**Last Name (STitle) 7047**] in [**12-18**] weeks Make an appointment with Dr. [**Last Name (STitle) **] in 4 weeks. Completed by:[**2157-8-30**]

[ "414.01", "458.29", "401.9", "272.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7957, 8012

6349, 6860

327, 387

8109, 8117

1094, 5517

8395, 8627

771, 785

7010, 7934

5554, 5584

8033, 8088

6886, 6987

8141, 8372

800, 1075

279, 289

5613, 6326

415, 585

607, 677

693, 755

29,282

176,024

31712

Discharge summary

report

Admission Date: [**2166-11-3**] Discharge Date: [**2166-11-19**] Date of Birth: [**2085-8-11**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2969**] Chief Complaint: Esophageal Cancer Major Surgical or Invasive Procedure: Upper endoscopy and transhiatal esophagectomy with feeding jejunostomy. History of Present Illness: Mr. [**Known lastname **] is an 81-year-old gentleman with diagnosis of esophageal cancer. His preoperative endoscope ultrasound stage was T2, N0, and a PET scan showed no evidence of metastatic disease. He is admitted for Upper endoscopy and transhiatal esophagectomy with feeding jejunostomy. Past Medical History: Hypothyroidism Hypertension Hyperlipidemia Multiple TIAs/CVA [**2151**] BPH PSH: s/p TURP '[**46**], R CEA [**Numeric Identifier 7084**], R Hernia repair '[**50**] Social History: Married, lives in [**Location 41708**] Tobacco: quit 30 years ago ETOH: none Family History: non-contributory Physical Exam: General: 80 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Card: regular, rate & rhythm, normal S1,S2, no murmur/gallop or rub Resp: decreased breath sounds otherwise clear GI: bowel sounds positive, abdomen soft non-tender/non-distended Extr: warm no edema Incisions: Left neck clean, dry intact, mid-abdomen with staples clean dry intact. Mild erythema along staple line. J-tube site clean, no erythema Neuro: non-focal Pertinent Results: [**2166-11-3**] WBC-5.3 RBC-3.31*# Hgb-10.1*# Hct-29.3* Plt Ct-96* [**2166-11-11**] WBC-16.8* RBC-3.62* Hgb-10.8* Hct-32.7 Plt Ct-335 [**2166-11-18**] WBC-7.4 RBC-3.52* Hgb-10.5* Hct-31.8 Plt Ct-586 [**2166-11-3**] Glucose-131* UreaN-17 Creat-1.0 Na-133 K-3.9 Cl-105 HCO3-20 [**2166-11-11**] Glucose-171* UreaN-19 Creat-0.9 Na-138 K-3.9 Cl-102 HCO3-26 [**2166-11-19**] Glucose-138* UreaN-14 Creat-0.9 Na-131* K-4.4 Cl-96 HCO3-31 CHEST (PA & LAT) [**2166-11-11**] FINDINGS: In comparison with the study of [**11-9**], the surgical clips and drain have been removed from the lower left chest. There has been some decrease in opacification at the right base, though residual combination of infiltrate of atelectasis, effusion, and possible pneumonia persists. There is little change in the increased opacification described previously at the left base. Pathology Examination SPECIMEN SUBMITTED: Esophagus and proximal stomach, left gastric lymph nodes. Procedure date Tissue received Report Date Diagnosed by [**2166-11-3**] [**2166-11-3**] [**2166-11-10**] DR. [**Last Name (STitle) **]. BROWN/mb???????????? Previous biopsies: [**-6/3994**] GASTRIC BIOPSIES 2. A. Esophagogastrectomy specimen: 1. Barrett's esophagus with polypoid high grade dysplasia. No invasive carcinoma identified. Entire lesion examined. 2. Proximal margin with squamous mucosa. No glandular mucosa present. 3. Distal margin with gastric body type mucosa. No dysplasia. 4. One lymph node with no tumor seen. B. Left gastric lymph nodes: Seven nodes with no tumor seen. CTA CHEST W&W/O C&RECONS, NON-CORONARY CTA OF THE CHEST: There is no evidence of pulmonary embolism or aortic dissection. The aorta is tortuous with a moderate amount of plaque within the ascending aorta (3:29). Heart size is normal and there is a tiny to small pericardial effusion, measuring simple fluid density. Scattered coronary calcifications are noted within the LAD and RCA. The bronchi are patent to the subsegmental level. There are large bilateral pleural effusions, right greater than left, with associated atelectasis at the lung bases. The lungs demonstrate moderate paraseptal emphysema, worst at the lung apices. No suspicious nodules or masses are identified. Small mediastinal lymph nodes are noted, which do not meet CT criteria for pathologic enlargement. The patient is status post esophagectomy with gastric pull-through. This exam is not tailored for subdiaphragmatic assessment. An incompletely characterized cystic lesion is seen off the upper pole of the right kidney - correlation with recent PET CT suggests that this is a large simple cyst. There are no bone findings of malignancy. Multilevel degenerative changes are seen in the thoracic spine, with prominent anterior osteophytosis. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Moderate-sized bilateral pleural effusions with associated atelectasis. 3. Status post esophagectomy and gastric pull-through. [**2166-11-19**] 06:24AM BLOOD Glucose-138* UreaN-14 Creat-0.9 Na-131* K-4.4 Cl-96 HCO3-31 AnGap-8 Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2166-11-3**] and underwent successful upper endoscopy and transhiatal esophagectomy with feeding jejunostomy. He was monitored in the PACU and transferred to the SICU in stable condition. While in the SICU he was hypertensive and a question of a new right bundle branch block was seen on ECG. Cardiology was consulted and he ruled out for an myocardial infarction. They recommended continuing beta-blocker and good blood pressure control. His pain was managed with an epidural by the acute pain service. His left chest-tube and nasal gastric tube were to suction. The neck drain was to bulb with moderate serosanguinous drainage. He remained hemodynamically stable and was transferred to the floor on POD #1. He was seen by nutrition who recommended Nutren Pulmonary tube feeds with a goal rate of 60cc/hr. Physical therapy was consulted. On POD day #2 the tube feeds were started at 20cc/hr. The chest-tube was placed to water seal with no leak. On POD #3 the chest-tube and epidural were removed and his pain was managed with a PCA. The foley was removed and he voided without difficulty. His tube feeds were slowly advanced to goal which he tolerated. His blood pressure and heart rate were well controlled. On POD day #7 he was administer PO grape juice which revealed no anastomotic leak. His neck drain was removed. He was started on a clear liquid diet which he tolerated. He was constipated and given laxatives with a good result. On POD day #8 his PCA was stopped and was converted to pain medication via J-tube. He was started back on his home PO meds. His neck staples were removed and every other abdominal staple removed. He had mild erythema along the staple line of his abdominal wound. On POD #9 the inferior portion of the neck wound begin to ooz. The neck and abdominal wound was open, the sites were clean and packed with a moist to dry dressing. He continued to require oxygen and on POD 14 a chest CT was obtained and no pulmonary embolism was seen but had bilateral pleural effusions which was tapped. A follow-up chest x-ray revealed no pneumothorax. He continued to work with physical therapy and was discharged to rehab on POD #15. He will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Synthroid 75 mcg once daily Diovan 160 mg once daily HCTZ 12.5 mg once daily Terazosin 2 mg once daily Atenolol 50 mg once daily MAVIK 4 mg twice dialy Lipitor 20 mg once daily Omeprazole 20 twice daily Aspirin 81 mg once daily MVI Doxycycline b.i.d Hydralazine 50 mg every 8 hrs Discharge Medications: 1. Atenolol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily): crush give via J-tube 2. Senna 8.6 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO BID (2 times a day) as needed. 3. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30) ML PO Q6H (every 6 hours) as needed. 4. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO TID (3 times a day). 5. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs PO Q4H (every 4 hours) as needed. 7. Levothyroxine 75 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily): Crush give via J-tube 8. Valsartan 160 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily): Crush give via J-tube. 9. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily): Crush give via J-tube hold while giving lasix. 10. Trandolapril 2 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day): crush give via J-tube. 11. Atorvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily): Crush give via J-tube. 12. Terazosin 1 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO HS (at bedtime): Crush give via J-tube. 13. Lasix 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day for 7 days. 14. Potassium Chloride 20 mEq Packet [**Last Name (STitle) **]: One (1) PO once a day for 7 days: give via J-tube. 15. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection TID (3 times a day). 17. Hydralazine 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day: Crush give via J-tube 18. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: One (1) PO four times a day: swish & spit. 19. Prevacid 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day: via J-tube. Discharge Disposition: Extended Care Facility: [**Hospital1 11057**] Nursing & Rehabilitation Center - [**Location (un) 3320**] Discharge Diagnosis: Esophageal Cancer Stage I Hypothyroidism Hypertension Hyperlipidemia CVA Multiple TIA's BPH Discharge Condition: Good Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you experience chest pain, shortness of breath, fever, chills, nausea, vomiting, diarrhea, or abdominal pain. If your feeding tube sutures become loose or break, please tape tube securely and call the office [**Telephone/Fax (1) 170**]. If your feeding tube falls out, save the tube, call the office immediately [**Telephone/Fax (1) 170**]. The tube needs to be replaced in a timely manner because the tract will close within a few hours. Crush all medication administer via J-Tube: then flush tube with 100cc of water. Flush your feeding tube with 50cc every 8 hours if not in use and before and after every feeding. Daily weights: keep log when discharged to home Monitor CBC, lytes, BUN & Cre: repletes lytes as needed. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**12-11**] at 2:00pm on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]. Esophagus Swallow evaluation at 11:00am. [**Telephone/Fax (1) 44714**] on [**11-25**] Report to the [**Location (un) 861**] Radiology Department. HOLD TUBE FEEDS after Midnight [**11-24**] for barium swallow. Completed by:[**2166-11-19**]

[ "530.81", "600.00", "511.9", "530.85", "E878.6", "426.4", "244.9", "150.8", "401.9", "998.12", "V12.54" ]

icd9cm

[ [ [] ] ]

[ "44.29", "96.6", "34.91", "43.99", "46.39" ]

icd9pcs

[ [ [] ] ]

9434, 9541

4607, 6900

307, 381

9677, 9684

1515, 4584

10534, 10976

1004, 1022

7231, 9411

9562, 9656

6926, 7208

9708, 10511

1037, 1496

249, 269

409, 706

728, 894

910, 988

32,607

185,206

26241

Discharge summary

report

Admission Date: [**2162-8-5**] Discharge Date: [**2162-8-10**] Date of Birth: [**2081-8-7**] Sex: F Service: MEDICINE Allergies: Quinidine / Iodine / Indocin Attending:[**First Name3 (LF) 10842**] Chief Complaint: Fevers, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: This is an 80 yo F with a past medical history of SSS s/p pacer, hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV Replacement, presents to the ED with weakness, found to be febrile to 102, with a distended tender abdomen. She said that the abdominal pain started today ([**2162-8-5**]), her stools have been relatively normal, no brbpr/hematochezia. In the ED, she underwent a CT abd/pelvis which showed evidence of diverticulosis but no diverticulitis, and a small amount of free fluid in the abdomen. Out of concern for a possible GI source, the patient was to receive cipro/flagyl, but got cipro and subsequently got hives. She was then given a dose of zosyn. Surgery saw the patient in the ED and felt that her abdominal exam, initially was concerning, but over time had improved and given no obvious findings on CT, did not feel that there should be any surgical intervention at this time. . She was to be admitted to the floor initially for further work up, but her initial BP of 115/93 dropped to the 80's without compensatory HR elevation. She then received 2L of NS, despite concern that she was volume overloaded. A RIJ was attempted, but was unsuccessful. BP's returned to the 110's but then just prior to transfer to [**Hospital Unit Name 153**], they were back in the high 80's systolic, satting 99% 2L. . Notable labs were no leukocytosis but a small left shift, mild anemia, thrombocytopenia, lactate of 1.5, creatinine of 1.6, TB 1.7 in the setting of normal LFT's. She is transferred to the [**Hospital Unit Name 153**] for stabilization of her hypotension and further work up of her fevers. . Currently, at time of ICU admission her BP is 115/42, and she is asymptomatic with a temp of 98.6. She c/o abdominal pain. She also claims she had chest pain in the emergency department, but it has been going away gradually over the last few hours. She denies loose stool. Past Medical History: - Diabetes - Dyslipidemia - Hypertension - Pacemaker placement [**2154**] for SSS s/p generator replacement [**2159**] - Legal blindness - Pulmonary Fibrosis on 2 L O2 at home; fibrosis @ lung bases bilaterally (reported as unlikely to be amiodarone related) - Diastolic CHF (last EF wnl in [**3-12**]) - AS s/p AVR [**2157**] -with "horse valve"- [**Hospital1 2177**] by Dr. [**Last Name (STitle) 65008**] - Paroxysmal atrial fibrillation/AVJ ablation [**2158**]- [**Hospital3 5097**] - Hypothyroidism, (two thyroid surgeries as a child) - s/p Appendectomy - Uterine cancer, s/p complete hysterectomy - s/p Hernia repair - s/p cholecystectomy - Severe aortic stensois of the AVR - R Humerus Neck Fracture - R Knee Hemarthrosis, r knee hemarthrosis Social History: Patient is widowed and lives alone. She lives in an independent living facility. Her son lives a few blocks away and helps her with her medications. No tobacco, no ETOH, no illicits. Family History: Mother deceased from kidney disease and ruptured aorta, father deceased from CHF. Physical Exam: **ICU admission physical exam: Physical Exam: VS T = 98.6 P = 65 BP = 115/42 RR = 28 O2Sat = 95% 3L NC General: Elderly female NAD. AAOx3 HEENT: EOMI, PERRL, no scleral icterus, very dry MM, OP clear, poor dentition Lungs: bibasilar rales Cardiac: RR, nl. obliteration of S1, normal S2, loud [**3-11**] holosytolic, harsh decrescendo murmur with radiation to the carotids, L>R. Abdomen: soft, mildly distended, normoactive bowel sounds, well healed scar midline, with ventral hernia, with significant ttp just below the umbilicus into the suprapubic region. Unable to reduce hernia. No rebound or guarding. Extremities: no c/c, trace pretibial edema, good pulses. Neurologic: Moves all extremities. Alert, oriented x 3. Skin: scattered ecchymoses on arms. Pertinent Results: [**2162-8-10**] 07:40a Na 140 K 3.6 Cr 1.5 Mg 2.5 INR 3.5 **Pertinent [**2162-8-5**] ICU admission imaging as below: KUB: FINDINGS: Single view is somewhat limited by body habitus. There is an overall generalized paucity of bowel gas with no definite dilated loops of small bowel evident. There is no ascites or organomegaly detected. Degenerative changes are noted throughout the lumbar spine, particularly at the lumbosacral junction. Surgical clips are noted in the upper left hemipelvis. Phleboliths are noted throughout the lower pelvis. IMPRESSION: Non-obstructive bowel gas pattern. . CXR: Single AP chest radiograph compared to [**2162-5-13**] show mild interstitial edema slightly improved compared to prior exam. Bibasilar atlectasis persists. The heart size remains moderately enlarged, unchanged, with incidentally noted dense mitral annulus calcification. There is no pneumothorax or pleural effusion. Post surgical changes related to median sternotomy are pressent. Dual leads of a left chest wall pacemaker terminate in the right atrium and right ventricle. IMPRESSION: Very mild interstitial edema slightly improved compared to prior exam. . CT Abd/pelvis (prelim): diverticulosis without itis. no obstruction. small amount of free fluid in the abdomen, which may relate to volume overload. Liver, small and nodular suggestive of underlying cirrhosis. No free air or LAD. s/p cck. Mild body wall anasarca. . EKG: V-paced @ 75, left axis. TWI in AVL. No changes from prior. [**2162-8-5**] 09:31PM LACTATE-1.5 [**2162-8-5**] 08:44PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2162-8-5**] 08:44PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2162-8-5**] 08:44PM URINE RBC-0-2 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0 [**2162-8-5**] 03:21PM LACTATE-1.5 [**2162-8-5**] 03:00PM GLUCOSE-102 UREA N-34* CREAT-1.6* SODIUM-136 POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-30 ANION GAP-13 [**2162-8-5**] 03:00PM estGFR-Using this [**2162-8-5**] 03:00PM LIPASE-24 [**2162-8-5**] 03:00PM ALT(SGPT)-23 AST(SGOT)-67* ALK PHOS-82 TOT BILI-1.7* [**2162-8-5**] 03:00PM WBC-9.2 RBC-4.09* HGB-11.1* HCT-34.3* MCV-84 MCH-27.2 MCHC-32.4 RDW-16.2* [**2162-8-5**] 03:00PM PT-19.4* PTT-36.4* INR(PT)-1.8* Brief Hospital Course: 80 year old female with history of CHF (diastolic dysfunction), atrial fibrillation on coumadin, CAD, AVR with stenosis, DM, PPM, pulmonary fibrosis on 2.5L O2 at baseline presented [**8-5**] with fevers, diarrhea, and hypotension. She was rehydrated with IVF, and subsequently experienced pulmonary edema. In MICU, diuresed and treated empirically for possible GI source for fevers. On floor, was further diuresed and treated for possible diverticulitis. Brief hospital course, by problem, is as follows: . 1. Hypotension, now resolved: On presentation, the ICU team felt the patient's low blood pressure (systolic in 80s) were secondary to early sepsis etiology, given fevers, but on further labs and cultures there was no clear source and no leukocytosis. She responded transiently to 2L fluids, but then seemed to have worsened pulmonary edema on chest film. Despite this, she had a drop in her BP again. Was resuscitated with IVF. It was thought that given her underlying heart disease, she could not maintain the forward flow for such a sudden increase in venous return. Additionally, she did not have a compensatory increase in her HR to aid in increasing her cardiac output. Given hypotension and acute renal failure with low serum sodium on labs, etiology of hypotension was thought to be due to volume depletion. Pulmonary embolism was also considered, however, the patient was on chronic anticoagulation for atrial fibrillation and AVR so this was unlikely. Pericardial effusion was also explored but no evidence of this on exam. While in the [**Hospital Unit Name 153**] she was given gentle IVFs, urine lytes assessed, monitored urine output with goal >35cc/hr. Diuretics were initially held. Furosemide 80mg twice daily per home regimen was restarted in [**Hospital Unit Name 153**] with good urine output. On medicine floor, spironolactone 25mg daily and metolazone 10mg QMonday, Friday were restarted in succession. Patient had good diuresis, with over 1 liter net negative each day. Creatine stayed in the range of 1.4-1.5, with BUN/creatinine ratio greater than 20. We considered that patient may be intravascularly depleted, although clinically she looked excellent. We asked that she have her chemistries checked again at the rehabilitation facility to ensure that she does not experience renal failure. Potassium also had to be repleted on a daily basis. Given her possibility for renal failure, we did not send her out with potassium. Rather we asked that she have her labs checked within the week to reassess potassium status. . 2. Fevers: On presentation, patient reported fevers to 102 in context of diarrhea, abdominal pain, and isolated elevations in ALT and Tbili. Unclear etiology, did not seem to be a pattern of biliary obstruction. Of note, ALT was more double than AST, but this ratio appears to be chronic. Urinalysis was unremarkable and portable chest film did not have any obvious consolidation. Pain was in location of ventral hernia which when evaluated by CT showed no obstruction or entrapment of bowel. Blood cultures were without growth. WBC remained in normal range. CT abdomen/pelvis showed diverticulosis but no diverticulitis. In ED, was given ciprofloxacin which was later stopped [**2-6**] fever. She was then covered with Zosyn in the [**Hospital Unit Name 153**] given concern for sepsis with low blood pressure as above. In [**Hospital Unit Name 153**], fevers and diarrhea resolved. On medicine floor, patient remained afebrile. Given that likely etiology of fevers and abdominal pain was diverticulitis, antibiotic regimen was changed to Bactrim and Flagyl. Abdominal pain resolved, and as above patient remained afebrile and with normal WBC count. C diff panel was negative. She was discharged with Flagyl and Bactrim for full 7 day course. Of note, repeat 2 view CXR on day prior to discharge showed consolidation that was considered to be pneumonia. Clinically, the patient did not appear to have pneumonia - afebrile, without cough or pleuritic chest pain, and improving on baseline oxygen requirement. We decided not to treat for a pneumonia, but sent off for urine legionella given presentation with abdominal pain; she had been on antibiotic treatment for 4 days when it was sent; it was negative. . 3. Hypoxia - Patient is on 2.5L home O2. In the [**Hospital Unit Name 153**], she was satting in mid 90's on 3L O2. This was felt to be secondary to mild pulmonary edema given aggressive fluid resuscitation. Diuresis was initially held given that it was felt that she was intravascularly depleted. On medicine floor, patient diuresed well and was satting 99-100% on 2L O2. Tachypnea also resolved. She has persistent bibasilar crackles, although this may have been in part due to her reported pulmonary fibrosis. . 4. Diastolic dysfunction heart failure, acute on chronic - LVEF >= 55% by TTE [**4-13**]. Initial portable CXR with volume overload after 2 liters of fluid (initial chest film in ED actually indicated improvement from last imaging in [**Month (only) 116**]). Improved with diuresis per home medications (furosemide, spironlactone, and metolazone). As above, persistent basilar crackles although this may be her baseline given pulmonary fibrosis. . 5. Coronary artery disease - Continued statin, aspirin. Not on beta blocker, paced in the 60s. Was on amiodarone for SSS, but stopped secondary to IPF and progressive hypoxia. . 6. Aortic valve replacement with severe stenosis: s/p AVR in [**2157**]. Likely contributed to acute on chronic heart failure as above. . 7. Pulmonary Fibrosis: On admission, slightly more hypoxic than at her baseline. Required 3L in ICU, and on floor came down nicely to 2L. Continue advair and as needed albuterol nebs per home regimen. . 8. Diabetes mellitus, type II: In hospital, oral hypoglycemics held. Continued on sliding scale insulin with good blood glucose control. . 9. Atrial Fibrillation: Continued coumadin. After start of antibiotics, INR increased to 3.5. Coumadin held on the day of discharge, and on discharge gave instructions to the rehabilitation facility to monitor INR and dose accordingly while on antibiotics, with likely return to home dose after completing antibiotics. . 10. Anemia: Iron-deficiency. Hematocrit stable at baseline. Continue iron supplentation per home regimen. . 11. Hypothyroidism: Continued synthroid per home regimen. . 12. Hyperlipidemia: Continued statin per home regimen. . 13. Thrombocytopenia - Trasient. Given elevated LFTs and cirrhosis noted on CT abdomen, may be [**2-6**] to reduced TPO production. Also given mild splenomegaly, may be [**2-6**] sequestration. On discharge, platelets trending up and in normal range. *Code status: FULL CODE, confirmed with patient Medications on Admission: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY 2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY 11. Hexavitamin Tablet Sig: One (1) Tablet PO once a day. 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 5X/WEEK (MO,TU,WE,TH,FR). 17. Metolazone 10mg qmonday, friday Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metolazone 5 mg Tablet Sig: Two (2) Tablet PO EVERY MONDAY AND FRIDAY (). 13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. Disp:*6 Tablet(s)* Refills:*0* 14. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 15. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Every Mo, Tu, We, Th, Fr: While you are on the antibiotics the next 2 days, you should have your INR check daily at the rehabilitation facility. They will determine how much warfarin you should take those 2 days. After you complete your antibiotics Thursday night, you can resume your coumadin regimen as normal on Friday, [**8-13**]. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Fever, possibly secondary to diverticulitis Hypotension, now resolved LLQ pain, now resolved Diastolic dysfunction heart failure, acute on chronic Discharge Condition: Hemodynamically stable, ambulatory Discharge Instructions: You were admitted on [**8-5**] for fevers and abdominal pain. In the first couple days of your hospital course, your blood pressure dropped and you were given fluids through your IV to maintain your blood pressure and you ended up having fluid in your lungs. You were also started on antibiotics to cover a possible infection in your abdomen. You were slowly started back on your home diuretic regimen (furosemide, spironolactone, and metolazone) and your breathing improved considerably. At discharge, you should complete your antibiotic course and continue to take your medications just as you were at home. It is also very important that you follow up with your doctors as below. Given your diagnosis of heart failure, you should weigh yourself every morning and call your physicians if weight increases > 3 lbs. You should also adhere to a 2 gm sodium diet and restrict your daily fluid intake to less than 2 liters. If you experience any shortness of breath, chest pain, dizziness, or abdominal pain, please contact your primary care provider or come to the emergency department immediately. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**0-0-**]. Date/Time: [**2162-9-3**] - 1:45pm Or make an appointment for within 1 week after discharge from rehabilitation facility. Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time: [**2162-9-14**] 11:10 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time: [**2162-9-14**] 11:30 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time: [**2162-9-14**] 11:30 Completed by:[**2162-8-10**]

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Discharge summary

report

Admission Date: [**2135-10-4**] Discharge Date: [**2135-10-26**] Date of Birth: [**2057-10-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: pneumonia Major Surgical or Invasive Procedure: A-line placement Central Line Placement LE angiogram PICC catheter History of Present Illness: 84 yo male with past medical history of ESRD on peritoneal dialysis, diabetes mellitus, coronary artery disease, and heart failure was transferred from [**Hospital 4199**] Hospital with hypotension and pneumonia. . [**Name (NI) **] wife reports that 2-3 weeks ago, patient developed necrotic areas on his toes and he was started on gabapentin and bacitracin ointment. Shortly after that he developed a cough productive of yellow, nonbloody sputum. Additional symptoms include progressive fatigue, weakness, multiple falls, decreased PO intake, and confusion. Then one day prior to admission, patient was noted to have subjective fever and worsening of his feet infections and he was recommended to come to the ED. . Upon arrival at [**Hospital 4199**] Hospital, temp 99.5, HR 57, RR 32, BP 107/32, and 88% on room air. While in the ED, he became hypotensive to 70/28, febrile to 103.4, and tachycardic to 104. The patient was then pancultured. A CXR demonstrated right lower lobe infiltrate. He was administered tylenol 650mg PR x 1, Rocephin (ceftriaxone) 1gram IV, avelox (moxifloxacin) 400mg IV x 1, Ativan 1mg IV x 1, and Haldol 3mg IV total. A VBG was performed with pH 7.37 / PCO2 45. Past Medical History: Diabetes Mellitus ESRD on PD x 6 years Coronary Artery Disease (MI x 2 in [**2122**] and [**2128**], no PCI or CABG per PCP) Diastolic Congestive Heart Failure AAA repair in [**2129**] PVD Social History: Home: lives with wife in [**Name (NI) **] [**Last Name (NamePattern1) 1139**]: roughly 30 PPY smoking history, quit 10 years ago EtOH: denies Drugs: denies Family History: noncontributory Physical Exam: T 97.6 / HR 98 / BP 110/50 / RR 24 Gen: mild distress, resting in bed HEENT: Clear OP, dry mucous membranes NECK: Supple, No LAD, No JVD CV: tachycardic and irregular rhyhtm, no murmurs/rubs/gallops LUNGS: scattered crackles at the bases bilaterally with poor inspiratory effort ABD: Soft, NT, ND. NL BS. PD catheter site without erythema, drainage, or tenderness; abdominal hernia present EXT: No edema. bilateral dry necrotic toes without tenderness. Left great toe and medial 2nd toe; right 2nd toe with necrotic toes. diminished light touch sensation in lower extremities bilaterally. trace dopplerable left PT pulses. cool lower extremities bilaterally. SKIN: no rash but black eschar on toes bilaterally NEURO: A&Ox3 but occasionally requiring redirection. CN 2-12 grossly intact. Diminished light touch. Trace - 1+ reflexes bilaterally. Normal coordination. Gait assessment deferred Pertinent Results: [**2135-10-4**] 06:24AM PT-14.5* PTT-32.6 INR(PT)-1.3* [**2135-10-4**] 06:24AM PLT SMR-NORMAL PLT COUNT-288 [**2135-10-4**] 06:24AM NEUTS-92* BANDS-2 LYMPHS-4* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2135-10-4**] 06:24AM WBC-27.8* RBC-3.48* HGB-11.0* HCT-32.5* MCV-94 MCH-31.6 MCHC-33.8 RDW-15.7* [**2135-10-4**] 06:24AM ALBUMIN-2.4* CALCIUM-8.8 PHOSPHATE-5.5* MAGNESIUM-1.9 [**2135-10-4**] 06:24AM CK-MB-5 cTropnT-0.27* [**2135-10-4**] 06:24AM ALT(SGPT)-20 AST(SGOT)-24 CK(CPK)-359* ALK PHOS-128* TOT BILI-0.7 [**2135-10-4**] 06:24AM GLUCOSE-156* UREA N-42* CREAT-9.9* SODIUM-145 POTASSIUM-3.0* CHLORIDE-100 TOTAL CO2-25 ANION GAP-23* [**2135-10-4**] 06:53AM LACTATE-4.4* [**2135-10-14**] 04:24AM BLOOD WBC-19.0* RBC-2.90* Hgb-9.1* Hct-27.1* MCV-94 MCH-31.3 MCHC-33.5 RDW-17.6* Plt Ct-401 [**2135-10-13**] 06:20AM BLOOD PT-13.9* PTT-49.4* INR(PT)-1.2* [**2135-10-14**] 04:24AM BLOOD Glucose-127* UreaN-44* Creat-8.6* Na-136 K-3.8 Cl-97 HCO3-24 AnGap-19 [**2135-10-6**] 04:43AM BLOOD CK(CPK)-3103* [**2135-10-5**] 03:50PM BLOOD CK(CPK)-3839* [**2135-10-5**] 03:10AM BLOOD CK(CPK)-5568* [**2135-10-4**] 06:08PM BLOOD CK(CPK)-5493* [**2135-10-4**] 10:58AM BLOOD CK(CPK)-3197* [**2135-10-4**] 06:24AM BLOOD ALT-20 AST-24 CK(CPK)-359* AlkPhos-128* TotBili-0.7 [**2135-10-6**] 04:43AM BLOOD CK-MB-12* MB Indx-0.4 [**2135-10-5**] 03:50PM BLOOD CK-MB-16* MB Indx-0.4 [**2135-10-5**] 03:10AM BLOOD CK-MB-17* MB Indx-0.3 cTropnT-0.19* [**2135-10-4**] 06:08PM BLOOD CK-MB-15* MB Indx-0.3 cTropnT-0.24* [**2135-10-4**] 10:58AM BLOOD CK-MB-10 MB Indx-0.3 cTropnT-0.26* [**2135-10-4**] 06:24AM BLOOD CK-MB-5 cTropnT-0.27* [**2135-10-14**] 04:24AM BLOOD Calcium-8.2* Phos-5.7* Mg-2.2 [**2135-10-5**] 01:05PM BLOOD Cortsol-43.8* [**2135-10-7**] 04:26AM BLOOD Lactate-1.1 [**2135-10-18**] WBC 28.4* HCT 23.4* Plt 334 Diff N 85.4* L 10.1* M 4.3 E 0.2 B 0.1 [**2135-10-24**] 06:11AM WBC 10.5 HCT 26.7* MCV 92 Plt 220 INR 3.0 [**2135-10-25**] 11:10AM WBC 9.5 HCT 25.3* MCV 95 Plt 203 INR 3.2 [**2135-10-26**] 05:48AM WBC 9.3 HCT 26.8* MCV 96 Plt 217 INR 2.8 PT 27.2 PTT 48.2 . MICROBIOLOGY: blood cultures from [**10-4**], [**10-5**], [**10-16**] and [**10-17**] NO GROWTH dialysis fluid cultures [**10-4**], 10/14/ [**10-17**] NO GROWTH TTE [**10-4**]: The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. No vegetation seen (cannot definitively exclude). . CXR [**10-4**]: 1. PULMONARY EDEMA VERSUS VOLUME OVERLOAD. 2. Asbestos exposure . Plain films right and left feet [**10-4**]: 1. Chronic or subacute fracture of the distal aspect of the first proximal phalanx on the left. 2. No specific radiographic evidence of osteomyelitis. MR would be more sensitive for detection of osteomyelitis if clinically indicated. . LE Doppler (arterial) [**10-5**]: Doppler evaluation was performed on the bilateral lower extremity arterial systems at rest only. On the right, the Doppler tracings are monophasic at the femoral level and this is the only level that was checked. The ankle-brachial index was unable to be obtained and the pulse volume recordings are markedly decreased and in fact flat at the thigh, calf, ankle, and metatarsal level. On the left, the only Doppler tracing that was obtained with a monophasic left femoral tracing. The ABI was unable to be obtained and the pulse volume recordings are flat at the thigh, calf, ankle, and metatarsal level. IMPRESSION: There is a severe flow deficit to both lower extremities from the level of the femorals distally. This is likely secondary to aortoiliac occlusive disease. . [**10-6**] TEE: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (mobile) atheroma in the descending aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. IMPRESSION: No ASD or intracardiac thrombus seen. Complex, mobile atheroma of the descending aorta. . [**10-6**] Left Foot MRI: Images are limited by motion. There is edema in the dorsal lateral soft tissues. There is no abnormal signal within the osseous structures to suggest osteomyelitis. There is no joint effusion. What is visualized of the tendons and ligaments of the ankle are normal. There is degenerative change of the first MTP joint. IMPRESSION: Dorsolateral soft tissue edema of left foot without evidence of osteomyelitis. . [**10-11**] CT Aorta/Bifem/Iliac: 1. Abdominal aortic aneurysm with extensive atherosclerosis is present in the entire vasculature of the abdomen and the lower extremities. There is an aortobifemoral graft with complete occlusion of left limb as well as occluded and retrograde filling of the left internal and external iliac arteries. 2. Fem-fem graft with luminal thrombus causing almost 30% narrowing of the graft with extensive atherosclerosis and calcific plaque causing significant attenuation of the vasculature of the lower extremities as described above. 3. Atrophic small kidneys with multiple cysts in keeping with the known diagnosis of chronic renal failure. 4. Ventral abdominal hernia with loops of bowel without definite evidence of bowel obstruction. 5. Grade 3 spondylolisthesis at L5-S1 level. . [**2135-10-17**] EGD: Impression: Erosions in the gastroesophageal junction compatible with esophagitis; Abnormal mucosa in the stomach; Erythema in the duodenum compatible with duodenitis; Protruding lesion vs. thickened fold found near papilla in 2nd portion of duodenum. Additional notes: GI bleeding likely secondary to erosive esophagitis at GE junction. Abnormal appearing polypoid lesion vs. thickened fold at papilla could not be adequate visualized. Next step would be evaluation with side-viewing scope and EUS if patient/family wish to pursue workup. Benefit of anticoagulation needs to be weighed against risk of re-bleeding given esophagitis. Would favor low INR goal if possible, once patient is further stabilized. . [**2135-10-17**] CT Chest w/out contrast IMPRESSION: 1. 18 mm nodule in the left lung apex is concerning for possible lung cancer and less likely apical scar. PET CT is recommended for further evaluation. 2. 18 mm rounded lesion at the right lung base most likely represents rounded atelectasis; however, this finding, and the adjacent pleural thickening, can also be evaluated at the time of the recommended PET CT to exclude neoplasm. 3. Resolving posterior segment right upper lobe and superior segment right lower lobe pneumonia versus aspiration pneumonia. 4. Dilated esophagus containing an air-fluid level. 5. Increased peritoneal fluid since the [**2135-10-11**] examination. 6. Partially imaged aortic stent graft; however, this study was not designed to evaluate stent patency. 7. Large ventral hernia, incompletely imaged. 8. Extensive atherosclerotic disease within the imaged aorta and coronary arteries. . [**2135-10-18**] RIGHT UPPER EXTREMITY ULTRASOUND: [**Doctor Last Name **] scale and Doppler son[**Name (NI) 1417**] of the right internal jugular, axillary, brachial, basilic, and cephalic vein demonstrate normal flow, compressibility, augmentation, waveforms. No intraluminal thrombus identified. CVL is noted within the left subclavian. IMPRESSION: No right upper extremity DVT identified. Brief Hospital Course: 77-year-old gentleman with ESRD, PVD, DM, and CAD with RLL pneumonia and necrotic toes. Transferred on [**2135-10-4**] from OSH w/ RLL PNA and sepsis. He was also evluated for revascularization options for ischemic digits in his lower extremities from his PVD. A TEE showed complex atheroma in his aorta and he was started on heparin gtt and coumadin. On [**10-17**] he became hypotensive to SBP 70s-80s associated with an episode of coffee ground emesis and guaiac positive stool and he was transferred to the MICU. He was given IVF and 1U PRBC and his anticoagulation was stopped. An upper endoscopy showed erosive esophagitis at the GE junction but no brisk bleeding. His Hct and blood pressure remained stable, and he was subsequently called out to the floor for further management. On the floor he was monitored and anticoagulation was restarted. He remained stable with but began refusing medications and care, saying he wanted to die. On [**10-23**] a family meeting was held and it was determined that he would be taken home with VNA services for care. On [**10-25**] he passed melena. His anticoagulation was held. He was monitored overnight- his HCT and vitals were stable, and he did not pass melena again, so given that his family was anxious to take [**Last Name (un) **] home, he was discharged with plan to follow up with his PCP the next day ([**2135-10-27**]) with his scheduled appointment. . # SEPSIS Patient met clinical criteria for sepsis in MICU, with fever, hypotension, tachycardia, and elevated lactate. Patient was given a 14 day course of Vanc/Zosyn to cover both pneumonia and soft tissue infection, to which he responded well. Patient never required pressors. A LLE MRI was negative for evidence of osteomyelitis (although the study was somewhat limited due to lack of gadolinium). His blood cultures from [**Hospital1 18**] were never positive. He also received 5 days of stress dose steroids for concern of relative adrenal insufficiency. . # LE NECROTIC TOES Patient's exam was notable for non-dopplerable DP pulses and dry gangrene of toes on both feet. He was evaluated by vascular surgery with a CT of his aorta/iliac/femoral vessels and then by a lower extremity angiogram. There was no stentable lesion identified on angiogram. Cardiology consult assessed the patient to be high risk for a high risk procedure, and it was decided not to pursue revascularization. As he did not show evidence of having infection in his lower extremities, it was decided to continue wound care of his feet rather than to amputate at present. . # MOBILE ATHEROMA Mobile atheroma of the descending aorta was noted on TEE done to evaluate sources of possible thromboemboli to necrotic toes. The patient was started on a heparin gtt and then switched to coumadin. Coumadin was held for GI bleed (see below) but restarted once resolved. At the time of discharge the coumadin has been held given 1 episode of melena [**10-25**] and INR 2.8, goal INR 2-2.5. Plan to f/u with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on the day after d/c, to adjust anticoagulation accordingly. . # DELIRIUM During the patient's MICU admission, he had waxing/[**Doctor Last Name 688**] mental status and at times became agitated. His delirium was felt to be multifactorial, including infection, ICU admission. He received haldol with good effect. By the time he was on the medical floor, he remained alert and oriented, although there were times when he would try to get out of bed despite his necrotic toes. Haldol was not needed. . # ESRD on PD Patient was followed by nephrology. He received alternating 1.5% and 2.5% dialysis baths to help with fluid removal after he was discharged from the ICU. Renal team planned to discuss dialysis with his PCP/nephrologist, Dr. [**Last Name (STitle) **]. . # DEPRESSION Patient had reportedly tried Paxil for depression as an outpatient. This was stopped when his wife clarified that the paxil had been making him drowsy and hence he had no longer been taking it at home. . # DM Although the patient is on oral agents at home, he was given insulin during his admission, especially since the 2.5% dialysis bath increased his insulin requirement. He was switched back to his home regimen lantus 6u qhs, but because of decreased po intake was changed to half dose, 3u qhs. . # CARDIAC A. CAD The patient's PCP was [**Name (NI) 653**], who reported that the patient has had MI x 2 in the past, but is not aware of any PCI or CABG. Patient was put on aspirin and a low dose beta blocker as tolerated by his BP. [**Name (NI) **] wife reported that the patient's statin had been stopped by a doctor in the past; she was not sure why. On the floor the patient was started back on ASA 1 week after resolution of GIB (see below), and statin. BB was held as his SBPs were ~100s. ASA was held [**10-25**] due to 1 episode of melena. It is recommended that the PCP [**Name Initial (PRE) **] 2 weeks after GIB before restarting ASA. . B. RHYTHM Patient was found to be in atrial fibrillation without rapid rhythm. He was put on heparin drip and then switched to coumadin. He was also started on a beta blocker. . C. PUMP Echo demonstrated preserved EF, though the patient was felt to have chronic diastolic heart failure. Although he was volume overloaded after being treated for sepsis in the MICU, he remained euvolemic after the extra volume was removed by dialysis. . . # Upper GI bleed: Did not appear brisk. GI performed EGD showing erosion of gastric esophageal junction. He was transfused 1 unit pRBC, and hct responded appropriately 23 - 26 and remained stable. Coumadin and ASA were held, but after 1 week of remaining clinically stable were restarted. On [**10-25**] he had an episode of melena, coumadin and ASA were held. He was monitored overnight, his HCT the next day remained stable around 26, he was hemodynamically stable and his family was insistent that he leave, so he was discharged home with plan to f/u with PCP the next day. . # lung nodule and duodenal polyps - were observed on CT (see report), recommended for PCP to [**Name Initial (PRE) **]/u as outpatient. . The patient was discharged in stable condition [**2135-10-26**]. Medications on Admission: Hectorol 5mcg qMTWThF KDur 20mEq PO tid Lactulose 1 tbsp PO daily prn Nephrocaps 1 PO daily Nexium 20mg PO daily Prandin 2mg qAM / 1mg qPM Renagel 800mg PO tid Senna 2 tabs PO qhs Sensipar 30mg PO daily alternating with 60mg daily Compazine one tablet po PRN Colace 1 tsp po daily prn Atarax 1 tablet po bid prn itch Discharge Medications: 1. [**Doctor Last Name 2598**] lift 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 7. Potassium Chloride 2 mEq/mL Parenteral Solution Sig: Five (5) ml Intravenous Q6H (every 6 hours). 8. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Three (3) units Subcutaneous at bedtime. 11. Pantoprazole 40 mg IV Q12H Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: PRIMARY 1. Sepsis 2. Lobar Pneumonia 3. Multiple necrotic toes with overlying gangrene 4. Severe peripheral vascular disease 5. Diabetes Mellitus 6. Erosive esophagitis SECONDARY 1. End stage renal disease on peritoneal dialysis 2. Coronary Artery Disease 3. Abdominal Aortic Aneurysm repair [**2129**] 4. History of Cerebral Vascular Accident Discharge Condition: Patient was not having fevers and his vital signs were stable. Discharge Instructions: You were admitted with pneumonia and with poor blood flow in your feet. You were treated in the ICU with antibiotics, and you were evaluated by vascular surgery. It was felt that surgery was too high risk in your case. You were also diagnosed with erosive esophagitis which caused some bleeding in your gastrointestinal tract. 1. Take all medications as prescribed 2. Make all follow-up appointments 3. If you develop fevers, chills, nausea, vomiting, bloody or black stool or any other concerning symptoms, contact your provider or report to the Emergency Department. Followup Instructions: 1. Please follow-up with Dr. [**Last Name (STitle) 1391**] in vascular surgery on [**2135-11-16**] at 9am, his office phone number is [**Telephone/Fax (1) 1393**] 2. Please follow up with your PCP and nephrologist, Dr. [**Last Name (STitle) **] on Thursday [**2135-10-27**] [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2135-10-26**]

[ "535.60", "428.0", "481", "403.91", "412", "530.82", "311", "211.2", "530.19", "707.03", "038.9", "444.0", "585.6", "995.91", "276.8", "293.0", "285.8", "427.31", "428.32", "414.01", "250.00", "440.24" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.13", "88.72", "99.04", "38.91", "54.98", "88.48" ]

icd9pcs

[ [ [] ] ]

18661, 18732

11233, 17461

326, 395

19120, 19185

2960, 11210

19804, 20240

2017, 2034

17828, 18638

18753, 19099

17487, 17805

19209, 19781

2049, 2941

277, 288

423, 1615

1637, 1827

1843, 2001

2,107

100,663

51745

Discharge summary

report

Admission Date: [**2173-2-27**] Discharge Date: [**2173-3-4**] Date of Birth: Sex: F Service: NEUROSURG HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old female with a history of a fall in the morning of admission who was taken to the [**Hospital 8**] Hospital at that time and was noted to be somnolent but arousable and moving all four extremities. She had an episode of emesis times two and was therefore intubated. She was then transferred to the [**Hospital1 346**] and was found on arrival to the [**Hospital1 1444**] to be unresponsive with pupils 5 mm bilaterally and minimally reactive. She was moving her bilateral lower extremities slightly and on CT scan was found to have a large left-sided subdural hematoma with midline shift and was taken urgently to the Operating Room for evacuation. PAST MEDICAL HISTORY: 1. History of hypertension. 2. Depression. 3. She is hard of hearing. MEDICATIONS: 1. Verapamil. 2. Hydrochlorothiazide. 3. Zestril. 4. Zoloft. 5. Ativan. 6. Enteric coated aspirin. ALLERGIES: She has no known drug allergies. PHYSICAL EXAMINATION: At the time of admission, she had pupils that were 5 mm and minimally reactive in the Emergency Room. Lungs were clear to percussion and auscultation. Heart rate was regular in rate and rhythm. Abdominal examination was soft, nontender with no organomegaly. The extremities showed a right foot to be slightly cyanotic with no evidence of Doppler pulses in the dorsalis pedis or posterior tibials. There was a scar on the leg from previous surgery and there was eschar at the heel. The left foot was warm. The remainder of the physical examination was rather limited due to the condition of the patient's unresponsiveness and the urgency of taking the patient to the Operating Room. LABORATORY: Preoperatively, her hematocrit was 33. Chem-7 was stable. Coagulation studies were considered stable with a PT of 12.9 and PTT of 21.6. INR 1.2. The urinalysis was negative. Urine cultures were obtained. Lactate was 1.7, glucose 218. HOSPITAL COURSE: Due to the clinical findings, the patient was taken urgently to the Operating Room where, under general endotracheal anesthesia, the patient underwent a left sided craniotomy with evacuation of subdural hematoma. The patient tolerated the procedure well and went to the Neurology Intensive Care Unit in stable condition, but remained essentially intubated and unresponsive to all but noxious stimuli, for which she showed occasional withdrawal of the extremities. During the [**Hospital 228**] hospital course, she showed at several occasions throughout the remainder of the hospitalization, the pupils were noted to be 3 mm and reactive to 2 mm with brisk withdrawal of the right arm and spontaneous movement of the bilateral lower extremities and a flicker of movement of the left arm. She did not open eyes spontaneously to command; occasionally would open eyes to sternal rub, but did not follow commands. Due to the clinical findings and the gravity of the situation, a discussion was held with the family and a decision was made to provide no heroic measures. The patient was subsequently extubated and transferred to the Hospital Floor on the [**2173-3-3**], and later on the 30th, the family decided to continue with comfort measures only. The patient never regained evidence of neurologic function beyond that described previously. Her examination continued to show limited spontaneous movement with the patient never opening her eyes to noxious stimuli. She developed mild tachycardia early on the [**3-4**] with decreased breath sounds in the right side and remained comatose until approximately 08:57 a.m. on the [**2173-3-4**], when the patient was found to have expired. CONDITION AT DISCHARGE: Deceased. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Doctor Last Name 7239**] MEDQUIST36 D: [**2173-5-24**] 18:55 T: [**2173-5-25**] 10:33 JOB#: [**Job Number 107188**]

[ "593.9", "852.20", "311", "401.9", "E888.9" ]

icd9cm

[ [ [] ] ]

[ "01.31", "96.72", "96.04" ]

icd9pcs

[ [ [] ] ]

2093, 3797

1131, 2075

3813, 4080

157, 846

868, 1108

1,754

103,405

23195

Discharge summary

report

Admission Date: [**2144-12-5**] Discharge Date: [**2144-12-23**] Date of Birth: [**2093-10-19**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: altered mental status; malaise Major Surgical or Invasive Procedure: 1. Endo-trachael intubation from [**2144-12-7**] to [**2144-12-15**] for airway protection secondary to supraglottic, upper pharyngeal swelling 2. Hemodialysis for ARF [**2-24**] ATN started on [**12-10**] 3. Left internal jugular central venous catheter placement. 4. Right triple lumen tunneled catheter placement. History of Present Illness: 51 yo F w/o significant PMH presented to ED on [**2144-12-4**] c/o malaise and change in mental status x 2d. Pt had been in USOH until approx 4 days previous when began having URI sxs consisting of non-productive cough and sore throat. One day prior to admission she felt worse w/ increased fatigue and states she slept all day. On the day of admission, her mental status had significantly worsened as noted by her husband and he brought her in to [**Name (NI) **]. In the ED, the patient was confused and disoriented. She was febrile to 101.6, tachycardic and tachypneic, and had episode of rigors. Pt resuscitated with 2 L of NS, CXR obtained and was negative, Head CT neg for bleed, UA neg for infection. No history of trauma. Past Medical History: Social History: + tobacco >30pack/yr hx + social EtOH denies drugs Lives with husband of 26yrs in [**Location (un) 686**] with two children. Works in [**Location (un) 86**] school system. Family History: Mother: + DM, HTN Father: EtOH abuse Sibs and offspring: no health probs Physical Exam: At the time of discharge to medicine [**Hospital1 **] svc: General: Obese AA female in NAD, no complaints of chest pain, shortness of breath, leg pain, or abdominal pain HEENT: NCAT, PERRL, EOMI, injected sclera bilaterally, MMM, oral pharynx clear without significant posterior pharyngeal swelling NECK: thick neck, no visible JVP, no palpable LAD PULM: CTA bilaterally, equal breath sounds, no wheeze, no stridor CV: RRR, nl S1, S2, no M/R/G ABD: soft +BS, non-tender, non-distended GU: Foley in place EXT: significant [**2-25**]+ bilateral UE/LE edema, middle finger of right hand black ischemic, contracted, duskiness of toes on bilateral feet, significant weakness 3/5 strength of UE and LE [**2-24**] deconditioning NEURO: CN II-XII intact, alert and oriented x 4 Pertinent Results: [**2144-12-16**] 02:33AM BLOOD WBC-25.2* RBC-3.01* Hgb-8.9* Hct-25.6* MCV-85 MCH-29.5 MCHC-34.7 RDW-16.6* Plt Ct-265 [**2144-12-15**] 05:20PM BLOOD Hct-27.3* [**2144-12-16**] 02:33AM BLOOD Plt Ct-265 [**2144-12-16**] 02:33AM BLOOD PT-13.3 PTT-54.2* INR(PT)-1.1 [**2144-12-13**] 04:13AM BLOOD Fibrino-303 [**2144-12-16**] 02:33AM BLOOD Glucose-112* UreaN-103* Creat-6.8*# Na-139 K-4.2 Cl-102 HCO3-21* AnGap-20 [**2144-12-16**] 02:33AM BLOOD Calcium-8.9 Phos-9.0* [**2144-12-15**] 04:42AM BLOOD Calcium-9.0 Phos-8.9* Mg-2.0 [**2144-12-11**] 09:50AM BLOOD calTIBC-166* Ferritn-588* TRF-128* [**2144-12-5**] 09:32PM URINE HOURS-RANDOM UREA N-388 CREAT-91 SODIUM-17 POTASSIUM-52 CHLORIDE-19 [**2144-12-5**] 09:32PM URINE OSMOLAL-329 [**2144-12-5**] 04:05PM GLUCOSE-222* UREA N-30* CREAT-1.8* SODIUM-140 POTASSIUM-4.1 CHLORIDE-115* TOTAL CO2-18* ANION GAP-11 [**2144-12-5**] 04:05PM HCT-39.9 [**2144-12-5**] 09:47AM GLUCOSE-243* UREA N-25* CREAT-1.5* SODIUM-143 POTASSIUM-5.1 CHLORIDE-118* TOTAL CO2-18* ANION GAP-12 CT HEAD W/O CONTRAST [**2144-12-4**] 10:29 PM IMPRESSION: No acute hemorrhage or mass effect. ECHO Study Date of [**2144-12-9**] Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. No vegetation seen (cannot definitively exclude). CT NECK W/O CONTRAST (EG: PAROTIDS) [**2144-12-8**] 10:10 AM IMPRESSION: 1. Limited examination, with no evidence of abscess on the current study. RENAL U.S. [**2144-12-9**] 6:39 PM IMPRESSION 1. Prior seen right kidney upper pole lesion clearly identified on the current study. This likely represents an artifact due to the heterogeneous echotexture of the renal cortex. 2. Heterogeneous renal echotexture, likely due to medical renal disease. 3. Normal arterial and venous waveforms. Brief Hospital Course: [**Date range (1) 40897**]: The patient was initially admitted to the MICU service for her altered mental status and potential sepsis. Her initial labs showed an elevated wbc w/ bandemia, thrombocytopenia. In addition she had a significant metabolic acidosis with a lactate of 5.6. She also had elevated Cr, elevated LFTs, markedly elevated CK 5516. A code sepsis was called and the pt was treated with ceftriaxone and Vanc for presumed sepsis of unknown source. U/A, CXR, and head CT wnl. A discussion regarding the utility/need for a lumbar puncture was discussed, but as the patient did not have any signs of meningismus it was not performed. Blood cultures were drawn. On admission the patient's skin on her legs from knees to feet was mottled as well as from elbows to fingers bilaterally. Petechia were noted on both thighs and upper arms. Radial, DP/PT pulses however were 2+ and palpable bilaterally. Her mental status briefly improved but then began to wax and wan again. On [**12-6**] she began complaining of a sore throat. A speculum exam was performed to r/o a retained tampon and was negative. On [**12-7**] blood ctx from [**12-4**] came back positive for strep pneumo. ID was consulted and advised continuation of ceftriaxone and discontinuation of vanc. The patient's mental status worsened and she had progressive respiratory distress, odynophagia, hypoxemia. Her speech was noted to be hoarse (breath w/ harsh soft noises), but no drooling or stridor. Oral exam revealed bleeding mucosa, palate fullness, inability to visualize posterior pharynx, mild tongue angioedema, blood tinged secretions noted in oral cavity, unable to expectorate. Elective intubation was performed by anesthesia at the bedside for airway protection and the patient was started on solumedrol for probable supraglottitis. [**12-7**] to [**12-15**]: The patient remained intubated for airway protection. Since admission the Renal team was following the patient. Her kidney function continued to worsen with her creatine peaking at 6.3. She was oliguric throughout her admission. Renal failure was thought to be secondary to ATN and possibly post-streptococcal glomerular nephritis. A left IJ HD line was placed and the patient was started on HD. In addition, she developed purpura fulminans with full ischemia and necrosis of her right middle finger and ischemia of her toes. Vascular surgery was consulted and recommended anticoagulation with heparin and eventual elective removal of the digit. On [**12-15**] after HD to remove excess fluid, the patient was taken to the OR where she was extubated under controlled conditions without difficulty. The patient also had anemia. Hemolysis labs were sent and Heme/Onc was consulted. There was no evidence of hemolysis. [**12-16**]: The patient passed her speech and swallow eval and was able to tolerate PO. PT and OT were both consulted regarding deconditioning and strength exercises for the patient. [**12-16**] to [**2144-12-23**] by problem: 1. Strep pneumo sepsis: the patient was transferred to the Medicine service afte extubation, and continued ceftriaxone to complete a 14 day course of IV antibiotics in the hospital. After completing antibiotics, she had no signs or symptoms of infection for the remainder of her hospital stay. At d/c, she is afebrile with no signs of infection. 2. Acute renal failure: she continued to be oliguric throughout her admission, with creatinine peaking at 9.4. However, her urinary output showed progressive improvement throughout the last week of hospitalization. On the day of DC, the pt produced nearly 30cc/hour of urine. During her admission, she was followed by the Renal service and received hemodialysis and ultrafiltration based on electrolyte abnormalities and fluid overload. She will require continued dialysis after d/c, initially every other day, for acute renal failure likely [**2-24**] ATN and post-Strep glomerulonephritis. Her renal function is expected to show continued improvement. She must be followed closely by a Renal physician to determine the schedule of her dialysis as her renal function improves. 3. Purpura fulminans with dry gangrene of the digits: her sepsis was complicated by dry gangrene of the right 3rd/5th digits and bilateral toes. She was evaluated by Vascular and Plastic Surgery during her admission. She was intially treated with heparin gtt for dry gangrene, which was d/c when antibiotics were finished and pt had obviously cleared her sepsis. Plastic surgery recommends daily dressings to the effected digits with gauze and bacitracin, and close monitoring for signs of infection. The patient must follow-up with Plastic Surgery clinic in 2 weeks to be assessed for surgical debridement. At DC, there is no redness, drainage, or other signs of infection of the digits. 4. Anemia: the patient has been anemic throughout her admission. Lab studies were consistent with anemia of inflammation; she has no iron or B12/folate deficiency. Her HCT trended down throughout her admission to 27, where it plateaued and remained stable for the final 3 days of her stay. She was continuously guaiac negative and showed no signs of GI bleed. At DC, HCT is stable and there are no symptoms of anemia. She will require close monitoring of HCT. 5. Hyperphosphatemia: serum phosphorous levels started to increase after she developed acute renal failure. Phosphorous climbed to a peak of 9 despite treatment with AlOH, PhosLo, and Renagel. However, with conistent use of these medications, serum phosphorous decreased to 5 on the day of DC. She will require continued treatment with AlOH, PhosLo, and Renagel. 6. Respiratory failure: after extubation, she had no further respiratory distress, maintaining O2 saturation greater than 93% on room air. Medications on Admission: tylenol ibuprofen theraflu Discharge Medications: 1. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 2. Acetaminophen 160 mg/5 mL Elixir Sig: Six [**Age over 90 1230**]y (650) mg PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. 3. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 7. Calcium Acetate 667 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 12. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 13. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Sixty (60) ML PO QID (4 times a day) as needed for increasing phos. 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: 1. Pneumococcal sepsis 2. Acute renal failure with hemodialysis 3. Post-streptococcal glomerulonephritis 4. Anemia 5. Septic emboli with ischemia of digits Discharge Condition: Stable to go to rehab. No signs or symptoms of infection. Renal function recovering slowly, but still recovering hemodialysis every other day, and requiring close monitoring by Renal team. Ischemic digits on R hand and bilateral feet with dry gangrene, awaiting surgical debridement of necrotic tissue in 2 weeks. Discharge Instructions: Please take all medications regularly as prescribed. Please follow-up closely with all of your doctors as detailed below. Present to the ED for evaluation if you have fever, shaking chills, dizziness, bleeding, confusion, or other concerning symptoms. You will need hemodialysis often until your kidneys recover, likely every other day. Followup Instructions: Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], your new Primary Care Physician, [**Name10 (NameIs) **] [**Name11 (NameIs) 191**] clinic on [**2144-12-29**] (call [**Telephone/Fax (1) 250**] for appointment) Follow-up with Plastic Surgery Clinic in [**2145-1-12**] at 9:30 AM ([**Telephone/Fax (1) 274**]) Follow-up with [**Hospital 2793**] clinic in 1 week (call [**Telephone/Fax (1) 60**] for appointment) [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "275.3", "276.2", "286.6", "518.5", "785.4", "481", "038.2", "995.92", "584.5", "305.1", "580.0", "619.1", "372.00", "034.0", "728.88", "285.9", "287.5", "278.00" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "96.04", "99.05", "99.04", "38.93", "96.6", "97.39", "31.42", "96.72" ]

icd9pcs

[ [ [] ] ]

12148, 12203

4829, 10625

347, 669

12402, 12719

2537, 4806

13106, 13687

1656, 1730

10703, 12125

12224, 12381

10651, 10680

12743, 13083

1745, 2518

277, 309

697, 1428

1451, 1451

1467, 1640

19,461

109,952

11431

Discharge summary

report

Admission Date: [**2121-10-25**] Discharge Date: Service: CARD/[**Last Name (un) **] ATTENDING:[**Last Name (STitle) 36538**] HISTORY OF THE PRESENT ILLNESS: The patient is a 77-year-old female status post CABG in [**2103**], and PTCA in [**2115**]. She presented with chest pain and positive stress test to the ER. The catheterization showed LIMCA 40% ostia occluded, 40% to 59% distally occluded, LAD 100% occluded, LCX proximally at 90% occluded, RCA 100% occluded. Ejection fraction was 45%. PAST MEDICAL HISTORY: History is significant for coronary artery disease, status post CABG in [**2103**], PTCA in [**2115**], hypercholesterolemia and GERD. MEDICATIONS: (home). 1. Hydrochlorothiazide. 2. Lipitor. 3. Imdur. 4. Accupril. 5. Lopressor. 6. Aspirin. HOSPITAL COURSE: The patient was taken by Dr. [**Last Name (STitle) 5873**] to the ER for CABG times three on [**2121-10-28**]; LIMA to LAD, SVG to OM and SVG to RPDA. Postoperatively, the patient did very well being extubated and weaned off drips. The chest tube was discontinued without incident. On postoperative day #2, the patient was transferred to the floor and ambulating and working with the physical therapist without any problems. The patient achieved physical therapy level III. On postoperative day #3, the patient would express a desire to leave and a rehabilitation facility was arranged for the patient. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg p.o.b.i.d. 2. Lasix 20 mg p.o.b.i.d. times five days. 3. [**Doctor First Name 233**]-Ciel 20 mEq p.o.b.i.d. times five days. 4. Aspirin 81 mg p.o.q.d. 5. Lipitor 10 mg p.o.q.d. Upon discharge, the patient was in regular rate and rhythm, normal sinus. Chest was clear to auscultation. Incision was clean, dry, and intact, no drainage, no pus, sternum stable. The patient was ambulating with assistance at level III. The patient was discharged to rehabilitation with instruction to followup with Dr. [**Last Name (STitle) 5873**] in three to four weeks. DR.[**Last Name (STitle) **],[**First Name3 (LF) 275**] E. 02-248 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2121-10-31**] 10:45 T: [**2121-10-31**] 10:49 JOB#: [**Job Number 36539**]

[ "V45.81", "530.81", "410.01", "272.0", "414.02" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

1434, 2244

802, 1411

534, 784

20,568

116,797

44532

Discharge summary

report

Admission Date: [**2168-1-22**] Discharge Date: [**2168-1-29**] Date of Birth: [**2127-3-4**] Sex: M Service: Urology HISTORY OF PRESENT ILLNESS: Left renal mass. PHYSICAL EXAMINATION: Patient is a well-developed and well-nourished male in no apparent distress. HEENT: Mucous membranes are moist. No oral ulcers, no evidence of scleral icterus and no cervical lymphadenopathy. Cranial nerves II through XII are intact. Chest was clear to auscultation bilaterally with mild decreased breath sounds in the left lower base. Cardiac: Regular, rate, and rhythm, no murmurs. Abdomen is soft, nontender, nondistended with oblique incision in the left upper aspect of the abdomen with staples intact. No evidence of cellulitis noted. No purulence noted. Extremities: No evidence of rash. No edema noted. PERTINENT LABORATORIES: On [**2168-1-28**]: Hematocrit 34.4, PT 31.9, PTT 51.5, and INR of 3.2. This is after the Heparin has been discontinued and the Lovenox therapy was initiated. SUMMARY OF HOSPITAL COURSE: Mr. [**Known firstname **] [**Known lastname **] is a 29-year-old male with past medical history remarkable for multiple Crohn's bowel resection, who underwent an uncomplicated left radical nephrectomy. Patient's postoperative course was complicated by a sudden desaturation on postoperative day #1 to 70% on room air with cognatant tachycardia. Although workup with VQ scan revealed low probability for a pulmonary embolus, due to the high clinical suspicions, CT angiogram was performed which revealed a pulmonary embolus localized in the left upper lobe pulmonary artery and right lower lobe branch of basilar segments. No electrocardiogram change was noted during this period. The patient was transferred to the Intensive Care Unit, where Heparin therapy was initiated and targeted for a PT of 60-70. During this time, a baseline check of coagulation showed an INR of 1.9 rising to 3.2 thereafter. Hematology/Oncology consult was obtained which directed the source of elevated INR to the probable vitamin K deficiency secondary to Crohn's as well as Heparin infarct. Decision was made after extensive discussion with Hematology/Oncology and Pulmonary Service, to initiate Lovenox therapy, and give a trial of vitamin K. Throughout this course, the patient's hematocrit was stable, and the patient's bowel function returned with corresponding advancement of diet. Decision was made to discharge the patient to home with VNA service to ensure compliance with Lovenox regimen. Because biopsy results indicated renal cell carcinoma, the patient was referred to Biologics Oncology service for followup for both anticoagulation as well as Oncology issues. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSIS: Status post left radical nephrectomy. DISCHARGE MEDICATIONS: 1. SubQ Lovenox 80 mg [**Hospital1 **]. 2. Dilaudid 3 mg po q2-4h prn pain. FOLLOW-UP PLANS: The patient was instructed to call the office of Dr. [**Last Name (STitle) 986**] for a follow-up appointment. The patient was also instructed to contact the Biologics Oncology Service for a follow-up appointment regarding the results of the nephrectomy as well as the anticoagulation issues. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 38941**] Dictated By:[**Name8 (MD) 95396**] MEDQUIST36 D: [**2168-1-29**] 10:37 T: [**2168-2-1**] 11:41 JOB#: [**Job Number **]

[ "555.9", "415.11", "189.0", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "55.51" ]

icd9pcs

[ [ [] ] ]

2853, 2930

2791, 2830

1045, 2709

205, 1016

2948, 3497

164, 182

2734, 2769

72,993

182,458

40435

Discharge summary

report

Admission Date: [**2181-6-8**] Discharge Date: [**2181-6-10**] Date of Birth: [**2100-11-10**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 99**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Endotracheal intubation Central venous line placement Arterial line placement History of Present Illness: 80 yo cantonese speaking female with history cirrhosis secondary to hepatitis C presented with abdominal pain. She reports the pain has been present for the past 4 days. She reports it started on Sunday, then became progressively worse over the course of the week. The pain radiates to the chest, back and left shoulder. She denies nausea, vomiting, diarrhea, reports decreased PO intake. Reports low grade temp for the last two days. She called her PCP who told her to go to [**Location (un) 620**]. At [**Location (un) 620**], she was hypotensive to 60/40, labs were significant for WBC 3.4 with 65% neutraphils 14% bands, Hct 26.2, lactate 3.8, Crn 2.4, Na 126, heme neg, UA positive for nitrates. There, she received 6L NS and one dose of IV vanco. . In the ED, initial VS were 96.7 100 118/74 20 98% 4L NC. She was reportedly peritoneal on exam. Initial labs were apparently diluted. Repeat labs were significant for hyponatremia of 132, HCO3 of 16, Crn 1.6, Ca 6.0, Mg 1.3, Alb 2.5, ALT 48, AST 33, AP 26, lactate of 2.6, WBC 1.6 with 31% bands (repeat 1.2 bands 20% neutr 43%), Hct 24.7 (repeat 33.2). Received zosyn and iv fluids (1LNS). CT abd showed ascities, concerning for SBP and colitis. Surgery saw the patient and does not feel surgical. Transplant surgery seeing as well. 2 18 guage PIVs were placed. VS on transfer 97 105 100/60 18 97% on RA. After report was called, BPs dropped to the 80s systolic, L IJ was placed and she was started on levophed. . On the floor, the patient has persistent abdominal pain. She is mentating appropriately. . Review of systems: (+) Per HPI, also right arm pain (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Cirrhosis [**2-28**] hepatitis C from a blood transfusion many years ago Social History: She lives in [**Hospital1 189**], daughter in [**Name (NI) 932**]. - Tobacco: denies - Alcohol: denies - Illicits: denies Family History: Noncontributory Physical Exam: On Admission: General: cantonese speaking female, alert, oriented X3, in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: voluntary guarding, mildly tense in the lower quadrant, hypoactive bowel sounds GU: foley in place with minimal urine output Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Pronouncing death: Patient unresponsive to sternal rub or deep pain stimuli. Pupils 4mm and fixed bilaterally, no constriction or accomodation. No respiratory activity with no chest rises. No pulse auscultated or palpated for 60 seconds. Cool extremities. Pertinent Results: On admission: [**2181-6-8**] 12:30PM BLOOD WBC-1.6* RBC-2.11* Hgb-7.8* Hct-24.7* MCV-117* MCH-36.9* MCHC-31.5 RDW-13.7 [**2181-6-8**] 12:30PM BLOOD Neuts-40* Bands-31* Lymphs-5* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-10* Myelos-7* Promyel-1* [**2181-6-8**] 12:30PM BLOOD PT-28.4* PTT-57.1* INR(PT)-2.7* [**2181-6-8**] 12:30PM BLOOD Glucose-978* UreaN-30* Creat-1.3* Na-103* K-2.7* Cl-80* HCO3-11* AnGap-15 [**2181-6-8**] 12:30PM BLOOD ALT-37 AST-24 AlkPhos-20* TotBili-2.2* [**2181-6-8**] 12:30PM BLOOD Albumin-1.9* Calcium-3.9* CXR: IMPRESSION: Left base opacity including the retrocardiac region may be due to atelectasis with possible small effusion, underlying consolidation not excluded. Pulmonary vascular engorgement. CT Abdomen/Pelvis: IMPRESSION: 1. Wall thickening and fat stranding of the ascending colon. Differential diagnosis includes portal colopathy or colitis (infectious, inflammatory or ischemic etiologies). 2. Diffuse stranding in the upper abdomen and mesenteric edema. Findings are non-specific and may be secondary to portal hypertension or inflammation of any of the upper abdominal organs as described above. 3. Pericholecystic fluid. Normal gallbladder without stones. 4. Bibasilar consolidations and small effusions, left greater than right. Likely atelectasis, though infection cannot be excluded. 5. Cirrhotic liver with splenomegaly suggesting portal hypertension. Brief Hospital Course: 80 yo cantonese speaking female with history cirrhosis secondary to hepatitis C admitted to the ICU for presumed septic shock and abdominal pain found to have GNR sepsis. . # GNR bacteremia/septic shock: Presumed secondary to intra-abdominal infection. CT revealed fat stranding in the upper abdomen around the ascending colon, duodenum. Transplant surgery was consulted and felt patient poor operative candidate with very high risk of mortality if taken to OR. Patient had CVL placed and was treated with pressors - initially levo and vasopressin. She received volume with nearly 9 L IVF. She was treated empirically with vancomycin/cefepime/flagyl. Patient had elevated lactate ranging from 9 - 11, which did not improve with antibiotics. Patient's did not have respiratory compensation for metabolic acidosis and required intubation. Platelets fell, INR went from 1.9 to 2.7. Fibrinogen and haptoglobin remained normal making DIC less likely. Patient was initally neutropenic, but her WBC increased to 5 with 30% bands. She was hypotensive and required pressor support with levophed and vasopressin. A long discussion was held with the family regarding overall poor prognosis and patient's family elected to extubate patient and focus on comfort care. # Respiratory Distress: The patient complaining of some shortness of breath likely secondary to fluid overload. She was net positive 8-9 liters during the first 2 days of admission. Otherwise the patient??????s ABG did not show that she was hypoxic or hypercarbic. Differential also included pneumonia which could be possible given the patient??????s complaint of chest pain and LLL consolidation seen on CT scan and CXR. No evidence of ARDS. She had metabolic acidosis with lactate [**10-7**] without respiratory compensation and was intubated, after which her acidosis improved. . # Neutropenia: ANC of 960 on admission. Unclear etiology, but likely secondary to sepsis. She was started on empiric vanc/cefepime/flagyl and blood cultures returned with GNR sensitive to everything except ampicillin. Her WBC, as above, was rising and had 31% bands. . # ARF: Unclear baseline. Likely related to ATN vs. prerenal state. Cr on admission was 1.9, but down from 2.4 at [**Location (un) 620**] after aggressive fluids. Down to 1.7 the following day. FeNa was 0.14% consistent with pre-renal etiology. She was continued on IVF but Cr continued to rise to 2.0. . # Cirrhosis: Unknown baseline LFTs, unclear if related to Hep b or C or both. Hepatically dosed medications. Synthetic function appears to be effected with INR 1.9 and Alb 2.8. Platelets dropped to 40, INR up to 2.7, PTT up to 46.4, WBC 5.2 with 31% bands. As above, was made CMO after overall poor prognosis in setting of sepsis. . # CMO: family meeting was held to discuss goals of care and sons and daughters elected to withdraw all therapy and to focus on comfort care only. Patient was removed from pressors the morning of [**6-10**] and her BP began to drop quickly. At 3:35pm she did not show any respiratory or cardiac activity and was pronounced at bedside. Family was present and declined autopsy. Case was not reported to the medical examiner. Medications on Admission: -alendronate 70 mg 1 x week -ranitidine 150 mg Twice Daily -spironolactone 50 mg Twice Daily -folic acid 1 mg Daily -iron 27 mg Daily -Centrum Silver daily Discharge Medications: Pt expired Discharge Disposition: Expired Discharge Diagnosis: Septic shock GNR bacteremia Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2181-6-10**]

[ "275.41", "070.54", "785.52", "789.59", "276.4", "038.42", "584.5", "571.5", "288.04", "995.92", "275.2", "518.81" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8392, 8401

4963, 8150

317, 396

8472, 8481

3542, 3542

8537, 8575

2711, 2728

8357, 8369

8422, 8451

8176, 8334

8505, 8514

2743, 2743

2022, 2456

263, 279

424, 2003

3556, 4940

2478, 2552

2568, 2695

6,598

128,971

49220

Discharge summary

report

Admission Date: [**2188-7-16**] Discharge Date: [**2188-7-23**] Date of Birth: [**2116-11-8**] Sex: M Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 800**] Chief Complaint: fevers and shakes Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: Mr. [**Known lastname **] is a 71 yo male with a h/o CAD, afib on coumadin, and pulmonary vasculitis who presented to [**Hospital3 **] on [**7-15**] with fever to 103.6, complaining of shakes. Patient states that he was previously feeling well and had taken care of his grandkids and went swimming earlier in the day. On the night of presentation, he developed chills, rigors x 1 hour, and a fever to 103.6. On arrival to the ED at [**Hospital1 **], a CXR was interpreted to show a RLL infiltrate, and he was started empirically on levofloxacin. Patient was witnessed to rigor again and become very hypoxic and cyanotic with SpO2 in 50's, improved with 100% NRB. ABG at that time 7.34/39/100. He was transferred to the ICU at [**Hospital1 **] for closer monitoring, and antibiotic coverage was broadened to Vanc and Zosyn. On the morning of [**7-16**], a d-dimer returned at 472.5; a CTA chest was performed and was reported as negative for PE. He was noted to have elevated troponins and thus was transferred to the CCU at [**Hospital1 18**]. . On review of symptoms, 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. As above, ROS is notable for recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: 1. pANCA/MPO positive vasculitis - diagnosed during admission for hemoptysis from [**Date range (3) 103195**]. Started on prednisone in [**7-/2187**], now on 7.5 mg qd. Cytoxan [**9-/2187**]/23/[**2187**]. Started on Imuran [**2188-5-12**]. 2. CAD s/p CABG in [**2163**], s/p PCI in [**2176**] and [**2180**], s/p repeat CABG in [**11/2184**] with LIMA to LAD, SVG to OM, and SVG to PDA. 3. Atrial Fibrillation on coumadin 4. Seizure disorder [**7-/2187**] 5. Hypertension 6. Hyperlipidemia 7. Restless leg syndrome 8. s/p bilateral hernia repair 9. GERD 10. Sleep apnea 11. Chronic anxiety 12. Rt knee arthritis 13. s/p Cholecystectomy in [**3-/2188**] 14. H/o Hepatitis B in [**2159**]'s Cardiac History: CABG, in [**2165**] and re-do in [**2184**], anatomy as follows: CABG [**2165**] - SVG->LAD+D1 with subsequent ostial stent 4X8 Bx Velodity in [**2176**] and also LAD stent in [**2180**]; other grafts SVG->OM and SVG->RPDA occluded; most recently SVG->LAD/D1 with slow flow Redo CABG in [**2184**]: LIMA->LAD, SVG->OM and SVG->PDA Social History: Widowed, has 4 sons. Lives with one son in [**Name (NI) 1268**], retired from electrical engineering but works one day a week at golf course during spring/summer season. Very active at baseline and golfs frequently. No prior tobacco history. Rare ETOH in the past, and none now. No illicits/IVDU. Was out vacationing in [**Hospital3 **] three weeks ago. No pets. Family History: Father had DM and CAD, 1st MI age 51 and later died of MI at age 62. Brother with CAD. Physical Exam: VS: T 96.8, BP 103/67, HR 55, RR 12, O2 99% on RA Gen: elderly male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple without JVD. CV: Irregularly, irregular rhythm. PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2, with third heart sound. LV impulse is hyperdynamic. [**12-26**] harsh blowing murmur best heard at the apex. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: 1+ lower extremity edema to mid-tibia bilaterally. No femoral bruits. Skin: Non-blanching petechiae over ankles to mid-tibia. No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Brief Hospital Course: # Microscopic polyangiitis: Pt with BAL positive for blood and macrophages consistent with flare of his pulmonary vasculitis. Rheumatology consulted. Pt was given 1g solumedrol per day for three days and then planned for steroid taper. Azathioprine was held. Pt did extremely well on this regimen and was transfered off of the MICU service for further management and steroid taper. Pt was restarted on cyclophosphamide per rheumatology recs. It is worth noting that the Pt has some blood and protein in his urine with R CVA tenderness for the past few weeks, the same timeframe in which this flare occured. This raises the concern for renal involvement by his disease, but there is no clear evidence for renal vasculitis at this time. Pt was discharged on cyclophosphamide and prednisone. Pt will follow up with Dr. [**Last Name (STitle) 2087**] at [**Hospital1 2025**], Rheumatology at [**Hospital1 18**], and Pulmonology at [**Hospital1 18**]. He will be monitored with weekly CBCs and UAs. . # Pancytopenia: leukopenia and anemia seemingly a sequelae of azathioprine use. Given the pancytopenia and the polyangiitis flare while on this drug, azathioprine was held. Pancytopenia resolved and pt was restarted on cyclophosphamide per rheumatology. . # Fevers: An extensive fever work up was undertaken before the etiology of his symptoms and signs were clear. As of transfer off of the MICU service all cultures, serologies, and test were negative. Fever likely secondary to alveolar hemorrhage. Fever resolved and did not return during hospitalization. . # A-fib: Stable; Pt was continued on home meds for rate control. Coumadin was held in setting of alveolar hemorrhage. Will be restarted in one week under the supervision of his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4469**]. Medications on Admission: - azathioprine 50 mg daily - prednisone 7.5 mg daily - pantoprazole 40 mg daily - TMP/SMX 400/80 mg daily - calcium citrate 1000 mg [**Hospital1 **] - vitamin D3 400 units [**Hospital1 **] - aledronate 70 mg every week - levetiracetam 1000 mg [**Hospital1 **] - tamsulosin 0.4 mg qHS - aspirin 325 mg daily - Mirapex 0.25 mg 1-3x daily PRN - Lorazepam 1 mg TID PRN - Folic acid 5 mg daily - Warfarin 4-6 mg daily as directed - metoprolol 12.5 mg [**Hospital1 **] Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*21 Tablet(s)* Refills:*0* 3. Cyclophosphamide 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Please take with at least 500 mL of water. Disp:*21 Tablet(s)* Refills:*0* 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Citrate 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 13. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). 14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. Outpatient Lab Work CBC, Urinalysis Please send results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr [**Last Name (STitle) 4469**] at [**Telephone/Fax (1) 4475**] Discharge Disposition: Home Discharge Diagnosis: Microscopic polyangitis Alveolar hemorrhage Anemia Leukopenia Thrombocytopenia Discharge Condition: Good. Hemodynamically stable and afebrile. No signs of active bleeding. Discharge Instructions: You were transferred to the [**Hospital1 18**] from an outside hospital after having fevers, shaking chills and a low oxygen level. You were found to have a condition known as alveolar hemorrhage which means you had bleeding into your lungs because of your known history of microscopic polyangitis. Prior to admission, you had a change in your medications from cyclophoshpamide to azathioprine. It was felt that your current relapse was because of this medication change and we would recommend that you continue treatment with cyclophosphamide. We also stopped your coumadin because of the active bleeding. You should follow up with Dr. [**Last Name (STitle) 4469**] within 2 weeks to discuss restarting this medication. The following changes were made to your medications: 1) Stopped coumadin - discuss with Dr. [**Last Name (STitle) 4469**] when to restart this medication 2) Stopped azathioprine 3) Started cyclophosphamide at 75 mg daily 4) Increased prednisone from 7.5 mg to 60 mg daily Please return to the emergency department if you develop shortness of breath, bleeding from any site, cough with or without blood, fevers, chills or night sweats, diarrhea, abdominal pain, chest pain or any other symptoms that are concerning to you. Followup Instructions: Please follow up with Dr [**Last Name (STitle) 4469**] within 1 week to discuss when to restart coumadin. Call [**Telephone/Fax (1) 4475**] for an appointment. . Please follow up with Dr. [**Last Name (STitle) 2087**] at [**Hospital1 2025**] within 1 week to discuss treatment for your vasculitis. You were started on high dose steroids and cyclophosphamide and need to be monitored closely while on this therapy. Please discuss with Dr. [**Last Name (STitle) 2087**] when to taper steroids. . Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) 103196**] from Rheumatology. You have an appointment scheduled for Friday [**8-1**] at noon in the [**Hospital1 18**] [**Hospital Ward Name 517**] [**Hospital Unit Name **]. . Please follow up with Dr. [**Last Name (STitle) **] from Pulmonology. You have an appointment scheduled for [**8-6**] at 2pm on [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] builiding. . You will need weekly blood and urine tests for monitoring while you are receving cyclophosphamide. A prescription has been given to you for these tests and results will be sent to Dr. [**First Name (STitle) **] [**Name (STitle) 103196**] and Dr. [**Last Name (STitle) 4469**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

[ "300.4", "446.0", "333.94", "455.0", "287.5", "417.8", "288.50", "787.91", "784.7", "427.31", "285.9", "414.01", "780.57", "780.6", "786.3", "E934.2", "345.90", "284.1", "414.02", "E933.1", "799.02" ]

icd9cm

[ [ [] ] ]

[ "33.24" ]

icd9pcs

[ [ [] ] ]

8403, 8409

4532, 6339

283, 297

8532, 8606

9900, 11266

3382, 3470

6853, 8380

8430, 8511

6365, 6830

8630, 9877

3485, 4509

226, 245

325, 1922

1944, 2985

3001, 3366

28,896

102,610

33337

Discharge summary

report

Admission Date: [**2122-2-26**] Discharge Date: [**2122-3-3**] Date of Birth: [**2056-6-6**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 974**] Chief Complaint: trauma/MVC Major Surgical or Invasive Procedure: none History of Present Illness: 64M transferred from [**Hospital3 **] s/p MVC, unrestrained driver of a high-speed vehicle +rolled over, fully ejected from the vehicle, +LOC. GSC=3 at scene, intubated at scene and brought to [**Hospital3 **]. Past Medical History: PMHx,Allergies,Meds, social history, family history, ROS: unable to determine Social History: nc Family History: nc Physical Exam: PHYSICAL EXAM: O: SBP: 70's-120's/palp-70's unstable HR: 100-140 R-intubated AC RR 14 O2Sats:99% Gen: intubated, best exam: GCS 4T HEENT: Pupils: 1mm bilat, minimally responsive Neck: in c-collar Lungs: +BS bilat Cardiac: reg rate Abd: Soft Extrem: cool to touch Neuro: GCS 4T, best exam: grimaces to pain, but does not open eyes, w/d LLE to pain Brief Hospital Course: 64 M s/p MVC, unrestrained driver, rollover, ejected, intubated at scene for GCS 3, needle and L CT placed at OSH with no blood. +Etoh hypotensive, tachy in trauma bay--3uPRBC given, femoral a line placed . Injuries: 1)Right diaphysis ulnar Frax 2)[**Doctor First Name **], R temp IPH 3)Aortic Dissection of descending aorta 4)B/L Hemothorax, L pneomothorax 5)B/L Rib frax 6)Mandibular fx, L maxialry sinus, L orbital wall fx, nasal bone fx 7)Nasal Lac down to cartilage, L Eyelid Lac:down to orbicularis muscle, chin lac 8)L common corotid throombosis, reconstitution of LIC, LEC . The patient was transfered to the TSICU and remained intubated. The patient's family arranged for special religious ceremonies and the patient was made CMO on [**3-3**]. The patient died at 1430 on [**3-3**]. Autopsy was refused Medications on Admission: n/a Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: na Followup Instructions: na

[ "901.0", "881.00", "883.0", "881.10", "873.44", "802.21", "813.82", "860.4", "807.09", "434.91", "958.4", "870.3", "870.8", "V66.7", "806.4", "E816.0", "285.9", "900.01", "873.22", "802.8", "801.36", "802.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.6", "99.07", "96.72", "86.28", "86.59", "02.2", "79.02" ]

icd9pcs

[ [ [] ] ]

2001, 2010

1104, 1919

322, 328

2062, 2072

2123, 2128

708, 712

1973, 1978

2031, 2041

1945, 1950

2096, 2100

742, 1081

272, 284

356, 570

592, 672

688, 692

20,931

136,161

52508

Discharge summary

report

Admission Date: [**2178-12-28**] Discharge Date: [**2179-1-2**] Date of Birth: [**2133-4-4**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 23753**] Chief Complaint: Abdominal pain & blurry vision Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 45yo woman with a history of DM type I on home lantus and sliding scale who presented with abdominal pain & blurry vision. One day prior to admission, pt developed photophobia (TV bothering her eyes), blurry vision, sharp abdominal pain, shortness of breath, chest tightness & unsteady gait. Also, (+) polyuria, polydypsia, nausea & vomiting. Pt's family called EMS & brought her to [**Hospital1 18**]. . In [**Name (NI) **], pt was found to have blood glucose in 800's. ABG 6.9/17/60 HCO3 5. EKG showed changes that were initially concerning for STEMI and pt started on heparin gtt because of this. Cardiology reportedly saw pt & reviewed EKG in ED and felt that pt was not having ACS and that heparin was not indicated. (EKG changes actually J point elevation in V2-V4, which were unchanged from previous EKG. Additionaly, other changes, including ST depressions 1-2mm in I, V5, V6; TWI in I, aVL, biphasic T waves in V5-V6, were all unchanged from previous EKGs.) Past Medical History: 1. DM type I; A1C 8.2 in [**11-3**]; no h/o DKA, but multiple ED visits for hypoglyemia 2. HTN 3. depression 4. Bartholin gland abscess s/p I and D Social History: Lives with her children. Smokes 1/3ppd, drinks 1 beer/day. No known STD's, has boyfriend. Family History: History of HTN; no DM, CAD or cancer. Physical Exam: VS: Tc 98.5F Tmax 99.1F HR 69 (69-111) BP 176/97 (131-182/65-93) RR 19 100%RA Gen: awake, alert, pleasant, sitting up eating dinner, NAD HEENT: PERRL, EOMI, anicteric sclera, OP clear, MMM, poor dentition Neck: supple, no JVD CV: RRR, Normal S1, S2 Pulm: CTAB Abd: Normoactive bowel sounds, soft, ND/NT Ext: WWP, no edema Pertinent Results: Admit Labs: [**2178-12-28**] 07:05AM GLUCOSE-848* UREA N-38* CREAT-2.4*# SODIUM-126* POTASSIUM-GREATER TH CHLORIDE-83* TOTAL CO2-5* [**2178-12-28**] 07:05AM WBC-31.2*# HCT-39.0 [**2178-12-28**] 12:57PM ALT(SGPT)-15 AST(SGOT)-23 CK(CPK)-276* ALK PHOS-77 AMYLASE-63 TOT BILI-0.1 [**2178-12-28**] 03:57PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* POLYS-2 BANDS-0 LYMPHS-70 MONOS-28 PROTEIN-28 GLUCOSE-345 [**2178-12-28**] 12:57PM CK-MB-15* MB INDX-5.4 cTropnT-0.08* [**2178-12-28**] 09:20PM CK-MB-21* MB INDX-4.2 cTropnT-0.13* [**2178-12-29**] 04:01AM cTropnT-0.09* . CHEST AP: The heart and mediastinum are normal. The lung fields are clear. The costophrenic angles are sharp. There is no evidence of failure or infiltrate. IMPRESSION: Normal chest . ECHO: EF > 75%. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. No valvular pathology or pathologic flow identified. . Stres MIBI: Tolerated 7.5 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol without symptoms. Resting EKG is notable for chronic anteroseptal Q waves and left ventricular hypertrophy with STT wave abnormalities affecting the inferior leads and V4-V6. EKG during stress demonstrated frequent VPB's. The additional ST segment changes seen during exercise and in recovery period are uninterpretable for ischemia in the presence of baseline abnormalities. Heart rate response was adequate, achieving 85% of maximum predicted heart rate and a rate-pressure product of [**Numeric Identifier **]. Blood pressure was hypertensive reaching 220/100 at peak exercise. IMPRESSION: No angina-type symptoms with uninterpretable EKG for ischemia. Below average exercise tolerance for age. Resting hypertension exacerbated with exercise. INTERPRETATION: The image quality is good. Left ventricular cavity size is normal. Resting and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 65%. IMPRESSION: Normal myocardial perfusion study. Brief Hospital Course: 45F with h/o type I diabetes mellitus who presents with DKA. . # DKA - DKA likely resulted from medication non-compliance. Pt reports to infrequent FSBS checks and had last checked her FSBS more than 36 hours prior to admission. She reports FSBS mostly running in high-200's. HgbA1c nearly 12. Infectious etiologies also considered as cause of DKA although her CXR, UA, blood cultures and LP were all negative. The pt may have had cardiac event in the setting of DKA; however, it is not thought that her DKA was triggered by ACS. Her enzymes were elevated: troponin to 0.13 and CK index positive. The pt was treated with insulin drip and IVF. She was transitioned to Humalog sliding scale and Lantus 30units QPM. [**Last Name (un) **] was consulted. The pt will follow-up with them as an outpatient. . # Elevated cardiac enzymes: on presentation to the ED, the pt was found to have elevated CE's as well as EKG changes that were thought to be ST elevations. Because of this, she was started on a heparin gtt in the ED. The pt was reportedly seen by cardiology in the ED, who reportedly felt that the pt was not having ACS, though there is no note documenting this. On further review, her EKG changes were interpreted as J-point elevations (not ST elevations) and were noted to be old. Her heparin was discontinued, as she was not felt to be having Acute Coronary Syndrome. While in the MICU, the pt had additional sets of enzymes checked. Her enzymes peaked at a troponin of 0.13, CK of 502 and CK index of 5.4. The pt was treated with b-blocker, lisinopril, & aspirin. After being called out of the MICU, the floor team consulted cardiology regarding her enzyme elevation and need for further evaluation. The cardiology team felt that the pt had in fact had an event based on her enzymes. Given that she was >24 hours out from the event, catheterization was not undertaken. Rather, the pt underwent a stress MIBI, which showed normal myocardial perfusion study and calculated LVEF of 65%. Based on these results, the pt was treated medically with B-blocker, ACEi and aspirin. Cardiology recommended a statin as well. This was not started as her PCP preferred to start it as an outpatient given concern that the discharging her with too many new medications might lead to non-compliance w/ them. (The pt has had medication compliance issues in past.) Thus, a statin will likely be started as an outpatient once the pt has complied with her insulin regimen, which is the most critical of her medications at present. . # HTN - metoprolol and lisinopril were titrated for BP & HR control. . # Mental status changes - Resolved following treatment of DKA. Likely the result of toxic-metabolic causes in setting of DKA & acidemia. Unlikely infection given all cultures negative. LP unremarkable. . # Acute renal failure - Due to DKA and related dehydration causing prerenal azotemia. Resolved with hydration. . # Depression: pt seen by social work. They recommended she resume her outpatient therapy/counseling. Pt planning on restarting counseling at [**Hospital1 **] following discharge. . # PPx - SC heparin, PPI . # Code - full Medications on Admission: -Lisinopril 40mg daily -Lantus 40units daily -HISS Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Humalog 100 unit/mL Solution Sig: Per Sliding Scale Subcutaneous Brkfast, lunch, dinner, bedtime. Disp:*4 vials* Refills:*5* 4. Lantus 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime. Disp:*2 vials* Refills:*5* 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. insulin Please take 34u lantus insulin EVERY night. Please also check your blood glucose four time/day and take humalog according to the humalog insulin sliding scale. Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic ketoacidosis hypertension . Secondary: Depression Discharge Condition: Good Discharge Instructions: You were admitted to the hospital with extremely elevated blood sugar levels. This happened because you were not taking your insulin as prescribed. As well, your diet likely contributed to this as well. . Please contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 4255**] or go to the emergency room if you develop fever, chills, abdominal pain, chest pain, shortness of breath, or any other concerning symptoms or change in your health. . Please take your medications as prescribed. You will be starting on a new blood pressure medication called metoprolol. You should take this twice a day, once in the morning and once in the evening. . Your insulin and lantus regimen has been changed. Please follow the new sliding scale that you got at the time of discharge. Followup Instructions: You have the following appointments scheduled, please attend them: . Please follow up at [**Last Name (un) **] on [**1-4**] (Monday) at 9AM with . Please make a follow up appointment at [**Hospital **] clinic when you are there on Monday. Please see Dr. [**Last Name (STitle) **] at [**Hospital1 **] on [**1-7**] (next Thursday) at 1pm.

[ "584.9", "250.13", "728.88", "276.51", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

[ "03.31" ]

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8337

Discharge summary

report

Admission Date: [**2148-10-31**] Discharge Date: [**2148-11-3**] Date of Birth: [**2085-10-3**] Sex: F Service: NEUROSURGERY Allergies: Sulfamethoxazole/Trimethoprim / Valium / Erythromycin Base / Neurontin / Estrogens / Quinine / Zoloft / Paxil / Barbiturates Attending:[**First Name3 (LF) 1835**] Chief Complaint: L IPH/IVH Major Surgical or Invasive Procedure: None History of Present Illness: 63yo woman with PMH significant for MVR (on coumadin), CAD, CHF, trigeminal neuralgia, AAA, COPD, L eye enucleation, GIB, is transferred from [**Hospital3 7571**]Hospital for management of intracranial hemorrhage. She presented to the OSH on Monday with a left-sided headache and chest pain. The headache was thought to be secondary to her trigeminal neuralgia and she was treated with narcotic analgesics. BP 171/76. She was ruled out for MI by cardiac enzymes. The day prior to transfer, she was somnolent, which was thought to be due to the analgesics. That night her BP rose to the 190s and her HR to the 110s. The next morning she was obtunded. HCT showed a large left temporal hemorrhage extending into the L ventricle and through much of the left ventricular system. Her [**Hospital3 263**] was 2.7. She was intubated and hyperventilated. Her BP was lowered with nitro initially, then was stable on propofol after intubation. She was given 10mg vitamin K IV and 4 units cryoglobulin at the OSH, with an additional 2 units FFP on transfer. She was sent by [**Location (un) **] to the [**Hospital1 18**] SICU. Past Medical History: Mitral valve replacement(#25 Carbomedics valve) [**7-21**] AAA (3.6 cm in [**8-22**] on MRI) CAD s/p s/p ST elevation IMI [**6-21**], CABG in [**7-21**] LIMA to LAD, reverse SVG from aorta to R PDA Multiple caths as follows: [**2-25**]: RCA engaged with difficulty heavily calcified with diffuse plaquing prox-mid 60%, distal 40% in-stent restonosis, distal 60% just before PDA, 70% prox PDA; LIMA to LAD patent; SVG -RCA known occluded; no intervention [**9-23**]: patent LIMA, native RCA with 40% proximal disease, 40-50% ISR in the mid stent, RCA was very difficult to engage, but was finally done with an AL1 catheter. [**3-22**]: patent LIMA, SVG to RCA was occluded, 2 hepacoat stents to her native mid + distal RCA. [**6-21**]: 2.75 x 18 mm stent to her RCA. [**2148-1-30**] ([**Location (un) **]) Stress test with reversible ant wall defect. EF 75% Past Medical History: - porphyria cutanea tarta- presented with blisters on hands, scleral icterus, red urine, diagnosed with + protoporphyrins in urine, not active x 4 years, hx of phlebotomy for this, none in several years - COPD - Nucleated L eye - [**2-22**] complications from trauma -> leading to trigeminal neuralgia -> s/p surgery for pain control -> loss of nerve function with damage to eye -> enucleation - Anemia - Trigeminal neuralgia - CHF - calculated LVEF on P-MIBI [**3-8**] 83%, 50-55% on last TTE in [**2-23**] - Hyperlipidemia - Kidney stones 8 months ago - s/p L ankle repair Social History: Retired speech therapist, married, 30+ pack year tobacco history, quit 3 years ago, no ETOH, no drug use. Family History: Mother is alive and well Father has [**Name (NI) 29512**] disease Physical Exam: PE: VS: HR 102, BP 159/76, RR 12, SaO2 100%/vent Genl: intubated HEENT: L eye artificial, R clear, ETT & OGT in place CV: RRR, nl S1, S2 Chest: CTA bilaterally w/ vented breath sounds Abd: soft Ext: warm & dry Neuro: MS: intubated, unresponsive CN: +corneal reflex on R, artificial eye on left but no reflex on brushing eyelids, +gag, eye at midline Motor: moves all four extremities spontaneously, only RLE slightly less. Sensory: moves to noxious stimuli in all four Pertinent Results: [**2148-10-31**] 12:07PM PT-14.5* PTT-26.2 [**Month/Day/Year 263**](PT)-1.3* [**2148-10-31**] 12:07PM PLT COUNT-290 [**2148-10-31**] 12:07PM WBC-12.7* RBC-4.23 HGB-11.1* HCT-31.4* MCV-74*# MCH-26.1*# MCHC-35.2* RDW-17.5* [**2148-10-31**] 12:07PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.1 [**2148-10-31**] 12:07PM GLUCOSE-120* UREA N-16 CREAT-1.1 SODIUM-137 POTASSIUM-3.0* CHLORIDE-96 TOTAL CO2-28 ANION GAP-16 [**2148-10-31**] 12:38PM freeCa-1.16 [**2148-10-31**] 12:38PM TYPE-ART PO2-131* PCO2-46* PH-7.42 TOTAL CO2-31* BASE XS-5 Brief Hospital Course: Pt was admitted directly to the SICU, on arrival she had a poor exam was unresponsive but moving all extremeties she had a repeat CT/CTA which showed a large intraventricular hemorrhage involving most of the left ventricle, with source not entirely clear, perhaps left thalamus or corpus callosum. The left temporal and occipital horns are considerably expanded with edema and hemorrhage. Right lateral ventricle not dilated at this time. CT shows no large aneurysm on preliminary review prior to availability of reconstructions. Her bP was kept less than 140, she was loaded on Dilantin and had a platelet transfusion given her [**Month/Day/Year **] history. Her coumadin was reversed and cardiology was consulted to manage cardiac disease in setting of being not be able to anticoagulated. Dr [**Last Name (STitle) **] had a long discussion with the family and offered surgery to possibly evacuate the clot or also place an external ventriculostomy drain. The patients family stated given her lengthy medical problems would not want to live with a possible brain injury they made her DNR/DNI followed by the next day making her CMO. She passed away on [**2148-11-3**]. Medications on Admission: Meds: (on last discharge): 1. Aspirin 325 mg qd 2. Amitriptyline 50 mg qhs 3. Hydromorphone 4 mg q4h prn 4. Fentanyl 100 mcg/hr Patch q72HR 5. Atorvastatin 10 mg qd 6. Metoprolol Tartrate 25 mg [**Hospital1 **] 7. Cyanocobalamin 1000 mcg qd 8. Omeprazole 20mg daily 9. Isosorbide Dinitrate 40 mg SR [**Hospital1 **] 10. Furosemide 20 mg qd 11. Coumadin 3 mg (Tues/[**Last Name (un) **]/Sun) 2mg ([**Doctor First Name **],Mo,Wed,Fri,Sat) 12. K 40mEq daily Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Left temporal/parietal hemorrhage into ventricle Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2148-12-18**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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47024

Discharge summary

report

Admission Date: [**2201-7-29**] Discharge Date: [**2201-9-4**] Date of Birth: [**2132-5-30**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8850**] Chief Complaint: Scheduled chemotherapy admission Major Surgical or Invasive Procedure: High-dose MTX Hemodialysis History of Present Illness: Ms. [**Known lastname 1007**] is a 68-year-old woman diagnosed with primary high grade B cell CNS lymphoma here for 5th cycle of methotrexate. Patient has newly diagnosed CNS lymphoma per brain biopsy, however bone marrow biopsy results reveal no lymphomatous involvement and CT torso showed no signs of mets. On her last admission, she developed exacerbation of her delirium and was monitored with a 1:1 sitter, as well as restraints as needed to prevent the removal of lines. She received two cycles of methotrexate which were well tolerated. After the fourth cycle, her mental status improved significantly and she no longer required restraints. Furthermore, follow-up MRI showed good response of her tumor to methotrexate therapy. In addition, on her last admission, the patient was noted to have one likely seizure while in-house on a therapeutic dose of dilantin ([**10-25**]). She has not had any repeat seizures. Past Medical History: -[**1-15**] multiple posterior circulation strokes, found to have an occluded right vertebral artery and plaque in her aorta, placed on coumadin (please see d/c summary for other details) - [**10-15**] bilateral SAH while on coumadin, taken off coumadin. has been on dilantin - HTN - CAD - obesity - OSA on bipap - hypothyroidism - GERD Social History: She lived with her sister, formerly a nurse but now retired, never married, no kids, quit tob [**2178**], no etoh, no drugs. Has been living at [**Hospital3 2558**]. Family History: No h/o strokes. Physical Exam: VITALS: Temperature 97.0 F, blood pressure 110/50, heart rate 62, respiratory rate 16, oxygen saturation 95% in room air. GENERAL: Pt is morbidly obese, somnolent, lying in bed. SKIN: no rashes HEENT: PERRL, EOMI, MMM, sclerae anicteric CHEST: CTA b/l CARDIOVASCULAR: RRR, nl S1S2, no m/r/g ABDOMEN: soft, NT, ND, obese. +BS EXTREMITIES: Pain on palpation of L hip, bruise noted on LUE, trace edema, 2+ pulses. On discharge Afebrile, blood pressure 155/64, pulse 80, oxygen saturation 97% 3L on nasal cannula. GENERAL: Patient is morbidly obese, alert and oriented x 1. Answers questions appropriately. SKIN: no rashes HEENT: PERRL, EOMI, MMM, sclerae anicteric CHEST: CTA b/l CARDIOVASCULAR: RRR, nl S1S2, no m/r/g ABDOMEN: Soft, NT, ND, obese. +BS EXTREMITIES: Pain on palpation of L hip, bruise noted on LUE, trace edema, 2+ pulses. Neurological Examination: Her Karnofsky Performance Score is 50. She is sleepy but arousable and becomes alert. She is disoriented but able to follow commands. There is no right-left confusion or finger agnosia. Her language is fluent with good comprehension, naming, and repetition. Her recent recall is poor. Cranial Nerve Examination: Her pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. Her face is symmetric. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She does not have a drift. She can move all 4 extremities well. Her muscle tone is normal. Her reflexes are 0-1 and symmetric bilaterally. Her ankle jerks are absent. Her toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal gross dysmetria. She cannot walk. Pertinent Results: [**2201-7-21**] MRI head: Decreased perilesional edema in the left temporal region. No change in the area of enhancement in the left temporal region. Gyriform enhancement in the right medial occipital lobe and left inferior cerebellar hemisphere [**7-29**] Hip Xray: No acute left hip fracture detected. No displaced fracture is seen about the pelvic girdle. Degenerative changes of lower lumbar spine and hips noted. On the AP view, there is a metallic density overlying the left iliac in the region of the anterior superior iliac spine seen only on that view. MRI hip: No evidence of avascular necrosis. Increased signal present within the distal left iliopsoas tendon near its insertion at the lesser trochanter with surrounding fluid signal and inflammatory change, consistent with tendonitis and iliopsoas bursitis. Edema within the gluteus muscles on the left, as well as the left vastus lateralis muscle [**8-7**] eccho: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**] dilated. LV size, thickness and systolic function is normal (LVEF>55%). Moderate PA HTN. No valvular dz. [**8-26**] CXR: Moderately severe pulmonary edema has changed in distribution but not in overall severity since [**8-17**]. [**8-14**] head CT: Stable appearance of the brain parenchyma in comparison to the prior exams. No new intracranial hemorrhage or mass effect is identified. on discharge: WBC 5.1, hct 27.3, plt 894 na 141, k 34.2, cl 102, bicarb 32, BUN 13, Cr 1.0, gluc 96 Cultures: [**8-17**] bld cx: [**1-14**] gram neg rods, lactose non-fermeter, not pseudomonas 8/12 [**1-14**] bld cx with coag neg staph All other cultures no growth to date. Brief Hospital Course: Ms. [**Known lastname 1007**] is a 69-year-old woman with CNS lymphoma who presents for her 5th cycle of MTX. She has a one month history of psychiatric changes and ataxia secondary to the CNS lymphoma. (1) Primary CNS Lymphoma: Ms. [**Known lastname 1007**] presents with a history of posterior circulation strokes and aortic atheroma, a one month history of psychiatric changes, ataxia, and word finding difficulties. She is s/p 4 cycles of HD MTX which she tolerated well and cleared after 96hrs. She was admitted for her 5th cycle of high-dose MTX and underwent the standard urine alkalinization and hydration with D51/2NS with 3amps of bicarb at 150cc/hr and given 650mg bicarb TID. However, the patient did not alkalinize sufficiently after the first evening of hospitalization and required an additional day of alkalinization with bicarbonate supplementation. Strict Is/Os were kept and Lasix was administered to attempt to maintain fluid balance. However, she became several liters positive and gained 6 lbs, stopped diuresing to the given doses of Lasix and on [**2201-8-14**] she was found to have a MTX level of 488, oliguria, altered mental status, hypothermia, hypotension, and bradycardia to 38. At that point she was transferred to the [**Hospital Unit Name 153**] for MTX toxicity and ARF for urgent hemodialysis management. A left HD cath was placed and hemodialysis was initiated. She tolerate the hemodialysis well, and her MTX levels decreased incrementally (488, 137, 43, 23, 9, 2.5, 1.21, 0.96, 0.73, 0.4, 0.18, and 0.1). During that time she was given leucovorin, as well as 1/2 NS with bicarbonate to alkalinize her urine. Urine pH was kept at 8 to 9 during her [**Hospital Unit Name 153**] stay. She consistently produced >200 ml/hr of urine. They also removed between 1 to 4 kg of ultrafiltrate each day. She pulled out her hemodialysis catheter on [**2201-8-21**] and another one was replaced without incident on the right femoral vein. Her last hemodialysis was on [**2201-8-26**] and her creatinine continued to trend downward to a level of 0.1 on the date of discharge. (2) Left Hip Pain: Per NH report, Ms. [**Known lastname 1007**] had fallen out of her wheelchair while attempting to stand up. She fell on her left side and has resultant bruises noted on admission. A hip xray was obtained which revealed no fractures, however she complained of pain on her left during the hospitalization. Ecchymoses were noted along her left abdomen and thigh. An MRI of the left hip was also done which showed bursitis/tendonitis. She was treated with occasional morphine for pain. (3) Seizures: Ms. [**Known lastname 1007**] had a seizure on a previous admission despite being therapeutic on Dilantin and Keppra. She presents with a low phenytoin level, likely secondary to medication refusal at the nursing home. She required bolus doses of dilantin in the first few days of admission to bring her to an adequate phenytoin level between 15 to 20. Daily Dilantin levels were checked with one time bolus doses given if her level (corrected for albumin) dropped below 15. While in the [**Hospital Unit Name 153**], her seiure medications were renally dosed given her ARF. She did not experience any seizures during her ICU stay. She did not have any seizures on this admission. (4) Mental Status: The patient has a waxing and [**Doctor Last Name 688**] mental status. She was often agitated during her stay and has required Zyprexa 10 mg [**Hospital1 **] to prevent her from pulling out IV's and her Portacath. She was also written for Haldol as needed for agitation. She was on sitters and restraints during the early part of her hospitalization in order to prevent pulling access sites. Periodic EKGs were checked which did not show any QTc prolongation. Since transfer out of the [**Hospital Unit Name 153**] her mental status has been much improved. She has been off of sitters for 2 days and has only required 2 doses of 2 mg Haldol and no ativan. She has been alert and oriented x 2. She answers many questions appropriately. Further brain imaging should be done at a later date to access for response to her MTX treatments. (5) Hypoxia: Ms. [**Known lastname 1007**] had a hypoxic episode during the hospitalization and required 4L NC for multiple days. A CXR was done which showed worsening pulmonary edema likely due to the fluid she received for MTX therapy. She had gained 10 lbs over the week in the hospital and examination was positive for bibasilar crackles. Aggressive diuresis was done to remove fluid with a resultant return to her baseline weight. The pulmonary service saw the patient and recommended further diuresis in addition to BIPAP as the patient has known obstructive sleep apnea. Diuresis continued, however the patient did not tolerate BIPAP. O2 supplementation was continued and weaned as tolerated with a goal of keeping O2 sats above 90%. While in the [**Hospital Unit Name 153**], she continued to experience periodic SOB related to fluid overload and pulmonary edema. CXR were c/w pulmonary edema. She ruled out by cardiac enzymes, and EKG's did not show any acute changes. She was given Lasix 20 mg qhs as well as Lasix 40 mg IV periodically for lowered oxygen saturations. At one point she did require BIPAP, but recovered nicely from diuresis. Also, Ms. [**Known lastname 1007**] has had episodic desaturation while sleeping that recovers in the morning. This is likely secondary to her known ostructive sleep apnea. She did not tolerate BIPAP in the hospital (makes her agitated), but this should be reinstituted as an outpatient if she tolerates it. (6) Oral Thrush: She was on nystatin swish and swallow and magic mouthwash for thrush. Now resolved. (7) Hypertension: Ms. [**Known lastname 1007**] had hypertension as an outpatient and was on numerous medications for this. In the [**Hospital Unit Name 153**] Ms. [**Known lastname 1007**] was maintained on hydralazine plus Labetolol, amplodipine and Imdur with good effect. Her Lisinopril was held during her ICU stay given her ARF. After her transfer back to the floor she continued to have poorly controlled hypertension and had one incident of pulmonary edema/respiratory distress associated with SBP of 180. She responded to IV hydralazine and diuresis. Her antihypertensive regimen was titrated with institution of captopril with stabilization of her Creatinine. She is being sent out on lisinopril, amlodipine, labetelol, and isosorbide mononitrate (see medications below) (8) Anemia: This is not from iron deficient, B12 and folate levels normal. Most likely anemia of chronic disease. Has been stable after requiring a few blood transfusions during the hospitalization. The patient developed thrombocytosis during the last week of her admission. There are no identifyable causes. The patient is asymptomatic. This should be followed as an outpatient. (9) Hyperlipidemia: The patient has a known history of hyperlipidema, however her Lipitor was held during the hospitalization and may be restarted on discharge. (10) Coronary Artery Disease: Ms. [**Known lastname 1007**] was continued on Lisinopril and labetolol as per her outpatient regimen. While in the [**Hospital Unit Name 153**], her ACEI was held due to ARF, and she was put on amplodipine. She is being sent out on the regimen listed below. Medications on Admission: 1. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 6. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 11. Labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 14. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): please give only if nonambulatory and refuses pneumoboots. 17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 18. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 19. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QAM (once a day (in the morning)). 20. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 2X/WEEK (MO,TH). 21. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 22. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 23. Oxcarbazepine 600 mg Tablet Sig: Two (2) Tablet PO twice a day: give qAM and qHS. 24. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 26. magic mouthwash Maalox/Diphenhydramine/Lidocaine 1:1:1 30 ml PO TID:PRN mouth pain 27. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for heartburn. 28. insulin Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Olanzapine 10 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO tid. 12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 14. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 16. Labetalol 100 mg Tablet Sig: 1.25 Tablets PO TID (3 times a day). 17. Ativan 1 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for agitation. 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 19. Haloperidol 2 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed for severe agitation. 20. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 21. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 22. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for leg cramps. 23. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: for severe pain. try tylenol first. hold for oversedation or RR<12. 24. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 25. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 26. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 27. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: if weight increases by 3 lbs, increase to 60 [**Hospital1 **] until wt normalizes. 28. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 29. Lactulose 10 g Packet Sig: One (1) PO every 4-6 hours as needed for constipation. 30. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: 1. CNS lymphoma 2. Methotrexate toxicity 3. Acute renal failure 4. Congestive heart failure 5. Hypertension 6. Obstructive sleep apnea 7. Obesity 8. GERD Discharge Condition: good Afebrile, BP 155/64, HR 80, 97% on 3L n/c Discharge Instructions: 1. Please take all medications as prescribed. 2. Please keep all of your outpatient [**Location (un) 4314**]. 3. If you begin to experience shortness of breath, chest pain, fever over 100.4, or any other concerning symptoms, please [**Name6 (MD) 138**] your MD. 4. Please weigh the patient daily and if gains>3 lbs increase lasix from 40 po bid to 60 po bid until wt normalizes 5. Please take T, BP, HR, and O2 sats twice per day. 6. Please use supplumental O2 to keep sats > 92% Followup Instructions: You have the following [**Name6 (MD) 4314**]: 1. [**First Name4 (NamePattern1) 8990**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2202-3-19**] 2:00 2. With Dr. [**Last Name (STitle) 4253**] at 10 a.m. on [**10-12**]. [**Telephone/Fax (1) 45043**].

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icd9cm

[ [ [] ] ]

[ "99.04", "99.25", "39.95", "93.90", "38.95" ]

icd9pcs

[ [ [] ] ]

18041, 18111

5602, 8929

348, 377

18317, 18366

3915, 5153

18896, 19190

1892, 1910

15474, 18018

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1708, 1876

18,739

141,681

7665

Discharge summary

report

Admission Date: [**2136-9-3**] Discharge Date: [**2136-9-7**] Service: HISTORY OF PRESENT ILLNESS: This is an 80 year-old white male with a past medical history significant for coronary artery disease, hypertension, myocardial infarction times three with recent stent placement, congestive heart failure (with a recent admission), ICD placed (complicated by ventricular tachycardia), end stage renal disease secondary to FSGS on hemodialysis three times a week, prostate cancer, hypothyroidism, hypercholesterolemia who was initially transferred to [**Hospital1 69**] from an outside hospital with pleuritic chest pain that was not relieved with nitroglycerin, but was relieved with Toradol. His first set of cardiac enzymes at the outside hospital were negative. The patient had a recent admissions for congestive heart failure the first being secondary to ICD firing and stent restenosis status post percutaneous transluminal coronary angioplasty and hemodialysis and the second being for flash pulmonary edema on [**8-21**] and cardiac catheterization was negative for new lesion at that time. At the outside hospital the patient received aspirin, nitroglycerin, intravenous Toradol and gastrointestinal prophylaxis. The patient complained of mild nausea. She denies abdominal pain, fevers, chills, calf pain, shortness of breath, diarrhea, diaphoresis. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction times three, status post stent times two. 2. Ventricular tachycardia status post ICD placement. 3. End stage renal disease secondary to FSGS and hemodialysis three times a week. 4. Left AV fistula on [**9-/2133**]. 5. History of superficial thrombophlebitis in [**2135-2-21**]. 6. Deep venous thrombosis status post thrombectomy in [**2092**] in the left lower extremities. 7. Factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] heterozygous on Coumadin goal INR 1.3 to 1.5. 8. Prostate caner in [**2133-11-23**]. 9. Hypertension. 10. Hypercholesterolemia. 11. Hypothyroidism. 12. Gout. 13. Status post cholecystectomy. MEDICATIONS: 1. Metoprolol 50 twice a day. 2. Lipitor 20 once a day. 3. Warfarin. 4. Amiodarone 200 once a day. 5. Allopurinol 100 once a day. 6. Lisinopril 20 once a day. 7. Levoxyl 200 mcg once a day. 8. Plavix 75 once a day. 9. Aspirin 325 once a day. 10. Isosorbide 30 three times a day. 11. Trazodone 150 once a day. 12. Celexa 20 once a day. 13. Nitroglycerin prn. 14. Casodex 50 once a day. ALLERGIES: Codeine (nausea and vomiting). Morphine (hallucinations). SOCIAL HISTORY: Forty pack year history of tobacco use. Quit 35 years ago. Denies alcohol use. The patient walks with cane at baseline. He is retired and lives with his daughter. FAMILY HISTORY: Positive cardiomyopathy in mother. PHYSICAL EXAMINATION: Vital signs on admission to the MICU were temperature 97.2. Blood pressure 116/53. Pulse 80. Respirations 20. 100% on 3 liters nasal cannula. The patient was in no acute distress. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Oropharynx was dry. The patient with right IJ in place. Bibasilar crackles. Cardiovascular S1 and S2, regular rate and rhythm. Positive rub heard. Abdomen soft, nontender, nondistended. Positive bowel sounds. No hepatosplenomegaly. Extremities no edema. Left AV fistula, left arm AV fistula with bruit. Cranial nerves II through XII intact. Alert and oriented. LABORATORY: White blood cell count of 12.7, hematocrit 34.3, platelets 270, D-dimer 1157, CK 11, MB of 2, troponin T 0.02. Outside hospital CK was 15, troponin T was 0.025. Potassium 5.5, creatinine of 7.3, BUN 68. Echocardiogram showed an ejection fraction of 45%, mild pulmonary hypertension. Chest x-ray showed stable cardiac enlargement, upper zone redistribution without overt pulmonary edema, persistent left lower lobe opacity (pneumonia versus atelectasis). CTA showed bibasilar atelectasis, resolution of bilateral pleural effusions and diffuse ground glass opacities, residual thickening reflex, residual mild pulmonary edema, no PE. Urinalysis was positive for nitrites, greater then 300 protein, large blood, moderate leukocytes, 21 to 50 red blood cells, greater then 50 white blood cells and occasional bacteria. PT 14.4, INR 1.4, and PTT 31.6. HOSPITAL COURSE: The patient is an 80 year-old male with coronary artery disease status post stent placement with ICD and end stage renal disease on hemodialysis who is transferred from outside hospital with pleuritic chest pain. 1. Pleuritic chest pain: The patient is admitted with pleuritic chest pain. He has cardiac enzymes negative times three for an myocardial infarction. CTA was negative for PE and echocardiogram showed ejection fraction of 45%, mildly depressed left ventricular function, mildly thickened aortic valve and mitral valve, 1 to 2+ mitral regurgitation, mild pulmonary hypertension, no effusion. On hospital day number two the patient's cardiac friction rub disappeared. A repeat echocardiogram was done to rule out new effusion. A physiologic effusion was noted. No change from prior study from the day before. Etiology of chest pain unclear. Appears to be noncardiac. Possible gastrointestinal etiology. 2. Hypotension: In the Emergency Department the patient became hypotensive to a systolic blood pressures of 83 and he was started on a Dopamine drip and a right IJ was placed and intravenous fluids were given. His systolic blood pressure increased to the 90s to 100s and Dopamine was discontinued. Initially he was started on Zosyn and Vancomycin for questionable sepsis. The patient was transferred to the MICU overnight for observation. His hypotension resolved and he was transferred the next day to the regular cardiac floor. The patient's hypertensive medications were held during hospital stay. Prior to discharge his beta blocker and a low dose ace inhibitor were restarted. In addition the patient received 1 unit of packed red blood cells during hemodialysis for a drop in his hematocrit, however, his blood pressure remained stable. Cause of hypotension is unclear. This could be secondary to taking all of hypertensive medications at the same time versus SIRS versus sepsis. Two sets of blood cultures were negative. Urine cultures were positive for coag negative staph. Chest x-ray was negative for pneumonia. 3. End stage renal disease: The patient received hemodialysis while at [**Hospital1 69**]. He is followed by the renal consult team. 4. Urinary tract infection: The patient with a history of staph epididymis urinary tract infection in the past. During this hospitalization his urine was positive for staph epididymis. The patient was maintained on Zosyn for five days. He was discharged to home without antibiotics. 5. Hematology: The patient's hematocrit dropped from 34.3 to 29.6 and he received 1 unit of packed red blood cells during dialysis. In addition, he was guaiac positive. An outpatient colonoscopy is recommended for further evaluation. 6. Hypothyroidism: The patient was maintained on Synthroid. 7. Prophylaxis: PPI and subcutaneous heparin were given. 8. Anticoagulation: The patient was kept on Coumadin for a factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], goal INR 1.3 to 1.5. 9. FEN: He was on a cardiac and renal diet. 10. Coronary artery disease/hypertension: The patient was maintained on aspirin, Plavix and Lipitor. Beta blocker, ace inhibitor and nitrate were held during this admission. His beta blocker and a low dose ace inhibitor were restarted prior to discharge. The patient will be followed as an outpatient and his blood pressure will be monitored by home nursing aids. His blood pressure medication will slowly be added back as needed. 11. Loose stools: The patient had multiple episodes of loose stools and C-difficile culture was sent and it was negative. CONDITION ON DISCHARGE: Good, blood pressure stable, tolerating a po diet. DISCHARGE STATUS: To home with services. FINAL DIAGNOSES: 1. Transient hypotension requiring Dopamine drip. 2. Probable systemic inflammatory response for sepsis. 3. Urinary tract infection with coag negative staph. 4. Diarrhea. 5. History of hypertension. 6. Coronary artery disease with myocardial infarction times three with stents placed. 7. Congestive heart failure ICD placed. 8. History of ventricular tachycardia. 9. End stage renal disease on hemodialysis. 10. History of FSGS. 11. History of prostate cancer. 12. Hypothyroidism. 13. Gout. 14. Hypercholesterolemia. 15. Factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. 16. History of urinary tract infection with coag negative staph. DISCHARGE MEDICATIONS: 1. Aspirin 325 once a day. 2. Clopidogrel 75 once a day. 3. Warfarin 1 mg once a day. 4. Citalopram 20 mg once a day. 5. Atorvastatin 20 mg once a day. 6. Allopurinol 100 mg once a day. 7. Levothyroxine 200 mcg once a day. 8. Trazodone 25 mg q.h.s. as needed. 9. Amiodarone 200 mg once a day. 10. Metoprolol 12.5 mg twice a day. 11. Bicalutanide 50 mg once a day. 12. Sevelamer 1600 mg three times a day. 13. Lisinopril 5 mg once a day. FOLLOW UP PLANS: The patient is to follow up with [**Last Name (NamePattern4) 27881**], RN-[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 27882**] from cardiology on [**9-12**]. Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] on [**2136-9-26**], earlier if his systolic blood pressures are greater then 140 or less then 100. These will be monitored by home nursing care. In addition, the patient has an outpatient appointment with Dr. [**Last Name (STitle) **] [**Name (STitle) 1911**] on [**10-1**] with cardiology. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 26586**] Dictated By:[**Last Name (NamePattern1) 6581**] MEDQUIST36 D: [**2136-9-18**] 05:51 T: [**2136-9-19**] 06:49 JOB#: [**Job Number 27883**]

[ "458.29", "428.0", "604.99", "581.1", "786.51", "585", "428.20", "414.01", "E942.6" ]

icd9cm

[ [ [] ] ]

[ "39.95", "99.05", "38.93" ]

icd9pcs

[ [ [] ] ]

2793, 2829

8834, 10136

4390, 8000

8137, 8811

2852, 4372

109, 1372

1394, 2592

2609, 2776

8025, 8120

40,405

176,274

1894

Discharge summary

report

Admission Date: [**2146-2-19**] Discharge Date: [**2146-3-3**] Date of Birth: [**2097-10-29**] Sex: M Service: MEDICINE Allergies: Penicillins / Abacavir Attending:[**First Name3 (LF) 9598**] Chief Complaint: febrile neutropenia Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: 48 y/o M with AIDS-related Burkitt's lymphoma who was recently hospitalized [**2146-2-7**] to [**2146-2-13**] for chemotherapy with R-IVAC (rituximab, ifosfamide/mesna, etoposide,ara-C, and intrathecal methotrexate). He presented to the [**Hospital 478**] clinic today and was found to have fever and neutropenia. In clinic, his VS were BP 140/92; HR 105; T 99.1; RR 18; O2 Saturation 99. Lab work was drawn and was significant for an ANC 0 and an H&H of 9.5 and 24.8. He was given 1 units of PRBCs and 650 mg of neupogen. After the blood transfusion, he was noted to spike a temperature to 100.4. Blood cultures were drawn, and the patient was referred to the OMED service for admission and further management. . On arrival to the floor, the patient's VS were T 99.8; BP 140/90; HS 95; RR 20; SaO2 97% on RA. He states that, since his discharge, he has not been feeling well. He has been experiencing malaise, nausea, and decreased appetite. He reports that he has not had a fever until today. He also reported a left-sided temporal headache that has continued since his prior hospitalization. He reports that he has some light sensitivity but denies any neck stiffness. He reports diarrhea that has been continuing since the start of his therapy, but denies any blood in his stools. . Review of Systems: (+) Per HPI. He also reports some sensitivity to smells. (-) Denies chills, night sweats. Denies chest pain or tightness, palpitations. Denies cough, shortness of breath. Denied vomiting. No recent change in bowel or bladder habits. No dysuria. Past Medical History: [**Known firstname **] was diagnosed with HIV infection in [**2144-10-5**]. At the time CD4 was 311, viral load 96,934 range ([**2144-10-22**]). Atripla was started. In [**2145-10-5**], [**Known firstname **] noted tightness and pressure across his left chest associated with a new mass. This was subsequently biopsied on [**2145-11-4**], which confirmed Burkitts lymphoma (c-myc positive). At or about the same time, he was seen by oral surgery for swelling on upper and lower gums. This too showed the same lymphoma. PET-CT scan (see full note on OMR) was floridly positive. . He started chemotherapy with Cyclophosphamide, Doxorubicin, Rituximab. The external mass resolved 100% within two days. At no point did patient develop tumor lysis syndrome. Ommaya reservoir was placed. Course was complicated by peri-orbital cellulitis in the setting of grade 4 neutropenia. He was treated successful with cipro, flagyl and vancomycin. . He then received high-dose methotrexate with leucovorin rescue. He did well though did develop perianal mucositis. . PET/CT done after 2 cycles of therapy showed resolution of his disease. . Other past medical history: 1) HIV infection as above; medication-related diarrhea, typically twice a day 2) Depression since [**2144**] 3) Hypertension since [**2143**] 4) Dental extractions 5) Left humerus spiral fracture in [**2136**] after falling down flight of stairs Social History: Single gay man, not currently in a relationship, not currently sexually active. Currently not working. Patient is still smoking cigarettes, 1/2-1 ppd. Drinks 1 bottle of wine a week. He smokes marijuana occasionally for relief of nausea and poor appetite. Family History: Father died in [**2135**] of AML, Mother is alive in her 70s and is well. Three brothers and three sisters; all alive and well. One sister had hysterectomy for endometriosis. No children. He is closest to sister [**Name (NI) 1022**] in [**Name (NI) 7349**]. Physical Exam: GEN: Alert; NAD; Somewhat toxic appearance. Vitals: T 99.8; BP 140/90; HS 95; RR 20; SaO2 97% on RA HEENT: EOMI, PERRL, OP clear and non-erythematous without evidence of mucositis. NECK: Supple LUNGS: CTA bilaterally CARDIOVASCULAR: RRR; No murmurs, rubs, or gallops appreciated ABDOMEN: BS present; S/NT/ND NEURO: Alert; NAD; No focal neurologic deficits noted. Pertinent Results: [**2146-2-18**] 08:45AM BLOOD WBC-0.1*# RBC-3.00* Hgb-9.7* Hct-26.5* MCV-88 MCH-32.3* MCHC-36.6* RDW-16.7* Plt Ct-16* [**2146-2-20**] 06:00AM BLOOD Neuts-0* Bands-0 Lymphs-80* Monos-0 Eos-20* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2146-2-21**] 06:35AM BLOOD Gran Ct-0* [**2146-2-23**] 07:45AM BLOOD Gran Ct-64* [**2146-2-24**] 06:15AM BLOOD Gran Ct-152* [**2146-2-25**] 06:30AM BLOOD Gran Ct-399* [**2146-2-26**] 05:35AM BLOOD Gran Ct-350* [**2146-2-27**] 12:50AM BLOOD Gran Ct-571* [**2146-2-28**] 06:45AM BLOOD Gran Ct-870* [**2146-3-1**] 08:35AM BLOOD Gran Ct-1080* [**2146-3-2**] 07:10AM BLOOD Gran Ct-1420* [**2146-3-3**] 07:40AM BLOOD Gran Ct-2380 [**2146-2-19**] 05:20PM BLOOD Glucose-109* UreaN-13 Creat-0.9 Na-138 K-3.2* Cl-103 HCO3-26 AnGap-12 [**2146-2-19**] 05:20PM BLOOD ALT-12 AST-13 LD(LDH)-110 AlkPhos-106 TotBili-1.0 [**2146-2-21**] 08:11PM BLOOD Hapto-238* [**2146-2-23**] 07:45AM BLOOD IgG-1035 CRYPTOCOCCAL ANTIGEN (Final [**2146-2-22**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. Respiratory Viral Antigen Screen (Final [**2146-2-22**]): Positive for Respiratory viral antigens. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to Respiratory Virus Identification for further information. REPORTED BY PHONE TO [**First Name8 (NamePattern2) 10561**] [**Last Name (NamePattern1) 2113**] @ 2137 ON [**2-22**] - [**Numeric Identifier 10562**]. Respiratory Virus Identification (Final [**2146-2-22**]): POSITIVE FOR RESPIRATORY SYNCYTIAL VIRUS (RSV). Viral antigen identified by immunofluorescence. CMV Viral Load (Final [**2146-3-2**]): CMV DNA detected, less than 600 copies/mL. Performed by PCR. Detection Range: 600 - 100,000 copies/ml. FOR RESEARCH USE ONLY.. NOT FOR USE IN DIAGNOSTIC PROCEDURES. This test has been validated by the Microbiology laboratory at [**Hospital1 18**]. CXR: IMPRESSION: No evidence of acute cardiopulmonary process. CT head [**2-20**]: 1. Stable appearance to right frontal approach ventriculostomy catheter. Stable ventricle size. 2. No acute findings in the brain, no enhancing masses. Mild ethmoid, and sphenoid sinus mucosal thickening. . MR head: 1. Pansinusitis is a potential explanation for the patient's headaches and fevers. 2. Stable appearance of the Ommaya catheter without abnormal intracranial enhancement or other acute findings. Bihemispheric white matter changes may relate to the patient's underlying AIDS versus treatment related. Brief Hospital Course: # neutropenic fever - Patient presented with ANC 0 and fevers to 103 and was started on vancomycin/cefepime empirically. Blood cultures, urine cultures showed no growth. The patient began to complain of severe headaches during the hospitalization, which raised the concern of meningitis. The patient had no mental status changes (although did have increased irritability), no meningeal signs. As there was concern that the patient's antibiotic regimen was insufficiently covering CNS infections, he was transferred to the [**Hospital Unit Name 153**] for an LP to be performed as well as the meropenem desensitization protocol (patient with anaphylaxis to PCN, ~1% chance of crossreactivity with meropenem). The patient tolerated desensitization well but the LP failed. The patient is known to be a difficult tap, and had an Ommaya placed by NSGY previously for intrathecal MTX drug delivery during his chemotherapy regimen. After returning to the floor from the [**Hospital Unit Name 153**], patient continued to have persistent fevers and now began to complain of nasal/chest congestion. Microbiology testing revealed positive viral DFA for RSV. As the patient's IgG was WNL, ID opted against giving IVIG or any other treatment. At this point, it was felt that his fevers may be drug-induced, and vancomycin was discontinued and meropenem continued as single [**Doctor Last Name 360**]. The patient's frequency of fevers decreased but he continued to have severe HA. Given his continued severe symptoms, even in the setting of an ANC which had now risen to >1000, an MRI brain was performed, which showed evidence of severe pansinusitis. The patient was switched to levofloxacin to provide superior atypical coverage. He showed significant improvement on this regimen and defervesced completely with improved headaches. Per ID, he is to continue on a 21-day course of levofloxacin. After that time period, his symptoms should be reassessed by a physician; if they have resolved, the levofloxacin should be discontinued at that time. # [**Name (NI) 10563**] Lymphoma - Pt is s/p recent hospitalization for chemotherapy with R-IVAC. Per primary oncologist (Dr. [**Last Name (STitle) **], pt has completed all chemotherapy. . # HIV - Most recent CD4 count was 479 and VL was less than 48 copies/mL in 10/[**2145**]. Per ID, patient could potentially have abacavir hypersensitivity given that blood bank testing indicated he was HLA-B5701 positive. He was switched to Atripla for his HAART regimen. Additionally, the patient received INH pentamidine for PCP prophylaxis as well as acyclovir prophylaxis. . # anemia / thrombocytopenia - The patient had severe anemia and thrombocytopenia during his hospitalization thought [**3-8**] myelosuppresion. He received several transfusions of both pRBCs and platelets. Medications on Admission: ABACAVIR-LAMIVUDINE [EPZICOM] - 600 mg-300 mg Tablet - one Tablet(s) by mouth once daily ACYCLOVIR - 400 mg Tablet - one Tablet(s) by mouth twice daily CIPROFLOXACIN [CIPRO] - 500 mg Tablet - one Tablet(s) by mouth twice daily CITALOPRAM - (Prescribed by Other Provider) - 20 mg Tablet - one Tablet(s) by mouth once daily EFAVIRENZ [SUSTIVA] - 600 mg Tablet - one Tablet(s) by mouth once nightly LORAZEPAM - 1 mg Tablet - 1-2 mg Tablet(s) by mouth twice daily as needed for nausea ONDANSETRON HCL - 8 mg Tablet - one Tablet(s) by mouth two to three times per day PROCHLORPERAZINE [COMPAZINE] - 10 mg Tablet - one Tablet(s) by mouth three times a day as needed for nausea ZOLPIDEM - 10 mg Tablet - [**2-5**] to 1 Tablet(s) by mouth once nightly as needed for insomnia DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider; Pt reports recently starting.) - Dosage uncertain ??Pentamidine 300mg Recon soln once monthly (due) Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 3. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 4. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-5**] Sprays Nasal QID (4 times a day) as needed for congestion. Disp:*1 inhaler* Refills:*2* 8. Ibuprofen 200 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 18 days: please take until you run out of pills. Disp:*18 Tablet(s)* Refills:*0* 10. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety, nausea. 12. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 13. ATRIPLA [**Telephone/Fax (3) 567**] mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary: RSV infection, sinusitis, febrile neutropenia, Burkitt's lymphoma . Secondary: HIV Discharge Condition: Activity Status:Ambulatory - Independent Level of Consciousness:Alert and interactive Mental Status:Clear and coherent Discharge Instructions: You were admitted for fevers and low blood counts. Your blood cultures were negative, but you were found to have a viral infection called RSV which causes colds and flu like illnesses. This virus is generally self limited. You were also found to have sinusitis, which is being treated with an antibiotic called levofloxacin. Finally, we changed your HIV meds to make them easier to take. You improved and are being discharged to home with close follow up with your doctors. . Please continue to take you medications as ordered. We have made the following changes: 1. STOP taking Epzicom and Sustiva for HIV 2. START taking Atripla 1 tablet at bedtime for HIV 3. Take Levofloxacin 500mg daily until [**2146-3-21**] 4. Use a saline nasal spray to help treat your sinusitis 5. We have adjusted your pain medications and are discharging you on Percocet, [**2-5**] pills four times daily 6. Please take senna and colace while taking pain medications to decrease constipation as a side effect 7. Please take ibuprofen 200mg twice daily to decrease pain and inflammation . Please attend your follow up appointments. . Followup Instructions: Monday, [**2146-3-7**] at 1:00pm with Dr. [**Last Name (STitle) **] [**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**] Completed by:[**2146-3-5**]

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icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

12075, 12081

6855, 9686

303, 321

12216, 12302

4288, 6832

13496, 13705

3631, 3890

10663, 12052

12102, 12195

9712, 10640

12361, 13473

3905, 4269

1666, 1913

244, 265

349, 1647

12316, 12337

3094, 3341

3357, 3615

5,806

170,409

15797

Discharge summary

report

Admission Date: [**2161-1-25**] Discharge Date: [**2161-1-30**] Date of Birth: [**2099-8-18**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: S/P Fall with transfer from outside hospital with head bleeds Major Surgical or Invasive Procedure: Left sided subdural hematoma evacuation History of Present Illness: 61 y/o M w/ h/o MVC resulting in coma 5 yrs ago and 2 SDH resulting after bad falls in subsequent years presents to ED with CT scan showing SDH, SAH after wife noticed pt acting more lethargic, sleepy and agitated over the past 4 days. Wife states that the patient fell out of bed at 8pm on [**1-24**] and EMS was called to bring pt to [**Hospital 4068**] Hospital. She also states that on Wednesday night, she heard a thud at 1am and did not investigate the noise. She suspects that the patient fell at that time as well. Patient denies loss of consciousness, but does state that he hit his head. At baseline, the patient has an unsteady gait and dysarthric speech acording to his wife. She became worried when she noticed that the patient wasn't acting quite right, his eyes had not been focusing like they usually do. Past Medical History: hypertension, depression, CAD with cardiac arrest, anxiety, s/p MVC 5yrs ago resulting in a coma for 7 days and deficits in gait and speech, s/p fall backwards 4yrs ago resulting in SDH, s/p fall down stairs 2-3yrs ago resulting in left frontal lobe SDH with midline shift. Social History: pt lives at home with his wife as caretaker, attends adult daycare Family History: unknown Physical Exam: O: T: 97.4 BP: 173/94 HR: 91 R 22 O2Sats 95% RA Gen: WD/WN, agitated, NAD. HEENT: Pupils: PERRL, unable to test EOMs, but tracks examiner somewhat Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, mostly cooperative with exam, normal affect. Orientation: Oriented to person, and year. Thinks that he is in a rehab hospital, and thinks the date is [**2160-8-26**]. Language: Speech fluent, moderate expressive aphasia and significant dysarthria. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 5mm to 3mm on right and 5mm to 4mm on left. III, IV, VI: Unable to test EOMs due to limited cooperation throughout exam. V, VII: Mild facial droop on left. Smile asymmetric. 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 deviated slightly to right without fasciculations. Motor: Normal bulk and tone bilaterally. Moves all 4 extremities spontaneously. No abnormal movements, tremors. Full strength in BUE. In BLE, patient has full strength in hip flexors and quadriceps, uncooperative with extensor examination or motor exam of feet. Sensation: Intact to light touch Toes equivocal on left, upgoing on the right. Pertinent Results: [**1-25**] CT ANGIOGRAPHY OF THE HEAD PRELIMINARY REPORT: Provided by Dr. [**Last Name (STitle) 18936**]. He indicated "Left extra-axial hematoma representing epidural hematoma has increased in size, measuring 26 mm in greatest dimension. Mass effect on the occipital [**Doctor Last Name 534**] of the left lateral ventricle is new. Right and left-sided subdural hematoma also along the falx and layering over the tentorium. Subarachnoid hemorrhage, more significant on the left. Minimal effacement of the suprasellar cistern and compression of the brainstem is concerning for impending herniation. Nasogastric tube is coiled within the oropharynx. No gross aneurysm. Old nasal bone fracture. Paranasal sinus mucosal disease. Discussed with Dr. [**Last Name (STitle) **] at 5:30 a.m. FINDINGS: Comparison with the prior [**Hospital 4068**] Hospital CT scan does indicate that there has been relatively prominent interval increase in size of the left-sided posterior temporal extra-axial hemorrhage. I believe this finding still represents subdural hemorrhage, as there is also considerable subdural blood more anteriorly overlying the anterior aspect of the left temporal lobe. The large right-sided cerebral convexity acute subdural hemorrhage is stable in size. There is somewhat increased mass effect upon the left atrium, and perhaps a few millimeters rightward shift of the septum pellucidum. The suprasellar cistern, particularly when viewed on the CT angiographic sections, remains visible. There is probably a minimal quantity of subarachnoid blood in the left sylvian fissure and layering in the left atrium. As was noted by Dr. [**Last Name (STitle) 18936**], the nasogastric tube is coiled in the oropharynx. CT angiography was obtained. Compared with the prior CT angiogram performed on [**2157-7-4**], there does not appear to be any overt interval change. There is the expected displacement of the cortical vessels away from the inner table of the skull, secondary to the large extra-axial hemorrhages. No definite sign of an aneurysm is seen. Moreover, there is redemonstration of the apparent discontinuous appearance of the basilar artery. It was my impression at that time of the first study that there was a left-sided trigeminal artery present, which is a congenital carotid/basilar anastomosis accounting for the basilar artery discontinuity. The CT angiogram does not appear to show definite sign of an aneurysm at this time. CONCLUSION: 1. Enlargement of left posterior temporal component of large subdural hemorrhage, compared with the prior study. 2. Small amount of subarachnoid hemorrhage within the left sylvian fissure. Tiny amount of blood within the left lateral ventricle. [**1-25**] NON-CONTRAST HEAD CT FINDINGS: Patient underwent interval repeat left-sided craniotomy with new post-operative and subcutaneous pneumocephalus/emphysema. The majority of the left-sided extra-axial hemorrhage has been evacuated with a small component remaining. Additionally the amount of subdural hemorrhage tracking along the falx and tentorium appears improved. Right-sided subdural hematoma is not significantly changed extending up to 16 mm from the skull base (2:10). Intraventricular hemorrhage is again noted within the lateral ventricles bilaterally with a small component likely within the inferior fourth ventricle. There has been worsening of hydrocephalus involving the left lateral ventricle with dilatation of the occipital and temporal horns which is new from prior exam. Additionally there is slightly increased mass effect noted along the right lateral ventricle. Suprasellar and ambient cisterns remain patent. Regions of encephalomalacia involving the left frontal and parietal lobe are stable as is diffuse paranasal mucosal sinus disease. Subarachnoid components bilaterally are not significantly changed. IMPRESSION: 1. Evacuation of left-sided extra-axial component with decreased subdural hemorrhage tracking along the falx and tentorium. Right-sided subdural hematoma displays no short interval change from 5 a.m. examination. 2. Persistent intraventricular hemorrhage within the lateral ventricles and likely within the fourth ventricle. There is new hydrocephalus involving the left ventricle predominantly within the occipital and temporal horns which are dilated. Part of this may relate to re-expansion after evacuation. Slightly increased mass effect noted along the right lateral ventricle. 3. Diffuse unchanged subarachnoid hemorrhage. [**1-26**] CT HEAD W/O CONTRAST Preliminary Report FINDINGS: Similar appearance of left subdural hematoma status post evacuation, although with decreased pneumocephalus. Similar appearance of subdural hemorrhage tracking along the falx and tentorium. Right-sided subdural hematoma is essentially unchanged measuring up to 13 mm. Intraventricular hemorrhage is seen bilaterally, although more pronounced on the left. Slight improvement of hydrocephalus involving the left ventricle with decreased size of the occipital [**Doctor Last Name 534**]. Mass effect is not worse than prior. The subarachnoid hemorrhage component appears essentially the same. IMPRESSION: Similar appearance to prior scan with stable appearance of subdural hematomas and mild improvement in hydrocephalus. Brief Hospital Course: Mr [**Known lastname 45462**] was admitted to the Neurosurgery service to the ICU. His BP was kept less than 140 with frequent neurochecks. He underwent left sided craniotomy for evacuation of subdural hematoma. He had a CTA which showed no source for for the blood. Follow up CT showed slight improvement of left sided subdural and continued with right sided subdural. CT scan on POD 1 showed no interval change in the subdural heamtomas from the post operative CT scan. Mr. [**Known lastname 45462**] was started on tube feeds at this time since a return to the OR for a right craniotomy was deferred at that time. the patient was extubated on [**1-26**] and was able to maintain his oxygen saturations despite this. His neurologic exam on the morning of [**1-27**] was worse than on admission. He was intermittently following commands and not moving his right arm at all, even to noxious stimuli. With his right leg, he withdrew from pain. On his left side, he was moving both his arms and his legs spontaneously. On [**1-27**], a repeat Head Ct was performed which showed a left extraaxial fluid collection increased in size from 7mm to 9mm, increased mass effect on lateral ventricles, effacement of sulci and minimal increase in shift of midline structures. The patient's neurologic exam deteriorated. He was made DNR/DNI on [**1-30**] and passed away later that day. Medications on Admission: Amoxicillin - for nasal sinus infection started [**1-23**], Lisinopril (dose uncertain at this time), Atenolol (dose uncertain at this time), Zocor (dose uncertain at this time), Klonopin 5mg qhs, Depakote 50mg [**Hospital1 **], Folic Acid (dose uncertain at this time) Discharge Disposition: Expired Discharge Diagnosis: Bilateral subdural hematomas and SAH Discharge Condition: Expired Completed by:[**2161-5-19**]

[ "E885.9", "852.20", "348.4", "401.9", "V09.0", "311", "482.41", "300.00", "852.00", "518.5" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "01.31", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

10149, 10158

8450, 9828

381, 423

10239, 10277

3107, 8427

1675, 1684

10179, 10218

9854, 10126

1699, 1963

280, 343

451, 1276

2260, 3088

1978, 2244

1298, 1574

1590, 1659

81,978

197,940

35384

Discharge summary

report

Admission Date: [**2178-2-9**] Discharge Date: [**2178-2-13**] Date of Birth: [**2137-10-15**] Sex: F Service: MEDICINE Allergies: Percocet / Latex / Erythromycin Base Attending:[**Doctor First Name 1402**] Chief Complaint: admission for VT ablation Major Surgical or Invasive Procedure: Insertion of pacemaker Ventricular Tachycardia Ablation History of Present Illness: 40yo female with history of myoclonic dystrophy, obstructive sleep apnea, ASD was admitted from [**Hospital1 **] for VT ablation. . Patient was in USOH until last week when both she and her husband got gastroenteritis with N/V/D. She saw her PCP [**Last Name (NamePattern4) **] [**2-3**] and was given a medication that the patient could not name. She took one dose and it made her so tired that she stopped taking the rest. She describes feeling tired for the past week. She saw her cardiologist today for a regular check up and a routine EKG showed VT and she was admitted. . Upon further questioning, patient denied chest pain and shortness of breath. She reports fatigue with exertion but no dyspnea. She endorsed some faint palpitations and slight dizziness/lightheadedness when she saw her cardiologist. She denies orthopnea, PND and lower extremitiy swelling. She denies fever, chills, and cough. She endorsed anxiety, nausea, and lightheadness and was tearful throughout the interview. Reports prolonged relaxation for musculature secondary to dystrophy. However, at baseline is independent of ADL and able to walk unassisted. . Upon arrival to the OSH ED, her vital signs were BP 111/72 P 170 R20 100%2L. She was given a 500cc NS bolus, 100mEq total potassium, IV lidocaine 50mg followed by 75mg, and then lidocaine gtt at 2mg/min. She then received etomidate and fentanyl prior to cardioversion at 200J. She converted back to NSR after one shock. She was then transferred to [**Hospital1 18**] for consideration of VT ablation. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Se denies recent fevers, chills or rigors. Se denies exertional buttock or calf pain. All of the other review of systems are described above. Past Medical History: 1. Myoclonic Dystrophy 2. Obstructive Sleep Apnea 3. Ventricular Tachycardia 4. ASD Social History: Married, lives with husband. [**Name (NI) 1403**] as a school bus driver. Denies ever smoking or drinking alcohol. Plans to have a child with a surrogate mother. Family History: Mother has Myoclonic Dystrophy. Father died of MI at 49. Daughter died quickly after birth because of Myoclonic Dystrophy and pulmonary hypoplasia. Grandmother had a stroke. Physical Exam: VS - T 99.8 HR 100 BP 106/81 RR 29 92%2L Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect anxious and tearful. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 6cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Faint crackles L base. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Admission Labs [**2178-2-9**] 10:24PM GLUCOSE-136* UREA N-13 CREAT-0.8 SODIUM-144 POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-25 ANION GAP-14 [**2178-2-9**] 10:24PM estGFR-Using this [**2178-2-9**] 10:24PM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-2.1 Discharge Labs [**2178-2-12**] 06:00AM BLOOD WBC-5.7 RBC-3.66* Hgb-11.4* Hct-34.0* MCV-93 MCH-31.1 MCHC-33.5 RDW-13.9 Plt Ct-215 [**2178-2-11**] 01:12AM BLOOD WBC-7.3 RBC-3.50* Hgb-10.8* Hct-32.1* MCV-92 MCH-30.7 MCHC-33.5 RDW-14.1 Plt Ct-233 [**2178-2-12**] 06:00AM BLOOD Glucose-93 UreaN-12 Creat-0.6 Na-146* K-4.2 Cl-111* HCO3-30 AnGap-9 [**2178-2-11**] 01:12AM BLOOD ALT-64* AST-46* . [**2-11**] CXR IMPRESSION: 1. Dual-chamber pacemaker in left upper chest, with leads in the expected location of right ventricle and right atrium. 2. Interval increase of left pleural effusion. Air bronchogram in LLL, compatible with atelectasis or consolidation. Recommend clinical correlation. 2. Unchanged prominent interstitial marking, compatible with congestion. [**2178-2-10**] 04:37AM BLOOD ALT-101* AST-76* LD(LDH)-649* AlkPhos-99 TotBili-0.7 [**2178-2-12**] 06:00AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1 Brief Hospital Course: 40yo female with history of myoclonic dystrophy and obstructive sleep apnea transferred from OSH for VT ablation. 1. Ventricular Tachycardia: Etiology of her new onset ventricular tachycardia thought to be due to conduction disorders associated with myotonic dystrophy. She was initially on lidocaine gtt which was discontinued because of concern over worsening myotonic dystrophy. She underwent EP study and had ablation of ventricular bundle block re-entry. In addition, because of extensive conduction system disease the patient was taken back to the EP lab for a pacemaker which she tolerated well. CXR showed good lead placement and no PTX. Her settings were adjusted so she was consistently RV paced. She had no further episdoes on telemetry. She will follow up in device clinic. Patient should not drive until she follows up with EP. . 2. Respiratory Status: Patient was mildly hypoxic and tachypneic on admission. Likely from combination of baseline diaphragm weakness, atelectasis, and anxiety. Clinically euvolemic with clear initial CXR and possible LLL atelectasis. Had elevated BNP from OSH but difficult to interpret in setting of Myotonic Dystrophy. No fever, leukocytosis or cough to suggest PNA. She spike a post op fever which was thought [**12-22**] to atelectasis in setting of weak diaphragm but remained afebrile >48 hours with oxygen sats low to mid 90s on room air prior to discharge. Encouraged incentive spirometry. Continued home BiPaP. . 3. Elevated LFTS: Patient had slightly elevated LFTs and complaints of nausea but has no other localizing symptoms. Elevtaed LFTs attributed to medications, possible lidocaine, as repeat LFTs trended down. She should have repeat tests as outpatient. . 4. Myotonic Dystrophy: Stable. Highly associated conduction abdnormalities. Also with resultant diaphragmatic weakness. . 5. Obstructive Sleep Apnea: Patient used BiPap at home and brought in own machine to be used at night. . #. Code: FULL CODE, confirmed Medications on Admission: asa 81mg PO qday Vit D Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day. 3. Outpatient Lab Work please check CBC, LFT's and chem 7 on Monday [**2-16**], please send results to Dr.[**Last Name (STitle) 5051**]([**Telephone/Fax (1) 20259**] Discharge Disposition: Home Discharge Diagnosis: PRIMARY: 1. Ventricular tachycardia 2. Prolonged H-V interval SECONDARY: Myoclonic Dystrophy Obstructive Sleep Apnea ASD Discharge Condition: Hemodynamically stable, afebrile, ambulating Discharge Instructions: You were admitted for an arrhythmia called ventricular tachycardiac (VT). You had a cardiac ablation to treat this arrythmia. Because you have abnormalities in your heart's conduction system, you also had a pacemaker placed. You will need to follow up with your cardiologists to make sure the pacemaker is working properly. You have an appt in the Device clinic in 1 week. This is on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Clinical Center at [**Location (un) **] on the [**Hospital Ward Name **] of [**Hospital1 **]. There is a parking garage under the building that you can access [**Hospital1 80653**]. Until you are seen at the device clinic, do not shower or get the pacer dressing wet. If you notice swelling, bleeding, redness or increasing pain at the pacer site, please call the device clinic at [**Telephone/Fax (1) 62**]. . For the next 6 weeks, no lifing more than 5 pounds with your left arm, no reaching over your head with your left arm, you can wash and brush your hair normally. . ***Please do not drive until you are cleared by Dr. [**Last Name (STitle) 5051**].**** Please take all medications as prescribed. If you have any chest pain, shortness of breath, palpitations, lightheadedness or loss of consciousness, please call your doctor or go to the emergency department. If you have any concerning symptoms in general, you should seek medical attention. Followup Instructions: Device clinic: office will call you with an appt . Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5051**] Phone: ([**Telephone/Fax (1) 20259**] Date/time: [**2-17**], 3:00pm Heart Ctr of [**Hospital1 **] [**Last Name (NamePattern1) 26916**] [**Location (un) 551**] [**Location (un) 47**], [**Numeric Identifier **] . Primary Care: [**Doctor Last Name **],[**Doctor First Name 57825**] Phone: [**Telephone/Fax (1) 80654**] Date/Time: Please make an appt to see your primary care doctor in 2 weeks.

[ "327.23", "285.9", "426.11", "359.21", "427.1", "745.5", "780.62" ]

icd9cm

[ [ [] ] ]

[ "37.83", "89.45", "37.72", "37.34" ]

icd9pcs

[ [ [] ] ]

7111, 7117

4717, 6699

324, 382

7283, 7330

3542, 4694

8782, 9313

2611, 2786

6773, 7088

7138, 7262

6725, 6750

7354, 8759

2801, 3523

259, 286

410, 2308

2330, 2416

2432, 2595

47,045

188,612

7670

Discharge summary

report

Admission Date: [**2126-3-11**] Discharge Date: [**2126-3-16**] Date of Birth: [**2050-2-11**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 443**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 76 year-old man with CAD, chronic systolic CHF, CKD, who p/w DOE and chest "burning" on exertion. For the last several weeks the patient has been complaining of increased fatigue. Prior to this the patient could walk about 1 walk, but now becomes dyspnic w/ minimal exertion. He has PND and 2 pillow orthopnea. No syncope, dizziness, URI symptoms. The patient also has right sided chest pain that is best described as a "burning" that starts in his back and radiates to his right chest. It is worse w/ exertion and relieved w/ nitro. His SOB is also relieved w/ rest and nitro. . Of note the patient was recently addmitted on [**11/2125**] for CHF exacerbation and found to have new onset A. flutter. The patient was diuresed and put on coumadin. He had a GI bleed and was taken off of coumadin. He decided not to undergo GI evaluation because the GI bleed stopped and he could not tolerate the prep. Past Medical History: CAD- as above HTN DM 2 Hypercholesterolemia Peripheral vascular disease-aorto fem bypass in early 90s. Carotid stenosis 60-69% right ICA stenosis, 70-79% left ICA stenosis in [**7-/2125**] Mixed sleep disorder . CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension . CARDIAC HISTORY: CAD history: -Emergent CABG in [**2109**], with SVGs to OM1/2. -Repeat CABG [**2117**] with LIMA-->LAD and SVG-->distal LAD. SVG-OM1 patent SVG om2 60% stenosis. -Cath [**3-13**] stent to SVG-->OM. -Repeat cath [**10-13**] in stent restenosis of vein graft stent rxd with brachytherapy. -Cath [**1-14**] 90% stenosis prior to stents in SVG-OM and 70% stent stenosis. Repeat cyphering done. -Repeat cath for CP in [**9-14**]. SVG-->OM2 occluded. PTCA/stent to distal LMCA and LCx treating a 70% ostial lesion. 70% proximal RCA stented. -Repeat cath [**9-15**]- restenting of LMCA-->LCx (80%) -Cath [**11-16**]- patent stent in the LMCA. The LAD had an 80% ostial lesion, but the vessel filled well via LIMA graft. The LCX had a 70% focal instent restenosis at the LCX ostium; the OM1 had <50% disease after insertion of the SVG; there was no other significant disease in the LCX system. The RCA had 60% disease in the acute marginal branch; there were 60% long lesions in the mid and distal RCA. The 80% lesion in the LAD was dilated with a 3.0 x 8 High sail balloon. The lesion in the LCx was then dilated with a 3.5 x 13 High sail balloon upto 29 ATM when the *balloon ruptured*. It was decided not to proceed with stent placement due to 2 layers of previously placed BMS and DES. Final angiography demonstrated 10-20% residual stenosis and no angiographic evidence of dissection, thrombus or perforation with TIMI III flow in the distal vessel. . Social History: Retired. Machine operator in [**Last Name (un) 27903**] stethoscope factory. Married with three children. Stopped smoking 30 years ago. Smoked 2-3 packs per day. No EtOH. No drugs. Family History: B: Died of MI at 42, B: had multiple MIs; F, M: died. Whole mothers side diabetes mellitus Physical Exam: VS: T=97.7 BP=120/49 HR=109 RR=22 O2 sat= 93% on 4L BG: 250 GENERAL: NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 12 cm. (mid neck) CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Slight expiratory wheeze, diffuse rhonci worse on right side, ABDOMEN: Soft, NTND. Abd aorta not enlarged by palpation. EXTREMITIES: 1+ edema bilaterally, warm extremeties SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Radial 2+ DP 1+ Left: Radial 2+ DP 1+ Pertinent Results: Admisison labs: [**2126-3-11**] WBC-12.8* RBC-4.47* Hgb-12.4* Hct-39.0* MCV-87 MCH-27.7 MCHC-31.8 RDW-15.4 Plt Ct-215 Glucose-146* UreaN-35* Creat-1.9* Na-144 K-4.1 Cl-105 HCO3-28 AnGap-15 Calcium-9.0 Phos-2.4* Mg-2.8* Cholest-120 Triglyc-94 HDL-36 CHOL/HD-3.3 LDLcalc-65 TSH-3.5 . Other labs: [**2126-3-13**] 06:35AM BLOOD CK-MB-2 cTropnT-0.54* [**2126-3-12**] 05:24PM BLOOD CK-MB-3 cTropnT-0.49* [**2126-3-12**] 06:25AM BLOOD CK-MB-4 cTropnT-0.62* [**2126-3-11**] 09:16PM BLOOD CK-MB-8 cTropnT-0.50* [**2126-3-11**] 12:49PM BLOOD CK-MB-8 cTropnT-0.11* proBNP-4787* . Discharge Labs: [**2126-3-16**] WBC-8.4 RBC-3.86* Hgb-11.1* Hct-33.5* MCV-87 MCH-28.8 MCHC-33.2 RDW-15.1 Plt Ct-281 Glucose-135* UreaN-51* Creat-1.8* Na-142 K-4.1 Cl-101 HCO3-28 AnGap-17 Calcium-9.0 Phos-3.2 Mg-2.4 . Echo: [**2126-3-12**] The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with infero-septal, inferior and infero-lateral hypokinesis to akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2125-11-21**], pulmonary hypertension is now detected. . [**2126-3-12**] CXR: Moderate cardiomegaly has not changed since [**2125-11-21**]. The heterogeneous consolidative abnormality in the right lower lung is minimally improved, but persistence in light of diuresis suggests it is not edema alone. Differential diagnosis includes pulmonary hemorrhage and pneumonia. Pleural effusions if any are small. No pneumothorax. . [**2126-3-11**] CXR: Moderate cardiomegaly is stable. Haziness of the hila bilaterally and bilateral mainly lower lobe opacities associated with small bilateral pleural effusions, are consistent with moderate pulmonary edema. Sternal wires are aligned with unchanged disruption of the most distal wires. . CT chest w/o: [**2126-3-14**] 1. Recurrent or progressive widespread, multifocal airspace abnormality. Differential includes pulmonary hemorrhage, drug reaction, hypersensitivity pneumonitis . Clinical correlation is recommended. 2. Mild mediastinal adenopathy is minimally worse, likely reactive. 3. Coronary and aortic arch calcifications. 4. Mild vocal cord asymmetry with nodular prominence of the right, warrants direct examination. Brief Hospital Course: 76 yo M w/ CAD, s/p 2 CABGS, CKD, HTN, CHF, p/w DOE and atypical CP . # CORONARIES: Patient has known 3 vessel disease and numerous CAD risk factors. HgBA1C is 7.4. Lipids panel normal. Patient had increase in troponins, but not in CKMB. This like likly [**2-12**] demand and decreased clearance from CKD. No indication for cardiac catherization this admission. Patient told to continue his ASA, Plavix, Statin, beta blocker, ACE-I. . # PUMP: Echo repeated and showed EF of 30%. Patinet was initially fluid overloaded and diuresed with lasix gtt. However, at one point patient was likely overly diuresed and had hypotension. He was sent to the CCU overnight for monitoring, but quickly regained his baseline blood pressures and transferred back to the floor. He was started on levaquin for possible CAP given that he had a low grade temp of 100.4 the night prior. He will finish his course of levaquin. Initially patient was on 5-10L face tent but was discharged on RA. Patient to continue on lisinopril, Isosorbide mononitrate, metoprolol, nifedipine, HCTZ, and home dose of lasix. . # RHYTHM: Atrial flutter seen on EKG. Patient has known atrial flutter but did not tolerate coumadin [**2-12**] bleeding. Normal TSH. Continued rate control with beta-blocker . # CKD: Cr temporarily increased with diuresis. Improved prior to discharge. . # SOB: Per above, patient was diuresed and back on RA prior to discharge. However, given the extended course before improvement a CT chest was done and pulmonary was consulted because the read suggested possible hypersensitivity pneumonitis. The pulmonary team felt it was more likely [**2-12**] pulmonary hemorrhage superimposed on interstitial edema [**2-12**] elevated left-sided pressures. They also stated that a right heart cath (measuring rest and exercise pressures) could be considered to firmly evaluate his pulmonary vascular and left-sided pressures. . # DM 2: Patient was discharged on NPH 20 before breakfast and 25 at night with good glucose control. . # Peripheral vascular disease: Continued Pentoxifylline . COMM: [**Name (NI) **] and wife [**Name (NI) 27905**] [**Name (NI) **] [**Telephone/Fax (1) 27906**] Medications on Admission: Atorvastatin 40 mg Tablet po qday Citalopram 20mg po qday Clonazepam 0.5 mg Tablet [**Hospital1 **] prn anxiety Plavix 75 mg Tablet po qday Eszopiclone [Lunesta] 3mg po qday Furosemide 120mg po BID Hydrochlorothiazide 25mg po qday Isosorbide Mononitrate [Imdur] 60mg po BID Lisinopril 60mg po qday Metoprolol Succinate [Toprol XL] 100mg po BID Nifedipine [Procardia XL] 90 mg po qday Nitroglycerin 0.4 mg Tablet, Sublingual prn Pentoxifylline 400 SR TID Aspirin EC 325 mg Tablet po qday Insulin Regular Human [Humulin R] 3 units in the am, 4 units in the evening NPH Insulin Human Recomb [Humulin N] 40 units in the morning and 50 units every evening- patient heavily adjusts this dose based on blood gluocse Discharge Medications: 1. Oxygen 2-3L continuous pulse dose for portability 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lunesta 3 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). 9. Lisinopril 30 mg Tablet Sig: Two (2) Tablet PO once a day. 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO twice a day. 12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 13. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO TID (3 times a day). 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H (every 48 hours) for 1 days: Please take on [**2126-3-17**]. Disp:*3 Tablet(s)* Refills:*0* 16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit Injection twice a day: as directed. 17. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: One (1) unit Subcutaneous twice a day: 20 units before breakfast and 25 units before dinner. 18. Lasix 80 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*180 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: Acute on chronic CHF . Secondary CAD Diabetes Hypertension Hyperlipidemia Carotid Stenosis Discharge Condition: Stable, alert and oriented, able to ambulate Discharge Instructions: You were admitted to the hospital for shortness of breath. This was primarily due to having too much fluid in your lungs from your poor heart function. We used a medication called lasix to decrease the fluid in your lungs. It temporarily dropped your blood pressures so you were sent to the intensive care unit for further monitoring. . A chest CT was done that showed some abnormalities in your lung. You were started on an antibiotic, Levofloxacin. You take this medication every other day, and your last dose of this medication will be tomorrow on [**2126-3-17**]. Lung specialists were consulted and they recommend that you get a repeat chest x ray in 4 to 6 weeks. You should let your primary care doctor know about this so he can schedulue it. . We have made the following changes to your medications: 1. Levofloxacin 750mg by mouth on [**2126-3-17**] 2. Increase your lasix to 160 mg twice a day (two 80 mg pills) 3. You will also be discharged with home oxygen . Please go to your follow up appointments (see below) Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow up with your primary care provider. [**Name10 (NameIs) **] have an appointment scheduled with [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 12637**], M.D. on [**2126-4-5**] at 8:20 am. If you need to change this appointment the phone number is:[**Telephone/Fax (1) 250**]. Please tell Dr. [**First Name (STitle) **] that you will need to get a follow up chest x ray in 4 to 6 weeks. Please also follow up with your cardiologist, [**Name6 (MD) 2053**] [**Name8 (MD) 27907**], MD. You have an appointment already scheduled for [**2126-4-8**] at 2 pm. However, we would like you to be seen sooner than this. Someone from the office will call you in the next few days to reschedule. If you do not hear from anyone please call the office at: [**Telephone/Fax (1) 62**]. You should schedule an appointment for 2 weeks from now. Completed by:[**2126-3-17**]

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icd9cm

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icd9pcs

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11613, 11671

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3231, 3323

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133,193

53772+53773

Discharge summary

report+report

Admission Date: [**2126-4-27**] Discharge Date: [**2126-5-8**] Date of Birth: [**2064-1-12**] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 165**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2126-4-27**] - Cardiac Catheterization [**2126-5-2**] - 1. Urgent coronary artery bypass graft x4; left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal obtuse marginal and posterior descending arteries. 2. Endoscopic harvesting of the long saphenous vein. 3. Mitral valve repair with a size 28 CG Future complete band. History of Present Illness: Mr. [**Known lastname 83712**] is a 62 y/o M with PMH notable for DMII and HTN who presents at the request of Dr. [**Last Name (STitle) 911**] due to worsening exertional chest pressure and DOE. . The patient reports that in [**5-/2124**] he began to note shortness of breath and chest pressure when walking more than 30 feet or a flight of stairs blocks. In [**6-/2124**], while in [**Location (un) 9012**] on a buisiness trip, he developed positional chest pain and was diagnosed with pericarditis. Had a (-) stress test but developed fib during exercise. Discharged on a course of NSAIDs and sotalol for arrhythmic control (nl EF on echo). . Seen by cardiologists in [**Location (un) 86**] [**7-/2124**] where he had a CTA done that showed no PE. A repeat stress test was indeterminate. The patient continued to have CP and dyspnea with exertion over the subsequent year. He was seen at [**Hospital1 498**] in [**3-/2126**] where a nucler stress test revealed anterior ischemia. He opted not to have an intervention at [**Hospital1 498**]. . The patient was referred to Dr. [**Last Name (STitle) 911**] due to persistence of symptoms. . Direct admit to cardiology on [**2126-4-27**]. VS on arrival were 97.0 173/102 108 20 94%RA. The patient reported that he could reproduce his symptoms with any exertion however denied any CP, palp or SOB while lying in bed. . ROS: (+) as per HPI. Otherwise denies N/V/D, fever/chills, changes in bowel or bladder habits, HA or changes in vision. Past Medical History: Coronary artery disease Mitral regurgitation Diabetes Hypertension Hyperlipidemia cholelithiasis Social History: The patient lives at home with his wife. WOrks as a VP at a consulting firm. No EtOH, smoking or other recreational drug use. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On Admission: VS: 97.0 173/102 108 20 94%RA GENERAL: Lying in bed in NAD HEENT: PERRLA, EOMI, anicteric, MMM, OP clear Neck: Supple, No JVD CV: Tachycardic, S1 and S2, no m/r/g Lung: CTAB, no w/r/r Abdomen: Soft, NT/ND, BSx4 Extremities: No edema Neuro: Awake, alert and oriented. Moving all extremities. Pertinent Results: On Admission: [**2126-4-27**] 10:57AM BLOOD WBC-8.8 RBC-5.10 Hgb-14.9 Hct-44.4 MCV-87 MCH-29.2 MCHC-33.5 RDW-13.2 Plt Ct-293 [**2126-4-27**] 10:57AM BLOOD PT-11.2 PTT-29.9 INR(PT)-1.0 [**2126-4-27**] 10:57AM BLOOD Glucose-159* UreaN-6 Creat-0.7 Na-138 K-4.0 Cl-103 HCO3-25 AnGap-14 [**2126-4-27**] 01:33PM BLOOD ALT-16 AST-20 CK(CPK)-72 AlkPhos-65 Amylase-59 TotBili-0.5 DirBili-0.1 IndBili-0.4 [**2126-4-27**] 10:57AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.0 [**2126-4-27**] 01:33PM BLOOD VitB12-90* [**2126-4-28**] 06:36AM BLOOD Folate-15.7 [**2126-4-27**] 01:33PM BLOOD %HbA1c-7.4* eAG-166* Studies: Catheterization Report Coronary angiography: right dominant LMCA: Diffuse 40-50% LAD: Proximal calcific 60-80%. Diagonal with diffuse proximal 60% LCX: Origin 60%, proximal 70% at small OM1, 50% at slightly larger (1.5 mm OM2) and 80% origin moderate (2.5 mm) OM3. Occluded AVG Cx. RCA: Totally occluded proximally. Collaterals fill PDA and distal RCA back to mid vessel. . Intra-op TEE [**2126-5-2**] Conclusions PREBYPASS No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mild distal anterior wall hypokinesis.. Overall left ventricular systolic function is normal (LVEF>55%). The remaining left ventricular segments contract normally. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. POST-BYPASS Biventricular systolic function remains normal. A ring prosthesis is visualized in the mitral position. There is trace residual MR. [**Name13 (STitle) **] evidence of [**Male First Name (un) **]. The remaining study is unchanged from prebypass. [**2126-5-8**] 04:17AM BLOOD WBC-10.9 RBC-3.83* Hgb-10.9* Hct-33.9* MCV-89 MCH-28.6 MCHC-32.2 RDW-13.9 Plt Ct-259 [**2126-5-7**] 04:25AM BLOOD WBC-10.2 RBC-3.95* Hgb-11.5* Hct-34.4* MCV-87 MCH-29.1 MCHC-33.4 RDW-13.6 Plt Ct-265 [**2126-5-8**] 04:17AM BLOOD PT-33.8* INR(PT)-3.3* [**2126-5-7**] 04:25AM BLOOD PT-20.5* INR(PT)-1.9* [**2126-5-6**] 04:37AM BLOOD PT-14.0* INR(PT)-1.3* [**2126-5-2**] 01:26PM BLOOD PT-12.6* PTT-34.8 INR(PT)-1.2* [**2126-5-2**] 06:05AM BLOOD PT-11.4 PTT-50.5* INR(PT)-1.1 [**2126-5-8**] 04:17AM BLOOD Glucose-110* UreaN-14 Creat-0.9 Na-132* K-4.4 Cl-97 HCO3-27 AnGap-12 [**2126-5-7**] 04:25AM BLOOD Glucose-114* UreaN-15 Creat-0.9 Na-137 K-3.9 Cl-99 HCO3-29 AnGap-13 [**2126-5-6**] 04:37AM BLOOD Glucose-118* UreaN-16 Creat-0.9 Na-135 K-4.2 Cl-99 HCO3-27 AnGap-13 [**2126-5-8**] 04:17AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0 [**2126-5-7**] 04:25AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.3 Brief Hospital Course: Mr. [**Known lastname 83712**] is a 62 year-old gentleman with no known coronary artery disease who presented with chest pain and dyspnea with even mild exertion. Found to have 3-vessel coronary disease and underwent bypass surgery. HOPSITAL COURSE --------------- The patient was directly admitted to the cardiology floor due to CP and dyspnea with exertion. He underwent cardiac catheterization that showed 3-vessel coronary disease. No intervention was performed and the patient was transferred back to the cardiology floor to await bypass surgery. On the cardiology floor, the patient was initially hypertensive and started on a nitro drip while metoprolol was uptitrated. Also uptitrated atorvastatin. The patient began to have intermittent chest pain at rest and was placed on a heparin drip. On [**2126-5-2**], he was taken to the operating room where he underwent coronary artery bypass grafting to four vessels and a mitral valve repair with ring. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. He had a brief episode of post-op a-fib which converted to sinus rhythm with amiodarone. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. AFib returned intermittently. Coumadin was initiated. 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 6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to LifeCare of [**Location (un) **] in good condition with appropriate follow up instructions. Medications on Admission: - Benicar 40mg daily - Aspirin 81mg daily - Metformin 1000mg [**Hospital1 **] - Amaryl 1mg twice daily - Lipitor 10mg daily - Sotalol 80mg twice daily (stopped 2 days prior to procedure) - Glargine 15-20 units at night 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 pain. 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then 200mg daily until further instructed. 7. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. olmesartan 20 mg Tablet Sig: One (1) Tablet PO daily (). 11. glimepiride 1 mg Tablet Sig: One (1) Tablet PO daily (). 12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 14. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 7 days. 15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 16. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) Subcutaneous at bedtime: 15 units glargine hs. 17. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: per attached sliding scale. 18. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: dose daily for goal INR 2-2.5, dx: afib. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) **] Discharge Diagnosis: Coronary artery disease Mitral regurgitation Diabetes Hypertension Hyperlipidemia cholelithiasis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage Edema - none Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] *Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2126-6-4**] 1:15 Cardiologist: Dr. [**Last Name (STitle) 911**] [**Telephone/Fax (1) 62**] Date/Time:[**2126-6-5**] 1:40 Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 72730**] in [**4-4**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2126-5-8**] Admission Date: [**2126-5-11**] Discharge Date: [**2126-5-13**] Date of Birth: [**2064-1-12**] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 165**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 62 y/o Male well known to the csurg service.He is status post Urgent coronary artery bypass graft x4 on [**2126-5-2**] with Dr.[**First Name (STitle) **].Please refer to the discharge summary of [**2126-5-8**] for further details of his recent admission and hospital course. He presents to the ED today, from Lifecare in [**Location (un) **], complaining of worsening shortness of breath, orthopnea and cough.TTE done in ED reveals no pericardial effusion. He is afebrile, with a wbc count of 13. He is being admitted to csurg for further workup. Past Medical History: [**2126-5-2**] - 1. Urgent coronary artery bypass graft x4; left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal obtuse marginal and posterior descending arteries. 2. Endoscopic harvesting of the long saphenous vein. 3. Mitral valve repair with a size 28 CG Future complete band. Coronary artery disease Mitral regurgitation Diabetes Hypertension Hyperlipidemia cholelithiasis Social History: The patient lives at home with his wife. WOrks as a VP at a consulting firm. No EtOH, smoking or other recreational drug use. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Physical Exam: On Admission: VS: HR-73, RR-16,100% o2 SAT on RA GENERAL: A&Ox3,NAD HEENT: AT/NC CV: RRR Lung: (L)basilar crackles, diminished bilateral Abdomen: benign Extremities:trace-1+(B)LE edema Sternal incision: mid-lower pole-pinpoint bloody drg expressed. Sternum stable, no [**Doctor Last Name **]/click. Pertinent Results: [**2126-5-13**] 04:31AM BLOOD WBC-11.0 RBC-3.68* Hgb-10.4* Hct-32.5* MCV-88 MCH-28.3 MCHC-32.0 RDW-13.2 Plt Ct-416 [**2126-5-12**] 02:49AM BLOOD WBC-11.9* RBC-3.83* Hgb-10.9* Hct-33.2* MCV-87 MCH-28.3 MCHC-32.7 RDW-13.2 Plt Ct-381 [**2126-5-11**] 03:45PM BLOOD WBC-13.4* RBC-4.18* Hgb-11.8* Hct-36.8* MCV-88 MCH-28.2 MCHC-32.0 RDW-13.4 Plt Ct-408# [**2126-5-13**] 04:31AM BLOOD PT-19.3* INR(PT)-1.8* [**2126-5-11**] 03:45PM BLOOD PT-21.4* PTT-33.6 INR(PT)-2.0* [**2126-5-13**] 04:31AM BLOOD Glucose-114* UreaN-12 Creat-1.0 Na-135 K-4.4 Cl-99 HCO3-25 AnGap-15 [**2126-5-12**] 02:49AM BLOOD Glucose-180* UreaN-13 Creat-1.1 Na-134 K-4.3 Cl-99 HCO3-27 AnGap-12 . CXR [**2126-5-11**] Final Report INDICATION: Recent CABG with worsening dyspnea and productive cough. COMPARISON: [**2126-5-7**]. PA AND LATERAL VIEWS OF THE CHEST: The patient is status post median sternotomy, CABG, and mitral valve repair. The cardiac silhouette size remains mildly enlarged. The aorta is slightly tortuous. Mild pulmonary vascular congestion is present. Bibasilar airspace opacities presents, likely atelectasis, though infection cannot be excluded. Small bilateral pleural effusions are relatively unchanged. There is no pneumothorax. No acute osseous abnormality is seen. IMPRESSION: Mild pulmonary vascular congestion with small bilateral pleural effusions and likely bibasilar atelectasis. Please note that infection at the lung bases cannot be completely excluded. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: SAT [**2126-5-11**] 11:26 PM Imaging Lab There is no report history available for viewing. Brief Hospital Course: Mr. [**Known lastname 83712**] is a 62 y/o Male well known to the csurg service. He is status post Urgent coronary artery bypass graft x4 on [**2126-5-2**] with Dr.[**First Name (STitle) **]. Please refer to the discharge summary of [**2126-5-8**] for further details of his recent admission and hospital course. He presented to the ED [**5-11**], from Lifecare in [**Location (un) **], complaining of worsening shortness of breath, orthopnea and cough. TTE done in ED revealed no pericardial effusion. He has been afebrile, with a mild leukocytosis of 13. He was admitted to csurg for presumed pneumonia. CXR was done with question of left lower lobe infiltrate versus effusion. He was placed on diuresis and antibiotics for presumed hospital acquired pneumonia. All cultures were negative. He continued to progress and was discharged home on hospital day 3 with a 10 day course of antibiotics. Medications on Admission: 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 pain. 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then 200mg daily until further instructed. 7. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. olmesartan 20 mg Tablet Sig: One (1) Tablet PO daily (). 11. glimepiride 1 mg Tablet Sig: One (1) Tablet PO daily (). 12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 14. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 7 days. 15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 16. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) Subcutaneous at bedtime: 15 units glargine hs. 17. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: per attached sliding scale. 18. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: dose daily for goal INR 2-2.5, dx: afib. Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR Coumadin for post-op AFib Goal INR 2-2.5 First draw [**2126-5-14**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [**Last Name (STitle) 8026**] Results to phone: [**Telephone/Fax (1) 72730**] fax: [**Telephone/Fax (1) 110370**] 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400mg daily x 1 week, then 200mg daily until further instructed. Disp:*60 Tablet(s)* Refills:*2* 5. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2* 6. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 7. glimepiride 1 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*2* 8. olmesartan 20 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*2* 9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/temp. 10. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dr. [**Last Name (STitle) 8026**] to dose daily for goal INR 2-2.5. Disp:*30 Tablet(s)* Refills:*2* 11. Augmentin XR 1,000-62.5 mg Tablet Extended Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO every twelve (12) hours for 10 days. Disp:*40 Tablet Extended Release 12 hr(s)* Refills:*0* 12. tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 13. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) Subcutaneous at bedtime. Disp:*qs * Refills:*2* 14. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: see attached sliding scale. Disp:*qs * Refills:*2* 15. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 16. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 7 days. Disp:*14 Tablet Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Pneumonia Coronary artery disease Mitral regurgitation Diabetes Hypertension Hyperlipidemia cholelithiasis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage Edema - none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Wound Check: [**2126-5-21**], 10:15am, 110 [**Doctor First Name **] [**Hospital Unit Name **] [**Telephone/Fax (1) 170**] Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2126-6-4**] 1:15 Cardiologist: Dr. [**Last Name (STitle) 911**] [**Telephone/Fax (1) 62**] Date/Time:[**2126-6-5**] 1:40 Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 72730**] in [**4-4**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR Coumadin for post-op AFib Goal INR 2-2.5 First draw [**2126-5-14**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [**Last Name (STitle) 8026**] Results to phone: [**Telephone/Fax (1) 72730**] fax: [**Telephone/Fax (1) 110370**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2126-5-13**]

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icd9cm

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icd9pcs

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52575

Discharge summary

report

Admission Date: [**2164-10-21**] Discharge Date: [**2164-12-1**] Date of Birth: [**2101-6-19**] Sex: M Service: SURGERY Allergies: Benadryl / Morphine Attending:[**First Name3 (LF) 1781**] Chief Complaint: L toe pain, shortness of breath Major Surgical or Invasive Procedure: Left 2nd and 3rd toe ray amputation. . Left popliteal to posterior tibial bypass graft with in-situ greater saphenous vein and intraoperative angioscopy with valve lysis, intraoperative arteriogram . Wide excisional debridement of the left foot with fourth and fifth toe amputation, placement of a vacuum dressing. . NAME OF PROCEDURE: 1. Debridement of foot and ankle wounds. 2. Left completion TMA with flap closure. 3. Split thickness skin graft, 91 cubic cm to residual open wound on foot and ankle. History of Present Illness: This is a 63 year old male with multiple medical problems including ESRD on HD, CHF EF 15%, CAD s/p MI ([**2155**], [**2160**]), PVD s/p multiple bypass grafts, DM2 with ESRD on HD recently discharged from [**Hospital1 **] on [**2164-10-16**] after being hospitalized for CHF exacerbation who presented to the ED with shortness of breath. Pt is well known to this service due to his multiple hospital stays. The patient usually takes 80 mg PO lasix [**Hospital1 **] at home and during his admission was given the same dose as his outpatient regimen. He states that he has been taking his medications at home. He states that he is compliant with his low-salt diet but when asked further, states that he frequently eats fried chicken and barbeque. The patient denies any chest pain, calf pain. The patient believes that his shortness of breath symptoms are worse usually on Sundays as he is dialyzed MWF. . The patient denies orthopnea and uses [**2-5**] pillows at home which is his baseline. He denies any increased lower extremity edema. . In the ED, a CXR on [**2164-10-21**] was consistent with CHF with a possible RLL pneumonia or opacity. He was also found to have an ischemic left third toe and vascular surgery was consulted. He had a lactate of 2.3 with a gap of 16 with a Cr of 5.7 (baseline Cr [**5-8**], 6 during his last admission). His troponin was 0.15 which is his baseline troponin in the setting of his chronic renal insufficiency. His CK was flat at 44. A pro-BNP was checked and is pending. . In additon, he had a CT-A which was negative for PE with no significant change from his prior admission with trace ascites. . His EKG showed sinus tachycardia with rate of 129, leftward axis. LVH. QTc 459. [**Street Address(2) 4793**] depression in V5, V6 with TWI (changed from baseline). TWI I, AVL (unchanged). . Pt also has ulceration of left foot. Past Medical History: 1. Coronary artery disease: Myocardial infarction in [**2155**], MQWMI in [**2160**]. Most recent cath, [**2163-10-18**]: LCx stenting; previous RCA stent patent at that time. 2. Nonischemic dilated cardiomyopathy; EF [**12-6**] 33%. EF [**2164-1-11**] to 25% 3. Diabetes greater than 20 years; with triopathy. 4. Hypertension. 5. End stage renal disease on hemodialysis, q. Monday, Wednesday and Friday via right arteriovenous fistula. 6. Hypothyroidism. 7. Chronic obstructive pulmonary disease. 8. Hepatitis C. 9. Chronic pancreatitis. 10. Peptic ulcer disease. 11. Right perinephric hematoma; status post embolization. 12. Obstructive sleep apnea on CPAP. 13. Ruptured right groin abscess; recurrent right groin abscess in [**2162-12-4**]. 14. Peripheral vascular disease. 15. Status post R PFA to BK [**Doctor Last Name **] bypasss graft with vein 16. Status post 2nd and 3rd toe amps 17. Status post left CFA to AK [**Doctor Last Name **] with PTFE 18. Status post L inguinal hernia repair 19. Status post umbilical hernia repair 20. Ischemic left foot 21. A - Fib Social History: Social: [**Location (un) 686**], lives with wife, has older children, tob: 1 ppd, no EtOH Family History: Non contributary Physical Exam: VS: Tm 99.2 BP112-126/66-87 HR72-97 RR14-16 O2sat: 97-98% 2L Is/Os not recorded o/n. Gen: NAD, AOX3, anicteric, pupils minimally responsive to light but equal bilaterally, EOMI, lying supine without difficulty on 1 pillow HEENT: 10 cm JVD, dry MM, positive hepatojugular reflex Heart: Regular, nml s1,s2. No s3. No murmurs. Lungs: Bibasilar crackles, otherwise CTAB. Abdomen: Soft, NT, + hepatomegaly 3 fingerbreadths below the costal margin, ND, + BS, palpable graft from left flank to left groin Ext: Left foot TMA noted/ Skin graft in place / some minimul necrotic areas around wound. Slight redness on lower ball of foot TTT, B/L pulses: weakly palpable d. pedis bilaterally, +1 femoral pulses bilaterally, palp graft site Skin: No rashes Pertinent Results: . PMibi [**10-24**] IMPRESSION: 1. Mild, partially reversible defects in the lateral wall, in the inferior wall, and apex. 2. Left ventricular cavity profoundly dilated on stress and rest with an end-diastolic volume of 393 ml. 3. Global hypokinesis with an ejection fraction of 15%, appearing to be interval worsening since the last Persantine MIBI of [**2162-12-20**]. . CTA [**10-21**] IMPRESSION: 1. No evidence of pulmonary embolism. 2. Cardiomegaly and significant coronary artery calcifications. 3. Small amount of ascites in the visualized portions of the abdomen. [**2164-11-27**] BLOOD WBC-11.5* RBC-3.10* Hgb-9.9* Hct-28.8* MCV-93 MCH-32.1* MCHC-34.5 RDW-18.3* Plt Ct-300 [**2164-11-26**] Neuts-78.0* Lymphs-11.4* Monos-3.8 Eos-6.2* Baso-0.6 [**2164-11-26**] Hypochr-2+ Anisocy-1+ Macrocy-2+ [**2164-11-27**] Plt Ct-300 [**2164-11-27**] Glucose-110* UreaN-32* Creat-4.5*# Na-138 K-3.7 Cl-96 HCO3-31 AnGap-15 [**2164-11-15**] ALT-26 AST-35 LD(LDH)-197 CK(CPK)-12* AlkPhos-99 Amylase-118* TotBili-0.4 [**2164-11-27**] Calcium-8.8 Phos-4.3 Mg-1.8 [**2164-10-23**] VitB12-350 Folate-6.8 [**2164-10-22**] %HbA1c-6.6* [Hgb]-DONE [A1c]-DONE [**2164-10-22**] Triglyc-72 HDL-46 CHOL/HD-1.9 LDLcalc-27 [**2164-10-30**] Ammonia-29 [**2164-11-9**] TSH-6.0* [**2164-11-26**] Vanco-10.9* [**2164-11-8**] Glucose-143* Lactate-3.4* Na-136 K-4.8 Cl-103 [**2164-11-20**] Hgb-8.5* calcHCT-26 [**2164-11-9**] freeCa-1.22 [**2164-11-20**] ECG Study Sinus rhythm. Poor R wave progression suggestive of anteroseptal myocardial infarction. Lateral ST-T wave abnormalities. Since the previous tracing of [**2164-11-15**] atrial flutter has resolved. Intervals Axes Rate PR QRS QT/QTc P QRS T 69 1 62 100 416/434.71 -7 -38 111 RADIOLOGY Final Report [**2164-11-15**] 5:47 PM CHEST PORT. LINE PLACEMENT INDICATION: 63-year-old man with septic foot. COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared with the previous study of [**2164-11-11**]. The tip of the new left-sided PICC line is identified at cavoatrial junction. No pneumothorax is seen. The right jugular IV catheter remains in place. There is continued cardiomegaly. Patchy atelectasis is seen in the left lung base. The lungs are clear otherwise. IMPRESSION: The tip of the left-sided PICC line in the cavoatrial junction. Continued cardiomegaly. [**2164-11-2**] ART DUP EXT LO UNI;F/U Reason: Evaluate L. ax fem grft patency and flow. The left axillary-femoral bypass graft is patent. Peak systolic velocities in the left axillary artery proximal to the graft are 70 cm/second, peak systolic velocity of the left proximal anastomosis is 129 cm/sec, the peak systolic velocity in the graft in the mid torso is 40 cm/sec, peak systolic velocities in the graft at the distal anastomosis is 36 cm/sec, and the peak systolic velocity in the proximal aspect of the left femoral popliteal graft is 19 cm/sec. The left femoral popliteal graft and remainder of the left lower extremity was not evaluated. Two anechoic areas are found surrounding the axillofemoral graft in the left groin and in the left upper torso. These anechoic areas are well defined and demonstrates enhanced through-transmission, consistent with seromas. IMPRESSION: 1. The left axillary-femoral bypass graft is patent. There is a change in velocities between the proximal anastomosis in the mid graft, suggestive of a possible narrowing in the proximal aspect of the graft. The single measured velocity in the proximal femoropopliteal bypass graft appears low but is relatively similar to the prior study from [**2164-9-3**]. 2. Small fluid collections are present around the left axillary-femoral bypass graft in the upper torso and in the groin. These could be consistent with seromas. [**2164-10-31**] 12:52 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: please do mri,a,dwi for stroke FINDINGS: There is no evidence of acute infarction. The ventricles and the sulci are prominent in caliber and configuration. There is no evidence for hemorrhage, edema, masses, or mass effect. There is extensive hyperintensity of the periventricular white matter on the long TR images. These findings suggest chronic small vessel ischemia. Many of the images are severely degraded by motion artifact. The MRA demonstrates apparent narrowing of the carotid arteries bilaterally in their cavernous segments. However, this may be in part due to susceptibility artifact. CONCLUSION: No evidence of acute infarction. Small vessel ischemia changes. Possible cavernous carotid artery narrowing. RADIOLOGY Final Report [**2164-10-30**] CT HEAD W/O CONTRAST Reason: r/o bleed Multiple axial images are obtained from base to vertex without intravenous contrast administration. Comparison is made to the prior exam from [**2162-1-12**]. There is slightly decreased attenuation involving the posterior periventricular white matter and centrum semiovale, suggestive of chronic microvascular ischemic or gliotic changes. The ventricular system remains symmetrical without hydrocephalus. There is a small area of low attenuation involving the right occipital lobe suggestive of a small infarct. This is of uncertain chronicity. It was not present on the previous exam. If the patient has recent visual symptoms, correlation with MRI and diffusion images would be helpful. There is no intraparenchymal or subdural hemorrhage. The calvarium is intact. IMPRESSION: Small area of low attenuation involving the right occipital lobe suggestive of a small infarct of uncertain age. No intraparenchymal hemorrhage is seen. [**2164-11-10**] STOOL CONSISTENCY: WATERY Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2164-11-11**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. [**2164-11-3**] 2:45 pm SWAB Site: FOOT L FOOT. **FINAL REPORT [**2164-11-7**]** GRAM STAIN (Final [**2164-11-3**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). WOUND CULTURE (Final [**2164-11-7**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). GRAM NEGATIVE ROD(S). MODERATE GROWTH . STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. 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. PROBABLE ENTEROCOCCUS. SPARSE GROWTH. STAPH AUREUS COAG + CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2164-11-7**]): NO ANAEROBES ISOLATED. [**2164-11-1**] BLOOD CULTURE AEROBIC BOTTLE (Final [**2164-11-7**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2164-11-7**]): NO GROWTH. Brief Hospital Course: A/P: 63 year old male with a history of CHF EF 15%, CAD, DMII, ESRD(baseline Cr [**5-8**]) on HD now with likely CHF exacerbation and left ischemic toe. . # CHF exacerbation - The patient takes 80 mg PO lasix [**Hospital1 **] at home. During his last admission, the patient did not receive IV lasix and was discharged on his outpatient regimen. - The patient was given 40 mg IV lasix in the ED. - Pt without much UOP. Lasix not very helpful in light of this fact - d/ced Lasix per renal recs. Cont HD for volume removal. Will consider having increased HD on friday, or weekend HD to prevent frequent presentations to hospital Sunday night/Monday AM. CXR not dramatically different from last hospitalization but has severe right-sided failure as well. - Continue [**Hospital1 **], Lopressor, Lisinopril 5 mg QD. . # CAD/Dilated cardiomyopathy - The patient will be monitored on telemetry with no acute ischemic ST changes on EKG - r/oed, no events on tele x2-3 days. D/c'ed tele. -Troponins negative x3. -Pt has not had any CP c/o during this admission. -Cont [**Hospital1 **]/[**Hospital1 **], Lipitor, Lopressor, Lisinopril -LFTs nml on statin. -Started Lopressor 25mg po bid with admission, pt had hx of being on Bblocker in past, and was discharged on Bblocker from last admission, but pt admits to not taking them. -Cholesterol panel normal LDL 27, HDL 46. No need to increase statin at this time. - P-mibi results as above. Pt with multiple, mild, partially reversible defects. [**Name (NI) 108555**], pt with dilated cardiomyopathy out of proportion to coronary disease. Pt with multiple lesions that although theoretically stentable, would not likely improved his dilated cardiomyopathy and poor EF. Pt is at high risk of mortality from operation, and risks likely outweight benefits. Have discussed this issue at length with patient today, and he verbalizes risks of procedure including high risk of death with anesthesia/operative stress. . # DM.2 - It is unclear what the patient takes as an outpatient. This should be readdressed with the patient's PCP in the am. - HgA1c 6.6%. His sugars have remained <120 throughout admission, and pt has not required SQ Insulin based on parameters written for sliding scale. Will d/c FS, Insulin SS. Will defer outpatient hypoglycemics to PCP as needed. . # HTN - The patient takes Lisinopril 5 mg PO QD. Added Lopressor 25 mg PO BID for rate control and monitor his BP. - BPs remain well controlled during this admission. . # ESRD -Will continued HD MWF. -Increased Sevelamer to 1600 mg PO TID per renal recs. . # AF: - Pt did have a bout of Afib. Started on amiodorone IV, hr recieved this for a total of 18 hours. He is now on PO amiodorone. -Cont Lopressor 25 [**Hospital1 **]. Rate well controlled. -In addition, the patient takes coumadin 5 mg at home with an INR of 1.5 on admission. We will increase this to 7.5 mg PO on discharge, with a goal INR of [**3-8**], continued coumadin 5mg qhs. ( his usual dose ) -Pt not given coumadin untill DC, there was a chance to take the pt to the OR. -On discharge pt is INR 1.1. Cont the above coumadin dose, and will defer on bridging Heparin until therapeutic. -A TSH was done this was elevated (6.0). To follow with PCP. . # Left ischemic toe - The patient had received vanco / pipercillan at HD. He is to remain on [**Last Name (un) 8114**] dose untill cleared by Dr [**Last Name (STitle) **]. - Vascular surgery was consulted in the ED. Appreciate surgical input. Please see above note for discussion on preoperative clearance results and surgical risk. - In addition, the patient is currently on [**Last Name (STitle) **], [**Last Name (STitle) **], coumadin. Patient to the OR during this admission. . - Left 2nd and 3rd toe ray amputation. . Left popliteal to posterior tibial bypass graft with in-situ greater saphenous vein and intraoperative angioscopy with valve lysis, intraoperative arteriogram . Wide excisional debridement of the left foot with fourth and fifth toe amputation, placement of a vacuum dressing. . NAME OF PROCEDURE: 1. Debridement of foot and ankle wounds. 2. Left completion TMA with flap closure. 3. Split thickness skin graft, 91 cubic cm to residual open wound on foot and ankle. . # Chronic Anemia - The patient has a baseline Hct of 39-40 and is at his baseline at present. - Will guaiac all stools and monitor although his Hct appears stable at this time. Iron studies last sent 5 years ago with low normal iron and normal ferritin, likely consistent with chronic disease and renal failure. The patient had been on Epo in the past but not presently. - Goal Hct >30 given h/o CAD. . # Hyporthyroidism - TSH - 6.0. The patient is not currently on Synthroid and likely needs it now. ? dx of hypothyroidism, He should follow up wiith his PCP and have the ATSH redrawn. Pt had a TSH originally 1.1. . # ID . ENTEROCOCCUS. SPARSE GROWTH. STAPH AUREUS COAG + CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S . Pt [**Name (NI) 1788**] on Vancomycin / Pipercillan . # Pain control - Will cont to titrate up long acting narcotics, and consider pain consult if unable to control pain. . # h/o COPD - Albuterol nebs prn, no wheezes currently on exam. - Pt with nebs at home, although admits to noncompliance because he does not believe that that is what is his [**Last Name 3545**] problem. . # h/o PUD - Continue PPI. No current complaints. . # FEN - Diabetic, cardiac diet. Monitor lytes given ESRD. . # PPx - On coumadin, [**Last Name 4532**]. PPI. bowel regimen as needed. . # Code: Full code . #Dispo: Wife of patient refuses to accept patient home, stating that she believes he will not tolerate ambulating at home and requests a Rehab facility. Medications on Admission: Warfarin 5 mg Tablet 1 Tablet PO HS Furosemide 80 mg Tablet (1) Tablet PO BID Metoclopramide 10 mg Tablet 1 Tablet PO QIDACHS Pantoprazole 40 mg Tablet, Delayed Release (E.C.) QD Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily Aspirin 81 mg Tablet, Delayed Release (E.C.) (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Clopidogrel 75 mg Tablet (1) Tablet PO DAILY Sevelamer800 mg PO TID Atorvastatin 20 mg Tablet (1) Tablet PO DAILY Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous WITH DIALYSIS (): Dr [**Last Name (STitle) **] to DC - presumably 6 weeks from discharge. ive during dialysis and moniter trough. Adjust accordingly. 10. PICC LINE FLUSH 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 11. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours): Dr [**Last Name (STitle) **] to DC - presumably 6 weeks from discharge. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 17. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 19. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 21. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 22. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 23. INSULIN SLIDING SCALE Insulin SC Sliding Scale Fingerstick q6h Times given: Breakfast Lunch Dinner Bedtime Regular Insulin Glucose Insulin Dose 0-65 mg/dL 4 oz. Juice and 15 gm crackers 4 oz. Juice 66-120 mg/dL 0 Units 121-160 mg/dL 2 Units 161-200 mg/dL 4 Units 201-240 mg/dL 6 Units 241-280 mg/dL 8 Units 281-320 mg/dL 10 Units > 320 mg/dL 12 Units 24. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR goal [**3-8**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Volume overload . Atrial Fibrillation . L toe pain . Ischemic and necrotic left foot, status post incision and drainage and status post a left popliteal to posterior tibial artery bypass graft. . Nonhealing ulcer, left foot, status post left popliteal to PT bypass graft. . Ischemic left foot with open, necrotic wound s/p I and D. . Septic left foot. . Post operative delerium . toxic-metabolic encephalopathy secondary to infection, renal insufficiency, medications. . ESRD on HD MWF CHF EF 15-20% Dilated cardiomyopathy CAD s/p stents DMII Discharge Condition: Pain well controlled, no shortness of breath, afebrile, stable to be discharged to Rehab with IV antibiotics Discharge Instructions: 1. Please follow up with Dr. [**First Name (STitle) **] in [**2-5**] weeks. . 2. Please follow up with Dr. [**Last Name (STitle) **] from vascular surgery regarding follow up for your L metatarsal amputation and skin graft surgery. This appointment should be made for two weeks from your discharge. . 3. Please take medications as below. Especially the Antibiotics. . 4. If develop shortness of breath, chest pain, abdominal pain or any other symptoms, please call Dr. [**First Name (STitle) **] or report to the nearest ER. . DISCHARGE INSTRUCTIONS FOLLOWING TRANSMETATARSAL AMPUTATION . This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. . ACTIVITY: . There are restrictions on activity. On the side of your transmetatarsal amputation you are non weight bearing for [**5-9**] weeks. You should keep this amputation site elevated when ever possible. . You may use the heel of your amputation site for transfer and pivots. But try not to exert to much pressure on the site when transferring and or pivoting. If possible avoid using the heel of your amputation site when transferring and pivoting. . No driving until cleared by your Surgeon. . PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: . Redness in or drainage from your leg wound(s). . New pain, numbness or discoloration of your foot or toes. . Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. . Exercise: . Limit strenuous activity for 6 weeks. . Do not drive a car unless cleared by your Surgeon. . No heavy lifting greater than 20 pounds for the next 14 days. . Try to keep leg elevated when able. . BATHING/SHOWERING: . You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place and changed daily. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. . WOUND CARE: . Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. . When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. . Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. . MEDICATIONS: . Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. . Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. CAUTIONS: . NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. . Avoid pressure to your amputation site. . No strenuous activity for 6 weeks after surgery. . DIET: . There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. . For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. . If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. . If you have diabetes and would like additional guidance, you may request a referral from your doctor. FOLLOW-UP APPOINTMENT: . Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! . Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. . PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5004**] [**Telephone/Fax (1) 250**] Call to schedule appointment Call and scheduler an appointment with Dr [**Last Name (STitle) 108556**]. She can be reached at [**Telephone/Fax (1) 2395**]. Hemodyalysis M/W/F Completed by:[**2164-11-29**]

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icd9cm

[ [ [] ] ]

[ "39.29", "38.93", "86.69", "99.04", "84.3", "39.95", "84.12", "88.48", "84.11", "86.22" ]

icd9pcs

[ [ [] ] ]

21663, 21742

12217, 18129

312, 818

22329, 22440

4730, 12194

28478, 28809

3933, 3951

18630, 21640

21763, 22308

18155, 18607

22464, 24817

3966, 4711

241, 274

24830, 27770

27794, 28455

846, 2715

2737, 3809

3825, 3917

28,742

136,468

4417

Discharge summary

report

Admission Date: [**2143-7-27**] Discharge Date: [**2143-8-1**] Date of Birth: [**2071-1-13**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 358**] Chief Complaint: fever, fatigue Major Surgical or Invasive Procedure: none History of Present Illness: 72yoF with h/o breast cancer metastatic to liver/lung/bones/CNS, s/p whole brain XRT on [**7-4**] who presents today to the ED with c/o 2wks of fatigue and generalized weakness and 1 day of temperature at home to max of 100.3. She states she has been feeling exhausted x nearly 2 wks with increased fatigue; she has been sleeping most of each day. She denies subjective fever, but reports her husband recommended taking her temperature today (max as above/). She denies cough, shortness of breath, chest pain. She further denies abdominal pain, diarrhea, dysuria, hematuria. No headache nor changes in vision. She does, however, endorse visual hallucinations (flies in the room) intermittently since her last XRT and steroid taper. She reportedly finished steroid taper last week s/p whole brain XRT. Of note, her last chemotherapy was late [**Month (only) **] at which time she received oral CMF and did not become neutropenic. On a [**2143-7-17**] visit with her oncologist, her coreg dose was cut in half [**1-25**] to significant fatigue and her lasix was discontinued. She reports, however, that she has been eating/drinking well at home over the past few weeks although reports feeling chronically thirsty. Past Medical History: Prior Onc Hx: In [**2133**] pt had a mass noted in her R breast and she underwent mastectomy. She had 2 positive LN. She was diagnosed with inflammatory breast CA, estrogen receptor positive. SHe received cyclophosphamide, adriamycin, 5 FU, and chest XRT. She then took Tamoxifen for 2 years; then changed to Arimidex. In [**7-28**] she developed metastatic disease with rising tumor markers. She was taken off Arimidex and placed on Taxol/Avastin. She has bone/liver mets and mediastinal adenopathy (bone mets to T12, iliac crest, L2/L3. In [**1-29**] CT head showed multiple areas of cerebral calcifications--however pt . In [**2-26**] repeat CT of torso showed regression of all of her mets and she had decreased tumor markers. She is now receiving weekly Taxol which was restarted in [**3-29**] after Taxol/Avastin had been held for fatigue and CHF. Additionally, is s/p brain irradiation. . PMH: 1. cardiomyopathy from Adriamycin. TTE [**2142-2-16**]: There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. EF 25-30%. 2. bilateral knee replacements, one in [**2134**] and another in [**2136**]. 3. osteoarthritis 4. lymphedema right arm Social History: No tobacco, ETOH, or illicit drug use. Lives with her husband. Family History: father died of rectal cancer Physical Exam: Afebrile, vital signs stable, on room air without hypoxia Gen -- overweight elderly female in NAD HEENT -- sclera anicteric, PERRLA, EOMI, oropharynx clear, alopecia, neck supple, LAD Heart -- regular, SEM at LUSB Lungs -- clear bilaterally Abd -- obese, benign, +BS Ext -- dry skin, no edema Pertinent Results: [**2143-8-1**] 05:18AM BLOOD WBC-4.2 RBC-3.22* Hgb-11.1* Hct-31.5* MCV-98 MCH-34.6* MCHC-35.4* RDW-17.1* Plt Ct-283 [**2143-8-1**] 05:18AM BLOOD Glucose-102 UreaN-7 Creat-0.5 Na-142 K-4.0 Cl-105 HCO3-25 AnGap-16 [**2143-7-29**] 04:17AM BLOOD LD(LDH)-475* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2143-7-28**] 03:01AM BLOOD CK-MB-2 cTropnT-<0.01 [**2143-7-27**] 06:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2143-7-29**] 04:17AM BLOOD Hapto-362* [**2143-7-27**] 06:00PM BLOOD calTIBC-170* VitB12-311 Folate-15.1 Ferritn-[**2106**]* TRF-131* [**2143-7-27**] 06:00PM BLOOD Cortsol-17.7 [**2143-7-31**] 10:21AM BLOOD CEA-96* CA27.29-PND Chest plain film [**2143-7-27**]: The left subclavian CV line is unchanged in position, projecting at the level of distal SVC. Heart contour is mildly enlarged. Venous congestion is noted. Bilateral linear opacities are visible at lung periphery. Pulmonary vascular congestion is also noted at both lung hila. Areas of increased opacity within the right lower lobe is consistent with hostory of pulmonary nodules which are difficult to see due to the interstitial edema. Small right pleural effusion is also present. The deformity of the right chest wall is unchanged. Brief Hospital Course: 1. fever/hypotension -- Initially admitted to the medical ICU for concern of sepsis, particularly with an indwelling central venous catheter. Blood cultures were drawn, and empiric coverage for staphylococcal bacteremia and community acquired pneumonia (with vancomycin and levaquin) were initiated. A CXR showed new left lower infiltrate. She improved without pressor support, and was transferred to the general medicine team for further care. No obvious infectious source was delineated, blood cultures did not grow organisms. The vancomycin was discontinued, and a full course of Levaquin was planned on discharge. 2. deconditioning -- The patient's weakness and fatigue were a large part of her subjective complaints surrounding admission. She worked with PT daily, and will continue to have daily physical therapy at home. 3. cardiomyopathy with LV dysfunction -- with normalized blood pressures, she was instructed to resume her home carvedilol and lisinopril at low doses. 4. metastatic breast cancer -- followed by Dr. [**Last Name (STitle) **]. No active issues during her hospitalizations. She has no pain complaints on discharge. Medications on Admission: Percocet 1-2 tabs q4-6hrs prn Paxil 20mg qam Zantac 75mg PO bid Ambien CR 6.25mg hs prn Coreg 3.125mg PO daily Lasix 40mg PO daily (d/c'd on [**2143-7-17**]) Lisinopril 5mg PO daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 7. Coreg 3.125 mg Tablet Sig: One (1) Tablet PO once a day. 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Hickman line care Per VNA protocol Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: deconditioning possible community acquired pneumonia metastatic breast cancer Discharge Condition: stable, ambulating with assistance Discharge Instructions: You were hospitalized with fever and hypotension. This has resolved. We are treating you with antibiotics, which you will continue after leaving the hospital. Finish all the antibiotics. Please call your doctor or return to the hospital with any concerns, particularly fever greater than 101, redness or pus around your port, headache, mental status changes, or falls at home. Followup Instructions: Call your oncologist, Dr. [**Last Name (STitle) **], for a follow up appointment at [**0-0-**]. Call your primary physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] at [**Telephone/Fax (1) 4775**] for a follow up appointment. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2143-9-9**] 1:00 Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2143-11-1**] 11:00

[ "425.4", "V10.3", "198.3", "197.0", "V43.65", "486", "197.7", "198.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6543, 6626

4462, 5614

299, 306

6748, 6785

3237, 4439

7214, 7733

2877, 2908

5847, 6520

6647, 6727

5640, 5824

6809, 7191

2923, 3218

245, 261

335, 1549

1571, 2778

2794, 2861

76,717

159,241

51073

Discharge summary

report

Admission Date: [**2191-7-28**] Discharge Date: [**2191-8-4**] Date of Birth: [**2108-3-28**] Sex: M Service: MEDICINE Allergies: Allopurinol And Derivatives Attending:[**Doctor Last Name 10493**] Chief Complaint: AMS, fever Major Surgical or Invasive Procedure: [**Date range (3) 106076**] Central venous line History of Present Illness: History of Present Illness: 83 year old male with history of mild cognitive impairment, hyperlipidemia, BPH, and gout presents with altered mental status, vomiting, and shaking chills. He was watching [**First Name8 (NamePattern2) 892**] [**Last Name (NamePattern1) 1806**] speak at the DNC and he began to feel very cold and started vomiting. As the night went on, he became more tired and less responsive and the wife called EMS. She reported to them that he was not acting like himself and was talking nonsense. On transfer, he became more lethargic and even less responsive. Patient triggered on arrival for altered mental status. [**Last Name (NamePattern1) **] sugar was normal. He took his first dose of donepezil tonight, but did not make any other medication changes. No other localizing symptoms to speak of. Per urgent care note from Dr. [**Last Name (STitle) 1007**], he experienced malaise with numbness in his fingers and chills while in [**Location (un) 7581**], [**Location (un) 5426**] about 4 weeks ago. He was taken to the local emergency room in that area (Northern [**Hospital 7581**] Community Hospital) and his symptoms of fever and malaise resolved since then. No definite cause of this acute illness was found. There was a concern about possible Lyme disease because of exposure to deer near his home. The patient denies any tick bite and claims that he rarely goes out in his yard, where they do have deer. He was started on doxycycline for concern of potential Lyme exposure given that they live in a wooded area. Lyme serology eventually returned negative. The wife reports that his current symptoms are very similar to this presentation, but he appeared more confused this time. In the ED, initial vitals were: 122 102/55 28 91% 2L NC. He was following basic commands on arrival. Rectal temp of 103. Labs were notable for low WBC at 3.5 and otherwise normal CBC. Creatinine on 1.3 close to baseline and LFTs within normal limits. Lactate originally at 4.3, then repeated at 5.7 after 2L NS. Urinalysis unremarkable and CXR clear. Head CT without acute intracranial process and moderate paranasal sinus disease, similar to prior. CT abd/pelv showed a hiatal hernia, cholelithiasis w/o cholecystitis, nonspecific perinephric stranding, enlarged prostate, small left fat-containing inguinal hernia (similar to prior CT in [**2188**]). Without obvious infectious cause, he was covered empirically with vanc/zosyn + ceftriaxone. LP refused by wife. [**Name (NI) **] pressures have trended down to the SBPs 80s but wife also refused [**Name (NI) 14938**] placement so patient was started on peripheral norepinephrine. 4th liter hanging prior to transfer and SBPs in 90s with normal oxygenation. On arrival to the MICU, he continued to be hypotensive despite uptitration of levophed and another 1L NS bolus. The wife is amenable to a central line placement here in the unit and willing to discuss further procedures needed for his care. The patient is having word-finding difficulties per his baseline and has trouble completing sentences. Orientation is therefore difficult to assess. Past Medical History: PMH: Uric acid nephrolithiasis s/p GU interventions in the past Hypercholesterolemia Gout (last attack 3 years ago) PSH: L URS with laser and cystolithalopaxy with [**Last Name (un) 938**] in [**6-29**] Cystolithalopaxy in [**1-26**] Social History: Tob: Distant history of smoking in 20s Alc: Rare Illicits: None Family History: - Diabetes in uncles - [**Name (NI) **] [**Name2 (NI) 3730**] in father Physical Exam: Vitals: T: 98.2, BP:85/60, P: 101 R: 9, O2: 93% on 3L General: eyes closed, responds to command intermittently but is responsive to question, has difficulty forming his answers, no acute respiratory distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Fasciculations evident in calves bilaterally (patient unaware) Neuro: CNII-XII intact, difficult to assess strength/sensation given inability to follow commands reliably. Pertinent Results: [**2191-7-28**] 08:13PM LACTATE-5.4* [**2191-7-28**] 07:24PM GLUCOSE-206* UREA N-19 CREAT-1.4* SODIUM-138 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-18* ANION GAP-21* [**2191-7-28**] 07:24PM ALT(SGPT)-20 AST(SGOT)-27 ALK PHOS-29* TOT BILI-0.3 [**2191-7-28**] 07:24PM CALCIUM-7.0* PHOSPHATE-3.8# MAGNESIUM-1.6 [**2191-7-28**] 07:24PM WBC-38.7* RBC-4.29* HGB-12.8* HCT-38.3* MCV-89 MCH-29.8 MCHC-33.3 RDW-13.7 [**2191-7-28**] 02:52PM URINE [**Month/Day/Year 3143**]-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2191-7-28**] 02:52PM URINE RBC-137* WBC-4 BACTERIA-FEW YEAST-NONE EPI-0 [**2191-7-28**] 02:21PM LACTATE-6.8* [**2191-7-28**] [**Month/Day/Year **] Culture: GNR SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ GRAM NEGATIVE ROD(S) | CEFTAZIDIME----------- S CEFTRIAXONE----------- S CIPROFLOXACIN--------- S GENTAMICIN------------ S MEROPENEM------------- S TOBRAMYCIN------------ S Imaging: Echo [**2191-7-29**] IMPRESSION: No vegetations or clinically-significant regurgitant valvular disease seen. Normal global and regional biventricular systolic function. [**2191-7-28**]: NO GROWTH. KUB [**2191-7-28**]: IMPRESSION: No signs of obstruction or intraperitoneal free air. Prostate US [**2191-7-28**] IMPRESSION: 1. No evidence of an abscess within the prostate. 2. Substantial BPH with a prostatic volume of 72 mL, correlating with a predicted PSA of 8.6. [**2191-7-28**] CT abdomen, pelvis IMPRESSION: 1. No acute intra-abdominal process; moderate colonic fecal burden. 2. Hiatal hernia. 3. Enlarged prostate and left fat- and bladder-containing inguinal hernia. 4. Mildly thickened left renal pelvis urothelium of unclear significance; no evidence of hydronephrosis or pyelonephritis. [**2191-7-28**] CT head w/o contrast IMPRESSION: Minimal paranasal sinus mucosal thickening. Otherwise normal study. CXR [**2191-7-28**] IMPRESSION: Low lung volumes but no evidence of pneumonia. Brief Hospital Course: Assessment and Plan: 83 year old male with prior history of mild cognitive impairment, gout, BPH, and hyperlipidemia presenting with worsening mental status, vomiting, and hypotension after similar presentation 1 month prior. ACUTE ISSUES: # Septic shock with altered mental status: His initial symptoms, including emesis and worsening disorientation and weakness, were concerning for a meningitis/encephalitis picture. His worsening lactate despite volume resuscitation and developing hypotension with bandemia were concerning for a septic picture. He was covered initially with Ampicillin, CTX, acyclovir, and doxycycline. On the morning after arrival to the ICU, [**Month/Day/Year **] cultures grew gram-negative rods and his WBC trended to a peak of 38. A RIJ [**Month/Day/Year 14938**] was placed upon arrival to the ICU and norepinephrine was titrated to MAPs>60. With GNRs, LP was deferred. [**Month/Day/Year **] cultures speciated pansensitive E. coli and his antibiotic regimen was narrowed to Ceftriaxone. His leukocytosis continued to improve and his pressor requirement decreased dramatically. His mental status also improved to close to his baseline. ID was also consulted and agree with the above treatment. To look for a source of his GNRs, we performed a prostate ultrasound which was negative. Initial CT scan was done without PO contrast, so this study was repeated to look for occult infection (i.e. abscess) and showed no evidence of abscesses. TTE was performed to rule out endocarditis and RUQ U/S did not show any significant findings to explain the GNR bacteremia. Tick-borne illnesses were also explored, with negativeserologies. Patient was transfered to general internal medicine floor on [**2191-7-30**]. IV Ceftriaxone was continued to finish 7 day course of IV antibiotics, then patient was started on a 7 day course of Ciprofloxacin to complete a total of 14 day course of antibiotics. Last day of Cipro will be [**2191-8-11**]. # Drug Eruption. Patient had diffuse pruritic non-blanching macular rash on his thighs, abdomen, and upper arms. Improved with Sarna cream and ice. Patient will follow up closely in outpatient setting with Dr. [**Last Name (STitle) 1007**]. CHRONIC ISSUES: # Mild cognitive impairment: His baseline mental status confound his current picture, but per his wife he was not at his most recent baseline on admission. He recently saw a cognitive neurologist, who instructed him to start donepezil to see if this would help him. His struggles are primarily with word-finding difficulties. He also responded robustly to low-dose quetiapine, resulting in significant somnolence. He was transferred out of the ICU once he was awake and alert, and returned to baseline status within a day. Donepezil held during the hospital course and restarted on discharge. # Mild renal insufficiency: Creatinine of 1.3 at recent baseline of 1.3-1.5. Remained stable in the ICU. # Gout: No flare. His probenecid was held during the hospital course and restarted on discharge. TRANSITIONAL ISSUES: - Drug Eruption MEDICATION STARTED: - Ciprofloxacin 500mg [**Hospital1 **]. First dose 9/14, Last dose 9/20. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Meclizine 50 mg PO X1 PRN vertigo 2. Clotrimazole Cream 1 Appl TP QHS to feet 3. Ibuprofen 200 mg PO DAILY pain 4. Donepezil 10 mg PO AT NOON WITH LUNCH 5. tadalafil *NF* 20 mg Oral q72h PRN erectile dysfunction 6. Probenecid 500 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: E. Coli septic shock. Secondary: Acute confusion on chronic mild cognitive impairment. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], It was a pleasure taking care of you at the [**Hospital1 18**]. You were admitted for altered mental status and fever. We found a serious bacterial infection in your [**Hospital1 **]. You were admitted to the intensive care unit where you received lots of fluids, intravenous antibiotics, and [**Hospital1 **] pressure support. After a few days you were transfered to the general medicine floor where you finished your 7 day course of intravenous antibiotics. You will go home and take antibiotic pills by mouth for another 7 days to complete the course of the antibiotics. You had a rash on your legs, abdomen and arms the last day and half of your stay. The rash is likely due to a reaction to the antibiotic Ceftriaxone. This will likely start to spread over the next few days, and may itch. You can use the sarna lotion for itch, or over-the-counter hydrocortisone. Call Dr. [**Last Name (STitle) 1007**] if the rash spreads over the entire body, if you have severe itching, or if you develop ANY BLISTERING AT ALL. Please call your primary physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] at [**Telephone/Fax (1) 10492**] if you have any signs of infection again. These include fevers, chills, cough, pain on urination, increased frequency of urination among other symptoms. Please finish all the antibiotic we have given you. An appointment has been made for you with Dr. [**Last Name (STitle) 1007**] on [**8-15**]. However, he will likely see you sooner than that. He will call you in the next few days to schedule an appointment with him as early as tomorrow or Monday. MEDICATIONS STARTED: Ciprofloxacin 500mg twice a day for 7 days starting FRIDAY [**8-5**] Followup Instructions: Department: INTERNAL MEDICINE When: MONDAY [**2191-8-15**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD [**Telephone/Fax (1) 10492**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 24**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: MEDICAL SPECIALTIES When: MONDAY [**2191-8-22**] at 11:20 AM With: BONE DENSITY TESTING [**Telephone/Fax (1) 4586**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: COGNITIVE NEUROLOGY UNIT When: TUESDAY [**2192-1-24**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**] Completed by:[**2191-8-6**]

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Discharge summary

report

Admission Date: [**2175-9-11**] Discharge Date: [**2175-9-17**] Date of Birth: [**2091-11-10**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4679**] Chief Complaint: transferred for EBUS Major Surgical or Invasive Procedure: EBUS History of Present Illness: 83 yo F with hypothyroidism, HTN, bipolar d/o, PVD, former smoker, recent incidental lung mass on CT angio of carotids ([**8-/2175**]), f/u CT chest showed LLL mass with ? necrosis and prominent LAD (hilar, subcarinal, and pretracheal nodes), presented to [**Hospital 1562**] Hospital today for Outpatient Bronchoscopy/biopsy left main bronch mass, attempted biopsy, but with brisk bleeding just with suction, epinephrine injected. Now requesting transfer to [**Hospital1 **] for bronch +/- EBUS. Per OSH pulm, pt is asymptomatic and hemodynamically stable. . Vitals prior to transfer: T: afebrile BP: 145/70 HR: 88 RR: 18 O2 Sat: 95% on RA. Here, on the floor, she appeared well without any respiratory distress. Reported involuntary weight loss for the past 2 month (10lb). . Past Medical History: PVD/carotid stenosis HTN GERD HLD bipolar d/o hypothyroid Social History: 20 pack year smoking history quite in [**2153**] ETOH social no recent travel, no animal or tick exposure Family History: non-contributory Physical Exam: VS: 98.8 122/74 78 20 95%RA GENERAL: thin appearing, elderly female NAD HEENT: MMM. NECK: Supple, no thyromegaly, no JVD. HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: NBS, SNTND EXTREMITIES: WWP, no edema SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: [**2175-9-11**] 07:45PM PT-12.5 PTT-23.1 INR(PT)-1.1 [**2175-9-11**] 07:45PM PLT COUNT-345 [**2175-9-11**] 07:45PM WBC-13.6* RBC-3.65* HGB-10.0* HCT-29.0* MCV-79* MCH-27.4 MCHC-34.6 RDW-14.5 [**2175-9-11**] 07:45PM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-2.1 [**2175-9-11**] 07:45PM ALT(SGPT)-9 AST(SGOT)-17 ALK PHOS-66 TOT BILI-0.3 [**2175-9-11**] 07:45PM estGFR-Using this [**2175-9-11**] 07:45PM GLUCOSE-100 UREA N-16 CREAT-0.8 SODIUM-140 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14 Brief Hospital Course: 83 yo F with hypothyroidism, HTN, bipolar d/o, PVD, former smoker who was referred by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7631**] of [**Hospital 1562**] Hospital after flexible bronchoscopy on [**9-11**] revealed a friable left mainstem tumor with airway obstruction. She underwent rigid bronchoscopy with tumor debridement and balloon dilatation on [**2175-9-12**] that was complicated by post-procedure hypoxemia requiring intubation in the OR. She was a difficult intubation, however the rigid bronchoscope was able to be advanced to stablize the airway and was exchanged for an #8.0 ETT. She was then transferred to the T-SICU, requiring small amounts of pressors felt to be related to the use of anesthesia and sedatives. A repeat bronchoscopy was performed on [**9-13**] to remove clot and continue debridement with argon plasma coagulation laser that resulted in opening the left mainstem with a residual 50% airway obstruction. An endobronchial stent placement was attempted but was removed after noting it did not seat well within the airway without obstructing the left lower lobe. She was admitted to the T-SICU. Sputum culture grew S. Pneumoniae, and left lung continued with haziness consistent with evolving pneumonia. She initially failed spontaneous breathing trials for hypoxemia, however on [**9-16**], she performed well on pressure support trials and was then extubated in the early afternoon of [**9-16**]. She developed hypoxemic respiratory distress and stridor in the first 30 minutes following extubation, that was not responsive to bronchodilators, racemic epinephrine, Heliox, or a dose of IV steroids. The decision was made to re-intubate the patient after discussion with the health care proxy. Several attempts to intubate by the senior staff were unsuccessful, using traditional blades, bronchoscopic-guided intubation, and a Glide-Scope. After nearly 30 minutes of attempts and worsening hypoxemia, the patient underwent an emergency cricothyroidotomy by the surgical service with stabilization of the airway and a slow return to normoxemia on 100% FiO2. A flexible bronchoscopy with a detailed assessment of the glottis revealed severe post-extubation laryngeal edema and vocal cord trauma that explained the difficult airway. The small diameter bronchoscope had significant difficulties passing into the proximal trachea during assessment. In detailed discussion between the health care proxy and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], it was learned that the patient would never want a tracheostomy for any reason. The need to convert to a proper surgical tracheostomy was therefore declined. She was then transitioned to IV morphine for comfort, expiring within hours of terminal extubation. Pathology of the tumor was still pending at the hour of death, with a high degree of certainty that the patient had a diagnosis of Stage IIIA lung cancer. The health care proxy and referring physician were notified of her death, autopsy was declined by the executor to the patient's estate. Medications on Admission: Paxil 62.5 daily Singulair 10mg daily Zetia 10mg qhs Synthroid 112 daily (6 days per week) Lipitor 10 twice a week Seroquel 100mg QHS Depakote 500mg dialy Norvasc 5mg dialy Nexium 40mg daily Lorazepam 0.5 [**Hospital1 **] prn Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: post-extubation laryngeal edema due to S. pneumoniae pneumonia due to lung cancer. Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

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icd9cm

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Discharge summary

report

Admission Date: [**2138-1-31**] Discharge Date: [**2138-2-7**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: Fatigue/Weakness Major Surgical or Invasive Procedure: S/P EGD with duodenal biopsy ERCP with sphincterotomy and biliary stenting History of Present Illness: 86F with h/o DM, HTN, Dyslipidemia, and AFib on coumadin, who presents with 2 weeks of increased fatigue and jaundice/pale appearance (per family), and 1 month of decreased appetite. Per daughter, patient appears to have lost "a significant amount" of weight in the last month, but is not sure how much. Daughter also notes that there has been a change in the odor of the stool in the last week. Stool has always been dark secondary to iron supplementation. Patient denies BRBPR and hematochezia. Patient also denies recent illness, fevers, chills, abdominal pain, chest pain. Also denied dizziness/light-headedness, syncope. No prior history of GERD or GIB. No new changes in medications. Patient is compliant with all medications with aid of daughter. Of note, patient had one episode of emesis this AM consisting of "brown mucous-like material," witnessed by daughters. [**Name (NI) **] is independent with ADLs, walks with a cane at baseline. Patient last saw PCP in [**Month (only) **]. Last INR 2.2 [**2138-1-10**]. ED course: T97.7 BP121/63 HR92 RR16 100%RA; HCT17.5 (baseline 35), INR 14.8. Patient received VitK 10mg SQ, 2L IVF, protonix 40mg iv x1, insulin SQ for FS 400. Past Medical History: Mild Dementia DM2 HTN AFib on Coumadin Dyslipidemia Breast Cancer s/p L mastectomy [**2117**]; no chemo/XRT. Social History: Lives with Daughter [**Name (NI) **] (HCP). Remote history of tobacco <[**1-27**] ppd, quit 49 years ago. No ETOH. 4 daughters and 2 sons. PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9751**] (cardiologist) at [**Hospital3 **] [**Telephone/Fax (1) 9752**]. Family History: Non-contributory Physical Exam: T 96.9 BP 105/51 HR 84 RR 18 Sats 100% Gen: pale, elderly woman, NAD HEENT: PERRL, EOMI, OP-clear, MMM neck supple, no LAD, elevated JVP to jaw, +hepatojugular reflex Lungs: bibasilar crackles, otherwise clear CV: irreg irreg, nl S1, S2, no murmurs. Abd: 3-4cm mass at epigastrium, tender to palp. Non-distended. normoactive bowel sounds. Ext: no edema, palpable pulses. Rectal: guaiac positive dark stool per ED Pertinent Results: REPORTS: . Duodenal mass, mucosal biopsies: 1. Fragments of adenoma, with high grade dysplasia, suspicious for adenocarcinoma. 2. There is no definite submucosal tissue to evaluate for invasion. . CT CHEST/ABD/PELVIS [**2138-2-3**] 11:15 AM IMPRESSION: 1. 5.3 x 3.1 cm enhancing lesion in the region of the pancreatic head and second portion of the duodenum. This could represent a primary pancreatic, ampullary, or less likely duodenal malignancy. There is associated moderate biliary ductal dilatation and massive distention of the gallbladder. 2. Numerous hypodense hepatic lesions consistent with metastatic disease. 3. Small left adrenal lesion, which cannot be classified as an adenoma based on this exam. 4. Multiple prominent mediastinal lymph nodes. 5. Faint 3 mm right middle lobe nodule, which may be inflammatory in nature but neoplasm cannot be excluded. 6. Bilateral moderate pleural effusions. 7. Aneurysmal dilatation of the infrarenal aorta up to 3.8 cm. 8. Multiple bilateral low attenuation renal foci, which may represent cysts but are too small to be fully characterized. . CXR [**2137-1-31**]: No evidence of pneumonia or congestive heart failure. . EKG:Afib at 78, LBBB. Qs inferiorly (old) TWI I,avL (old), V5-6 (new). no evid of acute ischemic changes. (compared to EKG from PCP [**11-30**]). . OSH Echo [**1-29**]: Normal LV size and function except for asynchronous septal motion due to LBBB. Concentric LVH. Dilated LA. Normal RV size/contractility. Aortic valce sclerosis with normal aortic valve opening. Mitral annular calcification with normal mitral leaflet motion. Normal tracuspid valve. Trace MR, mild TR with calculated PA sys pressure of 34mmHg. . LABS: . [**2138-2-7**] 05:35AM BLOOD WBC-6.0 RBC-3.87* Hgb-11.1* Hct-33.0* MCV-85 MCH-28.7 MCHC-33.7 RDW-16.1* Plt Ct-202 [**2138-2-3**] 01:00PM BLOOD WBC-9.9 RBC-3.87* Hgb-11.5* Hct-32.6* MCV-84 MCH-29.8 MCHC-35.3* RDW-17.5* Plt Ct-186 [**2138-2-2**] 05:39AM BLOOD WBC-10.7 RBC-3.96* Hgb-11.4* Hct-32.8* MCV-83 MCH-28.7 MCHC-34.8 RDW-16.8* Plt Ct-179 [**2138-2-1**] 05:39AM BLOOD WBC-9.0 RBC-3.52*# Hgb-10.7*# Hct-29.0* MCV-82 MCH-30.3 MCHC-36.8* RDW-17.4* Plt Ct-164 [**2138-1-31**] 09:30AM BLOOD WBC-10.9 RBC-1.99* Hgb-5.8* Hct-17.5* MCV-88 MCH-28.9 MCHC-32.8 RDW-17.0* Plt Ct-273 [**2138-2-7**] 05:35AM BLOOD Plt Ct-202 [**2138-2-3**] 01:00PM BLOOD Plt Ct-186 [**2138-1-31**] 04:59PM BLOOD PT-15.6* PTT-31.3 INR(PT)-1.7 [**2138-1-31**] 09:30AM BLOOD PT-43.4* PTT-54.8* INR(PT)-14.8 [**2138-1-31**] 09:30AM BLOOD D-Dimer-930* [**2138-2-7**] 05:35AM BLOOD Glucose-140* UreaN-14 Creat-0.8 Na-133 K-4.2 Cl-100 HCO3-21* AnGap-16 [**2138-2-4**] 10:55AM BLOOD Glucose-275* UreaN-11 Creat-0.6 Na-136 K-3.5 Cl-104 HCO3-20* AnGap-16 [**2138-2-1**] 05:21PM BLOOD Glucose-124* UreaN-23* Creat-0.8 Na-142 K-3.4 Cl-107 HCO3-20* AnGap-18 [**2138-1-31**] 09:30AM BLOOD Glucose-342* UreaN-40* Creat-1.0 Na-136 K-4.1 Cl-101 HCO3-20* AnGap-19 [**2138-2-7**] 05:35AM BLOOD ALT-259* AST-243* LD(LDH)-634* AlkPhos-348* Amylase-223* TotBili-6.4* [**2138-2-6**] 06:05AM BLOOD ALT-207* AST-203* AlkPhos-299* TotBili-8.6* [**2138-2-5**] 06:00AM BLOOD ALT-168* AST-156* LD(LDH)-338* AlkPhos-144* Amylase-269* TotBili-7.1* DirBili-5.0* IndBili-2.1 [**2138-1-31**] 09:30AM BLOOD ALT-235* AST-157* LD(LDH)-172 CK(CPK)-23* AlkPhos-198* Amylase-182* TotBili-2.7* [**2138-2-7**] 05:35AM BLOOD Lipase-252* [**2138-2-5**] 06:00AM BLOOD Lipase-481* [**2138-1-31**] 09:30AM BLOOD Lipase-269* [**2138-1-31**] 09:30AM BLOOD cTropnT-<0.01 [**2138-2-7**] 05:35AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.1 [**2138-2-6**] 06:05AM BLOOD Albumin-3.0* Calcium-8.6 Phos-3.0 Mg-1.8 [**2138-2-3**] 06:20AM BLOOD Calcium-8.8 Phos-2.2* Mg-2.1 [**2138-2-1**] 05:39AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.0 [**2138-1-31**] 09:30AM BLOOD Digoxin-<0.2* [**2138-1-31**] 09:34AM BLOOD Glucose-345* [**2138-1-31**] 09:34AM BLOOD Hgb-6.2* calcHCT-19 Brief Hospital Course: 86F with history of Afib on coumadin who presented with likely slow uGIB in setting of supratherapeutic INR. Found to have abdominal mass on physical exam and by EGD. CT scan shows likely metastatic disease to the liver. Boiopsy of mass showed adenoma with high-grade dysplasia. . #) uGIB- Patient with likely upper GIB with guaiac positive stool and melena. Warfarin reversed with 4 units FFP and Vitamin K. Pt received 4U PRBC's during the admission, and her Hct subsequently stabilized. - GI was consulted. EGD showed 4cm erythematous, duodenal mass. Path showed ademoma with high grade dysplasia. - CT scan revealed metastatic disease to the liver, with BL pleural effusions, and biliary ductal dilitation. Likely metastatic pancreatic/ampullary CA. - antihypertensives were held in the setting of GI bleed. Only the norvasc was re-started on discharge. . #) Abdominal mass- Given recent history of weight loss, physical exam findings of a tender abdominal mass and jaundice, associated with transaminitis, elevated alk phos and t.bili, malignancy was thought likely. Biopsy results from mass and CT of the torso confirmed the diagnosis of metastatic disease. - onc follow-up for pt's metastatic disease is scheduled as an outpatient. - pt had elevated LFT's, significantly elevated bili, where were likely secondary to compression [**2-27**] mass. Pt underwent ERCP with sphincterotomy and stenting, and tolerated the procedure well. Her diet was advanced slowly. . #) [**Name (NI) **] pt was rate controlled on Dig. Coumadin was held given GI bleed. . #) DM2- Pt was maintained on RISS, and oral diabetes meds were held. Pt was then restarted on glipizide XL (but at 2.5mg qd, which is lower than prior home dose). Continue RISS while in the hospital. . #) [**Name (NI) 1623**] pt was tolerating clear liquid diet, was being advanced as tolerated. . #) Prophylaxis- PPI, pneumoboots. . #) Communication- Daughter [**Name (NI) **] (HCP) [**Telephone/Fax (1) 65479**] . #) Code: Full. . #) Dispo - to rehab facility, with outpatient oncology follow-up. Medications on Admission: Norvasc 5mg po qday Glucotrol XL 10mg po qday Lipitor 20mg po qday Coumadin 2mg po q M,T,Th,F,Sun; 1mg po qW, Sat Tricor 48mg po qday Digoxin 0.125 QOD Iron 65mg [**Hospital1 **] Quinapril 10mg po qday Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 4. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Glucotrol XL 2.5 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary diagnosis: GI bleed Secondary diagnosis: Duodenal/pancreatic mass Dementia Type 2 diabetes mellitus HTN Atrial fibrillation Hypercholesterolemia Discharge Condition: Stable, but poor prognosis. Taking PO. Discharge Instructions: 1. Please take all medications as prescribed. 2. Please keep all follow up appointments. 3. Seek medical attention for fevers, chills, chest pain, shortness of breath, abdominal pain, or any other concerning symptoms. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-2-12**] 1:30 . Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[**2138-2-12**] 1:30 Completed by:[**2138-2-7**]

[ "197.8", "401.9", "199.1", "427.31", "285.1", "790.92", "578.1", "V10.3", "250.00", "197.7" ]

icd9cm

[ [ [] ] ]

[ "51.85", "99.04", "45.16", "99.07", "51.87", "51.10" ]

icd9pcs

[ [ [] ] ]

9179, 9264

6386, 8445

276, 353

9462, 9504

2489, 6363

9772, 10063

2022, 2040

8697, 9156

9285, 9285

8471, 8674

9528, 9749

2055, 2470

220, 238

381, 1582

9335, 9441

9304, 9314

1604, 1715

1731, 2006

69,992

123,618

35999

Discharge summary

report

Admission Date: [**2145-2-25**] Discharge Date: [**2145-3-10**] Date of Birth: [**2097-8-21**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Steatorrhea and abdominal pain. Major Surgical or Invasive Procedure: Pylorus-perserving Whipple and open cholecystectomy [**2145-2-25**] History of Present Illness: Mrs. [**Known firstname **] [**Known lastname 81709**] if a delightful 47-year-old woman who has suffered from abdominal discomfort and apparent steatorrhea and has been imaged by endoscopic procedures and found to have a pancreatic ductal abnormality and cellular atypia on brush cytology. While no definitive mass was identified on CT angiography, there is no evidence of metastatic disease and nothing to suggest unresectable carcinoma of the pancreatic head. Nevertheless, on the basis of a suspected but unproven malignancy, definitive resection was recommended to the patient, especially in light of the cellular atypia. More worrisome is that the pancreatic duct itself was dilated out proximal to this body and tail of the pancreas. She had no antecedent history of biliary obstruction. Past Medical History: Seasonal Allergies Vaginal Hysterectomy (partial ovary remains), bladder band Social History: Patient lives on [**Hospital3 **]. She moved there from [**Location (un) 5503**] to raise her children. Family History: No family history of pancreatitis. Physical Exam: VS: T: 97.7, BP: 124/50, HR: 99, RR: 20, SaO2: 94% RA GEN: A+Ox3 in NAD. HEENT: Sclerae anicteric. O-P moist, intact. NECK: Supple. No lymphadenopathy. LUNGS: CTA(B). ADB: Incision with Steri-strips C/D/I. Abd soft/NT/ND. EXTREM: No c/c/e. SKIN: As above, otherwise well-perfused, intact. Pertinent Results: [**2145-2-25**] 03:58PM GLUCOSE-144* UREA N-12 CREAT-0.5 SODIUM-140 POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-25 ANION GAP-12 [**2145-2-25**] 03:58PM WBC-24.0*# RBC-3.38* HGB-11.4* HCT-31.8* MCV-94 MCH-33.6* MCHC-35.7* RDW-13.2 [**2145-2-25**] 03:58PM PLT COUNT-439 [**2145-2-25**] 03:58PM PT-13.9* INR(PT)-1.2* [**2145-2-25**] 02:42PM GLUCOSE-113* LACTATE-2.7* NA+-141 K+-5.0 CL--110 [**2145-2-25**] 02:42PM freeCa-1.08* [**2145-2-25**] 01:45PM GLUCOSE-126* LACTATE-1.5 NA+-139 K+-3.4* CL--107 [**2145-2-25**] 01:45PM HGB-11.3* calcHCT-34 [**2145-2-25**] 10:46AM GLUCOSE-123* LACTATE-1.6 NA+-138 K+-4.6 CL--99* [**2145-2-25**] 10:46AM HGB-12.9 calcHCT-39 . MICRO [**3-8**] SputumCx: Contaminated [**3-8**] Bcx: Pending [**3-8**] UrineCx: Pending [**3-1**] Viral Screen: No growth [**3-1**] BAL: No growth [**3-1**] CMV: Negative [**3-8**] sputum: dirty [**3-8**] Blood: pending pathology = chronic pancreatitis . [**2145-3-8**] Torso CT W/ contrast: 1. Bilateral pleural effusions and compressive atelectasis, with a possible concomitant focus of LLL infectious consolidation. Overall significant improvement in pulmonary parenchymal aeration with mild residual ground-glass reticular opacities. 2. Adrenal Indistinctness and fat stranding, raising the possibility of adrenalitis/hemorrhage. Clinical correlation is recommended. 3. Mediastinal and hilar adenopathy,slightly improved. Could reflect reactive changes. Document resolution after treatment. 4. Focal area of low attenuation in the left hepatic lobe (2:62) measuring 1.1 x 1.6 cm with peripheral rim of enhancement and a small anterior fluid collection. This could represent retractor/clamp-related injury during the surgery or a small focus of infection. Correlation with ultrasound is recommended. 5. Small non-occlusive filling defect in the right internal jugular vein. Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment. Underwent pylorus-preserving Whipple and open cholecystectomy [**2145-2-25**] without complication. After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO, on IV fluids, with a foley catheter, NG tube and JP in place. She was on a Dilaudid PCA for pain control with adequate pain control. The patient was hemodynamically stable. [**2145-2-26**]: Remained stable on IVF, NPO. Pain well controlled on Dilaudid PCA. On pathway w/o events. [**2145-2-27**]: Experienced diffuse wheezes, bothersome cough. O2 requirement 3L. Blood and sputum cultures sent. Started on xopenex and atrovent nebulizer treatments. Hemodynamically stable at that time. [**2145-2-28**]: Worsened from respiratory standpoint; CXR revealed developing bilateral infiltrates consistent with pneumonia. Chest CT confirmed finding; did not reveal PE. ABG was 7.46/42/98/31. She was placed on a NRB with improved SaO2 in 90s. IV Vancomycin started. Due to further worsening of tachypnea and hypoxia, patient was transfered to the SICU. Once arrived on ICU, IV Levaquin was also started, patient was presumptively placed on Heparin drip as a precaution against PE, Lovenox restarted. Intensive respiratory therapy. Gentle diuresis. Continued on a Dilaudid PCA for pain control with good effect. A-line placed with improvement of PaO2. Cough improved with cough supressants. Blood cultures sent. [**2145-3-1**]: Started on IV Zosyn. Continued intensive respiratory toilet and PT. [**Last Name (un) 1372**]-pharygeal and expectorate sputum cultures sent. Intubated. Underwent bronchoscopy with BAL of (R)lower lobe and (L) upper lobe. [**2145-3-2**]: Extubated in morning, maintaining saturation. Vancomycin dose increased. Started on sips, then clears with good tolerability. [**2145-3-3**]: Tolerating face mask, tolerating regular diet, IV KVO. [**2145-3-4**]: Decreased O2 requirement, CVL discontinued. Changed to PO medications. Transfered back to floor on PO Levaquin as only antibiotic. [**2145-3-5**]: Experienced severe lower back spasms most likely from prolonged time in bed; treated successfully with IV Dilaudid and Valium, subsequently converted to PO medications. Increased activity out of bed also helped to resolve issue. [**Date range (3) 81710**]: Continued increasing activity level with improved tolerance and decreasing O2 demand, until patient able to ambulate the floor without supplemental oxygen. Continued on aggressive nebulizer treatments and chest physical therapy. Tolerated diet. Muscle spasms subsided and pain well controlled. Repeat Torso CT and CXR demonstrated improvement of pleural effusions as patient continued on PO Levaquin. Also, no leaks or fluid collections evident on Abdominal/pelvic portion of CT study. [**2145-3-10**]: Patient demonstrated ability to ambulate floor and up/down stairs with stable SaO2 and pulse, without the need of supplemental oxygen. Pain remained well controlled. Tolerating regular diet. No further signifiant events. At the time of discharge, the patient was doing well, afebrile with stable viral signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Respiratory status was stable on inhalers. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Hydrochlorothiazide 25, Lovenox, Percocet Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*60 Patch 24 hr(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 6. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day as needed for cough. Disp:*1 MDI* Refills:*2* 9. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: [**4-18**] MLs PO Q4H (every 4 hours) as needed. 10. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 11. Lovenox 80 mg/0.8 mL Syringe Sig: Seventy (70) mg Subcutaneous twice a day: take 0.7 mg of the 0.8 mg syringe to deliver 70 mg per dose. Discharge Disposition: Home Discharge Diagnosis: Chronic cholecystitis, Severe chronic pancreatitis, Moderate pancreatic duct dysplasia (PanIN II) and focal squamous metaplasia of common bile and pancreatic ducts 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 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. Incision Care: -Your steri-strips will fall off on their own. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 468**] on [**3-22**] at 10:45 in [**Hospital Ward Name 23**] 3. Please call [**Telephone/Fax (1) 2835**] to confirm or change your appointment (if needed). Completed by:[**2145-3-16**]

[ "285.9", "275.41", "275.3", "492.8", "V12.51", "579.8", "577.1", "724.8", "486", "401.9", "790.29", "575.11", "276.8", "V45.89" ]

icd9cm

[ [ [] ] ]

[ "96.05", "52.7", "51.22", "33.24" ]

icd9pcs

[ [ [] ] ]

8630, 8636

3715, 7172

345, 415

8844, 8851

1839, 3692

10318, 10546

1479, 1515

7265, 8607

8657, 8823

7198, 7242

8875, 10018

10033, 10295

1530, 1820

274, 307

443, 1239

1261, 1340

1356, 1463

5,885

114,939

23890

Discharge summary

report

Admission Date: [**2195-8-28**] Discharge Date: [**2195-9-8**] Date of Birth: [**2142-7-7**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2777**] Chief Complaint: acute left lower extremity ischemia and hypotension Major Surgical or Invasive Procedure: [**2195-8-29**] Mesenteric arteriogram, SMA stent, thrombectomy of left limb or aortobifemoral graft, endarterectomy of left CFA/SFA/PFA, left lower leg fasciotomy History of Present Illness: 52 year-old gentleman with a complicated h/o peripheral vascular disease s/p aorto-bifemoral bypass in [**2191**], pancreatic mass s/p Whipple in [**2192**], and esophageal cancer s/p esophagectomy with colonic interpostion 4 months ago complicated by necrosis of the neoesophagus and development of an enterocutaneous fistula who presents with altered mental status. Pt was found by his wife to have altered mental status this AM and presented to an OSH. He was found to be hypotensive, hypernatremic and hyperchloremic, abd was fluid resuscitated, and started on levophed. He had a CXR which showed a right middle lobe pneumonia. Pt was started on abx prior to being transferred to [**Hospital1 18**]. His left leg was found to be acutely ischemic with no dopplerable signals in the left foot with coolness up to the left mid-thigh. Past Medical History: Aorto-bifemoral bypass [**8-19**] MI HTN R CEA ([**7-19**]) Knee athroscopy Whipple operation ([**Doctor Last Name 468**]) in [**2192**] for benign pancreatic mass Esophagectomy with colonic interposition complicated by neoesophagus necrosis requiring resection and spit fistula creation ([**2195-4-22**]) Social History: Pt lives with family. He works on an assembly line at a brickyard. He formerly smoked 2 PPD x 40 years. Family History: Father with liver cirrhosis from ETOH use Physical Exam: Afebrile/VSS No distress, alert and oriented x 3 PERLA, EOMI, anicteric Neck with spit fistula draining to ostomy appliance RRR, no murmurs, lungs clear Abdomen soft, nontender, midline wound healing by secondary intention with good granulation tissue in place; known ECF in right aspect of wound drainge brown fluid Left groin incision C/D/I, left lower leg fasciotomy incisions C/D/I . Pulses: palpable femorals, dopplerable PTs bilaterally Pertinent Results: Admission: [**2195-8-28**] 07:55PM BLOOD WBC-12.9*# RBC-4.19*# Hgb-11.9*# Hct-39.8*# MCV-95# MCH-28.5 MCHC-30.0* RDW-17.2* Plt Ct-170 [**2195-8-28**] 07:55PM BLOOD Neuts-78.4* Lymphs-16.0* Monos-5.2 Eos-0.2 Baso-0.3 [**2195-8-28**] 08:08PM BLOOD PT-14.4* PTT-24.9 INR(PT)-1.2* [**2195-8-28**] 07:55PM BLOOD Glucose-247* UreaN-42* Creat-1.1 Na-177* K-2.7* Cl-GREATER TH HCO3-17* [**2195-8-28**] 07:55PM BLOOD CK(CPK)-1423* . CK trends: [**2195-8-29**] 12:10PM BLOOD CK(CPK)-3334* [**2195-8-30**] 12:59AM BLOOD CK(CPK)-4913* [**2195-8-30**] 04:25PM BLOOD CK(CPK)-7135* [**2195-8-30**] 10:13PM BLOOD CK(CPK)-7338* [**2195-8-31**] 12:20PM BLOOD CK(CPK)-6963* [**2195-9-1**] 04:47AM BLOOD CK(CPK)-5514* [**2195-9-1**] 12:07PM BLOOD CK(CPK)-4823* . Discharge: [**2195-9-7**] 05:05AM BLOOD WBC-4.7 RBC-3.19* Hgb-9.4* Hct-28.9* MCV-91 MCH-29.4 MCHC-32.5 RDW-16.7* Plt Ct-308# [**2195-9-8**] 04:13AM BLOOD PT-17.5* PTT-74.0* INR(PT)-1.6* [**2195-9-7**] 05:05AM BLOOD Glucose-219* UreaN-13 Creat-0.4* Na-136 K-4.2 Cl-104 HCO3-25 AnGap-11 [**2195-9-8**] 04:13AM BLOOD Mg-1.7 Brief Hospital Course: Mr. [**Known lastname 60925**] was admitted on [**2195-8-28**] with hypotension and an acutely ischemic left leg. A CT revealed a SMA stenosis with concerns for acute mesenteric ischemia given the patients hypotension requiring a vasopressor. It also revealed that the left limb of his previous aorto-bifemoral graft was thrombosed causing his left leg to be ischemic. On [**2195-8-29**] he was taken emergently to the operating room where an arteriogram and SMA stent were performed. Simultaneously, his left groin was explored and a thrombectomy performed of the left limb of his aortobifemoral graft. An endarterectomy was performed of his left CFA, SFA, and PFA. Due to concerns for ischemia and potential compartment syndrome formation, a left lower leg fasciotomy was performed. He was taken to the CVICU and continued on broad spectrum antibiotics post-operatively. . Pulses: He left foot had no dopplerable signals and his femoral was weakly dopplerable. Post operatively his exam was notable for a palpable femoral pulse and a strong dopplerable left PT signal. Initially, in the post-operative period, his left PT signal was weak, but this was due to global hypoperfusion and vasopressors. Once his pressors were weaned down, his PT signal became very strong. His fasciotomy incisions are healing nicely. . Neuro: Post-operatively he required propofol and then fentanyl and versed to maintain adequate sedation and pain control while intubated. His neuro exam remained intact and these were discontinued when he was extubated. He is currently on prn dilaudid for pain control. He does have left drop foot requiring a multipodis boot. . Cardiovascular: He required vasopressor support post-operatively and aggressive resuscitation. He remained in vasodilatory shock for a number of days and the neosynephrine was finally able to be weaned off on [**2195-9-4**]. He remained hemodynamically stable and was able to be transferred out of the CVICU and into the VICU. He is stable. . Pulmonary: He remained intubated until POD4. On POD zero, he was noted to have increased opacification of his right hemithorax. He underwent a bronchoscopy where copious secretions were encountered and suctioned. His post-bronch CXR showed improved aeration of his lungs. He was continued on broad spectrum antibiotics with double coverage for Pseudomonas due to his recent hospitalization being complicated by resistant Pseudomonal pneumonia. His BAL specimen never grew any organisms and his antibiotics were discontinued by one antibiotic daily. . Gastrointestinal: He was able to be started on trophic tube feeds while in the CVICU. Once he was off pressors and stable, these were able to be advanced to goal. He continues to have a spit fistula that drains to an ostomy appliance. His known enterocutaneous fistula started to have feculent drainage. General and Thoracic surgery were consulted and a wound vac was placed in attempts to isolate the fistula. The was continued leakage of fistula output and the vac was only functioning part of the time. Thoracic surgery is managing his fistula and recommended discontinuing the wound vac and starting moist to dry dressing changes to his abdominal wound. . Genitourinary: He had more than adequate urine output beginning in the immediate post-operative period. His foley catheter was able to be removed once he was out of the ICU and he voids without difficulty. . Heme: He was maintained on a heparin gtt to maintain patency of his circulation. He is currently being transitioned to coumadin. His did require transfusion of 3 units of PRBC in the early post-operative period, but his hematocrit has remained stable since transfusion. . Endocrine: His blood sugars have been well controlled on sliding scale insulin. . Infectious Disease: Due to his septic physiology on admission he was placed on broad spectrum antibiotics empirically. On POD zero there were concerns for pneumonia based on CXR and bronchoscopy so double coverage was started for his history of Pseudomonas pneumonia. Infectious disease was consulted. All of his culture date returned negative so his antibiotics were discontinued one at a time. He is currently on no antibiotics and his WBC is normal. . He is discharged in good condition to rehab. He will need physical therapy and nursing care for his spit fistula, enterocutaneous fistula, and healing midline abdominal wound. Medications on Admission: Atenolol 50mg daily, Simvastatin 40mg daily, Diovan 160-25mg daily, percocet prn Discharge Medications: 1. Acetaminophen 650 mg Suppository [**Date Range **]: One (1) Suppository Rectal Q6H (every 6 hours) as needed for fever/pain. 2. Clopidogrel 75 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily) for 30 days: For 30 days only. 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 4. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: per sliding scale units units Subcutaneous ASDIR (AS DIRECTED): glucose dose 121-140 2 units 141-160 4 units 161-180 6 units 191-200 8 units 201-220 10 units 221-240 12 units 241-260 14 units 261-280 16 units 281-300 18 units. 5. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID (4 times a day) as needed for thrush. 6. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H:PRN pain 7. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Once Daily at 4 PM: Goal INR of [**2-17**]. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Acute left leg ischemia Mesenteric ischemia Enterocutaneous fistula Discharge Condition: Good Discharge Instructions: Incision Care: Keep clean and dry. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. -If you have staples, they will be removed during at your follow up appointment. . 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 ambulate several times per day. * No heavy ([**10-29**] lbs) until your follow up appointment. . * Continue tube feeds * Continue coumadin with a goal INR of [**2-17**], adjust dose accordingly * Continue spit fistula care * Continue abdominal wound and enterocutaneous fistula care * Continue physical therapy daily * Continue to wear multipodis boots Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2195-9-24**] 11:00

[ "440.31", "995.92", "287.5", "729.72", "996.79", "V44.1", "V10.03", "440.4", "998.89", "998.6", "557.1", "276.2", "276.9", "276.0", "412", "E878.8", "038.9", "E878.2", "785.52", "401.9", "518.81" ]

icd9cm

[ [ [] ] ]

[ "93.57", "96.04", "96.72", "38.93", "33.24", "96.6", "39.50", "39.90", "00.45", "88.49", "00.40", "39.49", "83.14", "88.42", "38.18" ]

icd9pcs

[ [ [] ] ]

9062, 9134

3476, 7905

364, 530

9246, 9253

2388, 3453

11320, 11476

1866, 1910

8037, 9039

9155, 9225

7931, 8014

9277, 9277

9293, 11297

1925, 2369

273, 326

558, 1397

1419, 1726

1742, 1850

23,933

105,266

7540

Discharge summary

report

Admission Date: [**2113-4-26**] Discharge Date: [**2113-5-10**] Date of Birth: [**2039-11-3**] Sex: M Service: MEDICINE Allergies: Penicillins / Morphine Attending:[**First Name3 (LF) 3705**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: Central venous line placement (Attempted EGD, patient unable to tolerate w/ low oxygenation) History of Present Illness: 73 year old male with history of renal transplant, CAD, PVD, DM presenting with marked fatigue, poor appetite, nonproductive cough and generalized weakness/failure to thrive. He was admitted to the MICU on [**2113-4-26**], see H/P from that date for details. He was found to have profound anemia with HCT of 18.7 (baseline high 20s-30s), acute renal failure with creatinine of 5.5 (baseline [**1-29**]), new cerebellar lesion on CT head, and RLL pneumonia. While in the ICU, he was treated with cefepime, vancomycin and azithromycin for pneumonia in an immunosuppressed patient. He developed acute shortness of breath after admission and evaluation revealed pulmonary edema (though imaging suggestive of noncardiogenic etiology), and was diuresed. LOS fluid balance at transfer was approximately negative 800 cc. He was transfused 3 units of blood, had negative stool guaiacs, iron studies consistent with anemia of chronic disease and iron deficiency, and had negative hemolysis labs (haptglobin 677). He was started on IV iron supplementation for plan of 8 doses. Hematocrit at transfer 24.5, and CT torso did not reveal intra-abdominal source of blood loss. Renal transplant service followed the patient and his acute renal failure was thought to be due to dehydration/pre-renal azotemia with ATN. His creatinine mildly improved after the blood transfusions and some diuresis to 4.5 at transfer. His rapamycin level was elevated and his doses were held with plan to restart once <8. Troponin was elevated at 0.16-0.18, thought to be due to renal failure and anemia. Lastly, neurology/stroke was consulted regarding the cerebellar lesion seen on CT scan and his falls at home. His neuro exam was nonfocal and the lesion was thought to be a chronic infarct vs. metastases as opposed to an acute lesion. . Currently, the patient continues to complain of weakness/fatigue and generalized feeling "unwell." He feels his breathing is better, but not baseline. He complains of back pain, leg pain, neck pain and a headache--all are chronic per him. He is concerned about having to be transferred in the bed as opposed to the chair because he cannot lay down comfortably. Past Medical History: 1. DM 2. HTN 3. hypercholesterolemia 4. CAD s/p MI ([**2104**]) 5. severe osteoarthritis of the hips/shoulders/knees 6. spinal stenosis 7. ESRD s/p LRRT ([**9-/2105**]) 8. PVD s/p R SFA-tib/peroneal trunk NRSVG (99), jump graft from R tib/peroneal trunk to distal R PT NR cephalic VG ([**4-/2105**]), PTA of R SFA-PT bypass ([**10-2**]), angioplasty L CIA ([**11/2104**]), L CFA-PT [**Name (NI) **] with in-situ SVG ([**1-29**]), b/l TMA, b/l sesamoidectomies 9. lung adenoca s/p VATS/wedge resection of nodule 10. BPH 11. diastolic heart dysfunction 12. Klebsiella bacteremia/urosepsis ([**2-2**]) Social History: Smoked cigarettes until [**2083**]. No ETOH. He lives at home. Retired, but was previously a truck driver. Family History: Significant for lung cancer in the patient's father who developed this at age 75, but subsequently died of a stroke. Physical Exam: gen-sitting up in chair, uncomfortable/fatigued HEENT-EOMI, MM dry, R IJ in place-c/d/i, JVP could not be assessed, neck thick chest-[**Month (only) **] BS at bases, R>L, RLL crackles, otherwise clear. heart-RRR, no M/R/G, nl S1 S2 abd-obese, soft, nontender over graft, + BS ext-marked LE edema of both legs--4+ pitting to knees, L>R. Legs wrapped in kerlex bilaterally. right LE with necrotic ulcer, 5-6 cm diameter on dorsal foot. . Pertinent Results: admission labs: 8.9>----<381 18.7 . mcv 69 . 139 99 97 -------------< 147 3.9 21 5.5 . other important labs . PTH [**4-30**]: 226 . aldolase - [**4-29**]: 3.9 PARVOVIRUS B19 ANTIBODIES (IGG & IGM): [**4-27**]: negative . esr [**4-30**]: 60 . MICRO urine culture [**4-26**] no growth blood culture [**4-26**] no growth legionella ab negative [**4-27**] sputum culture: [**4-30**]: contaminated . imaging. . venous ultrasound [**5-2**]: IMPRESSION: No DVT in the left leg. . TTE [**4-27**] The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Diastolic function could not be assessed because of significan mitral valve disease. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are three moderately-thickened aortic valve leaflets. There is mild aortic valve stenosis (area 1.2-1.9cm2). The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is mild functional mitral stenosis (mean gradient 8 mmHg) due to mitral annular calcification. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Symmetric LVH with preserved global biventricular systolic function. Mild aortic stenosis. Mild non-rheumatic mitral stenosis. . CT abdomen / chest / pelvis 1. Lungs show interlobular septal thickening and bilateral perihilar alveolar opacities, which given lack of interstitial abnormality on CT from [**2113-2-27**], is most suggestive of non cardiogenic pulmonary edema given normal heart size and lack of pleural effusion. 2. Cholelithiasis without evidence of cholecystitis. 3. Sigmoid diverticulosis, without evidence of diverticulitis. 4. Stable appearance of transplanted kidney within the left lower quadrant. No stone, hydronephrosis, or perinephric fluid collection. 5. Bladder wall thickening, which may be secondary to under-distension; however, recommend correlation with UA to exclude cystitis. 6. Generalized atrophy of the muscles, especially involving bilateral iliopsoas, which may account for patient's lower extremity weakness. 7. Diffuse atherosclerotic disease involving the aorta and branch vessels. Brief Hospital Course: 73 y.o male with h.o renal transplant in [**2104**], CAD, diastolic dysfunction, PVD, DM, HTN, severe OA presented to the ED from home with six weeks of productive cough, nausea, decreased po intake, generalized weakness. . # Failure to thrive / poor PO intake Poor PO intake / nausea / vomiting initially had a very long differential, including med toxicity (sirolimus), uremia, depression, diabetic gastroparesis, peptic ulcer disease, colonic mass, obstruction, and chronic mesenteric ischemia. EGD, small bowel follow through, and gastric empyting study were all attempted, but could not be performed given poor room air saturation (for EGD) and back pain / not tolerating procedure (when laying flat for SBFT and GE study). Reglan 5 mg QID was started emperically; after 3 days his diet improved, and all nausea / vomiting ceased spontaenously. Regarding depression, patient was also started on citalopram and mirtazipine, which he tolerated well. The patient did report being sad after learning about his future right AKA. . # Anemia secondary to chronic renal disease Admission hct was 18.7. This was considered [**1-28**] to renal failure. He was transfused 3 units PRBCs in the MICU. Stools were guaiac negative. On the medical floor his HCT remained stable, however he was transfused another unit of PRBCs to help with his generalized weakness. He received 8 days of IV iron repletion as well, and was continued on PO iron repletion thereafter. . # Acute on chronic diastolic heart failure/bacterial pnemonia He was admitted with respiratory distress, secondary to acute on chronic diastolic CHF. He was diuresed with IV lasix and received vancomycin/cefepime / flagyl initially and then levofloxacin for his RLL infiltrate on CXR. He diuresed well and no longer required oxygen supplementation. He completed a 7 day course of antibiotics for the pneumonia. He was diuresed aggressively with 120 mg IV daily lasix, and then was backed down after re-initiation of renal failure. . # Acute on Chronic Renal failure, autolgous renal transplant Renal transplant was consulted. He was thought to have ATN [**1-28**] to anemia and hypotension. His rapamycin level was also found to be elevated, secondary to med toxicity with azithromycin. His rapamycin was held until the level was < 8. His renal function improved daily. His other immunosuppressants, including prednisone and mycophenolate mofetil were continued. When the rapamycin / sirolimus level was < 8, he was restarted at his home dose, 3mg / day. Bactrim prophylaxis was changed to single strength daily. . After diuresis and a low creatinine of 2.8, his creatinine trended up again to 4.0. His FeUrea at the time was low, and lasix was held. He was instructed to hold his lasix for 2 days post discharge and then restart at the initial home dose, 40 mg [**Hospital1 **] PO. . His PTH was checked. Renal adjusted his calcitriol dose. . # Weakness / Muscle Aches The differential for his weakness was quite extensive: anemia, depression, renal failure, polymyalgia rheumatica, motor nerve dysfunction. . On arrival, head CT showed a cerebellar hypodensity. Neurology was consulted, who thought this was consistent with prior chronic CVA changes and did not represent an acute CVA. Given his gait difficulty and muscle atrophy on CT, spinal cord impingement was considered. Head MRI with gadolinium was recommended non acutely to better evaluate this and rule out the unlikely possibility of a primary lung metastasis; the MRI was witheld due to ARF, decreased GFR, and as mentioned above, the patient's inability to tolerate MRIs. This can be performed as an outpatient or a PET scan can be done to rule out metastasis. . Because of weakness, muscle atrophy, diffuse aches, and moderately elevated CK, his home statin was stopped. . Given shoulder aches and weakness, ESR ~ 60, patient was thought to potentially have PMR. His prednisne dose was increased to 10 mg / day. After no response after 2 days of treatment, the prednisone was dropped back to 3 mg / day. . His weakness improved as his diet and mood improved. The statin can probably be restarted as an outpatient, given his severe PAD and presumed CAD. . His neurontin was stopped initially in the MICU. Given lack of symptomatic changes with respect to peripheral neuropathy, we kept holding off on this medication. . # PAD Vascular surgery determined right AKA the best management option. The team's preference was to rehab the patient before surgery with diet. He will revisit w/ Dr. [**Last Name (STitle) 21080**] in [**1-29**] weeks. . # Wound care The wound care team was consulted, and left recommendations regarding the ulcers on his feet/legs as well as sacrum. Dressings were changed and decompression of the sacral wounds was utilized. . # DM type 2 uncontrolled with complications Transitioned to lantus and blood sugars ranged 100-200. The wife and patient were agreable to humalog prandial dosing as well with sliding scale. This change was made when the patient was not taking POs well, such that long acting lantus could be dosed unchanged and humalog used for mealtime BS control. Medications on Admission: amlodipine 10mg daily asa 81mg daily doxazosin 4mg [**Hospital1 **] lasix 40mg [**Hospital1 **] Isosorbide dinitrate 30mg daily lipitor 60mg daily metoprolol 75mg [**Hospital1 **] niaspan SR 500mg qhs humalog SS NPH 38units Qam, 36units Qpm iron calcitriol 0.25mg daily cellcept 1000mg TID prednisone 3mg daily rapamnue 3mg qhs bactrim 800/160mg daily zaroxolyn 2.5mg every third day epo 4,000 units/wkly neurontin 100mg [**Hospital1 **] percocet 5/325 1-2 tabs q6h prn protonix 40mg daily colace Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Doxazosin 1 mg Tablet Sig: Four (4) Tablet PO every twelve (12) hours. 4. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: START taking this medication on [**5-12**]. Disp:*60 Tablet(s)* Refills:*2* 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 7. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO QHS (once a day (at bedtime)). 8. Insulin Glargine 100 unit/mL Cartridge Sig: Sixty (60) units Subcutaneous at bedtime. Disp:*qs * Refills:*2* 9. Insulin Lispro 100 unit/mL Cartridge Sig: Ten (10) units Subcutaneous three times a day: please take 10 units with each meal; also follow sliding scale. Disp:*qs * Refills:*2* 10. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO Q TU/TH/SA/[**Doctor First Name **] (). Disp:*16 Capsule(s)* Refills:*2* 12. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO MWF (Monday-Wednesday-Friday). Disp:*12 Capsule(s)* Refills:*2* 13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection once a week. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 18. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*112 Tablet(s)* Refills:*2* 19. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 20. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 21. Outpatient Lab Work Full Chemistry panel, Na, K, Cl, HCO3, BUN, CREAT, Calc, mag, phos 22. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 23. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 24. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1) Congestive heart failure, acute on chronic diastolic 2) Acute on chronic renal failure 3) Anemia, transfusion dependent 4) Failure to thrive 5) Diabetes Mellitus 6) Spinal Stenosis . Secondary 1) Esophagitis 2) Remote hx of lung cancer Discharge Condition: Stable. Chronically ill. Tolerating POs well. Discharge Instructions: You were admitted to the hospital with poor eating and generalized lethargy. You were found to have severe anemia and renal failure and congestive heart failure. You were treated with blood transfusions and adjustment of your medications. . We attempted to study why you are not able to reliably eat, but you were not able to tolerate the different studies required to do so. We started you on a new medication called reglan, and you began to tolerate foods better. You should continue to take this medication 30 minutes before each meal and at bedtime. . If you experience the following please return for evaluation or call your primary care doctor: fevers, chills, pain with urination, lightheadedness, nausea, vomiting, diarrhea, shortness of breath. . PLEASE have your labs checked in 1 week, fax to Dr. [**First Name (STitle) 805**] at the [**Hospital **] Clinic [**Telephone/Fax (1) 12142**]. . MEDICATION CHANGES 1) Lantus + humalog insulin Your insulin has been changed. Take 60 units of lantus at night. If you are not eating, please take only 30 units of lantus. Check your blood sugar with each meal and bedtime. Take 10 units of humalog insulin with each meal. Take an additional amount of humalog per the sliding scale you are being provided. 2) START Reglan 5 mg, 30 minutes before each meal and at bedtime 3) START citalopram 10 mg daily 4) START mirtazipine 15 mg at night 5) STOP LIPITOR 6) CHANGE CALCITRIOL - 0.5 mcg on MON / WED / FRI 0.25 mcg on TUE / THURS / SAT / SUN 7) STOP zaroxolyn 8) LASIX - continue with your regular dose 40 mg [**Hospital1 **], BUT WAIT TO START UNTIL [**2113-5-12**] 9) STOP neurontin 10) START bactrim single strength every day for prophylaxis . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500mL / day Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27555**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2113-5-18**] 2:00 . Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2113-6-1**] 11:20 . Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2113-6-5**] 3:30 . Dr. [**First Name (STitle) **]: [**6-23**] @ 10:30am, [**Hospital **] Clinic

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Discharge summary

report

Admission Date: [**2200-3-7**] Discharge Date: [**2200-3-8**] Date of Birth: [**2123-7-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 1402**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: pacemaker placement History of Present Illness: 76 year old male with DM, ESRD on HD via LUE AV fistula placed [**12/2196**] s/p multiple stenoses and angioplasties with angioplasty [**2200-1-16**] who is undergoing IV antibiotic therapy cefazolin at HD for MSSA bacteremia of unclear duration and source. He was at HD today for his regular visit and was noted to have hypotension. His pulse was then checked and found to be low, and his dialysis was cut short by 2 hours and he was transferred to [**Hospital1 18**] ER for further evaluation. . Upon presentation, pt denied complaints, but was noted to be in complete heart block with a wide complex escape rhythm (RBBB pattern) at 40 bpm. Known to have second degree AV block on EKG prior. BP was 110/68 and RR 18 with sats 94%. Pacer pads were placed. Carotid sinus massage and exercise were performed with no prominent effect on AV nodal conduction. He was noted to have WCB that was likely in the His bundle. As a pacemaker was recommended, ID was consulted due to recent infection/bacteremia. A TEE was performed and did not reveal any vegetations. He was afebrile with negative Blood cx's since [**2-22**], maintained on Abx at dialysis. Went for PPM placement today and was complicated by very difficult to access anatomy. In holding area post procedure pt delirius and confused, needed a team of ten people to keep control of him. Glucose was 17 on one measurement. Repeat was 200. He started the procedure with a glucose of 100. He had been NPO all day awaiting the procedure.He remained confused even after and was admitted to CCU for 1:1 monitoring. Past Medical History: -Diabetes mellitus 2 -chronic kidney disease stage 4 on HD MWF -Ulcerative colitis: no flares x 25 years -Right adrenal adenoma. -Gout. -History of prostate cancer, status post prostatectomy. -Remote history of nephrolithiasis. -Hypertension -Peripheral vascular disease s/p left [**Doctor Last Name **]-dp bypass -carotid stenosis -infrarenal abdominal aortic aneurysm -deep venous thrombosis in [**2195**] -iron deficiency anemia -recent episode of aphasia which resolved - ? TIA Social History: Quit smoking at age 73. Retired as a chemical mixer from a leather tannery. No alcohol or illicit drug use. Lives at home with his wife and family. Family History: Brother had liver cancer. Father and mother had cerebrovascular accidents. Paternal grandfather rectal cancer. Physical Exam: PE: T: 98.8 HR: 95 BP: 106/65 RR: 23 100% RA. Neuro: PERRLA, A0X3 CVS: [**12-18**] HSM heard best at apex R chest: dressing over pacemaker C/D/I Lungs: CTA-B abd: +bs, soft, nt, nd Ext: wwp,trace edema pulses dopplerable Pertinent Results: [**2200-3-7**] 11:28PM GLUCOSE-163* UREA N-25* CREAT-5.1*# SODIUM-145 POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-38* ANION GAP-15 [**2200-3-7**] 11:28PM ALT(SGPT)-0 AST(SGOT)-24 ALK PHOS-112 TOT BILI-0.7 [**2200-3-7**] 11:28PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-2.1 [**2200-3-7**] 11:28PM WBC-11.9* RBC-2.84* HGB-7.8* HCT-27.3* MCV-96 MCH-27.6 MCHC-28.7* RDW-25.9* [**2200-3-7**] 11:28PM PLT COUNT-151 [**2200-3-7**] 11:28PM PT-14.0* PTT-28.3 INR(PT)-1.2* [**2200-3-7**] 11:50AM GLUCOSE-94 K+-4.0 . Echo [**2200-3-7**] 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. Right atrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect is seen by 2D or color Doppler. with mild global free wall hypokinesis. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**12-14**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is at least mild pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No valvular vegetations or peri-valvular abcesses seen. Mild to moderate mitral regurgitation. Mildly depressed left ventricular and moderately depressed right ventricular systolic function. Complex plaque in descending aorta and aortic arch. Mild pulmonary hypertension. . CXR [**2200-3-8**] - IMPRESSION: Evidence for mild vascular congestion and very small pleural effusions. Cardiomegaly. A transvenous pacemaker in place. Brief Hospital Course: 76 yo M w/ PMHx of HTN, DM, and ESRD on HD who was known to have second degree AV block on prior EKG noted on admission to have deteriorated to complete heart block. Altered Mental Status: His course post PM placement was complicated by delirium, in the setting of hypoglycemia to 17. He received an amp of d50 with improvement of his GFS to the 200s. He was delirious initially on the floor and per discussions with his spouse he is confused at baseline. In addition to the hypoglycemia, he may have been particularly sensitive to sedating medications, and there may be some metabolic component given his ESRD although his electrolytes were not markedly abnormal. His GFS were checked every 4 hours, he received repeated reorientation, and benzodiazepines were avoided. His sensorium continued to improve. Complete heart block s/p Pacemaker: He had a [**Company **] DDD pacemaker placed set at 60-120. He was appropriately V paced on telemetry and subsequent EKG. He received a CXR the day following his procedure showing that the leads were appropriately positioned. EP interoggation post procedure showed the pacemaker was working appropriately. He was instricted to wear a slight to immobilize his right arm for several weeks post procedure. A plan was made for him to follow up with the device clinic within one week of discharge. He needs a new cardiologist and the phone number for the cardiology clinic was given to him to set up an appointment. ESRD on HD: He has ESRD on hemodialysis MWF. Due to his episode of hypotension, his Friday hemodialysis session was terminated prematurely, and he only received half of his dialysis. He was discussed with our renal team and was not found to be grossly volume overloaded nor were the electrolytes particularly abnormal. Dialysis was deferred to his next scheduled session on Monday. MSSA bacteremia: undergoing IV antibiotic therapy cefazolin at HD for MSSA bacteremia of unclear duration and source. At this point he is 13 days into his course. He should complete the course of cefazolin decided by his nephrologists at dialysis. HTN: He was normotensive this hospitalization. His antihypertensive regimen with metoprolol and lisinopril was continued. Carotid stenosis /Infrarenal AAA/PVD: He was continued on asa, simvastatin, lisinopril. Medications on Admission: 1. Albuterol Sulfate 2 puffs QID PRN 2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TIDAC 3. Clopidogrel 75 mg PO q day 4. Fluticasone-Salmeterol 100-50 mcg/Dose [**Hospital1 **] 5. Lasix 40 mg PO BID 6. Glipizide 2.5 mg ER PO BID 7. Lisinopril 40 mg PO Q day 8. Metoprolol Tartrate 100 mg Tablet PO Q day 9. Ranitidine HCl 150 mg PO Q day 10. Silver Sulfadiazine 1 % Cream Sig: Q day 11. Simvastatin 10 mg Tablet PO Q HS 12. Aspirin 325 mg PO Q day 13. Folic Acid 1 mg PO Q day 14. B Complex-Vitamin C-Folic Acid 1 mg Capsule PO Q day 15. Cefazolin at HD Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY (Daily) as needed for apply to foot wounds. 12. Cefazolin 10 gram Recon Soln Sig: Two (2) grams IV Injection HD PROTOCOL (HD Protochol). 13. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2* 14. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 15. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary. Complete heart Block S/P pacemaker placement Secondary End Stage Renal Disease Diabetes Discharge Condition: Alert and oriented to person, place and time. Mildly confused. Discharge Instructions: You were admitted to the hospital because you had dropped your blood pressure during dialysis. You were found to have complete heart block on EKG, a condition where the [**Doctor Last Name 1754**] of your heart do not communicate electrically. For this reason, you had to have a pacemaker placed. You were disoriented after the procedure because your blood sugar was low however this has been corrected. Some of the sedating medications may take some time to wear off, so you may be a little confused intitially. Please see your doctor if you still feel confused after a couple of days. The following changes were made to your medications: - DECREASE glipizide to 2.5mg ONCE a day. It is very important that you do not engage in any stretching or lifting using your right arm. Please keep the pacemaker area dry for 1 week. Please limit movement of your right arm and wear the arm sling for six weeks. Followup Instructions: Provider: [**Name10 (NameIs) **] Clinic. Please follow up within one week of discharge. The number to call to make your appointment is [**Telephone/Fax (1) 62**]. You need a new cardiologist. Please call [**Hospital1 18**] cardiology at ([**Telephone/Fax (1) 2037**] to set up an appointment Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1142**] Date/Time:[**2200-3-19**] 3:00 Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2200-3-20**] 10:30 Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2200-4-17**] 8:30

[ "274.9", "585.6", "V45.11", "403.91", "041.11", "V10.46", "443.9", "357.2", "426.0", "780.09", "250.60", "790.7" ]

icd9cm

[ [ [] ] ]

[ "37.72", "37.83", "88.72" ]

icd9pcs

[ [ [] ] ]

9204, 9210

4930, 5105

326, 348

9352, 9416

3003, 4907

10370, 11108

2632, 2744

7849, 9181

9231, 9331

7257, 7826

9440, 10347

2759, 2984

275, 288

376, 1945

5120, 7231

1967, 2450

2466, 2616

46,926

133,577

41397

Discharge summary

report

Admission Date: [**2134-3-1**] Discharge Date: [**2134-3-10**] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2569**] Chief Complaint: Unresponsive Major Surgical or Invasive Procedure: Endotracheal intubation Central venous line Tracheostomy PEG tube History of Present Illness: The pt is a 87 year-old man with a past medical history of a.fib (does not currently appear to be on Coumadin), HTN who was found down near his car and sent from an OSH with a large right sided intraparenchymal bleed. All information is obtained solely from EMS and OSH notes as patient is not responsive and no contact is currently available. The patient was reported to the police as missing at 3:44 this morning. He was staying with his sister in [**Name (NI) 8117**], but apparently lives somewhere else. He was found not far from the house on the ground about 50-75 feet from his car (not clear if he was driving or this was near the driveway). Police noted that he was supine, was moving his right side, slurring his speech and saying incoherent things, and not following commands. In the field he was noted the be very cold ~90-[**Age over 90 **]F, BP was 160/103. The patient was brought to nearby [**Hospital3 **] where a CT scan was done that showed a IPH, however no report was sent and the CD could not be opened. The patient was noted to continue to be cold (one recorded temp in the vitals chart lists 90.9). At some point he was intubated for "airway protection." He was then med flighted to [**Hospital1 18**] for further evaluation. Here neurosurgery was called and then neurology was called. The patient remains intubated and was given a number of fentanyl boluses for sedation, and his temp was noted to be 94.3 and a warming blanket was placed on the patient. On neuro ROS, general ROS not currently available Past Medical History: - HTN - A.fib (was noted in [**2132**] to be on Coumadin at LGH but normal INR today) - Rheumatic fever as a child - b/l inguinal hernia repair 20 years prior Social History: Apparently was visiting his sister in [**Name (NI) 8117**]. Is a Jehovah's Witness and would not want blood transfusions, otherwise social history an unknown Family History: Unknown Physical Exam: Vitals: T: 94.3 P: 82 R: 16 BP: 114/72 SaO2: 100 intubated General: Intubated, sedated, not following commands, eyes open a small amount to sternal rub HEENT: NC/AT, in c-collar, no bruits heard Pulmonary: Load mechanical and coarse breath sounds bilaterally Cardiac: RRR, nl. S1S2, systolic murmur Abdomen: soft, ND, normoactive bowel sounds Extremities: edema bilaterally, and venous stasis changes on legs Neurologic: -Mental Status: Eyes closed in c-collar, eyes open slightly to deep sternal rub, moves and fights restraints on right side. Doesn't follow commands I: Olfaction not tested. II: PERRL 2mm small non-reactive bilaterally (just given fentanyl) III, IV, VI: Dolls eyes present V, VII: corneal's intact IX, X: coughs, but no gag to stim -Motor: Normal bulk, slightly increased tone on right arm, normal in legs, flaccid in left arm Moves right arm and leg spontaneously, moves left leg spontaneously but less than right. Does not move left arm to noxious stimulation -Sensory: Withdraws to pain at right arm/leg, left leg, moves other arm to stim on left arm -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 extensor bilaterally. Pertinent Results: EEG [**3-5**]: This is an abnormal portable EEG due to slowing and disorganization of the background rhythm consistent with a moderate to severe encephalopathy. There were sharp waves, at times occuring periodically at 0.5 to 1 Hz and in short runs, and well as focal slowing in the left frontal region indicative of cortical and subcortical dysfunction in this region; although no clear clinical correlate was demonstrated, some of the sharp waves were noted to be associated with movement of the right foot. These findings are consistent with patient's history of a left frontal hemorrhage. No electrographic seizures were seen in this recording. Note is made of an irregularly irregular cardiac rhythm with occasional wide complex ectopic beats. CT (head) [**3-4**] Large right frontal intraparenchymal hemorrhage with associated areas of vasogenic edema with minimal improvement of leftward shift of midline structures. There is small amount of subarachnoid hemorrhage and right frontal subdural hematoma, essentially unchanged from prior exam. CXR: [**3-8**] Moderately severe pulmonary edema continues to worsen since [**3-4**] accompanied by moderate left and small right pleural effusion, also increasing, and obscuring cardiac silhouette, probably moderately enlarged and unchanged. No pneumothorax. Tracheostomy tube abuts the right tracheal wall and should be evaluated clinically to see if it is appropriately positioned. Left subclavian line ends in the mid SVC. No pneumothorax Brief Hospital Course: Right frontal hemorrhage The patient was admitted after being found down beside his car. He was initially hypothermic (94 F), but was warmed in the ED. His exam was notable for minimal responsiveness, no eye opening, intact brainstem reflexes and some spontaneous movement of the right arm. He was intubated for airway protection. On HD 2 he was noted to be following some commands with his right arm. Family was present and made the decision that they would like to go forward with care, even if that involved a trach and PEG. The patient had a tracheostomy and PEG tube placed by the ICU team and was able to come off of ventilator support to humidified O2 with q4 hour suctioning. During his hospital course he did not open his eyes to voice or sternal rub. Seizures While the patient was in the ED he was noted to have shaking movements of his right arm. He was loaded with Dilantin - which was eventually changed over to Keppra at 750 mg [**Hospital1 **]. He had 2 routine bedside EEGs performed which showed moderate encephalopathy and slowing over the right frontal region in the region of the IPH. MSSA pneumonia The patient had coag + staph aureus that was pan-sensitive cultured from his sputum on [**2134-3-3**]. He was initially treated with Vancomycin and Zosyn (on [**2134-3-4**]) and then transitioned to Nafcillin when sensitivities returned. Total course should be 14 days (end date [**2134-3-18**]). Nutrition Patient had a PEG tube placed and was started on tube feeds. Code Status Discussion was had with his 2 sisters who made him DNR - but felt that ventilator assistance would be OK so long as it was not prolonged. The patient will be discharged to LTAC. He needs telemetry and will be transported by ALS. Medications on Admission: unknown Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day) as needed for constipation. 3. senna 8.8 mg/5 mL Syrup Sig: Five (5) ml PO DAILY (Daily). 4. acetaminophen 650 mg/20.3 mL Solution Sig: 20.3 ml PO Q6H (every 6 hours) as needed for fever/pain. 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 6. levetiracetam 100 mg/mL Solution Sig: 7.5 ml PO BID (2 times a day). 7. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) g g Intravenous Q6H (every 6 hours) for 4 days. 9. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Intracerebral hemorrhage Partial seizures Methicillin-sensitive S. Aureua pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: Patient was admitted with the diagnosis of intracerebral hemorrhage. He was minimally responsive during his hospital course. He had a trach and PEG placed for breathing assistance and nutrition. He no longer required ventilator assistance on discharge. He was [**First Name9 (NamePattern2) **] [**Male First Name (un) **] antibiotics for an MSSA pneumonia. He will need to remain on Nafcillin until [**2134-3-18**] for a total of 14-day course. He currently has a subclavian line that can be removed after antibiotic course has been completed. He was started on Keppra 750 mg [**Hospital1 **] for seizures that were seen on presentation. He will need to be continued on that medication. He was made DNR by his sisters who were appointed health care proxies, but they would allow for ventilator assistance should that be required. Followup Instructions: Patient will be transferred to an LTAC. NEUROLOGY APPOINTMENT Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) **]:[**Telephone/Fax (1) 657**] Date/Time:[**2134-5-18**] 2:30 [**Hospital Ward Name 23**] Clinical Center [**Location (un) **] **please call registration to update your insurance information and get a referral before this appointment call registration at [**Telephone/Fax (1) 10676**] [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "431", "V49.86", "401.9", "511.9", "780.39", "277.39", "427.31", "E901.0", "348.5", "991.6", "342.90", "348.30", "482.41" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.93", "31.1", "43.11", "96.6", "33.29" ]

icd9pcs

[ [ [] ] ]

7668, 7742

5084, 6820

264, 331

7870, 7870

3563, 5061

8864, 9424

2281, 2290

6878, 7645

7763, 7849

6846, 6855

8010, 8841

2305, 2731

212, 226

359, 1906

7885, 7986

1928, 2089

2105, 2265

11,139

133,568

4661

Discharge summary

report

Admission Date: [**2129-4-15**] Discharge Date: [**2129-4-27**] Date of Birth: [**2052-8-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2932**] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: intubation, PICC line placement History of Present Illness: 76 yo M tranferred from [**Hospital6 **] intubated with pneumococcal pneumonia. Patient developed malaise and anorexia starting [**4-6**] then cough, congestion, and dypnea starting [**4-8**]. He was admitted to [**Hospital6 33**] with hypoxia and a R sided infiltrate. Initially was hypotensive to the 70's, hypoxic to 80's on NRB, with a WBC of 40k. He required 10 L of IVF for resucitation hypotension and oligouria. He was intubated after a short attempt at mask ventillation. Urine pneumococcus antigen was positive and sputum grew pan-sensitive pneumococcus. His antibiotics were then switched from CTX/Azith to PCN. He has had poor mental recovery despite decreased sedation for the last two days of his hospitalization. Head CT and LP were wnl. Transferred to [**Hospital1 18**] for further work up. On [**4-14**] pt had a short episode of atrial fibrillation documented on ECG which resolved with IV dilt. Since being transferred to [**Hospital1 18**] he has been in sinus rhythm. Past Medical History: Recent GI bleed - admitted to [**Hospital1 **] [**10-18**]; Capsule endoscopy [**2-16**] with angioectasia of the duodenum, colon and small intestine NHL s/p chemo in remission x 13 years NIDDM Hypothyroidism Fe Def Anemia Hyperlipidemia h/o systolic murmur - [**1-14**] aortic sclerosis h/o rheumatic fever in childhood Arthritis Social History: Lives at home with his wife, retired. Former smoker, quit 35 years ago. No EtOH or illicits Family History: NC Physical Exam: Physical Exam on Admission (ICU) VS - 100.5, Tm = 101.2 118/77 75 Resp - PS 22/8 FiO2 50% RR 18 O2 Sat 98% Gen - intubated, sedated HEENT - MM dry, PERRL Neck - supple, no LAD, no thyroid nodules felt Cor - RRR, sounds obscured by lung sounds Chest - ronchi R>L Abd - soft, non-distended, +BS Ext - w/wp, 1+ edema bilat, 2+ DP Neuro - PERRL, + gag reflex Pertinent Results: Laboratory studies on admission: [**2129-4-15**] WBC-16.2* HGB-9.1* HCT-30.8* MCV-77* RDW-20.0* PLT COUNT-210 NEUTS-85* BANDS-0 LYMPHS-5* MONOS-8 EOS-0 BASOS-2 ATYPS-0 METAS-0 MYELOS-0 PT-16.0* PTT-28.2 INR(PT)-1.5* HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE HCV Ab-NEGATIVE CALCIUM-7.7* PHOSPHATE-2.7 MAGNESIUM-2.2 IRON-14* ALT(SGPT)-102* AST(SGOT)-48* ALK PHOS-175* AMYLASE-84 TOT BILI-0.8 LIPASE-285* GLUCOSE-119* UREA N-24* CREAT-0.8 SODIUM-149* POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-35* ABG: PO2-87 PCO2-46* PH-7.49* TOTAL CO2-36* BASE XS-10 INTUBATED-INTUBATED Laboratory studies on discharge: [**2129-4-27**] WBC-11.1* Hgb-10.4* Hct-35.1* MCV-80* RDW-21.4* Plt Ct-829* Glucose-135* UreaN-14 Creat-0.8 Na-137 K-4.6 Cl-100 HCO3-28 AnGap-14 [**2129-4-16**] EKG: Sinus rhythm. Normal ECG. Compared to the previous tracing of [**2128-11-3**] no significant change Radiology [**2129-4-16**] Chest CT: Dense multifocal opacities are seen within the right lung and left lung base consistent with multifocal pneumonia. No cavitary lesion is detected. There are small bilateral pleural effusions, right greater than left. Note is made of calcified aortic valve which may suggest aortic stenosis and can correlate with echocardiography if warrented. No filling defect is identified within the pulmonary arteries. There are multiple prominent mediastinal nodes the largest of which is a right paratracheal node measuring 18 x 9 mm. Enlarged lymph nodes are also seen within the left axilla, the largest measures 2.0 x 1.2 cm. The left lobe of the thyroid is enlarged and measures 3.0 x 3.5 cm. ET tube is present. Diffuse atherosclerotic calcification is seen within the aorta and coronaries. Visualized upper abdomen demonstrates cholelithiasis. NG tube is curled within the stomach. [**2129-4-16**] RUQ U/S: Limited evaluation of the right upper quadrant demonstrates a liver with normal echogenicity without focal lesion. There is no intra- or extra-hepatic biliary dilatation. A decompressed gallbladder is present containing multiple stones. There is no pericholecystic fluid or gallbladder wall edema to suggest cholecystitis. Portal vein is patent with hepatopetal flow. Note is made of renal cyst at the upper pole. [**2129-4-17**] MRI of head with and without contrast: There is opacification of the mastoid sinus air cells as well as scattered areas of mucosal thickening in the ethmoid sinuses. There is an air-fluid level in the nasopharynx. These findings are all consistent with intubation. There is no midline shift, mass effect or hydrocephalus. There are scattered foci of increased T2 signal within the periventricular and subcortical white matter of both cerebral hemispheres most consistent with chronic microvascular ischemic changes. There is no area of slow diffusion to indicate an acute infarct. There are no enhancing abnormalities. IMPRESSION: No evidence of an acute infarct or enhancing abnormalities. Tiny amounts of chronic microvascular ischemic change. [**2129-4-18**] transthoracic echocardiogram: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. No masses or vegetations are seen on the aortic valve. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild to moderate ([**12-14**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. [**2129-4-20**] CT Neck: No fluid collections are identified within the neck. Enlargement of the left lobe of the thyroid is unchanged compared to four days prior. Lung windows of the apices partially image patient's known multifocal opacities on the right. Bone windows reveal no acute fractures or dislocation. No spondylolisthesis is identified. Tiny avulsion injuries off the posterosuperior aspect of the C4 and C5 vertebral bodies appear old. Scattered calcifications of the anterior longitudinal ligament and ligamentum flavum are also observed. Vertebral body heights appear preserved. [**2129-4-23**] CXR PA/lat: PA and lateral views of the chest are obtained [**2129-4-23**] at 13:42 hours and compared with the prior radiograph of [**2129-4-21**]. The cardiomediastinal silhouette is unchanged. Again seen is bilateral interstitial edema which appears to be slightly increased since the previous examination. Patchy opacities at the right base and right midlung persists. New opacity developing in the left mid lung zone and in the right upper lobe. Brief Hospital Course: 76 year old male tranferred from [**Hospital6 **] intubated with pneumococcal pneumonia and resuscitated septic shock. 1) Pneumococcal pneumonia/respiratory failure: The patient was admitted to the intensive care unit intubated. He was initially covered with vancomycin/Zosyn, subsequently changed to Penicillin alone, and completed a 14 day course. His ventilation was managed per ARDS-NET protocol and he was extubated on [**2129-4-18**] and transferred to the general medical floor on [**2129-4-21**]. His respiratory status remained stable on the floor and, at time of discharge, he was 96% on room air. This is the patient's second severe pneumonia within the last 2 years, despite multiple pneumococcal vaccines; his primary care physician is planning further [**Name9 (PRE) 8019**] as an outpatient to determine what, if anything, is predisposing him to recurrent pneumonias. He was evaluated by the speech and swallow service, who recommended soft solids and pureed solid diet to prevent aspiration. 2) Change in mental status: Following extubation, the patient remained significantly altered in terms of mental status. A neurology consult was obtained, and he underwent a repeat LP with negative cultures and negative HSV PCR. An MRI of his head did not reveal an acute abnormality (see results section). Metabolic work-up, uncluding TSH, electrolytes, RPR, and vitamin B12, was unrevealing. The patient's change in mental status, which gradually improved over the course of his hospital stay, was likely due to delirium in the setting of acute illness (pneumonia, recent intubation). He will require continued occupational therapy as an outpatient. 3) Transaminitis: The patient underwent a right upper quadrant ultrasound which was unremarkable (with the exception of stones). Hepatitis B and C panels were negative. [**Doctor First Name **] was mildly positive at 1:40 (outpatient follow-up). His transaminitis, which resolved over the course of his hospital stay, may have been due to mild shock liver in the setting of sepsis. 4) Type II diabetes well-controlled: The patient was started on an insulin gtt in the ICU. He was subsequently transitioned to Lantus with a Humalog sliding scale. He can likely be transitioned back to his oral regimen at his rehabilitation facility 5) Iron deficiency anemia: The patient has undergone a recent extensive work-up for GI bleeding sources. He was restarted on iron supplements on discharge. 6) Hypothyroidism/Thyroid nodules: The patient will continue on levothyroxine. On his chest and neck CT, the left lobe of the thyroid was noted to be enlarged, measuring 3.0 x 3.5 cm. Outpatient thyroid ultrasound may be considered at the discretion of his PCP. 7) Lymphadenopathy: The patient's chest CT revealed prominent mediastinal and left axillary lymph nodes (see results section). These may be related to the patient's known extensive pneumonia, but outpatient follow-up is recommended once he recovers from his acute illness, particularly given the patient's history of non-hodgkins lymphoma. 8) Generalized weakness: Following extubation, the patient was noted to be generally weak in all 4 extremities. A neurology consult was obtained, who felt this could be secondary to deconditioning versus ICU-related myopathy. His strength markedly improved over the course of his hospital stay and, at time of discharge, the patient was working well with physical therapy. 9) Left foot redness: The patient was noted to have a rash involving his distal left foot; this was patchy, not painful/pruritic, and not cellulitic appearing. He was started on miconazole powder for possible fungal infection. This should continue to be monitored as an outpatient. Full Code Medications on Admission: Iron supplements levothyroxine Zetia - 10mg daily Glucotrol SR - 5mg daily Avandia - 2mg daily Metformin - 1000mg [**Hospital1 **] Discharge Medications: 1. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. 2. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding scale Subcutaneous before each meal and at bedside: If FS <150 give 0 units, if 151-200 give 2 units, if 201-250 give 4 units, if 251-300 give 6 units, if 301-350 give 8 units, if 351-400 give 10 units, if >400 give 12 units and [**Name8 (MD) 138**] MD . 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 4. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-14**] Drops Ophthalmic PRN (as needed). 8. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day): to left foot. 11. Iron sulfate 325 mg daily Discharge Disposition: Extended Care Facility: [**Hospital1 **] northeast [**Location (un) 38**] Discharge Diagnosis: Primary: streptococcal pneumonia Secondary: change in mental status, thrombocytopenia, Type II diabetes well-controlled, anemia, hypothyroidism Discharge Condition: Stable Discharge Instructions: You were admitted with a severe pneumonia 1) Please follow-up as indicated below. 2) Please come to the emergency room if you develop fevers, chills, shortness of breath, or other symptoms that concern you. Followup Instructions: Please call your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 2696**] ([**Telephone/Fax (1) 2697**]) to schedule an appointment 1 week after your discharge from the rehabilitation facility. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**] Completed by:[**2129-4-27**]

[ "785.6", "782.1", "293.0", "244.9", "787.2", "437.1", "250.00", "995.92", "V15.82", "799.3", "785.52", "272.4", "287.4", "481", "570", "518.81", "280.9", "038.2", "202.80", "716.90" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "03.31", "99.15" ]

icd9pcs

[ [ [] ] ]

12621, 12697

7525, 8548

335, 368

12884, 12892

2263, 2282

13147, 13544

1869, 1873

11431, 12598

12718, 12863

11276, 11408

12916, 13124

1888, 2244

2869, 7502

276, 297

396, 1388

2296, 2855

8563, 11250

1410, 1743

1759, 1853

14,885

132,243

1782

Discharge summary

report

Admission Date: [**2130-5-18**] Discharge Date: [**2130-5-24**] Date of Birth: [**2068-6-5**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 898**] Chief Complaint: GI bleeding Major Surgical or Invasive Procedure: EGD (upper GI endoscopy) - Recently bleeding ulcer found with covering blood clot. Colonoscopy - No active bleeding. History of Present Illness: 61 year old male with history of ITP and Stage IV NHL. He presented with 2d history increasing presyncope / lightheadedness. At [**Location (un) 620**] ER with recurrent melena, hematemesis with clots. NG suction gave 400 mL bright read blood. HCT 27 on arrival, INR 1.0, plt 300. Immediately given 3 U pRBC, IV octreotide and PPI (Nexium). 2 large bore IVs placed, given 2L NS. During ER stay SBP initially 80/60, stabilized at SBP ~100 after IVF. Transferred to [**Hospital1 18**] ER: once here, given 2 unit pRBC (total 6 units given), [**Last Name (un) 10045**] tamponade and transferred to MICU. Patient has GI physician at [**Hospital1 **] [**Name9 (PRE) 620**], recent EGD ([**2-13**]) demonstrating gastric varices, recent colonoscopy with rectal varices. Recent CT scan apparently showed pericardiac lymphadenopathy, scheduled for ex-lap with gastric bx in future. Past Medical History: Mantle cell lymphoma, status post 6 cycles of CHOP/Rituxan thought to be in remission. Coronary artery disease, status post CABG in [**2118**]. History of upper GI bleed [**2124**] due to gastric ulcer. H pylori positive. History of ITP, thought to be in remission. Hypertension. Hypercholesterolemia. Stress [**4-13**], exercised for 5-1/2 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol, had no symptoms or ST depression and a normal MIBI scan. Alcohol Abuse Social History: The patient is a US Army Veteran, on disability. No tobacco. Heavy alcohol consumption, drinks up to 10 beers a day. Lives with his wife and is independent in [**Name (NI) 5669**]. Lives with his wife in [**Name (NI) 86**] area. Family History: Noncontributory. Physical Exam: VS: T98.4, BP 135/85, P95, R20, 98% RA Gen: Overweight male in no distress. Nonicteric. HEENT: R neck bandage from previous central line location. CV: S1 S2 with no MRG. No JVD Lungs: Clear bilaterally Abd: Overweight, no fluid wave. Large easily reducible ventral (periumbilical) hernia. Ext: Trace pedal edema bilaterally. Pertinent Results: [**2130-5-18**] 06:07PM GLUCOSE-137* UREA N-27* CREAT-1.0 SODIUM-139 POTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-20* ANION GAP-13 [**2130-5-18**] 06:07PM CK(CPK)-51 [**2130-5-18**] 06:07PM CK-MB-4 cTropnT-0.07* [**2130-5-18**] 06:07PM HCT-28.8* [**2130-5-18**] 03:52PM TYPE-[**Last Name (un) **] TEMP-36.7 TIDAL VOL-500 PEEP-5 O2-50 PO2-25* PCO2-51* PH-7.26* TOTAL CO2-24 BASE XS--5 -ASSIST/CON INTUBATED-INTUBATED [**2130-5-18**] 12:32PM ALT(SGPT)-10 AST(SGOT)-16 LD(LDH)-137 CK(CPK)-65 ALK PHOS-46 AMYLASE-13 TOT BILI-0.7 [**2130-5-18**] 12:32PM WBC-10.6 RBC-3.69* HGB-10.9*# HCT-30.7* MCV-83 MCH-29.5 MCHC-35.5* RDW-15.5 [**2130-5-18**] 12:32PM FIBRINOGE-213# [**2130-5-18**] 09:15AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2130-5-18**] 09:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2130-5-18**] 09:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ECG: Sinus rhythm. Early R wave progression with splintered complex in lead VI. T wave inversions in the precordial leads. Since the previous tracing of [**2130-5-18**] the QRS voltage has increased, the precordial T wave inversions are new and the axis is less leftward. TJ liver bx: A. Parenchyma, small fragments of liver: 1. Steatosis, large and small droplet types, involving the majority of hepatocytes. 2. No cytoplasmic hyaline, balloon cell change, or apoptotic hepatocytes are identified. 3. No sinusoidal infiltrate of inflammatory cells. B. Portal areas: 1. Focal and minimal mononuclear inflammation. 2. Trichrome stain shows minimal fibrosis. Negative iron stain. Brief Hospital Course: In MICU, patient was stable over 4d stay, did not require pRBC since [**5-20**] (2 units pRBC given.) Currently HCT stable, no signs of bleeding. On [**5-20**] EGD demonstrated erosions in distal esophagus, likely from [**Last Name (un) **] tube. Single 1 cm ulcer in fundus with adherent clot. No fresh blood in stomach. Patient has had no previous variceal bleeds. Patient was transferred to medical floor on [**2130-5-23**], where he remained hemodynamically stable, with no sings of GI bleeding. He was evaluated by social work service who referred him to the SMART recovery program for continued maintenance of abstinence from alcohol. The patient was discharged on high dose proton pump inhibitor with close outpatient followup. Medications on Admission: 1. Atenolol 25 mg a day 2. simvastatin 80 mg a day 3. Prilosec 4. gabapentin 5. iron Discharge Medications: 1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day) for 28 days. Disp:*112 Tablet(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 28 days. Disp:*56 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Gastrointestinal bleeding from ulcer Discharge Condition: Good Discharge Instructions: You had a gastric ulceration which gave bleeding into the gastrointestinal tract. Please take all of your medications as directed, which can help prevent ulcers from forming. If you feel fatigued or notice changes in your stool (black, tarry stools or signs of blood), please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 10046**]d to the ER immediately for further evaluation. Please continue taking your outpatient medications unchanged (atenolol, simvastatin, gabapentin, and iron.) Do NOT take your prilosec -- instead, take the supplied prescription for Protonix (Pantoprazole) twice per day. Your outpatient doctor may change your regimen back to prilosec in the near future. Also take the supplied presciption for sucralafate. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Phone:[**Telephone/Fax (1) 3760**] Date/Time:[**2130-5-30**] 1:30 PM Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Phone:[**Telephone/Fax (1) 3760**] Date/Time:[**2130-7-20**] 9:00 AM

[ "414.00", "287.31", "785.59", "V10.79", "V45.81", "531.40", "305.00" ]

icd9cm

[ [ [] ] ]

[ "96.04", "45.13", "96.72", "50.11", "45.16" ]

icd9pcs

[ [ [] ] ]

5413, 5419

4210, 4948

278, 398

5500, 5507

2466, 4187

6315, 6629

2088, 2106

5083, 5390

5440, 5479

4974, 5060

5531, 6292

2121, 2447

227, 240

426, 1307

1329, 1826

1842, 2072

48,555

125,583

37436

Discharge summary

report

Admission Date: [**2196-1-2**] Discharge Date: [**2196-1-18**] Date of Birth: [**2131-11-23**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft Surgery x 3 with Left internal mammory artery to left anterior descending, vein graft to posterior descending artery and ramus History of Present Illness: Mr. [**Known lastname **] is a 64 year old male with recent diagnosis of CAD (non-intervenable 3VD) who was discharged from [**Hospital1 18**] on [**2196-1-1**] after 4 day hospitalization for chest pain who presented to OSH after 7-10 minutes of shortness of breath this morning, now transferred to [**Hospital1 18**] for further evaluation and management. Mr. [**Known lastname **] first presented to [**Hospital1 18**] on [**2195-12-28**] on transfer from OSH for catheterization after experiencing several episodes chest pain over the prevoius 4-5 days. He had multiple episodes of chest pain, at rest, felt like weight on his chest, accompanied by shortness of breath and dizziness. Denied palpitations, nausea, vomitting. During his previous [**Hospital1 18**] admission, he had cardiac catheterization which showed 3VD with totally occluded LAD and RCA and EF 30% that was not ameniable to intervention. He was medically maximized and discharged home for planned CABG on Thursday [**2196-1-7**]. Of note, there was Code Stroke called for new left facial droop on [**12-29**], CT and MRI head negative. Droop resolved. The morning after discharge, he was walking around his house and experienced 7 minutes of shortness of breath with mild chest pressure. The shortness of breath recurred later in the morning and he went to [**Hospital3 **] for evaluation. He states the chest pain is different than prior, however he did experience SOB before previous admission. At [**Hospital3 **], Troponin 0.02, chest pain free since admitted, started on heparin gtt and loaded with 600 mg plavix at 1537. On review of systems, he denies history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for dyspnea on exertion with 3 blocks of ambulation (worsening over months) and paroxysmal nocturnal dyspnea; denies orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: no-Diabetes, no-Dyslipidemia, no-Hypertension 2. CARDIAC HISTORY: Denies 3. OTHER PAST MEDICAL HISTORY: Denies Social History: Splits time between MA and NY, is originally from [**Country 3399**]. Lives with wife. -Tobacco history: 15 cig/day x 30-35 years -ETOH: denies -Illicit drugs: denies Family History: 2 brothers with Coronary artery disease Physical Exam: Admission VS: T= 97.6 BP= 124/73 HR= 68 RR= 18 O2 sat= 96RA GENERAL: Elderly male in NAD, lying in bed on 1 pillow with HOB elevated 30 degrees. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. 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: decreased BS at right posterior base, occasional bibasilar crackle, otherwise CTA bilaterally with no wheezes or rhonchi. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission [**2196-1-1**] 06:20AM PTT-30.8 [**2196-1-1**] 06:20AM PLT COUNT-119* [**2196-1-1**] 06:20AM WBC-5.4 RBC-4.21* HGB-12.7* HCT-37.6*# MCV-90 MCH-30.2 MCHC-33.8 RDW-12.7 [**2196-1-1**] 06:20AM CALCIUM-8.6 PHOSPHATE-3.9 MAGNESIUM-1.9 [**2196-1-1**] 06:20AM GLUCOSE-89 UREA N-19 CREAT-0.9 SODIUM-138 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13 [**2196-1-1**] 03:51PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2196-1-1**] 03:51PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2196-1-2**] 09:15PM PT-15.3* PTT-150* INR(PT)-1.3* [**2196-1-2**] 09:15PM CK-MB-4 cTropnT-<0.01 [**2196-1-2**] 09:15PM CK(CPK)-114 [**2196-1-2**] 09:15PM GLUCOSE-180* UREA N-13 CREAT-0.8 SODIUM-138 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-24 ANION GAP-13 Discahrge [**2196-1-17**] 06:20AM BLOOD WBC-7.5 RBC-3.28* Hgb-9.6* Hct-29.8* MCV-91 MCH-29.2 MCHC-32.2 RDW-15.3 Plt Ct-394 [**2196-1-17**] 06:20AM BLOOD Plt Ct-394 [**2196-1-14**] 07:21AM BLOOD PT-15.5* PTT-33.3 INR(PT)-1.4* [**2196-1-17**] 06:20AM BLOOD Glucose-112* UreaN-17 Creat-0.7 Na-138 K-4.6 Cl-105 HCO3-26 AnGap-12 [**2196-1-14**] 07:21AM BLOOD ALT-25 AST-29 LD(LDH)-305* AlkPhos-60 TotBili-0.6 [**2196-1-17**] 06:20AM BLOOD Mg-2.0 Radiology Report CHEST (PA & LAT) Study Date of [**2196-1-16**] 11:50 AM Final Report HISTORY: Status post CABG, evaluation for interval change. COMPARISON: [**2196-1-13**]. FINDINGS: As compared to the previous examination, there is marked improvement. The pre-existing right pleural effusion has completely resolved. The left pleural effusion has minimally decreased in extent, leading to improved ventilation of the left basal lung. The shape of the cardiac silhouette can be better delineated. Unchanged are the post-infectious small granulomas at the right lung apex. Unchanged course of the nasogastric tube. Unchanged alignment of the sternal wires. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Indication: Intraoperative TEE for CABG, ? MVR Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *6.3 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm Left Ventricle - Inferolateral Thickness: 0.6 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.5 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 15% >= 55% Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm Aortic Valve - LVOT diam: 2.1 cm Findings LEFT ATRIUM: Marked LA enlargement. Elongated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Depressed LAA emptying velocity (<0.2m/s) RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Moderately dilated LV cavity. Severe regional LV systolic dysfunction. Severely depressed LVEF. No LV mass/thrombus. RIGHT VENTRICLE: Normal RV chamber size. Focal apical hypokinesis of RV free wall. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Simple atheroma in aortic arch. Complex (>4mm) atheroma in the descending thoracic aorta. Focal calcifications in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of mitral valve chordae. No MS. Mild to moderate ([**12-12**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions: PRE BYPASS The left atrium is markedly dilated. The left atrium is elongated. 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. The left atrial appendage emptying velocity is depressed (<0.2m/s). A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with essentially anterior, septal, and anterolateral akinesis and moderate to severe hypokinesis of all remaining segments. The mid anterior wall and basal inferioseptal wall are mildly dyskinetic. Overall left ventricular systolic function is severely depressed (LVEF= 15 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-12**]+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is in sinus rhythm. The patient is receiving milrinone, epinephrine, and norepinephrine by infusion. The right ventricle displays continued severe apical hypokinesis with normal basal and mid free wall systolic function. The left ventricle shows slightly improved overall function but continued regional abnormalities as described above. The funtion of the lateral wall is improved. The ejection fraction is in the 15-20% range. The mitral regurgitation is improved and is now mild. The thoracic aorta is intact. No other significant changes from the pre-bypass period. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2196-1-4**] 15:48 ?????? [**2188**] CareGroup IS. All rights reserved. Brief Hospital Course: 64yo M with known 3VD on cardiac catheterization, discarged home after cardiac cath while awaiting bypass surgery. Admitted with recurrenat angina and brought urgently to operating room on day of admission. Please see operative report for details. In summary had coronary artery bypass graftin x3 with left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery and the obtuse marginal artery. Post-operative course was complicated by severe bleeding requiring mediastinal re-exploration. Following re-exploration the patient extubated but was reintubated for respiratory distress on POD3. BAL at that time revealed PROTEUS MIRABILIS, treated with Zosyn. The post-operative course was further complicated by delerium and failed bedside swallow evaluation requiring placement of temporary feeding tube. He remained hemodynamically stable throughout this period. All tubes, lines and drains were removed according to cardiac surgery protocol. He remained in the ICU during this period. The patients delerium and pulmonary status improved slowly and he was transferred from the ICU to the stepdown floor on POD10. He continued to make slow progress with activity. He passed a repeat swallow evaluation on POD 14. At that time it was decided he would benefit from a short rehab stay and he was transferred to rehabilitation at [**Hospital3 13990**] Health Care Center in [**Location (un) 5110**]. Medications on Admission: MEDICATIONS (home): Aspirin 325 mg qday Atorvastatin 80 mg qday Nicotine 21 mg patch q24h Isosorbide Mononitrate 30 mg qday Omeprazole 20 mg qday Metoprolol tartrate 37/5 mg [**Hospital1 **] MEDICATIONS IN OSH ED (prior to transfer): Heparin bolus and gtt Clopidogrel 600 mg x 1 Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*60 * Refills:*2* 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 5. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Coronary Artery Diseases/p coronary artery bypass grafting X3 Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with ultram or tylenol prn sternal wound healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Surgeon Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2-17**] @1pm ([**Telephone/Fax (1) 170**])-cardiac surgeon Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 62**]-Cardiologist Date/Time:[**2196-1-27**] 9:00- Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]-neurologist Date/Time:[**2196-2-1**] 2:00 Please call to schedule appointments Primary Care Dr. [**First Name (STitle) **] in [**12-12**] weeks [**Telephone/Fax (1) 9332**] Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2196-1-18**]

[ "998.11", "276.2", "305.1", "458.29", "414.2", "428.23", "V12.54", "411.1", "511.9", "518.5", "482.83", "E878.2", "428.0", "414.01", "287.5", "787.29", "311", "286.9", "293.0" ]

icd9cm

[ [ [] ] ]

[ "31.42", "36.12", "96.71", "33.24", "39.61", "96.6", "34.03", "96.04", "36.15" ]

icd9pcs

[ [ [] ] ]

13627, 13699

10729, 12197

332, 490

13805, 13962

4007, 10706

14503, 15287

3023, 3064

12527, 13604

13720, 13784

12223, 12504

13986, 14480

3079, 3988

2775, 2782

282, 294

518, 2662

2813, 2822

2684, 2755

2838, 3007

570

100,913

29617

Discharge summary

report

Admission Date: [**2181-1-15**] Discharge Date: [**2181-1-18**] Date of Birth: [**2155-4-21**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: 25 y/o male with hx of closed head injury as teenager, cocaine OD, lumbar spine surgery was transferred from an outside hospital with C6 Lamina fracture and ? C5 Fracture. Pt slipped and fell in puddle of water, hitting head as he fell down reports immediate neck right shoulder pain, no LOC no loss of bowel or bladder sensation Major Surgical or Invasive Procedure: ACDF C6-7 History of Present Illness: 25 y/o male with hx of closed head injury as teenager, cocaine OD, lumbar spine surgery was transferred from an outside hospital with C6 Lamina fracture and ? C5 Fracture. Pt slipped and fell in puddle of water, hitting head as he fell down reports immediate neck right shoulder pain, no LOC no loss of bowel or bladder sensation Past Medical History: Closed head injury as teenager, Cocaine OD, Lumbar spine surgery in [**6-22**]. Social History: Currently Prisoner went to jail on [**1-11**] for violating a restraining order according to patient. Smokes 1.5ppd, drinks 6-12 beers per day last drink [**1-10**]; Uses coccaine occassionaly Family History: Non contributory Physical Exam: T:98.0 BP:128/70 HR: 68 R 18 O2Sats 97% Gen: Awake on ICU bed conversant HEENT: Pupils: EOMs Neck: in collar Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Toes cool no injuries. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [**Last Name (un) 938**] G R 4+ 4+ 4+ 4+ 4+ 5 5 5 5 5 L 5 5 5 5 5 3 3 3 3 0 Sensation: Intact to light touch decreased on left leg, normal senation in pubic area and penis Reflexes: B T Br Pa Ac Right 2 2 2+ Left 2 2 2+ No clonus Propioception intact Toes mute Rectal exam normal sphincter control per ER and trauma resident Pertinent Results: [**2181-1-15**] 06:30AM PLT COUNT-264 [**2181-1-15**] 06:30AM NEUTS-64.9 LYMPHS-26.4 MONOS-5.9 EOS-0.9 BASOS-1.8 [**2181-1-15**] 06:30AM WBC-9.0 RBC-5.04 HGB-16.5 HCT-46.2 MCV-92 MCH-32.7* MCHC-35.6* RDW-13.0 [**2181-1-15**] 06:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2181-1-15**] 06:30AM PHOSPHATE-4.6* MAGNESIUM-2.4 [**2181-1-15**] 06:30AM estGFR-Using this [**2181-1-15**] 06:30AM estGFR-Using this [**2181-1-15**] 06:40AM GLUCOSE-100 LACTATE-1.5 NA+-144 K+-3.8 CL--108 TCO2-23 [**2181-1-15**] 06:40AM GLUCOSE-100 LACTATE-1.5 NA+-144 K+-3.8 CL--108 TCO2-23 [**2181-1-15**] 06:40AM PH-7.40 COMMENTS-GREEN TOP Brief Hospital Course: Mr [**Known lastname 1968**] was admitted to the trauma ICU he underwent cervical,thoracic, lumbar MRI: showing: Large disc protrusion at C6/7 extending from just left of midline rightward into the right neural foramen. This disc protrusion results in compression of the right anterolateral aspect of the spinal cord. 2. Small disc protrusions at T2/3 and T7/8. 3. Degenerative disc changes and protrusions as described at L3/4, L4/5, and L5/S1. It was felt that his C6/7 disc was the one that causing the majority of his symptoms, on [**1-16**] he underwent a ACDF with allograft plate C6-7. Post operatively he was full in strength in his right arm with continued neck pain. On Post operative day 1 he was moving all extremities with good strenght though was hesitent to move left leg at times though when pushed he had full strength. His pain medication was weaned and he was placed for a physical therapy consult. He was tolerating a regular diet and voiding without difficulty. Medications on Admission: None Discharge Medications: Percocet Colace Discharge Disposition: Extended Care Discharge Diagnosis: C6-7 HNP with C7 pedicle fracture Discharge Condition: Neurologically stable Discharge Instructions: ?????? Do not smoke ?????? Keep wound(s) clean and dry / No tub baths or pools for two weeks from your date of surgery ?????? If you have steri-strips in place ?????? keep dry x 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? you are required to wear cervical collar asinstructed ?????? You may shower briefly without the collar / back brace unless instructed otherwise ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits PLEASE RETURN TO THE OFFICE IN ____________DAYS FOR REMOVAL OF YOUR STAPLES/SUTURES ( IF YOUR SUTURES ARE UNDER THE SKIN YOU WILL NOT NEED TO BE SEEN UNTIL THE FOLLOW UP APPOINMENT Followup Instructions: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**Last Name (STitle) 548**] in 6 weeks YOU WILL NEED XRAYS (AP/lat) PRIOR TO YOUR APPOINMENT Completed by:[**2181-1-18**]

[ "E885.9", "V15.5", "305.60", "806.07", "305.1" ]

icd9cm

[ [ [] ] ]

[ "03.53", "81.62", "81.02" ]

icd9pcs

[ [ [] ] ]

3875, 3890

2790, 3780

651, 663

3968, 3992

2093, 2767

5636, 5834

1354, 1372

3835, 3852

3911, 3947

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4016, 5613

1387, 1598

280, 613

691, 1024

1613, 2074

1046, 1128

1144, 1338

3,575

124,520

46148

Discharge summary

report

Admission Date: [**2129-8-31**] Discharge Date: [**2129-9-2**] Date of Birth: [**2072-5-1**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: R IJ central line placement History of Present Illness: 57F w/ ESRD on hemodialysis and HCV cirrhosis who presents with altered mental status. Family unable to get in touch with her, called 911. Found lying in bed lethargic, responsive but somnolent, last HD Monday did not get HD today, no c/o pain, gluc=171. EMS brought to ED. . In the ED on arrival VS were T 98, HR 80, BP 163/95, RR 16, SpO2 100%/RA. She was unresponsive on exam. ABG was normal. Narcan given without improvement. Labs significant for K 5.7, BUN/Cr 36/7.5, lactate 2.2, hct 31.1. EKG: SR at 78, NA/NI, TWI in III and aVF, TWI V1-V5, c/w prior. CXR, CT Head and CT abdomen showed no acute pathology. Renal was called, and plan to take her for HD tomorrow. She was given vanc/zosyn for possible infectious cause of AMS. After several hours in ED, patient woke up, and is now droswy but arousable, AAO x 3, and answering questions appropriately. VS on transfer were 97.3 78 125/70 16 100/ra. . On the floor, patient is alert and coversant. She complains of back which is chronic. She also has some nasal congestion and thinks she is getting a cold. Past Medical History: -HTN -ESRD on hemodialysis -HCV cirrhosis -spinal stenosis with back pain -seizure disorder -depression -hypothyroidism -substance abuse -Lumbar laminectomy -status post failed renal transplant -cholecystectomy -thyroidectomy -Rt ovarian mass Social History: Retired special education teacher. Widowed, lives at home with sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy. # Tobacco: 3 packs per week since teenager # Alcohol: Denies # Drugs: Past IVDU, but not in several years Family History: Father: ESRD and hypertension Mother: lung cancer Physical Exam: VS - Temp 98.1 F, BP 135/72, HR 73, R 18, O2-sat 100% RA GENERAL - pt is lethargic but a well-appearing female in NAD, comfortable HEENT - NC/AT, EOMI NECK - supple, no JVD, no carotid bruits, RIJ CVL in place LUNGS - CTA bilat, no abnormal breath sounds appreciated, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - soft, mild ttp in rlq, ruq, bs + EXTREMITIES - no clubbing, cyanosis, edema, RUE AVF. SKIN - no rashes or lesions NEURO - awake but lethargic, A&Ox3, CNs II-XII grossly intact, + asterixis . Discharge: GENERAL - pt is lethargic but a well-appearing female in NAD, comfortable HEENT - NC/AT, EOMI NECK - supple, no JVD, no carotid bruits, RIJ CVL in place LUNGS - CTA bilat, no abnormal breath sounds appreciated, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - soft, mild ttp in rlq, ruq, bs + EXTREMITIES - no clubbing, cyanosis, edema, RUE AVF. SKIN - no rashes or lesions NEURO - awake but lethargic, A&Ox3, CNs II-XII grossly intact, no asterixis Brief Hospital Course: 57F w/ ESRD on hemodialysis and HCV cirrhosis who presents with altered mental status. Family unable to get in touch with her, called 911. Found lying in bed lethargic, responsive but somnolent, admitted and ms improved. . #ACUTE METABOLIC ENCEPHALOPATHY: Pt was initially found unresponsive by EMS with pinpoint pupils, garbled speech and hypotensive. Concern that this was due to possible opioid overdose given clinical improvement with narcan in the ED, however improvement was not immediate (took over an hour post narcan administration) and pt did not exhibit withdrawal symptoms after narcan. Pt does have history of seizures and it is possible that she had a seizure and AMS was a post ictal state. She denies missing any doses of keppra. Most likely explanation is polypharmacy in the setting of ESRD. She has been prescribed many sedating medications (gabapentin, hydromorphone, clonazepam, trazadone) in the past. Infectious workup was negative and pt was not hypoxic. Electrolytes were remarkable for K 5.7, BUN/Cr 36/7.5, lactate 2.2, hct 31.1. EKG: SR at 78, NA/NI, TWI in III and aVF, TWI V1-V5, and CE were flat, repeat ekg was normal and repeat CE unchanged. CXR, CT Head and CT abdomen showed no acute pathology. After dialysis and day in hospital pt's mental status was at baseline. She is encouraged to only take medications as prescribed from discharge medication list. She was also sent home with VNA services to assist with discarding non-active medications. A letter was sent to pt's methadone clinic to inform them of hospitalization. . #SEIZURE DISORDER: Pt could have had a seizure and post-ictal state caused her to be somnolent and difficult to arouse as discussed above. She reports that she has been taking home Keppra dose and has not missed any doses. A follow up appt with neurology was made and pt was encouraged not to operate a motor vehicle for at least 6 months or until she gets clearance from her neurologist. . #RENAL FAILURE/CKD V: Pt's BUN:Cr were extremely elevated on admission as would be expected for someone that missed dialysis the prior day. Pt's nephrologist reports that he does not believe that AMS was from euremia, rather it is more likely [**2-16**] polypharmacy as mentioned above. Pt's renal function improved after dialysis and she was discharged on home medications and normal dialysis schedule. . #CHRONIC BACK/LEG PAIN: chronic back pain for years with multiple back surgeries. Pt's pain and use of pain medications likely is contributing to her AMS. At time of discharge she was continued on home gabapentin renally dosed. . Transitional: Pt will need to follow up with PCP and neurology within next several weeks. Will have VNA assist in removing non-active medications from home Medications on Admission: 1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). 5. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. levothyroxine 100 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. levothyroxine 88 mcg Capsule Sig: One (1) Capsule PO once a day. 8. methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO once a day. 9. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Medications: 1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. levothyroxine 100 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. levothyroxine 88 mcg Capsule Sig: One (1) Capsule PO once a day. 7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. methadone 10 mg/mL Concentrate Sig: Forty Six (46) mg PO DAILY (Daily): being tapered, managed at methadone clinic. [**Telephone/Fax (1) 10953**]. 9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO q48h. Discharge Disposition: Home With Service Facility: Care Group VNA Discharge Diagnosis: altered mental status polypharmacy ESRD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs [**First Name8 (NamePattern2) **] [**Known lastname 3671**], It was a pleasure taking care of you. You were admitted to the hospital because you were found by EMS and you were confused and difficult to arouse. We believe that this happened because you might not be taking your medications properly. We have reviewed your medication list and noticed that you have been prescibed some very sedating medications in the past. Given that you are on dialysis, many of these medications can build up in your blood and cause confusion or oversedation. . We have provided you with a list of medications below. DO NOT TAKE MEDICATIONS NOT ON THIS LIST. Don't take clonazepam, trazodone or hydromorphone. These medications have been discontinued because we are concerned that they are contributing to your altered mental status. . There is a possibility that you could have had a seizure as well. We have set you up with a neurology appointment so that your medications can be properly dosed. Please do not operate a car or heavy machinery for at least six months. . We will be giving you a letter to present to [**Location (un) 86**] Independent Care in efforts to speed up the process of attaining services from them. . Please bring all of this paperwork with you to the methadone clinic when you go there next. Followup Instructions: Department: [**Hospital3 249**] When: THURSDAY [**2129-9-8**] at 2:20 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: NEUROLOGY When: THURSDAY [**2129-9-15**] at 1 PM With: [**First Name11 (Name Pattern1) 4092**] [**Last Name (NamePattern1) 4093**], MD [**Telephone/Fax (1) 2574**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

7450, 7495

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325, 355

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264, 287

383, 1447

7594, 7706

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25,713

128,078

48253

Discharge summary

report

Admission Date: [**2175-9-13**] Discharge Date: [**2175-9-29**] Date of Birth: [**2099-12-4**] Sex: F Service: MED Allergies: Aspirin / Codeine / Ativan / Opioid Analgesics Attending:[**First Name3 (LF) 3513**] Chief Complaint: Confusion and Hypotension x1d. Major Surgical or Invasive Procedure: 1. Temporary Hickman Cath placement by IR. 2. Hemodialysis. History of Present Illness: 75 F with ESRD on HD and h/o multiple line infections and chronic L5 osteomyelitis on chronic vanco who was recently admitted in [**Month (only) **] for HD cath line sepsis (grew ESBL E.coli/Klebsiella). Tx with broad spectrum abx and HD cath resited. D/c to NH. Had recent change in lopressor dose on [**2175-9-8**]. Son noted change in MS on AM of admission and found to be hypotensive by nurses in NH -->SBP 70's. Admitted to ED --> afebrile but hypotensive. recieved 1 L NS with SBP to 90's. Also noted to have leukocytosis (15) and elevated INR (5.1). Past Medical History: 1. ESRD - HD m/w/f -h/o multple line infections - [**7-2**] e.coli/klebisella - [**6-2**] proteus/pseudomonas/enterococus - h/o MRSA and VRE 2. h/o L5 MRSA osteo --> on chronic vanco; not surgical candidate for debridement 3. dm II 4. h/o RIJ DVT [**6-2**] --> on coumadin 5. htn 6. h/o c.diff [**6-2**] 7. CHF -echo [**6-2**]: EF 35%, PASP 46, +2 MR, +2 TR 8. s/p laminectomy [**2170**] 9. h/o GI bleed on NSAIDs [**10-1**] 10. Hx of laminectomy [**2171**]. 11. Osteoarthritis with chronic hip pain Social History: Lives in [**Name (NI) **], [**First Name3 (LF) **] is proxy. [**Name (NI) **] was deemed incompetent on last hospital stay and all decisions are made by her son. [**Name (NI) **] son/gaurdian confirms her code status is DNI/DNR. Family History: Non contributory Physical Exam: VITALS: Temp97.2F HR 73 BP 110/55 RR 17 O2 99% GEN: Elderly AAF, intermittent moaning HEENT: PERRL, EOMI, sclera anicteric, Dry mucosal membranes CVS: RRR, no m/r/g PUL: CTA bl, no rales / no wheezing ABD: Soft, NT, ND, NABS. Rectal guaiac negative, stool soft/brown. SKIN: Cool, dry. EXT: No edema. LUE PICC NEURO: Alert, orientedx3 (not date), moves all extremities, sensation intact. CN 2-12 intact. Pertinent Labs and Studies: WBC = 15 w/neutrophils 82%, Hct = 40.6, Platelets = 409, Potassium = 4.2 with remaining electrolytes WNL EKG = Sinus @ 71, old TWI on I and AVL. CXR = No pneumonia. CTHead, Bilaterall hip xray, Lspine film = Pending. Pertinent Results: [**2175-9-13**] 11:45PM TYPE-ART PO2-82* PCO2-39 PH-7.40 TOTAL CO2-25 BASE XS-0 [**2175-9-13**] 11:45PM GLUCOSE-170* LACTATE-2.5* NA+-134* K+-3.3* CL--104 TCO2-25 [**2175-9-13**] 11:45PM freeCa-1.00* [**2175-9-13**] 07:19PM CK(CPK)-20* [**2175-9-13**] 07:19PM CK-MB-1 cTropnT-0.10* [**2175-9-13**] 11:05AM PT-23.3* PTT-50.4* INR(PT)-3.4 [**2175-9-13**] 06:20AM GLUCOSE-80 UREA N-32* CREAT-3.4* SODIUM-140 POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-27 ANION GAP-21 [**2175-9-13**] 06:20AM CK(CPK)-18* [**2175-9-13**] 06:20AM CK-MB-NotDone cTropnT-0.11* [**2175-9-13**] 06:20AM CALCIUM-8.6 PHOSPHATE-4.5 MAGNESIUM-1.7 [**2175-9-13**] 06:20AM VIT B12-1040* [**2175-9-13**] 06:20AM TSH-4.2 [**2175-9-13**] 06:20AM CORTISOL-30* [**2175-9-13**] 06:20AM CORTISOL-30* [**2175-9-13**] 06:20AM VANCO-<2.0* [**2175-9-13**] 06:20AM WBC-12.6* RBC-5.02 HGB-12.8 HCT-42.6 MCV-85 MCH-25.5* MCHC-30.1* RDW-16.8* Brief Hospital Course: Pt presented to ED on [**9-12**] with hypotension likely due to sepsis from L5 MRSA osteomyelitis. Pt was transferred to MICU for approx 12 hours and weaned from pressor support. Transferred to the floor on [**9-14**]. Initial blood cx were positive for MRSA- existing HD line was pulled and a fresh HD catheter was placed in the right groin. Initial plan was for IR to place a permanent tunnel catheter when bacteremia cleared. Pt remained stable on the floor revieving Vancomycin at here Tues/Thurs/Sat HD from [**Date range (1) 12349**]. When daily blood cultures remained bacteremic, gentamycin q-dialysis was added per ID recs on [**9-21**]. On [**9-26**], decision was made to switch pt over to peritoneal dialysis so that the femoral HD catheter, which is likely infected, can be pulled. PD catheter was placed without incident on [**9-27**]. Pt will continue to recieve HD for two weeks following PD placement. On day of dishcarge, [**9-29**], pts right femoral HD catheter was changed over a wire. Daily blood cultures have been negative for one week prior to discharge. Medications on Admission: Lipitor 10mg QD / Dulcolax 100mg [**Hospital1 **] / Seroquel 12.5 [**Hospital1 **] / Senna-Gen 1 tab QDprn / Genahist 25mg q6prn / Dulcolax 10mg PR Tues&Sat / Magnesium Oxide 800mg QD / Miacalcin 200units 1spray per nostril QD / Omeprazole 20mg QD / Synthroid 50mcg QD / Nephrocaps 1cap QD / Prochlorperazine 10mg q6h/prn / Acetaminophen 325mg / Trazadone 50mg QHS / Coumadin 3.5mg QPM / Captopril 12.5mg TID / Lopressor 50mg [**Hospital1 **] Allergies to Medications: Aspirin / Codeine / Ativan / Opioid Analgesics Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 3. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) spray in each nostril Nasal QD (once a day). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO QD (once a day). 7. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for agitation. 11. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed. 12. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed. 13. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 14. Gentamicin in Normal Saline 100 mg/50 mL Piggyback Sig: One Hundred (100) mg Intravenous AFTER EVERY DIALYSIS () as needed for bacteremia for 6 days. 15. Vancomycin HCl 500 mg Recon Soln Sig: Four (4) Recon Soln Intravenous AFTER EACH DIALYSIS (). 16. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal EVERY TUESDAY AND SATURDAY (). 17. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 18. Heparin Sodium (Porcine) 2,500 unit/mL Solution Sig: see sliding scale in chart Intravenous once a day: Please continue heparin sliding scale until INR>2 then d/c. 19. Insulin Lispro (Human) 100 unit/mL Solution Sig: please dose per sliding scale in chart units Subcutaneous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 38**] Discharge Diagnosis: End stage renal disease Diabetes mellitus Chronic L5 osteomyelitis Depression Discharge Condition: Good / Stable. Discharge Instructions: Pt to recieve hemodialysis tues, thurs, friday for two weeks from [**9-27**], then switch to peritoneal dialysis. Continue Gentamycin for 6 days after discharge. Please continue heparin sliding scale until INR >2, then discontinue. Followup Instructions: Follow up with Dr. [**First Name (STitle) 3510**] within one week. Follow up with Dr. [**First Name (STitle) 805**] from [**Hospital1 18**] nephrology prior to switch to PD.

[ "730.18", "250.40", "403.91", "996.62", "995.92", "V09.0", "038.11", "785.52", "311" ]

icd9cm

[ [ [] ] ]

[ "38.95", "54.93", "39.95" ]

icd9pcs

[ [ [] ] ]

7009, 7114

3433, 4525

334, 395

7236, 7252

2489, 3410

7533, 7711

1785, 1804

5092, 6986

7135, 7215

4551, 5069

7276, 7510

1819, 2470

263, 296

423, 989

1011, 1522

1538, 1769

7,292

128,200

29140

Discharge summary

report

Admission Date: [**2184-9-27**] Discharge Date: [**2184-10-20**] Date of Birth: [**2138-10-13**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: i have pain in my back and it goes to my neck Major Surgical or Invasive Procedure: drainage of epidural abcess in cervical spine x 2 Incision and drainage of abscess to left anterior chast wall upper endoscopy placement of [**Location (un) **] filter History of Present Illness: This 45 y/o white male presents to ER at [**Hospital1 22160**] transferred from [**Hospital1 487**] ER for MRI. Pt states he has LBP radiating to neck x 2-3 weeks with progressive weakness. He went to PCP about [**Name Initial (PRE) **] week ago for this pain/ although not as weak at that time/ and was given antibiotics for a soft tissue mass at left clavicular region. He is not sure what kind of abx. He states the last two days have been the worst with regards to pain and weakness. Presented to outside ER via ambulance. Pt states able to void and move bowels / difficulty ambulating and moving around his home. He admits to fever, IVDA of coccaine that started 6months ago and he stopped two weeks ago ("heavy use"). he admits to 6pack beer per day. Denies trauma, sob, chest pain, incontinence. Pt received antibiotics in ER Past Medical History: PMHx:denies Social History: Social Hx: IVDA, ETOH Family History: Family Hx:noncontrib Physical Exam: PHYSICAL EXAM: on arrival O: T: 101.3, 153/84, 84, 24 sat 99% O2Sat Gen: WD/WN, appears stressed and uncomfortable HEENT: Pupils: errl EOMs intact Neck: Supple. Lungs: scattered inspiratory wheeze and LLL decreased BS. Cardiac: RRR. S1/S2. Abd: Soft, + tender to RLQ - ? bladder distention BS+ Extrem: Warm and well-perfused. No C/C/E. + track marks noted to B/l UE Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: exam limited [**12-25**] pain. Best effort elicits full strength to LLE, RLE with 4+/5 throughout, RUE and LUE grip strength 3/5, Biceps [**12-28**] 9internally rotates upper extremeties during bicep testing), triceps [**2-25**], shoulder adduction [**2-25**], abduction 4-/5. Sensation: Intact to light touch throughout however there is a sensory level at the level of the umbilicus, distal to proximal he perceives decreased sensation to legs compared with upper torso. Reflexes: slightly hyper-reflexive throughout, with 2 beat clonus Toes upgoing bilaterally Rectal exam normal sphincter control for this examiner Pertinent Results: Date: [**2184-10-2**] Signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9479**], MD on [**2184-10-2**] Affiliation: [**Hospital1 18**] GI Staff EGD note Uregent EGD showed severe ulcerative esophagitis which was friable, but not actively bleeding. In the antrum there was a ~1 cm ulcer with stigmata of recent hemorrhage (black spots) and several tiny erosions (non bleeding). There were several small to 5 mm erosions in the fundus (non bleeding). Duodenum was normal. We applied cautery to the antral ulcer in an attempt to reduce his chances of rebleeding. Suggest: transufse to keep Hct above 30%. Continue with NG suction, IV PPI, SICU hospitalization. Call us for repeat EGD if he rebleeds or becomes hemodynamically unstable despite transfusion. MR L SPINE W/O CONTRAST [**2184-10-16**] 1:21 AM MR L SPINE W/O CONTRAST Reason: please check progression Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 46 year old man with L5S1 discitis/osteo REASON FOR THIS EXAMINATION: please check progression EXAM: MRI of the lumbar spine. CLINICAL INFORMATION: Patient with L5-S1 discitis and osteomyelitis, for further evaluation and followup. TECHNIQUE: T1, T2 and inversion recovery sagittal and T1 and T2 axial images were obtained before gadolinium. T1 sagittal and axial images were obtained following gadolinium. Comparison was made with the previous MRI of [**2184-10-7**]. FINDINGS: Again at L5-S1 level, abnormal signal is seen within the left side of the disc with mild paraspinal soft tissue changes. Soft tissue changes extend to the left neural foramen with indentation and deformity of the exiting left L5 nerve root. Since the previous study, the extent of T2 signal within the disc has slightly decreased. In addition, the paraspinal soft tissue changes also appear to be slightly less prominent. A small focus of low signal within the enhancing soft tissues indicates a tiny 5-mm paraspinal abscess which is also smaller than before. Again noted are small areas of T2 hyperintensities within the posterior soft tissues bilaterally adjacent to the L4-5 facet joints which are slightly decreased from previous MRI examination but are still identified. There is no evidence of significant epidural enhancement identified or evidence of epidural abscess seen. Mild multilevel degenerative changes are identified in the lumbar region with mild bulging of disc at L4-5 level. There is no evidence of high-grade spinal stenosis seen. Note is made of significantly distended urinary bladder which is a new finding since previous study. IMPRESSION: Since the previous MRI examination, slight decrease in degree of signal changes and enhancement is identified at L5-S1 level. In addition, small posterior soft tissue abscesses seen on the previous study have also slightly decreased in size. These findings indicate overall improvement. A distended urinary bladder is seen on the current study for which clinical correlation is recommended. No significant new findings are identified. DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] CHEST (PORTABLE AP) [**2184-10-11**] 7:38 AM CHEST (PORTABLE AP) Reason: R/O pneumonia [**Hospital 93**] MEDICAL CONDITION: 45 year old man with cervial epidural abscess, s/p hardware placement, now with fevers REASON FOR THIS EXAMINATION: R/O pneumonia REASON FOR EXAMINATION: Fever. Portable AP chest radiograph compared to [**2184-10-1**]. The patient is after cervical orthopedic surgery. The left PICC line catheter terminates at the cavoatrial junction. The heart size is normal. Mediastinum width, contour and position are unremarkable. The lungs are clear. The pleural surfaces are smooth with no pleural effusion. IMPRESSION: No evidence of cardiopulmonary process. CT CHEST W/CONTRAST [**2184-10-11**] 5:47 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: please evaluate infectious process Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 45 year old man with hx of IVDA, s/p epidural abscess drainange. Now with neck abscess. REASON FOR THIS EXAMINATION: please evaluate infectious process CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: History of IV drug abuse status post epidural abscess drainage. Now with neck abscess. COMPARISON: CT neck dated [**2184-10-10**] and CT abdomen and pelvis dated [**2184-10-3**], and CT chest dated [**2184-10-2**]. TECHNIQUE: MDCT acquired images of the chest, abdomen and pelvis were obtained after the administration of IV and oral contrast. CT OF THE CHEST WITH IV CONTRAST: There is interval improvement in the previously demonstrated left pleural/upper chest fluid collection. Stranding in the anterior neck soft tissues with multiple foci of air is demonstrated, consistent with the patient's neck infection, that was more fully imaged on the neck CT of one day prior. There is a PICC catheter that terminates in the SVC. There are coronary artery calcifications. There is a trace right-sided pleural effusion, new compared to the previous exam. The previously demonstrated left-sided effusion has resolved. There are small areas of atelectasis in both lower lobes. Note is made of a prominent left paratracheal node measuring 9 mm. There are multiple other small mediastinal nodes that do not meet CT criteria for pathologic enlargement. The airways appear patent to the level of segmental bronchi bilaterally. There is no pneumothorax. CT OF THE ABDOMEN WITH IV CONTRAST: The previously demonstrated region of hypoenhancement in the posterior portion of the spleen is now less prominent, with two small residual round hypodense foci. Splenomegaly is again noted. There are no focal liver lesions. Gallbladder is decompressed. The adrenal glands and kidneys are unremarkable. An infrarenal IVC filter is again seen. Loops of small and large bowel are unremarkable. Appendix is normal. There is trace ascites tracking along the right pericolic gutter into the pelvis. CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter within the bladder. Air within the bladder is presumably secondary to the Foley catheter placement. The rectum and sigmoid colon are unremarkable. There is small free fluid. Bone windows demonstrate degenerative endplate changes at multiple levels. IMPRESSION: 1. Interval decrease in size and extent of previously demonstrated left anterior chest wall fluid collection. 2. Soft tissue stranding and air in the anterior and right neck is consistent with infection, incompletely imaged. 3. Previously demonstrated hypoenhancing peripheral focus in the posterior spleen is now less prevalent compared to the previous exam. 4. Emphysema. 5. Small ascites, predominantly located within the pelvis. Reason: evaluate status of abscess Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 45 year old man with epidural abscess s/p ACD C4-C5 and evacuation of abscess. REASON FOR THIS EXAMINATION: evaluate status of abscess EXAM: MRI of the cervical spine. CLINICAL INFORMATION: Patient with cervical abscess, for further evaluation. TECHNIQUE: T1, T2 and inversion recovery sagittal and T1 and T2 axial images of the cervical spine were obtained before gadolinium. T1 sagittal and axial images were obtained following gadolinium. Comparison was made with the previous studies of [**2184-9-27**] and [**2184-9-28**]. FINDINGS: There is evidence of increased signal seen within the C4, C5, and C6 vertebral bodies. In addition, increased signal is seen on inversion recovery and T2 images within the C4-5 and C5-6 discs. Following gadolinium, enhancement is seen in the epidural soft tissues with an area of which does not enhance, extending on the posterior margin of C4 and C5 vertebral bodies indicative of an epidural abscess. In addition, there is also a fluid collection indicative of epidural abscess seen in the prevertebral region extending from C4 to C6. The prevertebral soft tissue thickness is also prominent indicating inflammatory changes extending from C3 to C7. These findings indicate reaccumulation of the epidural abscess with a new prevertebral abscess. In addition, compared to the prior study, the signal changes within the intervertebral disc and enhancement have also increased. In addition, there is moderate- to-severe compression of the spinal cord seen at C4 and C5 level with increased signal within the spinal cord. This finding is more prominent since the previous study of [**2184-9-28**]. A small fluid collection at the anterolateral right nect could be post-operative fluid collection. IMPRESSION: Since the previous MRI of [**2184-9-28**], there is now a new epidural abscess identified at C4-5 level and a prevertebral abscess seen from C4 to C6 with increased epidural and prevertebral enhancement. There is also slight increase in spinal cord compression and increased signal in the spinal cord identified. Findings were discussed with the physician taking care of the patient at the time of interpretation of the study on [**2184-10-9**]. PATIENT/TEST INFORMATION: Indication: Endocarditis. Height: (in) 68 Weight (lb): 180 BSA (m2): 1.96 m2 BP (mm Hg): 111/71 HR (bpm): 70 Status: Inpatient Date/Time: [**2184-10-5**] at 15:24 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W000-0:00 Test Location: West Cath/EP Lab Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. 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 AS. No AR. No masses or vegetations on aortic valve. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [**Name13 (STitle) **] mass or vegetation on mitral valve. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or vegetation on tricuspid valve. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. No vegetation/mass on pulmonic valve. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 69920**]e throughout the procedure. The posterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related complications. 0.2 mg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe insertion. Conclusions: The left atrium is normal in size. 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. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No valvular vegetation or intracardiac mass seen. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD on [**2184-10-5**] 16:27. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] BILAT LOWER EXT VEINS PORT [**2184-10-4**] 3:39 PM BILAT LOWER EXT VEINS PORT Reason: eval for IVC filter placement [**Hospital 93**] MEDICAL CONDITION: 45 year old man s/p anterior cervical discectomy for epidural abscess with GI bleed REASON FOR THIS EXAMINATION: eval for IVC filter placement LIMITED BILATERAL LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND. CLINICAL HISTORY: 45-year-old man status post anterior cervical discectomy for epidural abscess, with GI bleed. Evaluate for IVC filter placement. No prior studies available for comparison. FINDINGS: Limited Doppler ultrasound of the bilateral common femoral veins was performed, as requested by the ordering physician. [**Name10 (NameIs) **] bilateral common femoral veins are widely patent and demonstrate normal compressibility, augmentation and phasic flow. No evidence of intraluminal thrombus. IMPRESSION: No evidence of deep venous thrombosis of bilateral common femoral veins. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: TUE [**2184-10-5**] 9:33 AM Brief Hospital Course: Pt was admitted through the ED for c/o low back pain that radiates to neck. Pt taken to the OR emergently for drainage of cervical epidural abscess. Postopereatively the pts exam was worse with diffuse weakness. He remained intubated for 2 days post op. His cultures were positive for gram pos cocci in pairs and clusters. Antibiotics were started broad spectrum in OR. He was seen and evaluated by ID and placed on Nafcillin to reach a total course of 6weeks time. A PICC line was placed. [**10-2**] he had an episode of UGI bleeding and was scoped with cauterization of a gastric ulcer. He recieved 2 units of packed cells. He Had CT's of chest abd pelvis to eval for further abscess formation. There was note of ?splenic infarct vs. abscess. This was followed by repeat CT and will be followed as an outpt by ID> It is not thought at this time to be an abscess. He had a bedside I and D of the LEFT anterior chest wall abcess x 2 by the surgical team. [**10-6**] His Hct dropped again from 28 to 25. He has remained stable - currently at 27. He had LE dopplers on the 13th which were negative [**10-7**] MRI showed worsening discitis with increased fluid in epidural space at C45 and new pre-vertebral abscess at C4-6. He was transfused one unit pre-op and was taken back to the OR [**10-10**] for 2 level corpectomy and discectomy / fusion as well as evacutation of recurrent abscess. He also had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] filter placed that day. His Na level has been fluctuatin between 128 and 132 this hospitalization - he was on a fluid restriction of 2000ml / day for a few days. His Na is stable at 132 as of [**10-17**]. He maintains a regular diet. pneumovax was given . [**10-15**] lumbar MRI has decreased abscesses and CRP now2.2 and ESR 57. PPD negative this hospitalization and he did receive pneumococcal vaccine. cdiff from [**10-15**] is negative His foley was d/c'd and he is being straight cath'd q 6 hours. He was seen and evaluated by PT and OT. They are working with him daily as his motor strength improves daily (LE strength >UE strength). Medications on Admission: none Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-24**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 14. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 15. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. 16. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 17. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 18. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 19. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed for nausea. 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 21. Nafcillin 2 g Piggyback Sig: One (1) Intravenous every four (4) hours: FOR A TOTAL OF 8 WEEKS - AS OF [**10-20**] PT IS DAY #23 . Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: epidural abcess Discharge Condition: Stable/improved Discharge Instructions: Return to ED ASAP if any new weakness, numbness/ fever / wound drainage Please check blood test weekly for CBC,diff, BUN/Cr, LFT while on antibiotics. AND FAX TO [**Telephone/Fax (1) **] Followup Instructions: Dr [**Last Name (STitle) **] in 6 weeks at [**Telephone/Fax (1) **] with ap and lateral xrays of c-spine. You will need to follow up with the gastroenterology department in [**2-26**] weeks with Dr. [**Last Name (STitle) **] - please call [**Telephone/Fax (1) **] for an appointment Infectious disease clinic follow up 12/19 11AM: check weekly, CBC,diff, BUN/Cr, LFT. NO SPECIFIC FOLLOW UP WITH THORACIC SURGERY NECESSARY PER THORACIC TEAM, PLEASE OCNTINUE DRESSING CHANGES FOR LEFT ANTERIOR CHEST WALL INCISION SITE AND CALL [**Telephone/Fax (1) **] Completed by:[**2184-10-20**]

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icd9cm

[ [ [] ] ]

[ "81.02", "80.99", "38.93", "96.71", "77.77", "83.95", "88.72", "81.62", "96.34", "44.43", "38.7", "80.51", "99.04", "34.01" ]

icd9pcs

[ [ [] ] ]

19582, 19662

15495, 17616

367, 537

19722, 19740

2691, 3608

19975, 20558

1501, 1524

17671, 19559

14395, 14479

19683, 19701

17642, 17648

19764, 19952

11766, 14112

1554, 1921

282, 329

14508, 15472

565, 1409

14144, 14358

1936, 2672

1431, 1445

1461, 1485

1,003

139,183

12662+56388

Discharge summary

report+addendum

Admission Date: [**2127-1-8**] Discharge Date: [**2127-1-22**] Date of Birth: [**2106-3-24**] Sex: M Service: TRANSFERRED FROM MICU ON [**2127-1-22**]. ALLERGIES: CEFTRIONE ALLERGY, POSSIBLE ANAPHYLAXIS. CHIEF COMPLAINT: Respiratory distress and sepsis. HISTORY OF THE PRESENT ILLNESS: This is a 20-year-old Caucasian male with no past medical history, who was medflighted from [**Hospital3 26615**] Hospital after intubation for acute respiratory failure. The patient had been in his usual state of health until three to four days prior to admission, when he began to have flu-like symptoms, including myalgias, fatigue, nausea, vomiting, and watery diarrhea. He was seen by his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 39128**] one day prior to admission. At that time, assessment was possible GI viral illness and he was given two liters normal saline for hypotension. That night, he had a syncopal event while talking to his family on the phone. The following afternoon he presented to the emergency department at [**Hospital3 26615**] Hospital for sore throat, cough, and increasing shortness of breath. Chest x-ray at [**Hospital3 26616**] Hospital showed bilateral infiltrates and he was given one gram IV Ceftriaxone and 250 mg Azithromycin for presumed pneumonia. At that time, temperature was 97.0, blood pressure 95/65, heart rate 137, room air saturation was 89%. Mr. [**Known lastname 26442**] became increasingly dyspneic with increasing respiratory rate, decreasing oxygen saturation requiring 100% nonrebreather. He was intubated for acute respiratory failure. LABORATORY DATA: Significant labs from the outside hospital included a white count of 14.2, with 95% neutrophils, platelet count 75,000, INR 1.4, PT 13.4, creatinine 4.8, BUN 64, and CK 1175 with MB fraction of 8%. HOSPITAL COURSE: The patient was then transferred to [**Hospital1 1444**] for further management. In the emergency department, the patient was febrile with blood pressure 130/67, heart rate 150s. He was given 2 liters normal saline, one gram of Vancomycin and the femoral line was emergently placed into the right groin. At this time, he was transferred to the MICU. PHYSICAL EXAMINATION: Examination on administered revealed the following: The patient was comfortable, sedated, intubated, moving all extremities spontaneously. HEENT: pupils small, 2-mm, but reactive. Posterior oropharynx could not be assessed secondary to the tube. Neck was supple. No JVD. No lymphadenopathy. HEART: Tachycardic, regular rhythm, no rubs, murmurs, or gallops. LUNGS: Lungs were clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended, no hepatosplenomegaly. EXTREMITIES: Warm, clean, dry, and intact. They were stiff and difficult to move. There was 1+ radial and DP pulses. SKIN: Mildly erythematous, raised with blanching papillary rash over the extremities and trunk. There was no petechiae. He had a few purpuric lesions over his lower extremities. NEUROLOGICAL: The patient was moving all four extremities spontaneously with mild decerebrate posturing of the upper extremities. He had stiff rigid extremities, 3+ reflexes at the biceps and patella bilaterally. Toes were downgoing bilaterally. LABORATORY DATA: Labs on admission revealed the following: CBC showed a white count of 15.1, hematocrit 36.4, with platelet count of 47. Chem 7: Sodium 134, potassium 4.1, chloride 101, bicarbonate 19, BUN 63, creatinine 4.2, blood sugar 155, ALT 23, AST 32, alkaline phosphatase 36, total bilirubin 0.3, CK 1077, amylase 29, albumin 2.6, phosphatase 6.3, magnesium 1.4, calcium 5.2, PT 14.7, PTT 46.6, INR 1.5, differential on the white count was 77% neutrophils, 10% bands, 10% monos, 2% eosinophils. Urine was significant for 3 to 5 white blood cells, 0 to 2 granulated casts, 0 to 2 hyaline casts. Serum and urine toxic-metabolic panel was negative. Lactate was 4.1. The ABG in the emergency department revealed pH 7.18, pCO2 50, O2 200, ionized 0.84. Chest x-ray in the emergency department showed a right lower lobe consolidation. Head CT showed no acute bleed, no hydrocephalus, no significant opacifications of the left sphenoid or maxillary sinus. CT of the abdomen and chest showed patchy bilateral infiltrates, consolidation of the right lower lobe, but no hydronephrosis. HOSPITAL COURSE: Upon arrival to the MICU, Mr. [**Known lastname 26442**] [**Last Name (Titles) 1834**] lumbar puncture, which had 8 white blood cells, 77% lymphocytes, 2% neutrophils, 21% monocytes. A femoral arterial line was also placed. The MICU course is significant for the following: PULMONARY: Mr. [**Known lastname 26442**] was admitted in fulminant respiratory failure with severe hypoxemic respiratory failure and poor compliance. Extensive adjustment of the ventilator including multiple recruitment maneuvers, a PEEP of 20, paralytics and proning was required to achieve PaO2s in the 60s on FiO2 of 1.0. Pressure control ventilation was utilized with volumes of 6cc/kg per the ARDSnet trial. He was ventilated in the prone position from [**1-8**] to [**1-11**] at which time enough margin was present to place the patient back into the supine position. He continued to gradually improve and was finally extubated on [**2127-1-21**]. Mr. [**Known lastname 26442**] also [**Known lastname 1834**] two bronchoscopies during the MICU stay. The initial bronchoscopy was on [**2127-1-9**], which was unremarkable with no significant sputum or clots. This was repeated approximately 2 to 3 days later after a desaturation which revealed thick brown clots, which were suctioned out successfully and sent for culture. Sputum cultures eventually grew out Staphylococcus aureus, which was pansensitive. He was treated since admission with Vancomycin, as well as other antibiotics, which will be detailed later for Staphylococcus aureus pneumonia. CARDIOVASCULAR: Mr. [**Known lastname 26442**] maintained his blood pressure until the morning of [**2127-1-8**]. At that time, blood pressure began to decrease and he was placed on Levophed and Vasopressin for blood pressure maintenance. He was gradually weaned off these pressors. Mr. [**Known lastname 26442**] was also tachycardiac throughout his stay, secondary to fever, septic cardiomyopathy. Echocardiogram was done on [**2127-1-19**], which showed EF of 15% with bilateral ventricular dysfunction. There were no focal-wall abnormalities - therefore this was reflective of sepsis related myocardial suppression. The echocardiogram was repeated on [**2127-1-21**], which showed mild right ventricular depression and dilatation, but left ventricular function was within normal limits. Mr. [**Known lastname 26442**] [**Last Name (Titles) 1834**] right heart catheterization on [**2127-1-8**]. Initial pulmonary artery pressure was 34/25 with the mean of 29, wedge of 22, CVP of 20, heart output of 4.69, cardiac index of 2.88, SVR of 921, PVR of 119. Over the next few days the SVR decreased to 600 with increasing cardiac output likely secondary to sepsis. He was placed on Dobutamine to increase cardiac output with success. The Dobutamine was finally discontinued approximately two days after initiation. FLUIDS, ELECTROLYTES, AND NUTRITION: Mr. [**Known lastname 26442**] was NPO for several days. He placed for about five days on TPN and then switched to tube feeds on [**2127-1-17**]. Tube feeds had been tried before unsuccessfully secondary to poor gastric motility. High residuals were noted. INFECTIOUS DISEASE: Mr. [**Known lastname 26442**] was initially suspected to have meningococcemia secondary to diffuse skin lesions and fulminant presentation. However, LP showed no organisms and only eight WBCs. Similarly, his blood cultures were negative. He received one dose of Ceftriaxone at the outside hospital. He was noted to have new maculopapular rash over his upper extremities and torso. Ceftriaxone was discontinued on admission to [**Hospital1 346**] secondary to possible allergy. However, this was restarted one day later per Infectious Disease recommendation and continued for two days. Mr. [**Known lastname 26442**] showed increasing angioedema over the face with CT of the neck showing significant laryngeal edema as well. There was eosinophilia within the blood and Ceftriaxone was discontinued at this time. It should be noted that Mr. [**Known lastname 26442**] has a CEFTRIONE ALLERGY, POSSIBLE ANAPHYLAXIS. He was also started on Clindamycin, Levaquin, Doxycycline, and Vancomycin for unknown infectious etiology. The Vancomycin and Clindamycin were for gram positive and Doxycycline for possibility Rickettsial disease even though it was not the usual season. Mr. [**Known lastname 26442**] also received IgG times two for possible toxic-shock syndrome. ASO was positive and all viral cultures, including influenza, RSV, parainfluenza were negative. All cultures returned negative, including urine, blood, stool, CSFs. The only positive cultures were Staphylococcus aureus and minimal yeast in the sputum. With the advent of the pansensitive Staphylococcus aureus Clindamycin and Doxycycline were discontinued six to seven days after starting. Levaquin was discontinued on [**2127-1-19**]. Vancomycin will be likely continued for ten days past the [**1-15**] positive culture for Staphylococcus aureus. It is currently dosed for hemodialysis. It should also be noted that Mr. [**Known lastname 26442**] received Xigris or APC activated protein C for approximately 30 hours. This was discontinued initially secondary to low platelets and high PTC and then again secondary to new anisocoria. Head CT was repeated on [**2127-1-11**], which showed no bleeding. RENAL: Mr. [**Known lastname 26442**] was admitted with high BUN, high creatinine of unknown etiology. At the outside hospital sediment was noted to have red blood cell casts and hyaline casts. This was repeated on admission to [**Hospital1 346**] and only hyaline casts were noted, signifying possible ATN. His renal function initially improved significantly with hydration and support. However, his CK which was mildly elevated on admission progressed to florid rhabdomyolysis with CKs peaking at over 250,000. This was felt secondary to massive sepsis response but perhaps related to paralytics. The Surgery team was consulted to rule out compartment syndrome which was determined not to be present. This unfortunately, caused a secondary significant renal insult. Despite alkalinizing the urine Mr. [**Known lastname 39129**] renal function again delined prior to ultimately recovering again. Within the first 24hours, he became increasingly acidotic with pH of 7.06 and decreasing urine output. The Renal Service was consulted and recommended and started CVVH via a left femoral catheter. About ten days later, a right sided CVH catheter was introduced but unfortunately clotted off approximately 24 to 48 hours later. The CVH was finally discontinued on [**2127-1-17**]. On [**2127-1-18**], Mr. [**Known lastname 26442**] [**Last Name (Titles) 1834**] hemodialysis and this will be continued on a three-times-weekly basis. Acidosis has completely resolved. SKIN: Mr. [**Known lastname 26442**] was noted to have ecchymotic regions over the anterior thighs, feet and ankles bilaterally shortly after admission. These lesions appeared to be an extension of the initial maculopapular rash noted on admission. In the intervening days, they were noted to become increasingly necrotic in appearance. Dermatology and Plastic Surgery services were consulted for guidance of management. Eventually, some of the skin sloughed off. Plastic Surgery continued to follow -- Mr. [**Known lastname 26442**] may require skin grafting at a later time. The fifth digit on both feet were affected. The Plastic Surgery team felt they may require amputation eventually. In the meantime, he has been treated with Silvadene, Xeroform, and Kerlix per Plastic Surgery recommendations with daily improvement. HEMATOLOGY: Mr. [**Known lastname 26442**] was noted to have low platelets and elevated creatinine suggesting possible HUS versus TTP. The Department of Hematology was following the patient and noted that the smear had only a few schistocytes, but no obvious signs for TTP or HUS. Instead, the remainder of the diagnosis was DIC and the coagulations were carefully monitored over the next few days. He received several platelet transfusions in the interim to keep his platelets above 30, especially while the patient was on APC. The thrombocytopenia eventually resolved and his platelets have returned to 369,000. Mr. [**Known lastname 39129**] hematocrit had been intermittently down to 21.5 from the upper limits of 34 to 40. He was given two units of packed red blood cells. Since then, Mr. [**Known lastname 26442**] has maintained his hematocrit successfully. He was on Epogen for three days for indication of decreased need for transfusions during his critical illness. ENDOCRINE: Mr. [**Known lastname 39129**] blood sugars were noted to be excessively high secondary to sepsis and he was started on insulin drip for three days. PROPHYLAXIS: Mr. [**Known lastname 26442**] was initially on IV Protonix and heparin via the CVVH. Pneumoboots were not used secondary to the skin lesions on his legs. Subcutaneous heparin was utilized once his coagulation issues were resolved. LINES: Mr. [**Known lastname 26442**] had right IJ placed, which was changed over a wire. He currently has right IJ in place, day #8. Right femoral hemodialysis on day #4. He recently had left radial line, which has been discontinued. DISPOSITION: Mr. [**Known lastname 39129**] family is very supportive and has been in contact daily. [**Name2 (NI) **] is full code. He was being transferred at this time from the MICU to the floor for further management. [**Last Name (LF) **],[**First Name3 (LF) **] P. M.D. [**MD Number(1) 10038**] Dictated By:[**Name8 (MD) 8073**] MEDQUIST36 D: [**2127-1-22**] 11:46 T: [**2127-1-22**] 12:05 JOB#: [**Job Number **] Name: [**Known lastname 7081**], [**Known firstname **] Unit No: [**Numeric Identifier 7082**] Admission Date: [**2127-1-8**] Discharge Date: [**2127-1-28**] Date of Birth: [**2106-3-24**] Sex: M Service: MEDICAL [**Hospital **] Medical ICU with transfer to [**Location (un) 6572**] Internal Medicine Firm. ADDENDUM: The following is a summary of the [**Hospital 1325**] hospital course from [**2127-1-23**] to [**2127-1-27**]. improve from an Infectious Disease and Pulmonary perspective with a diminishing white blood cell and good oxygenation on room air. He was to continue to receive Vancomycin 1 gram IV based on Vancomycin levels. The patient was dosed for Vancomycin level of less than or equal to 15. He was to continue his course of Vancomycin through [**2127-1-31**], which is 14 days after his bronchoscopy and last negative culture. #2. RENAL: The patient demonstrated improving urine output and diminishing creatinine. On the day prior to discharge, the creatinine had fallen to 4.0. Hemodialysis was discontinued on Friday, [**1-24**], and the dialysis catheter was removed secondary to some bleeding around the catheter site. It was anticipated by the renal team that the patient would have recovery of his baseline renal function within in approximately 40 days of discharge. He was continued on Amphojel until phosphorus level was less than 5, as well as Tums. #3. HEMATOLOGY: The patient's hematocrit remained stable during this portion of his hospital stay. He was started on Niferex 150 mg p.o. b.i.d. per renal recommendations. #4. DERMATOLOGY: The patient continued dressing changes as per the last part of the discharge summary. He was to be seen by the Plastic Service on the day of discharge and followup was to be arranged. #5. VASCULAR SURGERY: The patient was to be followed up by Dr. [**Last Name (STitle) 142**], Department of Vascular Surgery within two weeks following his discharge. It would be determined as an outpatient whether the patient would need amputation of his necrotic toes. #6. DISPOSITION: At the time of this discharge dictation, the patient was being screened for placement in an acute rehabilitation setting. DISCHARGE DIAGNOSES: 1. Staphylococcus aureus pneumonia with sepsis. 2. Toxic shock syndrome. 3. Rhabdomyolysis. 4. Acute renal failure, resolving. 5. Necrotic toe secondary to septic emboli. 6. Anemia. MEDICATIONS ON DISCHARGE: 1. Vancomycin 1 gram IV with dosing dependent on Vancomycin levels to be checked q.d. The patient was to be redosed for a level of less than or equal to 15 through [**2127-1-31**] and then the Vancomycin was to be discontinued. 2. Multivitamin one tablet p.o.q.d. 3. Niferex 150 mg p.o.b.i.d. 4. Ambien 5 to 10 mg p.o.q.h.s.p.r.n. insomnia. 5. Amphojel 30 cc p.o.t.i.d. with meals until phosphorus level is less than 5.0. 6. Morphine sulfate 1 mg subcutaneously b.i.d. before dressing changes. 7. Tums 500 mg p.o.t.i.d. 8. Sarna lotion to affected areas p.r.n. 9. Tylenol 650 mg p.o.q.4 to 6h.p.r.n. 10. Heparin 5000 units subcutaneously b.i.d. 11. Xeroform dressing to affected areas. 12. Silvadene ointment b.i.d. to necrotic areas. DISPOSITION: On discharge, it was anticipated that the patient would be discharged to an acute rehabilitation facility with followup as described above. The patient is to also followup with his primary care provider. CONDITION ON DISCHARGE: Much improved. [**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**] Dictated By:[**Last Name (NamePattern1) 5798**] MEDQUIST36 D: [**2127-1-27**] 16:35 T: [**2127-1-27**] 16:40 JOB#: [**Job Number 7083**]

[ "040.89", "038.11", "518.81", "785.59", "728.89", "287.5", "482.41", "276.2", "584.5" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "03.31", "99.15", "33.23" ]

icd9pcs

[ [ [] ] ]

16433, 16622

16648, 17614

4408, 16412

2259, 4390

244, 1864

17639, 17904

31,029

113,891

52703

Discharge summary

report

Admission Date: [**2106-9-28**] Discharge Date: [**2106-10-7**] Date of Birth: [**2039-2-13**] Sex: F Service: MEDICINE Allergies: Morphine / Dilaudid (PF) Attending:[**First Name3 (LF) 1253**] Chief Complaint: hypotension, confusion Major Surgical or Invasive Procedure: right internal jugular central venous catheter placement History of Present Illness: 67F with hx of CRI (bl cr 1.4), Crohn's, pancreatic insufficiency and multiple UTIs presents from rehab with complaints of fever and hypotension. Per the pt, she has been in rehabs since her discharge on [**2106-9-8**]. She was in her USOH until two days ago when she developed increased frequency of bowel movements, up to 6x/day from a baseline of 2x/day. She noted that the bowel movements were "liquidy" unlike her usual formed stools and denied abdominal pain, hematochezia or melena. She also noted chills but denied subjective fever. She stated she had not had cough, sob, cp, or dysuria. However she did note that during previous episodes of UTI she had always been without symptoms. She also noted that she uses pampers diapers because she sometimes has difficulty making it to the toilet, this has especially been the case in the last couple of days when she has been having bowel frequency. . Per the Rehab facility, two days ago the pt was confused and so she was sent for stat labs. Today the pt was complaining of weakness, and found to have T 100.4, pulse 107 bp 98/58 rr 18 92%RA, fsg 132. The labs returned showing WBC 14.3, Cr 2.5, and a u/a that was cloudy, 1+ LE, 6 wbc. UCx showed 10k-30k Gram Positive species. Given this picture, the decision was made to send the pt to the ED. . In the ED the pt was found to be 99.5 82 73/45 24 100% Non-Rebreather. She had a CBC showing WBC 14.8, Cr 2.6 from baseline 1.2, u/a with trace leuks and few bacteria, CXR without acute process. Trop 0.07. CT abd without evidence of colitis. A RIJ was placed, the pt was given 3L NS with improvement in BP to 100s/70s, and vanc, zosyn and flagyl. Systolics returned to the 80s so the pt was started on levophed 0.03 and transferred to the ICU. . On the floor, the pt was 96 108/54 (on levo) 75 100%2Lnc. She denied any pain but did endorse some confusion. She states that she had some diarrhea for the preceding few days and chills. The pt had a bm which was very loose and had 4 red capsules were found in it. She had repeat labs which showed wbc 12.9, hct 25.9, cr 2.0. . Review of systems: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Coronary artery disease s/p RCA w/ bare metal stent on [**2102-2-2**](single vessel disease) 2. Diastolic CHF (Recent ECHO [**2105-10-15**], EF~55%) 3. Crohn's Disease: h/o pancolitis w/o small bowel involvement; colonoscopy [**10-14**] showed no active disease, was on 5-[**Month/Year (2) **] 4. Chronic Renal Failure (Cr~1.4 at baseline) 5. DM Type II on insulin 6. Hypertension 7. h/o idiopathic dilated CMP, now resolved 8. Peptic ulcer disease 9. Alcoholic cirrhosis 10. GERD 11. Rheumatoid arthritis 12. Pulmonary embolus in [**2098**] 13. Total right knee replacement with subsequent chronic pain 14. [**Doctor Last Name **] mal seizure in childhood 15. Cervical disc disease 16. L5/S1 radiculopathy with anterolisthesis of L4 on L5 on X-Ray with EMG consistent with mild radiculopathy 17. History of GI bleed of unclear etiology ([**2-/2103**]), questionable hemorrhoids 18. h/o MRSA right knee wound infection s/p knee replacement 19. Anemia 20. H/o CDiff colitis ([**5-/2102**]) 21. Osteopenia 22. Chronic pancreatitis 23. Cervical spndylysis 24. h/o Candidal esophagitis Social History: Patient lives with a disabled son in [**Name (NI) 669**]. Recently discharged to rehab. She was married but divorced a long time ago. 4 pack year smoking history, quit 15 years ago. Drank ~1 pint alcohol/day x 10 years, quit 15 years ago. Denies illicit drug use. Ambulates with a walker at baseline. Family History: M: [**Name (NI) **] Ca F: DM with Bilateral [**Name (NI) 6024**] Sister: Cervical cancer & RA Son: Stroke Physical Exam: Vitals: 96 108/54 (on levo) 75 100%2Lnc General: obese female in nad, oriented x3 but somewhat confused, decreased alertness HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender to deep palpation in the RLQ, LLQ, and suprapubic regions, mild discomfort on palpation of the upper abdomen. neg [**Doctor Last Name **] sign. no rebound/guarding. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+pedal edema. Neuro: A&Ox3. 5/5 strength. CN intact. Neuro exam non-focal. Pertinent Results: Admission Labs: [**2106-9-28**] 10:35AM [**Month/Day/Year 3143**] WBC-14.8*# RBC-3.29* Hgb-9.9* Hct-29.1* MCV-88 MCH-30.1 MCHC-34.1 RDW-15.9* Plt Ct-274 [**2106-9-28**] 10:35AM [**Month/Day/Year 3143**] Neuts-77.6* Lymphs-16.0* Monos-5.6 Eos-0.6 Baso-0.1 [**2106-9-28**] 10:35AM [**Month/Day/Year 3143**] PT-14.1* PTT-27.1 INR(PT)-1.2* [**2106-9-28**] 10:35AM [**Month/Day/Year 3143**] Glucose-177* UreaN-41* Creat-2.6*# Na-133 K-4.2 Cl-98 HCO3-20* AnGap-19 [**2106-9-28**] 10:35AM [**Month/Day/Year 3143**] ALT-13 AST-20 AlkPhos-150* TotBili-0.5 [**2106-9-28**] 09:32PM [**Month/Day/Year 3143**] Calcium-8.0* Phos-4.0 Mg-1.3* . Discharge labs: [**2106-10-7**] 05:11AM [**Month/Day/Year 3143**] WBC-8.4 RBC-3.29* Hgb-9.9* Hct-31.4* MCV-95 MCH-30.0 MCHC-31.5 RDW-16.8* Plt Ct-379 [**2106-10-7**] 05:11AM [**Month/Day/Year 3143**] Glucose-82 UreaN-19 Creat-1.2* Na-140 K-4.8 Cl-108 HCO3-21* AnGap-16 [**2106-10-7**] 05:11AM [**Month/Day/Year 3143**] Calcium-9.4 Phos-4.9* Mg-2.4 . Microbiology: [**Month/Day/Year **] cultures [**2106-9-28**] (x2), [**2106-9-29**] (x1), and [**2106-10-1**]: No growth Urine culture [**2106-9-28**]: <10,000 organisms/ml Urine culture [**2106-9-29**]: No growth C. diff toxin [**2106-9-28**] and [**2106-10-6**]: Negative Stool cultures [**2106-10-6**]: pending C. diff PCR [**2106-10-2**]: negative . Imaging: . EKG [**2106-9-28**]: Sinus rhythm with a ventricular premature beat. Possible inferior myocardial infarction of indeterminate age. Poor R wave progression. Non-specific ST-T wave changes. Compared to the previous tracing of [**2106-9-4**] ventricular premature beat is new. . CXR [**2106-9-28**]: Appropriately positioned right IJ central venous catheter. No evidence of complication. . CT abdomen/pelvis (non-contrast) [**2106-9-28**]: 1. Findings consistent with acute epiploic appendagitis along the mid descending [**Month/Day/Year 499**]. Within the limitations of a non-contrast study, no evidence of colitis. 2. Multiple healed rib fractures of the visualized right lower ribs which are new since the since the [**2105-8-18**] study. However, no acute fractures identified. . Left foot (3 views) [**2106-10-5**]: No fracture or dislocation detected. Brief Hospital Course: 67F with CAD, DM2, CKD, Crohn's, pancreatic insufficiency, and muliple urinary tract infections presents from rehab with complaints of fever and hypotension. . # Septic shock: The patient presented from rehab with fever, altered mental status and hypotension. She was found to have SBPs in the 70s refractory to 3L IVF boluses and requiring levophed gtt to maintain MAPs >60. Fever was documented at up to 103. Wbc was 14 on presentation, with creatinine 2.6 (up from baseline 1.4). . The source of infection was unclear. [**Name2 (NI) **] cultures were negative. Urine culture from rehab grew 10-30K GPCs (never speciated). CXR was unremarkable. CT abdomen/pelvis showed only epiploic appendigitis. C. diff toxin and PCR were negative. Nonetheless, the patient was presumed to have a GI or GU source of infection, and was treated with broad spectrum antibiotics (vancomycin, meropenem, and metronidazole). Antibiotics were subsequently narrowed to ceftriaxone and metronidazole. The patient was discharged on cefpodoxime and metronidazole, with a plan to complete a 14-day course of antibiotics on [**2106-10-11**]. The patient was instructed to resume taking her prophylactic dose of cipro (which she takes twice daily for Crohn's) when her course of cefpodoxime and metronidazole is complete. . For the patient's hypotension, diuretics were held, and the patient was treated with IV fluids and norepinephrine. As her condition improved, she was weaned off of pressors, and called out of the ICU. On the medical floor, her [**Date Range **] pressure remained stable, and torsemide was restarted but then stopped in the setting of ongoing diarrhea. The patient was discharged off of torsemide. She was instructed to monitor her weight and discuss the medication change with her PCP. . # Acute on chronic kidney injury: The pt presented with Cr 2.6 up from 1.4. Her increased Cr likely represented a prerenal state in the setting of diarrhea, diuresis, and septic shock. The patient's creatinine improved with fluid resuscitation and treatment of her sepsis, and was 1.2 at the time of discharge. . # Altered mental status: The patient was confused on admission due to hypotension and infection. Her mental status returned to [**Location 213**] with normalization of her hemodynamics and treatment of her sepsis. . # Diarrhea: The patient had persistent watery, guaiac-negative diarrhea. The differential diagnosis included antibiotic induced diarrhea, infectious diarrhea, C. diff, Crohn's, and pancreatic insuffiency. CT abdomen pelvis showed only epiploic appendigitis. The patient received pancreatic enzyme supplementation without any effect on her diarrhea. C. diff toxin was repeatly negative, as was C. diff PCR. Once the C. diff PCR came back negative, the patient was started on loperamide, with marked improvement in her diarrhea. . # Chronic Anemia: The patient presented with hematocrit 29.1. Her hematocrit remained stable throughout her admission. Her diarrhea was guaiac-negative. . # Coronary artery disease: The patient has known single-vessel disease and is s/p RCA w/ bare metal stent on [**2102-2-2**]. [**Date Range **] 325mg daily was continued. The patient had a single episode of atypical chest pain on the evening of [**2106-10-5**], without any EKG changes or enzyme elevations. This episode was thought to be gastrointestinal rather than cardiac in etiology. . # Chronic systolic and diastolic heart failure (Recent ECHO [**8-19**], EF 45-50%): The patient was felt to be hypovolemic on admission, so diuretics and carvedilol were initially held. Carvedilol and torsemide were restarted, but then torsemide was stopped in the setting of persistent diarrhea. The patient was discharged off of torsemide, with the instruction to follow up with her PCP [**Last Name (NamePattern4) **] [**2106-10-11**], at which time restarting torsemide should be considered. . # Crohn's Disease: The patient has a history of pancolitis w/o small bowel involvement. CT of the abdomen and pelvis were notable only for epiploic appendigitis. The patient's diarrhea was thought to be unrelated to Crohn's. Mesalamine was continued. . # Diabetes mellitus, type II, on insulin: The patient was treated with Lantus and a Humalog insulin sliding scale, with good glycemic control. She was discharged on her pre-admission regimen of Lantus 40 units at bedtime. . # GERD: Continued [**Hospital1 **] omeprazole. The patient had a single episode of chest discomfort on the evening of [**10-5**] which was likely related to GERD. . # Chronic pain: The patient was discharged on oxycontin 20mg [**Hospital1 **], gabapentin 600 mg [**Hospital1 **], and lidoderm patch. She requested a prescription for oxycontin at the time of discharge. The inpatient team spoke with the patient's PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **], who confirmed it was okay to give the patient enough oxycontin to last until her follow-up appointment. The patient was warned not to drive or participate in other hazardous activities while on oxycontin. . # Chronic pancreatitis: The patient continued pancreatic enzyme supplementation. . # Toe pain: The patient stubbed her left toe. This was evaluated with x-rays which were negative for fracture. . # Code status: Full code . # Transitional issues: 1. A stool culture was pending at the time of discharge. 2. The patient was discharged off of torsemide. Consideration should be given to restarting this. 3. The patient will complete her course of cefpodoxime and metronidazole on [**2106-10-11**], at which time she should resume cipro, which she takes for Crohn's disease. Medications on Admission: oxycontin 20mg PO BID Lantus 40u qhs torsemide 30mg daily cipro 250mg PO BID Carvedilol 12.5mg [**Hospital1 **] MVI wtih mineral Neurontin 200mg PO q2pm Neurontin 300mg qam and qpm Lidocaine patch daily to L knee acetaminophen 325mg 2tabs q4h prn pain Aspirin 325mg daily Vit D 2tabs daily Mesalamine 1600mg TID Omega 2 fatty acids daily omeprazole 20mg [**Hospital1 **] Zocor 20mg daily Heparin sc Ferrous sulfate 325mg daily Ipratroprium bromide 17mcg aerosol inhaler 2puffs q6h prn Albuterol sulface mdi 1-2puffs q6h prn neurontin 300mg [**Hospital1 **] zenpep 20k-68k-9k 4 caps before meals zenpep 2 caps before shakes Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours): Do not drive or participate in hazardous activities while on oxycontin. Disp:*10 Tablet Extended Release 12 hr(s)* Refills:*0* 3. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Forty (40) units Subcutaneous at bedtime. 4. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a day. 5. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 6. multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for left knee pain: 12 hours on, 12 hours off. 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 10. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 11. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 13. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 16. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for sob/wheezing. 17. Zenpep 20,000-68,000 -109,000 unit Capsule, Delayed Release(E.C.) Sig: as directed Capsule, Delayed Release(E.C.) PO as directed: Take 4 tablets before each meal and 2 tablets before each snack. 18. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Disp:*30 Capsule(s)* Refills:*0* 19. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:*8 Tablet(s)* Refills:*0* 20. metronidazole 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 4 days. Disp:*12 Tablet(s)* Refills:*0* 21. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a day: Resume ciprofloxacin on [**2106-10-12**]. 22. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: 1. septic shock, source unclear 2. hypotension 3. diarrhea 4. acute on chronic kidney injury . Secondary: 1. Crohn's disease 2. Chronic pancreatitis 3. Coronary artery disease 4. Chronic systolic and diastolic congestive heart failure 5. Diabetes melllitus 6. GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital with fever and low [**Location (un) **] pressure. You were admitted to the intensive care unit, where you briefly required a pressor medication for [**Location (un) **] pressure support. You were treated with antibiotics. As you condition improved, you [**Location (un) **] pressure stabilized, and you were able to leave the intensive care unit. . You had persistent diarrhea. Multiple tests for a bowel infection called C. difficile were negative. A CT of your abdomen showed epiploic appendigitis, which is a benign, self-limited condition that is likely unrelated to your diarrhea. You were given loperamide (Immodium), with improvement in your diarrhea. Some stool studies were pending at the time of discharge and will need to be followed by your primary care doctor. . At the time of discharge, you had 4 days of antibiotics left. Your antibiotics are called cefpodoxime and metronidazole. When you have completed your 4 days of cefpodoxime and metronidazole, you should restart the ciprofloxacin that you take for Crohn's disease. . There are some changes to your medications: STOP torsemide for now and discuss with your primary care doctor whether you should restart this medication at the time of follow-up. START loperamide (Immodium) as needed for diarrhea START metronidazole and cefpodoxime (antibiotics) for another 4 days. Restart ciprofloxacin 250 mg twice daily when you have finished metronidazole and cefpodoxime. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. . Follow up as indicated below. Followup Instructions: Department: DIV. OF GASTROENTEROLOGY With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2163**], MD [**Telephone/Fax (1) 463**] Building: [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage ***The office is working on a follow up appt for you in the next few weeks and will call you at home with an appt. IF you dont hear from the office by [**Location (un) 2974**], please call them directly to book. Department: [**Hospital **] HEALTH CENTER When: MONDAY [**2106-10-11**] at 1:40 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 5808**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: WEST [**Hospital 2002**] CLINIC When: THURSDAY [**2107-1-20**] at 2:30 PM With: DR. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: DIV. OF GASTROENTEROLOGY When: MONDAY [**2107-3-21**] at 11:30 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2163**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

16308, 16365

7425, 9534

308, 367

16673, 16673

5201, 5201

18432, 19967

4373, 4480

13764, 16285

16386, 16652

13117, 13741

16824, 17906

5846, 7402

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17935, 18409

2491, 2930

246, 270

395, 2472

5217, 5830

16688, 16800

12765, 13091

2952, 4039

4055, 4357

74,860

187,966

46033

Discharge summary

report

Admission Date: [**2103-5-25**] Discharge Date: [**2103-6-7**] Date of Birth: [**2032-1-20**] Sex: F Service: CARDIOTHORACIC Allergies: mold / dust mites Attending:[**First Name3 (LF) 4679**] Chief Complaint: Esophageal Cancer Major Surgical or Invasive Procedure: 1. [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy with intrathoracic esophagogastric anastomosis. 2. Laparoscopic jejunostomy feeding tube. 3. Wrapping of intrathoracic anastomosis with pericardial fat. 4. Esophagogastroduodenoscopy . 5. Laparoscopic reduction of hiatal hernia. History of Present Illness: Mrs. [**Known lastname 97982**] is a 71 year-old woman who has a T2N1 esophageal cancer (Stage IIb) who is s/p chemo/radiation treatment. She recently underwent PET scan which shows no evidence of distant uptake, but does show two distinct areas of the esophagus with FDG avidity. She presented for surgical resection of her esophageal cancer. Throughout she denies denies fevers, chills, nightsweats, heartburn, nausea, vomiting, abdominal pain, odynophagia or dysphagia. Denies changes in weight. She has a concurrent hiatial hernia Past Medical History: Diabetes mellitus type II hypertension hyperlipidemia anemia large hiatel hernia asthma chronic sinus infections Social History: Widowed with three supportive sons. [**Name (NI) 1403**] part time as a social worker with her own company. Never smoker. ETOH: red wine 3-4x per week, [**11-19**] glasses each time. Denies illicit drug use. No known exposures. Family History: Mother died of liver and colon cancer at age 83, father- died of liver, colon and prostate cancer at age 89, son with atrial fibrillation. Physical Exam: VS: T: 97.2 HR: 80's SR BP: 120-140/70-90 Sats: 96% 4L Wt: 77 kg General: 71 year-old female sitting up in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR Resp: decreased breath sounds no crackles or wheezes GI: abdomen soft non-tender Incision: R chest incision clean dry intact Neuro: awake, alert oriented Pertinent Results: [**2103-6-7**] 06:45AM BLOOD WBC-10.8 RBC-3.22* Hgb-9.1* Hct-27.7* MCV-86 MCH-28.4 MCHC-33.1 RDW-18.1* Plt Ct-723* [**2103-6-6**] 04:19AM BLOOD WBC-12.8* RBC-3.26* Hgb-9.2* Hct-28.2* MCV-86 MCH-28.3 MCHC-32.7 RDW-18.2* Plt Ct-698* [**2103-6-2**] 03:21AM BLOOD WBC-11.2*# RBC-2.87* Hgb-8.3* Hct-24.9* MCV-87 MCH-28.8 MCHC-33.3 RDW-17.8* Plt Ct-300 [**2103-5-25**] 04:05PM BLOOD WBC-11.3*# RBC-3.79* Hgb-10.8* Hct-32.1* MCV-85 MCH-28.3 MCHC-33.5 RDW-19.6* Plt Ct-223 [**2103-6-7**] 06:45AM BLOOD Glucose-238* UreaN-18 Creat-0.6 Na-137 K-4.7 Cl-99 HCO3-27 AnGap-16 [**2103-5-30**] BRONCHIAL WASHINGS FINAL REPORT [**2103-6-3**]** GRAM STAIN (Final [**2103-5-31**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2103-6-3**]): ~1000/ML Commensal Respiratory Flora. STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. YEAST. >100,000 ORGANISMS/ML.. STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S CXR: [**2103-6-6**]: Pulmonary edema has markedly improved. Left lower lobe opacity is unchanged, likely atelectasis. Cardiomediastinal contours are unchanged. Right subclavian catheter remains in place with tip in the standard position. Multifocal right lung opacities are unchanged. Bilateral pleural effusions are small, associated with adjacent atelectasis. Patient is status post esophagectomy. Esophagus: [**2103-6-4**] Single-contrast upper GI series was performed. Barium passes freely into the esophagus and at the site of anastomosis. There is no evidence of a leak at this site. Barium is pooled within the stomach. After 30 minutes, a followup scout film and followup fluoroscopy image was taken, which continued to show barium retained within the stomach with little passing to the small intenstine. IMPRESSION: 1. No evidence of anastomotic leak. 2. Delayed gastric emptying MRI spine: [**2103-6-1**] IMPRESSION: No evidence of epidural abscess. Mild disc protrusion at T10-T11 level with anterior thecal sac indentation but no significant spinal canal narrowing or neural foraminal compromise seen. Chest/Pelvic CT [**2103-6-1**]: IMPRESSION: 1. Improving pleural effusion, pneumomediastinum and pneumothorax as compared to previous study. 2. No evidence of pneumonic process/evidence of pneumonia. 3. No evidence of lymphadenopathy in the visualized areas. 4. All tubes and lines appear well placed 5. No obvious foci of infection. 6. Area of reduced perfusion in left lobe of liver may reflect sequelae from retraction. Brief Hospital Course: Mrs. [**Known lastname 97982**] was admitted [**2103-5-25**] following [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy with intrathoracic esophagogastric anastomosis. Laparoscopic jejunostomy feeding tube.Wrapping of intrathoracic anastomosis with pericardial fat. Esophagogastroduodenoscopy. Laparoscopic reduction of hiatal hernia. She was transfer to the ICU extubated with an NGT, Foley and Epidural managed by the acute pain service. While in the SICU she required multiple fluid challenges for hypotension. Once hemodynamically stable she transfer to the Floor on [**2103-5-29**]. Events: [**2103-5-30**] developed respiratory distress (hypoxic) requiring intubation and transfer to the ICU. Bedside bronchoscopy was done [**2103-5-31**] with aspiration of sections and bile. An NGT was placed. Temp 102 Vancomycin and Zosyn started. Over the next few days here respiratory status improved. She was successfully extubated [**2103-6-1**]. Her oxygen requirements improved with nebs, incentive spirometer. Oxygen saturations of 93-97% on 4L NC. CT was done showed no anastomic leak. ID: she was seen by infectious disease. Cultures grew MSSA continue coverage for GNR/anaerobes, can switch vancomycin to Ampicillin/Sulbactam 3gm IV q6h x 14 days starting from [**2103-5-31**]. Of note an MRI of the spine was negative of epidural abscess following Epidural removal [**2103-5-30**]. Cardiovascular: Immediately postop was sinus tachycardia. IV Lopressor was started. She was hypotensive which responded to fluid bolus. Once taking PO's her home dose diltiazem was restarted. Sinus rhythm 80-100's and blood pressure improved to 130's. Lisinopril was titrated as an outpatient. GI: NGT was removed POD 4 requring placment on [**2103-6-1**] following aspiration event and removed [**2103-6-2**]. PPI and bowel regime continued Nutrition: Tube feeds Replete Full strength started POD increase to Goal of 75 mL/18hrs. Following esophagus study [**2103-6-4**] full liquid diet and will continue until seen by Dr. [**First Name (STitle) **]. Aspiration precautions at all times. Renal: Volume overload. She was gently diuresed with IV lasix converted to PO lasix until at preop weight of 72 kg. Her renal function remain normal with good urine output. Her electrolytes were replete as needed. Endocrine: maintained on insulin sliding scale to keep blood sugars < 150. She will restart her PO diabetic medications upon discharge. Heme: Chronic anemia HCT stable 25-19 Dispo: Followed by physical therapy. She was discharged to [**Hospital1 15454**] in [**Location (un) 701**] [**Telephone/Fax (1) 40835**]. She will follow-up with Dr. [**First Name (STitle) **] as an outpatient. Medications on Admission: citalopram 20 mg daily, diltiazem 240 mg daily, flovent [**Hospital1 **], glipizide 10 mg daily, lisinopril 30 mg daily, ativan 0.5 as needed, magic mouthwash, metformin 1000 mg daily, omeprazole 20 mg daily, zofran 8 mg as needed for nausea, roxicet [**3-27**] mL every 8 hours as needed for pain, compazine 5 mg every 8 hours as needed for nausea, simvastatin 20 mg daily, B vitamins, Vitamin D, Iron, MVI, fish oil Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) Injection TID (3 times a day). 2. ipratropium bromide 0.02 % Solution [**Month/Year (2) **]: Three (3) mL Inhalation Q6H (every 6 hours) as needed for wheezing. 3. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Month/Year (2) **]: Three (3) ML Inhalation Q6H (every 6 hours). 4. sodium chloride 0.9 % 0.9 % Syringe [**Month/Year (2) **]: Three (3) ML Injection Q8H (every 8 hours) as needed for line flush. 5. ampicillin-sulbactam 3 gram Recon Soln [**Month/Year (2) **]: Three (3) Recon Soln Injection Q6H (every 6 hours) for 8 days. 6. oxycodone-acetaminophen 5-325 mg/5 mL Solution [**Month/Year (2) **]: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 7. simvastatin 10 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily). 8. citalopram 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 9. fluticasone 110 mcg/Actuation Aerosol [**Month/Year (2) **]: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a day). 12. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]: Two (2) Puff Inhalation Q6H (every 6 hours). 13. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: Twenty (20) mL PO Q6H (every 6 hours) as needed for fevers/HA. 14. ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: Four (4) mg Injection Q6H (every 6 hours) as needed for nausea. 15. lisinopril 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: home dose 30 mg daily please increase as SBP tolerates. 16. metformin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day: home dose 1000 mg [**Hospital1 **] increase as blood sugars tolerate. 17. lorazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO every twelve (12) hours as needed for anxiety. 18. Humalog insulin sliding scale 71-100 mg/dL 0 Units 101-150 mg/dL 2 Units 151-200 mg/dL 4 Units 201-250 mg/dL 6 Units 251-300 mg/dL 8 Units 301-350 mg/dL 10 Units 19. furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day: Monitor daily weights and adjust as needed. 20. potassium chloride 10 mEq Tablet, ER Particles/Crystals [**Hospital1 **]: One (1) Tablet, ER Particles/Crystals PO once a day: give with lasix. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Esophageal Cancer s/p esophagectomy T2 diabetes mellitus Hypertension Hyperlipidemia Large hiatal hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or chest pain -Your incisions develop drainage -Difficult or painful swallowing -Nausea (take anti-nausea medication) or vomiting -Increased abdominal pain Pain -Acetaminophen 650 mg every 6-8 hours as needed for pain -Roxicet [**11-19**] teaspoon every 4-6 hours as needed for pain Acitivity -Shower daily. Wash incision with mild soap & water, rinse pat dry -No tub bathing, swimming or hot tubs until incision healed -Do Not apply lotions to incision sites -No driving while taking narcotics -Take stool softner with narcotics Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] [**2103-6-21**] 4:00 on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**] Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your appointment Completed by:[**2103-6-7**]

[ "V87.41", "276.69", "250.00", "196.1", "427.89", "507.0", "458.29", "401.9", "553.3", "272.4", "285.9", "150.8", "482.41", "493.90" ]

icd9cm

[ [ [] ] ]

[ "96.6", "42.52", "96.71", "38.93", "44.13", "96.04", "33.24", "53.71", "40.3", "38.91", "42.41", "46.39" ]

icd9pcs

[ [ [] ] ]

10822, 10894

5043, 7775

301, 620

11043, 11043

2134, 5020

11898, 12191

1586, 1727

8243, 10799

10915, 11022

7801, 8220

11194, 11875

1742, 2115

244, 263

648, 1187

11058, 11170

1209, 1324

1340, 1570

16,622

178,635

11804

Discharge summary

report

Admission Date: [**2136-11-29**] Discharge Date: [**2136-12-9**] Date of Birth: [**2063-5-3**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 73 year old woman, with a remote history of tuberculosis, status post wedge resection in [**2087**], and history of bronchoalveolar lung cancer, status post right upper lobe lung lobectomy and XRT in [**Month (only) 958**] of this year. She presented to an internist in [**State 108**] three to four weeks prior to admission, with a complaint of non productive cough. No fevers or shortness of breath above baseline. Cough was also associated with chest pain on the right side that was sharp and pleuritic, occurring with coughing. No sick contacts. [**Name (NI) **] international travel. The patient was started on a five day course of Azithromycin for treatment of bronchitis versus viral pneumonia. The patient reports that she has had viral pneumonia six times in the past 40 years. She received Pneumo-Vax immunization two years ago. The patient flew from [**State 108**] to [**Location (un) 86**] about five days prior to admission and worsening non productive cough on antibiotics. She developed low grade fevers to 100 to 100.5 and worsening dyspnea on exertion. Chest pain was unchanged. She saw her local physician. [**Name10 (NameIs) **] x-ray done per husband reports a right lower lobe pneumonia and pleural effusion. White count of 14.8. The patient was then started on Moxifloxicin. One day prior to admission, the patient's symptoms worsened and she spiked a temperature to 102 and had shaking chills. She presented to [**Hospital3 3834**] [**Hospital3 **]. Outside hospital temperature was 98.4. Pulse was 104. Respiratory rate of 20. Oxygen saturation 94%. Blood pressure 120/54. Chest x-ray showing worsening pneumonia in right middle lobe and right lower lobe. White blood cell count of 25. The patient was started on Vancomycin and Ceftazidime. The patient underwent ultrasound guided thoracentesis for small pleural effusion, with only 3 cc of fluid aspirated, which was hazy, yellow pleural fluid; however, pH was 6.89; glucose of 46; total protein of 4.5; LDH of 388. White count to 600; red count of 20,000 with 92 neutrophils, 4 lymphs, 4 monos. Pleural fluid culture was sent and did not grow any organisms. Infectious disease was consulted and the patient's antibiotics were changed to Vancomycin and Ciprofloxacin. Given low pH of pleural fluid and concerns for empyema, patient was transferred to [**Hospital1 188**] for thoracic surgery evaluation. On admission, CT scan of chest obtained showed one moderate sized, multi-loculated right pleural effusion with slight thickening of pleural rind, concerning for empyema. Patchy, peripheral consolidation of right lower lobe, as well as more diffuse ground glass opacity, consistent with pneumonia. Right hilar lymphadenopathy as well as slightly enlarged nodes in the zygoesophageal recess, may be reactive peripheral ground glass opacities in left upper lobe. Two small left lower lobe lung nodules. One contains component of calcification and an empyema. Of note, the patient reports a CT of chest was obtained [**11-10**], prior to head surgery, and was normal. The patient underwent pig tail catheter into right thoracic space with 100 cc of straw-colored fluid removed. Catheter was maneuvered in an attempt to direct as many loculations as possible. Gram stain showing 3+ PNM's, no micro-organisms. Fluid was sent for culture. ALLERGIES: No known drug allergies. MEDICATIONS: Hydrochlorothiazide 12 mg p.o. q. day. Zestril 10 mg p.o. q. day. Multi-vitamins. Calcium 150 mg p.o. q. day. [**Last Name (un) **]-Pro times 20 years for osteoporosis prevention. PAST MEDICAL HISTORY: Hypertension. History of tuberculosis in [**2087**], treated for two years with Streptomycin and PF. Status post wedge resection with phrenic nerve injury in [**2087**]. History of spondylosis, status post spinal fusion in [**2109**]. Hospital course complicated by meningitis and spinal leak. Bronchoalveolar lung cancer, status post right upper lobe lobectomy, [**2-9**], followed by XRT for three months, finished in [**5-11**], with reported negative chest CT on [**9-10**]. Bilateral hip replacements for osteoarthritis in [**12-12**] and [**9-10**]. Cutaneous porfira tarda, diagnosed in [**2129**], treated with phlebotomy. Status post appendectomy. SOCIAL HISTORY: Lived in [**Location **], [**State 350**]. Moved to [**State 108**] about five years ago. Patient lives with husband who is a retired family physician. [**Name10 (NameIs) 20282**] have four children. 30 year tobacco history, quit in [**2118**]. Ethanol, 14 glasses of wine a week. Had walked two miles a day prior to hip surgery. The patient reports six episodes of pneumonia over the last 30 years, although one was viral. PHYSICAL EXAMINATION: On admission, the patient was afebrile, temperature 99.1; heart rate 89 to 102; blood pressure 120 to 160 over 63 to 90; respiratory rate 20 to 22; oxygen saturation 97% on two liters. Weight is 43 kilograms. General: Awake, alert, breathing comfortably, in no apparent distress. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Oropharynx moist. No buccal lesions. Neck supple. Heart regular rate, tachycardia at 100, no murmurs, rubs or gallops. Lungs: Positive bronchial breath sounds and egophony at right breast. Pigtail catheter in place on the right side. Left diffuse sub crackles. Abdomen: Soft, nontender, non distended, positive bowel sounds. Extremities: no edema or clubbing. Neurologic: Cranial nerves 2 through 12 intact. Strength 5/5 proximally and distally. Sensation grossly normal to light touch. LABORATORY DATA: White count of 20. Hematocrit of 29. Platelets of 637. 92 neutrophils, 3 lymphs, 3 monos, 3 eosinophils. Sodium of 134; potassium of 4.4 and chloride of 103. Bicarbonate of 22. BUN of 9. Creatinine of 0.7. HOSPITAL COURSE: The patient was initially admitted to the medical service, with the history as described above. However, she was then transferred to the Medical Intensive Care Unit on [**2136-12-1**] because of an episode of tachypnea and respiratory distress, in the context of an examination showing diffuse wheezing and prolonged inspiratory to expiratory ratio. INITIAL IMPRESSION: The initial impression was that the patient was having some component of reactive airway disease, which responded to a combined treatment. Low on the differential was a possible congestive heart failure. The patient was treated for both. She received Lasix and nitrates and had some relief of symptoms. She also was treated with nebulizers. The patient ultimately stabilized of the Neonatal Intensive Care Unit day one on [**12-1**]. Later in the day, the patient had worsening respiratory distress, requiring intubation. Her arterial blood gases at the time was 6.95, 76 and 102. The patient then received a bronchoscopy. It was felt that the patient had significant secretions and may have had an episode of mucus plugging and causing her desaturations and hypocarbic arrest. The patient was noted to have a very small airway and a #6 endotracheal tube was placed. Results of bronchoscopy on [**2136-12-3**] revealed patent trachea, main right stem and right upper lobe bronchus are patent; right bronchus intermedius was patent and there were no masses visible. Right middle lobe was patent. Minimal to moderate amounts of white secretion. Right upper lobe bronchus was patent and visualized with anterior apical and post bronchial right lower lobe was also patent. The patient was transiently on Dopamine for an episode of hypotension, though she had a brief episode of atrial fibrillation on transfer to the Intensive Care Unit. She remained hemodynamically stable and out of atrial fibrillation. The patient was weaned to pressure support ventilation by [**2136-12-4**] but had increased tachypnea with decreased pressor support. Chest x-rays showed persistent middle and right lower lobe infiltrates; no significant effusion and also left upper lobe infiltrate. Culture data revealed positive Strep Milleri from her pleural fluid. Antibiotics were changed to Ceftriaxone for coverage of Strep Milleri. By [**2136-12-6**], however, the patient had increased respiratory distress, after being extubated on [**2136-12-5**]. The thought was that she likely had another episode of mucus plugging. Examination was consistent with reactive airways. She was intubated again on [**2136-12-6**], after discussing with the patient and her husband, who is her health care proxy. From a cardiac standpoint, the patient remained hemodynamically stable, slightly hypotensive, but ruled out for a myocardial infarction, with only some "T" wave inversions on electrocardiogram. Overall picture and impression of team at this time was that the patient had underlying poor pulmonary reserve, in the context of remote tuberculosis history and wedge resection on the left; recent bronchoalveolar carcinoma on the right, status post resection, with a concurrent empyema and probably some component of restrictive disease with fibrosis, as well as an active pneumonia, requiring repeat intubation. Over the next two days, the patient remained stable but then requiring continued treatment for Strep Milleri with continuous Ceftriaxone. Vancomycin was added for Mersa which grew from a bronchoalveolar lavage done on [**2136-12-7**]. After extensive discussion with family and the patient's husband, who is her health care proxy, consent was achieved between the patient's family and the team regarding the fact that the patient's overall prognosis for recovery was limited and moreover, the patient and her husband had strong feelings against undergoing a tracheostomy and a prolonged wean. Given this wish not to have a tracheostomy, it was felt that the patient would be unlikely to have any significant improvement over the next several days and would ultimately require a tracheostomy and require very prolonged Intensive Care Unit and then rehabilitation course, should she recover at all. At this point, the patient's husband and family reached consensus on [**2136-12-9**] that the patient's care should focus on comfort care. The patient was extubated on [**2136-12-9**] with her family present. She remained comfortable. The patient had respiratory failure and died at 4:07 p.m. on [**2136-12-9**]. The patient's husband requested a post mortem examination. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 37297**] Dictated By:[**Name8 (MD) 37298**] MEDQUIST36 D: [**2136-12-9**] 16:39 T: [**2136-12-17**] 08:28 JOB#: [**Job Number 37299**]

[ "510.9", "427.31", "515", "492.8", "493.90", "482.39", "518.81", "V10.11", "511.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "96.72", "33.24", "34.91", "38.91", "96.04" ]

icd9pcs

[ [ [] ] ]

6032, 10872

4903, 6015

156, 3747

3770, 4433

4450, 4880

58,108

123,615

12607

Discharge summary

report

Admission Date: [**2138-4-23**] Discharge Date: [**2138-4-29**] Date of Birth: [**2070-8-31**] Sex: M Service: MEDICINE Allergies: Ambien Attending:[**First Name3 (LF) 3043**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: [**Known firstname **] [**Known lastname 38975**] is a 67 yo male with severe COPD, s/p recent hospitalization for COPD exacerbation [**Date range (1) 38976**], cancer of the layrnx and prostate status post xrt who is admitted with hypercarbic respiratory failure [**12-24**] COPD exacerbation. . He was in his usual state of health since his last admission and had been weaning his prednisone over 4 weeks. He was down from 40 mg daily to 30 with a plan to decrease to 20 mg tomorrow. However, over the last week, he became more dyspneic with exertion with increased sputum production. He is normally sedentary but is able to bath himself without help (though has dyspnea when this is completed) and walk from his chair across the room. Over the last few days, he was unable to talk in complete sentences and was more dyspneic with any movement. He had an appointment with his outpatient pulmonologist today who sent him to the ED for evaluation. . He additionally reports several loose bowel movements a day for the last 3 days associated wtih mild abdominal cramping. This is not particularly bothersome and he does not have any abdominal cramping at [**Last Name (un) **] time. . In the ED, initial vs were: T 96.8 HR 75 BP 100/73 RR 16 O2SAT: 93% 4L. He was noted to be tachypneic and unable to speak in full sentences. No ABG was done. He was placed on BiPAP and was noted to have improved symptoms. CXR without new infiltrate. Given the chronicity ofhis symptoms over several days, he was sent over to the ICU on 4L NC. He was given Vancomycin, Zosyn, Solumedrol 80 mg IV and combivent nebs x3 prior to transfer. . On the floor, the patient is able to answer questions but begins to purse his lips and use accessory muscles to recover after speaking. He denies any other symptoms on review of systems including chest pain, headaches, weakness, abdominal pain, diarrhea, constipation, dysuria. He does endorse urinary hesitancy and frequency but this has been ongoing since his prostate cancer xrt. . Past Medical History: - COPD, on 4L home O2, followed by Dr. [**Last Name (STitle) **]. Pt uses CPAP at night and has done so for a long time possibly for OSA vs night time ventilatory support for COPD; planning for BiPAP at night but has not yet arranged this - T1 larynx cancer [**1-28**] - [**Doctor Last Name **] 8 prostate adenocarcinoma - Depression - h/o pyloric stenosis - Memory loss: no formal diagnosis of dementia Social History: Patient lives with his wife. [**Name (NI) **] 2 grown children. Reports 4 pack per day times 35 years. Quit in [**2112**]. Served in [**Country 3992**]; history of [**Doctor Last Name 360**] [**Location (un) 2452**] exposure. No current alcohol consumption. Denies any other illicit drug use. . Family History: Brother died of emphysema, also was a smoker Physical Exam: General: Alert, pursed-lip breathing, but not tachypneic. HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP 5cm, no LAD Lungs: Poor airflow, no wheezes, rales, rhonchi CV: Distant heart sounds, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: + epigastric scar,soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ radial, DP & PT pulses, no clubbing, cyanosis or edema Neuro: A&Ox2 (person & place only), strength 5/5 in UE & LE bilat, sensation grossly intact. Pertinent Results: ADMISSION LABS: pH 7.30 PO2 282 PCO2 101 [**2138-4-23**] 05:40PM BLOOD WBC-7.5 RBC-4.34* Hgb-11.9* Hct-39.9* MCV-92 MCH-27.5 MCHC-29.9* RDW-15.0 Plt Ct-169 [**2138-4-23**] 05:40PM BLOOD Neuts-93.2* Lymphs-3.7* Monos-2.4 Eos-0.6 Baso-0.2 [**2138-4-23**] 11:39PM BLOOD PT-11.8 PTT-28.7 INR(PT)-1.0 [**2138-4-23**] 05:40PM BLOOD Glucose-107* UreaN-15 Creat-0.6 Na-145 K-4.7 Cl-92* HCO3-46* AnGap-12 [**2138-4-24**] 03:44AM BLOOD CK(CPK)-29* [**2138-4-24**] 03:44AM BLOOD CK-MB-4 cTropnT-0.01 [**2138-4-24**] 03:44AM BLOOD Calcium-9.1 Phos-4.2 Mg-1.9 [**2138-4-23**] 09:42PM BLOOD Type-ART pO2-282* pCO2-101* pH-7.30* calTCO2-52* Base XS-18 [**2138-4-24**] 01:32AM BLOOD Type-ART pO2-60* pCO2-77* pH-7.41 calTCO2-51* Base XS-18 [**2138-4-24**] 04:07PM BLOOD Type-ART pO2-66* pCO2-65* pH-7.42 calTCO2-44* Base XS-13 [**2138-4-23**] 05:43PM BLOOD Lactate-1.1 [**2138-4-23**] 09:42PM BLOOD Lactate-0.6 DISCHARGE LABS: IMAGING/STUDIES: Actual Pred %Pred Actual %Pred %chg FVC 1.32 4.12 32 FEV1 0.27 2.83 10 MMF 0.12 2.68 5 FEV1/FVC 21 69 30 CXRAY ON [**2138-4-23**]: PA and lateral views of the chest were obtained. There is marked hyperexpansion of the lungs with upper lobe lucency and splaying of bronchovasculature, which is compatible with known severe emphysema. There is vague opacity in the left lower lung between the left eighth and ninth ribs posteriorly as well as at the left lung base, which could represent small foci of scarring or residual of infection in this patient with recent pneumonia. No pleural effusion or pneumothorax is seen. Cardiomediastinal silhouette is stable. Bony structures are intact. IMPRESSION: Severe emphysema. Residual infection versus scarring in the leftlower lung. . CXRAY PORTABLE ON [**2138-4-24**]: Comparison is made with prior study performed a day earlier. This examination is technically very limited. Only the upper portion of the thorax was included. Visualized portions of the lungs are clear. The upper mediastinum is unchanged. . EKG ON [**2138-4-23**]: Sinus rhythm with atrial premature beat. Consider left atrial abnormality although is non-diagnostic. Otherwise, tracing is within normal limits. Intervals Axes Rate PR QRS QT/QTc P QRS T 75 146 80 [**Telephone/Fax (2) 38977**] 57 . Abdominal X-ray [**2138-4-26**]: Single AP supine portable radiograph was submitted. There is stool throughout the colon. There is no evidence of bowel obstruction or pathologic calcifications in the abdomen. Degenerative changes are in the lumbar spine. Brief Hospital Course: 67 year old M with a PMH significant for severe COPD on 4L home oxygen, who presents with worsening shortness of breath and productive cough as well as diarrhea. . # Hypercarbic respiratory failure: Worsening of chronic CO2 retention and respiratory acidosis in the setting of COPD exacerbation requiring BiPAP. There was no clear clear infiltrate on plain film. The etiology was unclear though may have been in the setting of prednisone taper over the last week. He was continued on BiPap at night, which he found helpful. . # COPD exacerbation: Patient's dyspnea is most likely related to COPD exacerbation and possibly exacerbated by prednisone taper and changes in acid base status with diarrhea. Gold stage IV COPD. He was treated with standing nebs and a slow prednisone taper. He will continue his nebs at home. He was started on steroids and was discharged on 60mg prednisone; he has pulmonary follow up on the day after admission and will taper the steroids according to his pulmonologists' instructions. He completed a 5 day course of azithromycin. Advair was continued. . # Diarrhea: C. diff negative x 2. Resolved with conservative management. Unclear etiology. . # Anemia: Hct down from admission (39-36.8) though now closer to baseline. Normocytic in nature. Iron studies, B12 and folate wnl earlier this month. He is having guaiac positive stools. Hct remained stable throughout admission. - Will likely need inpatient or outpatient GI consultation. . # Memory difficulties: continued donazepil. . # T1 Larynx Cancer: Patient is status post radiation therapy. No current treatment. . # [**Doctor Last Name **] 8 Prostate Adenocarcinoma: Patient reports worsening urinary symptoms, increased avodart as outpatient. . # Depression: continued prozac. Medications on Admission: Fluticasone-Salmeterol 500-50 mcg/Dose Disk 1 Inhalation [**Hospital1 **] Donepezil 10mg PO AM Avodart 1 mg PO once a day. Fluoxetine 20 mg Capsule PO DAILY Ipratropium Bromide Q6H Albuterol Sulfate Q6H prn Omeprazole 20 mg Capsule, 2 tabs PO daily Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) unit dose Inhalation Q6H (every 6 hours). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) unit dose Inhalation Q2H (every 2 hours) as needed for SOB. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) unit dose Inhalation Q6H (every 6 hours). 4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Avodart 0.5 mg Capsule Sig: Two (2) Capsule PO daily (). Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: PRIMARY DIAGNOSES: - Hypercarbic respiratory failure - Acute exacerbation of chronic obstructive pulmonary disease SECONDARY DIAGNOSES: - Larynx cancer - Prostate adenocarcinoma - Depression - Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the [**Hospital1 69**] for evaluation and management of worsening of your respiratory condition. You were to have severe symptoms requiring initial management in the ICU. You improved significantly with treatment with BiPAP, IV steroids, antibiotics, nebulizers, and inhalers. You were transferred to the floor in stable condition. The pulmonary department arranged for you to have a BiPAP machine to use at home. You will be going home on a slow steroid (Prednisone) taper as well. You should call the Pulmonary Clinic for follow up within the next 2 weeks. MEDICATION CHANGES: 1. Prednisone XXmg to decrease by 5mg each week until you are seen in Pulmonary Clinic. Followup Instructions: Please make an appointment to be seen in Pulmonary Clinic within the next 1-2 weeks. Department: NEUROLOGY (SLEEP CLINIC) When: THURSDAY [**2138-5-22**] at 11:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2165-6-1**] Discharge Date: [**2165-6-5**] Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 613**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Abdominal angiography, superior mesenteric artery coiling History of Present Illness: [**Age over 90 **]F history of hypertension, diabetes, osteoarthritis, falls, history of diverticulosis who presented to the ED today with bright red blood per rectum. Pt states that she had large episode of rectal bleeding over night and felt lightheaded and dizzy. She also had one bloody bowel movement this morning before coming to the ER. She denied any episodes of CP or SOB at the time of the bleeding. She does not think she has had any episodes of bleeding that were this severe in the past. In the ED, initial VS were 97.6 76 138/63 20 100% 15L. She was noted to be diaphoretic at triage and reported dizziness. She experienced an additional large bowel movement with BRBPR. She was given 2 L NS in preparation for CTA, which showed extravasation from the transverse colon distal to the hepatic flexure, intra- and extra-hepatic and pancreatitis ductal dilation, mass vs. pancreatic ductal stenosis, highly stenotic celiac artery. She was also given fentanyl, ondansetron and 1U PRBCs and crossmatched for 6 units. A 16 and 18G IV were placed. Labs were notable for a crit of 33.3 (near baseline), creatinine of 1.7 (baseline 1.45). Vital signs on transfer were 97.4 ??????F (36.3 ??????C), Pulse: 63, RR: 15, BP: 135/65, O2Sat: 100, O2Flow: 3 L NC. She remained hemodynamically stable in the ED. On arrival to the MICU, vitals were stable. The patient was comfortable without complaints, however concerned about her active bleeding. She denied any CP/SOB/abd pain. She had another large bloody BM on arrival to the MICU. Past Medical History: # Diabetes Mellitus type II: last HgbA1C 6.2% ([**2164-12-17**]), diet-controlled # Hypertension # Hearing loss # Obstructive Sleep Apnea, on CPAP # Obesity # Colonic adenoma history # hx hemicolectomy [**2161**] # Urge incontinence # Osteoarthritis # Lower back pain # impingement and calcific tendinosis to both Shoulders # left rotator cuff tear # mild dementia Social History: Patient is widowed (husband was a physician). Three adult children - daughter lives in same apartment building, one son is a physician, [**Name10 (NameIs) **] son lives in [**Location 1514**]. Denies Etoh/tobacco/illicits. Family History: no heart or lung disease Physical Exam: ADMISSION EXAM Vitals: 98.2 118/49 67 21 100% RA General: Appears younger than stated age, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not visualized CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, diffusely mildly ttp, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE EXAM O: T 98.0 BP:130/54 HR:63 RR 18 O2sat 100% CPAP. GENERAL - NAD, comfortable appearing HEENT - anicteric, oropharynx clear NECK - no JVD HEART - RRR, nl S1-S2, no MRG LUNGS - CTAB, no crackles, no wheezing, good air movement BACK - no CVA tenderness ABDOMEN - soft, NDNT, no rebound/guarding EXTREMITIES - mild swelling in hands. No erythema or tenderness. 1+ LE edema b/l. WWP, distal pulses intact NEURO - Moving all extremities. No focal finding. Pertinent Results: ADMISSION LABS [**2165-6-1**] 05:25AM BLOOD WBC-8.1 RBC-3.49* Hgb-10.5* Hct-33.3* MCV-95 MCH-29.9 MCHC-31.4 RDW-14.1 Plt Ct-265 [**2165-6-1**] 05:25AM BLOOD Neuts-67.9 Lymphs-27.7 Monos-3.2 Eos-0.9 Baso-0.2 [**2165-6-1**] 05:25AM BLOOD PT-10.5 PTT-25.9 INR(PT)-1.0 [**2165-6-1**] 05:25AM BLOOD Glucose-196* UreaN-31* Creat-1.7* Na-136 K-4.2 Cl-99 HCO3-22 AnGap-19 . URINALYSIS [**2165-6-1**] 05:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2165-6-1**] 05:50AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM [**2165-6-1**] 05:50AM URINE RBC-<1 WBC-5 Bacteri-MANY Yeast-NONE Epi-2 TransE-<1 [**2165-6-1**] 05:50AM URINE CastHy-37* . HCT TREND [**2165-6-1**] 05:25AM BLOOD Hgb-10.5* Hct-33.3* [**2165-6-1**] 02:00PM BLOOD Hct-28.8* [**2165-6-1**] 05:46PM BLOOD Hct-28.0* [**2165-6-1**] 09:52PM BLOOD Hct-27.8* [**2165-6-2**] 03:36AM BLOOD Hgb-8.0* Hct-24.0* [**2165-6-2**] 04:19AM BLOOD Hgb-7.6* Hct-22.7* (2U PRBCs given) [**2165-6-2**] 08:35AM BLOOD Hct-26.4* [**2165-6-2**] 12:27PM BLOOD Hct-28.0* [**2165-6-2**] 04:07PM BLOOD Hct-29.6* . OTHER PERTINENT LABS [**2165-6-2**] 04:19AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2165-6-2**] 08:35AM BLOOD FDP-0-10 [**2165-6-2**] 08:35AM BLOOD Fibrino-158* [**2165-6-2**] 03:36AM BLOOD Hapto-103 DISCHARGE LABS Hematology: [**2165-6-5**] 06:20AM BLOOD WBC-6.7 RBC-2.99* Hgb-8.8* Hct-27.8* MCV-93 MCH-29.4 MCHC-31.6 RDW-15.2 Plt Ct-175 [**2165-6-5**] 06:20AM BLOOD Plt Ct-175 Chemistry: [**2165-6-5**] 06:20AM BLOOD Glucose-96 UreaN-13 Creat-1.0 Na-141 K-4.4 Cl-108 HCO3-26 AnGap-11 [**2165-6-5**] 06:20AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1 MICRO [**2165-6-1**] MRSA SCREEN (Final [**2165-6-3**]): No MRSA isolated. [**2165-6-1**] BLOOD CULTURE -PENDING [**2165-6-1**] BLOOD CULTURE -PENDING IMAGING [**2165-6-1**] CTA ABD/PELVIS FINDINGS: The lung bases demonstrate dependent atelectasis without pleural effusion. No pericardial effusion is seen. There may be mitral annular calcifications. ABDOMEN: There is severe intra- and extra-hepatic biliary ductal dilation to the level of the ampulla, measuring up to 15-mm. There is pancreatic duct dilation up to 6-mm throughout its course. The patient appears to be status post cholecystectomy. The spleen, pancreatic parenchyma, stomach, and small bowel are within normal limits. Bilateral renal hypodensities are incompletely evaluated on this study, but most likely represent cysts, many of which are too small to characterize. There is no free intraperitoneal air or ascites. Bilateral low density adrenal nodules likely represent adenomas. The colon is fluid filled without wall thickening; colonic diverticula are seen without evidence for inflammation. Calcification in the right rectus muscle may be postoperative. PELVIS: Distal colonic anastomosis appears patent. A Foley catheter is seen within the decompressed bladder. Prominent left gonadal and pelvic veins are seen. The uterus is unremarkable. MESENTERIC CTA: There is an area of arterial extravasation which increases on venous phase in the proximal transverse colon, concerning for acute bleeding. There is severe stenosis at the origin of the celiac artery with post-stenotic dilation. The superior mesenteric artery, inferior mesenteric artery, superior mesenteric vein, portal vein and splenic vein appear patent. Calcified and noncalcified arterial atherosclerotic plaque is seen. Severe degenerative changes are seen in the spine with levoconvex lumbar scoliosis. IMPRESSION: 1. Active extravasation into the proximal transverse colon. This finding was reported to Dr. [**First Name (STitle) **] by Dr. [**Last Name (STitle) 7867**] by telephone at 7:45 a.m. on [**6-1**] [**2165**] immediately upon discovery of this finding. 2. Intra- and extra-hepatic biliary ductal dilation and pancreatic duct dilation to the level of the ampulla. Differential diagnosis includes malignancy and ampullary stenosis. Further evaluation is recommended with ERCP or MRCP. Adrenal nodularity could be further evaluation with MR as well. 3. Severely stenotic origin of the celiac artery with post-stenotic dilation. . [**2165-6-1**] IR PROCEDURE NOTE CONCLUSIONS: 1. Active arterial extravasation from the third-order branch of the middle colic artery with contrast spilling into the proximal transverse colon was demonstrated on DSA angiogram of the superior mesenteric artery and on multiple subsequent supraselective injections through the microcatheter. 2. Successful transarterial coil embolization of the third-order branch of the middle colic artery effectively which stopped the bleeding. 3. Deployment of 6 French Angio-Seal closure device in the right common femoral artery. . [**2165-6-2**] CT ABD/PELVIS CT ABDOMEN: The visualized lung bases demonstrate mild dependent bibasilar atelectasis and trace pleural effusions. No pericardial effusion. There is a small hiatal hernia. Evaluation of the intra-abdominal organs is limited without intravenous contrast. The unenhanced liver is normal. Intrahepatic bile duct dilation seen on prior study is not well appreciated. The spleen and pancreas are normal. Bilateral adrenal nodularity is better assessed on prior study. The kidneys are small with numerous hypodensities, statistically likely representing cysts. Contrast in the collecting system is from prior CT and embolization procedure. The small and large bowel are normal in caliber without obstruction. Contrast within the large bowel is residual intravenous contrast administered during prior CTA and embolization procedures, limiting evaluation for acute colonic hematoma. Coils are seen adjacent to the transverse colon at site of prior bleed and embolization (2:28). There is no free fluid and no free air. Small mesenteric and retroperitoneal lymph nodes are not enlarged by size criteria. The aorta is of normal caliber. No retroperitoneal hematoma is identified. CT PELVIS: The rectum is normal. An anastomotic site in the sigmoid is intact. Small diverticula are seen in the sigmoid without inflammatory changes. A Foley catheter is in the decompressed bladder. The uterus is normal. There is no free fluid and no pelvic or inguinal lymphadenopathy. BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen. Multilevel degenerative change in the lumbar spine is noted. IMPRESSION: 1. No retroperitoneal hematoma. 2. Contrast within the large bowel is residual IV contrast administered during prior CTA and embolization procedures, limiting evaluation for acute colonic hematoma. UNILAT UP EXT VEINS US [**2165-6-4**] Reason: evaluate for LUE DVT FINDINGS: Grayscale color, and Doppler images were obtained of the left IJ, subclavian,axillary, brachial, basilic and cephalic veins. Normal flow, compression and augmentation is seen in all the vessels. IMPRESSION: No evidence of deep vein thrombosis in the left arm. Brief Hospital Course: [**Age over 90 **]F with hx of extensive diverticulosis & prior diverticular bleeds admitted for profuse rectal bleeding, found to have transferse diverticular bleed which stabilized after middle colic artery embolization. # DIVERTICULAR BLEED, TRANSVERSE COLON, with ACUTE BLOOD LOSS ANEMIA Pt has hx diverticular bleeds and extensive diverticulosis so recurrent diverticular bleed was the primary concern when she presented with profuse rectal bleeding. In the ED, she had clinical and radiographic evidence of ongoing bleeding - CTA abdomen clearly localized bleeding to proximal transverse colon. 3 units PRBCs given on admission. Surgery, GI, and IR consults followed closely. Hemostasis obtained by IR-guided embolization of the middle colic artery. Hct stabilized at 28 for >12 hours thereafter. Overnight the following evening, serial Hcts showed 5-pt Hct drop to 22.7. Transfused additional 2U (for 5 units total) with appropriate Hct bump to 29. Pt had not had a BM in the interim, was HD stable and asymptomatic so bleed site unclear. R groin access site not concerning for hematoma. Decision made to pursue CT abd/pelvis to evaluate for possible post-procedure RP bleed - this was negative. Hemolysis labs were also normal. Called out to floor after q4h hct stable x3, but kept in MICU overnight a second night when she had a melanotic BM and Hct dropped 3 pts again. No blood given and HCTs remained stable overnight and patient was called out to the floor the following day. While on the floor, she remained HD stable, with no further rectal bleeding. Her aspirin was held. Her HCTs were stable at 26-27. # ACUTE ON CHRONIC RENAL FAILURE Cr 1.7 on arrival, up from baseline creatinine 1.4. Acute elevation likey due to pre-renal state in the setting of GIB. Corrected to baseline by the following morning w/volume resuscitation via PRBC transfusions + the 3L IVF given in the ED. Cr continued to be stable at 1.1 - 1.3 on the floor and was 1.0 at discharge. . # HYPERTENSION Pt normotensive on arrival and throughout MICU stay, with BPs running 110s-140s, usually 120s systolic. Home anti-hypertensives and lasix were held in the setting of active GIB. While on the floor, her SBP went up to 160s-170s, so we restarted her hydralazine, initially 50 mg [**Hospital1 **] and then titrating up 100 mg [**Hospital1 **] which is her home dose. At discharge her BP was 130s/50s and we restarted her home Lasix 40 mg PO BID. Might consider BB or CCB rather than hydralazine/lisinopril in this pt given wide pulse pressure and extensive arterial calcification seen on imaging. # INCIDENTAL FINDING - BILIARY DUCTAL DILATION, PANCREATIC DUCT DILATION On admission CTA pt seen to have "intra- and extra-hepatic biliary ductal dilation and pancreatic duct dilation to the level of the ampulla. Differential diagnosis includes malignancy and ampullary stenosis." Pt is s/p CCY. Radiologist recommended follow-up ERCP or MRCP, deferred to outpatient follow-up. # DM2 Not on any home diabetes medications. Sugars managed with minimal ISS. # OSA Continued CPAP. # GERD Cont home omeprazole. TRANSITIONAL ISSUES -Follow-up Hct checks after discharge. -Consider restarting aspirin if Hct is stable and no signs of bleeding and if clinically indicated -Follow-up incidental CTA abd finding of intra- and extra-hepatic biliary ductal dilation and pancreatic duct dilation. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PharmacyAtrius. 1. Acetaminophen 650 mg PO TID 2. Docusate Sodium 100 mg PO BID 3. Senna 1 TAB PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Aspirin 325 mg PO DAILY 6. Furosemide 40 mg PO DAILY 7. Omeprazole 20 mg PO BID 8. HydrALAzine 100 mg PO Q8H 9. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. HydrALAzine 100 mg PO Q8H 3. Omeprazole 20 mg PO BID 4. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] RX *fluticasone 50 mcg twice a day Disp #*1 Bottle Refills:*0 5. Losartan Potassium 100 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Furosemide 40 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Senna 1 TAB PO DAILY 10. Outpatient Lab work Please check CBC on [**2165-6-11**]. Please fax results to Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 106314**]. Discharge Disposition: Home With Service Facility: greater [**Hospital **] home health Discharge Diagnosis: Primary: lower GI bleed secondary to diverticulosis acute blood loss anemia Secondary diagnoses: chronic stable asthma hypertension DM II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with lower gastrointestinal bleeding. You were found to have diverticulosis- an outpouching of the colon which can cause bleeding. You were given several pints of blood to replace the blood that you lost. You underwent a procedure with interventional radiology to stop the bleeding. You were monitored for several days and your bleeding stopped. We have stopped your aspirin as it increases the risk of bleeding. Please talk to your primary care doctor about whether or not you should restart this medication in the future. Followup Instructions: Please keep the following appointments. Dr.[**Name (NI) 106315**] office will work on getting you an appointment sooner as well. Wednesday [**6-26**] at 9 am [**Name6 (MD) **] [**Name8 (MD) **], MD [**Last Name (NamePattern1) 14305**] [**Location (un) 86**], [**Numeric Identifier 6425**] Phone: ([**Telephone/Fax (1) 106316**] Fax: ([**Telephone/Fax (1) 106314**] Please also go to have your blood work drawn next week. Dr. [**Last Name (STitle) **] will follow-up these results. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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Discharge summary

report

Admission Date: [**2196-8-15**] Discharge Date: [**2196-8-25**] Date of Birth: [**2133-1-26**] Sex: M Service: [**Last Name (un) **] CHIEF COMPLAINT: Inguinal hernia groin pain. HISTORY OF PRESENT ILLNESS: This is a 63-year-old male with end-stage liver disease due to PSC, on the transplant list with a MELD score of 24, with a history of CBD stricture, status post Roux-en-Y hepaticojejunostomy in [**2191-6-20**], admitted to the hepatology service on [**2196-8-15**] due to increasing ascites and bilateral inguinal hernia pain, status post paracentesis and removal of 3 liters of ascites by Dr. [**Last Name (STitle) 497**]. The patient was last seen by Dr. [**Last Name (STitle) **] in the clinic on [**7-20**]. OR was scheduled for [**8-26**] for the hernia repairs. The patient complained of inguinal pain, left greater than right, constant, worsening with sitting. The patient denied nausea, vomiting. He did report having a bowel movement, unchanged habits. PAST MEDICAL HISTORY: Primary sclerosing cholangitis diagnosed in [**2189**], end-stage liver disease on transplant list, common bile duct stricture, status post Roux-en-Y hepaticojejunostomy in [**2191-6-20**], ulcerative colitis, pericarditis, status post ventral hernia repair in [**2192-6-19**]. ALLERGIES: PERCOCET. MEDICATIONS AT HOME: Lasix 40 mg once a day, Aldactone 100 mg p.o. daily, hydralazine 25 mg p.o. p.r.n., vitamin D 400 mg once a day, calcium carb 500 mg once a day, lactulose 15 cc b.i.d. p.r.n., Actigall 600 mg t.i.d., multivitamin one daily, mesalamine 500 mg t.i.d., ciprofloxacin 250 mg p.o. daily. SOCIAL HISTORY: Remote history of smoking 30 years prior to admission but denied alcohol, denied IV drug use. PHYSICAL EXAMINATION: Temperature 99.3, heart rate 80, BP 80/44, respiratory rate 20, 98% on room air, weight 75.8 kg, status post tap 72. Alert and oriented. No acute distress, jaundiced, regular rate and rhythm. S1, S2 normal. Chest is clear. Soft abdomen, nontender, no guarding, bilateral inguinal hernias, left greater than right, reducible. The patient was scheduled for the OR on [**8-26**] when a liver transplant became available. On [**2196-8-17**] the patient underwent deceased donor liver transplant piggyback with Roux- en-Y hepaticojejunostomy, portal vein to portal vein anastomosis, hepatic artery to hepatic artery with extensive lysis of adhesions. Surgeon was Dr. [**First Name (STitle) **] [**Name (STitle) **], assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21082**]. Please see operative report for details. The biliary tube was brought out through the stab incision in the right side of the abdomen. He had 2 [**Doctor Last Name 406**] drains, 1 directly under the right lobe of the liver and 1 under the hilum of the liver. Postoperatively, he was transferred to the surgical intensive care unit where he was intubated. He received blood products to stabilize hematocrit. LFTs trended down. He was extubated on [**8-19**] and transferred to the medical surgical floor on [**8-20**] where his diet was advanced slowly and tolerated. Vitals remained stable. Hematocrit fluctuated between 26 and 30. Prograf was initiated on hospital day #1. He had received standard induction immunosuppression intraoperatively. CellCept 1 gram p.o. b.i.d. continued. Solu-Medrol was gradually tapered down to 20 mg p.o. daily. Prograf levels fluctuated between 15-7.9. He was doing well. He experienced significant edema bilaterally in lower extremities. Lasix was initiated and he diuresed nicely. His weight decreased as well. An ultrasound on postop day #1 demonstrated patent hepatic vasculature with diminished hepatic artery diastolic flow. There was small right pleural effusion. There were no extrahepatic collections identified. The patient continued to complain of bilateral inguinal hernias. JP drains were removed without incident. T-tube cholangiogram was done on postop day #5, demonstrating the tip of the catheter in the Roux limb and no opacification of the intra-hepatic biliary ducts. The T-tube was capped. He experienced moderate leaking at insertion site. The site was sutured without further drainage. The patient was followed by [**Hospital **] Clinic for management of hyperglycemia. He was initiated on NPH insulin and 5 units subcutaneously once a day q.a.m. was ordered. The patient was discharged home in stable condition on postoperative day 7. DISCHARGE MEDICATIONS: Discharge medications included Colace 100 mg p.o. b.i.d., fluconazole 400 mg p.o. daily, prednisone 20 mg p.o. daily, CellCept [**Pager number **] mg b.i.d., Bactrim Single Strength 1 tablet p.o. daily, Valcyte 900 mg p.o. daily, Protonix 40 mg once a day, oxycodone 5 mg p.o. p.r.n. q.4-6h. as needed, Lasix 20 mg once a day. The patient was instructed to stop if dizzy or weight dropped below pretransplant weight which was 72 kg, insulin regular per sliding scale q.i.d., Prograf 5 mg p.o. q.12h., NPH insulin 5 units subcutaneous once a day. DISCHARGE DIAGNOSES: Primary sclerosing cholangitis, ulcerative colitis, bilateral inguinal hernias, glucose intolerance secondary to steroids and liver transplant. The patient had follow-up appointments with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] as well as Dr. [**First Name (STitle) **] [**Name (STitle) **]. CONDITION ON DISCHARGE: Good. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 12072**] Dictated By:[**Name8 (MD) 4664**] MEDQUIST36 D: [**2196-8-26**] 19:47:11 T: [**2196-8-28**] 21:00:00 Job#: [**Job Number 42795**] cc:[**Last Name (NamePattern4) 42796**]

[ "568.0", "790.29", "550.92", "576.1", "789.5", "571.5", "556.0" ]

icd9cm

[ [ [] ] ]

[ "87.54", "51.37", "00.93", "54.59", "50.59" ]

icd9pcs

[ [ [] ] ]

5148, 5475

4578, 5126

1344, 1628

1763, 4554

172, 201

230, 997

1020, 1322

1645, 1740

5500, 5801

15,919

178,010

47200

Discharge summary

report

Admission Date: [**2185-9-23**] Discharge Date: [**2185-10-5**] Date of Birth: [**2145-10-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: hypotension, sepsis, CRF, obesity-hypoventilation syndrome Major Surgical or Invasive Procedure: debridement of abdominal surgical wound History of Present Illness: 39 year old man with Prader-Willi syndrome, morbid obesity, obesity hypoventillation (vent. dependent), Renal failure on HD, who was rectently admitted to ICU here with sepsis s/p abdominal abscess debridement ([**Date range (1) 99960**]) and discharged to rehab at the [**Hospital1 **] House - was found to be hypotense at HD today (sbp 55 - came up to 100/40 after HD stopped after 30 min), also noted to have hct. 22. Sent to [**Hospital1 18**] ED. . Past Medical History: Prader Willi Syndrome Morbid obesity T2DM CRI with baseline creatinine 1.8-2.0 OSA Mental retardation Hypothyroidism Status post tracheostomy and PEG tube placement Social History: Resident at [**Hospital 100**] Rehab. No smoking, ethanol or drug use. Family History: Family history of diabetes. Physical Exam: VS:98.6 86 116/doppler 12 96% (on FiO2 .4 on CMV on vent) HEENT: EOMI, PERRL COR: RRR, [**3-7**] HSM PULM: CTA anteriorly ABD:obese, foley in place as G tube with tube feeds leaking around ostomy, LLQ abscess drainage site with Wet-dry dsg in place. LLQ indurated, erythematous EXT:RLE edema greater than Lt LE, bilateral heel pressure ulceration NEURO:Opens eyes to voice, tracks, nods yes/no in response to questions . Pertinent Results: [**2185-9-23**] 05:09PM HCT-23.3* [**2185-9-23**] 12:48PM WBC-15.8* RBC-2.67* HGB-7.2* HCT-23.8* MCV-89 MCH-27.0 MCHC-30.2* RDW-22.6* [**2185-9-23**] 12:48PM PLT COUNT-265 [**2185-9-23**] 02:30AM GLUCOSE-96 LACTATE-1.7 NA+-143 K+-4.6 CL--105 TCO2-31* [**2185-9-23**] 02:10AM GLUCOSE-95 UREA N-46* CREAT-3.8*# SODIUM-141 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-28 ANION GAP-15 [**2185-9-23**] 02:10AM ALT(SGPT)-22 AST(SGOT)-24 ALK PHOS-462* AMYLASE-13 TOT BILI-0.5 [**2185-9-23**] 02:10AM LIPASE-11 [**2185-9-23**] 02:10AM CALCIUM-8.5 PHOSPHATE-2.5* MAGNESIUM-1.8 [**2185-9-23**] 02:10AM WBC-14.1* RBC-2.21* HGB-6.1* HCT-20.3* MCV-92 MCH-27.8 MCHC-30.2* RDW-23.2* [**2185-9-23**] 02:10AM NEUTS-90.1* BANDS-0 LYMPHS-7.3* MONOS-1.2* EOS-1.3 BASOS-0.1 [**2185-9-23**] 02:10AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ SPHEROCYT-OCCASIONAL [**2185-9-23**] 02:10AM PLT SMR-NORMAL PLT COUNT-261 [**2185-9-23**] 02:10AM PT-15.4* PTT-34.0 INR(PT)-1.4* Brief Hospital Course: 39 y/o with Prader-Willi, morbid obesity, obesity-hypoventilation syndrome (vent dependent), CKD on HD who was found to be hypotense and anemic at HD. The hospital course consisted of chronic hypotension, bacteremia, worsening abdominal abscess, and HD that could not take off fluid. His sister [**Name (NI) 2431**] was involved in his care and health care decision making daily (she is the HCP). After long discussions with family and consulting doctors, [**Doctor First Name 2431**] wished to take him home with hospice care to die at home. HD and all invasive procedures were held in hospital and antibiotics were continued until the day of discharge. [**Doctor First Name 2431**] came in and assisted with [**Known firstname 2979**] care in preparation to care for him at home. Supplies and hospice services were established and in place for the day of discharge. Dr.[**Name (NI) 20819**] (PCP) was called and aksed for an order for Hospice care DNR/DNI/DNH. Medications on Admission: Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ascorbic Acid 90 mg/mL Drops Sig: One (1) PO DAILY (Daily). 3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H as needed. 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID as needed. 6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY 7. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY 9. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY 10. Insulin Glargine 100 unit/mL Solution Sig: One (1) 60 units Subcutaneous q breakfast. 11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection q ACHS: Please administer insulin according to the following sliding scale. If BG 141-200, please give 8 units. If BG 201-240, give 12 units. If BG 241-280, give 16 units. If BG 281-320, give 20 units. If BG 321-360, give 24 units. If BG 361-400, give 28 units. 12. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY Discharge Medications: 1. Hydromorphone 2 mg/mL Syringe Sig: 1-2 mg Injection Q6H (every 6 hours) as needed for pain. 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**5-5**] Puffs Inhalation Q6H (every 6 hours). 3. Roxanol Concentrate 20 mg/mL Solution Sig: [**1-31**] PO every four (4) hours as needed for pain for 10 days. 4. Ventilator Set Misc Sig: One (1) Miscell. once a day. 5. Oxygen-Air Delivery Systems Device Sig: One (1) Miscell. continuous. 6. Oxygen Tubing Misc Sig: One (1) Miscell. continuous. Discharge Disposition: Home With Service Facility: Vista Care Hospice Discharge Diagnosis: 1. prader willi 2. Anemia 3. obesity hypoventilation syndrome ventilator dependent 4. bacteremia 5. abdominal abscess 6. chronic renal failure Discharge Condition: comfort measures only Discharge Instructions: Follow the suggestions and care of Hospice nurses and doctors. Followup Instructions: Please follow up with your physician as needed

[ "707.07", "518.83", "707.8", "995.92", "244.9", "759.81", "276.52", "682.2", "707.05", "319", "536.49", "V55.0", "250.00", "707.09", "285.21", "278.01", "585.6", "458.21", "327.23", "038.49" ]

icd9cm

[ [ [] ] ]

[ "93.59", "39.95", "96.72", "96.6", "99.04" ]

icd9pcs

[ [ [] ] ]

5416, 5465

2715, 3679

375, 417

5652, 5675

1680, 2692

5786, 5836

1194, 1223

4872, 5393

5486, 5631

3706, 4849

5699, 5763

1238, 1661

277, 337

445, 901

923, 1089

1105, 1178

16,076

172,600

5206

Discharge summary

report

Admission Date: [**2180-7-30**] Discharge Date: [**2180-8-18**] Date of Birth: [**2119-6-30**] Sex: M Service: MEDICINE Allergies: Lasix Attending:[**First Name3 (LF) 10370**] Chief Complaint: SOB, low grade fevers x2 days Major Surgical or Invasive Procedure: tracheostomy placement PEG placement intubation and mechanical ventilation History of Present Illness: HPI: This is a 61 yo w/h/o DM1, s/p cadaveric kidney transplant([**2175**]), h/o CVA and chronic aspiration with recent admission for multifocal pneumonia who p/w acute onset of SOB and low grade fever x 2 days. Pt notes that he'd been feeling well until 2 days ago when he began to feel sob and wheezy. He denies cough/chest pain, but notes low grade fevers. Denies excessive fatigue, also denies weight gain, LE edema, orthopnea, PND. Denies N/V/D and notes that he has been compliant with his medications. . His family brought him to the ED where he had Tm 100.8 and was sating 85% on RA, 95% on 3LNC RR 20-30. CXR revealed multifocal PNA. He was given IV Levofloxacin 750mg, MetRONIDAZOLE 500mg, Vancomycin 1g, Acetaminophen 650mg. . Currently denies cough, fever, chills, or SOB. . Past Medical History: cadaveric renal transplant in [**2175**] CVA-residual right hemiparesis DM Type I HTN Hx non-QMI and Vfib arrest [**2169**] with anoxic brain injury CAD/CABG [**2170**] Swallow study-showed silent aspiration Social History: Lives with wife at [**Year (4 digits) 5348**]. Most recently at [**Location (un) 582**] of [**Location (un) 583**] s/p clavicular fracture. Former endocrinologist in [**Country 532**]. Has homemaker who comes in 5 times a week. Has 3 daughters who visit him. Family History: Non-contributory Physical Exam: Physical Exam: VS: 101.2, 119/41, 63, 23, 100% FiO2 15%NRB GENERAL: conversational via interpreter, NAD, appears to be breathing comfortably HEENT: Anicteric sclerae, OP clear with no exudates, MMM Neck: flat JVP, no LAD noted LUNGS: diffuse rhonchi BL, no wheezes, rales HEART: RRR, 2/6 SEM to axilla, at apex, radiating up, no r/g ABDOMEN: Soft, no tenderness over renal transplant in RLQ, +BS, ND, no HSM EXTR: RUE w/trace edema compared to lef, thin extremities, scrapes and scars noted on RLE; diminished pulses BL no edema noted. NEURO: A&Ox3; [**5-13**] motor RUE, [**6-12**] motor LUE, RLE, LLE. SKIN: No jaundice, no rashes . Pertinent Results: EKG: NSR at 67bpm evidence of prior IMI, unchanged compared to prior [**2180-6-20**] . CXR: The patient is status post median sternotomy and CABG. Compared to the prior study, there are new multifocal consolidative opacities involving the left lower and the entire right lung, consistent with multifocal pneumonia. No sizable effusions or pneumothorax is seen. IMPRESSION: Multifocal consolidative process, most consistent with multifocal pneumonia. . Brief Hospital Course: Hospital Course: This is a 61 yo w/h/o DM1, s/p cadaveric kidney transplant([**2175**]), h/o CVA and chronic aspiration with recent admission for multifocal pneumonia who presented to the ED with a recurrence of multifocal PNA and later was admitted to the MICU with hypoxic respiratory failure requiring ET intubation and mechanical ventilation that was later replaced with a tracheostomy. He also developed lower extremity tremors attributed to his prior CVAs and acute mental status deterioration likely due to progression of his previous CV infarcts and his hypoxic respiratory failure. # Hypoxic Respiratory Failure: the patient most likely had an aspiration event resulting in an aspiration/multifocal PNA. This is considered a recurrence in this patient since he had a recent discharge for the same problem. Also, pt w/known h/o chronic aspiration, will cover for anaerobes. He also may have had some volume overload leading to pulmonary edema. All 4 blood cx's from admission on [**7-30**] were negative. He had a sputum cx/BAL x2 which was significant only for + HSV-1 cx/IF. It also showed no bacterial/fungal/mycobacterial growth or influenza positivity. His urine legionella was also negative. He was also given albuterol/ipratropium nebs. He was covered w/ Zosyn/Vancomycin/Ciprofloxacin for presumed HAP when the lobar collapse was noted on CXR on [**8-6**]. His CXRs afterwards remained clear, and his antibiotics were stopped when his sputum cx's had been negative for 72 hours. He also showed some evidence of pulmonary edema on CXR, which was initially treated w/ Lasix. After the development of an erythematous rash on his chest and upper extremities, he was started on ethycrinic acid with good diuretic effect, w/ goal Is = Os. He reached this goal and the diuresis was discontinued. He was weaned off sedation, and then a tracheostomy and PEG were placed. His oxygen saturations remained at 98-100% on trach mask with FiO2 of 40%. He was continued on bactrim for PCP [**Name9 (PRE) **], given his immunosuppression for the renal transplant. # Sepsis [**3-11**] Line Infection: Pt began experiencing fevers, an elevated leucocytosis, and episodes of hypotension. Broad spectrum abx (Vancy/Zosyn/Cipro) were started, and pt was pan-cultured. A blood cx from [**8-13**] drawn from a PICC line placed [**8-1**] came back positive for coagulase negative staph. His PICC line was removed. His fevers, WBC, and hypotension resolved w/ removal of the line and abx treatment. Zosyn and Cipro were d/c-ed He will be continued on a 2 week course of Vancomycin which was started on [**2180-8-13**] and will end on [**2180-8-27**]. His metoprolol was held, and then re-started at a lower dose (50 [**Hospital1 **]) when his BPs resolved. The beta blocker can be titrated up to his original dose of 100 [**Hospital1 **] as tolerated. # CKD s/p cadaveric renal transplant: A renal transplant consult was obtained, Per their recommendations, he was continued on his Tacrolimus with levels checked q3 days - weekly, prednisone 5 mg/day, and his CellCept was held. His Cre elevated to 1.4 after his episodes of hypotension, and were attributed to secondary ATN. His # Hypertension: Initially meds were held [**3-11**] low BPs. This resolved w/ fluid boluses, and he was re-started on Metoprolol. BPs were stable throughout hospital course. # DM1: Patient was treated with Lantus 20 QHS and humalog insulin sliding scale. Prior to discharge, pt was found to be hypoglycemic (23) after receiving half dose of Lantus while being NPO. Pt was given [**Location (un) 2452**] juice via PEG tube but started having tonic clonic movements. He received 2 amps of D50 and 6mg Ativan before seizure activity ended. Blood glucose came up to mid 200s. Tube feeds were restarted slowly. # CAD s/p CABG: The patient has extensive cardiac disease, as he is s/p NSTEMI and V-fib arrest in [**2169**] and CABG [**2170**]. No evidence of ischemia on EKG. His trops/CKs came back negative, and he was ruled out for MI. # Mental status- MRI shows progression of multiple old infarcts. Pt's MS [**First Name (Titles) 21299**] [**Last Name (Titles) 21300**] during ICU admission, and he began to respond to vocal commands, communicate minimally with his family, and track to voice. He was weaned off to Ativan. On [**8-17**], he exhibited Cheynes-[**Doctor Last Name **] respirations, and was more somnolent than usual. All VS were stable, and his saturations stayed in the high 90%s. FS was 190, EKG was unchanged from prior, and patient was not hypercarbic on ABG. Ativan and Reglan were d/c-ed, and the patient gradually awakened over the course of the day. # Rash- Patient developed erythrematous, petechial, blanching in nature on the chest and the upper extremities, most likely [**3-11**] drugs (cephtriaxone and lasix are likely). Platelets, coags stable. Rash is stable once his Lasix swithced to ethacrynic acid for diuresis and allergy was recorded. # Hypernatremia. Had Nas to high 140s during stay, likely associated w/ insensible water losses and inability to PO while being intubated. Continued free water boluses (200-300 ccs q4H through OG tube and [**Hospital1 **] lyte checkes. ) Eventually resolved to an sodium of 142 and remained stable during remainder of course. # LE tremors- Neuro consult was obtained, suggesting that this is a SC lesion. Per neuro, the tremors are likely associated w/ old spine infarcts, and do not require treatment per Neuro. There was c/f syphilis [**3-11**] onset of new rash and new neurologic findings, but an RPR negative. It is therefore unlikely syphilis given good sensitivity/rule out capabilities of RPR. Tremors can also occur w/ metabolic alkalosis, so the patient's contract alkalosis was treated with free water boluses. Tremors decreased tremendously with stabilization of blood pH. Patient will need Cervical/Thoracic MRI after stabilized per Neuro to further work up the etiology of these tremors. # Polypoid lesions- Pt has polypoid lesions in rectum. Stools were guiac negative. Please follow up with outpatient GI EGD/colonoscopy as needed. # FEN: Patient was kept on aspiration precautions and tube feeds through his oropharyngeal-gastric (OG) tube, and later through his PEG. # Access: Patient was discharged w/ PICC. # PPx: Pneumoboots; bowel regimen; heparin SC # Code: FULL Medications on Admission: Senna 8.6 mg PO BID as needed Docusate Sodium 100 mg PO BID Mycophenolate Mofetil 500 mg PO BID Prednisone 1 mg PO DAILY Tacrolimus 1 mg PO Q12H Pravastatin 20 mg PO DAILY Metoprolol Tartrate 50 mg PO BID Fluvoxamine 50 mg PO BID Amlodipine 5 mg PO DAILY Hydrochlorothiazide 12.5 mg PO DAILY Quetiapine 25 mg PO BID Trimethoprim-Sulfamethoxazole 160-800 mg PO EVERY OTHER DAY Insulin NPH Thirteen units Subcutaneous QAM. Albuterol Sulfate 2.5 mg/3 mL 1-2 puffs Inhalation Q6H as needed Ipratropium Bromide 1-2 puffs Inhalation Q6H as needed Aspirin 81 mg Tablet Insulin Regular Human 100 unit/mL Cartridge [**Month/Day (2) **]: One (1) sliding scale dose Injection four times a day as needed for sliding scale: <120: no insulin. 121-150: 1 unit. [**Unit Number **]-180: 2 units. 181-210: 3 units. 211-240: 4 units. 241-300: 5 units. 301-350: 6 units. 351-400: 8 units. >400: [**Name8 (MD) 138**] MD. . Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Name8 (MD) **]: One (1) mL Injection TID (3 times a day). 2. Pravastatin 20 mg Tablet [**Name8 (MD) **]: One (1) Tablet PO DAILY (Daily). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Name8 (MD) **]: One (1) Tablet PO QODHS (every other day (at bedtime)). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Name8 (MD) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Senna 8.6 mg Tablet [**Name8 (MD) **]: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 50 mg/5 mL Liquid [**Name8 (MD) **]: Ten (10) mL PO BID (2 times a day). 7. Albuterol 90 mcg/Actuation Aerosol [**Name8 (MD) **]: Six (6) Puff Inhalation Q6H (every 6 hours). 8. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Name8 (MD) **]: Six (6) Puff Inhalation Q6H (every 6 hours). 9. Epoetin Alfa 4,000 unit/mL Solution [**Name8 (MD) **]: One (1) mL Injection QMOWEFR (Monday -Wednesday-Friday). 10. Prednisone 5 mg Tablet [**Name8 (MD) **]: One (1) Tablet PO DAILY (Daily). 11. Tacrolimus 1 mg Capsule [**Name8 (MD) **]: Two (2) Capsule PO Q12H (every 12 hours). 12. Acetaminophen 160 mg/5 mL Solution [**Name8 (MD) **]: [**11-27**] mL PO Q6H (every 6 hours) as needed. 13. Metoprolol Tartrate 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). 14. Insulin Glargine 100 unit/mL Solution [**Month/Year (2) **]: Twenty (20) units Subcutaneous at bedtime: 1/2 dose when NPO. 15. Insulin Lispro 100 unit/mL Solution [**Month/Year (2) **]: One (1) unit Subcutaneous q6hrs: per sliding scale. 16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day. 17. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1) dose Intravenous Q 24H (Every 24 Hours): last dose 7/20. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Hypoxic respiratory failure due to aspiration pneumonia/pneumonitis Secondary Diagnosis Chronic renal failure s/p cadaveric renal transplant Type I Diabetes Mellitus Cerebrobvascular Accidents Discharge Condition: Fair Discharge Instructions: You were admitted to the [**Hospital1 18**] with a diagnosis of hypoxic respiratory failure attributed to aspiration pneumonia/pneumonitis. You were intubated and mechanically ventilated, and given antibiotics for your pneumonia. Once you were able to tolerate breathing on your own, you had a tracheostomy placed and a PEG (a percutaneous gastric tube) that will allow food to be placed directly into the stomach. You also had an infection of the blood attributed to a peripherally inserted central catheter (PICC) line that was placed in your right arm. You are being treated with a 2 week course of an antibiotic called Vancomycin, and the last day of your treatment will be [**2180-8-27**]. The infected line was removed, and another PICC line was placed in your other arm, so you may continue to receive your antibiotics. You are being transferred to a rehabilitation center for further care. Followup Instructions: Provider: [**Name Initial (NameIs) 2963**] (ST-4) GI ROOMS Date/Time:[**2180-8-22**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2180-8-22**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2180-9-26**] 11:15 Please contact radiology to schedule an outpatient cervical/thoracic MRI of the spine in order to better work up the cause of the lower extremity tremors. Test for consideration post-discharge: Modified Acid-Fast stain for Nocardia. Please consult with a GI to get an outpatient colonoscopy for colonic polyps, and/or an upper endoscopy . Completed by:[**2180-8-21**]

[ "E930.5", "V45.81", "E944.4", "403.90", "E878.0", "276.2", "276.0", "038.19", "996.81", "518.84", "438.20", "E879.8", "250.41", "486", "V58.65", "584.5", "999.31", "781.0", "V58.67", "693.0", "507.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "31.1", "96.04", "33.24", "43.11", "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

12057, 12123

2879, 2879

297, 373

12361, 12368

2403, 2856

13315, 14080

1714, 1732

10176, 12034

12144, 12340

9249, 10153

2896, 9223

12392, 13292

1762, 2384

228, 259

401, 1190

1212, 1421

1437, 1698