ChanBeDu/relevant_section_length · Datasets at Hugging Face

19,592

102,092

45323

Discharge summary

report

Admission Date: [**2155-4-18**] Discharge Date: [**2155-4-25**] Date of Birth: [**2081-10-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Bacteremia Major Surgical or Invasive Procedure: Central Venous Catheter History of Present Illness: 73 yo female transferred from [**Hospital 8629**] to [**Hospital1 18**] for intermittent fevers. Pt initially admitted to [**Hospital1 **] on [**2155-3-17**] after being discharged from [**Hospital1 18**] after prolonged hospitalization. Initially, the pt underwent CABG, prosthetic MVR, and closure of foramen ovale on [**2155-2-21**]. Post-op course complicated by mediastinal hemorrhage, prolonged shock, renal failure. The pt failed to recover neurologically, and the family decided to pursue trach and PEG. HD was initiated, and the pt was transferred to [**Hospital1 **] for rehab. Since admission, she has had intermittent fevers and leukocytosis, and recurrent infections. She initially was treated with a course of Vanc, Zosyn, and Flagyl. She was then started on Fluconazole for fungus in the urine, and [**Female First Name (un) 564**] bacteremia. This was changed to Caspofungin when the patient failed to respond to treatment. The pt also grew [**Female First Name (un) **] out of her blood and was started on Linezolid. She also had new bilateral pulmonary infiltrates on CXR, and was started on Imipenem for broad coverage. She developed fever and hypotension requiring pressors off and on from the 20th to the 24th. She underwent a TTE that showed no vegetations, EF 40%. Surveillance cultures have been NGTD. She was started on steroids empirically, and a random cortisol level returned at 3. She is transferred to [**Hospital1 18**] for further evaluation including TEE, CT, ID consult, and infected lined change. Past Medical History: 1. CAD, s/p CABG for 2VD 2. Cardiomyopathy, EF 40% on echo [**2155-4-8**] 3. anoxic encephalopathy 4. ESRD, on HD tues/thurs/sat 5. a-fib 6. trach/peg on [**2155-3-12**] 7. stent to LAD 97 8. htn 9. hypercholesterolemia 10. insulin dependent diabetes 11. spinal stenosis 12. COPD Social History: no ETOH, previous 20 pack year smoking history, quit 20 years ago, previously lived w/ daughter, [**Name (NI) 13788**] who is HCP Family History: nc Physical Exam: vitals: wt 72/ 95.2/ bp 107/72/ pulse 89/ vent: AC .40/ 500/ 14/5 GEN: comatose HEENT: conjunctiva injected, dry mucosa, OP clear NECK: no LAD. Trach in place CV: RRR, 2/6 systolic murmur LUNGS: bronchial BS ABD: distended, soft, hypoactive BS EXT: 3+ pitting edema B/L, symmetric up to knees and on UE. Multiple areas of skin breakdown. R PICC site clean, HD site clean NEURO: sluggish pupillary reflex, no corneal reflex, no spontaneous movement of extremities, no response to voice, minimal response to pain. Muscles contracted. Pertinent Results: [**2155-4-19**] 02:35a 142 110 32 120 AGap=12 3.5 24 0.5 Ca: 7.2 Mg: 1.7 P: 3.7 ALT: 22 AP: 99 Tbili: 0.2 Alb: 1.5 AST: 20 LDH: 235 Dbili: TProt: [**Doctor First Name **]: 82 Lip: 16 mcv 95 wbc 10.4 hgb 8.3 plts 196 hct 25.5 PT: 12.2 PTT: 28.1 INR: 1.0 . [**2155-4-19**] 12:38a pH 7.49 pCO2 35 pO2 33 HCO3 27 BaseXS 3 . blood cx [**4-18**], [**4-19**] from picc pending . cxr: Right lower lobe/right infrahilar opacity. Differential includes asymmetrically distributed alveolar edema or consolidation, possibly aspiration related. Mild vascular conjestion. . TEE - Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. A small left-to-right shunt across the interatrial septum is seen at rest consistent with a small secundum atrial septal defect. There is regional left ventricular systolic dysfunction with basal inferior akinesis. There are simple atheroma in the ascending aorta. There are complex (>4mm, non-mobile) atheroma in the aortic arch and scending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. A well seated mitral valve annuloplasty ring is present. The leaflets are mildly thickened with normal gradient. No mass or vegetation is seen on the mitral valve. Very mild mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Normal functioning mitral annuloplasty ring with very mild mitral regurgitation. No vegetations identified. Complex (non-mobile) aortic atherosclerosis. Small secundum type atrial septal defect. Regional left ventricular systolic dysfunction c/w CAD. Brief Hospital Course: 73 YOF with anoxic brain injury, renal failure and line infection. . Line infection - [**Female First Name (un) 564**] and [**Female First Name (un) **] grown at Rehab. Treated with caspofungin, linezolid, and meropenem. Hemodialysis and PICC lines removed, tip cultures negative. Left subclavian line placed. Repeat cultures neagative. TEE done which showed no vegetation or abcess. New PICC line placed [**2155-4-24**], left subclavian d/c'd. To complete a 14 day course of Meropenem, Linezolid, Caspofungin to end on [**2155-5-2**]. . Renal failure - Patient was on dialysis after prolonged hypotension leading to ATN. HD catheter removed at time of admission. Cr and electrolytes remained stable. Patient making ~1L of urine a day. Hemodialysis discontinued indefinetly. . Hypotension - Patient transiently hypotensive. Hypovolemia vs sepsis. Responded to fluids. . Anoxic Encephalopathy- secondary to prolonged shock, evaluated by neurologist at [**Hospital1 **], poor prognosis for recovery based on prolonged state of neurological decline. No change in neuro exam during hospitalization. . Respiratory Failure- trached. Per outside hospital physician, [**Name10 (NameIs) **] to wean from vent. Attempted to wean while here, but failed PS. - continue vent at current settings AC 500 x 12/PEEP 5/ FiO2 40% - MDIs standing - Growing pseudomonas in sputum, being treated with Meropenem x 2 weeks - VBG showed near normal pH with low pCO2 and low bicarb. pH 7.43 pCO2 29 pO2 38 Medications on Admission: 500 ml NS Bolus 500 ml Over 15 mins 500 ml NS Bolus 500 ml Over 15 mins Qvar *NF* 160 mcg IH [**Hospital1 **] 1 inhalation delivers 80 mcg of beclomethasone. Azithromycin 500 mg IV Q24H Meropenem 500 mg IV ONCE Meropenem 500 mg IV Q6H Pantoprazole 40 mg IV Q24H Linezolid 600 mg IV ONCE Albuterol-Ipratropium [**11-26**] PUFF IH Q4H Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] Aspirin 81 mg NG DAILY Artificial Tears 1-2 DROP BOTH EYES PRN Linezolid 600 mg IV Q12H Caspofungin 50 mg IV Q24H Dexamethasone 2 mg IV Q12H Heparin 5000 UNIT SC TID Insulin SC Docusate Sodium (Liquid) 100 mg PO BID Senna 1 TAB PO BID:PRN Bisacodyl 10 mg PO/PR DAILY:PRN Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary - Line infection ([**Last Name (LF) **], [**First Name3 (LF) 564**]) Pseudomonas in sputum Secondary - 1. CAD, s/p CABG for 2VD 2. Cardiomyopathy, EF 40% on echo [**2155-4-8**] 3. anoxic encephalopathy 4. ESRD, on HD tues/thurs/sat 5. a-fib 6. trach/peg on [**2155-3-12**] 7. stent to LAD 97 8. htn 9. hypercholesterolemia 10. insulin dependent diabetes 11. spinal stenosis 12. COPD Discharge Condition: Stable, normotensive and afebrile Discharge Instructions: Please continue course of antibiotics as specified in the dischartge summary for treatment of Pseudomonas, [**Date Range **], and [**Female First Name (un) 564**]. Continue medications as detailed. Wound care as directed, continue tube feeds. Vent settings as specified. Followup Instructions: Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2155-4-29**] 11:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2155-6-4**] 1:40 Completed by:[**2155-4-25**]

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icd9cm

[ [ [] ] ]

[ "88.72", "38.93", "96.72" ]

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54022

Discharge summary

report

Admission Date: [**2178-4-1**] Discharge Date: [**2178-4-3**] Date of Birth: [**2105-4-29**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7333**] Chief Complaint: elective pulmonary vein ablation Major Surgical or Invasive Procedure: Pulmonary vein ablation History of Present Illness: Mr. [**Known lastname 29132**] is a 72 y.o. gentleman with a history of CVA ([**2170**] and [**2174**]) with residual L-sided weakness, HTN, dyslipidemia, atrial flutter s/p unsuccessful cardioversion in [**State 108**] on [**2178-3-4**], s/p TEE with successful cardioversion [**2178-3-17**] who presented to hospital for elective pulmonary vein ablation. He tolerated his procedure well, which requried intubation with fentanyl 100mcg and was initially reversed and extubated. Shortly after extubation, he was groggy, but following commands and talking. Then about 10-15 min later, he started to become unresponsive and was no longer breathing. He was emergently re-intubated and had an ABG done. Glucose was wnl. He was given narcan 100mg with no improvement. Then became HTN to 150s and agitated and was started on a propofol gtt. He had no hypotension. Pupils were equal and reactive. He has sheaths still in place that will be removed shortly. His heparin gtt was stopped. He was then transfered to the CCU. Unable to get ROS given pt was intubated and sedated. Past Medical History: 1. CARDIAC RISK FACTORS: (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: - CABG: None. - PERCUTANEOUS CORONARY INTERVENTIONS: None. - PACING/ICD: None. - aflutter, s/p cardioversion [**3-16**], with amio load 3. OTHER PAST MEDICAL HISTORY: - CVA: history of right inferior MCA stroke in [**2170-8-3**] with residual mild left hemiparesis adn recurrence in [**2174**]. - Ulcerative Colitis: quiescent, followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2305**], M.D.; reportedly had 4+ guaiac stools in the past. - Depression - History of gastritis - Chronic renal insufficiency- Baseline Cr 1.2-1.4 Social History: CPA; Lives alone in [**Location (un) **], MA. Widower; lost wife about 1.5 years ago (cirrhosis). -Tobacco history: Current PPD smoker (states that he "quit when he came to the hospital"). Approx 45 pack year history. -ETOH: Last drink over a year ago. Used to drink [**2-5**] large cups of Vodka; more than [**1-4**] gallon of vodka every 10 days. -Illicit drugs: none Family History: Mother had pancreatic CA at 75. Father had MI at 81. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Admission Exam VS: T=97.0 BP=156/65 HR=63 RR=22 O2 sat=98% face mask 50% GENERAL: Awake and answering questions appropriately. HEENT: PERRL, EOMI. NECK: Supple, JVP difficult to assess. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CTAB anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Radial 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Radial 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: # RADIOLOGY [**4-2**] Chest Xray (Portable) IMPRESSION: 1. Right lower lobe opacity, focal atelectasis althoug pneumonia cannot be excluded. 2. New mild pulmonary edema. 3. Stable mild cardiomegaly. # MICROBIOLOGY URINE CULTURE (Final [**2178-4-3**]): GRAM POSITIVE BACTERIA. ~1000/ML. SUGGESTING STAPHYLOCOCCI. # LABORATORY DATA Admission Labs [**2178-4-1**] 07:45AM BLOOD WBC-6.0 RBC-4.06* Hgb-12.7* Hct-36.8* MCV-91 MCH-31.2 MCHC-34.5 RDW-13.2 Plt Ct-200 [**2178-4-1**] 07:45AM BLOOD Neuts-64.3 Lymphs-16.3* Monos-10.0 Eos-8.8* Baso-0.5 [**2178-4-1**] 07:45AM BLOOD PT-24.0* INR(PT)-2.3* [**2178-4-1**] 07:45AM BLOOD Glucose-88 UreaN-13 Creat-1.4* Na-138 K-3.9 Cl-102 HCO3-28 AnGap-12 [**2178-4-1**] 05:36PM BLOOD CK(CPK)-152 [**2178-4-1**] 05:36PM BLOOD Calcium-8.9 Phos-3.9 Mg-1.6 [**2178-4-1**] 03:53PM BLOOD Type-ART pO2-418* pCO2-38 pH-7.37 calTCO2-23 Base XS--2 Intubat-INTUBATED [**2178-4-1**] 03:53PM BLOOD Glucose-105 Lactate-0.8 Na-137 K-3.7 Cl-104 [**2178-4-1**] 03:53PM BLOOD Hgb-11.9* calcHCT-36 O2 Sat-99 COHgb-1 [**2178-4-1**] 03:53PM BLOOD freeCa-1.12 Cardiac Enzymes [**2178-4-1**] 05:36PM BLOOD CK-MB-8 cTropnT-1.05* [**2178-4-2**] 04:41AM BLOOD CK-MB-8 cTropnT-1.57* Discharge Labs [**2178-4-3**] 07:35AM BLOOD WBC-8.3 RBC-3.86* Hgb-11.9* Hct-35.0* MCV-91 MCH-30.9 MCHC-34.0 RDW-13.2 Plt Ct-167 [**2178-4-3**] 07:35AM BLOOD PT-34.5* PTT-36.3* INR(PT)-3.5* [**2178-4-3**] 07:35AM BLOOD Glucose-101* UreaN-10 Creat-1.0 Na-133 K-3.9 Cl-101 HCO3-23 AnGap-13 [**2178-4-3**] 07:35AM BLOOD Calcium-8.0* Phos-1.9*# Mg-1.8 Brief Hospital Course: Pt is a 72 year old man with history of Atrial fib/flutter and CVA x2 with residual left-sided hemiparesis who was admitted to the CCU after failed extubation and concern for repeat CVA. # Non-responsiveness after extubation: Likely medication-induced from prolonged anesthetic agents. There was initial concern for repeat CVA since he is at high risk, but there was no evidence of stroke. The patient improved significantly and was re-extubated; he tolerated shovel face mask well and was awake and alert. There were no arrhythmias on telemetry and ABG did no show acidosis or hypercarbia. Troponins trended up in the setting of PVI and atrial flutter ablation, however CK-MB remained flat. # SIRS: Likely secondary to pneumonia; there is concern that patient aspirated given multiple intubations. He spiked a fever to 101.3 axillary, was tachypneic and became hypotensive. Received 5 liters of normal saline; systolic BPs were in the 90-100s. He was started on broad spectrum antibiotics (vancomycin/piperacillin-tazobactam), but these were changed as the patient improved clinically. Ambulatory O2 sat was 94% prior to discharge. He was discharged home on 5 days of cefpodoxime and metronidazole. # RHYTHM: Remained in sinus rhythm status post pulmonary vein isolation and atrial flutter ablation. Received amiodarone 200mg daily, aspirin 81mg daily and warfarin 2.5mg daily. # Hypertension: Not an issue, in fact, patient had an episode of hypotension in the setting of infection. He was fluid resuscitated and his blood pressure stabilized without the need for pressors. # Hyperlipidemia: Continued atorvastatin 80mg daily. # History of gastritis: Not on an H2-blocker or PPI on admission. Was started on omeprazole. # Chronic renal insufficiency: Patient was at baseline Cr of 1.2. Discharged on lisinopril. # DVT Prophylaxis: Systemic anticoagulation with coumadin. # CODE: Full Code. Medications on Admission: -Coumadin 2.5mg alteranating with 5mg qday -Lipitor 80mg -thiamine 100mg qday -MV qday -Amiodarone 200mg qday Discharge Medications: 1. aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. 2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Zyrtec 10 mg Capsule Sig: One (1) Capsule PO once a day. 6. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for fever, pain. 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB, wheezing. Disp:*1 inhlaer* Refills:*2* 8. dextromethorphan poly complex 30 mg/5 mL Suspension, Extended Rel 12 hr Sig: Ten (10) ml PO Q12H (every 12 hours). Disp:*1 bottle* Refills:*2* 9. 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* 10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*20 Tablet(s)* Refills:*0* 12. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. Disp:*15 Tablet(s)* Refills:*0* 13. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-4**] Puffs Inhalation Q6H (every 6 hours). Disp:*1 inhaler* Refills:*2* 14. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a day. 15. Outpatient Lab Work Please check INR and chem-7 on Monday [**4-6**] with results to Dr. [**Last Name (STitle) **] at Phone: [**Telephone/Fax (1) 6937**] Fax: [**Telephone/Fax (1) 6936**] Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Atrial fibrillation/flutter s/p DCCv X2 Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. VS: Lungs clear AP RRR Abdomen is soft, nontedner (+) bowel sounds Bilateral groins without hematoma, bruit (+) peripheral pulses INR [**2178-4-2**]: 3.5 Discharge Instructions: You were admitted to the hopsital following a pulmonary vein ablation to treat atrial fibrillation. We had some trouble taking you off the ventilator and had to reinsert the tube again. Your blood pressure was low in the CCU but is now normal to high. Your lisinopril was restarted to better control your blood pressure. You also had a fever and we started you on antibiotics briefly in case you had a pneumonia. You are in a normal heart rhythm now but you should still continue on warfarin. . We made the following changes to your medicines: 1. Do not take your coumadin tonight and take 2.5 mg daily on Saturday and Sunday. You will get your INR checked on Monday by the VNA. 2. Start taking cefpodime and flagyl for the next 5 days to treat a possible pneumonia 3. Start taking albuterol inhaler when you feel short of breath or wheezy. 4. Use ipratropium-albuterol inhaler 4 times per day to treat your shortness of breath 6. Start taking omeprazole to prevent any stomach irritation from the procedure 7. Start taking dextromethorphan for your cough 8. Resume taking your lisinopril for your blood pressure. Followup Instructions: Department: GASTROENTEROLOGY When: MONDAY [**2178-5-25**] at 10:30 AM With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: WEST [**Hospital 2002**] CLINIC When: MONDAY [**2178-11-30**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage . Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Address: [**Location (un) **],[**Apartment Address(1) 77889**], [**Location (un) **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 1713**] Appointment: Thursday [**7-2**] at 9:30AM Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Specialty: Cardiology Address: [**Hospital1 **], [**Location (un) **],[**Numeric Identifier 6425**] Phone: [**Telephone/Fax (1) 6937**] Date/Time: [**2178-4-7**] 3:30PM **Please contact Dr [**Name (NI) **] confirm this appointment. You will need to be seen 2 weeks after you are discharged from the hospital** Completed by:[**2178-4-4**]

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icd9cm

[ [ [] ] ]

[ "37.27", "37.34" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2153-9-16**] Discharge Date: [**2153-9-22**] Date of Birth: [**2091-7-30**] Sex: M Service: MEDICINE Allergies: Biaxin Attending:[**First Name3 (LF) 3556**] Chief Complaint: # Productive cough # Shortness of breath # Dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: 62M h/o cadaveric renal transplant ([**2152-12-31**]) for membranous glomerulonephritis (previously HD-dependent x 8 years), s/p renal artery stent ([**2153-5-11**]), presented with T 100 x 4 days prior to admit, cough with brown sputum, hypotension to 90-100/40-50 (baseline 130-140/60s), and extreme DOE with walking a few feet. Pt has been using nebulizers instead of inhalers with some relief. . Pt had been discharged on [**2153-7-24**] after being treated for PNA (Gram-positive organisms in pairs/clusters) with 10-day course of levofloxacin 250mg q24h. Pt reported that his cough and respiratory status since that admission had not significantly improved. . ED course: T 99.2, PR 104, BP 109/47, RR 27, O2sat 92%RA -> 98% on 4L. Pt received levofloxacin 750mg x 1 dose, and was admitted to the floor. Past Medical History: # Membranous glomerulonephritis --Previously on HD: R forearm patent fistula --Calciphylaxis: Skin grafts on abdomen, leg --Cadaveric kidney transplant ([**2152-12-31**]) --Renal artery stent ([**2153-5-11**]) # CAD s/p 3CABG+BMS ([**Hospital1 2025**] [**2149**]) --Sternal wound dehiscence/infection-->Sternectomy-->Skin grafts, muscle flaps from abdomen-->LLQ hernia # Sick sinus syndrome: Sigma 300DR pacer ([**2153-4-6**]) # CVA ([**2146**]) --Cerebral angiography-->Stent --Residual L foot drop # Hypertension # Hyperlipidemia # CHF # Asthma # Anemia --Chronic disease --Iron deficiency # Pancreatic insufficiency, resolved after renal transplant Social History: # Employment: Retired police officer # Personal: Married # Tobacco: Quit remotely. 1ppd x 35 years. # Alcohol: No current use Family History: Noncontributory Physical Exam: VS = T 97.1, BP 130/50, P 80, R 16, O2sat 98% 4L . Gen: NAD, laying in bed. Appears fatigued. HEENT: NCAT, no LAD, CNII-XII grossly intact. CV: RRR, [**2-26**] murmur best heard at RUSB, S1S2, no r/g/S3/S4 appreciated Chest: Decreased breath sounds at R base. Dry rales heard throughout all fields. Abdomen: Soft, +BS, ND, large pannus. RLQ tenderness at location of healing abrasion along scar intersection. LLQ reducible hernia. Ext: No edema, warm. Darkened skin at distal BLE. Neuro: Nonfocal. Pertinent Results: Admission labs: . [**2153-9-16**] 02:31AM PLT COUNT-215 [**2153-9-16**] 02:31AM NEUTS-88.7* LYMPHS-6.7* MONOS-3.2 EOS-0.9 BASOS-0.5 [**2153-9-16**] 02:31AM WBC-3.6* RBC-3.27* HGB-8.2* HCT-25.3* MCV-77* MCH-24.9* MCHC-32.2 RDW-17.5* [**2153-9-16**] 02:31AM ALBUMIN-3.3* CALCIUM-8.3* PHOSPHATE-3.2 MAGNESIUM-2.1 [**2153-9-16**] 02:31AM CK-MB-NotDone [**2153-9-16**] 02:31AM CK(CPK)-71 [**2153-9-16**] 02:31AM GLUCOSE-123* UREA N-53* CREAT-3.1* SODIUM-134 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-19* ANION GAP-20 [**2153-9-16**] 02:46AM LACTATE-1.5 ================================ . Studies: . # CT CHEST W/O CONTRAST [**2153-9-16**] 10:34 AM CT OF THE CHEST WITHOUT CONTRAST: There is severe diffuse calcific atherosclerotic disease involving the aorta, left anterior descending, left circumflex and right coronary arteries. The heart is moderately enlarged. There is no pericardial effusion. Multiple median sternotomy wires are noted. A dual-chamber pacemaker remains in the left upper chest. Soft tissue windows again demonstrate prominent mediastinal lymphadenopathy. The largest lymph node is located in the pretracheal space and measures 14 mm in diameter is relatively unchanged in appearance compared to [**2153-7-20**] (2:22). Multiple other, non-pathologically enlarged mediastinal lymph nodes are noted. There is no axillary lymphadenopathy. A right lower lobe rounded area of consolidation is unchanged compared to the previous examination (2:41). A subcentimeter nodular mass in the left lower lobe is relatively unchanged in appearance or size, accounting for differences in technique, compared to the previous examination (3:34). Compared to the previous examination there are worsening multifocal patchy opacities present throughout all lung fields. Stable appearance of background centrilobular emphysema is noted. . Limited views of the upper abdomen demonstrate splenic artery calcifications _____ a tiny calcified granuloma located within the spleen. . BONE WINDOWS: No suspicious lytic or blastic lesions are present. . IMPRESSION: 1. Unchanged appearance of right lower lobe rounded area of either chronic organizing pneumonia versus atelectasis compared to [**2153-7-20**]. Allowing for differences in technique, unchanged appearance of sub- 1-cm left lower lobe nodule. 2. Interval worsening of scattered ground-glass opacities present within both lungs but worst on the left. Infectious etiologies such as bacterial and atypical/fungal processes remain within the differential diagnosis. There is persistent mediastinal lymphadenopathy, likely reactive and reflective of chronic ongoing infectious process. A small amount of underlying mild pulmonary edema cannot be completely excluded. . # CHEST (PORTABLE AP) [**2153-9-16**] 2:19 AM CHEST, SINGLE PORTABLE VIEW: The heart size and mediastinal contours are unchanged. The patient is status post sternotomy and CABG. Dual-lead pacemaker is unchanged in position. There remains a small right pleural effusion with fluid tracking into the minor fissure. Retrocardiac opacity on the right persists but has improved compared to [**2153-7-23**]. The left lung is clear. Increased interstitial markings bilaterally persist. . IMPRESSION: Small right pleural effusion. Right retrocardiac opacity persists although has improved, and could represent atelectasis or pneumonia. . # CHEST (PA & LAT) [**2153-9-16**] 10:32 AM Status post sternotomy with mediastinal clips. There is cardiomegaly and unfolded aorta. A left-sided dual lead pacemaker is present with lead tips over right atrium and right ventricle. The lungs are diffusely abnormal, there is upper zone redistribution, and diffusely increased interstitial markings. There is a more confluent opacity along the left lower chest wall and more focal opacity abutting the left upper chest wall. At the right base, there is pleural fluid and/or thickening, with extension into the right minor fissure. Compared with [**2153-9-16**], the right heart border is now indistinct and there is a new or more pronounced rounded mass at the right base. Possibility of some superimposed CHF cannot be excluded as the interstitial markings and upper zone redistribution is more pronounced on the current examination. . IMPRESSION: Background interstitial changes in both lungs, probably with some superimposed CHF. Right pleural fluid thickening, unchanged. New obscuration of the right heart border and new or more prominent right base opacity. Brief Hospital Course: 62M h/o [**2152**] cadaveric renal transplant for membranous glomerulonephritis, immunosuppressed, restrictive lung disease, presented with worsening productive cough and DOE, elevated temperature, low blood pressure, in setting of recent PNA treated with 10-day course of levofloxacin 250mg q24h. Pt was originally admitted to the wards but had worsening shortness of breath and hypoxia so was transferred to the MICU. Pt was placed on BIPAP originally, and treated empirically for pneumonia. Pt had bronch with BAL to rule out PCP or other fungal source of infection. Initial cultures did not show PCP but further cultures were pending. Additionally patient had worsening UOP and renal transplant was consulted. Pt thought to have rapamycin induced pneumonitis and his rapamycin was discontinued and changed to Prograf. Pts renal failure persisted throughout his course. Pt was on pressors to maintain a SBP of 110 to keep renal perfusion. On [**9-21**] pt had worsening respiratory failure and required intubation. Subsequently his family decided that given his chronic renal failure and the patients inherent desire not to want to undergo further hemodialysis, that they woudl like to withdraw care. A Family meeting was held and the decision was made to withdraw support. Pt died at 8:40pm on [**2153-9-22**]. Medications on Admission: Venlafaxine (Effexor) 37.5mg daily Aspirin 81mg daily Fluticasone/Salmeterol (Advair) 1IH [**Hospital1 **] Albuterol 1IH [**Hospital1 **] Esomeprazole (Nexium) 40mg daily Bactrim 1 tab daily Clopidogrel (Plavix) 75mg daily Alendronate (Fosamax) 35mg weekly Pravastatin (Pravachol) 40mg daily Toprol XL 200mg daily Amlodipine 10mg daily Furosemide 40mg daily Mycophenolate mofetil (CellCept) 250mg [**Hospital1 **] Ezetimibe (Zetia) 10mg daily (pt had not started this yet) Epoetin alfa 40,000 units weekly Sirolimus (Rapamune) 2mg daily Ferrous sulfate 325 mg [**Hospital1 **] Sodium bicarbonate 1300 mg PO TID Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

[ "414.01", "584.9", "428.0", "518.81", "V45.81", "585.9", "V45.01", "486", "403.90", "272.4", "996.81", "285.21", "493.90" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9041, 9050

7062, 8380

330, 336

9113, 9118

2566, 2566

9170, 9305

2011, 2028

9071, 9092

8406, 9018

9142, 9147

2043, 2547

228, 292

364, 1177

2582, 7039

1199, 1852

1868, 1995

28,037

178,004

43446+58618

Discharge summary

report+addendum

Admission Date: [**2124-2-19**] Discharge Date: [**2124-2-25**] Date of Birth: [**2048-12-1**] Sex: M Service: MEDICINE Allergies: Septra / Sulfonamides Attending:[**First Name3 (LF) 134**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization Ablation of ventricular tachycardia History of Present Illness: EVENTS / HISTORY OF PRESENTING ILLNESS: 75 M h/o CAD s/p PCI x 2, EF=45%, in his USOH until 6pm while eating dinner, when he developed acute onset SSCP "15/10" non-radiating, no associated sob, diaphoresis/n/v. He describes as central chest pressure, similar to his MI in [**2095**]. He felt it may be [**3-11**] his dinner, and induced vomiting with mild releif. He took nitro spray x3 with some benefit also ([**7-18**] pain). . EMS was activated, and after receiving amio bolus + drip, was apparently with 2/10 chest pain though per EMS remained in stable VT. . On arrival to [**Hospital1 18**] ED, VS=97.6 164 90/p 22 97%. His chest pain apparently persisted, [**3-19**], though per pt did not worsen. BP 119/86, pt given versed 2mg and shocked @ 100J x 1 though was apparently hemodynamically stable throughout, after which he converted to NSR. He was then noted to be lethargic and sats 100%NRB, though subsequently became more arousable. He also received 1L IVF NS and amio 150mg iv x 1. He was seen by cardiology, who recommended switching to lidocaine gtt. Post-cardioversion EKG was concerning for STD V2-4, thus pt was loaded with plavix 600mg, heparin gtt, integrellin gtt, and admitted to CCU in anticipation of cath in AM. . . Of note, pt has stable central chest pressures which occurs after walking [**2-11**] miles, and is releived by 1 SL NTG. Has episodes 2-3x/wk, never at rest, worse after drinking coffee. . . + h/o stroke [**2116**] (etiology unclear, denies "embolism"), dark stools (h/o UC, none in past 5 yrs). . On review of symptoms, he denies any prior history of TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis. 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, ankle edema, palpitations, syncope or presyncope. Past Medical History: CAD - MI '[**95**], PCA of RCA in '[**11**], in-stent re-stenosis/rotational ablation '[**12**], PCI Cx '[**14**], in-stent re-stenosis '[**15**]. TO LCx, with R->L collaterals. - HTN - hyperlipid - CHF (EF=40-45%) - COPD/Bronchitis - normal spirometry [**11-11**] (pred FEV1/FVC>100%) - multiple melanoma s/p multiple resections - ulcerative colitis s/p colectomy for uretocecal fistula - CVA - [**2116**] leading to slurred speach - peripheral neuropathy [**3-11**] "poor blood flow", numbness/tingling in feet, no claudication sx. - bowel spasm - cystitis Social History: Retired police officeer, works part-time as librarian; married with four children; 30 pack/yr smoking hx; quit 30 yrs prior; former alcoholic; quit in [**2095**] Family History: No family history of premature cardiac disease or sudden cardiac death Physical Exam: VS: 71 122/69 19 96%RA Gen: WDWN middle aged 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 with JVP of 8 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. 3/6 SEM LLSB, no radiation to carotids. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. crackles bilateral bases, no wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. vertical midline well healed scar [**3-11**] colectomy. No abdominial bruits. Ext: No c/c/e. No femoral bruits bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP RECTAL: guaic negative. Pertinent Results: [**2124-2-19**] 08:45PM PT-12.9 PTT-26.6 INR(PT)-1.1 [**2124-2-19**] 08:45PM PLT COUNT-249 [**2124-2-19**] 08:45PM NEUTS-75.8* LYMPHS-18.1 MONOS-3.6 EOS-2.2 BASOS-0.3 [**2124-2-19**] 08:45PM WBC-11.3*# RBC-4.47* HGB-14.3 HCT-40.0 MCV-90 MCH-32.1* MCHC-35.8* RDW-12.9 [**2124-2-19**] 08:45PM CALCIUM-9.6 PHOSPHATE-2.1* MAGNESIUM-2.0 [**2124-2-19**] 08:45PM cTropnT-0.01 [**2124-2-19**] 08:45PM CK(CPK)-76 [**2124-2-19**] 08:45PM UREA N-19 CREAT-1.2 SODIUM-141 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16 [**2124-2-19**] 11:41PM MAGNESIUM-2.1 [**2124-2-19**] 11:41PM POTASSIUM-3.8 . ECHO [**2124-2-24**] The left atrium is normal in size. The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis/akinesis of the inferior and inferolateral walls. Right ventricular chamber size and free wall motion are normal. The aortic valve is bicuspid. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (area 1.2cm2). The mitral valve leaflets are mildly thickened. Mild to moderate ([**2-9**]+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. . Cardiac CATH [**2124-2-21**] COMMENTS: 1. Selective angiography in this right dominant system revealed one vessel CAD. The LMCA was calcified but free of angiographically apparent obstructive CAD. The LAD had proximal 20% stenosis and 50% mid vessel. The LCX had moderate calcification and was proximally occluded. The RCA had minimal luminal irregularities, diffuse disease and serial 30-50% stenoses. 2. Resting hemodynamics revealed normal right sided and elevated left sided filling pressures with RVEDP of 6 mmHg and LVEDP of 15 mmHg. There was elevated systemic blood pressure with SBP of 143 mmHg. Cardiac index was preserved at 2.75 l/min/m2. 3. There was mild aortic stenosis with mean gradient of 16.55 mmHg and calculated aortic valve area of 1.36 cm2. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Mild aortic stenosis. Brief Hospital Course: . ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN MULTIDISCIPLINARY ROUNDS: . 75M h/o CAD, s/p PCI, EF=45%, presenting with stable VT s/p external shock x 1 with conversion to NSR, with ?STD on post-cardioversion EKG. . # CAD/Ischemia: baseline stable angina, unchanged over past [**3-12**] yrs, post-cardioversion EKG with STD in V2-5, and ?horizontal STE in III, aVF. CP. Taken to cath lab which showed diffuse dx and TO to LCX but no intervention was performed. Recommended medical management. Patient was continued on aspirin, statin and Betablocker and ACE inhibitor were titrated as blood pressure tolerated. Electrolytes were repleted aggressively. Not started on plavix as no intervention was performed. Patient remained chest pain free for duration of stay. . # Pump: Repeat ECHO on this admission demonstrated persistent hypokinesis of inferior walls with EF 45%, unchanged from prior. Treated with ACE inhibitor for afterload reduction. No need for diuresis as currently was not in decompensated heart failure. . # Rhythm: S/p VT ablation. 4 areas of inducible VT were noted.Pt had CP during VT underwent cardiac catheterization that showed TO of LCX but no lesion to intervene upon. The following day second EP study was performed. Several endocardial ablations were completed. 1 VT was induced and patient became hypotensive requiring external shock and pressors for short time. Not all foci could be ablated. Patient monitored on telemetry with no further episodes of VT. Did have occasional PVCs. . # Valves: Bicuspid aortic valve. Moderate AV stenosis [**Location (un) 109**] 1.2cm noted on ECHO, worse since prior study in [**2122**]. Will require serial ECHOs as outpatient . # Fever: Started augmentin. UA with 8 WBCs. As had line placements, patient treated empirically with 7 day course of augmentin. . # ulcerative colitis - s/p colectomy for uretocecal fistula, currently asx, on asacol, guaiac negative presently. Continued home dose asacol. . # CVA - [**2116**] leading to slurred speach. Continued on aspirin and statin. . # BPH - continued home finasteride. . # Code: FULL CODE. . # Communication: wife - [**Name (NI) **] - ([**Telephone/Fax (1) 93491**]. Medications on Admission: aspirin 81 mg po qdaily pravachol 80 mg po qdaily prilosec 20mg po qdaily finesteride 5mg po qdaily asacol 1600mg po tid metoprolol succinate 25mg po qdaily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 5. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 6 days. Disp:*12 Tablet(s)* Refills:*0* 6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Ventricular tachycardia Secondary: Coronary artery disease Discharge Condition: Vital signs stable, normal sinus rhythm, chest pain free Discharge Instructions: You were admitted to the hospital and were found to have an abnormal heart rhythm called ventricular tachycardia. This required electric shocks to reverse. . You were started on new medications. These include: Aspirin 325mg daily Toprol xl 50mg daily Lisinopril 5mg daily . You were also given a prescription for Augmentin. You were spiking fevers prior to discharge. Since starting your antibiotics, your fevers have improved. Please complete the course of medication. . Please call Dr.[**Name (NI) 9388**] office to set up an appointment at [**Telephone/Fax (1) 10662**] in the next 2 weeks. . Please call your primary care doctor, Dr. [**Last Name (STitle) 2204**] to set up an appointment in the next 2-3 weeks. . Please call your doctor or return to the emergency room if you develop any worrisome symptoms such as chest pain, shortness of breath, lightheadedness, palpitations (fluttering in your chest), etc. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD Phone:[**Telephone/Fax (1) 10662**] Date/Time:[**2124-4-11**] 9:30 Name: [**Known lastname 14742**],[**Known firstname 33**] E Unit No: [**Numeric Identifier 14743**] Admission Date: [**2124-2-19**] Discharge Date: [**2124-2-25**] Date of Birth: [**2048-12-1**] Sex: M Service: MEDICINE Allergies: Septra / Sulfonamides Attending:[**First Name3 (LF) 6568**] Addendum: Pt had an NSTEMI during his admission with elevation in his cardiac enzymes. He has acute on chronic systolic and diastolic CHF with a documented EF of 40-45%. He has aortic stenosis. Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3518**] MD [**MD Number(1) 3519**] Completed by:[**2124-3-10**]

[ "V12.54", "425.4", "600.00", "599.0", "496", "401.9", "V45.3", "428.43", "427.1", "272.4", "355.8", "413.9", "V10.82", "412", "V45.82", "410.71", "746.4", "428.0", "414.01", "458.29" ]

icd9cm

[ [ [] ] ]

[ "99.62", "37.34", "88.56", "37.23", "37.27" ]

icd9pcs

[ [ [] ] ]

11692, 11855

6532, 8725

292, 354

9948, 10007

4243, 6426

10971, 11669

3195, 3267

8933, 9807

9857, 9927

8751, 8910

6443, 6509

10031, 10948

3282, 4224

242, 254

382, 2415

2438, 3000

3016, 3179

82,433

150,068

41538+58455

Discharge summary

report+addendum

Admission Date: [**2129-12-5**] Discharge Date: [**2129-12-28**] Date of Birth: [**2062-5-24**] Sex: F Service: SURGERY Allergies: Nitrofurantoin / Yellow Dye / Iron / Calcium Attending:[**First Name3 (LF) 2836**] Chief Complaint: Increased abdominal pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: 67 yo F with h/o PUD which was c/b gastric outlet obstruction s/p vagotomy, antrectomy and bilroth II repair [**4-22**] c/b jejunal stump leak and recurrent liver abscesses s/p drainage and fistula creation, polymicrobial BSI s/p treatment course of daptomycin, meropenem, fluconazole (finished course of IV abx on [**2129-11-17**]) presenting with worsening abdominal pain. Patient has had an extensive medical course since surgery in [**4-22**] including multiple hospitalizations and rehab stays and was on IV abx until [**2129-11-17**]. She was living in an ECF ([**Month/Day/Year 5682**]) until around when abx were discontinued and went home to live with her husband. She was doing okay at home, with increasing PO intake and a stable level of pain and nausea however over the last few days, her pain has worsened. Per family, on Tuesday last week patient was admitted to [**Hospital **] Hospital after a fall. Patient doesn't remember the fall, but she had just taken several pain medications (incl dilaudid, which she takes every 4 hours 4 mg without fail) and per her daughter and husband she often gets confused after taking her medications. She had a workup at [**Hospital **] hospital which showed no fractures or other process, and was discharged within a few hours to [**Hospital 5682**] ECF again. . Over the last few days at [**Hospital 5682**], paitent has complained of worsening pain and stable nausea. Denies any vomiting, constipation, cough, fevers, chills, or other symptoms. She presented today for worsening pain despite her pain medications. Pain is stabbing in nature associated with nausea. Also thinks that her fistual output may be increasing. . In the ED, initial VS were 98.8 100 111/60 24 94% ra. ED exam with diffuse ttp mainly over the RUQ/RLQ. Ostomy site with green cloudy fluid. Labs notable for WBC 26.1, Hct 27.7 (at baseline), ALT 131, AST 51, Na 132, HCO3 19, alk phos 1452. CT abd/pelvis with Left lower lobe opacification compatible with pneumonia, decreased mid abdominal collection. She received dilaudid 1 mg IV x 2, zofran as well as IV ativan. Surgery consulted in ED, recommended CT abd with contrast, CT abd was done which showed abscesses largely unchanged but LLL PNA. Surgery recommended no intervention now, admit to medicine for IV abx for PNA with surgery following. Pt was given dose of vanco/zosyn for HCAP. . Currently, patient complains of [**4-21**] pain, much imprved from when she came in, howver she is not oriented to place or year having just received IV ativan and dilaudid. Per daughter who gave most history, patient veyr often gets like this after receiving pain or anxiety medications. . Per Opt ID note: Subsequent course after initial surgery was complicated by polymicrobial BSI (Enterobacter cloacae, VRE, MRSA, Clostridium) and hepatic abscess requiring drainage on [**6-1**] (Enterobacter, Enterococcus) s/p drain removal and prolonged course of antibiotic therapy (daptomycin, ertapenem) ending [**7-6**]. . She was re-admitted on [**7-15**] with a recurrent fluid collection. Treatment with daptomycin and meropenem was re-initiated. She underwent CT guided drainage of that major collection and cultures grew [**Female First Name (un) 564**] albicans and [**Female First Name (un) 29361**], VRE. Micafungin was added to her antibiotic regimen. . In the setting of a persistent leukocytosis, she was found to have a new liver abscess on [**7-30**] and underwent CT guided drainage with fluid growing VRE, MRSA and yeast. On [**7-28**], her antibiotics were simplifed to tigecycline, micafungin. however due to abdominal cramping which may have been in part related to tigecycline, her regimen was changed to daptomycin, ertapenem, and fluconazole on [**2129-8-11**]. . On [**8-17**] she was readmitted to the hospital for elevation of LFTs and increasing abdominal pain. CT of the abdomen on [**8-17**] showed an increased fluid collection in the caudate lobe of the liver measuring 2.1x2.3cm. Patient had CT guided drainage of the fluid collection on [**8-19**] and culture results grew Klebsiella pneumoniae that was pansensitive. Patient was maintained on Daptomycin and Fluconazole however Ertapenem was changed to Meropenem on [**8-18**]. Decision was made to maintain the patient on Meropenem on discharge instead of ertapenem for coverage of Enterbacter which grew previously as she seemed to have improvement in her abdominal pain, transaminitis, and remained afebrile with Meropenem. Dosing was changed from q6h to q8h to help ease administration of the medicine. . Antibiotic course: [**Date range (1) 90350**] Daptomycin, Ertapenem [**Date range (1) 3047**] Daptomycin [**Date range (1) 90351**] Linezolid [**Date range (1) 90352**] Meropenem [**Date range (1) 29023**] Tigecycline (switched due to abd cramping) [**Date range (1) 90353**] Micafungin [**8-11**] abx changed to Daptomycin, Ertapenem, and Fluconazole on discharge [**8-18**] Daptomycin and Fluconazole continued from previous discharge and Ertapenem changed to Meropenem . She had a CT of the abdomen on [**11-1**] which showed some minimal improvement in previously seen fluid collections near the liver though a new 2cm fluid collection was found in between the loops of the jejunum (not amenable to percutaneous drainage). On [**11-17**], she was taken off Daptomycin, Meropenem. An was started on Bactrim DS 1 tab po BID and continue Fluconazole 400mg po daily. Past Medical History: chronic back pain sciatica HTN PUD adrenal adenoma uterine CA s/p hysterectomy depression anemia of chronic disease recurrent hepatic abscess Polymicrobial bacteremia - Enterobacter cloacae, VRE, MRSA, Clostridium - s/p several month course of abx, most recently daptomycin and meropenem (see ID OPAT note for details) Abdominal fluid collections growing [**Female First Name (un) 564**] albicans and [**Female First Name (un) 29361**], VRE Right hepatic vein thrombosis, on warfarin . PSH: EUS, pyloric ulcer bx, perigastric LNB ([**2129-4-25**]) EGD with duodenal stricture dilation ([**2129-4-25**]) Vagotomy and antrectomy with B2 reconstruction ([**2129-5-5**]) Re-exploration,lateral duo tube and feeding J-tube ([**2129-5-7**]) CT-guided catheter drainage of liver abscess ([**2129-6-1**]) perforated cyst/appendix s/p SBR, appendectomy cystectomy as a teenager s/p hysterectomy for uterine cancer @age 29 Social History: Lives at home with husband, was in long term rehab ([**Name (NI) 5682**] ECF) since her discharge in [**9-22**]. Former [**Date Range 1818**], half pack per day. Denies alcohol use. Family History: Father with peptic ulcer disease Physical Exam: On Admission: VS - 97.0 119/66 89 20 95% 2L GENERAL - thin and frail appearing F in NAD, comfortable, appears sleepy HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - + crackles about 1/3 up from base of L lung field, no wheezes, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft, diffusely TTP more prominantly in RLQ, no rebound/guarding, fistula output on R side with green turbid fluid, no masses or HSM EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, alert, oriented ot self, month, not to year or place (knows she is at hospital but thinks [**Hospital1 **]), CNs II-XII grossly intact, muscle strength 5/5 throughout On Discharge: VS: GEN: CV: PULM: ABD: EXTR: NEURO: Pertinent Results: [**2129-12-21**] 10:15AM BLOOD WBC-20.1* RBC-3.14* Hgb-8.3* Hct-26.5* MCV-84 MCH-26.6* MCHC-31.5 RDW-19.7* Plt Ct-612* [**2129-12-21**] 06:10AM BLOOD Glucose-83 UreaN-21* Creat-0.5 Na-135 K-4.6 Cl-104 HCO3-21* AnGap-15 [**2129-12-21**] 06:10AM BLOOD Calcium-8.3* Phos-4.4 Mg-2.1 [**2129-12-21**] 06:10AM BLOOD PT-16.3* PTT-26.6 INR(PT)-1.4* [**2129-12-22**] 05:17AM BLOOD WBC-19.2* RBC-2.83* Hgb-7.5* Hct-24.0* MCV-85 MCH-26.6* MCHC-31.3 RDW-20.6* Plt Ct-457* [**2129-12-21**] 06:10AM BLOOD Glucose-83 UreaN-21* Creat-0.5 Na-135 K-4.6 Cl-104 HCO3-21* AnGap-15 [**2129-12-21**] 06:10AM BLOOD Calcium-8.3* Phos-4.4 Mg-2.1 [**2129-12-5**] 4:45 am URINE Source: Catheter. **FINAL REPORT [**2129-12-8**]** URINE CULTURE (Final [**2129-12-8**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 128 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R [**2129-12-16**] 12:29 am STOOL CONSISTENCY: SOFT **FINAL REPORT [**2129-12-17**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2129-12-17**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [**2129-12-10**] 5:42 pm BLOOD CULTURE 2 OF 2. **FINAL REPORT [**2129-12-16**]** Blood Culture, Routine (Final [**2129-12-16**]): NO GROWTH. [**2129-12-10**] 9:52 am URINE Source: Catheter. **FINAL REPORT [**2129-12-11**]** URINE CULTURE (Final [**2129-12-11**]): NO GROWTH. [**2129-12-5**] CT ABD: IMPRESSION: 1. Left lower lobe consolidation concerning for pneumonia. In addition, stable areas of right nodular opacification since [**2129-11-1**]. 2. Interval decrease in mid abdominal collections in the region of prior surgery at the duodenal stump with no new fluid collections identified; however, a few small bubbles of gas remain with the shrunken residual collection. 3. Stable appearance of enterocutaneous fistula within the right mid abdominal wall. 4. Stable appearance of intrahepatic biliary dilation. Correlation with laboratory data and other clinical factors is recommended; sequelae of a stricture or even potentially a stone is possible despite the lack of change. A small calcified gallstone on the prior study is now absent and may have passed in the interim. 5. Stable appearance of markedly narrowed main portal vein and attenuation of the left portal vein which is probably occluded with collateral flow. Persistent areas of differential enhancement of the liver may accordingly be related to different flow patterns although it is difficult to exclude cholangitis. [**2129-12-5**] LIVER & GALLBLADDER US: IMPRESSION: 1. Turbulent flow in the proximal portion of the main portal vein consistent with severe narrowing as seen on the preceding CT. 2. The left portal vein could not be visualized, which could be related to thrombosis, as seen on the CT. 3. Intrahepatic biliary dilatation consistent with postinflammatory stricture as noted previously. Gall bladder wall thickening appears to relate to this contiguous scarring/inflammatory change. [**2129-12-10**] CXR: IMPRESSION: Improved, but still present left lower lobe infiltrate. [**2129-12-15**] CT ABD: IMPRESSION: 1. Status post Billroth 2 with partial small bowel obstruction of the efferent limb of the gastrojejunostomy, with marked upstream dilatation of the jejunal limb continguous with the duodenal stump, and moderate gastric distention. 2. Increase in extraluminal gas in right upper quadrant including along the border of the left lobe of the liver, near the oversewn duodenal stump and proximal jejunum, and at the base of the enterocutaneous fistula. Compared to [**2129-12-5**], there is a new 2.9 x 1.3 cm rim enhancing aortocaval fluid collection near liver hilum. 3. Stable intrahepatic biliary dilatation and left chronic portal vein occlusion with cavernous transformation. 5. Persistent bibsilar pneumonia, improved on the left but worsened on the right. [**2129-12-16**] ECG: Sinus rhythm with an atrial premature beat. Baseline artifact. Since the previous tracing ventricular premature beat is not seen. Atrial premature beat is new. Brief Hospital Course: 67 yo F with h/o PUD which was c/b gastric outlet obstruction s/p vagotomy, antrectomy and Billroth II repair [**4-22**] c/b jejunal stump leak and recurrent liver abscesses s/p drainage and fistula creation, polymicrobial BSI s/p treatment course of daptomycin, meropenem, fluconazole (finished course of IV abx on [**2129-11-17**]) presenting with acute onset sharp abdominal pain, LLL infiltrate on CXR and CT and unchanged abdominal collections . # Transaminitis: This is likely related to hepatic abscesses which appear stable on CT scan vs hepatic vein thrombosis, although is on Coumadin. US and CT abdomen largely unchanged from prior. She was placed on linezolid and meropenem. She underwent ERCP on 10/27th and was hold off Coumadin prior to her going over for ERCP. After she returned, heparin gtt was started with bridge to warfarin. INR goal is [**3-17**]. She became supratherapeutic and her Coumadin was held until her INR normalized. LFTs improved prior discharge. INR was 1.7. The patient was send home with [**Month/Day (3) 269**] to continue INR monitoring. . # LLL pneumonia/leukocytosis: Most likely related to PNA despite lack of symptoms from PNA or cough. Patient does have leukocytosis however to 26, with elevated alk phos and transaminitis. Imaging does not support intra-abdominal process, but given extensive history, still a concern. The patient has UTI with ENTEROCOCCUS SP., blood cultures x 2 and stool were negative. Knowing her history with multiple drug resistant organisms in blood stream infections, including VRE, Enterobacter resistant to pip/tazo (from [**2129-5-31**]), she was changed to IV linezolid/meropenem. ID was consulted and their recommendations were followed. The patient underwent empirical treatment with IV Linezolid, Meropenem and Fluconazole, after completion of the course, she was restarted on her home antibiotic coverage with Bactrim DS and PO Fluconazole. Repeat urine cultures were negative. She will continue to follow up with ID as outpatient. On discharge, patient still has mild leukocytosis, was afebrile with stable vital signs. . #SBO: Abdominal pain: worse in the last few days, abdominal pain can be associated with PNA. CT abd doesn't appear to be changed from prior, nausea is stable, no diarrhea or vomiting. Repeat CT scan on [**2129-12-15**] demonstrated partial bowel obstruction. The patient was made NPO with NGT, IVF and nutritional service was called for TPN recommendations. PICC line was placed and TPN was started on [**2129-12-17**]. On [**12-18**], NGT was removed, and diet was advanced on [**12-19**], which were well tolerated. Diet was advanced to regular on [**12-21**], and TPN was discontinued. Patient tolerated regular diet well with good appetite and adequate oral intake. . #Anemia of chronic disease: The patient has a history of anemia with Hct ~ 25. On [**2129-12-15**] Hct was 22.1 and patient received one unit of RBC. After transfusion, Hct improved to baseline and was 24.0 prior discharge. Patient's PCP will continue to monitor her Hct as outpatient. . #Chronic pain: The patient has a history of chronic pain and takes Soma, Dilaudid and Hyoscyamine. Fentanyl patch was added to achieve better pain control per Chronic Pain Service. The patient was discharged home with instruction to taper down her Fentanyl patch within 3 weeks. [**Date Range 269**] instructed to monitor patient's pain and will contact [**Name (NI) **] Surgery Service at [**Hospital1 18**] with any questions or concerns. . At the time of discharge on [**2129-12-22**], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with services and home PT. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: -CARISOPRODOL 350 mg Tablet by mouth three times daily -CITALOPRAM 10 mg Tablet by mouth daily -DRONABINOL 2.5 mg Capsule by mouth twice daily -HYDROMORPHONE 2 mg Tablet 2 Tablet(s) by mouth every 4 hours -HYOSCYAMINE SULFATE 0.375 mg Tablet daily -MEGESTROL [MEGACE ES] 40mg [**Hospital1 **] -METOPROLOL TARTRATE 50 mg Tablet - 1 Tablet(s) by mouth twice a day -MIRTAZAPINE 15 mg Tablet by mouth at bedtime -PANTOPRAZOLE 40 mg Tablet by mouth daily -SULFAMETHOXAZOLE-TRIMETHOPRIM - 800 mg-160 mg Tablet - [**Hospital1 **] -WARFARIN 0.5 daily -Flagyl 200mg 2tabs daily -Fentanyl 25mcg/hr TP Q72H -DOCUSATE SODIUM 100 mg Capsule - 1 Capsule(s) by mouth twice daily -POLYETHYLENE GLYCOL 3350 [MIRALAX] -17 g daily Discharge Medications: 1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:*60 Tablet(s)* Refills:*0* 2. carisoprodol 350 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. hyoscyamine sulfate 0.375 mg Capsule,Extended Release 12 hr Sig: One (1) Capsule,Extended Release 12 hr PO BID (2 times a day). Disp:*60 Capsule,Extended Release 12 hr(s)* Refills:*0* 5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO BID (2 times a day). Disp:*60 * Refills:*2* 10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 11. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 12. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a day: Start on [**2129-12-20**]. Disp:*60 Tablet(s)* Refills:*0* 13. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 14. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: PLease continue to check INR. Therapeutic INR [**3-17**]. Disp:*30 Tablet(s)* Refills:*2* 15. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours for 3 doses. Disp:*3 patches* Refills:*0* 16. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours for 3 doses: Please use 50 mcg/hr patch x 3 times, then continue with 25 mcg/hr patch x 3, then stop Fentanyl patch. Disp:*3 patch* Refills:*0* 17. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Northeast Clinical Services Discharge Diagnosis: 1. Left lower lobe pneumonia 2. Partial small bowel obstruction 3. Left portal vein thrombosis 4. Chronic pain 5. Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-21**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Right abdominal drain (ostomy) site: Empty pouch when it is [**2-14**] full and document output from drain site. Change ostomy appliance twice a week. Monitor erythema and induration peri drain site. . Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . Coumadin (Warfarin): What is this medicine used for? This medicine is used to thin the blood so that clots will not form. How does it work? Warfarin changes the body's clotting system. It thins the blood to prevent clots from forming. What you should contact your healthcare provider [**Name Initial (PRE) **]: Signs of a life-threatening reaction. These include wheezing; chest tightness; fever; itching; bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat, severe dizziness or passing out, falls or accidents, especially if you hit your head. Talk with healthcare provider even if you feel fine, significant change in thinking clearly and logically, severe headache, severe back pain, severe belly pain, black, tarry, or bloody stools, blood in the urine, nosebleeds, coughing up blood, vomiting blood, unusual bruising or bleeding, severe menstrual bleedin, or rash. Call your doctor if you are unable to eat for several days, for whatever reason. Also call if you have stomach problems, vomiting, or diarrhea that lasts more than 1 day. These problems could affect your Coumadin??????/warfarin dosage. Coumadin (Warfarin) and diet: Certain foods and beverages can impair the effect of warfarin. For this reason, it's important to pay attention to what you eat while taking this medication. Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid foods high in vitamin K. This is because large amounts of vitamin K can counteract the benefits of warfarin. However, recent research shows that rather than eliminating vitamin K from your diet, it is more important to be consistent in your dietary vitamin K intake. These foods contain vitamin K: Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli, Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower, Peas, Lettuce, Spinach, Turnip, collard, and mustard greens, Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver. Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins, Soybeans and Cashews. Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage but it does not mean you must avoid all alcohol. Serious problems can occur with alcohol and Coumadin??????/warfarin when you drink more than 2 drinks a day or when you change your usual pattern. Binge drinking is not good for you. Be careful on special occasions or holidays, and drink only what you usually would on any regular day of the week. Monitoring: The doctor decides how much Coumadin??????/warfarin you need by testing your blood. The test measures how fast your blood is clotting and lets the doctor know if your dosage should change. If your blood test is too high, you might be at risk for bleeding problems. If it is too low, you might be at risk for forming clots. Your doctor has decided on a range on the blood test that is right for you ([**3-17**]). The blood test used for monitoring is called an INR. Use of Other medications: When Coumadin??????/warfarin is taken with other medicines it can change the way other medicines work. Other medicines can also change the way Coumadin??????/warfarin works. It is very important to talk with your doctor about all of the other medicines that you are taking, including over-the-counter medicines, antibiotics, vitamins, or herbal products. The [**Month/Day (3) 269**] will check you blood for Coumadin level. They will send results to your PCP (Dr. [**Name (NI) 70277**]) and he will continue to adjust your Coumadin intake. . Please continue to taper down your Fentanyl patch as prescribed. Followup Instructions: Department: INFECTIOUS DISEASE When: THURSDAY [**2129-12-29**] at 10:30 AM With: [**Name6 (MD) **] [**Name8 (MD) 32437**], 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: SURGICAL SPECIALTIES When: WEDNESDAY [**2130-1-4**] at 10:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 2998**] Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site . Please follow up with you PCP ( Dr. [**Name (NI) 70277**]) to continue monitor you INR level in [**2-13**] weeks after discharge. Completed by:[**2129-12-22**] Name: [**Known lastname 14279**],[**Known firstname 511**] Unit No: [**Numeric Identifier 14280**] Admission Date: [**2129-12-5**] Discharge Date: [**2129-12-28**] Date of Birth: [**2062-5-24**] Sex: F Service: SURGERY Allergies: Nitrofurantoin / Yellow Dye / Iron / Calcium Attending:[**First Name3 (LF) 3149**] Addendum: The patient was ready to go home with VNA services on [**2129-12-22**]. Approximately at 11 am, patient developed severe nausea and she vomited x 3. She was started on IV fluids and her discharge was put on hold. The patient was stable, afebrile with vital signs within normal limits. Approximately at 3 pm, patient was found to have rigors, her vital signs revealed hypotension with SBP to the 70s, and hyperglycemia with FS 470s and altered mental status. The patient received IV fluid bolus (2L LR), SC insulin and was transferred to ICU for further management. Her blood revealed increased leukocytosis, hyponatremia, hyperkalemia and Cre 1.7 (0.4-0.6 baseline). The patient was started on broad spectrum antibiotics, levophed gtt to maintain BP and agressive fluid resuscitation, NGT was placed. Abdominal CT scan revealed LLL consolidations, persistent 2.9 x 1.3 cm rim enhancing aortocaval fluid collection near the liver hilum and was grossly stable compare with CT from [**12-15**]. With interventions patient continue to improve. Her BP stabalized and pressors were weaned off, hyperglycemia improved with insulin, Cre started to downward with fluids. WBC started to downward 26->19.8->12.6 with abx treatment. Her blood, urine and stool samples were sent for culture. Patient received 2 units of pRBC and HCT improved (24->30.2), and her mental status returned to her baseline. The patient returned to the floor on [**2129-12-24**]. Her urine and stool cultures were negative, last blood cultures still pendind. Patient's Cre returned back to normal, her Bactrim and Fluconazole were restarted. The patient's Coumadin was hold since [**2129-12-23**] for INR 4.4. The patient still to have supratherapeutic INR on discharge (3.6), her INR will be followed daily by VNA and her Coumadin will be restarted when INR therapeutic ([**3-17**]). Patient's PCP will be notify by VNA about INR level and he will adjust patient's daily Warfarin base on INR result. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Discharge Disposition: Home With Service Facility: Northeast Clinical Services [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 3151**] Completed by:[**2129-12-29**]

[ "V10.42", "560.9", "E935.2", "293.0", "349.82", "V85.0", "276.7", "704.00", "V15.82", "599.0", "288.60", "338.29", "V12.71", "486", "263.0", "276.1", "E939.4", "238.71", "V09.81", "569.81", "995.92", "576.8", "300.4", "292.81", "V12.51", "V88.01", "452", "285.29", "041.04", "V12.04", "401.9", "038.9", "V44.4", "785.52", "572.0" ]

icd9cm

[ [ [] ] ]

[ "99.15", "00.14", "38.97", "51.10" ]

icd9pcs

[ [ [] ] ]

28609, 28825

12451, 16381

331, 337

19537, 19537

7956, 12428

25088, 28586

6947, 6981

17146, 19274

19376, 19516

16407, 17123

19720, 25065

6996, 6996

7898, 7937

266, 293

365, 5795

7010, 7884

19552, 19696

5817, 6732

6748, 6931

9,776

190,336

25093

Discharge summary

report

Admission Date: [**2136-10-13**] Discharge Date: [**2136-10-17**] Date of Birth: [**2086-5-17**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: unresponsive Major Surgical or Invasive Procedure: Craniotomy with evacuation acute subdural hematoma History of Present Illness: 50yoM fell off bar stool, after unresponsive for 7 hours brought to ER. Past Medical History: unknown Social History: unknown Family History: unknown Physical Exam: Pertinent Results: [**2136-10-13**] 06:25PM PT-14.2* PTT-24.9 INR(PT)-1.4 [**2136-10-13**] 06:25PM PLT COUNT-258 [**2136-10-13**] 06:25PM WBC-12.5* RBC-3.83* HGB-13.1* HCT-37.8* MCV-99* MCH-34.3* MCHC-34.8 RDW-13.7 [**2136-10-13**] 06:25PM ASA-4 ETHANOL-244* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2136-10-13**] 06:25PM AMYLASE-71 [**2136-10-13**] 06:25PM UREA N-7 CREAT-0.5 [**2136-10-13**] 06:33PM GLUCOSE-144* LACTATE-6.5* NA+-144 K+-3.5 CL--107 [**2136-10-13**] 06:33PM TYPE-ART PO2-504* PCO2-32* PH-7.43 TOTAL CO2-22 BASE XS--1 Brief Hospital Course: Pt had CT in ER showing large acute subdural hematoma, after discussion with family they requested surgical intervention. He was brought stat to OR for craniotomy with evacuation of large subdural hematoma. From OR, pt was brought to CT which showed good post op resolution of hematoma but continued shift. From there pt was admitted to Trauma ICU. He was monitored closely but his neurological exam deteriorated. Family was repeatedly updated on his very poor prognosis.On [**10-17**] at 15:25 death exam check list completed. [**Location (un) 511**] [**Last Name (un) **] Bank notified.As of [**2136-10-17**] at 20:10 patient declared death and transferred to morg, state medical examiner notified. Medications on Admission: unknown Discharge Disposition: Expired Discharge Diagnosis: Large subdural hematoma Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2136-10-18**]

[ "276.0", "E884.2", "331.4", "852.25", "348.4" ]

icd9cm

[ [ [] ] ]

[ "01.31", "99.04", "99.07", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

1939, 1948

1176, 1881

334, 386

2015, 2024

604, 1153

2077, 2113

559, 568

1969, 1994

1907, 1916

2048, 2054

585, 585

282, 296

414, 487

509, 518

534, 543

50,110

157,136

41244

Discharge summary

report

Admission Date: [**2159-7-2**] Discharge Date: [**2159-7-11**] Date of Birth: [**2105-6-2**] Sex: M Service: CARDIOTHORACIC Allergies: vancomycin Attending:[**Known firstname 922**] Chief Complaint: Endocarditis Major Surgical or Invasive Procedure: [**2159-7-2**] AVR (25 mm On-X mechanical)/ flex cystoscopy History of Present Illness: 54 year old male with Asperger's syndrome was noted to have a murmur at his [**Hospital 3390**] clinic visit in the Spring of [**2158**]. An echocardiogram revealed vegetation on the aortic and mitral valves in the setting of a positive UTI and a new diagnosis of a non functioning right kidney. He was admitted to [**Hospital1 18**] on [**2159-3-9**] with aortic valve staph epidermidis endocarditis with [**2-9**] + aortic insufficiency without evidence of CHF. It was thought that his endocarditis was most likely from a urologic source. He has been treated with at least six weeks of IVAB. He has since undergone a right laparoscopic nephrectomy and ureterectomy on [**2159-5-7**]. Most recent urine culture was negative. His sister reports that from a cardiac standpoint, he has been essentially asymptomatic. Just up until his diagnosis, he was able to walk up to 1.5 miles per day. He currently denies fatigue or other complaints. He is admitted for an Aortic valve replacement on [**2159-7-2**] with Dr. [**Last Name (STitle) 914**]. Past Medical History: Asperger syndrome Endocarditis with significant aortic insufficiency Atrophic non functioning right kidney, s/p Right laparoscopic nephrectomy, ureterectomy on [**2159-5-7**] Hx of UTI's - [**2159-3-9**] grew coagulase negative staph in [**5-14**] bottles, Staph epidermitis was cultured from his urine Hypospadias Urethral stricture disease s/p dilation [**2159-4-17**] Bilateral ureteral reflux Inguinal hernia Hydrocele [**11-8**]: scrotal hernia repair [**2142**]: urethral blockage release VRE Social History: Patient is single. He was previously living with his father prior to his admission for endocarditis. His father was placed in a nursing home at the time of his hospitalization. Around the same time, his mother passed away. Following his admission for endocarditis, he was residing in a rehab. He is currently living with his sister [**Name (NI) 1894**] in [**State 2748**]. Contact: [**Name (NI) 1894**] (sister) Phone #cell: [**Telephone/Fax (1) 89829**]; home: [**Telephone/Fax (1) 89830**] Occupation: does not work. Does light house work Tobacco use: denies ETOH: denies Illicit drug use: denies Family History: Both parents with atrial fibrillation Physical Exam: Pulse:81 Resp:16 O2 sat:99/RA B/P Right:130/47 Left:133/41 Height:5'[**58**]" Weight:195 lbs General: Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade _III SEM___ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [] Neuro: Grossly intact [x] Pulses: Femoral Right:Palp Left:Palp DP Right:Palp Left:Palp PT [**Name (NI) 167**]:Palp Left:Palp Radial Right:Palp Left:Palp Carotid Bruit Right: None Left: None Pertinent Results: [**2159-7-2**] ECHO: PRE-CPB: The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. No thoracic aortic dissection is seen. There are three aortic valve leaflets. Aortic leaflet prolapse is present, most notably of the non-coronary cusp. . There are moderate-sized vegetations on each of the three aortic valve leaflets. Severe (4+) aortic regurgitation is seen. There is holodiastolic flow reversal seen the in the distal descending thoracic aorta. The mitral valve leaflets are mildly thickened. There is a focal thickening of the mid anterior mitral leaflet that may represent healed scar from prior vegetation. Mild (1+) mitral regurgitation is seen. There is a small to moderate sized pericardial effusion. POST-CPB: After initial separation from bypass, the LV systolic function appears decreased from preop, estimated EF=30%. There is new segmental wall motion abnormality noted in the inferior wall. The patient is started on an epi infusion. He is also receiving norepi infusion. The inferior wall hypokinesis and the global systolic function improves gradually with time. Estimated EF at time of chest closure is 40%. The left ventricular wall thickness appears much greater now that the chamber size has decreased. Wall thicknesses measure approximately 1.6cm, representing moderate concentric hypertrophy. There is a mechanical valve seen in the aortic position. The valve is well-seated with normal leaflet mobility. There are the normal washing jets. There appears to be a small sewing ring leak in the area between anatomical left and non-coronary cusps, but it is not well seen in all views. The peak gradient across the aortic valve is 20mmHg, the mean gradient is 12mmHg with CO of 7.3. The RV systolic function remains normal. There is no evidence of aortic dissection. [**2159-7-10**] CXR: Low lung volumes without focal radiopacity suggestive of pneumonia. Moderate cardiomegaly stable from prior exam. Cardiomediastinal and hilar contours are unremarkable otherwise. No evidence of pleural effusion or pneumothorax. Sternotomy wires are intact. A new pacemaker is observed in the left axilla with leads in standard positions in the right atrium and ventricle, right-sided IJ line is observed at the junction of the IJ with the brachiocephalic vein. [**2159-7-11**] 06:13AM BLOOD WBC-8.7 RBC-3.54* Hgb-10.4* Hct-32.1* MCV-91 MCH-29.4 MCHC-32.4 RDW-13.1 Plt Ct-684* [**2159-7-9**] 04:10AM BLOOD PT-20.8* PTT-29.4 INR(PT)-1.9* [**2159-7-10**] 02:26AM BLOOD PT-20.1* PTT-29.2 INR(PT)-1.8* [**2159-7-11**] 06:13AM BLOOD PT-28.7* PTT-31.9 INR(PT)-2.8* [**2159-7-11**] 06:13AM BLOOD Glucose-115* UreaN-40* Creat-1.5* Na-142 K-4.0 Cl-105 HCO3-28 AnGap-13 [**2159-7-10**] 02:26AM BLOOD Calcium-8.5 Phos-4.8* Mg-2.2 Brief Hospital Course: Mr. [**Known lastname 89831**] was admitted and taken to the OR on [**2159-7-2**] where he underwent an Aortic valve replacement with a 25-mm On-X mechanical valve and Pericardial reconstruction with CorMatrix. Please see operative note for details. His operative course was complicated by a difficult Foley insertion for which the GU service was called and performed a cystoscopy for Foley placement (see operative note for details). Post-operatively he was admitted to the ICU on Epi, Levo and propofol drips. He was intubated and sedated. Within 24 hours, sedation was weaned off and he awoke neurologically intact and was weaned from the vent and extubated without difficulty. His pressors and inotropes were d/c'd and on post-op day one he was started on beta blocker and diuretics and received Coumadin for prosthetic AVR. Also on post-op day one he was found to have a right groin pseudoaneurysm and was given a thrombin injection. His temporary pacing wires and chest tubes were removed per protocol. Infectious disease was consulted for gm + cocci in aortic valve tissue in OR and he was treated with Daptomycin due to vanco allergy. A PICC line was placed on [**7-7**] and he will receive at least 4 weeks of Daptomycin. Further antibiotics recommendations will be made by Dr. [**Last Name (STitle) 9461**] in [**Hospital **] clinic. On post-op day two he was noted to have a high degree heart block on his routine EKG. On post-op day three he developed post-op afib/flutter and was started on oral amiodarone and his Lopressor was discontinued per his Atrius cardiologist (and with Dr.[**Name (NI) 9379**] approval). On post-op day five he developed frequent [**3-14**] second pauses while on Amiodarone. Amiodarone was discontinued, external pacing pads were placed and he was transferred to the CVICU for closer monitoring. A temporary transvenous pacing wire was placed via right IJ and EP was consulted for possible permanent pacemaker placement if heart rhythm didn't improve. Coumadin was stopped and Heparin started for anticoagulation pending possible need for pacemaker. He continued to have no improvement with his rhythm and on [**7-9**] a permanent pacemaker was placed. Following the procedure he was brought back to the CVICU where he remained for one day for observation and on the following day he was transferred back to the step-down floor for further care. Coumadin was restarted and titrated for goal INR for mechanical aortic valve of 2.5-3. EP recommended restarting beta-blockers, as well as reinstitution of Amiodarone and/or Cardioversion when he follows up with his own Cardiologist (Dr. [**Last Name (STitle) **] as an outpatient. On post-op day nine he appeared ready for discharge home with VNA services and all the appropriate follow-up appointments. His INR was therapeutic and will be followed by his PCP. [**Name10 (NameIs) **] mentioned earlier, his Daptomycin will be continued at least 4 weeks and will be managed by ID. Finally, Dr. [**Last Name (STitle) **] will make recommendation during outpatient visit whether to restart amiodarone or perform cardioversion. Medications on Admission: None Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication mechanical AVR Goal INR 2.5-3.0 First draw day after discharge................. Results to Dr. [**First Name (STitle) 1022**] phone [**Telephone/Fax (1) 56757**]/ [**Hospital 3678**] [**Hospital **] clinic [**Telephone/Fax (1) 87875**] (contact [**Name2 (NI) 3548**] [**Name (NI) 6358**]) 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. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. Disp:*50 Tablet(s)* Refills:*0* 5. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) Intravenous Q4H (every 4 hours) for 4 weeks. Disp:*180 doses* Refills:*0* 6. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 11. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily). Disp:*10 Tablet Extended Release(s)* Refills:*2* 12. 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* 13. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO every other day: Start [**7-12**] and alternate 1 tab with 2 tabs every day. Take as directed by Dr. [**First Name (STitle) 1022**] for an INR goal of 2.5-3.0. Disp:*45 Tablet(s)* Refills:*2* 14. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). Disp:*600 ML(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Endocarditis with significant aortic insufficiency s/p Aortic Valve Replacement [**2159-7-2**] Post-op afib/flutter and complete heart block s/p Pacemaker implantation Past medical history: Asperger syndrome Atrophic non functioning right kidney s/p Right laparoscopic nephrectomy, ureterectomy on [**2159-5-7**] History of UTI's Hypospadias Urethral stricture disease s/p dilation [**2159-4-17**] Bilateral ureteral reflux Inguinal hernia Hydrocele [**11-8**]: scrotal hernia repair [**2142**]: urethral blockage release VRE Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) 914**] Tuesday [**8-14**] @ 1:30pm in the [**Hospital **] medical office building [**Hospital Unit Name **] [**Telephone/Fax (1) 170**] Cardiologist: Dr. [**Last Name (STitle) **] on [**7-30**] at 9:20am in [**Location (un) 2274**] [**Location (un) **] office Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2159-7-24**] 2:00 ID Provider: [**Name10 (NameIs) 9462**] FLASH, MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2159-7-24**] 3:30 Please call to schedule appointments with your Primary Care Dr.[**First Name (STitle) 1022**] in [**3-13**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication mechanical AVR Goal INR 2.5-3.0 First draw day after discharge, [**2159-7-12**] Results to Dr. [**First Name (STitle) 1022**] phone [**Telephone/Fax (1) 56757**]/ [**Hospital 3678**] [**Hospital **] clinic [**Telephone/Fax (1) 87875**] (contact [**Name2 (NI) 3548**] [**Last Name (un) 6358**]) Dr. [**First Name (STitle) 1022**] to manage Coumadin Completed by:[**2159-7-11**]

[ "997.2", "421.0", "E849.7", "427.31", "E878.1", "598.9", "442.3", "041.19", "424.1", "299.80", "426.0", "E879.0", "997.1", "427.32", "752.61", "V45.73" ]

icd9cm

[ [ [] ] ]

[ "37.83", "38.93", "88.72", "88.77", "99.29", "35.22", "37.78", "57.94", "57.32", "39.61", "37.34", "37.72" ]

icd9pcs

[ [ [] ] ]

11910, 11962

6557, 9670

286, 347

12531, 12707

3330, 6534

13547, 14815

2578, 2617

9725, 11887

11983, 12151

9696, 9702

12731, 13524

2632, 3311

234, 248

375, 1418

12173, 12510

1957, 2562

78,214

184,530

8832+55981

Discharge summary

report+addendum

Admission Date: [**2138-1-14**] Discharge Date: [**2138-1-24**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7651**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Aortic valvuloplasty History of Present Illness: 87 year old female with coronary artery disease, atrial fibrillation on coumadin, s/p mitral valve replacement, severe aortic stenosis ([**Location (un) 109**] 0.4cm), defibrillator in place, presenting with progressive dyspnea on exertion. Patient has presented to be evaluated and determine if surgical management is an option for her. She had been feeling quite short of breath before admission, and had generally not been feeling herself. Two weeks prior to admission, she was admitted to a [**Location (un) 30804**], NY ED for a similar complaint and was diuresed with Lasix. She felt much better after leaving the hospital at that time, but progressively got worse since being discharged. She had been getting short of breath on minimal activity with associated substernal chest pressure. Specifically, she used to be able to ambulate around her house without any problem, but at the time of admission could not walk more than five steps without getting dyspneic. She had also noted significant orthopnea and PND, which seemed to get worse on the night before admisssion. She reported no chest pain, palpitations, or presyncope. She noted no dysuria or fever/chills. There had been no URI symptoms, but there was an occasional cough productive of clear sputum. She had also noted increased lower extremity swelling over the week prior to admission. . Patient's cardiologist in NY noted that patient had been having 6 months to 1 year of progressive dyspnea. Her last BNP was 500. . In the ED, initial vitals were pain 0, T 97.3, P 62, BP 168/70, R 26, Sat 96%RA. EKG showed regular, 65 beats per minute, ? sinus, normal axis, TWI V4-V6 c/w prior. Labs showed leukocytosis and UA showing urinary tract infection, creatinine at 1.4. INR was supratherapeutic at 8.3. Imaging was significant for pleural effusion on left side and fluid overload. Patient was given 20mg IV lasix, and ceftriaxone for an apparent UTI. . Vitals on transfer were P 64 R 18 BP 152/65 Sat 97/3L. . On arrival to the floor, patient was less dyspneic than previously, while on oxygen. She noted no chest pain, palpitations, or nausea. . On review of systems, she denied any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. She denied recent fevers, chills or rigors. She denied exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems was notable for absence of chest pain, palpitations, syncope or presyncope. . Past Medical History: 1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia, (+) Hypertension 2. CARDIAC HISTORY: Coronary artery disease s/p CABG [**2118**] Cardiac arrest ([**2118**]) Severe aortic stenosis ([**Location (un) 109**] 0.4 cm2) Systolic congestive heart failure s/p ICD placement ([**2131**]) Atrial fibrillation s/p Mitral valve replacement ([**2119**]) s/p permanent pacemaker ([**2126**]) -CABG: [**2118**], unknown anatomy -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: ICD placed in [**2131**] 3. OTHER PAST MEDICAL HISTORY: Hypothyroidism h/o GI bleed s/p right hip open reduction/internal fixation. s/p cataract surgery Social History: Lives in [**Location (un) 5131**] with her son. She is currently living with her daughter in [**Name (NI) 3307**], MA, while she is being seen by Dr. [**Last Name (STitle) **]. -Tobacco history: none -ETOH: occasional -Illicit drugs: none Family History: Mother and brother both with myocardial infarctions in theirs 60s and 70s. Physical Exam: On admission: VS: T= 98.0 BP= 174/78 HR= 64 RR= 24 O2 sat= 95%2L O2 GENERAL: Frail female in NAD. Oriented x 3. Mood, affect appropriate. Pleasant and cooperative. HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva are pink, MMM with no lesions noted and no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP at the jaw line, no cervical LAD. CARDIAC: RR. III/VI SEM loudest at RUSB with radiation to carotids, III/VI mechanical-sounding murmur at left sternal border. No thrills, lifts. + pulsus parvus et tardus. LUNGS: No chest wall deformities, mild kyphosis. Respirations are currently unlabored, no accessory muscle use. Rales halfway up the lung bilaterally, occasional wheeze with no audible rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. + BS normoactive. EXTREMITIES: 1+ edema to halfway up shin, symmetric. WWP. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ On discharge: VS: Tm/Tc 98.6/97.9 BP 112/40 (112-130/47-74) P 66 (50-66) R 16 Sat 93%RA GENERAL: Thin, frail female in NAD. Oriented x 3. Mood, affect appropriate. Pleasant and cooperative. HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva are pink, MMM with no lesions noted and no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP 4 cm above the clavicle when lying at 30 degrees, no cervical LAD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Irregularly irregular. S1 with soft S2. Grade III/VI late-peaking systolic murmur consistent with AS. Harsh holosytolic murmur best heard at apex. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored. Decreased breath sounds on left with dullness to percussion. Rales present to 1/3 up lungs bilaterally. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: WWP, trace edema at the ankles bilaterally. SKIN: Venous stasis dermatitis. Multiple ecchymoses in UE. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS -------------- [**2138-1-14**] 08:35AM BLOOD WBC-11.9*# RBC-4.51# Hgb-12.5# Hct-38.0 MCV-84 MCH-27.8 MCHC-33.0 RDW-19.7* Plt Ct-389 [**2138-1-14**] 08:35AM BLOOD Neuts-88.4* Lymphs-5.8* Monos-4.7 Eos-0.5 Baso-0.6 [**2138-1-14**] 10:15AM BLOOD PT-70.8* PTT-38.6* INR(PT)-8.3* [**2138-1-14**] 08:35AM BLOOD Glucose-154* UreaN-43* Creat-1.4* Na-137 K-5.0 Cl-100 HCO3-24 AnGap-18 [**2138-1-14**] 08:35AM BLOOD CK(CPK)-49 [**2138-1-14**] 08:35AM BLOOD CK-MB-5 [**2138-1-14**] 08:35AM BLOOD cTropnT-0.02* [**2138-1-14**] 03:25PM BLOOD Calcium-9.8 Phos-4.3 Mg-2.3 [**2138-1-14**] 08:35AM BLOOD Digoxin-1.5 DISCHARGE LABS -------------- White Blood Cells 5.7 Red Blood Cells 3.69 Hemoglobin 10.5 Hematocrit 31.8 MCV 86 MCH 28.4 MCHC 33.0 RDW 19.3 BASIC COAGULATION (PT, PTT, PLT, INR) Platelet Count 186 PT 15.7 PTT 32.1 INR(PT) 1.4 Glucose 110 Urea Nitrogen 38 Creatinine 1.2 Sodium 140 Potassium 3.7 Chloride 99 Bicarbonate 30 Anion Gap 15 Calcium, Total 9.1 Phosphate 2.6 Magnesium 2.2 MICROBIOLOGY ------------ [**2138-1-14**] 09:35AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.021 [**2138-1-14**] 09:35AM URINE Blood-LG Nitrite-POS Protein-150 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2138-1-14**] 09:35AM URINE RBC-0-2 WBC-[**11-16**]* Bacteri-MANY Yeast-NONE Epi-0 . Urine culture on admission: Time Taken Not Noted Log-In Date/Time: [**2138-1-14**] 3:45 pm URINE Site: NOT SPECIFIED CHEM# [**Serial Number 30805**]M. **FINAL REPORT [**2138-1-17**]** URINE CULTURE (Final [**2138-1-17**]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . . IMAGING ------- ECG on admission: Artifact is present. Probable atrial flutter with 4:1 block. ST-T wave changes most consistent with left ventricular hypertrophy, although ischemia or myocardial infarction cannot be excluded. Compared to the previous tracing of [**2126-12-28**] atrial and ventricular pacing is no longer present. . Chest X-ray [**2138-1-14**]: IMPRESSION: . 1. Left pleural effusion and vascular cephalization, consistent with congestive heart failure. Followup chest radiograph after diuresis is recommended to rule out underlying pneumonia. . 2. Left tracheal deviation at the thoracic inlet, likely goiter. If not done previously, evaluation with thyroid ultrasound is recommended. . CT Chest [**2138-1-14**]: IMPRESSION: Moderate cardiomegaly, moderate-to-severe aortic and coronary calcifications, status post mitral valvuloplasty and CABG. Bilateral pleural effusions with mild-to-moderate pulmonary edema. No lymphadenopathy. Pacemaker and status post sternotomy. Diffuse airway wall calcifications. 3.3 cm right thyroid nodule. . Transthoracic echocardiogram [**2138-1-15**]: The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with near-akinesis of the inferior and lateral walls. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The prosthetic mitral valve leaflets are thickened. The gradients are higher than expected for this type of prosthesis. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. . IMPRESSION: Regional left ventricular systolic dysfunction. Mild right ventricular cavity dilation with borderline function. Severe aortic stenosis. Severe pulmonary hypertension. At least moderate mitral regurgitation (may be underestimated) in a well-seated bioprosthetic mitral valve. Moderate tricuspid regurgitation. . Compared with the prior report (images unable to be reviewed) of [**2127-12-31**], aortic stenosis, mitral regurgitation, severity of pulmonary hypertension have all progressed. . . Cardiac catheterization [**2138-1-20**]: COMMENTS: 1. Severe pulmonary artery hypertension 2. Severe mitral valve regurgitation 3. Severe aortic stenosis with low gradient low flow AS 4. Patent SVG to LAD, SVG to OMB, and SVG to LPLA 5. Medical therapy . FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe aortic stenosis. 3. Severe mitral regurgitation. 4. Severe systolic and diastolic ventricular dysfunction. . . Transthoracic echocardiogram [**2138-1-21**]: Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed with inferior/inferolateral akinesis and hypokinesis elsewhere (LVEF= 35 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is dilated with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial/physiologic pericardial effusion. . Compared with the prior report (images reviewed) of [**2138-1-15**], the estimated aortic valve area is now higher related to measurement of a higher left ventricular outflow velocity (this was likely underestimated in the prior study). Mitral regurgitation appears similar. . . CXR [**2138-1-22**]: FINDINGS: In comparison with the study of [**1-21**], there is continued enlargement of the cardiac silhouette with pulmonary vascular congestion and bilateral pleural effusions. Retrocardiac opacification is consistent with substantial volume loss in the left lower lobe. Biventricular pacer remains in place. Impression on the lower cervical trachea is again consistent with right thyroid enlargement. Brief Hospital Course: 87 year old female with coronary artery disease, atrial fibrillation on coumadin, s/p mitral valve replacement, severe aortic stenosis ([**Location (un) 109**] 0.8 cm), defibrillator in place presenting with progressive dyspnea on exertion, for evaluation for aortic valve replacement. . ACTIVE ISSUES ------------- # Systolic congestive heart failure, acute on chronic: reported EF 30-35%, warm and wet, NYHA class III. Patient appeared volume overloaded based on lung exam and chest X-ray, elevated JVP, and peripheral edema. Patient had ICD and permanent pacemaker placed with no recent shocks, for which interrogation was performed showing the patient was in need of a generator change. Heart failure symptoms were likely due to her severe aortic stenosis and severe mitral regurgitation. CT showed bilateral pleural effusions and ground glass opacities. She was continued on her home dose of furosemide to keep her fluid status slightly negative. Her blood pressure was controlled originally with her home dose of captopril, later switched to lisinopril, and then back to captopril. Her home dose of carvedilol was given intermittently when blood pressure was elevated, but not given consistently due to episode of hypotension. Ultimately, it was given as a decreased dose, which is the dose patient will be discharged with. She was continued on her home dose of spironolactone and digoxin. Daily weights were recorded and fluid balance was recorded. Patient diuresed well to furosemide 20 mg IV with net -500 cc to -1L fluid balance per day. She required lasix drip while in the coronary care unit, which was later transitioned to PO lasix, which she will be discharged on. She is going home with home hospice care. She will continue her carvedilol, captopril as an oupatient to prevent further symptoms. . # Aortic stenosis: [**Location (un) 109**] recorded by echocardiogram at [**Hospital1 18**] was 0.8 cm2, peak gradient 50 mm Hg. Patient was determined to not be a candidate for aortic valve replacement due to patient risk. Patient had symptoms of heart failure and angina, with no reported syncope. Exam was consistent with severe aortic stenosis. Blood pressure control was accomplished with an ACE inhibitor as well as a beta blocker intermittently. The patient's home dose of isosorbide dinitrate was held due to the patient's dependence on preload. Patient was carefully dosed with furosemide with a goal to keep her net negative. An aggressive bowel regimen was instituted to keep the patient from straining when defecating. She was taken for aortic valvuloplasty on [**2138-1-20**] and no intervention was performed due to significant mitral regurgitation and only a mildly elevated aortic valve gradient. Mitral regurgitation was thought to be the dominant cause of her CHF. She is being treated symptomatically through home hospice care. # Mitral regurgitation - it became apparent on cardiac catheterization that the gradient across the aortic valve was not severely elevated and that much of the patient's symptoms are due to severe mitral regurgitation in her bioprosthetic valve. . # Atrial fibrillation: CHADS2 score was 3. Patient was in atrial fibrillation on pacemaker interrogation. Her warfarin dose was held in order to let her INR, initially supratherapeutic, trend down for aortic valvuloplasty. Patient was given 2 mg Vitamin K PO x 1 to facilitate downtrending of her INR. She was monitored on telemetry during her stay. Her carvedilol was held due to an episode of hypotension early in her hospital course, and rate remained normal with no medication. Digoxin level was measure and was determined to be therapeutic. She did not receive it while on the [**Hospital Unit Name 196**] service, but was reloaded and continued on home regimen in the CCU. INR on discharge was 4. She will continue taking coumadin with intermittent measurements of INR to be continued as an outpatient and further adjustment of warfarin dosage to be completed through the patient's designated provider. . # Supratherapeutic INR: patient presented with INR > 8 and her warfarin dose was held on admission. One dose of PO vitamin K was given. INR was < 2 at the time of aortic valvuloplasty. Coumadin was restarted after cardiac catheterization and started to trend up upon discharge. She will continue to have her INR checked as an outpatient. . # s/p Pacemaker placement: patient's pacemaker was interrogated and it was determined that the patient will need a generator change after discharge. She was monitored on telemetry. The electrophysiology planned to schedule her for a generator change upon discharge. . # Leukocytosis: patient presented with leukocytosis, likely due to urinary tract infection based on positive urinalysis and urine culture performed on admission. CT chest could not rule out an infectious process, but patient did not clinical signs of pneumonia. Patient was given ceftriaxone in the ED, but was switched to ciprofloxacin for UTI, for a planned course of three days. WBC count downtrended, and patient showed no signs of infection upon discharge. . # Urinary tract infection: urine culture were found to be positive for E.coli. Patient completed a three day course of ciprofloxacin for a presumed urinary tract infection. She remained asymptomatic for the remained for the hospital course. Urine was rechecked before discharge and was not suggestive of infection. . # Acute kidney injury: creatinine last check 1.4, baseline 1.0. Patient was diuresed and creatinine level was watched closely. Her creatinine was relatively stable during most of her admission. . # Hypertension: as noted above, on discharge, patient will resume therapy with carvedilol and captopril, at reduced doses compared to her presenting regimen. She will no longer take isosorbide dinitrate as an outpatient. . INACTIVE ISSUES --------------- # Coronary artery disease: patient s/p CABG after cardiac arrest about 18 years prior to presentation. There have been no acute coronary events since this event. Patient with new T wave inversions in II, III, aVF on admission, with ST depressions in V5, V6. ST changes may have been due to left ventricular hypertrophy. Cardiac biomarkers were minimally elevated and stable on three sets. She will be continued on carvediolol, captopril, and simvastatin. . # Hypothyroidism: patient will continue home dose levothyroxine as an outpatient. . TRANSITION OF CARE ------------------ # Code status: patient is confirmed DNR/DNI on home hospice . # Emergency contact: [**Name (NI) 30806**] [**Name (NI) 1637**] (daughter) (c) [**Telephone/Fax (1) 30807**] (H) [**Telephone/Fax (1) 30808**] [**First Name5 (NamePattern1) 30809**] [**Last Name (NamePattern1) 30810**] (daughter) [**Telephone/Fax (1) 30811**] . # Goal of care: After discussion with family, decision was made to make patient DNR/DNI. Palliative care consult was called and plan was to arrange for home hospice. . # Follow-up: patient will receive home hospice care. She will call the cardiology department for an appointment with electrophysiology to have her pacemaker generator changed as an outpatient. Medications on Admission: Carvedilol 25 mg PO BID Spironolactone 12.5 mg PO qod Isordil 20 mg PO BID Captopril 50 mg PO BID Lasix 40 mg PO daily Coumadin 2 mg PO daily Digoxin 0.125 mcg PO daily Simvastatin 20 PO daily Synthroid 75 mcg PO daily Aciphex 20 PO daily Klor-con 20 mEq PO BID Folic acid 1 mg PO daily Oscal 500 mg PO BID Feosol 45 mg PO BID Multivitamin PO daily Procrit Discharge Medications: 1. Wheel chair Wheel chair 2. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*15 Tablet(s)* Refills:*0* 4. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*0* 5. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*0* 7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Klor-Con 20 mEq Packet Sig: One (1) PO twice a day. 12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 14. Feosol 45 mg Tablet Sig: One (1) Tablet PO twice a day. 15. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Procrit Injection 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*60 Tablet(s)* Refills:*0* 19. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). Disp:*1 bottle* Refills:*0* 20. Outpatient Lab Work Please draw INR on [**2138-1-26**] and fax results to MD Discharge Disposition: Home With Service Facility: Season's Hospice and Palliative Care Discharge Diagnosis: Primary diagnosis: Systolic congestive heart failure Aortic stenosis Mitral regurgitation Atrial fibrillation Urinary tract infection Acute kidney injury Secondary diagnosis: Coronary artery disease Hypothyroidism 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 30812**], It was a pleasure taking care of you at the [**Hospital1 18**]. You came for further evaluation of aortic stenosis and congestive heart failure. It was decided that you would not be a good candidate for surgery during your admission, and due to worsening mitral regurgitation, it was decided to focus on comfort measures going forward. You are being discharged on home hospice care. It is important that you continue to take your medications as indicated. Weigh yourself every few days, and [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. The following changes have been made to your medications: We INCREASED your dose of furosemide for better control of your shortness of breath and leg swelling. We DECREASED your dose of carvedilol so your blood pressure doesn't drop too low. We DECREASED your dose of captopril so your blood pressure doesn't drop too low. We STOPPED isordil, so your blood pressure doesn't drop too low. We ADDED docusate, senna and polyethylene glycol, so you have regular bowel movements where you don't have to strain. Followup Instructions: None Name: [**Known lastname 5390**],[**Known firstname **] Unit No: [**Numeric Identifier 5391**] Admission Date: [**2138-1-14**] Discharge Date: [**2138-1-24**] Date of Birth: [**2050-11-24**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4868**] Addendum: Addendum to follow-up: She will need her INR checked as an outpatient by home hospice to assure therapeutic levels. Brief Hospital Course: Addendum to follow-up: She will need her INR checked as an outpatient by home hospice to assure therapeutic levels. Discharge Disposition: Home With Service Facility: Season's Hospice and Palliative Care [**Name6 (MD) **] [**Last Name (NamePattern4) 4869**] MD [**MD Number(2) 4870**] Completed by:[**2138-1-24**]

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icd9cm

[ [ [] ] ]

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48528

Discharge summary

report

Admission Date: [**2158-3-21**] Discharge Date: [**2158-3-24**] Date of Birth: [**2100-7-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Bright red blood per rectum. Major Surgical or Invasive Procedure: [**First Name3 (LF) **] with endoclipping History of Present Illness: Mr. [**Known lastname **] is a 57 y/o male with a history a mitral valve fibroelastoma and recent screening [**Known lastname 2792**] on [**2158-3-7**] with polypectomy who presents with bright red blood per rectum x 1 day. Patient was in his usual state of good health until one day prior to presentation. He began having blood bowel movements with associated fecal urgency this morning. He has since had at least one large bloody bowel movement every hour. He has diffuse crampy abdominal pain but no nausea or vomiting. He had some lightheadedness at home prior to presentation but no chest pain or shortness of breath. He has had normal PO intake and is making normal urine output. He has never had gastrointestinal bleeding before. He is not constipated at baseline. He does take aspirin and plavix for a history of TIAs in the past and took these on the morning of presentation. In the emergency room his intial vital signs were T 97.5, BP 129.79, HR 74, RR 16, O2 98% RA. He was non-toxic appearing with a benign abdominal exam. Recal notable for gross blood, no melena. Hct of 41. He was seen by the gastroenterology consult service who recommended [**Date Range 2792**] in the morning. On arrival to the floor the patient continued to have crampy abdominal pain and blood bowel movements. His hematocrit trended down from 41 on presentation to 30.4. His blood pressure also decreased to the 90s systolic. He received approximately 500 cc normal saline. He was transferred to the ICU for further management. Upon arrival to the ICU his blood pressure had improved to the 130s systolic. On review of systems he currently denies lightheadedness, dizziness, chest pain, dyspnea, nausea, vomiting. He endorses crampy abdominal pain and BRBPR. He denies dysuria or hematuria. He denies leg pain or swelling. All other review of systems negative in detail. Past Medical History: - Mitral valve fibroelastoma - lumbar radiculopathy - CVA in [**2151**] - Migraines - increased cholesterol - left inguinal hernia - history of TIAs in the past Social History: Lives independently, current unemployed, history of tobacco use - [**12-16**] ppd, social etoh. Family History: Non-contributory. Physical Exam: Vitals: T: 95.9 HR: 65 BP: 138/72 RR: 18 O2: 100% on RA General: Pleasant, well appearing man in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple Cardiac: Regular rhythm, normal rate. Normal S1, S2. Systolic murmur at LUSB and at apex, no rubs or [**Last Name (un) 549**]. Lungs: CTAB, good air movement biaterally. Abdomen: NABS. Soft, mild tender diffusely. No HSM, no rebound, no guarding. Extremities: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. Skin: No rashes/lesions, ecchymoses. Neurologic: A&Ox3. Appropriate. CN 2-12 grossly intact. [**4-18**] strength throughout. [**12-16**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred Psych: Listens and responds to questions appropriately, pleasant Pertinent Results: Labs on admission: [**2158-3-21**] 04:15PM BLOOD WBC-12.0*# RBC-4.84 Hgb-14.7 Hct-41.2 MCV-85 MCH-30.3 MCHC-35.6* RDW-13.0 Plt Ct-422 [**2158-3-21**] 04:15PM BLOOD Neuts-56.3 Lymphs-31.4 Monos-7.1 Eos-4.0 Baso-1.3 [**2158-3-21**] 04:15PM BLOOD PT-12.9 PTT-23.9 INR(PT)-1.1 [**2158-3-21**] 04:15PM BLOOD Glucose-121* UreaN-18 Creat-1.1 Na-138 K-4.5 Cl-106 HCO3-22 AnGap-15 [**2158-3-23**] 02:25AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.1 Labs on discharge: [**2158-3-24**] 04:25AM BLOOD WBC-9.8 RBC-4.84 Hgb-14.6 Hct-40.7 MCV-84 MCH-30.1 MCHC-35.7* RDW-14.2 Plt Ct-241 [**2158-3-24**] 04:25AM BLOOD PT-12.6 PTT-25.4 INR(PT)-1.1 [**2158-3-24**] 04:25AM BLOOD Glucose-105 UreaN-12 Creat-0.9 Na-138 K-4.2 Cl-106 HCO3-24 AnGap-12 [**2158-3-24**] 04:25AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.0 [**Year/Month/Day **] [**2158-3-22**]: Post polypectomy ulcer in the transverse colon - hemostasis was achieved using endoclips and epinephrine. (endoclip, injection). Blood in the whole colon. Otherwise normal [**Month/Day/Year 2792**] to cecum Brief Hospital Course: This is a 57 year old male with a history a mitral valve fibroelastoma and recent screening [**Month/Day/Year 2792**] on [**2158-3-7**] with polypectomy who presents with bright red blood per rectum x 1 day and hypotension. # Gastrointestinal Bleeding: On [**Date Range 2792**], arterial bleeding was seen and clipped in site of recent polypectomy with good hemastasis. He received 6 total PRBC transfusions. HCT was serially measured and was stable post-procedure. He did not require blood transfusion since night of [**2158-3-22**]. He was able to tolerate a regular diet without N/V, and was restarted on home lisinopril with stable blood pressure. The patient was advised to monitor himself for further bloody stools and have his HCT measured as outpatient within the next week. # Hypotension: Patient with hypertension after his procedure and was restarted on home lisinopril with stable blood pressure. He was advised to continue to hold home verapamil until outpatient follow-up at which time restarting this medication can be discussed. # History of TIAs: His aspirin and plavix were held, and the patient advised not to restart for a period of two weeks given his recent bleed. Medications on Admission: Aspirin 81mg Plavix 75mg daily Omeprazole 40 daily Lisinopril 10mg daily Verpamil 240mg daily Amoxicillin PRN pre-procedure Lipitor 20mg daily Discharge Medications: 1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Lower GI bleeding Hypotension Acute blood loss anemia Discharge Condition: Stable, normal hematocrit Discharge Instructions: You were admitted with bleeding after having [**Year (4 digits) 2792**] and polypectomy. The gastroenterology doctors performed another [**Name5 (PTitle) 2792**] with clips to stop the bleeding. You have done very well since your procedure and are eating well without further bleeding. Please return to the hospital or call your doctor if you have any further blood in your stools, diarrhea, fever, abdominal pain, or any new symptoms that you are concerned about. Since you were admitted, we have made the following medication changes: * We have temporarily stopped ASPIRIN and PLAVIX. Please do not take these medications for two full weeks. You can restart these two weeks after discharge from the hospital. * We have also stopped VERAPAMIL due to low blood pressures related to your bleeding. Do not take this until instructed to do so by your primary care doctor. Followup Instructions: Please followup with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5717**], at [**Telephone/Fax (1) 250**], within 2 weeks. You also have the following upcoming appointments at [**Hospital1 18**]: [**Name6 (MD) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2158-3-28**] 6:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2158-7-18**] 10:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2158-12-14**] 1:00 Completed by:[**2158-3-24**]

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icd9cm

[ [ [] ] ]

[ "45.43" ]

icd9pcs

[ [ [] ] ]

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50104

Discharge summary

report

Admission Date: [**2204-6-4**] Discharge Date: [**2204-6-11**] Date of Birth: [**2142-12-26**] Sex: F Service: MEDICINE Allergies: Norvasc / Infed Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: Pulmonary Edema Major Surgical or Invasive Procedure: RIGHT tunneled IJ HD catheter History of Present Illness: 61 yo F with CAD, CHF EF 30%, ESRD s/p transplant, now failed who presents with pulmonary edema, AoCRF and need for dialysis. Patient was seen by PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**5-29**] who thought she was euvolemic at the time. After that went to [**Hospital3 **] for vacation with her family and for the past several days she has been feeling progressively more SOB. Today was the worst day so she decided to go to [**Hospital3 **] Hospital. At CCH she was found to be in respiratory distress and was intubated. She was given furosemide 60 mg IV and kayexalate 30 mg but her urine output was only 30 mL. Her labs were remarkable for WB 8.3, trop 0.274, BNP 4428, K 5.5 and BUN/Cr 88/5.4. She was then transferred to [**Hospital1 18**] for futher care. . In the ED, initial labs remarkable for WBC 11.3, Hct 27.8, BNP [**Numeric Identifier 104608**], BUN 88/5.7. Patient was initially on dopamine for low BP but after propofol was switched to fentanyl/midazolam her BP came up and dopamine was weaned off. CXR was consistent with pulmonary edema. Renal was contact[**Name (NI) **] for need of emergent dialysis. VS prior to transfer BP 97/59 HR 57 Sat 100% on CMV 100% FiO2, Tv 480 mL and PEEP 10. . On the floor, she is intubated and sedated. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - systolic CHF with EF 30 % - recent NSTEMI 3. OTHER PAST MEDICAL HISTORY: -end-stage renal disease, status post allograft transplant in [**2197**] complicated by rejection, now again with chronic renal insufficiency -CAD, status post LAD and RCA stents -congestive heart failure (EF 30%, [**2201**]) -HTN, poorly controlled -peripheral [**Year (4 digits) 1106**] disease s/p R to L fem-fem bypass, R external iliac stenting -scleroderma -history of GI bleed Social History: Lives at home with husband and son. - Tobacco history: Heavy [**Year (4 digits) 1818**], quit in [**Month (only) 958**] - Alcohol/Drugs: Denies EtOH and drug use. Family History: No FmHx of MI, HTN, CA, HL. Father - brain cancer, died in his 30's Physical Exam: ADDMISSION EXAM: General: Intubated, sedated, not responding to stimuli HEENT: Sclera anicteric, DMM, 1-2mm pupils but equal and reactive Neck: supple, no LAD Lungs: Bilateral crackles 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, multiple surgical scars GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE EXAM: General: NAD, comfortable HEENT-PERRLA, EOMI LUNGS: CTABL, symmetrical chest wall movement GU: foley removed, urinating without difficulty Rest of exam unchanged from admission Pertinent Results: [**2204-6-4**] 11:49AM GLUCOSE-145* UREA N-89* CREAT-5.8* SODIUM-143 POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-23 ANION GAP-21* [**2204-6-4**] 04:23AM UREA N-88* CREAT-5.7* [**2204-6-4**] 04:23AM CK-MB-6 proBNP-[**Numeric Identifier 104608**]* [**2204-6-4**] 04:23AM WBC-11.3* RBC-3.06* HGB-9.0* HCT-27.8* MCV-91 MCH-29.2 MCHC-32.2 RDW-15.5 [**2204-6-4**] 04:23AM FIBRINOGE-545* [**2204-6-4**]:Rate PR QRS QT/QTc P QRS T 67 172 106 394/406 47 -1 106 DISCHARGE LABS: [**2204-6-10**] 07:00AM BLOOD WBC-6.2 RBC-3.08* Hgb-9.2* Hct-27.6* MCV-90 MCH-29.9 MCHC-33.3 RDW-15.1 Plt Ct-154 [**2204-6-11**] 06:40 Glucose 140 UreaN 58* Creat3.9* Na141 K 4.0 Cl100 HCO327 AnGap18 [**2204-6-11**] 06:40 Ca 9.0 P 5.6* Mg 1.9 [**2204-6-9**] 08:00 TacroFK <2.01 [**2204-6-4**] ECHO: 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 size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %) with global hypokinesis and regional akinesis/dyskinesis of the distal LV/apex.The inferior wall is akinetic. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal with borderline free wall contractility (RV apex not well seen). The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. CXR [**2204-6-4**]: Cardiomegaly, [**Month/Day/Year 1106**] congestion, and bilateral parenchymal opacities most compatible with pulmonary edema. Radiographic followup after diuresis is recommended. Renal Transplant US [**2204-6-4**]: Progression of high resistance pattern of flow within the transplanted kidney with lack of antegrade diastolic flow in the intrarenal and main renal arteries. Patent renal vein. BILAT LOWER EXT VEINS PORT [**2204-6-4**] No evidence of DVT. CHEST (PORTABLE AP) [**2204-6-5**]: Pulmonary edema present on [**6-4**] has substantially improved. Residual opacification at the lung bases is probably a combination of residual edema, pleural effusions and atelectasis. Heart size is normal. Mediastinal and hilar contours are unremarkable. Tip of the endotracheal tube, with the chin in neutral or elevation is less than 2 cm from the carina and should be withdrawn 2-3 cm to avoid unilateral intubation. Clinical service notified. CHEST (PA & LAT) [**2204-6-7**] Comparison is made with prior study [**6-5**]. Cardiomegaly is unchanged. Moderate-to-large bilateral pleural effusions are larger on the left side associated with atelectasis in the bases of the lungs, left greater than right. Multiple calcified lung nodules in the right upper lobe are again noted. Pulmonary edema continues to improve, now mild. There are no new lung abnormalities. Brief Hospital Course: Assessment and Plan: 61 yo F with CAD, CHF EF 30%, ESRD s/p transplant now failing, not yet on HD who presented to OSH with dyspnea and was intubated due to pulmonary edema causing respiratory distress. Now transferred to [**Hospital1 18**] for emergent HD. #. Respiratory distress: Patient presented to OSH with dyspnea and was intubated due to respiratory distress. A CXR showed pulmonary edema and her BNP was measured at [**Numeric Identifier 104608**]. Felt to be secondary to worsening renal function causing oliguria, fluid overload and pulmonary edema due to fluid poor cardiac reserve. Patient was started on lasix drip with good urine output and was extubated on [**6-6**]. She has been slowly weaned off of O2 requirements and is now saturating 98% on room air. #. AoCRF: Patient's last Cr was 4.4 at PCP's office on [**5-29**] and 5.7 on [**6-6**] during this admission. Unclear as to cause of acute change but failing transplant is most likely. Renal ultrasound showed progression of high resistance pattern of flow within the transplanted kidney with lack of antegrade diastolic flow in the intrarenal and main renal arteries. Patent renal vein. A right IJ tunneled line was placed and hemodialysis was started during this admission. She received 3 HD treatments prior to discharge. She will be continuing HD on a regular out patient basis. Per nephrology recommendations we will be continuing Tacrolimus, Mycophenolate Mofetil and Prednisone for her renal transplant. She was setup for M,W,F HD as outpt. #. Congestive Heart Failure: A cardiolgy evaluation was performed while she was in the MICU given her history of worsening SOB and fluid overload on admission. An echocardiogram was performed on this admission which showed overall left ventricular systolic function that is severely depressed (LVEF= 20-25 %) with global hypokinesis and regional akinesis/dyskinesis of the distal LV/apex and an akinectic inferior wall. This EF is decreased from 30% documented on a prior echo on [**9-2**]. She has been diuresed with furosemide 80mg [**Hospital1 **]. She is not longer hypervolemic on exam and her SOB has resolved. We are holding her Carvediolol and Lasix at the present time due to sbp's lower than her baseline. #. Hypotension: Presented with low BP in setting of propofol. Her blood pressures have remained low during this admission sbp's 90s-100s. We have held her out pt HTN meds: carvedilol, clonidine, enalapril, hydralazine, isosorbide mononitrate, Lasix and amlodipine. She has a close follow up appointment with her Cardiologist where her blood pressures can be reassessed at that time. #. Anemia: felt to be secondary to decreased eyrhtropoesis. At her baseline H/H at the time of discharge. #. Sceleroderma: not an active issue while inpatient. #. Transitional: She will have a follow up appointment with her primary care physician, [**Name10 (NameIs) **] cardiologist following this hospitalization. She will be receiving weekly regular hemodialysis treatment and her nephrologist will be following her in this setting. Her blood pressures should be re-checked following this admission for re-evaluation of her home HTN medication needs. Medications on Admission: -Torsemide 20 mg daily -ProAir 1-2 puffs inhalation 4-6 hours p.r.n -Aspirin 81 mg daily -atorvastatin 80 mg daily -Calcitrol 0.25 mcg oral daily -Carvedilol 25 mg p.o. b.i.d. -Clonidine 0.1 mg 24-hour patch weekly -Darbepoetin 100 mcg inj every other week -Enalapril 5 mg daily -Hydralazine 25 mg p.o. b.i.d. -Isosorbide mononitrate ER 120 mg daily -Nitroglycerin 0.4 sublingual p.r.n. for chest pain -Prednisone 2 mg daily -Sodium bicarbonte 1300 mg b.i.d. -Tacrolimus 1 mg b.i.d. -mycophenolate mofetil 500 mg [**Hospital1 **] -amlodipine 5 mg daily -famotidine 20 mg daily -pantoprazole 40 mg daily Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 3. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 9. sodium bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO twice a day. 10. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day as needed for heartburn. 11. darbepoetin alfa in polysorbat 100 mcg/0.5 mL Syringe Sig: One (1) Injection every other week. 12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual every 5 minutes up to 3 times as needed for chest pain. 14. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day as needed for heartburn. 15. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**11-27**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 16. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Renal Failure Acute on Chronic Systolic Congestive Heart Failure Exacerbation Secondary Diagnosis: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with acute renal failure and fluid in your lungs. The fluid in your lung was reduced with diurectic medications. It was determined that you will need hemodialysis in the future and you will be following up with nephrology for this treatment. Changes to your Medications: STOPPED: CARVEDILOL, CLONIDINE, ENALAPRIL, HYDRALAZINE, ISOSORBIDE MONONITRATE, AMLODIPINE,TORSEMIDE STARTED: FUROSEMIDE 80MG TWICE A DAY VITAMIN B COMPLEX-VITAMIN C COMPLEX-FOLIC ACID 1MG CAPSULE ONCE A DAY Please weigh yourself every morning, and call Dr. [**Last Name (STitle) 171**] if weight goes up more than 3 lbs. Followup Instructions: Department: [**Hospital3 249**] When: THURSDAY [**2204-6-21**] at 10:00 AM With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**] Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ***This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. Department: CARDIAC SERVICES When: TUESDAY [**2204-6-19**] at 10:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Location (un) **] [**Location (un) **] Dialysis Center [**Location 8262**], [**Numeric Identifier 99847**] Fax:[**Telephone/Fax (1) 10374**] Tel: [**Telephone/Fax (1) 5972**] Nephrologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Your outpatient dialysis schedule will be every Mon, Wed and Fri at 3:30pm Department: GASTROENTEROLOGY When: WEDNESDAY [**2204-6-13**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2204-6-20**] at 9:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

[ "428.0", "518.81", "276.0", "710.1", "414.01", "585.5", "E878.0", "272.4", "443.9", "584.9", "V15.82", "996.81", "403.91", "428.23" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "96.71" ]

icd9pcs

[ [ [] ] ]

11696, 11782

6438, 9624

300, 331

11975, 11975

3181, 3646

12866, 14908

2399, 2469

10278, 11673

11803, 11803

9650, 10255

12151, 12489

3662, 6415

2484, 2968

1742, 1786

2984, 3162

12518, 12843

245, 262

359, 1648

11939, 11954

11822, 11918

11990, 12127

1817, 2202

1670, 1722

2218, 2383

29,137

188,600

30240

Discharge summary

report

Admission Date: [**2108-1-24**] Discharge Date: [**2108-1-27**] Date of Birth: [**2039-3-9**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5569**] Chief Complaint: GI bleeding Major Surgical or Invasive Procedure: [**2108-1-24**] EGD duodenal ulcer injected and ligated History of Present Illness: Mr. [**Name13 (STitle) 15942**] is well-known to the transplant surgery service. Briefly, he is a 68 year-old male who is s/p OLT [**8-/2104**] with ESRD on HD who was recently admitted to [**Hospital1 18**] for a GI bleed and discharged 4 days prior. During his previous admission, he underwent EGD and colonoscopy that did not show a source of bleeding. He did not have any episodes of bloody stools while he was in the hospital and was transfused a total of 1 unit PRBC. He did have episodes of diarrhea but was C.Diff negative x 3. Furthermore, he is s/p a PEG tube [**3-/2106**] and has been getting tube feeds at home. Per his wife, he awoke this AM (~530AM) and had one episode of bloody BM. By approximately 930AM, he had a total of 4 bloody BMs, unknown quantity. He presented to [**Hospital3 **] Hospital and was found to have a hematocrit of 20. He was transfused one unit of PRBC and was transferred to [**Hospital1 18**] via [**Location (un) **]. In the emergency room, his repeat hematocrit was 26.0 after his transfusion. He has been hemodynamically stable without signs of hypotension. Gastroenterology evaluated him and plans for a EGD given the coffee ground drainage from his PEG tube. REVIEW OF SYSTEMS: Denies Fatigue, Weakness, Fevers, Chills, Cough, Chest pain, Palpitations (rapid/skip, Headache, Fainting, Blackouts, Seizures, Confusion, Change in appetite, Heartburn, Nausea, Vomiting, Abd. pain, Bloating, Diarrhea, Constipation, Jaundice/hepatitis, Dysuria, Nocturia, Polyuria, Hematuria. Past Medical History: HCC, EtOH Cirrhosis s/p OLT, CAD, HTN, CHF/Cardiomyopathy (EF 25-30%) with frequent admissions for systolic heart failure, Stage IV CKD (Baseline Cr 3.6), pancreatic insufficiency, Anemia, Bronchitis, COPD, Tube feeds at home through G-tube, COPD Past Surgical History: OLT [**2104-8-22**], PEG placement [**2106-3-18**] Social History: Married, lives at home with wife. Previously smoked 1PPD, now trying to quit smoking. No current EtOH use for past 5 years. Family History: Father died of prostate cancer. Physical Exam: Vital Signs: Temp: 98.1 Pulse:88 BP:138/69 RR:18 O2 SAT:98% on room air Gen:WD/WN, cachectic Neuro/Psych: Oriented x3, Affect Normal, NAD, Cooperative with exam. Neck: No masses, Trachea midline, Thyroid normal size, non- tender, no masses or nodules, No right carotid bruit, No left carotid bruit, Supple. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy . Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Soft not distended, no masses, guarding or rebound, No hepatosplenomegaly, No hernia, No AAA, Not tender to palpation, Bowel sounds present. Rectal: Normal tone, No gross blood, Guaiac Negative. Extremities: No popliteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial:P. Ulnar:P. Brachial:. LUE Radial:P. Ulnar:P. Brachial:. RLE Femoral:. Popliteal:. DP:P. PT:P. LLE Femoral:. Popliteal:. DP:P. PT:P. DESCRIPTION OF WOUND: Well-healed abdominal chevron incision LABORATORY DATA: 134 | 93 | 92 / --------------- 95 5.1 | 29 | 4.5 \ Ca: 8.8 Mg: 1.4 P: 0.5 ∆ ALT: 23 AP: 130 Tbili: 0.6 Alb: 2.8 AST: 42 LDH: Dbili: TProt: [**Doctor First Name **]: Lip: 55 \ 8.8 / 16.3 ------ 195 / 26.0 \ N:56 Band:5 L:17 M:7 E:2 Bas:2 Atyps: 3 Metas: 3 Myelos: 2 PT: 13.8 PTT: 28.3 INR: 1.2 MICROBIOLOGY: None IMAGING AND STUDIES: None Pertinent Results: [**2108-1-24**] 01:40PM BLOOD WBC-16.3* RBC-3.07* Hgb-8.8* Hct-26.0* MCV-85 MCH-28.6 MCHC-33.8 RDW-15.9* Plt Ct-195 [**2108-1-27**] 05:43AM BLOOD WBC-13.7* RBC-3.50* Hgb-10.4* Hct-29.4* MCV-84 MCH-29.6 MCHC-35.3* RDW-16.3* Plt Ct-99* [**2108-1-27**] 05:43AM BLOOD PT-14.0* PTT-28.6 INR(PT)-1.2* [**2108-1-27**] 05:43AM BLOOD Glucose-141* UreaN-48* Creat-3.6*# Na-139 K-3.2* Cl-103 HCO3-28 AnGap-11 [**2108-1-27**] 05:43AM BLOOD ALT-12 AST-34 AlkPhos-120 TotBili-0.9 [**2108-1-25**] 05:23AM BLOOD rapmycn-7.8 Brief Hospital Course: 68M s/p OLT, ESRD on HD s/p PEG with GI bleed, likely from an upper GI source. He was admitted to SICU on the Transplant Service. He was kept NPO and given 2 units of PRBC. Dr. [**Last Name (STitle) **] performed and EGD noting the following: a single oozing ulcer was found in the superior fornyx of the duodenal bulb. There was a large adherent red clot (1-2cm); the base could not be visualized. One triclip was successfully applied for the purpose of hemostasis. 3 1 cc.Epinephrine 1/[**Numeric Identifier 961**] injections were applied for hemostasis with success. Otherwise normal EGD to third part of the duodenum Recommendations included a PPI drip x 72 hours then PO BID until repeat EGD in 6 weeks. Hct remained stable and he as transferred out of the SICU. Of note, H.pylori testing on [**1-25**] was negative. On [**1-25**], Hct dropped from 27 to 25. 2 units of PRBC were given. Hct then remained stable. He continued to have 8 BMs/day. Diet was resumed on [**1-26**] as well as tube feeds. Imodium was started. BMs slowed down and were not bloody. These were well tolerated without further GI bleeding. Hct remained stable. Hemodialysis was performed on [**1-27**] without incident. Protonix drip was switched to prilosec [**Hospital1 **]. CVL was removed and he was discharged to home. Follow up with Dr. [**Last Name (STitle) 1852**] (Heme/Onc)was rescheduled to [**2-1**]. Medications on Admission: Carvedilol 3.125 mg PO BID, bisacodyl 10 mg PO DAILY PRN, B complex-vitamin C-folic acid 1 mg PO DAILY, nicotine 14 mg/24 hr Transdermal DAILY, prednisone 5 mg PO DAILY, epoetin alfa 10,000 unit/mL One, simvastatin 10 mg PO DAILY, testosterone 2.5 mg/24 hr Transdermal DAILY, omeprazole 20 mg PO BID, lipase-protease-amylase 12,000-38,000 -60,000 unit PO TID W/MEALS, sirolimus 1 mg PO DAILY, loperamide 2 mg PO BID PRN, sulfamethoxazole-trimethoprim 200-40 mg/5 mL PO QOD, mirtazapine 30 mg PO HS, methylphenidate 2.5 mg PO BID ALLERGIES: NKDA Discharge Medications: 1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 6. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 9. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 10. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day. 11. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: GI bleed duodenal ulcer h/o liver transplant CRF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: PLease call the Transplant Office [**Telephone/Fax (1) 673**] if you experience any GI bleeding/dizziness, fevers, chills, nausea, vomiting, increased abdominal pain or increased fatigue. You can take imodium twice daily if needed for diarrhea Continue Tube feedings: Vivonex @100cc/hour x 17 hours Resume your usual hemodialysis schedule Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 11058**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2108-2-1**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 8770**] Date/Time:[**2108-2-1**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2108-2-15**] 10:00 Completed by:[**2108-1-27**]

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icd9cm

[ [ [] ] ]

[ "39.95", "96.6", "44.43" ]

icd9pcs

[ [ [] ] ]

7597, 7603

4486, 5881

314, 372

7696, 7696

3954, 4463

8331, 8837

2436, 2469

6479, 7574

7624, 7675

5907, 6456

7879, 8308

2225, 2278

2484, 3935

1637, 1932

263, 276

400, 1618

7711, 7855

1954, 2202

2294, 2420

15,190

164,258

30462

Discharge summary

report

Admission Date: [**2181-6-5**] Discharge Date: [**2181-6-11**] Date of Birth: [**2112-3-30**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Norvasc / Verapamil Attending:[**First Name3 (LF) 1505**] Chief Complaint: preop w/for knee surgery revealed cardiac dz, asymptomatic Major Surgical or Invasive Procedure: CABGx4([**6-6**]) History of Present Illness: 69yoM with OA having workup for knee replacements found to be in Afib, had stress test that was positive followed by cardiac catheterization which revealed severe 3VD. Then referred for CABG Past Medical History: HTN ^chol AFib OA needs bilat arthroplasty CRI Social History: Lives with wife. Remote tobacco, quit [**2164**]. + ETOH (1-2 drinks/[**Known lastname **]) Family History: Brother died 64/MI Physical Exam: Admission VS T 98 HR 74 BP 136/88 RR 18 Gen NAD Neuro A&Ox3, nonfocal Chest CTA bilat CV irreg-irreg, no M/R Abdn soft, NT/ND/+BS Ext warm no edema Discharge T99.9 HR 70AF BP 120/69 RR 20 O2sat 94%RA Neuro A&Ox3 MAE, non focal exam Pulm CTAB CV irreg irreg, sternum stable incision CDI Abdm soft, NT/ND/+BS Ext warm 2+ edema Pertinent Results: [**2181-6-5**] 04:10PM GLUCOSE-97 UREA N-44* CREAT-2.0* SODIUM-143 POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-27 ANION GAP-13 [**2181-6-5**] 04:10PM ALT(SGPT)-19 AST(SGOT)-19 LD(LDH)-153 ALK PHOS-58 TOT BILI-0.4 [**2181-6-5**] 04:10PM ALBUMIN-4.3 [**2181-6-5**] 04:10PM %HbA1c-5.7 [**2181-6-5**] 04:10PM TSH-1.2 [**2181-6-5**] 04:10PM WBC-7.0 RBC-3.92* HGB-12.6* HCT-36.4* MCV-93 MCH-32.1* MCHC-34.6 RDW-13.6 [**2181-6-5**] 04:10PM PLT COUNT-207 [**2181-6-5**] 04:10PM PT-11.8 PTT-22.4 INR(PT)-1.0 [**2181-6-11**] 07:30AM BLOOD WBC-8.7 RBC-3.18* Hgb-10.4* Hct-30.4* MCV-96 MCH-32.7* MCHC-34.3 RDW-13.5 Plt Ct-303 [**2181-6-11**] 07:30AM BLOOD Plt Ct-303 [**2181-6-11**] 07:30AM BLOOD PT-14.4* PTT-24.2 INR(PT)-1.3* [**2181-6-10**] 06:45AM BLOOD Glucose-99 UreaN-40* Creat-1.9* Na-137 K-4.1 Cl-99 HCO3-28 AnGap-14 CHEST (PORTABLE AP) [**2181-6-10**] 11:26 AM CHEST (PORTABLE AP) Reason: Effusion? Pntx? [**Hospital 93**] MEDICAL CONDITION: 69 year old man with s/p Off Pump CABG REASON FOR THIS EXAMINATION: Effusion? Pntx? PORTABLE CHEST ON [**2181-6-10**] AT 11:39 INDICATION: CABG with chest tube in place. COMPARISON: [**2181-6-9**]. FINDINGS: Left chest tube remains in place with some density adjacent to the tip, but there is no significant interval change vs. prior. Specifically, there is no pneumothorax and no interval development of effusion. Cardiac silhouette and mediastinal contours are stable. IMPRESSION: No change vs. prior. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**] Brief Hospital Course: 69yoM with known Atrial fibrillation and coronary artery disease admitted preop for transition fro Coumadin to Heparin. Brought to the OR on [**6-6**] for CABG, please see OR report for details. In summary pt had off pump CABGx4 with LIMA-LAD, SVG OM-Ygraft-Diag,SVG-PDA. Pt tolerated surgery well and was transferred to CT [**Doctor First Name **] ICU. He did well in immediate post-op period was extubated and on POD1 he was transferred to the step down floor. On POD2 his chest tubes and epicardial pacing wires were removed and his Coumadin was restarted. Over the next several [**Known lastname **] his activity was advanced on POD5 it was decided he was stable and ready to be discharged home with visiting nurses. Medications on Admission: Atenolol 200' HCTZ 25' Lisinopril 20' Ultram 50' Prilosec 20' Zocor 40' Levitra/prn Warfarin 4' Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a [**Known lastname **]). Disp:*60 Tablet(s)* Refills:*2* 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a [**Known lastname **] for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 3. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a [**Known lastname **] for 2 weeks. Disp:*28 Tablet Sustained Release(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a [**Known lastname **]). Disp:*60 Capsule(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a [**Known lastname **]: target INR 1.5-2. Disp:*60 Tablet(s)* Refills:*2* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a [**Known lastname **]. 10. Ultram 50 mg Tablet Sig: One (1) Tablet PO Q6 hrs/PRN. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] vna Discharge Diagnosis: s/p off pump CABGx4 LIMA-LAD,Y SVG-OM-Diag, SVG-PDA ([**6-6**]) PMH:HTN,^chol,AF,OA, CRI, s/p bilat knee surgery Discharge Condition: good Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed Call for any fever, redness or drainage from wounds. Followup Instructions: [**Hospital 409**] clinic in 2 weeks Dr [**Last Name (STitle) 7389**] in [**3-17**] weeks Dr [**Last Name (STitle) **] in 4 weeks Completed by:[**2181-6-11**]

[ "403.90", "585.9", "715.36", "414.01", "272.0", "427.31" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.13" ]

icd9pcs

[ [ [] ] ]

4938, 4993

2767, 3489

358, 378

5150, 5157

1180, 2094

5358, 5519

793, 813

3635, 4915

2131, 2170

5014, 5129

3515, 3612

5181, 5335

828, 1161

260, 320

2199, 2744

406, 598

620, 668

684, 777

55,597

177,736

53981

Discharge summary

report

Admission Date: [**2122-5-9**] Discharge Date: [**2122-5-15**] Date of Birth: [**2070-2-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 9160**] Chief Complaint: Tachypnea and tachycardia noted at facility Major Surgical or Invasive Procedure: Percutaneous cholecystostomy tube placement right internal jugular vein central venous catheter placement History of Present Illness: 52 yo M with h/os anoxic brain injury [**2-12**] substance abuse s/p trach and PEG [**1-/2122**] (which occurred in [**Hospital 5503**] Rehab), recent admission for G-tube related complication discharged on [**2122-5-4**] transferred from [**Hospital **] Rehab for tachypnea and tachycardia. . Of note, patient was recently admitted from [**Date range (1) 110683**] for malpositioned G tube (after a manual G-tube replacement in the rehab)in the left rectus muscle complicated by sepsis, s/p debridement and later replacement. He was found to have urinary tract infection during that admission with Klebsiella and Psuedomonas and was discharged on Bactrim for UTI. . Patient was noted to have 1 day of tachypnea and tachycardia. His RR was up to 40s with abdominal breathing. He was started on ceftin 500 mb [**Hospital1 **] x 7 days on [**5-8**] for UTI in additional to the Bactrim that he was discharged on. Flagyl 500 mg TID was also started for planned x 10 days for ? C. diff given increased stool frequency. Outside lab noted for WBC 15.6, Hgb 14, Hct 40, Plt 323, Diff of 82.6% neutrophils, Na 132, K 4.3, Cl 95, HCO3 21, BUN 25, Crt 1. Upon transfer, VS were BP 112/70, HR 116, RR 40, T 98.6, pOx 95 RA. . En route, HR was 115, SBP 97/50 (received 300 cc NS bolus x 1), pOx mid-90s on 35 % TM, AF. FSBS 135 . In the ED, initial VS were: 99.0 118 118/76 32 94% 50% o2 mask via trach. Patient was noted to be unresponsive (baseline) with aniscoria left 4 mm and right 6 mm, + crackles. Rectal temperature was noted to be 104. He got 1000 mg IV Tylenol. He also received IVF and metoprolol 5 mg iv x 1 for sinus tachycardia. EKG showed sinus tachycardia at 117, normal axis, normal interval, no STT changes, TWI III, similar to prior. Labs were significant for Hgb 11.1 (down from 14.4), ALT 46 but otherwise normal LFTs, baseline chemistry panel. Portal CXR showed low lung volumes with right lung atelectasis and no pleural effusion, no evidence of pneumonia. UA was +. Blood and urine cultures were sent. ABG 7.54/29/75/26. Lactate 1.5. Patient was given vanc/zosyn/levofloxacin. CT abd showed extensive gallbladder wall thickening and fat stranding toward the duodenum and pancreatic head, c/w cholecystitis. Liver U/S did not show obvious stone. General surgery was consulted and did not think that patient was a surgical candidate. . Upon arrival to the MICU, patient is not-interactive. Past Medical History: - TBI secondary to anoxia during substance overdose - s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1003**] G tube placement [**2122-4-18**] - s/p exploratory G tube tract incision and drainage of the retro-rectus/peri-rectus space and drain placement [**2122-4-14**] - s/p Tracheostomy and PEG placement [**1-/2122**] - Sepsis secondary to acute cholecystitis with placement of drain [**4-/2122**] Social History: according to guardian - from [**Name (NI) **] - h/o substance abuse, was on methadone - unclear if used EtOH or smoked - no kids Family History: Not addressed this admission Physical Exam: Physical Exam on Admission General: not interactive, not oriented HEENT: Sclera anicteric, MMM, EOMI, aniscoria left 4 mm and right 6 mm Neck: supple, JVP not elevated, no LAD CV: tachycardic, normal rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: coarse breath sounds, no wheezes/ronchi/crackles Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding, G-tube in place, skin around appeared erythematous/firm GU: + Foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: PERRLA but aniscoria, gait did not examine, withdrawals from pain, decorticate posturing . Discharge: Vitals: 98 121/78 95 98%RA General: not interactive HEENT: Aniscoria left pupil 4 mm and right pupil 6 mm; former LIJ site with no bleeding or hematoma CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: coarse breath sounds, no wheezes/ronchi/crackles Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding, G-tube in place, no purulent drainage. Perc cholecystostomy tube in place draining greenish-brown fluid GU: + Foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: decorticate posturing SKin: notable for stage I sacral decub; Pertinent Results: Labs on Admission [**2122-5-9**] 10:15AM BLOOD WBC-12.2* RBC-3.44* Hgb-11.1*# Hct-33.7*# MCV-98 MCH-32.3* MCHC-33.0 RDW-13.7 Plt Ct-268 [**2122-5-9**] 10:15AM BLOOD Neuts-84.5* Lymphs-10.0* Monos-4.1 Eos-0.8 Baso-0.5 [**2122-5-9**] 10:15AM BLOOD PT-14.9* PTT-27.6 INR(PT)-1.4* [**2122-5-9**] 10:15AM BLOOD Ret Aut-1.9 [**2122-5-9**] 10:15AM BLOOD Glucose-117* UreaN-35* Creat-0.8 Na-133 K-3.9 Cl-99 HCO3-23 AnGap-15 [**2122-5-9**] 10:15AM BLOOD ALT-46* AST-26 LD(LDH)-228 AlkPhos-46 TotBili-0.3 [**2122-5-9**] 10:15AM BLOOD Lipase-43 [**2122-5-9**] 10:15AM BLOOD Albumin-3.0* Calcium-7.9* Phos-2.9 Mg-2.4 Iron-22* [**2122-5-9**] 10:15AM BLOOD calTIBC-182* Hapto-382* Ferritn-1013* TRF-140* [**2122-5-9**] 10:28AM BLOOD Type-ART FiO2-35 pO2-75* pCO2-29* pH-7.54* calTCO2-26 Base XS-2 Intubat-NOT INTUBA [**2122-5-9**] 11:00AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.024 [**2122-5-9**] 11:00AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2122-5-9**] 11:00AM URINE RBC-5* WBC-46* Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 [**2122-5-9**] 11:00AM URINE CastGr-6* CastHy-2* [**2122-5-9**] 11:00AM URINE AmorphX-RARE CaOxalX-OCC [**2122-5-9**] 11:00AM URINE Mucous-FEW Micro: [**5-9**] blood cx x2: gram positive cocci in clusters x1/4 bottles [**5-10**] blood cx x2: pnd [**5-9**] urine cx: [**2122-5-9**] 11:00 am URINE **FINAL REPORT [**2122-5-11**]** URINE CULTURE (Final [**2122-5-11**]): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. _________________________________________________________ PSEUDOMONAS AERUGINOSA | AMIKACIN-------------- 4 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 4 I PIPERACILLIN/TAZO----- I TOBRAMYCIN------------ 8 I [**5-9**] sputum cx: cancelled [**5-9**] bile cx: pnd (0PMNs, 0org) [**5-10**] C diff assay: negative [**5-10**] urine cx: pnd [**5-11**] blood cx: pnd . Images: CT abd/pelvis with and without contrast [**5-9**] Acute cholecystitis, new from prior study. Likely bibasilar atelectasis but superimposed pneumonia is not excluded. . CXR [**5-9**] IMPRESSION: Right basilar atelectasis. Otherwise, no acute intrathoracic process. . CTA IMPRESSION: 1. No pulmonary embolus to the segmental levels. 2. 2-cm right middle lobe opacity may represent focal atelectasis versus nodule. Recommend 3-month follow-up CT. . [**2122-5-9**] - IR percutaneous chole tube . Discharge labs: [**2122-5-15**] 06:30AM BLOOD WBC-7.1 RBC-3.97* Hgb-12.9* Hct-38.6* MCV-97 MCH-32.6* MCHC-33.5 RDW-14.0 Plt Ct-454* [**2122-5-15**] 06:30AM BLOOD Plt Ct-454* [**2122-5-15**] 06:30AM BLOOD Glucose-125* UreaN-13 Creat-0.5 Na-133 K-4.5 Cl-101 HCO3-24 AnGap-13 [**2122-5-10**] 03:59AM BLOOD ALT-37 AST-30 AlkPhos-38* TotBili-0.4 [**2122-5-14**] 06:40AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.3 Brief Hospital Course: SUMMARY: 52 yo M with h/o anoxic brain injury [**2-12**] substance abuse s/p trach and PEG, recent G tube placement complication s/p exploratory tract incision and drainage with replacement, who presented to MICU [**5-9**] with sepsis and transferred to floor for further management. # Sepsis/SIRS: the most likely source of infection was acute cholecystitis, and a drain was placed in the gallbladder. The patient completed a 7 day course of tigecycline in-house per ID recommendations. He grew a pseudomonas species in his urine, which the ID team felt was most likely colonization. # Tachycardia: The patient was noted to be tachycardic to 140s (sinus), and was ruled out for a pulmonary embolism. He was restarted on previous doses of metoprolol after significant volume resuscitation. # Lung nodule: Will need follow-up CT in 3 months, pending change in overall goals of care. # Anemia: Improved during the course of admission, and no evidence for bleeding. # Pressure ulcer: Stage I, over buttock, will need good wound care and frequent repositioning. # Nutrition: The patient has a history of infections at the site of his G-tube. It will be important to closely monitor the site, with routine care. This was not an active issue this admission. # Code Status: The patient is Full Code, with a court appointed guardian. Changes in clinical status should be discussed with the guardian. The prognosis overall of the patient's grim chance of neurological recovery was discussed this admission, and the guardian is exploring options through the court system to potentially make the patient DNR/DNI, however currently he is full code. # Communication: [**First Name5 (NamePattern1) 8214**] [**Last Name (NamePattern1) 8215**] [**Telephone/Fax (1) 8216**] (court appointed guardian). Okay to speak with [**Name (NI) 17148**] (sister [**Telephone/Fax (1) 110684**]; [**Telephone/Fax (1) 110685**]), [**Name (NI) **] [**Name (NI) **] (friend [**Telephone/Fax (1) 110686**]) ============================== Transitional issues: -Needs to be taken to f/u appointment with surgery to evaluate biliary drain -Pending goals of care, the patient should have repeat chest CT scan in 3 months (early [**Month (only) 216**]) to evaluate a lung nodule Medications on Admission: per [**Hospital1 **] Record - metoprolol tartrate 50 mg every 6 hours, via G tube - colace 25 mg [**Hospital1 **] - heparin 5000 units TID - vitamin C 500 mg daily - famotidine 20 mg [**Hospital1 **] - bactrim DS 1 tab [**Hospital1 **]- for UTI, [**Date range (1) 12721**] (discharged med from prior admission for intended 10 day course) - ceftin 500 mg [**Hospital1 **] x 7 days [**5-8**]- for ? - flagyl 500 mg TID x 10 days [**5-8**]- for loose stool (diagnosed - acidophilus x 30 days ppx - ISS - miralax 17 g prn - senna [**Hospital1 **] prn - MOM 30 mL daily prn for constipation - dulcolax 10 mg suppository rectally daily prn - fleet enema 1 rectally daily prn - maalox 30 mL q6h prn Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 7. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. 8. Fleet enema 1 enema PR PRN constipation 9. Oxygen Therapy Continuous bland aerosol mask 40 % Via Trach Mask Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: Acute cholecystitis with sepsis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Not interactive, withdraws to pain Activity Status: Bedbound. Discharge Instructions: Mr. [**Known lastname 110682**] was admitted for an infection, and was treated with a course of IV antibiotics to kill the infection, which likely originated from an infected gallbladder. His antibiotic course has completed. He also had a drainage catheter placed in his gallbladder, to drain the infection. . He also had a test to rule out a blood clot in the lung, called a CTA of the chest, and this test was negative (there was no blood clot). . Please STOP previous antibiotics, including bactrim, ceftin, flagyl. It will be very important to follow-up at the scheduled surgery appointment to have the gallbladder drain evaluated. Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: TUESDAY [**2122-5-26**] at 1:30 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**] Completed by:[**2122-5-15**]

[ "793.11", "599.0", "V15.52", "038.9", "V44.1", "707.05", "276.3", "276.1", "707.21", "575.0", "785.0", "995.91", "518.0", "285.9" ]

icd9cm

[ [ [] ] ]

[ "38.97", "51.01", "96.6" ]

icd9pcs

[ [ [] ] ]

11559, 11600

7870, 9887

347, 455

11676, 11676

4875, 7446

12484, 12921

3504, 3534

10866, 11536

11621, 11655

10150, 10843

11822, 12461

7463, 7847

3549, 4856

9908, 10124

264, 309

483, 2904

11691, 11798

2926, 3341

3357, 3488

79,673

187,424

17148+17149+56828

Discharge summary

report+report+addendum

Admission Date: [**2184-7-23**] Discharge Date: [**2184-7-30**] Date of Birth: [**2125-5-23**] Sex: M Service: CARDIOTHORACIC Allergies: Tetracycline Attending:[**First Name3 (LF) 1406**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2184-7-23**] Coronary artery bypass grafting x4 with a left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the diagonal artery, and sequential reverse saphenous vein graft to the posterior left ventricular branch artery and posterior descending artery. History of Present Illness: 59 year old male with history of coronary artery disease s/p LAD stent in [**2175**] and ongoing left sided chest pain and exertional dyspnea relieved with rest (5 minutes). He had stress echo in [**Month (only) 116**] which showed mid-to distal inferior septal HK and basal to mid anterioseptal HK consistent with inducible ischemia. He was referred for cardiac catheterization which revealed severe two vessel coronary artery disease with 95% instent restenosis. Now referred for surgical revascularization. Past Medical History: Coronary artery disease s/p LAD stent [**2175**] Hypertension Dyslipidemia Tobacco abuse Social History: Family History: -Premature coronary artery disease Father MI < 55 [] Mother < 65 [] Race: Asian Last Dental Exam: Lives with: Wife and daughter Contact: Phone # Occupation: Works in a restaurant Cigarettes: Smoked no [] yes [X] last cigarette current smoker Hx: 0.5ppd with 20-pack-year, *reports has cut back in past month* Other Tobacco use: Denies ETOH: Denies Illicit drug use: Denies Family History: non-contributory Physical Exam: Pulse: 54 Resp: 16 O2 sat: 100% B/P Right: 116/76 Height: 67" Weight: 160lbs General: Well-developed male in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [] grade ______ Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema/Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: ECHO: PRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Left ventricular wall thicknesses and cavity size are normal. 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, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results before surgical incision. Post_Bypass: Normal biventricular systolic function. LVEF 55%. Intact thoracic aorta. No new valvular findings. [**2184-7-29**] 05:14AM BLOOD Hct-31.3* [**2184-7-27**] 03:18AM BLOOD WBC-11.0 RBC-3.29* Hgb-10.3* Hct-31.1* MCV-95 MCH-31.2 MCHC-33.0 RDW-13.2 Plt Ct-245 [**2184-7-29**] 05:14AM BLOOD Glucose-102* UreaN-21* Creat-1.0 Na-142 K-4.1 Cl-103 HCO3-31 AnGap-12 [**2184-7-28**] 06:16AM BLOOD UreaN-17 Creat-0.9 Na-140 K-3.8 Cl-103 [**2184-7-27**] 03:18AM BLOOD Glucose-117* UreaN-14 Creat-0.8 Na-138 K-3.9 Cl-102 HCO3-29 AnGap-11 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2184-7-23**] where the patient underwent Coronary artery bypass grafting x4 with a left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the diagonal artery, and sequential reverse saphenous vein graft to the posterior left ventricular branch artery and posterior descending artery. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He was initially to sleepy to extubate but finally extubated later on POD 1. He was found to be alert and oriented and breathing comfortably. The patient was neurologically intact. He was hypotensive on POD1 and Neo gtt was slowly weaned off. He was eventually started on low dose Lopressor and Lasix and hemodynamically stable on no inotropic or vasopressor support. Pacing wires and chest tubes were discontinued without incident and he was transferred to the telemetry floor for further recovery. While recovering on the floor he developed nausea and vomiting which was related to his constipation. He received laxatives and slowly his nausea resolved after several bowel movements. 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 home with visiting nurse services in good condition with appropriate follow up instructions. All instructions given to patient via interpreter. Medications on Admission: Lisinopril 5 mg daily Atenolol 50 mg daily Simvastatin 80 mg daily Aspirin 81 mg daily Prilosec OTC Discharge Medications: 1. Aspirin EC 81 mg PO DAILY if extubated 2. Docusate Sodium 100 mg PO BID 3. Furosemide 40 mg PO BID RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*5 Tablet Refills:*0 4. Metoprolol Tartrate 25 mg PO TID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 5. Potassium Chloride 20 mEq PO BID Hold for K >4.5 RX *potassium chloride 20 mEq 1 by mouth daily Disp #*5 Tablet Refills:*0 6. Simvastatin 40 mg PO DAILY 7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *Ultram 50 mg 1 tablet(s) by mouth Q 4 hrs Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: Multicultural VNA Discharge Diagnosis: Coronary artery disease s/p LAD stent [**2175**] Hypertension Dyslipidemia Tobacco abuse Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Trace lower extremity Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] Date/Time:[**2184-8-5**] 10:15 in the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **] Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2184-8-26**] 1:15 in the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **] Cardiologist Dr. [**First Name (STitle) 437**] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2184-8-18**] 11:20 Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 32199**],[**First Name3 (LF) 3078**] H. [**Telephone/Fax (1) 8236**] in [**4-8**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2184-7-29**] Admission Date: [**2184-7-23**] Discharge Date: [**2184-7-30**] Date of Birth: [**2125-5-23**] Sex: M Service: CARDIOTHORACIC Allergies: Tetracycline Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2184-7-23**] Coronary artery bypass grafting x4 with a left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the diagonal artery, and sequential reverse saphenous vein graft to the posterior left ventricular branch artery and posterior descending artery. History of Present Illness: 59 year old male with history of coronary artery disease s/p LAD stent in [**2175**] and ongoing left sided chest pain and exertional dyspnea relieved with rest (5 minutes). He had stress echo in [**Month (only) 116**] which showed mid-to distal inferior septal HK and basal to mid anterioseptal HK consistent with inducible ischemia. He was referred for cardiac catheterization which revealed severe two vessel coronary artery disease with 95% instent restenosis. Now referred for surgical revasculariozation. Past Medical History: Coronary artery disease s/p LAD stent [**2175**] Hypertension Dyslipidemia Tobacco abuse Social History: Lives with: Wife and daughter Contact: Phone # Occupation: Works in a restaurant Cigarettes: Smoked no [] yes [X] last cigarette current smoker Hx: 0.5ppd with 20-pack-year, *reports has cut back in past month* Other Tobacco use: Denies ETOH: Denies Illicit drug use: Denies Family History: non-contributory Physical Exam: Pulse: 54 Resp: 16 O2 sat: 100% B/P Right: 116/76 Height: 67" Weight: 160lbs General: Well-developed male in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [] grade ______ Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema/Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: [**2184-7-23**] Intra-op TEE: Conclusions PRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Left ventricular wall thicknesses and cavity size are normal. 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, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results before surgical incision. Post_Bypass: Normal biventricular systolic function. LVEF 55%. Intact thoracic aorta. No new valvular findings. [**2184-7-29**] KUB: FINDINGS: This is an extremely limited exam due to significant motion Preliminary Reportartifact. Supine and upright views of the abdomen demonstrate no overt Preliminary Reportdilated loops of bowel. There appears to be interval improvement in the bowel Preliminary Reportgas pattern since previous imaging. There is a left pleural effusion Preliminary Reportvisualized. The right IJ is in place. Sternotomy wires are visualized. Preliminary ReportThere is no free air under the diaphragm. Visualized osseous structures are Preliminary Reportunremarkable [**2184-7-29**] PA and lateral chest radiographs. FINDINGS: The position of right IJ line is unchanged. Cardiomediastinal silhouette is stable. Lungs are better expanded and clear. There is a small-moderate left pleural effusion. Vertical lucency noted projecting over the sternum on the prior study is not as prominent. No pneumothorax. IMPRESSION: Persistent small-moderate left pleural effusion. [**2184-7-30**] 03:22AM BLOOD WBC-11.6* RBC-3.45* Hgb-10.8* Hct-32.7* MCV-95 MCH-31.3 MCHC-33.1 RDW-13.6 Plt Ct-372# [**2184-7-27**] 03:18AM BLOOD WBC-11.0 RBC-3.29* Hgb-10.3* Hct-31.1* MCV-95 MCH-31.2 MCHC-33.0 RDW-13.2 Plt Ct-245 [**2184-7-26**] 09:00AM BLOOD WBC-11.9* RBC-3.23* Hgb-10.1* Hct-30.7* MCV-95 MCH-31.4 MCHC-33.0 RDW-13.3 Plt Ct-180 [**2184-7-30**] 03:22AM BLOOD Glucose-98 UreaN-22* Creat-1.0 Na-141 K-4.1 Cl-100 HCO3-30 AnGap-15 [**2184-7-29**] 05:14AM BLOOD Glucose-102* UreaN-21* Creat-1.0 Na-142 K-4.1 Cl-103 HCO3-31 AnGap-12 [**2184-7-28**] 06:16AM BLOOD UreaN-17 Creat-0.9 Na-140 K-3.8 Cl-103 [**2184-7-27**] 03:18AM BLOOD Glucose-117* UreaN-14 Creat-0.8 Na-138 K-3.9 Cl-102 HCO3-29 AnGap-11 Brief Hospital Course: Addendum to discharge summary on [**7-30**] Patient remained in the hospital for another 24hrs due to vomiting after receiving lactulose. He moved his bowels, started on prilosec 20mg [**Hospital1 **]. So far today he tolerted his diet. He remains hemodynamiclly stable. Patient states that he is feeling better. In light of his progress he is being discharged to home with strict instructions to call if nausea and vomiting returns. [**Month (only) 116**] need PO Reglan and GI consult if it persists. Medications on Admission: Lisinopril 5 mg daily Atenolol 50 mg daily Simvastatin 80 mg daily Aspirin 81 mg daily Prilosec OTC Discharge Medications: 1. Aspirin EC 81 mg PO DAILY if extubated 2. Docusate Sodium 100 mg PO BID 3. Furosemide 40 mg PO BID RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*5 Tablet Refills:*0 4. Metoprolol Tartrate 25 mg PO TID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 5. Potassium Chloride 20 mEq PO BID Hold for K >4.5 RX *potassium chloride 20 mEq 1 by mouth daily Disp #*5 Tablet Refills:*0 6. Simvastatin 40 mg PO DAILY 7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *Ultram 50 mg 1 tablet(s) by mouth Q 4 hrs Disp #*30 Tablet Refills:*0 8. Omeprazole 20 mg PO BID Discharge Disposition: Home With Service Facility: Multicultural VNA Discharge Diagnosis: Coronary artery disease s/p LAD stent [**2175**] Hypertension Dyslipidemia Tobacco abuse Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Trace lower extremity Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] Date/Time:[**2184-8-5**] 10:15 in the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **] Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2184-8-26**] 1:15 in the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **] Cardiologist Dr. [**First Name (STitle) 437**] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2184-8-18**] 11:15 Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 32199**],[**First Name3 (LF) 3078**] H. [**Telephone/Fax (1) 8236**] in [**4-8**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2184-7-30**] Name: [**Known lastname **],[**Known firstname 2237**] [**Doctor Last Name 8885**] Unit No: [**Numeric Identifier 8886**] Admission Date: [**2184-7-23**] Discharge Date: [**2184-7-30**] Date of Birth: [**2125-5-23**] Sex: M Service: CARDIOTHORACIC Allergies: Tetracycline Attending:[**First Name3 (LF) 135**] Addendum: lasix 20mg po daily x 5 days Potassium 20mEq po daily x 5 days Discharge Medications: laix 20mg po daily x 5 days Potssium 20mEq po daily for 5 days Discharge Disposition: Home With Service Facility: Multicultural VNA [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2184-7-30**]

[ "414.01", "996.72", "E879.8", "305.1", "272.4", "401.9", "V45.82" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

17514, 17719

13601, 14106

8744, 9050

15073, 15257

10747, 13578

16045, 17404

10034, 10052

17427, 17491

14961, 15052

14132, 14234

15281, 16022

10067, 10728

8693, 8706

9078, 9591

9613, 9704

9720, 10018

4,113

106,841

4896

Discharge summary

report

Admission Date: [**2145-1-17**] Discharge Date: [**2145-1-21**] Date of Birth: [**2103-6-23**] Sex: F Service: MEDICINE Allergies: Codeine / Amoxicillin / Blood-Group Specific Substance Attending:[**First Name3 (LF) 30**] Chief Complaint: Mental status change Major Surgical or Invasive Procedure: Endotracheal intubation Placement of right subclavian line (at outside hospital) History of Present Illness: 41yo woman with history of DM1, ESRD s/p transplant in '[**40**], CAD s/p CABG, PVD, CHF with EF of 45%, and HTN was admitted to [**Hospital6 33**] on ([**1-16**]) for Diabetic ketoacidosis. She initially presented on ([**1-13**]) for evaluation of "abnormal labs", which revealed an anion gap of 13, sodium of 131, and glucose of 91. She was sent home with instructions to maintain hydration. On morning of admission to [**Hospital6 **], she was found by her mother to be suffering from nausea/vomiting, and this persisted for many hours. She became progressively lethargic, diaphoretic and pale. At the outside hospital, she had significant acidosis with initial ABG of 6.80/11/158 on FiO2 of 21%. Anion gap was 32. Glucose was > 1000. Initial bicarb was less than 3. She had no evidence of UTI on UA, and no evidence of any focal infiltrates on chest xray. Urine and blood cultures were no growth to date at time of transfer. EKG demonstrated sinus tachycardia at 121bpm with nl axis and intervals; there were increased/consider hyperacute T waves in V1-3, and she had inverted T waves in V5-6 (seen on previous). Cardiac enzymes were negative with CK of 42, and troponin of less than 0.01. . She was intubated in the emergency department ther for lethargy and profound tachypnea. She was managed with IVF and insulin drip. She had a right subclavian TLC placed. Her anion gap had closed to 11 on day of transfer ([**2145-1-17**]). On transfer, her insulin gtt was at 4units/hr, and she was on D51/2NS at 200cc/hr. She was also placed on stress dose hydrocortisone given her history of steroid treatment. She was managed in the ICU, and her ventilatory support was weaned down to CPAP/PS. Last ABG done on day of transfer was 6.92/13/141. Past Medical History: 1. ESRD s/p living related donor transplant [**10-31**], baseline Cr 1-1.1. 2. Diabetes Mellitus type I with retinopathy, gastroparesis and neuropathy 3. CAD s/p CABG [**5-2**] (LIMA-LAD, SVG-PDA, OMI-Diag) 4. PVD s/p R fem-[**Doctor Last Name **] 5. CHF EF = 45-50% 6. HTN 7. Chronic ulcers 8. Sarcoidosis 9. Depression 10. Blindness bilaterally [**3-4**] diabetic retinopathy. L eye prosthesis. Social History: Lives with her mother in [**Name (NI) **]. Smoker: 1 ppd for 20 years. No alcohol or IVDU. Has had care at [**Last Name (un) **] Diabetes center; her primary doctor there is Dr. [**Last Name (STitle) 10088**]. Sees Dr. [**Last Name (STitle) 1852**] at [**Company 191**] Family History: no diabetes or kidney disease Father - MI at 74 Mother with hypertension Physical Exam: gen: intubated; sedated on vent. Responding to commands. heent: anicteric sclera; minimally responsive pupils neck: supple; full range of motion cv: RRR, 2/6 systolic murmur best at left sternal border resp: CTA bilaterally; no focal findings abd: soft, non-tender; nabs extr: no c/c/e; past surgical scars; healing previous ulceration at lle neuro: non-focal Pertinent Results: CXR: Comparison made to radiographs from the previous day. An endotracheal tube has been removed. A right subclavian line ends at the SVC/right atrial junction. Mild cardiomegaly is stable. CHF is slightly increased compared to the previous day. No focal parenchymal consolidation, or pneumothorax is seen. No large effusions or pneumothorax are seen. No osseous abnormalities identified. [**2145-1-20**] 07:32AM BLOOD PT-11.2* PTT-23.2 INR(PT)-0.8 [**2145-1-17**] 08:10PM BLOOD Ret Aut-2.2 [**2145-1-20**] 07:32AM BLOOD Glucose-246* UreaN-18 Creat-0.9 Na-137 K-4.7 Cl-108 HCO3-16* AnGap-18 [**2145-1-17**] 08:10PM BLOOD LD(LDH)-152 TotBili-0.1 [**2145-1-19**] 03:03AM BLOOD CK-MB-2 cTropnT-0.04* [**2145-1-19**] 02:45PM BLOOD CK-MB-2 cTropnT-0.03* [**2145-1-19**] 11:11PM BLOOD CK-MB-2 cTropnT-0.01 [**2145-1-20**] 10:58AM BLOOD Albumin-2.6* [**2145-1-17**] 08:10PM BLOOD calTIBC-187* VitB12-491 Folate-7.8 Ferritn-76 TRF-144* [**2145-1-20**] 07:32AM BLOOD FK506-4.6* [**2145-1-20**] 07:32AM BLOOD rapmycn-2.4* [**2145-1-18**] 05:32PM BLOOD Lactate-1.4 Brief Hospital Course: [**Hospital Unit Name 153**] course: Ms. [**Known lastname 19419**] was extubated on [**1-18**]. Anion gap closed with insulin gtt. D5 1/2NS given at 200mL/hr. Complicated by episode of flash pulmonary edema with HR 150s-160s - resolved with IV lasix, morphine, IV lopressor. Ruled out with three negative troponins. [**Last Name (un) **] service consulted, who suggested regimen of lantus 20U qHS with humalog SSI. Lantus started that evening as pt started taking PO, insulin gtt d/c'ed four hours later. On [**1-20**], pt spiked to 101.4, CXR showing consolidation at lung bases, probably [**3-4**] residual pulmoanry edema and atelectasis, but can't r/o PNA. On levofloxacin 500mg PO q24h (started [**1-17**]). ABG done: 7.4/27/96/17, lactate 1.4. has been afebrile since. Transplant surgery consulted, recommended daily prograf levels with goal [**6-6**], and qod rapamune levels with goal [**6-5**]. This AM, rapamune level subtherapic, increased dose to 3mg qD. Had been giving stress dose steroids, d/c'ed and placed back on chronic dose of 4mg qD due to no evidence of adrenal insufficiency. On transfer to floor, pt taking adequate PO, but somewhat limited [**3-4**] sore throat, most likely [**3-4**] intubation. Given cepacol lozenges, receiving tid sugar-free shakes with diabetic diet per nutrition recommendation. on AML, AG 13, bicarb 16, serum acetone positve, indicating and overlying element of starvation ketosis [**3-4**] poor PO intake. She admitted eating poorly over the past couple of weeks prior to admission. After transfer to floor, BS remained [**Month/Day (2) **]. Glargine increased to 28U qHS, with more aggressive sliding scale, which resulted in much improved control. Her PO intake continued to improve, and was taking a full consistency diet by time of d/c. She was discharged to home on Glargine 28U qHS, and the most recently utilized Humalog sliding scale. Transplant surgery was satisfied with her Prograf and Rapamune regimens. She was d/c'ed with the remainder of her levofloxacin regimen. A f/u appointment with her PCP at [**Name9 (PRE) 191**], Dr. [**Last Name (STitle) 1852**], was made for [**2145-2-11**]. She also has a f/u appointment with Dr. [**Last Name (STitle) **] in renal transplant on [**2145-2-5**]. She was instructed to call [**Last Name (un) **] to make an appointment within the next 2 weeks. Medications on Admission: DS bactrim three times per week prednisone 7.5mg daily ASA 81 daily reglan 40mg sirolimus 2mg daily metoprolol 25mg [**Hospital1 **] plavix 75mg daily ramipril 2.5mg daily protonix 40mg dialy lantus 100units HS zantac 150mg [**Hospital1 **] remeron 15mg HS Medications on transfer: Insulin drip at 4units/hour hydrocortisone 100mg IV q8h D51/2NS at 200cc/hr potassium, magnesium repletion heparin 5000 units sc tid protonix 40mg IV BID reglan 10mg IV QID compazine 25mg q12 prrn lopressor 5mg IV q6h sodium bicarbonate 100mEq once morphine 2mg IV q10min prn lorazepam 2mg IV once Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea. 6. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 9. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*2* 10. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). Disp:*50 Lozenge(s)* Refills:*0* 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Last dose [**2145-1-23**]. Disp:*2 Tablet(s)* Refills:*0* 12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28) Units Subcutaneous qHS. Disp:*1 month supply* Refills:*0* 14. Sliding scale insulin Please take your sliding scale Humalog insulin according the following scale. 1) Before meals: 0-50: Juice and call doctor 51-100: Nothing 101-150: 6U 151-200: 9U 201-250: 12U 251-300: 15U 301-350: 18U 351-400: 21U and call doctor 15. Sliding scale insulin Please take your sliding scale Humalog insulin as follows: 2) Before bed: 0-50: Juice and call doctor 51-150: Nothing 151-200: 3U 201-250: 6U 251-300: 9U 301-350: 12U 351-400: 15U and call doctor Discharge Disposition: Home Discharge Diagnosis: Diabetic ketoacidosis Urinary tract infection Discharge Condition: Good. Blood sugars under good control, afebrile, good oxygen saturation, renal function at baseline Discharge Instructions: You have been diagnosed with diabetic ketoacidosis. You were also followed by the [**Last Name (un) **] diabetes doctors and by the renal transplant team. You should return to the ED with abnormal blood sugars, fevers, chills, or for any other problems that concern you. You were also started on antibiotics for a urinary tract infection. You have two remaining days of antibiotics to complete, and you should take all of your prescribed medications as written. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) 1852**] in [**Company 191**] on [**2-12**] at 2pm. You can call [**Telephone/Fax (1) 250**] with any questions. You have an appointment with Dr. [**Last Name (STitle) **] in renal transplant on [**2-6**] at 9AM. You can call [**Telephone/Fax (1) 673**] with any questions. You need to be seen at [**Hospital **] clinic. You should call ([**Telephone/Fax (1) 12171**] to make an appointment to be seen in the next 2 weeks. In the meantime, you should keep to the insulin regimen as written.

[ "428.0", "V45.81", "250.11", "443.9", "518.81", "362.01", "357.2", "536.3", "V42.0", "135", "403.91", "280.9", "250.51", "585.6", "250.61", "599.0", "486" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

9204, 9210

4465, 6824

334, 417

9300, 9402

3385, 4442

9913, 10463

2915, 2989

7455, 9181

9231, 9279

6850, 7107

9426, 9890

3004, 3366

274, 296

445, 2189

7132, 7432

2211, 2611

2627, 2899

26,282

123,094

44331

Discharge summary

report

Admission Date: [**2152-3-30**] Discharge Date: [**2152-4-7**] Date of Birth: [**2074-3-20**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: Altered mental status Diaphoresis Abdominal pain Major Surgical or Invasive Procedure: Lap converted to open cholecystectomy History of Present Illness: This 78 year old russian speaking female presented to the emergency department on [**2152-3-30**]. Her family memebers stated that she was found at home with altered mental status and diaphoresis. She is diabetic. Mental status improved after binasal cannula oxygen applied, at which time she localized right upper quadrant pain. She developed leukocytosis and transaminasemia. Past Medical History: DM on insulin HTN gerd pvd osteo-arthritis osteoporosis anemia cholelithiasis left humeral fracture b/l cataracts s/p surgery s/p uterine myomectomy Social History: distant tobacco drinks often- including vodka walks without cane trained engineer in [**Country 532**] Has brother, nephew and daughter in law near by. Family History: denies cad Physical Exam: T: 99.2 HR 97 BP 131/68 RR: 20 Spo2 100% on RA Constitutional: alert & oriented x 3. Head/eyes: EOMI, PERRL Chest/respiratory: clear to auscultation bilaterally Cardiovascular: Regular rate & rhythm + S1/S2. No Mumur/regurgiation/gallop GI/Abdomen: soft. +[**Doctor Last Name 515**] sign, right upper quadrant tenderness. Nondistended. No rebounding Musculoskeletal: 5/5 strength all extremities Skin: no C/C/E Neuro: CN II-XII intact, no dysdiadokinesis. decreased Babinski's Pertinent Results: [**2152-3-30**] 07:10PM BLOOD Albumin-3.8 Calcium-9.0 Phos-2.6*# Mg-1.9 [**2152-3-30**] 07:10PM BLOOD ALT-295* AST-56* CK(CPK)-60 AlkPhos-208* Amylase-23 TotBili-1.6* [**2152-3-30**] 07:10PM BLOOD Glucose-280* UreaN-18 Creat-1.0 Na-135 K-4.2 Cl-98 HCO3-22 AnGap-19 [**2152-3-30**] 07:10PM BLOOD WBC-18.4*# RBC-4.27 Hgb-11.9* Hct-34.8* MCV-82 MCH-27.9 MCHC-34.1 RDW-15.0 Plt Ct-317 [**2152-4-7**] 06:35AM BLOOD ALT-82* AST-62* AlkPhos-145* Amylase-51 TotBili-0.4 [**2152-4-7**] 06:35AM BLOOD Glucose-134* UreaN-8 Creat-0.6 Na-144 K-3.7 Cl-106 HCO3-31 AnGap-11 [**2152-4-7**] 06:35AM BLOOD WBC-10.5 RBC-3.49* Hgb-9.6* Hct-28.0* MCV-80* MCH-27.5 MCHC-34.3 RDW-15.8* Plt Ct-504* . GB US [**2152-3-30**] IMPRESSION: 1. Distended gallbladder with impacted 1.6 cm gallstone, focal wall thickening, and positive son[**Name (NI) 493**] [**Name2 (NI) 515**] sign - findings consistent with acute cholecystitis. . 2. Right renal cysts - lower pole cyst is unchanged from prior exam of [**2147-10-9**] and upper pole exophytic cyst was not previously seen son[**Name (NI) 5326**]. . ERCP report [**2152-4-4**] IMPRESSION: 1. Successful removal of CBD stone and placement of plastic biliary stent for confirmed cystic duct leak. Brief Hospital Course: Ms [**Known lastname 95050**] was admitted on [**2152-3-30**] due to altered mental status and acute right upper quadrant abdominal pain. Gallbladder ultra sound revealed a distended 1.6 cm non mobile stone in the neck. HD#[**1-4**] She was monitored closely in the SICU. On [**2152-3-31**] she was taken to the OR for lap converted to open cholecystectomy. She tolerated the procedure well, see op report for details. She was extubated and recovered well in PACU. She remained NPO with IV fluids, foley catheter and Dilaudid IV for pain control, Unasyn for antibiotic coverage. She returned to SICU for further monitoring. She was noted to have low urine output at times. She responded well to fluid bolusing. . POD#1 she was transferred to CC6 for further recovery. She remained afebrile, she was given ice chips. Physical therapy was consulted for strength and mobility. POD#2 her pain was somewhat uncontrolled, she was placed on Dilaudid PCA with fair effect. Urine output remained adequate. She was monitored on telemetry for mild tachycardia and recieved IV beta blockers. She ambulated with assistance. POD#3 she was advanced to sips and clears, foley catheter was discontinued. POD#4, bilious drainage was noted in her JP. She had worsening abdominal pain on exam. She was held NPO. She was taken to ERCP where sphincterotomy was performed and biliary stent was placed. She tolerated the procedure well and returned to CC6 post-procedure. JP remained intact with serosainguinous drainage. . POD#5 she c/o difficulty voiding, pt was straight cathed after bladder scan was obtained and revealed >600 ccs urine. POD#[**5-8**] she continued with intermittent complaints of urinary retention. However she was able to void. Renal function remained normal. She did not require further straight catheterization. She was advanced to clear liquids again without nausea or vomiting. Her pain was well controlled by Tylenol. Her home regimen of lantus was resumed for elevated blood glucose. POD#6, her diet was advanced to regular. She required disimpaction and had hard stool in the rectum. She was initiated on a bowel regimen and had no further incidents of diarrhea or constipation. . POD#7 she was discharged to rehab in stable condition. Appropriate follow up appointments are recommended as well as prescriptions. She should return in 6 weeks for removal of biliary stent. Medications on Admission: Tramadol 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Buspirone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 17. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 18. Insulin sliding scale Insulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-60 mg/dL [**1-4**] amp D50 61-120 mg/dL 0 Units 121-140 mg/dL 3 Units 141-160 mg/dL 5 Units 161-180 mg/dL 7 Units 181-200 mg/dL 9 Units 201-220 mg/dL 11 Units 221-240 mg/dL 13 Units 241-260 mg/dL 15 Units 261-280 mg/dL 17 Units 281-300 mg/dL 19 Units 301-320 mg/dL 21 Units > 320 mg/dL Notify M.D. 19. Lantus 30 units Lantus insulin with breakfast Discharge Medications: 1. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Buspirone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 days. 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection [**Hospital1 **] (2 times a day). 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 17. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 18. Insulin sliding scale Insulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-60 mg/dL [**1-4**] amp D50 61-120 mg/dL 0 Units 121-140 mg/dL 3 Units 141-160 mg/dL 5 Units 161-180 mg/dL 7 Units 181-200 mg/dL 9 Units 201-220 mg/dL 11 Units 221-240 mg/dL 13 Units 241-260 mg/dL 15 Units 261-280 mg/dL 17 Units 281-300 mg/dL 19 Units 301-320 mg/dL 21 Units > 320 mg/dL Notify M.D. . 30 units Lantus insulin with breakfast Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Acute Cholecystitis Gangrenous cholecystitis with perforation Discharge Condition: good Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Activity: No heavy lifting of items [**10-16**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2152-5-17**] 9:30 Please call [**Telephone/Fax (1) 3201**] and schedule an appointment to see Dr. [**Last Name (STitle) **] in 2 weeks. You will be contact[**Name (NI) **] by the gastrointestinal doctors [**First Name (Titles) **] [**Name5 (PTitle) 19379**] the removal of your biliary stent in 6 weeks. Completed by:[**2152-4-7**]

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Discharge summary

report

Admission Date: [**2153-8-8**] Discharge Date: [**2153-10-12**] Date of Birth: [**2107-10-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Fever, night sweats, cough Major Surgical or Invasive Procedure: Intubation Lumbar puncture Bone marrow biopsy x 3 Right subclavian central line x 2 PICC line insertion History of Present Illness: Ms. [**Known lastname 83420**] is a 45 year old female with no significant past medical history who developed B symptoms of fevers and night sweats as well as some cough and progressive dyspnea. This led her to present to [**Hospital6 2561**] after approximately one week of symptoms on [**2153-8-7**]. At [**Hospital3 2568**] she was found to have a leukocytosis to 115,000 as well as thrombocytopenia with 7% blasts on differential. LDH was 1661 and uric acid was 4.2. She had a CT chest that showed diffuse ground glass opacities in both lungs, thickening of bronchovascular bundle, small right pleural effusion, and centrilobular emphysematous changes of the upper lobes with pretracheal and subcarinal adenopathy. Thus, she was started on levofloxacin and ceftriaxone. Hematology/Oncology evaluated her and a bone marrow biopsy was obtained prior to transfer to [**Hospital1 18**] for further work up. She was hypoxic, requiring supplementary oxygen by nasal cannula on arrival here but denied other complaints. Her antibiotics were switched to vancomycin, cefepime, and oseltamavir. After arrival at [**Hospital1 18**] a repeat CT showed similar findings to those seen on the [**Hospital3 **] scan and she was started on hydroxyurea for her initial leukocytosis of 120,000. With hydroxyurea her WBC count l WBC 120,000 and her WBC has improved today to 32,000. Bone marrow bx here suggestive of acute myeloid leukemia, cytogenetics pending. Despite broad antibiotic coverage, her O2 requirement began to increase and micafungin was added empirically [**8-10**] for fungal coverage. On [**8-11**] pt had worsening hypoxia with O2 sat 90% on 50% FM. She was given lasix 10 mg IV with ~1.5L urine output. ABG revealed respiratory alakalosis with concomittant metabolic alkalosis. Bicarb gtt was discontinued to improve metabolic alkalosis. She was noted to have a temperature of 104 and standing tylenol was ordered. She underwent a repeat CT thorax that revealed worsening widespread ground glass opacities in the lungs bilaterally, with airspace opacities in the lung bases, right middle lobe, and lingula. Due to lack of improvement in respiratory status, and also with plans to initiate chemotherapy for presumed component of infiltrative leukemia adding to worsening respiratory status, she was transferred to the [**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**] she was started on vancomycin and Bactrim and was transfused platelets and blood. She was intubated for increased work of breathing. A BAL was negative for PCP and the Bactrim was stopped. The bronch later was galactomannan positive and the pt was started on voriconazole. The pt eventually required pressors. On [**8-16**] she developed hypertension with bradycardia and suspicion for [**Location (un) 3484**] triad led to getting a head CT. This showed wedge-shaped hypodensity seen in the left cerebellar hemisphere and neurology was consulted. Pt was extubated [**8-22**]. MRI [**8-23**] showed Ring-enhancing lesion suspicious for abscess, lymphoma, or solitary metastasis. Pt came to the BMT floor in stable condition. She denied fever, chills, HA, vision changes, SOB, Chest pain, Cough, abdominal pain, diarhea, constipation, or urinary symptoms. Past Medical History: Rheumatic fever toxoplasmosis - causing spontaneous abortion at 8 months gestation in [**2133**] Social History: She moved to US from [**Country 9362**] 7 years ago. Russian is her native language. She also speaks English. Married. 2 sons, age 15 and 20, worked as a health aid. 25 pack year smoking history, quit 9 days ago. Family History: Mother with history of breast cancer, father with history of throat cancer. Physical Exam: ON ADMISSION: VS: 97.8 131/72 66 18 100% RA Gen: Well appearing, NAD HEENT: Normocephalic, anicteric, pupils constricted, symmetrical, OP mild petechia on roof of mouth and under tounge, MMM Neck: No masses or lymphadenopathy, no thyroid nodules appreciated CV: RRR, no M/R/G; there is no jugular venous distension appreciated; DP, 2+ bilaterally Pulm: decreased breath ounds in upper right lung, no wheezes, rhonchio, rhales Abd:Soft, NT, ND, BS+, no organomegaly or masses appreciated Extrem: Warm and well perfused, trace edema bilat Neuro: A and O*3, CNII-XII grossly intact, strength 5/5 in all extremities, left gaze nystagmus, normal gait, negative rhomberg Psych: Pleasant, cooperative ON DISCHARGE: afebrile, VSS Gen: Well appearing, NAD HEENT: Normocephalic, anicteric, pupils constricted, symmetrical, OP clear, MMM Neck: No masses or lymphadenopathy, no thyroid nodules appreciated CV: RRR, no M/R/G; there is no jugular venous distension appreciated; DP, 2+ bilaterally Pulm: CTAB, no wheezes, rhonchi, rhales Abd: Soft, NT, ND, BS+, no organomegaly or masses appreciated Extrem: Warm and well perfused, no CCE Neuro: A and O*3, CNII-XII grossly intact, strength 5/5 in all extremities, normal gait. Psych: Pleasant, cooperative Pertinent Results: Labs on admission: [**2153-8-8**] 11:35AM GLUCOSE-106* UREA N-7 CREAT-0.6 SODIUM-138 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14 Ca: 8.2 Mg: 2.1 P: 5.1 ALT: 55 AP: 280 Tbili: 0.3 Alb: AST: 24 LDH: 665 Dbili: TProt: [**Doctor First Name **]: Lip: Other Hematology FDP: 10-40 [**2153-8-8**] 11:35AM WBC-114.4* RBC-2.20* HGB-7.7* HCT-23.0* MCV-104* MCH-34.7* MCHC-33.3 RDW-20.7* N:35 Band:8 L:8 M:9 E:0 Bas:0 Metas: 20 Myelos: 10 Promyel: 1 Nrbc: 2 Other: 9 Neuts: 200 CELL DIFFERENTIAL Other: Blasts Other: Reviewed By [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],Md On [**2153-8-9**] PT: 14.8 PTT: 26.6 INR: 1.3 Fibrinogen: 343 Ca: 8.3 Mg: 2.1 P: 4.8 ALT: 64 AP: 307 Tbili: 0.4 Alb: AST: 27 LDH: 639 Dbili: TProt: [**Doctor First Name **]: Lip: UricA:4.8 N:46 Band:6 L:14 M:6 E:0 Bas:0 Metas: 11 Myelos: 3 Promyel: 4 Nrbc: 4 Other: 10 Comments: WBC: Notified Dr. [**First Name (STitle) **] [**2153-8-8**] 1pm Plt-Ct: Verified By Smear Lymphs: CORRECTED RESULT,PREVIOUS RESULT WAS 9 Other: Corrected Result,Previous Result Was 15 Other: Blasts Other: Reviewed By [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],Md On [**2153-8-9**] Hypochr: 1+ Anisocy: 2+ Poiklo: 1+ Macrocy: 3+ Microcy: 1+ Ovalocy: 1+ Tear-Dr: OCCASIONAL Plt-Est: Very Low PT: 14.9 PTT: 31.4 INR: 1.3 Fibrinogen: 348 ___________________________ Micro: CSF [**8-30**]: no organisms, no PMLs, toxo PCR negative, galactomannan negative [**8-25**]: cryptococcal antigen - negative [**2153-8-24**] Blood toxo: IgM negative, IgG positive [**2153-8-23**] CSF: no fungus isolated, bacterial and viral cultures pending, galactomannan pending, cryptococcal antigen negative [**2153-8-14**] BAL: Acid fast bacterial culture: pending FUNGAL CULTURE (Preliminary): no fungus isolated RESPIRATORY CULTURE (Final [**2153-8-16**]): no growth, <1000 CFU/ml. Pneumocystis jirovecii (carinii): negative ACID FAST SMEAR (Final [**2153-8-15**]): None seen on smear LEGIONELLA CULTURE (Final [**2153-8-22**]): no legionella isolated [**2153-8-11**]: Blood fungal and mycobacterial cultures (PRELIM): none isolated Influenza negative HIV-1 RNA not detected Sputum cultures negative x2 (final) C. diff negative MRSA negative Blood cultures [**2153-8-9**] - [**2153-8-16**]: no growth (all final) Urine cultures: no growth (all final), negative for legionella [**2153-8-16**] ________________________________________________________ IMAGING: [**8-9**] CT Chest: 1. Moderate diffuse upper lobe centrilobular emphysema. 2. Widespread ground-glass changes involving all lobes with a lower lobe reticular pattern due to uniform interlobular septal thickening with peribronchial cuffing and engorgement of the vasculature. 3. Multifocal airspace opacification in the right middle lobe and in the lung bases bilaterally with atelectasis. No airtrapping is seen on the expiratory views. 4. Central lymph node enlargement in the left paratracheal, subcarinal, paraesophageal, and pretracheal regions. 5. Splenomegaly The overall appearance is a widespread infiltrative abnormality with clear interstitial abnormality in the lungs. Differential diagnosis includes leukaemic infiltration of the lung, viral infection, non- cardiogenic pulmonary edema, possibly secondary to a drug reaction. Follow-up chest radiograph is recommended after initiation of treatment. . [**2153-8-17**]: CT head w/o contrast: Compared to CT Head [**2153-8-10**], There is a subtle new hypodensity in the left cerebellum which could represent acute ischemia versus artifact. . [**2153-8-19**] CTA head and neck: Stable left cerebellar hypodensity most compatible with infarction. No evidence of vascular abnormalities or other etiology for infarction on this study. . [**2153-8-20**] Portable TTE: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mass/vegetations seen (does not exclude). Very mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2153-8-9**], the findings are similar. . [**2153-8-21**] Portable TEE: The right atrium is dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No valvular vegetations. No ASD seen. . [**2153-8-23**] MRI/MRA: 1. Ring-enhancing lesion in the left cerebellar hemisphere with small foci of low intensity on susceptibility and surrounding edema. In the presence of immunosuppression, this may represent fungal disease such as Aspergillosis. Differential would also include abscess, lymphoma, or solitary metastasis. PET and Thallium scans can be performed to further assess. Correlation with CSF findings also recommended. 2. No neurovascular abnormality identified . [**2153-8-31**] MRI: IMPRESSION: 1. Stable size of the left cerebellar lesion with decrease in surrounding FLAIR signal abnormality, suggesting decrease in edema. In presence of immunosuppression, this may represent infection such as fungal infection- aspergillosis or toxoplasmosis. Differential diagnostic considerations remain the same as previously and include abscess, lymphoma, or solitary metastases. 2. Marked interval development of numerous low-intensity foci of susceptibility within the supratentorial and infratentorial regions as well as the brainstem. Given patients low platelet levels, this likely reflects microbleeds from low platelet count. . [**2153-9-11**] Chest x-ray ?????? As compared to the previous radiograph, the pre-existing bilateral parenchymal opacities, predominating at the lung bases, but also seen in the lung apices, show minimal regression. There is no evidence of pleural effusion. The size of the cardiac silhouette is unchanged. Minimal residual retrocardiac atelectasis. No change in position of pre-existing right central venous catheter. . [**2153-9-12**] Echocardiogram ?????? The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2153-9-12**] CTA chest ?????? FINDINGS: No filling defect is noted within the main pulmonary artery and its branches to suggest pulmonary embolism. There has been interval decrease in the diffuse bilateral ground glass opacities of the lung. New areas of consolidation are noted within the right lower lobe (3:90), and in the right upper lobe suprahilar region (5:29). Two new nodular foci of consolidation have developed in the right apex, the largest measuring 1.6 cm (3, 37). The previously noted foci of peribronchovascular consolidation of the middle lobe, lingula, and lower lobes have resolved. New foci of septal thickening at the bases. The centrilobular emphysema dominantly affecting the right upper lobe is unchanged. There has been no change in the central lymphadenopathy, dominantly affecting the prevascular space and left and right paratracheal regions. No pleural or pericardial effusion is noted. The visualized part of the upper abdomen including the liver, adrenal glands, and superior pole of the kidneys appear unremarkable. Moderate splenomegaly is unchanged. No concerning osseous lesion is identified. IMPRESSION: 1. No pulmonary embolism. 2. Interval resolution of patchy airspace consolidation within the lingula, right middle lobe, and bilateral lower lobes and decreasing widespread ground glass opacities. The findings could reflect interval improvement in previously reported clinical diagnosis of multifocal pneumonia. Residual ground glass opacities and septal thickening could also reflect hydrostatic edema or hemorrhage in the appropriate clinical setting. 3. Development of new foci of consolidation and ground glass within the right upper and lower lobes, concerning for a new infection. Considering nodular foci of consolidation in right apex, fungal infection (aspergillus) should be considered if the patient is neutropenic. 4. Unchanged centrilobular emphysema. 5. Resolution of bilateral pleural effusions. . [**2153-9-13**] CT abdomen/pelvis ?????? FINDINGS: The lung bases demonstrate trace bilateral pleural effusions which are new since the CTPA performed on [**2153-9-12**]. In addition, there has been interval worsening of bibasilar consolidations. The heart size is normal. Hepatosplenomegaly is present. The adrenal glands, kidneys, liver, pancreas, and gallbladder are within normal limits. A small soft tissue nodular density adjacent to the lateral edge of the spleen is likely a splenule. There is no hydronephrosis. There is no evidence of a hematoma or active bleeding within the abdomen. Small locules of air are seen within the abdomen centered on the right side. These locules of air located posterior to the right lobe of the liver (3:22) and also along the inferior tip of the liver. There is no extraluminal contrast seen; however, oral contrast has only made it to the distal small bowel with no contrast seen within the colon. CT OF THE PELVIS WITH IV AND ORAL CONTRAST: There is a small amount of free fluid within the pelvis. The bladder and uterus are within normal limits. Stool is seen throughout the entire colon. There is no pelvic or inguinal lymphadenopathy. BONE WINDOWS: No suspicious osseous lesions are identified. IMPRESSION: 1. Free intra-abdominal air centered in the right side of the abdomen. Localization around the right colon suggests source such as the ascending colon. The colon contains stool throughout and is incompletely evaluated as oral contrast has not yet made it to the colon. 2. Increasing bibasilar consolidations when compared to the previous CT chest study of [**2153-9-12**]. In addition, interval formation of small bilateral pleural effusions, left greater than right. [**2153-9-14**] CT abdomen/pelvis ?????? IMPRESSION: 1. No significant change in intra-abdominal free air and pneumatosis of ascending colon compared to [**2153-9-13**]. 2. Ill-defined areas of hyperdensity in the bilateral kidneys, left greater than right suggestive of abnormal retention of contrast from one day prior and could indicate subclinical acute tubular necrosis. 3. Unchanged small bilateral pleural effusions and bibasilar consolidation. 4. Hepatosplenomegaly. . [**2153-9-14**] Chest x-ray ?????? FINDINGS: Comparison to the previous study, there is new bilateral lower lobe airspace opacity with increased bibasilar atelectasis. Increased interstitial markings throughout the lungs suggest superimposed pulmonary edema. No pneumothorax or pleural effusion. Cardiomediastinal silhouette is unchanged. IMPRESSION: Increased bibasilar and infrahilar airspace consolidation with diffuse interstitial pattern throughout the lungs suggests consolidation with some possible superimposed pulmonary edema. Cardiomediastinal silhouette is unchanged. . [**2153-9-15**] Chest x-ray ?????? Again seen are bilateral lower lobe opacities consistent with volume loss and infiltrate. The overall appearance is similar to the film from the prior evening. . [**2153-9-16**] Chest x-ray ?????? FINDINGS: Again seen are bilateral alveolar infiltrates and volume loss in the lower lobes. There is pulmonary vascular redistribution with perihilar haze, suggesting fluid overload. The heart size is mildly enlarged. There is a small left effusion. Compared to the film from the prior day, the amount of fluid overload is increased. . [**2153-9-19**] CT abdomen/pelvis ?????? CT OF THE ABDOMEN WITH IV CONTRAST: Within the visualized lung bases, there is a left lower lobe consolidation, which is increased from [**2153-9-14**]. Patchy right lower lobe opacification is not significantly changed. A small left pleural effusion is increased in size. The visualized heart and pericardium are unremarkable. Hepatosplenomegaly is similar from [**2153-9-14**]. No focal lesion is identified. Splenules, adjacent to the splenic hilum and lateral to the spleen, are stable. High- density contents layering posteriorly within the gallbladder may reflect sludge. The gallbladder is otherwise unremarkable. The pancreas, adrenal glands, and kidneys are within normal limits. The stomach, small bowel, and large bowel are unremarkable, with the previously seen ascending colon pneumatosis no longer appreciated. A single locule of air in the right perihepatic location (2:25) is slightly less apparent. No new foci of free air is identified. There is no free fluid. No pathologic adenopathy is identified. CT OF THE PELVIS WITH IV CONTRAST: Urinary bladder, rectum, and uterus are unremarkable. There is no pelvic lymphadenopathy or free fluid. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is identified. IMPRESSION: 1. Resolution of previously seen pneumatosis of the ascending colon. 2. Tiny residual locule of free air, along the right perihepatic location, slightly less apparent from prior study. No new foci of free air identified. 3. Stable hepatosplenomegaly. 4. Bibasilar consolidation in the visualized lung bases, increased from prior study. 5. Small left pleural effusion, slightly larger in size. 6. Layering hyperdensity within the gallbladder, likely reflects sludge. . [**2153-9-20**] CT head ?????? FINDINGS: Along the left posterior tentorium are several areas of subtle hyperdensity (3:10, 3:8), which are concerning for an acute subdural hematoma, which measure approximatly 3mm in greatest thickness along the left posterior cerebellum (3:8). This finding is also well appreciated on coronal reformatted images (6:25 and 6:19). There are no other areas concerning for acute hemorrhage. There is no shift of normally midline structures and no mass effect. [**Doctor Last Name **]- white matter differentiation remains well preserved and there is no acute vascular territorial infarction. The paranasal sinuses, ethmoid and mastoid air cells are clear. Osseous structures appear intact. The globes are intact. IMPRESSION: Hyperdensity along the posterior aspect of the left tentorial leaflet and cerebellar hemisphere, new since [**2153-9-10**], concerning for acute subdural hemorrhage. No other foci of hemorrhage or shift of midline structures. NOTE ADDED IN ATTENDING REVIEW: Other diagnostic considerations include hemorrhage at site of the enhancing intra-axial lesion, demonstrated on the [**2153-9-6**] MR, or partial thrombosis of the adjacent transverse and proximal sigmoid sinus. . [**2153-9-22**] MRI head ?????? FINDINGS: Again an area of enhancement identified in the left cerebellar hemisphere which demonstrates subtle pre-gadolinium T1 hyperintensity as well in the region. There is chronic blood products identified in this region on susceptibility images. Compared to the prior study, on the post-gadolinium images, the enhancement appears to be slightly less intense compared to the examination of [**2153-8-23**] but is unchanged from the recent MRI of [**2153-9-6**]. There are no new areas of abnormal enhancement seen. A developmental venous anomaly is again seen in the right basal ganglia region. Multiple tiny punctate microhemorrhages are again identified in both cerebral and cerebellar hemispheres. Note is made of rim of high signal on pre-gadolinium images in the extra-axial region posterior to both cerebellar hemispheres and also extending at the craniocervical junction posterior to the thecal sac. These findings indicate small posterior fossa retrocerebellar subdural hematomas. This finding is new since the previous MRI examination of [**2153-9-6**]. There is no acute infarct seen on diffusion images. There is no mass effect, midline shift, or hydrocephalus. IMPRESSION: 1. New bilateral posterior fossa tiny subdurals posterior to the retrocerebellar hemispheres in a posterior cervicomedullary junction since the MRI of [**2153-9-6**] but is seen on the recent CT of [**2153-9-20**]. The subdurals could be secondary to patient's associated bleeding disorder and/or due to intracranial hypotension from CSF leak. No signs of thrombosis is seen in the adjacent transverse sinuses where normal flow voids are maintained. 2. Lesion in the left cerebellar hemisphere which demonstrates blood products and demonstrates enhancement is unchanged compared to the recent MRI of [**2153-9-6**] but has slightly decreased in size from [**2153-9-2**]. The differential diagnosis includes infections likely fungal given the presence of blood products or subacute infarct which is less likely given the duration of enhancement. 3. Multiple microhemorrhages are unchanged in the brain. . [**2153-9-26**] CT head ?????? COMPARISON: The head studies done before, the recent CT head done on [**2153-9-20**] and MR head done [**2153-9-22**]. FINDINGS: The areas of hyperdensity noted along the left posterior tentorium are less conspicuous in the current study, suggesting resolving subdural hematoma. The left cerebellar lesion detected in the prior MRI, is not visible in the current study and is better evaluated on MR. There are no new areas of hemorrhage. No edema or mass effect detected. There is normal [**Doctor Last Name 352**]-white differentiation, but no major vascular territorial infarction. Bilateral mastoid air cells and visualized paranasal sinuses appear unremarkable. IMPRESSION: 1. Resolving subdural hematoma in the left side of the tentorium. 2. Left cerebellar lesion seen in the prior MRI is not visualized in the current exam. This is better evaluated on MRI. . [**2153-9-28**] CT chest ?????? FINDINGS: Overall, there has been marked improvement in the multifocal parenchymal consolidations identified in the CT from [**2153-9-12**]. For example, consolidations in the right upper and right lower lobe have nearly completely resolved. Additionally, the diffuse ground-glass opacities seen bilaterally have markedly improved. Peribronchovascular consolidations in the right middle lobe and lingula as well as septal thickening at the bases have nearly resolved. The only new focus of consolidation seen today is small, present just inferior to the bronchus of the anterior segment of the left upper lobe (4:29). Band-like atelectasis is present in the lower lobes, right middle lobe and lingula. Moderate biapical emphysema, right greater than left, persists. There are no pathologically enlarged axillary, mediastinal or hilar lymph nodes. The heart and great vessels are unremarkable and there is no pericardial or pleural effusion. A right central venous catheter terminates in the lower superior vena cava. Although this exam is not tailored to evaluate subdiaphragmatic structures, limited evaluation of the upper abdomen partially reveals known hepatosplenomegaly. Hyperdense attenuation of the liver may reflect a transfusion requirement. Bone windows reveal no worrisome lytic or sclerotic lesion. IMPRESSION: Overall, there is marked improvement in the diffuse lung consolidations and ground-glass opacity compared to [**9-12**], though a new small focus of consolidation in the left upper lobe has developed since that time. . [**2153-10-2**] MRI head ?????? FINDINGS: The right cerebellar enhancing lesion which measures 1.6 x 0.9 cm is unchanged in size and appearance. There has been interval increase in the T2/T1 hyperintense extra-axial collection with associated mixed high and low intensity on susceptibility images, likely representing posterior fossa subdural hemorrhages. There has been interval decrease in the previously seen non-enhancing T1 isointense, T2 hypointense focus within the posterior cervicomedullary junction, also likely representing hemorrhage. There has been interval decrease in the numerous petechial hemorrhages involving the supra- and infratentorial regions. Incidental note is again noted of a right insular developmental venous anomaly. There are no foci of restricted diffusion to suggest acute infarction. No evidence for hydrocephalus is identified. The visualized major vascular flow voids are unremarkable. Orbital structures are unremarkable. There is mucosal thickening of the bilateral ethmoid air cells, unchanged. There is stable fluid within the bilateral, right greater than left, mastoid air cells. IMPRESSION: 1. Interval increase in subdural hemorrhage within the posterior fossa with slight decrease in the subdural hemorrhage at the cervicomedullary junction. 2. Stable intra-axial left cerebellar enhancing lesion. 3. Marked interval decrease susceptibility in both infratentorial and supratentorial microbleeds. 4. No new enhancement identified. CSF cytology is pending from [**2153-10-11**]. DISCHARGE LABS: [**2153-10-12**] 12:00AM BLOOD WBC-0.6* RBC-2.55* Hgb-7.6* Hct-21.7* MCV-85 MCH-29.7 MCHC-35.0 RDW-13.7 Plt Ct-60* [**2153-9-22**] 09:15AM BLOOD Fibrino-200 [**2153-10-12**] 12:00AM BLOOD Gran Ct-99* [**2153-10-12**] 12:00AM BLOOD Glucose-122* UreaN-17 Creat-0.5 Na-140 K-4.1 Cl-106 HCO3-26 AnGap-12 [**2153-10-12**] 12:00AM BLOOD ALT-13 AST-8 LD(LDH)-83* AlkPhos-85 TotBili-0.6 [**2153-10-12**] 12:00AM BLOOD Albumin-4.0 Calcium-8.6 Phos-3.2 Mg-2.0 DISCHARGE IMAGING: Repeat head MRI [**2153-10-9**]: IMPRESSION: 1. Stable appearance of the subdural hemorrhage in the posterior fossa. No new extra-axial collection is identified. 2. T1 hyperintense focus in the left cerebellum. Given the intrinsic T1 hyperintensity, it is difficult to assess the enhancing characteristics of this lesion. However, it is overall stable since the prior examinations. 3. Multiple foci of susceptibility artifact in the infra- and supra- tentorium, consistent with micro bleeds. This is stable in appearance since the most recent prior. While it does appear to be markedly decreased compared to older prior studies, this may be related to differences in technique given that all the other prior imaging was performed at 3 Tesla compared to the current and most recent prior study which were both performed at 1.5 Tesla MRI. If this is of clinical concern, followup imaging can be performed on a 3 Tesla MRI scanner may help clarify this difference. Repeat Chest CT [**2153-10-8**]: IMPRESSION: 1. Several areas of peribronchial infiltration and alveolitis due to infection have improved. New areas are less extensive than prior appearance. The wide variation in appearance suggests viral infection with a small airway component. 2. Moderate-to-severe emphysema, most pronounced in the right lung. 3. Persistent severe splenomegaly. Brief Hospital Course: After arrival at [**Hospital1 18**] a repeat CT showed similar findings to those seen on the [**Hospital3 **] scan and she was started on hydroxyurea for her initial leukocytosis of 120,000. With hydroxyurea her WBC count l WBC 120,000 and her WBC has improved today to 32,000. Bone marrow bx here showed complex acute myeloid leukemia. Despite broad antibiotic coverage, her O2 requirement began to increase and micafungin was added empirically [**8-10**] for fungal coverage. On [**8-11**] the patient had worsening hypoxia with O2 saturation 90% on 50% face mask. She was given lasix 10 mg IV with ~1.5L urine output. ABG revealed respiratory alakalosis with concomittant metabolic alkalosis. Bicarb gtt was discontinued to improve metabolic alkalosis. She was noted to have a temperature of 104 and standing tylenol was ordered. She underwent a repeat CT thorax that revealed worsening widespread ground glass opacities in the lungs bilaterally, with airspace opacities in the lung bases, right middle lobe, and lingula. Due to lack of improvement in respiratory status, and also with plans to initiate chemotherapy for presumed component of infiltrative leukemia adding to worsening respiratory status, she was transferred to the [**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**] she was started on vancomycin and Bactrim and was transfused platelets and blood. She was intubated for increased work of breathing. A Bronchioalveolar lavage was negative for PCP and the Bactrim was stopped. The bronch later was galactomannan positive so the patient was started on voriconazole. The patient eventually required pressors. On [**8-16**] she developed hypertension with bradycardia and suspicion for [**Location (un) 3484**] triad led to getting a head CT. Pt underwent head CT [**2153-8-17**] which demonstrated L cerebellar lesion, initally concerning for infarct. Of note she had a head CT on [**8-10**] which showed no acute intracranial process. Neurology was consulted. No source for thrombus seen on CTA head and neck. TEE negative for vegetations. MRI [**2153-8-23**] performed as follow up was concerning for mass or infection rather than infarct. LP was performed to evaluate for infection and sent for cytology per Hem/Onc. CSF cultures and galactomannan results were negative. On [**2153-8-24**] the pt was transfered back to the bone marrow transplant service. She reached the floor in stable condition and did not have any symptoms of infection including fever, chills, HA, vision changes, SOB, Chest pain, Cough, abdominal pain, diarhea, constipation, urinary symptoms. ID was still following the patient and there was concern that her ring enhancing lesion was toxoplasmosis especially since the pt had a strong history of having toxo in the past and loosing a pregnancy from it. She was started on clindamycin and pyrimethamine to empirically treat toxoplasmosis. She also had a repeat bone marrow biopsy on day +14 after her 7+3 induction chemotherapy, which showed 30% cellularity , or poor responce to the chemo. She had a repeat LP and was started on High dose Ara-C reinduction therapy. The LP was again negative for toxo by PCR and gallactomannan. A repeat MRI was performed on [**8-31**] to evaluate if the empiric treatment for toxoplasmosis was helping. It showed Stable size of the left cerebellar lesion with decrease in surrounding FLAIR signal abnormality, suggesting decrease in edema. It also showed numerous low-intensity foci that likely reflects microbleeds. Nuerology and infectious disease were still following the patient and it was decided that she would have a repeat MRI in one week to evaluate change in the microbleeds and another MRI in one month to evaluate for change in the ring enhancing lesion; these were found to be stable on repeat imaging. The appearance of the lesion on repeat imaging was concerning for fungal infection. In addition, she was transfused for a platelet level of less than 20 to prevent more microbleeds. Ms. [**Known lastname 83420**] [**Last Name (Titles) 8337**] her reinduction with Ara -C well with only mild nausea, headache, and weakness. On Day +12, she developed fever assocaited with erythema and redness of the tissue around her right eye. She was evaluated by ophthalmology and started on tobramycin ointment, which controlled the swelling. However, she remained febrile on and off (see complications, below). On [**2153-9-12**], she underwent repeat bone marrow biopsy which showed hypercellular marrow (90%) packed with monocytes (leukemic cells) and blasts. Over the next several days, her physical condition and respiratory status began to deteriorate and she required a non-rebreather O2 mask to maintain oxygen saturation > 90%. On [**2153-9-15**], Ms. [**Known lastname 83420**] began her first cycle of chemotherapy with dacogen. Although her cell counts were slow to recover, she improved significantly over the ensuing weeks, becoming afebrile and no longer requiring oxygen to breathe. In addition, she was able to tolerate a regular neutropenic diet and began taking daily walks around the unit without difficulty. A repeat CSF cytology from [**2153-10-11**] was pending at the time of discharge. She will be discharged to home with services to receive her second cycle of Dacogen as an outpatient. Complications addresssed during this admission include: #1. Febrile neutropenia - The patient developed fevers around [**9-10**] which occurred on and off for approximately 10 days. There was no clear etiology for fevers - a pulmonary process (given infiltrates in both lungs) was felt to be most likely, but the fevers may also have been due to disseminated fungal infection (e.g. related to the cerebellar lesion in the brain) or to primary AML disease (which may also have contributed to pulmonary infiltrates). The infectious disease service was consulted. She was continued on IV vancomycin (dose was ultimately increased to 1g Q6H when troughs returned low) and converted to IV voriconazole (from oral) and meropenem and IV bactrim (treatment dose of 6 mg/kg) were added to broaden coverage. After ~3 weeks, Bactim was stopped as it was felt that the organisms uniquely covered by this drug were unlikely pathogens in the setting of a stable patient. Just over a week after her treatment with Dacogen, the fevers resolved. However, per ID recommendations,treatment with broad spectrum antibiotics will be continued until her absolute neutrophil count is above 500. At the time of discharge, she was switched to po Voriconazole and Moxifloxacin per ID recommendations. . GIVEN THE POSSIBILITY OF THESE MEDICATIONS TO CAUSE QT PROLONGATION, the patient should have a repeat EKG on MONDAY, [**2153-10-15**]. Her baseline EKG on [**2153-10-11**] showed a QT interval of 398, any increase >25% over baseline should be concerning for QT prolongation and these medications should be discontinued with resumption of other antibiotic coverage. Further, the patient should have daily serum potassium and magnesium levels drawn, and these should be repleted immediately as needed to prevent any cardiac complications on these medications. #2. Pancytopenia: Mrs. [**Known lastname 83420**] remained afebrile from [**2153-9-21**] until the time of discharge, despite her neutropenia. Her hematocrit and platelets were checked daily and repleted with transfusion goals of HCT<21 and PLTs<50 (given subdural hematoma). She will have close follow-up of these blood levels during her second cycle of chemotherapy. #3. Microperforation of the ascending colon: The patient was kept NPO and this was medically managed without surgical intervention. She was able to tolerate a regular neutropenic diet on [**2153-10-1**] and was able to take excellent po intake of food and drink. #4. Subdural bleed: The patient's headaches largely resolved in the weeks prior to discharge. She remained asymptomatic; her PLTs were transfused if <50 and these were 60 at the time of discharge. A repeat head MRI showed stable subdural bleed. #5. Left cerebellar lesion: Per radiology, this lesion was considered to unlikely be a bleed given stable appearance on MRI > 1 month. Enhancement without substantial edema suggested possible fungal infection (vs. bacterial). Less likely related to AML infiltrates. Biopsy of the lesion was deferred given the patient's low HCT and PLTs. A repeat MRI on [**2153-10-9**] showed that this lesion was stable. #6. Lung infiltrate: A new left upper lobe infiltrate was noted on a chest CT from [**2153-9-28**]. The patient was maintained on broad spectrum antibiotics and voriconazole. She remained afebrile and asymptomatic. Repeat chest CT on [**2153-10-8**] showed interval improvement. Mrs. [**Known lastname 83420**] was deemed medically stable and discharge to home with services. She will complete her 2nd cycle of Dacogen as an outpatient, with daily follow-up in the 7 [**Hospital 1826**] Clinic. She will also be seen in follow-up by Infectious Disease and neurology. Medications on Admission: Ibuprofen PRN headaches, pain Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for headache for 30 doses. Disp:*30 Tablet(s)* Refills:*0* 2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for nausea/anxiety/insomnia. Disp:*72 Tablet(s)* Refills:*0* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Voriconazole 200 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). Disp:*120 Tablet(s)* Refills:*2* 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB. Disp:*1 inhaler* Refills:*0* 8. Moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Ibuprofen 200 mg Capsule Sig: One (1) Capsule PO every [**4-16**] hours as needed for pain, headache. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Acute Myelogenous Leukemia Pneumonia Febrile neutropenia Microperforation of the ascending colon Subdural hematoma Punctate hemorrhages of the cerebellum and cerebrum Cerebellar lesion (by CT, MRI) Discharge Condition: afebrile, hemodynamically stable. Discharge Instructions: You came to the hospital because you were having night sweats, fever, and cough. You were found to have acute myelogenous leukemia. You were started on chemotherapy. A repeat bone marrow biopsy showed that this chemotherapy did not work completely and you still had some cancer cells in your bone marrow. You were started on a different regimen of chemotherapy. A repeat bone marrow biopsy showed that the second dose of chemotherpy was also ineffective at controlling the leukemia, so you were started on a third regimen. Follow-up biopsy then showed some improvement, but still some presence of disease. During your hospitalization you also had worsening shortness of breath and required a breathing tube in the intensive care unit. You were found to have a pneumonia and were treated with antibiotics. Your pneumonia improved and you did not need the breathing tube anymore. You also had a head MRI which showed that you had a lesion in your brain. Many repeat studies showed that this lesion did not change much over time. You did not have symptoms of dizziness or balance problems. We could not confirm whether this was an infection or something else because that would require us to do a biopsy and this was not possible because of your leukemia. You were started on antibiotics to treat toxoplasmosis or fungal infection in case this was what you had. You should continue to take antibiotics for this until your absolute neutrophil count (ANC) laboratory test is higher than 500 or as directed by your physician. You experienced abdominal pain on [**2153-9-13**], and a CT scan showed that there was free air in your abdomen, most likely caused by air leaking out of the wall of your colon. You were instructed to stop eating or drinking until the air went away, and then you were slowly restarted on a regular diet. We have made the following changes to your medication regimen: NEW MEDICATIONS: Oxycodone 5 mg Tablet. One Tablet every 4 hours as needed for headache. Lorazepam 0.5 mg Tablet. 1-2 Tablets every 4 hours as needed for nausea/anxiety/insomnia. Folic Acid 1 mg Tablet Sig: One (1) tablet daily. Cyanocobalamin 100 mcg Tablet. Take HALF of one tablet daily. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Take one tablet once a day to protect your stomach. Voriconazole 200 mg Tablet Sig: Two (2) Tablets every 12 hours for infection. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Take two puffs every 4 hours as needed for shortness of breath. Moxifloxacin 400 mg Tablet. Take (1) once a day for infection. Please call your doctor or return to the hospital if you experience fever > 100.5 degrees, shortness of breath or cough, severe headache, vomiting (especially if you also have headache, or if you cannot keep down food or medicines), chest or abdominal pain, fainting or feeling like you are about to faint, or any other symptoms that are concerning to you. Please keep your follow-up appointments as outlined below. It was a pleasure caring for your during this hospital admission. Followup Instructions: We have scheduled follow-up appointments for you as outlined below: HEMATOLOGY/[**Hospital **] CLINIC 7 [**Hospital Ward Name 1826**] Date/Time:[**2153-10-14**] 11:00 Date/Time:[**2153-10-15**] 11:00 Date/Time:[**2153-10-16**] 12:30 You will have bloodwork done at these visits. On your Monday appointment, you should also have an EKG. INFECTIOUS DISEASE Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13895**] Tuesday, [**2153-11-6**] at 9 AM [**Last Name (NamePattern1) 439**], [**Hospital **] Medical Office Building Basement, Suite G [**Telephone/Fax (1) 457**] Please also call your neurologist and schedule a follow-up appointment within 2-3 weeks of discharge. Completed by:[**2153-10-12**]

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Discharge summary

report

Admission Date: [**2133-6-30**] Discharge Date: [**2133-7-6**] Date of Birth: [**2087-9-9**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 23753**] Chief Complaint: Leg weakness Major Surgical or Invasive Procedure: None History of Present Illness: 45 yo female w/PMHx sx for HIV cd4 823/37% vl <50 on [**2133-5-6**] and hepatitis C who presents with fall to ground. Patient was in her USOH until yesterday, when she got up from bed and her legs gave out under her. She fell to the ground, and the staff in her [**Hospital3 **] facility was alerted, and she was brought to the ED. She states that this has happened occasionally in the past when she first rises from bed. Patient denies any one-sided weakness, numbness, loss of vision, clumsy hand sx with this episode. She did not lose consciousness. Patient denies chest pain, SOB, palpitations with this episode as well. She denies any bowel incontinence. Patient does note urinary frequency and dysuria, but denies fever, chills, flank pain. Patient states that she has had a CVA in the past, during her breast surgery, for which she states that she has had no workup. The deficit from this was weakness, incoordination, and limping on her left side. She states that this has progressed gradually. Patient was brought to the ED, and she was found to have a positive UA, a nonfocal neurologic exam with some lethargy noted, and an MRI which was negative for abscesses but did show prior infarct. Patient is admitted for workup of her presyncopal episode. Past Medical History: 1. HIV x [**2122**]: No AIDS defining illness. 2. Hepatitis C, genotype 4, VL 1.05 million copies. 3. Breast reduction surgery [**2130-6-18**]. 4. Urinary tract infections. 5. Nephrolithiasis. 6. Lung nodule: Patient states that she had a lung biopsy at [**Hospital 53676**] Center 3-4 years ago. 7. Status post appendectomy. Social History: Born in [**Location (un) 86**]. Unemployed. Somked 1ppd sicne age 15. Drinks 1 drink/wk. Actively using cocaine. Lives in [**Hospital3 **] facility. Family History: Mother with HTN, father died in [**Name (NI) 8751**]. Sister with HIV. Physical Exam: VS: 108/62 HR 84 RR 20 O2 sat 100% RA Gen: well appearing in NAD. HEENT: No carotid bruits. No scleral icterus. MMM. No cervical LAD. Hrt: RRR. No MRG Lungs: CTAB no RRW. Abd: S/ND. Normoactive bowel sounds. Tenderness to palpation over LLQ (chronic). No guarding or rebound. No masses. Ext: WWP. No CCE. Neuro: CN2-12 intact. 5/5 strength BUE. 5/5 strength RLE. 4+/5 strength LLE. Sensation to LT intact. 2+DTRs throughout. Normal narrow based gait. Normal FTN. Pertinent Results: 141 107 11 / 94 AGap=14 ------------- 4.0 24 1.1 \ ALT: 16 AP: 89 Tbili: 0.5 AST: 27 [**Doctor First Name **]: 85 Lip: 22 HCG:<5 77 6.3 \ 7.2 / 415 ------- 23.2 N:66.0 L:25.0 M:4.5 E:3.9 Bas:0.8 INR 1.2 U/A: 1.005. mod leuk 0 RBC 21-50 WBC mod bacteria Serum tox screen: + for TCA otherwise negative Urine tox screen: pending Blood Cx x 2 pending . CT head ([**2133-6-30**]) hypodensities c/w old infarct/contusion in right and left frontal lobes. lacune in right internal capsule. right parietal hypodensity likely secondary to subacute (but old) infarct. no enhancing lesions seen, however, MRI is more sensitive in evaluation for subtle lesions and in patient with HIV, MRI would be recommended if there is any clinical concern . MRI L spine ([**2133-6-30**]): no abnormal enhancement within epidural space or within thecal sac. small amount of free fluid within pelvis and likely fibroid uterus. . MRI head w/ and w/o contrast ([**2133-6-30**]) No areas of abnormally restricted diffusion to suggest acute brain ischemia. No areas of abnormal enhancement within brain parenchyma. High FLAIR signal in the right parieto-occipital and right frontal regions likely relate to prior infarct or contusion. . CXR([**2133-6-30**]) Multiple small nodules in the right lung consistent with the findings on prior CT. No definite evidence of pneumonia. Mild cardiomegaly with mild CHF. Small left-sided pleural effusion. There is no evidence of pulmonary edema. Mild cardiomegaly. . Echocardiogram: The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (ejection fraction 20 percent). [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). Tissue velocity imaging demonstrates an e' of <0.08m/s c/w an elevated left ventricular filling pressure (>12mmHg). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The ascending aorta is moderately dilated. The aortic arch is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. There is no pericardial effusion. . Brief Hospital Course: Ms. [**Known lastname **] is a 45 yo female w/PMHx sx for HIV, hepatitis C who p/w episode with legs buckling under her, as well as lethargy. Patient was found to have UTI as well as old infarct on MRI. Etiology of patient's lethargy and fall was likely from infection with inability to take good pos, and resultant dehydration. Patient may have also been on larger than usual doses of home narcotics. By time of arrival to the floor, patient's lethargy had resolved. Her orthostatics were negative. Her EKG did not show any acute ST-T changes, and overnight telemetry showed no events. She was noted to have an old infarct on MRI, but no new infarcts to explain her initial lethargy. . Patient was noted to have severe iron deficiency anemia, and was started on iron replacement and given a transfusion of pRBC, during which she developed pleuritic chest pain and tachycardia. An EKG was performed, which showed sinus tachycardia. Her CXR did not show any acute changes, and patient was given nitroglycerin with symptomatic relief. She had cardiac enzymes and a D-dimer checked as well, with negative cardiac enzymes but with an elevated D-dimer. Patient was scheduled for a CTA at the time to assess for pulmonary embolus. She then proceeded to finish her blood transfusion without incident. Prior to receiving the CT scan, patient developed acute SOB, tachypnea with RR 30s and tachycardia again, and a code was called due to suspicion for massive pulmonary embolus. . She was found to be tachycardic, tachypneic and diaphoretic, still complaining of L sided pleuritic chest pain. She was transferred to the MICU. Her initial ABG was 7.33/39/115. A heparin gtt was empirically started, and she was taken urgently for a stat CTA. CTA did not show evidence for a PE so the heparin gtt was stopped. Pt responded well to morphine and nebs. Her CT chest showed ground glass opacities suggestive of pulmonary edema, and the etiology of the acute episode of chest pain was thought to be secondary to flash pulmonary edema. She was treated with IV lasix and symptoms improved. An echo was obtained and showed an EF of 20% with 3+ MR [**First Name (Titles) **] [**Last Name (Titles) **], but she had no prior echos here for comparison. Since the pt's symptoms improved she was transferred to a regular medicine floor. . Patient's dilated cardiomyopathy was thought secondary to cocaine use and HIV. A cholesterol panel was checked, as well as a TSH and RPR. She was started on lisinopril and metoprolol, which were titrated up for goal systolic blood pressure in the 80-90s. She was also started on digoxin, and will need outpatient followup of her digoxin level. A cardiology consult was called to evaluate if patient would need acute inpatient workup for ischemia as a cause of her cardiomyopathy. Cardiology consult recommended that patient undergo an evaluation for endocarditis given her degree of valvular regurgitation. Patient had blood cultures drawn which were all negative at time of discharge. She had a TEE performed, which was negative for vegetation. Patient was placed on a fluid restriction as well. Decision was made not to start her on standing furosemide and aldactone as well given her low systolic blood pressures. She will be started on these as an outpatient in followup with her PCP. [**Name10 (NameIs) **] was maintained on telemetry with no events seen. She will follow up in cardiology, and she will need teaching from the heart failure clinic, as well as an outpatient catheterization to be scheduled to evaluate for ischemia. . Patient was also foudn to have a positive urinalysis, and was started on levofloxacin given her history of enterococcal UTIs. She had a renal ultrasound performed with persistent hydronephrosis. Patient was seen by urology as an inpatient and outpatient and was recommended for outpatient lithotripsy in two weeks. She will continue her antibiotics for a total 14 day course. . Patient was continued on combivir and viramune. She was actively using cocaine at time of admission. She had a urine toxicology screen positive for cocaine and opiates. Patient's pain was controlled with her home doses of amitryptylline, morphine, and trazadone. Patient had lung nodules seen as well on CT scan, which were stable from prior imaging. She was discharged home with follow up with her primary care doctor. Medications on Admission: Viramune, Combivir, Trazadone 150 mg, Morphine 30 mg b.i.d., Topamax, Detrol-LA and Elavil 50 mg. Discharge Medications: 1. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Morphine 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Topiramate 50 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily): You should start taking this after you finish your course of antibiotics. . Disp:*30 Tablet(s)* Refills:*2* 10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Iron deficiency anemia 2. Urinary tract infection with nephrolithiasis 3. Sedation from substance abuse and narcotics 4. Dilated cardiomyopathy with ejection fraction 20% 5. Flash pulmonary edema 6. Cocaine abuse 7. Severe mitral valve and aortic valve regurgitation Discharge Condition: Stable Discharge Instructions: If you develop chest pain, shortness of breath, increased confusion, or fevers or chills, call your doctor or go to the emergency room. You were admitted with a diagnosis of urinary tract infection and weakness. You were also found to have a low blood count, and you were given a unit of blood. You had an episode of chest pain, thought to be related to acute fluid buildup in your lungs. Your EKG and CXR were both negative. You were found to have severe heart failure on echocardiogram. It is unclear the cause of this, but it is likely related to your cocaine use. You were started on medications for heart failure. You have iron deficiency anemia, and will need an outpatient colonoscopy. This can be scheduled with your primary care doctor. Followup Instructions: 1. Please follow up with Dr. [**Last Name (STitle) **] on [**2133-7-8**] at 10:00 a.m. The number to call is [**Telephone/Fax (1) 4255**]. At that time, she can add other medications for your heart failure including Lasix and Aldactone, which we did not add as an inpatient due to concerns for your blood pressure. You will need a digoxin level checked at the time as well. Also, you should have a colonoscopy performed as an outpatient. 2. Please follow up with urology in 2 weeks to have your lithotripsy procedure performed. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2133-7-14**] 11:20 3. Please follow up with cardiology as an outpatient. The number for the clinic is [**Telephone/Fax (1) 3512**]. Your appointment is on [**2133-7-20**] at 9:00 a.m. with Dr. [**First Name (STitle) 437**].

[ "592.1", "780.2", "599.0", "E888.9", "396.3", "305.1", "518.82", "591", "218.9", "305.60", "070.70", "280.9", "V13.01", "425.4", "V08", "398.91", "276.51" ]

icd9cm

[ [ [] ] ]

[ "99.04", "88.72" ]

icd9pcs

[ [ [] ] ]

11109, 11115

5389, 9742

327, 334

11429, 11438

2727, 5366

12233, 13122

2156, 2228

9892, 11086

11136, 11408

9768, 9869

11462, 12210

2243, 2708

275, 289

362, 1624

1646, 1974

1990, 2140

27,591

102,881

8900

Discharge summary

report

Admission Date: [**2193-6-26**] Discharge Date: [**2193-6-30**] Date of Birth: [**2151-7-11**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Speech arrest and confusion. Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a 41 year-old left-handed with a past medical history significant for metastatic breast cancer and a stroke in [**2189**] (left facial droop)who presents now after an episode of confusion and a motor vehicle accident. The patient was at a carboplatinum infusion appointment at the [**Company 2860**] today when she called her husband and spoke appropriately with him at 4:45pm. She then called her husband again at 5:05pm and was clearly confused. She didn't know where she was. When he asked her if she was on Route 9 or on the highway, she said that she didn't know. It seemed to him that she had a limited verbal vocabulary but was not dysarthric. 6:20pm is the first EMT note from the scene of an automobile accident. The patient was brought here. Code stroke was called at 8:28pm. I was at the bedside within minutes. On briefly obtaining the history from the patient's husband it became clear that the patient had 3 metastatic lesion related to her breast cancer with edema. NIH SS: 8:40 pm - 34 1a. Level of Consciousness: 3 1b. LOC questions: 2 1c. LOC commands:2 2. Best gaze: 0 3. Visual: 0 4. Facial palsy: 0 5a. Motor arm, left: 4 5b. Motor arm, right: 4 6a. Motor leg, left: 4 6b. Motor leg, right: 4 7. Limb ataxia: 2 8. Sensory: 2 9. Best language: 3 10. Dysarthria: 2 11. Extinction and inattention: 2 In the ED the patient had a non-contrast head CT that was suspicious for blood in the area of encephalomalacia on the right and there was considerable vasogenic edema on the left. In the scanner the patient had a right sided seizure that included right head deviation. The patient was diagnosed with invasive ductal carcinoma of the left breast in [**2189-5-28**]. Lymphnode biospy was positive. She is status post ACT chemotherapy and XRT. She has known mets to the brain - husband describes 3 lesions each measuring 6-8mm with surrounding edema. She also has mets to T12, Lung, leptomeninges and right hip. BRCA-1 positive. The patient's husband notes that the patient has a left sided pleural effusion related to her lymph node dissection. In [**2190-8-28**] the patient had a stroke with left facial droop. She presented outside the window for TPA and was not anticoagulated after this stroke. The left facial droop got better, but then suddenly got worse again in [**2191-12-29**]. The initial thought was that she either had another stroke or worsening of her stroke, but her husband reports that it was ultimately diagnosed as lepotmeningeal spread of her breast cancer. She then had whole brain irradiation. ROS Unable to obtain, but husband reports no fevers, chills, weightloss, nausea, vomiting, diarrhea, chest pain or shortness of breath. She complained of some right sided neck pain. There no obvious focal neurological deficits. Past Medical History: Breast Cancer per HPI Stroke per HPI cervical dysplasia, polycystic ovarian syndrome, depression. Left arm lymphedema. Patient has an accessible port. Social History: Lives in [**Location 11333**], MA Not working Has twin children - daughter and son, 7 years old. No ETOH, Tobacco or drugs. Family History: Biological mother died at age 46 of breast cancer. No other family medical history as patient was adopted. Physical Exam: General: alert, awake, normal affect Orientation: oriented to person, place, date, situation Attention: Months of the year backwards +. Follows simple/complex commands. Speech/Language: fluent w/o paraphasic errors; comprehension, repetition, naming. [**Location (un) **] intact Memory: Registers [**1-28**] and Recalls [**1-28**] when given choices at 5 min Praxis/ agnosia: Able to brush teeth. No field cuts. CN: I: not tested II,III: VFF to confrontation, PERRL 4mm to 2mm, fundi normal III,IV,VI: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: Facial strength intact/symmetrical VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline [**Doctor First Name 81**]: SCM/trapezeii [**4-1**] bilaterally XII: tongue protrudes midline, no dysarthria Motor: Normal bulk, no tremor, no asterixis or myoclonus. No pronator drift. Increased tone in both legs. Delt;C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7 Grip:C8/ T1 Left 5 5 5 5 5 5 Right 5 5 5 5 5 5 IP:L2 Quad:L3 Hamst:L4-S1 Dorsiflex:L4 [**Last Name (un) 938**]:L5 Pl.flex:S1-S2 Left 5 5 5 5 5 5 Right 5 5 5 5 5 5 Deep tendon Reflexes: No clonus. Bicip:C5 Tric:C7 Brachial:C6 Patellar:L4 Toes: Right +2 2 2 3 DOWNGOING Left +2 2 2 3 DOWNGOING Sensation: Intact to light touch, vibration, proprioception, and temperature. Coordination: *Finger-nose-finger normal. *Rapid Arm Movements normal. *Fine finger tapping. Gait/Romberg: Not examined Pertinent Results: [**2193-6-26**] 09:50PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2193-6-26**] 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2193-6-26**] 09:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2193-6-26**] 09:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2193-6-26**] 09:50PM URINE GR HOLD-HOLD [**2193-6-26**] 09:50PM URINE HOURS-RANDOM [**2193-6-26**] 09:50PM URINE HOURS-RANDOM [**2193-6-26**] 09:55PM PT-13.9* PTT-26.9 INR(PT)-1.2* [**2193-6-26**] 09:55PM PLT SMR-LOW PLT COUNT-92*# [**2193-6-26**] 09:55PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL [**2193-6-26**] 09:55PM NEUTS-87* BANDS-0 LYMPHS-3* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 [**2193-6-26**] 09:55PM WBC-8.5 RBC-3.39*# HGB-11.7* HCT-34.7* MCV-102*# MCH-34.5*# MCHC-33.7 RDW-14.0 [**2193-6-26**] 09:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2193-6-26**] 09:55PM CALCIUM-8.7 PHOSPHATE-4.4 MAGNESIUM-1.2* [**2193-6-26**] 09:55PM CK-MB-NotDone [**2193-6-26**] 09:55PM cTropnT-<0.01 [**2193-6-26**] 09:55PM CK(CPK)-50 [**2193-6-26**] 09:55PM estGFR-Using this [**2193-6-26**] 09:55PM GLUCOSE-237* UREA N-17 CREAT-0.8 SODIUM-138 POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-27 ANION GAP-16 [**2193-6-26**] 11:40PM TYPE-ART RATES-0/14 TIDAL VOL-500 PEEP-5 O2-50 PO2-162* PCO2-43 PH-7.38 TOTAL CO2-26 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED HCT - IMPRESSION: 1. No hemorrhage. 2. Encephalomalacia in the right frontoparietal lobe containing areas of linear calcification most consistent gyral mineralization. 3. Extensive edema surrounding a focus of calcification in the left parietal lobe is concerning for underlying metastases. Further evaluation with MRI is recommended. C-Spine CT IMPRESSION: 1. No fracture or subluxation. 2. 6-mm sclerotic focus in the left inferior endplate of T1 worrisome for metastasis. MRI/MRA Head - IMPRESSION: Irregular ring-enhancing lesion is identified on the left parietal lobe, measuring approximately 1.6 x 1.9 mm in size in the axial projection, associated with extensive vasogenic edema and possible focus of calcification. Encephalomalacia is identified on the right frontoparietal lobe demonstrating areas of linear and gyral hyperintensity signal, possibly consistent with gyral mineralization or pseudolaminar necrosis. Punctate focus of enhancement noted on the right frontal lobe measuring approximately 2-3 mm in size as described above, worrisome for metastatic lesion. MRA OF THE HEAD: There is evidence of vascular flow in both internal carotids and the anterior circulation without evidence of aneurysm or significant stenosis. The posterior circulation demonstrates very weak and low signal in the vertebral arteries at the junction with the basilar artery, possibly artifactual in nature versus stenosis, correlation with CTA is recommended if clinically warranted. IMPRESSION: Possible bilateral stenosis versus artifact involving the vertebrobasilar junction as described above. Brief Hospital Course: Ms [**Name13 (STitle) **] is a 41 y/o woman with breast Ca (metastatic to the CNS, lung, bone) s/p RT and chemoTx on current carboplatin therapy admitted with speech arrest/nonverbal/obtundation and three witnessed generalized seizures. As far as it is her first episode of seizure we searched for the etiology. Possibilities included CNS metastasis, infection. Once the MRI was performed (showing enhancing metastatic lesions in the left parietal and left frontal region) and the results for the ID screening came back, we believe the seizures were related to edema from her CNS metastasis. Pt was extubated and stabilized. PT was transferred to the stepdown unit. Her dexamethasone was tapered. Her RISS was increased. Her PHT was d/cd and her Keppra was increased to therapeutic doses. Contact[**Name (NI) **] Dr. [**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 30944**]: ([**Telephone/Fax (1) 30945**]: not available. Left a message. Pt was d/c on Sunday. [**2193-6-30**]. Medications on Admission: Carbopaltinum - every 3 weeks. Zomeda - every 6 weeks. Ativan Prozac Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a day: Please, take Keppra 2 tabs for breakfast and 2 tabs for dinner. . Disp:*120 Tablet(s)* Refills:*0* 3. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day: Please, take 3 tabs per day for 4 days, then 2 tabs per day for 4 days, then 1.5 tabs per day for 4 days, then 1 tab per day for 4 days. . Disp:*30 Tablet(s)* Refills:*0* 4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day: For four days after you have tapered your dose from 60 mg per day (3 pills of 20 mg per day) to 20 mg per day (1 pill of 20 mg per day). Once yo utake 10 mg per day for 4 days, stop it. . Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Seizures secondary to edema in the conext of CNS metastatic lesions (breast Ca primary). Discharge Condition: The patient is back to her baseline. Her neurological exam at discharge is: MS: General: alert, awake, normal affect Orientation: oriented to person, place, date, situation Attention: Months of the year backwards +. Follows simple/complex commands. Speech/Language: fluent w/o paraphasic errors; comprehension, repetition, naming. [**Location (un) **] intact Memory: Registers [**1-28**] and Recalls [**1-28**] when given choices at 5 min Praxis/ agnosia: Able to brush teeth. No field cuts. CN: I: not tested II,III: VFF to confrontation, PERRL 4mm to 2mm, fundi normal III,IV,VI: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: Facial strength intact/symmetrical VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline [**Doctor First Name 81**]: SCM/trapezeii [**4-1**] bilaterally XII: tongue protrudes midline, no dysarthria Motor: Normal bulk, no tremor, no asterixis or myoclonus. No pronator drift. Increased tone in both legs. Delt;C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7 Grip:C8/ T1 Left 5 5 5 5 5 5 Right 5 5 5 5 5 5 IP:L2 Quad:L3 Hamst:L4-S1 Dorsiflex:L4 [**Last Name (un) 938**]:L5 Pl.flex:S1-S2 Left 5 5 5 5 5 5 Right 5 5 5 5 5 5 Deep tendon Reflexes: No clonus. Bicip:C5 Tric:C7 Brachial:C6 Patellar:L4 Toes: Right +2 2 2 3 DOWNGOING Left +2 2 2 3 DOWNGOING Discharge Instructions: You have been admitted due to seizures. these episodes were related to swelling of the brain lesions related to your breast carcinoma. You need to take Keppra tomorrow 1500/1000 mg [**Hospital1 **] plus or Thursday 1500/ 1500 and dilantin should be stopped on Friday. Besides, we would like you to take Prednisone: 60 mg qam for 4 days, then 40 mg qam for 4 days, 30 mg qam for 4 days, 20 mg qam for 4 days, 10 mg qam for 4 days, then stop it. While taking the prednisone, you will take famotidine 20 mg [**Hospital1 **]. If you feel side effects from the new medication (Keppra) such as irritability or somnolence, please contact you [**Name2 (NI) 30946**] inmediately. Followup Instructions: You will f/u with Dr. [**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 30944**]: ([**Telephone/Fax (1) 30945**]. In addition, you will follow up with Dr. [**Last Name (STitle) **] please call [**Telephone/Fax (1) 2574**] to arrange for an appointment.

[ "198.5", "256.4", "198.3", "438.83", "780.39", "V16.3", "198.4", "V10.3", "V84.01", "197.0", "457.0", "E819.0", "196.9" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

10513, 10519

8583, 9583

354, 361

10652, 12244

5377, 8039

12964, 13236

3521, 3630

9703, 10490

10540, 10631

9609, 9680

12268, 12941

3645, 5358

285, 316

389, 3189

8057, 8560

3211, 3363

3379, 3505

48,297

187,284

52366

Discharge summary

report

Admission Date: [**2164-6-30**] Discharge Date: [**2164-7-12**] Date of Birth: [**2098-8-14**] Sex: F Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 3556**] Chief Complaint: Ventricular Tachycardia Arrest Major Surgical or Invasive Procedure: Electrophysiology Study History of Present Illness: Mrs. [**Known lastname 108231**] is a 65 year-old woman with CAD s/p CABG [**2164-4-18**] with post-op course complicated by pnemothorax, afib and pleural effusions with readmission for pneumonia/effusions s/p VATS and s/p trach PEG for persistant respiratory failure. She was dischared to LTAC on [**6-25**] and was being actively diuresed there with 40mg IV lasix [**Hospital1 **] and having received an additional 40mg IV on [**6-30**] for dyspnea associated with e/o CHF on CXR. Today she was noted to be in vtach and c/o chest pressure. She became pulsless and received one synchronized shock at 300 J with prompt return of sinus rhythm and spontaneous ciruculation. She was transfered to the ED where initial vitals were HR 79 BP 110/33 RR 22 O2sat 100 on vent. In the ED, she was transiently hypotensive and responsed ro 1L IVF. Given her hypotension, cultures were drawn and broad spectrum antibiotics initiated. A femoral line was placed (given elevated INR and trach). A bedside ultrasound by the ED resident was notable for what appeared to be global hypokinesis and a full IVC. She was transferred to the ICU for further care. Vitals on transfer were HR 80 and BP 83/33. Mag at [**Hospital 100**] rehab was 1.6. ECG showed a paced rhythm at 80 with LVH and <[**Street Address(2) 4793**] depressions in V3-V6. . On arrival here she is alert and oriented. She reports minimal chest pressure which is present chronically. She denies recent fevers/chills or any other symptoms of note. She reports that the only significant change was realtively aggressive diuresis with IV lasix over the past day and transfusion of 1 unit pRBCs for anemia with additional lasix. Her respiratory status is at baseline. . Patient has had a complicated course recently which began in [**4-/2164**] when she presented to the ED with anginal symptoms. Work-up at that time revealed 3 vessel disease and 90% in-stent stenosis of LCX. Underwent CABG on [**2164-4-18**] with LIMA to LAD, SVG to RCA and SVG to OM. Pt transferred to CVICU post-procedure with course complicated by a right-sided pleural effusion requiring a thoracentesis and complete reexpansion of her right lung, multiple pneumothoraces and subcutaneous emphysema requiring reintubation, and intermittent episodes of rapid atrial fibrillation alternating with periods of junctional rhythm requiring pacemarker placement. Patient was discharged to rehab and was readmitted on [**6-11**] with loculated left sided pleural effusion requiring left thoracotomy and decortication with hospital course complicated by hypoxic respiratory failure thought secondary to pneumonia now s/p percutaneous tracheostomy tube and percutaneous endoscopic gastrostomy tube. She was discharged to [**Hospital 100**] Rehab MACU on [**6-25**]. Her active problems there included: --hypokelmia --loose stools on vanc po, cdiff pending --anxiety on ativan prn --supratherapeutic INR, coumadin held --Anemia: ob + stool --metabolic alkalosis --delerium, improved on haldol --respiratory failure with complicated pleural effusions, CXR with bilateral fibrosis, effusions --systolic CHF on aldactone, metoprolol, amio reduced and lopressor increased on [**6-29**] --candidiasis with catheter tip positive on fluconazole --anasarca, albumin 1.8 . 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 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 with DES to LCx in [**2163**], S/p Cabg [**4-/2164**] (LIMA-LAD, SVG-RCA, SVG-OM) *Pulmonary emoblism (VTE) in '[**54**] on longterm low-dose Coumadin *Hodgkin's disease stage 2 in '[**22**] treated with total body radiation c/b functional asplenism and radiation induced ovarian failure s/p total hysterectomy and estradiol therapy *Reactive airways disease/Pulmonary Fibrosis *Multiple PNAs, most recently in [**2163-6-11**] requiring ICU care for sepsis/hypotension *Hypothyroidism *Supraventricular tachycardia (Presumably Afib) *GERD *Right chest lentigo *H/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 564**]/HSV esophagitis in setting of being on steroids (off since summer [**2163**]) Social History: She is a retired school administrator. She is independent and performs ADLs without limitation. Physically, she has difficulty climbing stairs and hills. No tob or drugs. Occasional EtoH, but rarely. Married and lives with husband in [**Location (un) 1514**], MA. Retired school administrator Family History: No family history of lung or cardiac diseases. NC for CAD, SCD or arrhythmia. Mother: [**Name (NI) 2481**] Maternal GM: Uterine cancer Physical Exam: Physical exam on admission: Gen: well appearing, awake, alert, trach in place HEENT: EOMI, PERRLA Neck: trach in place with no secretions CV: RRR, nl S1/S2, no m/r/g Chest: decreased breath sounds at bases, diffuse rhonchi and end-expiratory wheezes, no rales Abd: peg in place with dressing, no discharge, soft, NT/ND, BS+ Ext: trace pedal edema . Physical exam on discharge: Gen: well-appearing, awake, alert. conversant. HEENT: EOMI, PERRLA Neck: trach in place with Passy Muir valve in use. CV: RRR, nl S1/S2, no m/r/g Chest: decreased breath sounds at bases with faint crackles, soft rhonchi in low/mid lung fields. Abd: peg in place with dressing, no discharge, soft, NT/ND, BS+ Ext: 2+ pulses without edema. Neuro: AOX3. MAE. Pertinent Results: Laboratory Data: . CBC --------------- [**2164-6-30**] 09:25PM BLOOD WBC-12.6* RBC-3.85*# Hgb-11.1*# Hct-34.4*# MCV-89 MCH-28.8 MCHC-32.3 RDW-16.1* Plt Ct-522*# [**2164-7-11**] 04:03AM BLOOD WBC-7.8 RBC-3.28* Hgb-9.8* Hct-29.3* MCV-89 MCH-30.0 MCHC-33.5 RDW-15.8* Plt Ct-520* [**2164-6-30**] 09:25PM BLOOD Neuts-85.8* Lymphs-7.8* Monos-3.7 Eos-2.4 Baso-0.2 [**2164-7-7**] 03:12AM BLOOD Neuts-78* Bands-1 Lymphs-6* Monos-13* Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0 Coag Panel ----------------- [**2164-6-30**] 09:25PM BLOOD PT-50.0* PTT-36.6* INR(PT)-5.3* [**2164-7-10**] 03:09AM BLOOD PT-13.4 PTT-23.3 INR(PT)-1.1 Complete Metabolic Panel ----------------- [**2164-6-30**] 09:25PM BLOOD Glucose-150* UreaN-22* Creat-0.8 Na-141 K-4.0 Cl-96 HCO3-34* AnGap-15 [**2164-6-30**] 09:25PM BLOOD Calcium-8.4 Phos-4.1# Mg-1.8 [**2164-7-11**] 04:03AM BLOOD Glucose-82 UreaN-25* Creat-1.0 Na-137 K-4.5 Cl-99 HCO3-30 AnGap-13 [**2164-7-11**] 04:03AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1 Liver Tests ----------------- [**2164-7-8**] 05:09AM BLOOD ALT-50* AST-48* AlkPhos-271* TotBili-0.4 [**2164-7-10**] 03:09AM BLOOD ALT-47* AST-40 AlkPhos-258* TotBili-0.3 Urine Tests ----------------- [**2164-7-2**] 09:21PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2164-7-2**] 09:21PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2164-7-2**] 09:21PM URINE RBC-14* WBC-2 Bacteri-FEW Yeast-NONE Epi-0 MICROBIOLOGICAL DATA **FINAL REPORT [**2164-7-3**]** URINE CULTURE (Final [**2164-7-3**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 128 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R . . . **FINAL REPORT [**2164-7-7**]** GRAM STAIN (Final [**2164-7-3**]): [**12-4**] PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2164-7-7**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | KLEBSIELLA PNEUMONIAE | | AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- 16 I CEFTAZIDIME----------- 32 R =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 8 I <=1 S MEROPENEM------------- 4 S <=0.25 S PIPERACILLIN/TAZO----- I 16 S TOBRAMYCIN------------ <=1 S =>16 R TRIMETHOPRIM/SULFA---- <=1 S . . . Time Taken Not Noted Log-In Date/Time: [**2164-7-7**] 9:00 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2164-7-7**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. DORIPENEM SENSITIVITY REQUESTED BY DR. [**First Name8 (NamePattern2) 4503**] [**Last Name (NamePattern1) 4504**] ON [**2164-7-10**] . KLEBSIELLA PNEUMONIAE. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | KLEBSIELLA PNEUMONIAE | | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 16 I CEFTAZIDIME----------- 16 I =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 8 I <=1 S MEROPENEM------------- 8 I <=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S =>16 R TRIMETHOPRIM/SULFA---- <=1 S CXR [**7-7**] FRONTAL CHEST RADIOGRAPH: Right-sided PICC line and tracheostomy tube are in unchanged position. Cardiomediastinal silhouette is stable. Dual lead left-sided pacer with lead overlying the expected locations of the right atrium and right ventricle is noted. Multifocal patchy opacities are mildly improved, especially in the right lower lung zone. Small left-sided pleural effusion with associated atelectasis and smaller right-sided pleural effusion are stable. No pneumothorax is appreciated. IMPRESSION: Mildly improving multifocal parenchymal opacities. EKG [**7-10**]: Atrial paced rhythm with intrinsic ventricular conduction. Inferiora and anterolateral ST-T wave changes. Cannot exclude ischemia. Q-T interval prolongation. Compared to the previous tracing of [**2164-7-1**] the anteroseptal ST-T wave changes have improved. Brief Hospital Course: 65 yo F with recent AFib, CABG in [**Month (only) 958**], s/p trach and PEG secondary to repeated respiratory failure, presented on [**6-30**] s/p pulseless arrest, course complicated by klebsiella and pseudomonas pneumonia. Pneumonia: Patient became febrile on ICU Day # 2. She was started broadly on VAP protocol with vancomycin/zosyn/tobramycin. Tobramycin was discontinued and she was switched to meropenem 2 g every 8 hours, infused over 3 hours, for pseudomonas and klebsiella pneumonia. ID was consulted and based on doripenem sensitivities, she was swtiched to doripenem for 2 days. However, the final recommendation was to switch patient back to meropenem and resend doripenem sensitivities. These sensitivities were pending at the time of discharge. Thus, she is being discharged on 2 g meropenem every 8 hours, infused over 3 hours. We recommend that [**Hospital 100**] Rehab call the micro [**Hospital **] in the next 1-2 days at [**Telephone/Fax (1) 4645**] for the [**Telephone/Fax (1) **] results on the doripenem sensitivities. If the MIC of doripenem is less than the MIC of meropenem ( less than 8), we recommend that [**Hospital 100**] Rehab switch back to doripenem 1 g every 8 hours infused over 4 hours for the same 14 day duration. If the patient shows signs of intolerance to high dose meropenem (i.e. persistent nausea), can decrease dose to one gram every 8 hours infused over 3 hours. Day 1 of antibiotics was [**7-6**] for a total 14 day course. *Continue antibiotics up to and including [**2164-7-19**] *Will need to conitnue Flagyl for C.Diff prophylaxis per below. Respiratory compromise: Patient has chronic trach in place, on trach mask with intermittent pressure support ventilation. She alternated between pressure support and trach collar, progressively spending more time on trach collar. She usually rests on the vent overnight; however, on final night in the hospital, she was able to stay off the ventilator and maintained adequate respiratory status on the trach collar. *Continue intermittent pressure support for respiratory assitance. Nausea: Patient began to develop nausea on last several days of admission. This nausea was controlled with zofran 8 mg PO every 8 hours. We recommend that [**Hospital1 100**] Rehan hold all nonessential medications (multivitamins, vitamin supplementation) in the short term, and then restart slowly. Reactive airways disease / Pulmonary Fibrosis: Secondary to radiation from Hodgkin??????s. Chronic fibrotic changes radiographically. She was continued on Albuterol and ipratropium nebs. Status post pulseless arrest: s/p DCCV with return of NSR. Initially, felt to be ventricular tachycardia (VT). Went to EP study, could not induce VT, induced 1:1 Atrial flutter, which EP felt was the rhythm responsible for the arrest. Device not placed and pacer remained. She was continued on amiodarone. Atrial Fibrillation: Continued on amiodarone, metoprolol, and coumadin. Pacer: EP interrogated pacer during above study, and changed pacer to be a-paced, not v-paced. Nutrition: Patient initially was on tube feeds cycled at night. Due to poor PO caloric intake during the day, decided to run the tube feeds continuously at 40/hr. Tube feed setting = Isosource 1.5 Cal Full strength; Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 40 ml/hr Residual Check: q4h Hold feeding for residual >= : 200 ml Flush w/ 50 ml water q6h Clostridium Difficile: Patient was on PO Vancomycin for Clostridium Difficile prophylaxis. C. diff toxin x 2 and C diff PCR negative. ID service recommended continuation of PO Vanco through final dose of doripenem, which is [**7-19**]. Following this date, PO vancomycin should be discontinued if there are no signs of symptoms of a C. diff infection. Chronic systolic heart failure: EF~35%, likely ischemic cardiomyopathy. Required IV lasix for several days for pulmonary edema. Once patient euvolemic, she was switched to her home dose Lasix 40mg PO once a day. Vancomycin Resistant Enterococcus in Urine: Patient started on linezolid on [**7-6**]. Was discontinued on [**7-10**] per ID recs as inital urnalysis was negative and subsequent cultures were also negative. CAD: s/p PCI (DES to Lcx in [**9-/2163**]) s/p CABG in 3/[**2164**]. Patient continued on metoprolol at a decreased dose of 25 [**Hospital1 **], continued on lisinopril. Microcytic anemia: Previously work-up consisetent with anemia of chronic disease. Has had guaiac positive stools in past, but no signs of acute bleeding. She required one transfusion of 1 unit for Hct 24, which appropriately increased. Hypothyroidism: Continued on levothryoxine Medications on Admission: Atenolol 25 qam Lipitor 40 qhs Prilosec 20mg qam Xalatan 1 drop both eyes hs ASA 81 daily Celexa 20mg qam Timolol 1 drop r eye [**Hospital1 **] Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 2. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: One (1) PO Q6H (every 6 hours) as needed for pain/fever. 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: Two (2) Puff Inhalation Q4H (every 4 hours). 4. amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. chlorhexidine gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML Mucous membrane TID (3 times a day). 6. cyanocobalamin (vitamin B-12) 100 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 8. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 9. furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 10. levothyroxine 100 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 11. lisinopril 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 12. metoprolol tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 14. potassium chloride 20 mEq Packet [**Last Name (STitle) **]: Two (2) PO once a day. 15. spironolactone 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 16. vancomycin 125 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day: Please discontinue after course of doripenem Last day = [**7-19**]. 17. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (4) **]: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 18. lorazepam 0.5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 19. morphine 10 mg/5 mL Solution [**Month/Day (4) **]: One (1) PO Q4H (every 4 hours) as needed for pain. 20. ondansetron 4 mg Tablet, Rapid Dissolve [**Month/Day (4) **]: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 21. warfarin 2 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Once Daily at 4 PM. 22. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day (4) **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. 23. senna 8.6 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 24. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (4) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 25. prochlorperazine maleate 5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO every 6-8 hours as needed for nausea. 26. meropenem 1 gram Recon Soln [**Month/Day (4) **]: One (1) Recon Soln Intravenous Q8H (every 8 hours): Last Day of antibiotics through [**7-19**]. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Pulseless arrest Pseudomonas and Klebsiella pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [**Known lastname 108231**], . You were seen in the hospital after you had a pulseless cardiac arrest, which was treated with an electrical shock. You were evaluated by the cardiologists, who induced a rhythm called atrial flutter, which did not warrant an implantable defibrillator. You will continue your amiodarone and coumadin. . You also developed a pneumonia. We treated you with several antibiotics and you will continue to take an antibiotic called doripenem for a total of 14 days. . We made the following changes to your medications: STARTED Meropenem STOPPED fluconazole INCREASED Coumadin CHANGED tylenol to 650 every 6 hours as needed STOPPED Lasix 40 mg IV BID STARTED Lasix 40 mg PO once a day STOPPED Omeprazole STARTED Pantoprazole STARTED Lidocaine patch . It has been a pleasure taking care of you Ms. [**Known lastname 108231**]! Followup Instructions: Department: MEDICAL SPECIALTIES When: TUESDAY [**2164-7-31**] at 9:00 AM With: DR. [**First Name (STitle) **] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2164-8-15**] at 9:00 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GASTROENTEROLOGY When: MONDAY [**2164-8-20**] at 11:15 AM With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

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icd9cm

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Discharge summary

report

Admission Date: [**2127-8-11**] Discharge Date: [**2127-8-19**] Date of Birth: [**2054-1-13**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2641**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: 73yo m w/ hx of CAD s/p 4V CABG ([**2119**])and PCI w/ LAD stent, poorly controlled IDDM, HLD, COPD, and CKD (baseline cr 3.5)presented to [**Hospital3 **] Sunday AM after being found unresponsive at home. EMS FS at the scene was 63. In the [**Hospital3 5097**] ED was notable for BUN 98, Cr 5.0, troponin 1.85, Ck-MB 25.9 and BNP>5000. EKG was notable for Sinus tach, LVH with 1-2mm ST depressions in the lateral leads. Head CT was neg for intracranial pathology. He was started on a Hep ggt and given rectal aspirin and transferred to the OSH CCU. They could not plavix load or give beta blocker because not taking PO. He was evaluated by the renal team and given his acute on chronic renal failure with hyperkalemia (peak 5.5) metabolic acidosis and volume overload, a right IJ Vas-Cath was placed and he was emergently dialyzed with 1.2 kilos of fluid removed and creatinine fell to 3.7. His peak Troponin I 23.9 and CK-MB 57.1 (MB peaked on [**8-10**]). He was maintained on heparin ggt. A cardiac echo was done which demonstarated an EF of 38% hypokinesis of mid inferoseptal, mid inferior, mid inferolateral, basal inferolateral, basal anteroseptal, basal inferoseptal and basal inferior segments. His blood sugars fell into the 30's while in the CCU and he was placed on D10 and maintained his blood glucose in the 70's-90's. He was transefered to [**Hospital1 18**] CCU for further care. On arrival to the floor, patient remains altered. He is agitated and not oriented to person, place or time. He is unable to give any history at this time. His niece, his HCP, was [**Name (NI) 653**] and the situtation was discussed. She reports that his medication list is unchanged from his recent discharge from [**Hospital1 18**] and that the patient is responsible for administration of his own medication. She reports that he has a history of hypoglycemia episodes, most recently an admission to [**Hospital1 18**] from [**Date range (1) 23465**]/12. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: 4 vessel in [**11/2119**] -PERCUTANEOUS CORONARY INTERVENTIONS: cath with stent to LAD and LCx on [**4-/2119**] -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: CHF (EF <30%) CKD with baseline Cr (3.0-4.0) PVD s/p SFA and DP bypass left iliac stenting [**11-15**] s/p appendectomy s/p L 2nd toe amputation Social History: Social history is significant for current tobacco use, thenpatient has smoked up to 2 and [**1-13**] ppd for over 55 years, quit briefly for 6 months, now smoking again. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Admission Physical Exam: VS: T=97.5 BP=163/57 HR=78 RR=16 O2 sat=99% on RA GENERAL: WDWN male in NAD. Not oriented to person, place, or time. Mildly agitated at times. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 3/6 systolic ejection murmer best heard 2nd intercostal space. No r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. 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: Right: Carotid 2+ Femoral 2+ Left: Carotid 2+ Femoral 2+ DP 1+ Discharge Physical Exam: VS: T 98.0 BP 144/61 HR 57 RR 18 O2 96% General: Awake, alert, oriented to [**Hospital1 18**], [**2127-8-13**]. Struggles with days of the week in reverse HEENT: Oral mucosa without erythema, dry mucous membranes Heart: Regular rate and rhythm, grade II/VI systolic murmur, normal S1 and S2. Pulm: Soft bibasilar crackles that don't clear with cough. Good air movement, no wheezes, rales, ronchi. Abd: Soft, nontender, nondistended, normoactive bowel sounds, no organomegaly. Ext: Right BKA, good dorsalis pedis pulse. Pertinent Results: [**2127-8-12**] 03:33AM BLOOD WBC-5.6 RBC-3.14* Hgb-10.2* Hct-31.8* MCV-101* MCH-32.5* MCHC-32.1 RDW-14.7 Plt Ct-130* [**2127-8-11**] 09:26PM BLOOD Glucose-115* UreaN-64* Creat-3.7* Na-145 K-4.0 Cl-108 HCO3-21* AnGap-20 [**2127-8-12**] 03:33AM BLOOD Glucose-104* UreaN-65* Creat-3.8* Na-147* K-3.8 Cl-109* HCO3-20* AnGap-22* [**2127-8-12**] 08:37PM BLOOD Glucose-224* UreaN-73* Creat-4.1* Na-143 K-4.0 Cl-105 HCO3-21* AnGap-21* [**2127-8-12**] 08:37PM BLOOD CK(CPK)-423* [**2127-8-12**] 03:33AM BLOOD ALT-24 AST-47* LD(LDH)-379* AlkPhos-123 TotBili-0.4 [**2127-8-12**] 03:33AM BLOOD Calcium-7.2* Phos-6.2* Mg-2.1 [**2127-8-12**] 09:06PM BLOOD Type-MIX pO2-109* pCO2-39 pH-7.33* calTCO2-21 Base XS--4 [**2127-8-12**] 09:06PM BLOOD Lactate-0.9 [**2127-8-12**] 03:33AM BLOOD TSH-1.6 [**2127-8-12**] CT Head: No acute abnormalities. No hemorrhage. [**2127-8-12**] CXR: Right HD line terminating at the low SVC. No pneumothorax or effusion detected. Discharge Labs: [**2127-8-19**] 07:35AM BLOOD WBC-5.8 RBC-2.66* Hgb-8.6* Hct-27.5* MCV-104* MCH-32.5* MCHC-31.4 RDW-14.8 Plt Ct-108* [**2127-8-13**] 01:48AM BLOOD PT-12.2 PTT-29.9 INR(PT)-1.1 [**2127-8-19**] 07:35AM BLOOD Glucose-219* UreaN-96* Creat-4.2* Na-147* K-4.9 Cl-111* HCO3-24 AnGap-17 [**2127-8-16**] 07:42AM BLOOD ALT-23 AST-26 AlkPhos-115 TotBili-0.3 [**2127-8-16**] 07:42AM BLOOD GGT-69* [**2127-8-11**] 09:26PM BLOOD CK-MB-19* MB Indx-1.9 cTropnT-1.86* [**2127-8-19**] 07:35AM BLOOD Calcium-8.2* Phos-4.6* Mg-1.7 Iron-PND [**2127-8-12**] 03:33AM BLOOD TSH-1.6 [**2127-8-13**] 01:48AM BLOOD VitB12-566 [**2127-8-12**] 09:06PM BLOOD Lactate-0.9 Brief Hospital Course: 73 year old male with PMHx CAD s/p 4V CABG ([**2119**])and PCI w/ LAD stent, poorly controlled IDDM, HLD, COPD, and CKD who presented to the hospital with altered mental status that was complicated by NSTEMI, hypoglycemia, and hypernatremia. #Altered Mental Status: Pt presented to the OSH per report he was delirious and agitated, which seems to have been waxing and [**Doctor Last Name 688**]. On transfer to [**Hospital1 18**] he continued to be altered, A&Ox0. He recieved a workup that showed a clear head CT, normalized blood glucose, normal LFTs without physical exam findings of encelpalopathy, and did not improve following urgent dialysis. His mental status gradually improved over hospital day 1. He gradually became more agitated and on HD 3 he required haldol 2.5mg x2 following the patient punching a member of the staff. He continued to be agitated and pyschiatry was consulted. They felt that this most likely was acute delerium and favored a standing dose of haldol with prn for breakthrough agitation. He had a workup of other causes of his AMS including TSH, dosing with thiamine and folate, infection workup, head CT, LFTs, B12. All of which were non-diagnostic. At transfer to the floor, he had no more episodes of agitation. His haldol and seroquel were tapered and he eventually became oriented to [**Hospital1 18**], [**2127-8-13**]. # Renal Failure: Secondary to HTN and dibetes, admitted with chronic kidney disease stage 4-5, baseline creatinine of ~3.5 with eGFR ~15. He received dialysis due to heart failure and fluid overload as well as electrolyte control. During this admission, his Cr continued to steadily rise into the mid 4's. He has been evaluated for vein mapping and planning on establishing He is currently euvolemic and making about 50cc of urine an hour. His electrolytes are medically controlled and he has no acute indications for dialysis, however he will likely need dialysis soon as an outpatient. He has had vein mapping here [**2127-8-19**]. # NSTEMI: The patient has a hx of extensive CAD and is s/p 4v CABG and in the setting of his altered mental status he had elevated cardiac enzymes (MB peaked at 57) and echo with question of worsened WMAs. ECG with ST depressions in inferior and lateral leads, but unchanged compared to prior, consistent with abnormal repolarization. He recieved full dose ASA rectally and was started on heparin ggt. Due to his AMS he was unable to take PO medications and plavix was not able to be given. His biomarkers trended down on admission. He remained hemodynamically stable. He has had no complaints of chest pain. # Hypernatremia: On admission to OSH the patients NA was 145. On transfer to [**Hospital1 18**] his Na rose to 147 and he was started on D5W. This was gradually corrected and normalized at 143. He was monitered off D5W and his sodium remained normal for the remainder of his hospitalization. He is hypernatremic at discharge, but is also dry and encouraged to increase PO intake. # Hypoglycemia: Pt has been hypoglycemic on recent admission on [**7-20**] to [**Hospital1 18**] and was found to have a BS of [**Hospital 53689**] on [**8-10**]. Per niece, he doses his own insulin and she is not sure if he is dosing it correctly. He required dextrose infusion at OSH to maintain glucose levels, however on transfer to [**Hospital1 18**] hisblood glucose remained stable in the 120s off of dextrose. He was placed on a sliding scale of insulin without and basal insulin and his blood glucose was maintained. It was felt that this initial hypoglycemia was to to overdosing of a long acting basal insulin. This appears to best fit the clinical picture as he had no further episodes since his inital hospitalization at the outside hospital. # DM2: As noted above the patient was admitted with concern for hypoglycemia and his home insulin was held. While recieving D5W to correct for hypernatremia his bllod glucose began to rise into the 200's. The patient was placed on a RISS and his blood glucose was monitored during his hospitalization. # Chronic systolic CHF: Baseline patient has EF 45%. He was found to have an estimated EF of 38% based on echo at OSH on [**2127-8-11**]. No evidence of acute decompensation during hospitalization, with no rales, peripheral edema or elevated JVP. He maintained his volume status and had no episodes of SOB or incraased O2 requirements. # Hypertension: Pt has a history of this and is controlled with metoprolol, hydralazine, and imdur at home. BPs elevated on arrival with SBP into 170's. Given the patients AMS and inability to take PO medications he was placed on IV metoprolol and IV hydrazine with SBPs in the 120's. He was eventually transitioned to PO hydralazine and metoprolol. His furosemide has been held, and his blood pressures have remained stable. Transitional Issues: - Renal follow up Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver [**First Name (Titles) **] [**Last Name (Titles) 581**]. 1. Clopidogrel 75 mg PO DAILY 2. HydrALAzine 25 mg PO BID 3. Isosorbide Dinitrate 30 mg PO TID 4. Metoprolol Tartrate 25 mg PO BID 5. Simvastatin 10 mg PO QHS 6. Tamsulosin 0.4 mg PO HS 7. Nephrocaps 1 CAP PO DAILY 8. Calcium Acetate 667 mg PO TID W/MEALS 9. Sodium Bicarbonate 1300 mg PO TID 10. Furosemide 80 mg PO DAILY 11. Aspirin EC 81 mg PO DAILY 12. Glargine 6 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Calcium Acetate 667 mg PO TID W/MEALS 3. Clopidogrel 75 mg PO DAILY 4. HydrALAzine 25 mg PO BID 5. Glargine 6 Units Dinner Insulin SC Sliding Scale using HUM Insulin 6. Metoprolol Tartrate 50 mg PO BID 7. Nephrocaps 1 CAP PO DAILY 8. Sodium Bicarbonate 1300 mg PO TID 9. Tamsulosin 0.4 mg PO HS 10. Heparin 5000 UNIT SC TID 11. Lidocaine Jelly 2% (Urojet) 1 Appl TP PRN Straight cath 12. Nicotine Patch 14 mg TD DAILY 13. Nitroglycerin Patch 0.2 mg/hr TD Q24H Please have patch on for 12 hours. 14. Quetiapine Fumarate 12.5 mg PO DAILY Please give at 5PM 15. Senna 1 TAB PO BID:PRN Constipation 16. Vitamin D 50,000 UNIT PO 1X/WEEK (SA) 17. Atorvastatin 80 mg PO DAILY 18. Calcitriol 0.25 mcg PO DAILY 19. Docusate Sodium 100 mg PO BID:PRN Constipation 20. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 21. FoLIC Acid 1 mg IV Q24H 22. Acetaminophen 1000 mg PO Q8H Pain 23. Simvastatin 10 mg PO QHS Discharge Disposition: Extended Care Facility: [**Hospital 53690**] Healthcare of [**Location (un) 583**] Discharge Diagnosis: Renal failure with altered mental status. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking part in your care while at [**Hospital1 18**]. You were transferred to this hospital from another hospital to which you were admitted when you were found down at home. The cause of your collapse is unclear, but you were found to have a very low blood sugar. You were also found to have heart failure and you had to have hemodialysis to remove the fluid that accumulated from low output from the heart. When you were transferred here, you were maintained in the intensive care unit until your renal and cardiac function stabilized. Once they did, you were transferred to the regular hospital floor where your condition improved. Your heart has been functioning well, and your blood sugars have been well controlled. Unfortunately, your kidney function has not returned to what it was before this episode. While you do not currently need to be in the hospital to manage your kidneys, it is important that you see a nephrologist to continue managing. Once again, it was a pleasure to meet you, and I wish you the best going forward. Sincerely, [**First Name4 (NamePattern1) 2398**] [**Last Name (NamePattern1) 13651**] MD Followup Instructions: Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Thursday [**2127-9-4**] at 3:30. Greater [**Hospital3 **] Assocs [**First Name8 (NamePattern2) 53691**] [**Location (un) 583**] [**Numeric Identifier 994**] ([**Telephone/Fax (1) 53692**] When discharged from rehab, please call regular PCP [**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Doctor Last Name **], [**Telephone/Fax (1) 11144**].

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

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2399

Discharge summary

report

Admission Date: [**2123-6-1**] Discharge Date: [**2123-6-12**] Date of Birth: [**2046-6-2**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 2817**] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 11946**] is a 76 year-old man with ESRD (dialysis T/Th/Sat), DM2, CHF, and recent admissions for hypoglycemia who presents with 4 days of watery diarrhea. He states that the diarrhea began 4 days PTA on Saturday night. He had not eaten anything different from his family members except some fish on [**Name (NI) 2974**]. No one around him has been ill. The diarrhea is mainly watery, non-bloody. He states he has been having > 20 episodes/day. He denies abdominal pain, fevers, chills, n/v. Of note, he had one dose of Ancef on [**5-26**] before his balloon dilatation of his R AV fistula. . In the ED, vitals were 97.0 123/58 75 16 99% RA. CXR showed no e/o PNA and he was guaiac negative. Lactate was elevated to 7.3 and only decreased to 3.4 after 2 L IVF. He was admitted for further evaluation and further IVF. . Overnight, he continued to receive 125 cc NS/hr. This morning, he states that he continues to have several episodes of watery diarrhea. Denies fevers/chills, n/v, abdominal pain, HA, dizziness, lightheadedness, recent travel. Diarrhea has not slowed down. Past Medical History: 1. ESRD on HD through right AVF 2. Type 2 diabetes, oinsulin. 3. Vision loss on left eye 4. CHF, EF 35% in [**12-2**] 5. CAD s/p cath with stent placement in [**12-2**] 6. Hypertension 7. Hypercholesterolemia 8. Sickle cell trait 9. S/p bilateral cataract extraction 10. Low back pain. MRI [**7-1**] with DJD vs. spondylodiscitis, lumbar disk herniation and lumbar spinal stenosis. 11. H/o C.diff colitis [**9-1**] Social History: Originally from Montserrat, moved here in [**2094**]. Daughter is in charge of his home meds. Quit smoking 17 years ago, smoked 1 ppd x > 20 yrs. Quit EtOH 17 years ago and states that he drank heavily before that. No hx of illicit drugs. Family History: Son has renal disease. No family hx of MI, CVA. Father had diabetes. Physical Exam: Vitals: Tm 98.6, Tc 98.6, BP 111/56, HR 70, RR 18, O2sat 100% RA General: Elderly man sitting in bed, singing, in NAD. Difficult to understand. HEENT: NCAT, anicteric. Mucous membranes not markedly dry. OP clear. No LAD. CV: No JVD. RRR. 3/6 systolic murmur in RUSB. Resp: CTAB, no wheezes/rales/rhonchi. Abdomen: +BS. Soft, non-tender, non-distended. No masses. Ext: Cool, perfused, no edema. AV fistula in RUE with palpable thrill. Neuro: MS: A+Ox3, no asterixis. CN: II-XII intact. Motor: No pronator drift. Pertinent Results: [**2123-6-1**] 04:25PM BLOOD WBC-6.5 RBC-5.13 Hgb-13.6* Hct-44.3 MCV-86 MCH-26.6* MCHC-30.7* RDW-20.2* Plt Ct-137* [**2123-6-1**] 04:25PM BLOOD Glucose-103* UreaN-31* Creat-6.0*# Na-141 K-3.5 Cl-96 HCO3-28 AnGap-21* [**2123-6-1**] 04:25PM BLOOD ALT-13 AST-36 AlkPhos-110 TotBili-2.3* [**2123-6-3**] 07:00AM BLOOD Calcium-7.8* Phos-5.5* Mg-2.2 [**2123-6-1**] 04:36PM BLOOD Lactate-3.7* [**2123-6-1**] 09:55PM BLOOD Lactate-3.4* [**2123-6-2**] 11:35AM BLOOD Lactate-6.8* [**2123-6-2**] 02:41PM BLOOD Lactate-6.3* [**2123-6-3**] 07:05AM BLOOD Lactate-3.1* [**2123-6-3**] 07:44AM BLOOD Lactate-2.8* . CT abdomen/pelvis: IMPRESSION: 1. Retroperitoneal adenopathy and trace pelvic free fluid, of uncertain etiology. 2. Gallbladder sludge and trace pericholecystic fluid, without definite evidence of acute cholecystitis. Please correlate clinically. 3. New pulmonary abnormalities and cardiomegaly could reflect interstitial lung disease such as non-specific interstitial pneumonitis. 4. Atherosclerosis, with mild-to-moderate stenosis of multiple vessels. No secondary bowel signs of mesenteric ischemia. . RUQ U/S: IMPRESSION: Moderately distended gallbladder with sludge within and mild gallbladder wall edema. These findings are most likely related to third spacing in this patient with ascites and renal failure. Acute cholecystitis can not be completely excluded, but is considered unlikely. Clinical correlation is advised. If further imaging work up is considered, a HIDA scan can be performed. Brief Hospital Course: 77 yo M with history of diabetes, ESRD on dialysis, heart failure, originally presented to the ED with diarrhea on [**2123-6-1**]. Unknown etiology. On transfer to the ICU, the patient was on day 9 of hospitalization and has newly noted liver failure in last 3 days. Patient s/p apnea and subsequent intubation in dialysis suite and was transferred to the ICU on [**2123-6-10**]. . ## Respiratory failure: Apnea in dialysis suite was reason for intubation. Once patient transferred to MICU, was noted to have a fingerstick blood sugar of 30. During assessment in the dialysis suite, primary team reported that he had been hypoglycemic immediately prior to dialysis and had received an amp of D50. Given this information and patient's blood sugar shortly after intubation, possible that apnea related to hypoglycemia. Venous blood gas at time of respiratory arrest was 7.39/34/318 on NRB, which indicates that hypercapnea an unlikely cause of his altered mental status or repiratory failure. . ## Hypotension: Underlying tenous volume status given that patient is anuric and on HD. His baseline BP tends to be 90-100s systolic. All of his periods of hypotension, including a fall to 60/palp on morning of [**2123-6-8**] seem to correlate with periods of profound hypoglycemia. Sepsis is another possibility; however patient has not been febrile during his hospital course and his WBC count had a maximum of 11.3 on [**2123-6-8**] after period of hypotension. WBC count otherwise normal and was 8.0 at time of transfer to the ICU. Patient was hypothermic to 95.3 upon transfer to the ICU, but that in setting of FSBS of 30. Patient did have a lactate elevation to 4.8 at time of respiratory arrest, though has been as high as 6.8 during this hospitalization (on [**2123-6-2**]). Possible cardiogenic component of shock related to worsening systolic function. Related to this, should rule out acute ischemic event. Cardiac enzymes at time of respiratory arrest were CKMB of 6 and Trop of 0.22. Baseline troponin in [**2123-4-20**] of 0.13. The patient was started on empiric vancomycin and zosyn, however he had progressively increasing pressor requirements. At the time of expiration, he was maxed out on neo, levo and vasopressin. . ## Liver failure: Report that patient "triggered" on the floor for SBP in the 60s on [**6-8**], which was coincident with sharp rise in liver enzymes. This points to shock liver as an etiology of his acute liver failure. In expanding the differential, the degree of enzyme elevation would point to acute viral hepatitis, autoimmune hepatitis, toxic ingestion, drugs. Negative for AMA, [**Doctor First Name **], smooth muscle Ab, Hep C. Has immunity to Hep B (positive surface Ab) and past exposure to Hep A (Hep A Ab positive). Does have a ferritin that is greater than assay, which could indicate underlying hemachromatosis. There is a hereditary hemochromatosis mutation analysis pending. . ## Hypoglycemia: Patient with severe intermittent hypoglycemia of unknown etiology. He is a diabetic at baseline, though not receiving insulin this hospitalization gvein his hypoglycemia. Hypoglycemia likely worsened in setting of liver failure resulting in impaired gluconeogenesis. The patient was maintained on a D10W drip while in the ICU, with q1h fingersticks and subsequent normalization of his blood sugars. . ## Coagulopathy: PTT and INR to 57.2 and 5.2 today from 32.4 and 1.8 in [**Month (only) 547**] [**2122**]. He did not have coags at time of admission, so rapidity of rise unknown. Associated with elevated LDH creating a concern for hemolytic process. DIC at top of differential given concern for septic physiology. All complicated by underlying liver dysfunction with recent acute injury, though hepatology reporting that degree of coagulopathy is out of proportion to his liver failure. . #Shock: Due to the above medical problems, the patient developed a worsening lactate metabolic acidosis while in the ICU that did not respond to IV fluids or antibiotics. Ventilator support was increased to no avail. A family meeting was undertaken, and the patient was made CMO. On [**2123-6-12**], the patient expired at 5:52am. Medications on Admission: Aspirin 325 mg daily Nephrocaps daily Calcium acetate 667 mg TID with meals Cinacalcet 30 mg daily Clopidogrel 75 mg daily Docusate sodium 100 mg [**Hospital1 **] Gabapentin 100 mg with HD Toprol XL 200 mg daily Atorvastatin 80 mg daily (has not refilled since [**12-2**]) Lantus 30 U qAM Sertraline 25 mg daily Polyethylene glycol daily PRN Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO WITH HD (). 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days. Disp:*9 Tablet(s)* Refills:*0* 10. Lantus 100 unit/mL Solution Sig: Five (5) units Subcutaneous at 5 PM on days when you are eating. Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: Diarrhea Secondary Diagnosis: End-stage renal disease on hemodialysis, type 2 diabetes mellitus, systolic congestive heart failure, coronary artery disease, hypertension, hyperlipidemia Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2123-6-27**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

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27577

Discharge summary

report

Admission Date: [**2106-7-18**] Discharge Date: [**2106-8-20**] Date of Birth: [**2052-10-7**] Sex: M Service: CARDIOTHORACIC Allergies: Clindamycin / Vicodin Attending:[**First Name3 (LF) 922**] Chief Complaint: angina and STEMI Major Surgical or Invasive Procedure: cabg x4 on [**7-22**] PICC line [**7-30**] colonoscopies [**7-31**] and [**8-16**] sternal debridement/rewiring [**8-1**] rewiring of sternum / pect. and omental flap [**8-11**] History of Present Illness: 63 yo male transferred in from [**Hospital1 **] with STEMI there one week prior to admission here.He was treated there with ASA, integrilin, heparin, and nitroglycerin and underwent cath: RCA 100%, LAD 80%, CX 70-80%. EF 60-65% by echo.Stents were placed in LAD and RCA. CABG surgery moved up as pt. had recurrent chest pain and referred to Dr. [**Last Name (STitle) 914**]. Past Medical History: HTN elev. chol. STEMI s/p appy s/p RIH Social History: married no tobacco occ. ETOH runs own company Family History: father died of MI at 72 mother died of CVA at 53 sister with stents/MI another sister with CABG Physical Exam: 96.6 HR 67 140/89 RR 18 RA sat 98% 94.8 kg NAD, EOMI, PERRL, Oropharynx clear neck supple, no carotid bruits lungs CTAB RRR, nl S1 S2 no m/r/g soft,obese, + BS, NT, ND right groin ecchymosis at cath site, no heamtoma warm extrems, no c/c/e Pertinent Results: [**2106-8-20**] 05:25AM BLOOD WBC-5.9 RBC-3.56* Hgb-9.4* Hct-28.4* MCV-80* MCH-26.5* MCHC-33.2 RDW-15.9* Plt Ct-359 [**2106-7-18**] 07:38PM BLOOD WBC-6.6 RBC-4.61 Hgb-13.8* Hct-38.1* MCV-83 MCH-30.0 MCHC-36.3* RDW-13.7 Plt Ct-184 [**2106-8-20**] 05:25AM BLOOD PT-16.1* PTT-40.3* INR(PT)-1.5* [**2106-8-20**] 05:25AM BLOOD Plt Ct-359 [**2106-8-20**] 05:25AM BLOOD Glucose-113* UreaN-12 Creat-1.0 Na-135 K-3.6 Cl-100 HCO3-27 AnGap-12 [**2106-7-18**] 07:38PM BLOOD Glucose-99 UreaN-16 Creat-1.1 Na-139 K-4.2 Cl-104 HCO3-26 AnGap-13 [**2106-8-20**] 05:25AM BLOOD ALT-34 AST-22 LD(LDH)-211 AlkPhos-200* Amylase-99 TotBili-0.4 [**2106-8-20**] 05:25AM BLOOD Lipase-278* [**2106-8-20**] 05:25AM BLOOD Albumin-2.8* FINAL REPORT INDICATION: 52-year-old male with status post CABG, now with status post sternal closure. Evaluate for large bowel dilatation. COMPARISONS: Comparison is made to [**2106-8-18**]. TECHNIQUE: AP upright and supine views of the abdomen. FINDINGS: The patient is status post median sternotomy. There are two mediastinal drains. There are skin staples overlying the abdomen. There are surgical clips in the right lower quadrant as well as left upper quadrant. There are vasectomy clips. There is a moderate amount of stool within the colon. There is no evidence of small or large bowel obstruction. There is air in nondilated small bowel. The bowel gas pattern is unchanged when compared to [**2106-8-18**]. There is no evidence of colonic dilatation. IMPRESSION: No evidence of colonic dilatation. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [**First Name8 (NamePattern2) 16699**] [**Name (STitle) 16700**] DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**] FINAL REPORT REASON FOR EXAMINATION: Followup of a patient after sternal reexploration and closure. PA and lateral upright chest radiographs compared to [**2106-8-18**]. The appearance of the sternal wire, cardiomediastinal silhouette, and lungs has been unchanged. There is diffuse mild increase in the left pleural effusion which is still of small size and now partially entering the major fissure. There is no congestive heart failure or pulmonary infiltrates. The tip of the left PICC line is in the inferior portion of superior vena cava. IMPRESSION: Slightly increased pleural effusion on the left, still small. Otherwise, no change. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**] Approved: FRI [**2106-8-20**] 6:17 AM Procedure Date:[**2106-8-19**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 67394**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 67395**] (Complete) Done [**2106-8-11**] at 4:26:54 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2052-10-7**] Age (years): 53 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Coronary artery disease. Left ventricular function. Pericardial effusion. ICD-9 Codes: 410.92, 440.0, 396.9 Test Information Date/Time: [**2106-8-11**] at 16:26 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2006AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 40% to 50% >= 55% Findings LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No mass or thrombus in the RA or RAA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mildly depressed LVEF. RIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall hypokinesis. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate ([**1-18**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Moderate 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. Suboptimal image quality - poor echo windows. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No mass or thrombus is seen in the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is mildly depressed. . The right ventricular cavity is mildly dilated. There is moderate global right ventricular free wall hypokinesis. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-18**]+) mitral regurgitation is seen. There is a moderate sized pericardial effusion. Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting physician ?????? [**2103**] CareGroup IS. All rights reserved. Brief Hospital Course: Admitted on [**7-18**] for pre-op workup for cabg. Right groin US done to r/o fistula or pseudoaneurysm. Vertigo was treated with phenergan. Underwent cabg x4 with Dr. [**Last Name (STitle) 914**] on [**7-22**]. Transferred to the CSRU in stable condition on neosynephrine and propofol drips.Extubated and briefly on milrinone drip and repeat echo/cultures done. Amiodarone started for a fib and off milrinone on POD #2. Echo showed no pericardial effusion. Transfused to Hct of 30 and chest tubes removed with foley on POD #3. Transferred to the floor on POD #3 to begin increasing his activity level. Developed sternal drainage on POD #5 and started on abx. Developed abd. distention, had NG tube placed and ultimately diagnosed with dilated colon/ileus. PICC line placed for poor access on [**7-30**], and colonoscopy performed by GI service on [**7-31**] for decompression and rectal tube placement. Sternal debridement and rewiring was done by Dr. [**Last Name (STitle) 914**] on [**8-1**] for dehiscence. Developed SOB on [**8-8**] and CT scan showed a massive PE. Started on IV heparin and transferred back to the ICU. Lower extrem duplex showed no thrombus or DVT. Coumadin also started and diuresis continued. IP placed pigtail cath for drainage of pleural effusion and sternal drainage started again on POD # 19/9. Sternal debridement performed by Dr. [**Last Name (STitle) 914**] on [**8-11**], and pectoralis/omental flaps constructed by Dr. [**First Name (STitle) **]. KUB repeated for recurrent abd. distention and GI reconsulted. This improved and diet was advanced. Heparin stopped on [**8-16**] for therapeutic INR. Repeat colonoscopy done on [**8-16**] with improvement and continuing diet advancement. Pigtail cath removed on [**8-18**]. Cleared for discharge to home with VNA on [**8-20**]. Pt. will have lovenox until INR 2.0-2.5. First blood draw [**8-21**] with INR follow up/coumadin dosing per PCP [**Name Initial (PRE) **]. Medications on Admission: lipitor 10 mg daily atenolol 37.5 mg [**Hospital1 **] ASA 81 mg daily ?HCTZ Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 5. Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 days. Disp:*8 Tablet(s)* Refills:*1* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 9. Duricef 1 g Tablet Sig: One (1) Tablet PO once a day as needed for while drains are in: while drains are in. Disp:*10 Tablet(s)* Refills:*0* 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 11. Enoxaparin 100 mg/mL Syringe Sig: One (1) 90 mg dose Subcutaneous Q12H (every 12 hours): subcutaneous injecion [**Hospital1 **] until INR 2.0-2.5. Disp:*10 90 mg dose* Refills:*0* 12. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day: 5mg dose today [**8-20**], then all subsequent doses per Dr. [**Last Name (STitle) **]. Disp:*40 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] home Care Discharge Diagnosis: s/p cabg x4 s/p debridement/rewiring/flap reconstr. pulmonary embolus postop ileus with 2 colonoscopies postop AFib STEMI HTN elev. chol. Discharge Condition: stable Discharge Instructions: may have sponge baths until drains removed, and pat dry no lotions, creams or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, redness or drainage pt. to record JP drain output daily for Dr. [**First Name (STitle) **] first blood draw by VNA Sat [**8-21**], results to be called to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 9386**] Followup Instructions: follow up with Dr. [**Last Name (STitle) **] in [**1-18**] weeks follow up with Dr. [**First Name (STitle) **] (plastics) in 1 week follow up with Dr.[**Last Name (STitle) 6254**] (cardiologist) in [**2-19**] weeks follow up with Dr. [**Last Name (STitle) 914**] in 4 weeks Completed by:[**2106-8-20**]

[ "997.1", "427.31", "511.9", "560.89", "285.9", "401.9", "410.41", "997.4", "414.01", "V45.82", "415.19", "427.89", "276.6", "998.31", "560.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "34.04", "46.85", "34.79", "99.04", "83.82", "38.93", "86.72", "88.72", "36.15", "36.14", "77.61" ]

icd9pcs

[ [ [] ] ]

11366, 11423

7639, 9591

304, 484

11605, 11614

1408, 6401

12086, 12391

1030, 1127

9717, 11343

11444, 11584

9617, 9694

11638, 12063

6450, 7616

1142, 1389

248, 266

512, 888

910, 951

967, 1014

25,348

166,220

28670

Discharge summary

report

Admission Date: [**2120-11-15**] Discharge Date: [**2120-11-18**] Date of Birth: [**2083-6-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: Bright red blood per rectum. Major Surgical or Invasive Procedure: Colonoscopy. Blood transfusion. History of Present Illness: 37 year-old male with alcoholic cirrhosis who was transferred from OSH for gastrointestinal bleeding. He presented to [**Hospital **] hospital two days prior to admission complaining of two days of BRBPR. The patient states there were three episodes of about one half to a cup of blood with large clots mixed with brown stool for two days. He denies hemetemesis, although he states he vomited yellow emesis once in that time period. He states that for about one week he has experienced dizziness when getting up from bed or from a chair. He reports occassional blood on the toilet paper after having a bowel movement for months which he was told were due to hemorrhoids in the past. No abdominal pain at the time of the bleeding. . The patient did not have documentation of his stay at [**Hospital **] hospital when he arrived in the MICU. The only documentation included a hematocrit of 27 on [**2120-11-14**]. The patient was orthostatic on admission. Admission hematocrit 27.5 from 37.1 on last admission. . In the MICU, the patient was transfused one unit PRBC. The patient was followed by the GI and Liver teams. As the patient was stable, the decision was made to perform a colonoscopy [**2120-11-18**] and the patient was transferred to the floor. . Review of systems: As above. Also negative for fevers, chills. Negative for chest pain, shortness of breath, cough. Negative for dysuria, hematuria, frequency. Review of systems otherwise negative in detail. Past Medical History: Alcoholic cirrhosis Alcohol use, last in [**9-/2120**] Status post ERCP/sphincterotomy for biliary sludge [**10/2120**] Depression/anxiety Genital herpes Social History: Lives in the [**Location (un) **] with his son who is age 17 and is very supportive. Unemployed, he did work as a scale attendant at the refuge department on the [**Location (un) **]. He started drinking alcohol at approximately age 13. Drinks up to quart of peppermint schnapps daily. He smokes marijuana occasionally. He denies any history of IV drug use but did use nasal cocaine. He smokes 1 [**12-4**] - 2 PPD for the past 20 years. Family History: ETOH abuse in family. His mother has hypertension. His dad has asthma. His brothers and sisters are healthy. Grandmother with Diabetes. Physical Exam: On arrival to MICU: VITAL SIGNS: T 98.6 BP 131/74, HR 81, RR 20, O2Sat 91% RA Orthostatics: 147/77 72 lying, 127/75 80 sitting, 123/81 98 standing GEN: pleasant male in NAD HEENT: PERRLA, OP clear CV: RRR, +II/VI systolic murmur heard best at LSB Lungs: CTA b/l, moderate air movement ABD: palpable liver edge about 6cm below costal margins, palpable spleen tip, soft, nt, nd, no appreciable ascites. Rectal exam positive for hemorrhoids. Ext: no C/C/E Neuro: no asterixis . On arrival to the floor: VITAL SIGNS: T 98.1, BP 103/56, HR 81, RR 16, O2Sat 98% RA GEN: pleasant male in NAD HEENT: PERRLA, sclera anicteric, OP clear CV: RRR, +II/VI systolic murmur heard best at LSB Lungs: CTA b/l ABD: palpable liver edge about 6cm below costal margins, palpable spleen tip, soft, nt, nd, no appreciable ascites. Rectal exam positive for hemorrhoids on admission Ext: no C/C/E Skin: no palmar erythema, no spider angioma Neuro: no asterixis Pertinent Results: Labs on admission: [**2120-11-15**] 09:30PM BLOOD WBC-5.8 RBC-2.75*# Hgb-9.5*# Hct-27.5*# MCV-100* MCH-34.6* MCHC-34.7 RDW-13.9 Plt Ct-106* [**2120-11-16**] 08:05AM BLOOD Glucose-120* UreaN-4* Creat-0.6 Na-144 K-3.9 Cl-113* HCO3-26 AnGap-9 [**2120-11-15**] 09:30PM BLOOD ALT-24 AST-38 LD(LDH)-144 CK(CPK)-61 AlkPhos-80 TotBili-1.3 [**2120-11-15**] 09:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2120-11-15**] 09:30PM BLOOD Albumin-3.5 Calcium-8.4 Phos-3.2 Mg-1.7 [**2120-11-16**] 08:05AM BLOOD AFP-7.5 . ECG Study Date of [**2120-11-15**] 10:59:38 PM Sinus rhythm Since previous tracing,QRS changes in lead V2 - ? lead placement . CHEST (PORTABLE AP) [**2120-11-16**] IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Lungs are clear. Heart size top normal particularly left atrium. No pulmonary edema or pleural abnormality. . Colonoscopy [**2120-11-18**] Impression: Grade 1 internal hemorrhoids Normal mucosa in the colon Recommendations: High fiber diet . Labs on discharge: [**2120-11-18**] 04:45AM BLOOD WBC-4.8 RBC-3.03* Hgb-10.0* Hct-29.6* MCV-98 MCH-33.1* MCHC-33.8 RDW-14.0 Plt Ct-95* [**2120-11-18**] 04:45AM BLOOD Glucose-89 UreaN-3* Creat-0.6 Na-142 K-3.6 Cl-105 HCO3-26 AnGap-15 [**2120-11-18**] 04:45AM BLOOD ALT-21 AST-32 AlkPhos-79 TotBili-1.1 [**2120-11-18**] 04:45AM BLOOD Calcium-8.5 Phos-5.3* Mg-1.5* [**2120-11-16**] 08:05AM BLOOD AFP-7.5 Brief Hospital Course: 37 year-old male with alcoholic cirrhosis transferred from MV for gastrointestinal bleeding. . 1. Gastrointestinal bleeding: Most likely lower gastrointestinal bleeding from the patient's description. Colonoscopy the day of discharge visualized recently bleeding hemorrhoid; no further action necessary per Gastroenterology other than high fiber diet. NG lavage on admission negative and there was no evidence of upper variceal bleeding. The patient was initially treated with PPI IV but this was changed back to the patient's PO regimen prior to discharge. The patient's nadolol was initally held in the setting of GI bleed but was restarted prior to discharge. The patient's hematocrit remained stable throughout hospitalization with good response to blood transfusion. The patient's hematocrit was 30 on discharge from 27.5 on admission. . 2. Alcoholic cirrhosis: Liver function tests and synthetic function stable from previous. MELD score 14 on this admission. The patient has a history of grade I-II varices. The patient's nadolol was initally held in the setting of GI bleed but was restarted prior to discharge. The patient was continued on lactulose for prophylaxis of encephalopathy; there were no signs or symptoms of encephalopathy during this admission. . 3. Left upper extremity cellulitis: The day prior to discharge the patient complained of erythema and tenderness at the site of OSH IV line. The IV was pulled and the erythema and tenderness improved with keflex. The patient was discharged on keflex to complete a seven-day course. . 4. History of alcohol abuse: The patient denied current abuse. The patient had no signs or symptoms of alcohol withdrawal during hospitalization. . 5. History of biliary sludge: No active issues. The patient is status post ERCP/sphincterotomy 11/[**2119**]. The patient was continued on ursodiol. . 6. Depression: No active issues. The patient was continued on his outpatient medications. . 7. Thrombocytopenia: Likely related to liver disease/splenomegaly. Stable during admission. . 8. Coagulopathy: Likely due to liver disease. Stable during admission. Medications on Admission: Protonix 40 mg Risperdal 2 mg qhs, 1 mg qam Paroxetine 30 mg PO qd Nadolol 20 mg qd Ursodiol 300 mg tid Lacutlose 30 mg tid Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Gastrointestinal bleeding 2. Hemorrhoids 3. Left forearm cellulitis . Secondary: 1. Alcoholic cirrhosis 2. Alcohol use, last in [**9-/2120**] 3. Status post ERCP/sphincterotomy for biliary sludge [**10/2120**] 4. Depression/anxiety 5. Genital herpes Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: You were hospitalized with bleeding from the gastrointestinal tract. This was likely secondary to hemorrhoids seen on colonoscopy. You should follow a high fiber diet to prevent further bleeding. . You have a skin infection and should take keflex, an antibiotic, for 6 more days for treatment of this infection. . Please contact a physician if you experience fevers, chills, abdominal pain, black stools or increased bleeding with bowel movements, or any other concerning symptoms. . Please take your medications as prescribed. - You should take keflex (an antibiotic) for 6 more days. - You can tylenol up to 2 gm per day (up to four extra strength tylenol over a twenty-four hour period) for pain. - You can take ativan 0.5 mg once a night for anxiety. You should follow-up with your primary care doctor regarding further use of this medication. - No other changes were made to your medications. . Please keep your follow-up appointments as below. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2120-12-6**] 2:00 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "287.5", "455.2", "996.62", "311", "451.82", "571.2", "682.3" ]

icd9cm

[ [ [] ] ]

[ "45.23", "99.04" ]

icd9pcs

[ [ [] ] ]

7329, 7335

5044, 7154

345, 379

7641, 7673

3635, 3640

8671, 8956

2524, 2663

7356, 7620

7180, 7306

7697, 8648

2678, 3616

1683, 1873

277, 307

4638, 5021

407, 1664

3654, 4619

1895, 2050

2066, 2508

13,027

107,204

16889

Discharge summary

report

Admission Date: [**2177-11-9**] Discharge Date: [**2177-11-13**] Date of Birth: [**2159-1-28**] Sex: F Service: CHIEF COMPLAINT: Change in mental status. HISTORY OF PRESENT ILLNESS: The patient is an 18-year-old female with past medical history of type 1 diabetes mellitus presenting with progressive mental status changes. The patient has been thrown out of her family's home and has been living with different friends for an unspecified period of time. She recently ran out of insulin approximately five days prior to admission and had been taking insulin only sporadically or not at all since then. She was complaining of fever, a cough productive of yellow sputum, nausea and vomiting, epigastric pain, chest pain, no headache, no change in bowel habits, no dysuria. In the Emergency Department the patient was uncooperative. She was given 10 units of subcutaneous insulin by EMS prior to arrival and in the Emergency Department she was given 15 units of additional insulin and an insulin drip was started and intravenous fluids started. An initial glucose was found to be 1,138 which decreased to the mid-600 range after the above intervention; her potassium was initially 6.6 and dropped to 3.7 with the intravenous fluids and insulin. A CT of the head was ordered which was normal. A chest x-ray showed subcutaneous and pneumomediastinal air. A CT scan of the chest showed a pneumomediastinum. An esophagram done at the time of admission showed no extravasation of contrast. PAST MEDICAL HISTORY: Type 1 diabetes mellitus. MEDICATIONS: The patient takes insulin. ALLERGIES: The patient has no known drug allergies.. FAMILY HISTORY: Unknown except for positive for drug abuse. SOCIAL HISTORY: The patient denies alcohol, tobacco or drugs. There is a questionable history of one previous miscarriage/abortion. The patient is currently homeless. PHYSICAL EXAMINATION: On admission her temperature was 99.3, heart rate 137, blood pressure 127/84. In general she was an ill-appearing African-American young woman. Head, eyes, ears, nose and throat examination showed mucous membranes to be dry, pupils were equal, round, and reactive to light, extraocular movements intact, sclerae were anicteric. Neck was supple, no lymphadenopathy. Lungs were clear to auscultation bilaterally in anterior fields. Cardiovascular examination showed tachycardia, normal S1 and S2. Abdomen was soft and tender in the epigastrium. Bowel sounds were positive. There was no rebound. Extremities were cool with no edema. Neurological examination showed that she appeared to be alert and oriented, but difficult to assess as she refused to answer questions except to nod her head. She moved all four extremities. LABORATORY DATA: On admission her white blood cell count was 6.4, hematocrit 49.7, platelet count 446, sodium 141, potassium 5.0, chloride 101, CO2 15, BUN 54, creatinine 1.6, glucose 1,118, anion gap 25, estimated osmolarity was 322, measured osmolarity 389, calcium 13, magnesium 4.1, phosphate 1.7. White blood cell count differential showed 92% neutrophils, 3 bands, 3 lymphocytes. An arterial blood gas was 7.45/25/75 with CPK of 6.6 and large acetone. Serum and urine toxicology were negative. INR was 1.0. Urinalysis showed greater than 1,000 glucose, 15 ketones, otherwise clean. Chest x-ray showed positive air surrounding the heart and pericardium, subcutaneous air in neck. Abdominal x-ray showed a nonspecific gas pattern, no free air in the diaphragm. EKG showed sinus tachycardia at 138, normal axis, normal intervals, no ST or T wave changes. HOSPITAL COURSE: 1. Diabetic ketoacidosis: The patient was admitted to the medical intensive care unit with a diagnosis of diabetic ketoacidosis. She was put on an insulin drip on admission. She was taken off the insulin drip on [**2177-11-11**] and switched to a scale of Lantus and Humalog with sliding scale coverage. We worked intensively with endocrine and [**Last Name (un) **] on devising an insulin regimen for this woman. She has a very significant degree of insulin resistance as well as insulin deficiency, making glucose control difficult. She also tends to eat a great deal and erratically, making fixed time-based doses impractical. Prior to discharge her blood sugars were maintained consistently in the 100s to mid-200 range. The patient was asymptomatic and claiming repeatedly that she will do what she can to take her diabetes mellitus under control and follow up with both primary care and endocrine. The patient was repeatedly reminded of the severe, life-threatening nature of her illness and that she needs to take it seriously and not let these episodes happen again. The patient reports that she has been previously hospitalized two to three times for diabetic ketoacidosis. 2. Pneumomediastinum: This was felt to be secondary to a respiratory bleb from coughing or small esophageal tear which spontaneously healed secondary to retching. Despite CT and esophagogram, no specific source for this free air was ever found. On repeat chest x-ray the air was markedly diminished with no complications. Prior to discharge the patient was complaining of shortness of breath and dizziness on ambulation however. Repeat chest x-ray showed only a small degree of residual pneumomediastinum, otherwise the lungs were clear. On ambulation the patient did desaturate from 99% to 85% with symptoms of dizziness. It was thought at the time of discharge that this was secondary to anemia. Her hematocrit at discharge was approximately 31. However is symptoms persist we will pursue diagnosis further as an outpatient. 3. Psychosocial: This patient is homeless, she is unemployed, she has dropped out of high school. She has very little social resources from which to draw. She will need full support of social work and a resource specialist as well as diabetes mellitus specialist and primary care physician. [**Name10 (NameIs) **] will be followed up by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. at [**Hospital 191**] Clinic to begin with and we will work from there. The patient has been accepted for free care formulary at [**Hospital1 346**] and will receive her necessary medications without charge for the time being. She will also most likely be accepted into Mass Health in the near future. 4. Renal: The patient presented with acute renal insufficiency with a creatinine of 1.6. This was entirely prerenal in origin and responded quickly to fluid hydration with normal BUN and creatinine prior to discharge. DISCHARGE MEDICATIONS: 1. Insulin Lantus 100 units q.h.s. 2. Humalog 20 units before breakfast, 25 units before lunch and 25 units before dinner. 3. Iron, Niferex 150 mg b.i.d. for anemia. DISCHARGE DIAGNOSES: 1. Diabetic ketoacidosis. 2. Type 1 diabetes mellitus. 3. Acute renal insufficiency. 3. Iron deficiency anemia. DISPOSITION: The patient is discharged to home in good condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7198**], M.D. [**MD Number(1) 47562**] Dictated By:[**Last Name (NamePattern1) 1737**] MEDQUIST36 D: [**2177-11-13**] 15:24 T: [**2177-11-17**] 07:19 JOB#: [**Job Number 47563**]

[ "518.1", "593.9", "280.9", "250.11" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

1675, 1720

6812, 7275

6624, 6791

3633, 6601

1914, 3615

146, 172

201, 1511

1534, 1658

1737, 1891

21,460

166,047

51198

Discharge summary

report

Admission Date: [**2136-6-4**] Discharge Date: [**2136-6-23**] Date of Birth: [**2095-4-26**] Sex: F Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 41-year-old female with past medical history significant for alcoholic cirrhosis and antiphospholipid antibody syndrome, hemachromatosis, and history of neuropathy and myopathy, who presented for orthotopic liver transplant on [**2136-6-4**]. Her operation was relatively uneventful. She had a duct-duct anastomosis and two JPs. When she left the operating room, she left intubated. On postoperative day #1, she had a positive fluid balance, however, her mechanics were quite good. Made decision to electively extubate was made. Later in the day, the patient became progressively more agitated requiring increasing oxygen and sedative medications, and ultimately, she has to be reintubated. She was noted to have high pulmonary artery pressures and an echocardiogram revealed a new papillary muscle dysfunction in the mitral valve with 3-4+ MR. This in combination with the intraoperative events of her having a V-fib, V-tach arrest requiring ACLS resuscitation at the time of the unclamping of her IVC, prompted a rule out protocol that ultimately revealed that she had in-fact ruled in for a myocardial infarction. The Cardiology service investigated the patient and ultimately she underwent a coronary catheterization. No stenting procedure was performed, however, there was mild RCA disease that would explain the papillary muscle dysfunction. Her medical therapy was optimized. She was not anticoagulated, and ultimately her MR improved as her ischemia resolved. Her postoperative course otherwise was remarkable for what was presumed to be possible alcoholic withdrawal to some extent. Although she had been abstinent for many years, and she does have underlying anxiety disorder, it was quite difficult to control her sedation, therefore she required inpatient psychiatric consultation for assistance with her medication regimen. Over the next couple of weeks in the Intensive Care Unit, the patient's ventilatory support had been easily weaned, and she was ultimately extubated approximately a week after transplant. The patient was serially diuresed, and her immunosuppression levels were followed accordingly. Ultimately by postoperative day #15, the patient was discharged to the floor, where over the next 3-4 days the patient continued to ambulate, tolerate a diet, move her bowels without any difficulty. She remained afebrile. There is no evidence of other opportunistic or iatrogenic infection. On the day of discharge, her temperature is 99.0 with a blood pressure of 120/74, heart rate 62, respiratory rate of 18, and 95% on room air saturation. Fingersticks were under 165. Her white count was 9.2 with a hematocrit of 32.5 and a platelet count of 319. Her PT and INR were 13 and 1.2. Chemistries were remarkable for a potassium of 4.2, BUN and creatinine of 29 and 1.3. Her albumin is 3.6. ALT and AST were 18 and 13, alkaline phosphatase 105, total bilirubin equals 2.0. Otherwise, the patient had a cyclosporin level of 351. Remainder of her physical exam was benign. She had decreased breath sounds at the right base. Her wound was intact, clean, and dry with staples. No drainage. Remainder of examination unremarkable except for some right lower extremity edema. She was ruled out for DVT by Duplex of the lower extremity prior to the day of discharge. DISCHARGE MEDICATIONS: 1. Valcyte 450 mg po q day. 2. Fluconazole 400 mg q day. 3. Bactrim single strength one tablet q day. 4. Protonix 40 mg q day. 5. Lopressor 12.5 mg [**Hospital1 **]. 6. Captopril 25 mg [**Hospital1 **]. 7. Aspirin 81 mg q day. 8. OxyContin 10 mg po bid. 9. Lasix 20 mg po q day. 10. Neurontin 600 mg tid. 11. Dilaudid po prn. 12. Coumadin 3 mg po q day for a goal INR of 1.5-2 given her antiphospholipid antibody syndrome and risk of hepatic artery thrombosis. DISCHARGE INSTRUCTIONS: Have her PT/INR drawn in 48 hours from time of discharge. To see Dr. [**Last Name (STitle) **] and the Transplant coordinators in the clinic approximately 3-5 days from time of discharge. She will have her Neoral levels which she will leave on Neoral 100 mg [**Hospital1 **], prednisone 15 mg a day, and CellCept 1,000 mg po bid. Her Neoral will be titrated serially as an outpatient. She will get immunosuppression levels checks with a goal level of 350-400. DISCHARGE/DISPOSITION: Home, stable, afebrile, tolerating a diet. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,PH.D.[**MD Number(3) 12276**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2136-6-23**] 06:28 T: [**2136-6-23**] 06:39 JOB#: [**Job Number **]

[ "427.5", "997.1", "998.11", "410.71", "518.5", "486", "789.5", "359.9", "571.2" ]

icd9cm

[ [ [] ] ]

[ "99.63", "38.93", "33.22", "50.59", "99.15", "96.04", "96.72", "88.56", "88.53", "37.22" ]

icd9pcs

[ [ [] ] ]

3542, 4004

4029, 4840

179, 3519

28,827

177,322

22003

Discharge summary

report

Admission Date: [**2166-8-24**] Discharge Date: [**2166-8-27**] Date of Birth: [**2105-10-10**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 1973**] Chief Complaint: Cough, Hemoptysis Major Surgical or Invasive Procedure: None History of Present Illness: 50 year old Male with PMHx of HIV on HAART (last CD4 of 175), chronic Hepatits C, COPD, Benign Hypertension, CKD stage 4 recently weaned from HD who presents with acute on chronic dyspnea and hemoptysis. Pt reported significant worsening in his DOE over the 72 hours prior to admssion, much worsened over the 24hrs prior to admission, he began producing bloody sputum, initially blood streaked and then fully bloody and that continued intermittently throughout the day. He presented to the ER today for further work up. In the ED, initial vs were: T 98.6 P 110 BP 100/66 R 22 O2 sats 85% on 4L NC. The patient was placed on TB precautions as he has AIDS and underwent CXR which revealed RML ground glass opacities. Pt was given Ceftriaxone, Levofloxacin, Vancomycin, Methylprednisolone 125mg IV, nebs and ordered for po Bactrim BS. On arrival to the [**Name (NI) 153**], pt was comfortable and sating well on 4L NC. He reports significant DOE but denies SOB at rest. He was able to produce some bloody induced sputum but there was no frank hemoptysis. He denied any fevers, chills, weight loss, rash, travel exposures or diarrhea. Pt reports recent weight gain and denies any changes in bowel or bladder habits. He was stabilized and without massive hemoptysis was transferred to the floor for further management. Past Medical History: 1) HIV dx in [**2153**]. Most recent CL [**2166-2-6**] nondetectable, with decreasing CD4 count since he was taken off ARV most recent [**2166-4-1**] 132 (acute illness), [**2166-3-18**] 137 (acute illness), [**2166-2-6**] 261. Home ARV regimen was discontinued on [**2166-2-24**]: Atazanavir 300mg Qdaily, Ritonovir 100mg Qdaily, Truvada 1 tab qdaily, and bactrim ppx. No hx of OI. 2) Hep C dx in [**2153**]. Most recent bx [**11-21**] with no cirrhosis, grade 1. No hx of treatment. 3) COPD 4) GI bleed/ shock [**9-22**] Workup notable for CMV esophogitis s/p valganciclovir, Cdiff positive s/p po vancomycin. 5) Blindness R eye since [**2152**], unclear etiology 6) HTN 7) Polysubstance abuse 8) Diverticulitis s/p resection [**2150**] 9) Hypoplastic L kidney 10) CRF with concern for medication induced AIN/ATN as noted above 11) Tobacco Abuse Social History: The patient is a widower, he currently lives in [**Hospital1 392**] with his sister. [**Name (NI) **] reports he has a daughter and 2 cats The patient was previously employed as a bricklayer, now unable to work. The patient reports his Sister [**Name (NI) **] [**Name (NI) **] to be his HCP [**Name (NI) 1139**]: 2 PPD ETOH: Reports prior heavy use, none current Illicits: History if IV Heroin and Cocaine, last documented use [**2153**] Family History: Mother: [**Name (NI) **] CA Father: CAD Physical Exam: ROS: GEN: - fevers, - Chills, - Weight Loss 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 SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: VSS: 96.4, 130/76, 95, 20, 92%RA GEN: NAD, cachectic HEENT: R eye patch, MMM, - OP Lesions, bitemporal wasting PUL: Wheezes have resolved, occaisional rhonchi clear with cough COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE NEURO: CAOx3, Non-Focal Pertinent Results: [**2166-8-27**] 06:45AM BLOOD WBC-14.1* RBC-3.82* Hgb-12.0* Hct-38.9* MCV-102* MCH-31.3 MCHC-30.8* RDW-14.0 Plt Ct-134* [**2166-8-26**] 06:40AM BLOOD WBC-12.3* RBC-3.43* Hgb-10.9* Hct-33.8* MCV-99* MCH-31.8 MCHC-32.3 RDW-14.1 Plt Ct-97*# [**2166-8-25**] 10:33AM BLOOD WBC-18.0* RBC-3.62* Hgb-11.4* Hct-35.8* MCV-99* MCH-31.5 MCHC-32.0 RDW-14.0 Plt Ct-64* [**2166-8-24**] 11:07PM BLOOD WBC-21.7* RBC-3.78* Hgb-11.9* Hct-37.7* MCV-100* MCH-31.5 MCHC-31.6 RDW-13.9 Plt Ct-52* [**2166-8-24**] 07:20PM BLOOD WBC-24.9*# RBC-3.88* Hgb-12.4* Hct-38.6* MCV-100* MCH-31.9 MCHC-32.1 RDW-13.4 Plt Ct-65* [**2166-8-24**] 07:20PM BLOOD Neuts-85* Bands-2 Lymphs-8* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2166-8-26**] 06:40AM BLOOD PT-11.7 PTT-26.9 INR(PT)-1.0 [**2166-8-27**] 06:45AM BLOOD Glucose-88 UreaN-32* Creat-1.2 Na-139 K-4.6 Cl-104 HCO3-28 AnGap-12 [**2166-8-26**] 06:40AM BLOOD Glucose-202* UreaN-39* Creat-1.4* Na-134 K-4.2 Cl-99 HCO3-27 AnGap-12 [**2166-8-25**] 10:33AM BLOOD Glucose-218* UreaN-38* Creat-1.8* Na-135 K-4.6 Cl-98 HCO3-26 AnGap-16 [**2166-8-24**] 11:07PM BLOOD Glucose-174* UreaN-39* Creat-2.0* Na-135 K-4.9 Cl-100 HCO3-26 AnGap-14 [**2166-8-24**] 07:20PM BLOOD Glucose-103 UreaN-41* Creat-2.2* Na-134 K-4.5 Cl-99 HCO3-25 AnGap-15 [**2166-8-26**] 06:40AM BLOOD ALT-17 AST-21 LD(LDH)-199 AlkPhos-85 TotBili-1.4 [**2166-8-24**] 11:07PM BLOOD ALT-16 AST-21 LD(LDH)-137 CK(CPK)-97 AlkPhos-86 TotBili-1.6* [**2166-8-24**] 11:07PM BLOOD CK-MB-7 cTropnT-0.02* [**2166-8-24**] 07:20PM BLOOD cTropnT-0.02* [**2166-8-24**] 07:20PM BLOOD CK-MB-7 proBNP-5308* [**2166-8-27**] 06:45AM BLOOD Calcium-10.0 Phos-1.7* Mg-2.4 [**2166-8-26**] 06:40AM BLOOD Calcium-9.5 Phos-1.5*# Mg-2.6 [**2166-8-25**] 10:33AM BLOOD Calcium-9.8 Phos-3.4 Mg-2.3 [**2166-8-25**] 08:37AM BLOOD Type-ART Temp-36.7 pO2-68* pCO2-74* pH-7.25* calTCO2-34* Base XS-1 [**2166-8-24**] 09:15PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.025 [**2166-8-24**] 09:15PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-6.5 Leuks-NEG [**2166-8-24**] 09:15PM URINE RBC-0-2 WBC-[**3-20**] Bacteri-MOD Yeast-NONE Epi-0-2 [**2166-8-24**] 09:15PM URINE CastGr-[**6-25**]* CastHy-[**12-5**]* [**2166-8-24**] 11:07 pm MRSA SCREEN NASAL SWAB. **FINAL REPORT [**2166-8-27**]** MRSA SCREEN (Final [**2166-8-27**]): No MRSA isolated. ACID FAST SMEAR (Final [**2166-8-25**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST SMEAR (Final [**2166-8-26**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST SMEAR (Final [**2166-8-27**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. CHEST (PA & LAT) Study Date of [**2166-8-24**] 7:40 PM IMPRESSION: Extensive interstitial and airspace opacity in the right mid and lower lung zone concerning for infection. CHEST (PORTABLE AP) Study Date of [**2166-8-25**] 8:07 AM FINDINGS: Worsening diffuse pneumonia in the right lung with relative sparing of right lung apex, superimposed upon underlying emphysema. There is some degree of volume loss, with apparent slight shift of mediastinum towards the right. Small pleural effusion on the right side has slightly worsened. Left lung is hyperexpanded, but grossly clear. Brief Hospital Course: 1. Bacterial Pneumonia, Hemoptysis - Patient ruled out for TB with 3 concentrated sputums - Improved with Levofloxacin, Ceftriaxone and Vancomycin - Total of 10 day course - Hemoptysis was never massive, but was more than simply rust colored. It has started to resolve to rust-colored at time of discharge. 2. COPD Exacerbation - Steroid Taper was started in the [**Hospital Unit Name 153**] and was continued through discharge - Advair, Albuterol, Tioproprium - Oxygen requirement had resolved by day of discharge. 3. Acute on Chronic Diastolic CHF - This is the likely cause of the elevated BNP, as it was in the setting of hypoxia and tachycardia. The symptoms resolved with resolution of the pneumonia 4. HIV/AIDS - His HAART was continued as was his bactrim 5. CKD Stage 4 - Renal Dosing 6. Chronic Hepatitis C - Avoid Tylenol 7. Thrombocytopenia - Continued improvement 8. Nicotine Dependence - Smoking Counseling given - Patient was maintained on nicotine patch, but proceeded to smoke in respiratory isolation. Medications on Admission: Atazanavir 300mg daily Diazepam (unclear dose) [**Name (NI) 57593**] 200mg every other day Advair diskus inhaled [**Hospital1 **] Oxycodone SR 40mg TID Ranitidine 150mg qhs Ritonavir 100mg daily Tenofovir 300mg daily Spiriva daily Bactrim SS daily (has not taken in 5 days) Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H (every 48 hours) for 6 days. Disp:*9 Tablet(s)* Refills:*0* 2. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q72H (every 72 hours). 3. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO Q72H (every 72 hours). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). Discharge Disposition: Home Discharge Diagnosis: Bacterial Pneumonia Hemoptysis COPD Exacerbation HIV/AIDS Chronic Kidney Disease Stage 4 Chronic Hepatitis C Thrombocytopenia Discharge Condition: Good Discharge Instructions: Return to the hospital with worsening of your cough, increased coughing of blood, shortness of breath, fevers/chills or diarhea. You are being discharged on an antibiotic called Levofloxacin. This medication can weaken your tendons while taking it, so you should avoid strenuous sports or activities. If you feel palpitations in your heart, contact your doctor or go to the Emergency Room. Finish all this medication even if you feel better. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2166-9-25**] 3:00 Please contact your Infectious Disease Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2148**] for follow up of this infection

[ "491.21", "070.54", "369.60", "753.0", "584.9", "336.3", "799.4", "287.4", "428.0", "585.4", "403.10", "428.33", "276.2", "042", "338.29", "481", "305.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9448, 9454

7120, 8148

294, 300

9623, 9629

3840, 7097

10120, 10425

2991, 3032

8472, 9425

9475, 9602

8174, 8449

9653, 10097

3562, 3821

237, 256

328, 1646

1668, 2518

2534, 2975

22,289

162,281

2420

Discharge summary

report

Admission Date: [**2108-5-12**] Discharge Date: [**2108-5-14**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: Hemetemasis Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: Briefly, patient is an 82 y/o M hx DM2, CKD, presented with hemetemasis, Hct drop, lightheadedness. Patient presented to the ED after he had 1 episode of hemetemesis with associated dizziness. He was found to be orthostatic in the ED, and NG lavage was positive for 100 cc of dark red blood. He underwent an EGD in the ED which revealed only mild gastritis but no obvious source for upper GI bleed. He was transfused 2 units pRBCs and transferred to the ICU for further monitoring. . While in the MICU, his antihypertensive medications were held and he remained HD stable with no further episodes of hemetemesis and no melena or BRBPR. His diet was advanced to clears and his clonadine was reintroduced . On transfer he denies nausea, vomiting, dizziness, CP, SOB, abd pain. He has not had a BM. He reports feeling well. Past Medical History: HTN DM Prostate cancer CKD Anemia baseline HCT 33-35 urinary incontinence s/p prostatectomy Diastolic dysfunction Social History: Lives with daughter and [**Name2 (NI) 802**]. Smoking: quit several years ago EtOH: rare Family History: stroke, no malignancy Physical Exam: T:99.5 BP: 100/60 P: 88 RR: 18 O2 sats: 96% on RA Gen: Elderly male lying in bed in NAD. HEENT: Op clear, MM mildly dry, EOMI, PERRL Neck: no LAD CV: rr, no m/g/r Resp: CTA b/l Abd: NABS, soft, NT/ND Back: no spinal or paraspinal tenderness, no CVAT Ext: trace LE edema, no calf tenderness, warm well perfused Neuro: AAOx3, CN II-XII intact, strength in right hand diminished [**1-13**] to past nerve injury, otherwise strength 5/5 and equal and upper and LE b/l Skin: no rashes Pertinent Results: Admission labs: [**2108-5-12**] 11:30PM HCT-26.7* [**2108-5-12**] 04:05PM URINE HOURS-RANDOM [**2108-5-12**] 04:05PM URINE UHOLD-HOLD [**2108-5-12**] 04:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2108-5-12**] 04:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2108-5-12**] 01:45PM GLUCOSE-163* UREA N-82* CREAT-2.8* SODIUM-141 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-31 ANION GAP-14 [**2108-5-12**] 01:45PM estGFR-Using this [**2108-5-12**] 01:45PM ALT(SGPT)-13 AST(SGOT)-21 ALK PHOS-66 AMYLASE-118* [**2108-5-12**] 01:45PM WBC-9.2 RBC-3.13* HGB-8.0* HCT-25.0*# MCV-80*# MCH-25.6*# MCHC-32.0 RDW-16.3* [**2108-5-12**] 01:45PM NEUTS-77.3* BANDS-0 LYMPHS-16.5* MONOS-4.4 EOS-1.4 BASOS-0.4 [**2108-5-12**] 01:45PM PT-12.9 PTT-25.5 INR(PT)-1.1 [**2108-5-12**] 01:45PM PLT COUNT-196 . Discharge Labs: [**2108-5-14**] 04:06AM BLOOD WBC-11.5* RBC-3.47* Hgb-9.7* Hct-28.6* MCV-83 MCH-27.9 MCHC-33.9 RDW-17.3* Plt Ct-138* [**2108-5-14**] 04:06AM BLOOD Glucose-154* UreaN-48* Creat-2.5* Na-141 K-4.1 Cl-103 HCO3-29 AnGap-13 . MICRO: [**2108-5-13**] 2:00 am SEROLOGY/BLOOD **FINAL REPORT [**2108-5-14**]** HELICOBACTER PYLORI ANTIBODY TEST (Final [**2108-5-14**]): NEGATIVE BY EIA. (Reference Range-Negative). . Imaging: CXR: FINDINGS: An NG tube is noted coiled in the gastric cavity, its tip is excluded. The cardiac silhouette is at the upper limits. The mediastinal and hilar contours are unremarkable. The lungs are clear. No evidence of pleural effusions. No evidence of pneumothorax. The osseous structures are unremarkable. IMPRESSION: No evidence of acute cardiopulmonary process. NG tube is noted coiled in the gastric cavity, its tip is excluded. Brief Hospital Course: 82 y/o M hx type 2 DM, CKD, prostate ca s/p prostatectomy admitted with hematemesis. His hospital course is as follows: . Acute Blood Loss Anemia due to Acute Gastritis: Hematemesis: Patient was found to have a Hct of 25 in the ED (baseline 30). NG lavage demonstrated 100ml of blood. The patient was otherwise stable. GI was consulted and EGD was performed in the ED, demonstrating gastritis. He was given 2 units of PRBCs and transferred to the MICU for overnight observation. His Hct remained stable at 28 thereafter. He was put on a PPI [**Hospital1 **]. His anti-hypertensives and diuretics were initially held. However, as he was stable we added back his clonidine and a lower dose of his beta blocker. We discharged him on a [**Hospital1 **] PPI, clonidine, and a lower dose BB. He will need a follow up colonoscopy and have his H. pylori serologies followed up. His anti-hypertensives and diuretics can likely be re-started as an outpatient. . Tachycardia: Sinus rhthym. Was thought likely ssecondary to the fact he had been off his BB for his GI bleed. His beta blocker was re-started at a lower dose, to be up-titrated as an outpatient. He was also given gentle IVF to maintain his volume. . Benign Hypertension: Held all anti-hypertensives. Re-started his clonidine and BB at a lower dose prior to D/C. . Type 2 DM uncontrolled: Continued his home regimen and ISS while in house. . CKD: Baseline creatinine 2.5 and stable during this admission. . Code: FULL for this admission. Medications on Admission: Protonix 40 mg daily metolazone 2.5 mg daily (added to regimen on [**2108-4-17**]) metoprolol 50 mg [**Hospital1 **] Diovan 320 mg daily Calcitriol 0.25 MWF clonidine 0.2 mg [**Hospital1 **] lasix 80 mg [**Hospital1 **] imipramine 10 mg QHS isosorbide dinitrate 20 mg TID Humulin 70/30 Pen 100 unit/mL (70-30)--14units in am and 14 in pm daily ASA 325 mg PO QD Discharge Medications: 1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. [**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO MWF (Monday-Wednesday-Friday). 3. Imipramine HCl 10 mg Tablet Sig: One (1) Tablet PO qhs (). 4. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day: until follow up with your doctor. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 6. Humulin 70/30 100 unit/mL (70-30) Suspension Sig: Fourteen (14) units Subcutaneous twice a day: take each morning and evening daily. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Gastritis . Secondary Diagnoses: Hypertension Diabetes Mellitus Chronic Kidney Disease Anemia Diastolic Congestive Heart Failure Discharge Condition: Good, afberile, hemodynamically stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 liters . You were diagnosed with an upper gastrointestinal bleed due to gastritis, an inflammation of the stomach. This was likely caused by ibuprofen. You were given a blood transfusion and your hematocrit stabilized, as did your blood pressure. You were also started on an acid blocker called protonix. Please resume all of your previous medications as before, EXCEPT for your blood pressure medications (diovan, lasix, metolazone, isosorbide dinitrate). We have decreased your metoprolol (lopressor) to 12.5 mg twice daily until you see your doctor. DO NOT take anymore ibuprofen, advil, motrin, alleve, or other NSAIDS. . Please follow up with your primary care physician regarding restarting all of your blood pressure medications and your water pill. You will be given a new medication called protonix to be taken twice daily for 2 weeks. . You will also need to schedule a colonoscopy through your primary care physician. [**Name10 (NameIs) **] will need to follow up H. pylori serologies. . Please return to the hospital immediately if you experience additional bleeding, cehst pain, dizziness/lightheadedness, or any other symptoms that concern you. Followup Instructions: Please follow up with your PCP as already scheduled. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2108-5-16**] 4:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2108-5-22**] 8:30 . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2108-5-22**] 10:30

[ "403.10", "V10.46", "428.0", "250.42", "E935.6", "285.1", "535.51", "428.32", "585.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.13" ]

icd9pcs

[ [ [] ] ]

6412, 6418

3790, 5296

274, 303

6610, 6651

1953, 1953

7988, 8500

1415, 1438

5708, 6389

6439, 6439

5322, 5685

6675, 7965

2863, 3767

1453, 1934

6491, 6589

223, 236

331, 1154

1969, 2847

6458, 6470

1176, 1292

1308, 1399

52,666

187,543

41707

Discharge summary

report

Admission Date: [**2184-11-24**] Discharge Date: [**2184-12-5**] Date of Birth: [**2114-3-22**] Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending:[**First Name3 (LF) 594**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: Endotracheal Intubation Arterial Line placement Bronchoscopy History of Present Illness: 70-year-old woman with a complicated medical history, including CAD s/p PCI, BOOP/COP with bronchiectasis, PAD, renal artery stenosis, hypertension who was referred by her Pulmonary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]: "70 year old female with chief complaint of recurrent anginal symptoms. Known CAD and abrupt worsening of oxygenation, with concern for PE. Had CT earlier today before I saw her, but w/o contrast. Hx of BOOP which has responded to Pred/MTX in past." The patient reports that her overall worsening began in [**Month (only) 359**] when she developed a cough and wheeze. She has never had a wheeze before despite multiple episodes of BOOP/COP. In [**Month (only) **], the patient was seen at [**Location (un) 21541**] Hospital for sharp chest pain, where a heart attack was ruled out but the patient did not receive a stress (according to her report). She was placed on Keflex, then Avelox and seen by ENT for development of sores in her nose, which she still complains of. The patient was seen by Dr. [**Last Name (STitle) **] because of increased shortness of breath and has been on prednisone and methotrexate for a suspected recrudescence of BOOP/COP. Over the past week, however, the patient has had intermittent short-lived episodes of substernal chest heaviness, which she reports most closely resemble angina from her previous heart problems (which include 3 stents in her coronary vessels; the patient also reports renal artery stents and what seem to be iliac stenting on left). The patient reports that her angina-like symptoms do indeed appear upon exertion and appear to be relived with rest. Over the past week, however, the patient has also had an increased oxygen requirement at home and desaturates upon activity into the mid 70s (she has a finger pleth at home). Finally, the patient has been reporting dysphagia-type symptoms, where food and pill seem to get stuch at the bottom of her esophagus. She has had a barium swallow and reports she has been asked to have an endoscopy as well. She further mentions having occaional positive ANCA tests in past (when I was querying about her nasal sores). The patient also mentions that all of her symptoms started in [**Month (only) **] after she developed an itchy foot rash that has cleared since the introduction of prednisone. . In the Emergency Department, the patient's initial vital signs were P 0, T 98.4, HR 72, BP 155/60, RR 22, 91% on 2L. The patient underwent chest X-rat, chest CT, and then CTA after having an elevated d-dimer. Her first troponin was negative. Upon leaving the ED, her vitals were T 98.4, BP 133/55, HR 66, RR 22, 97% on 4L. . On the floor, the patient is comfortable in bed, although conversation makes her short of breath. A short walk caused her systolic blood pressure to read in the 190s. After a brief rest, her SBP has returned to the 150s. Past Medical History: BOOP/COP s/p Bx [**2172**] HTN HLD CAD s/p 3 stents GERD T2DM s/p knee replacement ([**2181**]) s/p TAH h/o proctitis ([**2177**]) h/o Babesiosis ([**2180**]) Social History: She is married and lives with her husband. She has no pets at home. She drinks minimal amounts of alcohol. She does not smoke. She quit many years ago. Family History: Significant for coronary artery disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp 97.7F, BP 142/70, HR 59, R 18, O2-sat 100% 4L GENERAL - pleasant appropriate HEENT - NC/AT, EOMI, sclerae anicteric and without injection, MMM, OP clear NECK - supple, cannot evaluate JVD LUNGS - diffuse rales across all fields, denser at bases b/l. Good air movement, no wheeze or rhonchi. No use of accessory muscles. Becomes short of breath and RR increases to mid-20s on conversation. HEART - RRR, nl S1 S2, muffled heart sounds ABDOMEN - NABS, soft, non-tender, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3 Pertinent Results: Admission Labs: [**2184-11-24**] 05:40PM BLOOD WBC-14.1* RBC-3.62* Hgb-11.2* Hct-34.5* MCV-95 MCH-30.9 MCHC-32.3 RDW-15.5 Plt Ct-241 [**2184-11-24**] 05:40PM BLOOD Neuts-95.2* Lymphs-3.7* Monos-0.6* Eos-0.4 Baso-0.1 [**2184-11-24**] 05:40PM BLOOD PT-12.6* PTT-22.4* INR(PT)-1.2* [**2184-11-25**] 06:00PM BLOOD ESR-77* [**2184-11-24**] 05:40PM BLOOD Glucose-220* UreaN-50* Creat-1.4* Na-138 K-4.8 Cl-99 HCO3-25 AnGap-19 [**2184-11-24**] 05:40PM BLOOD ALT-35 AST-34 LD(LDH)-436* AlkPhos-66 TotBili-0.4 [**2184-11-24**] 05:40PM BLOOD proBNP-1448* [**2184-11-25**] 06:00PM BLOOD Albumin-3.4* Calcium-9.2 Phos-2.7 Mg-1.3* [**2184-11-24**] 05:54PM BLOOD D-Dimer-1243* [**2184-11-24**] 05:49PM BLOOD Glucose-211* Lactate-2.5* Na-136 K-4.7 Cl-96 calHCO3-27 . [**Hospital3 **]: [**2184-11-24**] 05:40PM BLOOD cTropnT-<0.01 [**2184-11-24**] 11:45PM BLOOD cTropnT-<0.01 [**2184-11-25**] 06:00PM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-2145* [**2184-11-26**] 09:07AM BLOOD CK-MB-2 cTropnT-<0.01 [**2184-11-26**] 09:07AM BLOOD Ret Aut-1.3 [**2184-11-24**] 02:04PM BLOOD ANCA-NEGATIVE B [**2184-11-24**] 02:04PM BLOOD [**Doctor First Name **]-NEGATIVE [**2184-11-24**] 05:40PM BLOOD CRP-97.7* [**2184-11-25**] 06:00PM BLOOD RheuFac-13 CRP-106.2* [**2184-11-24**] 05:40PM BLOOD C3-214* C4-43* [**2184-11-26**] 06:35AM BLOOD Lactate-1.3 [**2184-11-26**] 09:19AM BLOOD Lactate-1.8 . Discharge Labs: . Microbiology: [**2184-11-26**] MRSA SCREEN-PENDING [**2184-11-25**] CMV Viral Load-PENDING [**2184-11-25**] CRYPTOCOCCAL ANTIGEN-NEGATIVE [**2184-11-25**] Blood Culture-PENDING [**2184-11-25**] SPUTUM Immunoflourescent test for Pneumocystis jirovecii (carinii)-negative [**2184-11-24**] URINE CULTURE-PRELIMINARY {GRAM NEGATIVE ROD(S)} [**2184-11-24**] BLOOD CULTURE-PENDING . Imaging: CT Chest ([**11-24**]): IMPRESSION: Acute exacerbation of a more chronic fibrotic process with a segmental distribution. The more chronic process is most likely fibrotic NSIP. This is not the radiologic appearance of COP. - Coronary calcifications. - There is calcification of the mitral annulus. - Decrease in size in mediastinal lymphadenopathy. - Hiatal hernia. . CXR ([**11-24**]): IMPRESSION: 1. Increased interstitial markings, correlating with the history of organizing pneumonia. 2. Increased bibasilar opacities may represent atelectasis or potentially infection. . CTA Chest ([**11-24**]): IMPRESSION: 1. Findings compatible with known interstitial disease and inflammatory airways disease. The only change is increased diffuse attenuation of lung parenchyma which may be due to differences in technique although superimposed processes such as edema are not excluded. 2. No evidence of pulmonary embolism. 3. Diffusely enlarged intrathoracic nodes, similar in size. 4. Atherosclerosis. . Echo ([**11-25**]): The left atrium is mildly dilated. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve is not well seen. No aortic regurgitation is seen. The mitral valve leaflets are not well seen. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy and normal cavity size with preserved global biventricular systolic function. Mildly dilated aortic arch. No clinically significant valvular regurgitation or stenosis. Indeterminate pulmonary artery systolic pressure. Brief Hospital Course: 70F with PMH BOOP/COP, CAD s/p stent x3, PAD who presents with dyspnea on exertion, hypoxia, chest pressure of two months duration. . # Dyspnea, Hypoxia, Chest Pressure: DDx is broad, including cardiac, pulmonary, and inflammatory causes. Although the patient had Hx CAD, her chest pressure appeared to be mild and associated with hypoxia. She had no sign of cardiac disease given negative troponin, normal echo. Pulmonary hypertension would explain her dyspnea and hypoxia, although it could be secondary to multiple etiologies. Echo was not able to measure her PA pressure. She could have worsening BOOP, but it was also possible she had a new pulmonary process, either infectious or inflammatory. Given her use of steroids without ABX prophylaxis, PCP or other infection also needs to be considered. She has been afebrile and without sputum production, but has noted cough and is on immune suppression. Pulmonary was consulted and planed bronchoscopy. Given the background of foot rash and nasal lesions, Wegener's was of concern. Rheumatology was consulted and labs drawn. ENT was called but biopsy deferred to resolution of infectious and rheumatologic workup. . On the morning of [**11-26**], she was found to have worsening hypoxia and was transferred to the MICU. While in the MICU, the patient was placed on a NRB. She was continued on treatment for presumed PCP with steroids and Bactrim. She was also started on vanc/ceftax for possible HAP for seven day course. The possibility of intubation was discussed with the patient for possible bronchoscopy. However, because of the risk of intubation and the potential for a very difficult extubation [**1-14**] her underlying lung disease, she was not immediately intubated. However, over a few days, the patient's respiratory status continued to decline, and she had an acute episode of prolonged desaturation for which she was intubated. CT chest performed [**2184-12-3**] showed substantial worsening of her ILD. Several attempts were made to wean her from the ventilator but failed due to hypoxia. patient was made CMO on [**2184-12-5**], and was terminally extubated, as below. . # Goals of care: The patient knew the risk of intubation, and she felt that if she needed to be intubated once, she would not want to be reintubated if she failed extubation. She also declined the option for a tracheostomy. While the patient was intubated, her family also decided to make her DNR. On [**2184-12-4**] patient's husband [**Name (NI) **] [**Name (NI) 10132**] together with his family, decided to extubate [**Known firstname 4115**] and to change the goals of her care to comfort care. She was extubated and maintained oxygen saturation of 60-70% overnight, though was unresponsive to verbal stimuli. On [**2184-12-5**], she was noted to be bradycardic, and her oxygen saturation dropped to 35% on the mnitor. She became pulseless and was declared dead at 12:02 pm. Her family was called and came to be bedside. Autopsy was declined. Attending [**Doctor Last Name **] notified by telephone. . # UTI: Found to have dirty UA, Ucx growing out pan sensitive Klebs. Was covered by Ceftaz/Bactrim. . # Kidney injury: BUN 50, creatinine 1.4. Patient does have history of renal artery stenosis with stenting. Per PCP records, this was baseline renal function. While in the MICU, her renal function worsened, with creat increasing to 2.1; possible related to medication effects of Bactrim. Her creat gradually trended back down to baseline. . # Leukocytosis: Likely secondary to recent increase in steroids, especially as patient is afebrile. Blood cultures were negagive, while urine cultures showed yeast and Klebsiella pneumoniae. She remained afebrile prior to ICU transfer. . # Hypertension: Continued home regimen of atenolol and HCTZ. . # Hyperlipidemia/CAD: Verified pravastatin dose, continued. . # Diabetes mellitus, type 2: continued ISS, held metformin . # GERD: continued home pantoprazole therapy. . # Depression: continued home citalopram therapy. Provided trazodone for sleep . . # FEN: Replete lytes prn / regular diet # PPX: heparin SC, bowel regimen, APAP # ACCESS: PIV # CODE: Full # CONTACT: husband Medications on Admission: Medication list per PCP records from visit [**11-9**]: ATENOLOL 25mg AM, 50mg PM (same as OMR) HYDROCHLOROTHIAZIDE 25mg daily (same as OMR) CITALOPRAM 20mg daily (same as OMR) PANTOPRAZOLE [PROTONIX] 40mg daily (same as OMR) METFORMIN 500mg [**Hospital1 **] (same as OMR) PREDNISONE taper from 40mg (same as OMR) PRAVASTATIN 10mg daily (same as OMR, dose not listed, confirmed with Pharmacy) METHOTREXATE SODIUM 10mg weekly Q Tuesday (same as OMR) Ativan PRN (not in OMR) Ventolin Q4-6H PRN (not in OMR) saline nasal rinse PRN (not in OMR) Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Interstitial Lung Disease Anemia Acute Renal Failure Discharge Condition: Expired Discharge Instructions: n/a Followup Instructions: n/a

[ "041.3", "280.9", "311", "272.4", "599.0", "560.1", "401.9", "584.9", "416.8", "V43.65", "415.11", "V49.86", "515", "250.00", "288.60", "530.81", "599.71", "V45.82", "287.5", "V58.65", "V58.69", "518.84", "578.9" ]

icd9cm

[ [ [] ] ]

[ "96.72", "33.24", "96.6" ]

icd9pcs

[ [ [] ] ]

12999, 13008

8178, 12380

286, 349

13105, 13115

4329, 4329

13167, 13174

3640, 3682

12971, 12976

13029, 13084

12406, 12948

13139, 13144

5706, 8155

3722, 4310

239, 248

377, 3270

4345, 5690

3292, 3453

3469, 3624

29,487

116,532

45565

Discharge summary

report

Admission Date: [**2163-1-16**] Discharge Date: [**2163-1-31**] Service: MEDICINE Allergies: Iodine / Cipro / Sulfonamides / Morphine / Codeine / Levofloxacin Attending:[**First Name3 (LF) 545**] Chief Complaint: left hip pain/concern for sepsis in ED Major Surgical or Invasive Procedure: None History of Present Illness: 86 yo F with hx Renal Cell Carcinoma, ovarian CA, arthritis, s/p right hip replacement with new onset L hip pain for 3 days. pt has had difficulty ambulating, endorses pain with any movements at all. Pt has chronic UTI on keflex at home. She presented to the ED for evaluation of L hip pain. during w/u for possible pathologic Fx pat was noted to be hypotensive to 70s. She was found to have a WBC of 14K, a positive U/A, as well as an elevated creatinine of 2.4 (baseline 1.6-1.8). Her initial lactate was 2.1. CXR was negative for PNA. She was ordered for hip/pelvis plain films. A central line was placed, pat was given zosyn and 3-4L IVF. Started on levophed. Admitted to ICU for urosepsis. Past Medical History: Left renal tumor x2, status post CyberKnife radioablation in [**2162-5-23**]. h/o ovarian cancer with peritoneal metastases (followed by Dr [**Last Name (STitle) 19**] h/o recurrent partial small bowel obstructions CRI (1.3 to 1.6) CHF (EF 50% with mod AS, [**11-24**]+AR, 2+MR) h/o PAD h/o C. difficile infections HTN h/o diverticulitis, h/o recurrent UTIs s/p left CEA, h/o talc pleurodesis TAH/BSO 19 years ago Gout h/o Collagenous colitis Allergies: Iodine / Cipro / Sulfonamides / Morphine / Codeine / Levofloxacin Social History: Lives by herself; close relatives live [**Name2 (NI) 97184**]. No tobacco, EtOH, or IV drug use. Husband died in [**2161-6-23**]. Family History: Not contributory Physical Exam: Gen: lying in bed, non-toxic, well-appearing HEENT: dry MMM Neck: supple, JVD 8 cm, no carotid bruits Chest: CTAB, no wheezes, decreased BS L base CVS: rrr, Grade II/VI syst murmur LUSB Abd: soft, + BS, minimal tenderness LLQ, no rebound or guarding, no masses Extrem: no c/c; 2+ pitting edema b/l Neuro: nonfocal, moves all extremities Pertinent Results: [**2163-1-13**] UCx: PSEUDOMONAS AERUGINOSA. pan-sensitive [**2162-2-23**], [**2162-1-26**]: ESCHERICHIA COLI AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S CXR: 1. Low-lying new central venous catheter, which should be partially withdrawn; no definite pneumothorax. 2. CHF with bilateral pleural effusions. Hip films (WET READ): No cortical irregularity or disruption of trabecular lines detected to suggest acute fracture in the left hip. Right hip replacement and pelvis similar in appearence to previous. No hip dislocation. Given osteopenia, dedicated left hip views vs CT/MRI may be considered if indicated to evaluate subtle fractures. MRI Abd [**2162-12-15**]: 1. Two left-sided renal lesions are again identified. Overall, the size of these lesions is slightly decreased in size since the aforementioned recent prior MRI. 2. Arterial spin labeling sequence does demonstrate blood flow within these lesions as noted. However, no prior ASL is available for comparison. 3. Stable large, cystic lesion within the left adnexa as noted above. RENAL U/S: Limited portable ultrasound performed. No hydronephrosis or stones in the left kidney. The right kidney which is small could not be visualized given overlying bowel gas. A CT abdomen and pelvis may be obtained if warranted for further evaluation. ECHO [**2162-8-31**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. There is mild global left ventricular hypokinesis (LVEF = 45%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area 0.7cm2). Mild to moderate ([**11-24**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-24**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. CT CHEST/ABD/PELV: 1. No evidence of loculated pleural effusion or empyema, though evaluation is limited without intravenous contrast. 2. New opacification at the right lung base, and posterior segment of the right upper lobe, concerning for pneumonia, possibly related to aspiration. 3. Unchanged appearance of nonspecific focally distended loops of small bowel. No specific evidence of bowel obstruction. 4. Unchanged appearance of numerous calcified lesions throughout the peritoneum and abdomen, limited evaluation without intravenous contrast, but suspicious for metastatic foci. 5. Unchanged appearance of predominantly cystic left adnexal mass. Brief Hospital Course: 86 y/o F with PMHx of severe AS & CHF admitted with urosepsis, s/p extubation on [**2163-1-23**], had recurrent A.fib with RVR & hypotension that responded to repeat IV fluid boluses, made DNR/DNI on [**1-27**] with continued delirium. . # A.Fib/CV: Pt with severe AS & CHF with EF 50%. Pt developped Afib with RVR c/b hypotension that responded to repeated IVF boluses. Concern for aggressive fluid resuscitation sending pt into pulm edema, likely to compromise resp status. Per family meeting, pt was made DNR/DNI, no lines, no pressors. Pt had intermittent episodes of hypotension requiring further fluid boluses. Avoiding aggressive volume boluses due to tenous volume status. Was on Digoxin 0.125mg every other day to help control rate. . #UTI/Septic Shock: Pt recently completed a 10 day course of Zosyn for pseudomonas urosepsis, successfully extubated on [**1-23**]. WBC had trended down, afebrile. However, pt developed recurrent hypotension likely cardiogenic etiology but was restarted on empiric ABx prior to leaving the ICU (Zosyn/Vancomycin). Upon arrival to the floor, the patient remained afebrile with WBC trending down. Culture data was also negative. Therefore, antibiotics were stopped and the patient was monitored. . # RENAL FAILURE, ACUTE on chronic: Pt initially with oliguric renal failure likely [**12-25**] hypoperfusion vs ATN in setting of shock. Pt began to naturally diurese on [**2163-1-26**], then UOP dropped in setting of hypotension on [**1-27**]. Currently, avoiding volume overload with gentle IVF boluses. Creatinine gradually increasing after transfer from ICU to medicine floor. Urine output decreased and urine studies consistent with pre-renal picture. Patient given intermittent IVF given poor PO intake. . # RESP FAILURE: Pt was intubated on [**1-18**] due to worsening acidosis & MS changes. CXR with bilateral pleural effusions R>L & pulm edema. CT on [**1-18**] showed possible airspace disease in RLL vs chronic changes [**12-25**] to right sided pleurodeisis. Pt extubated successfully on [**1-23**] and has been maintaining sats on 2-3LNC. Was given nebulizer treatments as needed. . # MS CHANGES: Pt with delirium likely secondary to intubation, polypharmacy & prolonged ICU stay. Sleep/wake cycles now very disturbed. Pt has been pulling out lines overnight, had to place restraints temporary. Was started on Zyprexa (initially 5mg [**Hospital1 **], then 2.5/5mg, then 2.5mg [**Hospital1 **] w/ PRN doses). . # LEFT HIP PAIN: Etiology unclear but unlikely due to infectious source. CT neg for joint effusion, bone scan neg for pathologic fracture/metastatic lesion. PT consulted to assist with getting OOB. Initially received Dilaudid in the ICU, however that was stopped due to worry for hypotension and clouding mental status. On transfer to the floor, patient still with significant pain. In discussing with family, decision made to re-start Dilaudid (however in PO form) to control pain, with the understanding that this may cloud mental status. . #Thrombocytopenia ?????? pt has baseline plt ct 50-70s, trended down to 40 & heparin products held [**2163-1-24**]. Plts have been stable. Suspician of HIT very low and HIT Ab never sent from lab. Heparin products were held. . #Sacral Decub/intertriguinous rash - was seen by the wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 7219**] implemented for wound care. Also placed on kinair mattress with regular position changes. Was given antifungal cream as well. . #Nutrition Pleasure feeds with pureed nectar thickened feeds (maintained on aspiration precautions). . Code status: DNR/DNI, no lines, no pressors . On [**1-31**], patient rapidly became hypotensive and unresponsive and expired. Family was notified. Medications on Admission: ALLOPURINOL 100 mg--2 tablet(s) by mouth twice a day CEPHALEXIN 500 mg--1 capsule(s) by mouth twice a day DULCOLAX STOOL SOFTENER 100 mg--1 capsule(s) by mouth four times a day FUROSEMIDE 40 mg--4 tablet(s) by mouth every day Fish Oil 1,000 mg-- HYDROCORTISONE 1 %--apply to affected area twice a day as needed Hydralazine 50 mg--2 tablet(s) by mouth three times a day ISOSORBIDE DINITRATE 20 mg--1 tablet(s) by mouth three times a day MULTIVITAMIN --1 capsule(s) by mouth once a day Micro-K 10 mEq--2 capsule(s) by mouth daily OMEPRAZOLE 40 mg--1 capsule(s) by mouth once a day TAMOXIFEN 10 mg--2 tablet(s) by mouth once a day Discharge Disposition: Expired Discharge Diagnosis: Patient expired Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "38.91", "96.04", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

9731, 9740

5292, 9051

311, 317

9799, 9808

2139, 5269

9861, 9868

1748, 1766

9761, 9778

9077, 9708

9832, 9838

1781, 2120

233, 273

345, 1041

1063, 1585

1601, 1732

15,170

164,648

12503

Discharge summary

report

Admission Date: [**2126-2-21**] Discharge Date: [**2126-4-1**] Date of Birth: Sex: Service: MEDICAL INTENSIVE CARE UNIT HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname **] is a 65-year-old man who was driving in his car when he hit a tree head-on. It is unknown whether a cardiac event had preceded the accident because a witness reported that the patient's eyes rolled back in his head prior to the accident. The patient was extracted from the vehicle with loss of pulse. He was defibrillated and found to be asystolic. While they were preparing to intubate the patient he regained consciousness and was transferred to BIMDC. While en route, he was intubated for airway protection. Abdominal and head CT showed multiple rib fractures. He also had sustained a laceration to his head. He was admitted to the Surgical Intensive Care Unit for further management. However, after it was noted that his surgical needs were not operable, he was transferred to Medicine. PAST MEDICAL HISTORY: 1. History of CHF. 2. Type 2 diabetes mellitus. 3. Psoriasis. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Digoxin. 2. Lasix. 3. Insulin. SOCIAL HISTORY: The patient lived alone in [**Location (un) 86**]. His brother, [**Name (NI) **] [**Name (NI) **], and [**Name (NI) 2013**] had been in to see the patient occasionally. HOSPITAL COURSE: The patient was unresponsive during his stay in the Medical Intensive Care Unit for two months. He had numerous Intensive Care Unit related infections and difficulty weaning from the ventilator. After approximately greater than a month in the Intensive Care Unit and failure to wean the patient from the ventilator and off numerous pressors including persistent congestive heart failure, the patient's brother and sister agreed to make the patient [**Name (NI) 3225**]. The patient was withdrawn from care and died on [**2126-4-1**] at 8:11 p.m. DISCHARGE DIAGNOSIS: 1. Motor vehicle accident. 2. Congestive heart failure. 3. Sepsis. 4. Respiratory arrest. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Name8 (MD) 24585**] MEDQUIST36 D: [**2126-9-20**] 14:57 T: [**2126-9-22**] 11:04 JOB#: [**Job Number 38775**]

[ "518.81", "518.5", "E823.0", "427.5", "410.71", "428.0", "785.51", "482.41", "427.41" ]

icd9cm

[ [ [] ] ]

[ "31.1", "34.91", "96.04", "38.93", "89.64", "96.6", "43.11", "96.72", "33.22" ]

icd9pcs

[ [ [] ] ]

1984, 2307

1413, 1963

1169, 1207

1026, 1146

1224, 1395

56,529

119,161

46539

Discharge summary

report

Admission Date: [**2115-1-16**] Discharge Date: [**2115-1-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4760**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: This is a [**Age over 90 **] year-old male with a history of dementia, CAD s/p CABG and atrial fibrillation who presents with altered mental status from nursing home. Pt recently with ? VRE UTI versus VRE colonization was treated with nitrofurantoin from [**Date range (1) 13926**]. Per wife, pt with new cough, since 1 week ago. Pt at baseline minimally communicative, she felt that yesterday, he was more lethargic than his baseline. Per discussion with physician at [**Name (NI) **], pt briefly "CMO" then yesterday decision made by family to bring him into the hospital. Wife is currently concerned about pt's lack of PO intake. Until a few days ago, pt ate with assitance. He now refuses to eat. Wife would also like pt's pacer interrogated. In the ED, VS T 98 BP 137/75 HR 68 RR 20 96% on NRB. Found to have bilateral lower lobe infiltrate and positive U/A, was given vanco 1 gm, CTX 1 gm, azithromycin 500. Found to have Na 162 and started on D5W 250 cc/h. ROS: Unable to be obtained Past Medical History: 1. Memory loss, most likely Alzheimer's dementia. He has been taking Aricept 10 mg once daily. 2. Syncope with orthostatic hypotension. 3. Coronary artery disease, status post bypass surgery many years ago. 4. Atrial fibrillation status post pacemaker placement five years ago for possible sick sinus syndrome. 5. Gait disturbance. 6. Frequent falls. 7. Depression. He is on Celexa 10 mg once daily. 8. H/o Urinary frequency and Nocturia Social History: He immigrated from Poland many years ago. Former smoker, quit many years ago. Denies alcohol. Family History: His first wife, child, siblings and parents were all killed in the Holocaust and so he does not know his family history of medical illness. Physical Exam: Vitals: T: 96.9 BP: 140/60 HR: 81 RR: 25 O2Sat: 97% 2L GEN: At times agitated, confused, non-verbal, unable to follow commands HEENT: MM dry, PERRL, sclera anicteric, no epistaxis or rhinorrhea, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Diffuse crackles bilaterally with expiratory wheezing ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: Difficult exam as pt unable to cooperate, CN grossly in tact, moving all extremities freely SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2115-1-16**] 10:05AM GLUCOSE-113* UREA N-47* CREAT-1.3* SODIUM-162* POTASSIUM-3.9 CHLORIDE-121* TOTAL CO2-31 ANION GAP-14 [**2115-1-16**] 10:05AM WBC-10.3 RBC-4.85# HGB-13.9* HCT-42.9# MCV-89 MCH-28.6 MCHC-32.3 RDW-14.1 [**2115-1-16**] 10:05AM NEUTS-79.7* LYMPHS-17.9* MONOS-2.0 EOS-0.2 BASOS-0.2 [**2115-1-16**] 10:05AM PLT COUNT-244 [**2115-1-16**] 10:05AM PT-15.5* PTT-23.6 INR(PT)-1.4* [**2115-1-16**] 10:05AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2115-1-16**] 10:05AM URINE RBC-[**11-8**]* WBC->50 BACTERIA-MOD YEAST-NONE EPI-0-2 ============ CXR [**2115-1-16**] FINDINGS: There are infiltrates present at both lung bases. Cardiomediastinal silhouette is stable. The pacemaker position is unchanged. There are stable areas of atelectasis in the left mid and lower zones. CONCLUSION: Infiltrates at both lung bases suggestive of pneumonic consolidation. Please ensure followup to clearance. ========== Brief Hospital Course: [**Age over 90 **] yo male nursing home resident with dementia now admitted with worsening mental status at NH and then admitted with severe hypernatremia and likely active urinary tract infection. He had, following arrival, some persistent and worsening of respiratory status with concern for aspiration pneumonia leading to two foci of infection as well. # Altered Mental Status/delerium/underlying dementia: Pt was noted to be altered on admission, per family it seems his baseline is orientated to self, on admission pt was non-verbal. Etiology of his Altered Mental Staus was multifactoral given his Alzheimers dementia, positive U/A, PNA, hypernatremia. Overnight pt's mentation improved to the point that he was able to verbalize his name, and this improvement was in the setting of correction of his hypernatremia and antibiotics. His delirium was likely multifactorial and due to PNA, dehydration, change of residence, etc. B12/folate/TSH WNL in [**8-27**]. Given goals of care, aspiration risk, etc, namenda, remeron, and risperdal were not restarted. . # Hypernatremia: Na on admission was 162. Pt was started on D5W with a goal sodium of 140, pt's Na was monitored at a 4-6hour interval. Na levels normalized. Discussed goals of care with pts wife, and she has stated that if pt were to continue poor po intake and to become dehydrated again, she would not want a PEG placed or rehospitalization (ie comfort measures at that point). . # Aspiration Pneumonia Vs HCAP: Given the nursing homes history of aspiration and the family continuing to feed the pt, pt's PNA most likely [**1-21**] aspiration. Speech and Swallow consult obtained and stated that he was unsafe to be fed orally and recommended keeping him NPO. Pt was also continued on a 7 day course of Levofloxacin. A sputum culture was sent which grew out coag + staph aureus and gram neg rods. He was started on Vanc as he came from a nursing home and is at risk for MRSA (also completed 7 day course). Upon speech and swallow reevaluation, he was noted to be aspirating on thin liquids, but felt best diet to place pt on was pureed, nectar thickened diet. He continued to cough and have evidence of aspiration even on this diet. Only essential medications were restarted and these include :ASA, proscar, and Plavix. On discussion with wife, if pt has further aspiration events, she would want aggressive care still short of intubation. . # Positive UA: The patient has had two positive UAs, however his urine culture was contamined. Treated with Vanc/Levoflox for PNA as well as per above. . # Anemia: Hct dropped from 42 on admission down to 31 on [**1-19**], which is actually closer to pts baseline. B12/folate WNL in [**8-27**]. Likely just dilutional. Guaiac negative brown stool on exam. Hct remained stable at 31-33. . # ?Parkinson's vs. Parkinsonism: Pt has no prior documented history of Parkinsons' but he does have masked facies, rigidity of his extremities, aspiration. This may be related to progressive dementia with parkinsonism, but further evaluation for Parkinson's disease may be further pursued by a geriatric neurologist at his living facility. . # HTN: Held norvasc and lasix while aspiration risk, dehydrated, normotensive; would not advocate for restarting lasix or BP meds in setting of poor po intake, no need for tight BP control given pts age, aspiration risk with extra pills. . # Orthostasis: Holding fludrocortisone while mostly bed-bound, aspiration risk, and not felt to be an essential med. . # CAD s/p CABG: While NPO, given ASA PR. Once restarted essential meds, plavix was restarted. Statin not restarted as this is unlikely to benefit this [**Age over 90 **] yo gentleman much. . # atrial fibrillation: On ASA. Rate controlled here, no need for nodal blockade. . # Stage II sacral decub: Needs frequent turning and ongoing wound care. . # Goals of care: The patient had originally been CMO, however this was reversed by his wife and he was admitted to the hospital. A meeting with the patient's wife and son was held where his poor prognosis was discussed, however at this time they want to continue treatment with antibiotics. He is still DNR/DNI. Geriatrics was consulted for further discussion surrounding goals of care and placement. Given his aspiration risk, only essential medications were restarted.ts wife wants pt to be DNR/DNI, and would not want a feeding tube. If he were to stop eating or become dehydrated again, she would allow for IV fluids, not a feeding tube. If he were to aspirate again with complications, she would want him hospitalized. Medications on Admission: Medications: ASA 81 Plavix 75 Lipitor 10 mg qhs Norvasc 5 mg daily Lasix 20 daily Trazodone 25 QHS Risperidol 0.25 [**Hospital1 **] CaCO3 500 [**Hospital1 **] Omeprazole 20 daily Nemenda 5 mg Proscar 5 QD Vit D [**Numeric Identifier 1871**] units Q monthly Remeron 15 qhs Fludrocortisone 0.1 daily Levsin drops 0.125 Ativan 0.5 q4h prn Colace Senna Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for wheezing . 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 5. Aspirin 300 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: 1. pneumonia, bacterial (HCAP versus aspiration) 2. delerium with underlying Alzheimer's dementia 3. hypernatremia from hypovolemia 4. UTI versus chronic colonization (VRE) 5. coronary artery disease 6. atrial fibrillation Discharge Condition: afebrile, mental status at baseline Discharge Instructions: You were hospitalized with a pneumonia, possibly from swallowing food or secretions into your lungs. You were treated with antibiotics. You were seen by speech and swallow, and a pureed nectar thickened liquid diet was recommended. This still will not prevent further episodes of aspiration. When admitted, you were also very dehydrated. You were given IV fluids to correct this. . Because you were aspirating, we have chosen to only give you essential medications. We feel that these are: Aspirin, Proscar, and Plavix. . Call your doctor or return to the ER for any worsening dehydration, fever, shortness of breath, chest pain, worsening confusion, or any other concerning symptoms. Followup Instructions: Please call your primary care physician for follow up [**Last Name (LF) **],[**First Name3 (LF) 1569**] M. [**Telephone/Fax (1) 95663**]

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Discharge summary

report

Admission Date: [**2154-12-31**] Discharge Date: [**2155-2-21**] Date of Birth: [**2094-3-15**] Sex: F Service: MEDICINE Allergies: Penicillins / Cefepime Attending:[**First Name3 (LF) 2698**] Chief Complaint: SOB Major Surgical or Invasive Procedure: cardiac catheterization intra-aortic balloon pump placement History of Present Illness: 60 year-old female with fibromyalgia, OA, and schizophrenia but no known prior cardiac history presented to [**Hospital1 18**] ED on [**12-31**] with dyspnea and weakness and was found to be both grossly overloaded and in shock. Apparently, her hx dates back to [**Month (only) 359**], when she first noted a fairly rapid decrement in her normal exercise function. Prior to [**9-/2154**], she felt her exercise capacity was fairly limitless; however, beginning in [**Month (only) **], she became increasingly dyspneic with decreasingly small amounts of exertion. Around the same time she developed lower extremity edema and up to four-pillow orthopnea, whereas she'd previously had none. The week prior to admission, she felt her sx began to worsen. On the day of admission, she fell out of bed and was far too weak to right herself, so she called EMS who found her on the floor and appearing extraordinarily dyspneic and tachypneic. . At [**Hospital1 18**] ED, she was found to have a temp of 99.8, bp in the 90's, and was hypoxemic (to unclear value, but required a 100% NRB-mask to raise her o2 sat to 100%). Her initial labs included a WBC of 19, lactate of 6.9, BNP of [**Numeric Identifier 65367**], an ABG of 7.36/30/36, and a cVo2 of 40%. She was given ceftriaxone and azithromycin for a RLL infiltrate. She was given 3.5L of NS for her hypotension, started on dobutamine, and sent to the ICU. In the ICU she was kept on a NRB, and the dobutamine was changed to norepi. She became anuric for 7-8 hours, and her lactate climbed to 7 and Cr from 1.1 to 1.4. Given the confusing picture, a PA-catheter was placed, and the numbers demonstrated cardiogenic shock, with PAD 20-30's, PCWP in the 20's, and SVR around 2500; as such, she was switched to dobutamine and nitroprusside, with good urine response. Her creatinine also began to decline. Past Medical History: -Syncope 3yrs ago -Neck pain, eval in 2/99 at [**Hospital1 336**] with some fibromyalgia points, occured after viral syndrome -Fibromyalgia -Diverticulosis -Internal Hemorrhoids -Osteopenia -Schizophrenia -Gastritis -Bursitis Social History: Patient lives in a boarding house. She denies any cigg, ETOH, or illicit drug use. She denies being sexually active; no inter-personal relationships; no family or friends involved. Family History: n/c Physical Exam: T 98.5 HR 129 BP 91/75 (80) RR 20 O2Sat 99% gen- chronically-ill appearing, thick mascara, looks age, fair function, non-tox, nad heent- anicteric, op clear with mmm, poor dentition neck- jvp to angle cv- tachy but reg, quiet, no m/r/g pul- moves air fairly well, diffuse wheeze, rhonchi abd- soft, mild diffuse tenderness, no rebound, nabs extrm- [**1-25**]+ pitting edema up to back, sacral edema, warm/dry, dopplerable pulses nails- no clubbing, long and painted, thickened neuro- a&ox3, no focal cn/motor deficits Pertinent Results: CHEST (PORTABLE AP) [**2154-12-31**] IMPRESSION: Bibasilar consolidations. Differential diagnosis other than pneumococcal infection includes legionella pneumonia and aspiration. . CT ABDOMEN W/CONTRAST [**2155-1-6**] IMPRESSION: 1. No bowel wall thickening. Normal caliber of the bowel without obstruction. Visualized celiac, superior mesenteric and inferior mesenteric arteries are patent. 2. Large bilateral pleural effusions with extensive areas of atelectasis and consolidation bilaterally, left greater than right. 3. Small amount of free fluid in the pelvis. 4. Anasarca. 5. Diverticulosis without evidence of diverticulitis. 6. Small left adrenal lesion, incompletely characterized. An MR could be performed for further assessment. . C.CATH Study Date of [**2155-1-9**] *** Not Signed Out *** BRIEF HISTORY: 60 year old woman with cardiogenic shock of uncertain etiology. . INDICATIONS FOR CATHETERIZATION: Cardiogenic shock . PROCEDURE: Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 6 French left [**Last Name (un) 2699**] catheter, advanced to the ascending aorta through a 6 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 6 French JL4 and a 5 French JR4 catheter, with manual contrast injections. Intra-aortic balloon counterpulsation: was initiated with an introducer sheath using a Cardiac Assist 9 French 30cc wire guided catheter, inserted via the left femoral artery. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. . **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA DISCRETE 50 2) MID RCA DIFFUSELY DISEASED 70 3) DISTAL RCA DIFFUSELY DISEASED 50 4) R-PDA NORMAL 4A) R-POST-LAT DISCRETE 70 **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN DISCRETE 40 6) PROXIMAL LAD DISCRETE 90 6A) SEPTAL-1 NORMAL 7) MID-LAD DIFFUSELY DISEASED 60 8) DISTAL LAD DIFFUSELY DISEASED 60 9) DIAGONAL-1 DISCRETE 80 10) DIAGONAL-2 DISCRETE 60 14) OBTUSE MARGINAL-1 DIFFUSELY DISEASED 15) OBTUSE MARGINAL-2 DIFFUSELY DISEASED 16) OBTUSE MARGINAL-3 NORMAL TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 1 hour 0 minutes. Arterial time = 0 hour 50 minutes. Fluoro time = 7.2 minutes. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 60 ml Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin 0 units IV Cardiac Cath Supplies Used: 7F ARROW, IABP 30CC - ALLEGIANCE, CUSTOM STERILE PACK COMMENTS: Three vessel coronary artery disease. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. There is 40% ostial stenosis involving the left main coronary artery. 3. The left anterior descending is diffusely diseased with serial 50% stenoses and a 90% stenosis at a large bifurcating second diagonal. The first diagonal branch has an 80% origin stenosis and the second diagonal has a 60% origin stenosis. 4. The AV groove circumflex is totally occluded in the mid vessel with a large thrombus burden. A large obtuse marginal branch reconstitutes via left to left collaterals. 5. There is a high takeoff of the right coronary artery with a 50% ostial stenosis and diffuse 60-80% stenosis and 70% stenosis of the origin of the posterolateral branch. ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **] ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] S. . C.CATH Study Date of [**2155-1-19**] BRIEF HISTORY: 60 year old woman with multivessel CAD now with cardiogenic shock referred for PCI as pt is non-surgical candidate at present. INDICATIONS FOR CATHETERIZATION: Coronary artery disease, Canadian Heart Class IV, unstable. Prior MI, PREV WEEK. Cardiogenic shock PROCEDURE: Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 5 French angled pigtail catheter, advanced to the left ventricle through a 6 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 5 French JL4 and a 5 French JR4 catheter, with manual contrast injections. Intra-aortic balloon counterpulsation: was initiated with an introducer sheath using a Cardiac Assist 9 French 30cc wire guided catheter, inserted via the right femoral artery. Percutaneous coronary revascularization was performed using placement of bare-metal stent(s). **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD NORMAL 6A) SEPTAL-1 NORMAL 7) MID-LAD DIFFUSELY DISEASED 80 8) DISTAL LAD DIFFUSELY DISEASED 20 9) DIAGONAL-1 DISCRETE 60 12) PROXIMAL CX DIFFUSELY DISEASED 100 13) MID CX DIFFUSELY DISEASED 100 13A) DISTAL CX DIFFUSELY DISEASED 100 14) OBTUSE MARGINAL-1 DIFFUSELY DISEASED 100 15) OBTUSE MARGINAL-2 DISCRETE 50 16) OBTUSE MARGINAL-3 DISCRETE 50 **PTCA RESULTS LAD **BASELINE STENOSIS PRE-PTCA [**27**] COLLATERAL GRADE (0-2) 0 **TECHNIQUE PTCA SEQUENCE 1 GUIDING CATH XBLAD GUIDEWIRES PILOT150 INITIAL BALLOON (mm) 1.5 FINAL BALLOON (mm) 2.5 # INFLATIONS 5 MAX PRESSURE (PSI) 240 **RESULT STENOSIS POST-PTCA 0 GRADIENT (RESIDUAL) 0 DISSECTION (0-4) 0 SUCCESS? (Y/N) Y PTCA COMMENTS: An XBLAD guide provided excellent support and positioning. Angiomax was used for PCI, the ACT was monitored. A Pilot 50 wire was directed into the LAD and into the lesion but would not cross. The wire was exchanged through a balloon for a Pilot 150 which did cross. The wire and balloon were advanced distally, the wire was withdrawn and exchanged for a Prowater. The lesion was predilated using a 1.5mm and then 2.5mm balloon to low pressure. Overlapping 2.5x18mm Microdriver stents were deployed across the lesion at 18atm with excellent results. No residual, no dissection, normal flow. During inflations, the SBP dropped to 60mm Hg and an IABP was inserted with excellent augmentation and rebound in blood pressure. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 1 hour 0 minutes. Arterial time = 0 hour 50 minutes. Fluoro time = 23 minutes. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol ml Anesthesia: 1% Lidocaine subq. Anticoagulation: ANGIOMAX units IV Cardiac Cath Supplies Used: .014 GUIDANT, PILOT 50, 300 .014 GUIDANT, PILOT 150, 300 .014 [**Doctor Last Name **], ASAHI PROWATER, 300 1.5 [**Company **], MAVERICK, 9 2.5 [**Company **], MAVERICK, 15 2.75 [**Company **], QUANTUM MAVERICK, 12 7.5 ARROW, IABP 30CC 2.5 [**Company **], MICRODRIVER, 18 2.5 [**Company **], MICRODRIVER, 18 - ALLEGIANCE, CUSTOM STERILE PACK - GUIDANT, PRIORITY PACK 20/30 6F [**Company **], VL 3.5 COMMENTS: Successful PTCA and stenting of a high grade LCX stenosis using overlapping bare metal stents as detailed in the procedural portion of this report. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful PTCA and stenting of the circumflex coronary artery. ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **] ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] E. . ECHO Study Date of [**2155-1-24**] Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (ejection fraction 20-30 percent) secondary to akinesis of the posterior wall (posterior wall is thin and fibrotic), severe hypokinesis of the inferior septum, inferior free wall, and lateral wall, and at least moderate hypokinesis of the anterior septum, anterior free wall, and apex. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Severe (4+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . CHEST (PORTABLE AP) [**2155-1-27**] IMPRESSION: Status post nasogastric tube placement with tip in the fundus of the stomach. Singificantly decreased bilateral pleural effusions since [**2155-1-24**]. Persistent right middle lobe and lower lobe consolidation. Slightly improved left lower lobe consolidation. . ECG Study Date of [**2155-2-6**] 11:16:44 AM Sinus tachycardia. Left axis deviation. Low voltage. Diffuse non-specific ST-T wave changes with minimal ST segment elevation in the inferior leads and possibly in lead V6. Compared to the previous tracing ST segment elevation is more apparent and may be compatible with acute infarction. . L-SPINE (AP & LAT) [**2155-2-16**] IMPRESSION: 1. Mild degenerative changes of the thoracic spine, no fracture detected. 2. Suspected right upper quadrant calcification - question related to the right kidney. However, I cannot exclude this represents something trapped in sheets around the patient. 2. Prominent loops of small bowel, not frankly dilated. Correlation for any abdominal, right upper quadrant, or right costovertebral symptoms to account for the patient's back pain is requested. 3. Scattered abdominal aortic calcification. . Labwork on admission: [**2154-12-31**] 08:01AM WBC-19.2*# RBC-5.15# HGB-10.5* HCT-33.7* MCV-65*# MCH-20.4*# MCHC-31.2# RDW-21.4* [**2154-12-31**] 08:01AM NEUTS-81.1* BANDS-0 LYMPHS-13.4* MONOS-5.2 EOS-0.2 BASOS-0 [**2154-12-31**] 08:01AM PLT SMR-NORMAL PLT COUNT-245 [**2154-12-31**] 08:01AM PT-20.4* PTT-28.6 INR(PT)-2.0* [**2154-12-31**] 08:01AM cTropnT-0.03* [**2154-12-31**] 09:34AM ALT(SGPT)-109* AST(SGOT)-212* LD(LDH)-506* ALK PHOS-59 TOT BILI-1.5 [**2154-12-31**] 09:34AM LIPASE-18 [**2154-12-31**] 09:34AM proBNP-[**Numeric Identifier 65367**]* [**2154-12-31**] 09:34AM GLUCOSE-124* UREA N-37* CREAT-1.2* SODIUM-137 POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-15* ANION GAP-30* [**2154-12-31**] 09:44AM LACTATE-6.7* [**2154-12-31**] 10:12PM CK(CPK)-59 [**2154-12-31**] 10:12PM CK-MB-3 cTropnT-0.03* [**2154-12-31**] 10:12PM FDP-80-160* [**2154-12-31**] 10:12PM FIBRINOGE-131* D-DIMER-5263* . Labwork on discharge: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2155-2-20**] 07:20AM 7.4 3.38* 8.9* 27.3* 81* 26.5* 32.8 19.7* 258 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2155-2-20**] 07:20AM 84 21* 0.6 134 3.3 99 27 11 Brief Hospital Course: 60 year-old female with fibromyalgia, undefined psych diagnosis (cluster A) admitted with cardiogenic shock. . 1. Cardiogenic shock: The patient was admitted with hypotension, which in the setting of an elevated WBC and question infiltrate on CXR was presumed to be caused by pneumonia/sepsis. She was started on broad spectrum antibiotics. A Swan-Ganz catheter was placed which revealed an extremely elevated CVP and PCWP and PA pressures; which in the setting of hypotension made the diagnosis of cardiogenic shock. She was transferred to the CCU where she was initially managed with lasix drip with good diuresis; however she became progressively hypotense and oliguric requiring vasopressor (at one point was on dopamine, dobutamine, vasopressin, with large dose levophed). Echocardiogram showed lateral wall inferolateral akinesis with severe MR and q-waves on EKG. She was taken to the cath lab where she was found to have severe 3 vessel disease and an intra-aortic ballon pump was placed. She is felt to have ischemic cardiomyopathy with [**Hospital1 **]-V failure by swan complicated by severe mitral regurgitation with eccentric jet likely from dilated mitral annulus. Other contributing factors may include pulmonary hypertension, tachycardia induced cardiomyopathy, and malnutrition. The shock was much improved s/p IABP and within a day was weaned off all pressors and began diuresing well. She was also treated with nutritional support (TPN and vitamins). She was unfortunately a very poor CABG candidate secondary to her very poor medication compliance, no social support, overall poor condition. Her IABP was weaned and pulled with the hopes of improved CO which unfortunatley did not occur. She was restarted on milrinone with very poor urine output (non-responsive to lasix) and lactic acidosis likely from poor perfusion. As a last attempt at invasive therapy she was taken to the cath lab on [**2155-1-20**] where she had a BMS placed in her LCx and an IABP placed. With this, she was weaned quickly off the milrinone but had no appreciable improvement in her cardiac function even after aggressive diuresis. The IABP was discontinued a week later and a subsequent [**Date Range **] again showed severe global LV systolic dysfunction with an EF of 20-25%, 4+ MR, and 2+ TR. Since she was deemed not to be a surgical candidate and since all medical therapies had been maximized/exhausted, she was called out to the floor when medically stable and remained there until discharge. Due to her severe cardiomyopathy, her baseline systolic BPs are now in the low 80s. She was eventually converted to a stable dose of daily PO lasix. She was started on low-dose lisinopril, which her blood pressure tolerated. . 2. Coronary artery disease: The patient was found to have severe 3-vessel disease. The patient is status post BMS to left circumflex. The patient was started on aspirin, plavix, and lisinopril. The patient is not on a statin because of hepatic dysfunction. The patient is not on a beta-blocker because of hypotension. . 3. Rhythm: The patient presented with sinus vs atrial tachycardia which worsened throughout the intial part of her stay. She was rate controlled with amiodarone which was initially discontinued due to concern over hepatotoxicity; she then went into afib/flutter and was converted to sinus with dofetilide. EP was consulted who felt dofetilide was a poor choice for her and digoxen/amiodarone was restarted for rate/rhythm control. She was eventually maintained on amiodarone alone at a low dose due to her persistent transaminitis. She had very occasional bouts of a-fib with RVR and a-flutter, but these were always asymptomatic with stable blood pressure and were usually self-limited. For monitoring on amiodarone, the patient will need yearly PFTs, CXR and eye exam. She will also need q6month LFTs and TFTs. . 4. Mitral regugitation (4+ MR [**First Name (Titles) **] [**Last Name (Titles) **]): Thought to be a large contributant to severe heart failure/cardiogenic shock. Not a surgical candidate. . 5. ID/leukocytosis: Likely stress leukocytosis. The patient remained afebrile. All cultures no growth to date. CT abdomen negative. The patient is status post a 5-day course of azithromycin and 7-day course of ceftriaxone for question pneumonia early in her course. She later completed a 7-day course of empiric ciprofloxacin and aztreonam for 7-day course ([**Date range (1) 65368**]) due to concern for hospital-acquired pna (though cultures remained negative). She is status post 14-day course of empiric Flagyl ([**Date range (1) 65369**]) for presumed C. difficile infection, although toxins A and B were found to be negative. . 6. Acute renal failure: The patient was admitted with normal creatinine which steadily increased to 2.9. This was likely secondary to overdiuresis/ATN. This improved with time and her renal function remained stable throughout the rest of her hospital stay. Her creatinine was 0.6 on discharge. . 7. Thrombocytopenia: Initially there was concern for heparin-induced thrombocytopenia with a mildly positive PF4 antibody assay. Her serotonin release assay, however, returned negative and hematology advised that she may receive heparin products. . 8. Anemia: The patient had anemia that was strikingly microcytic with ferritin of 106, Fe 16. Minimally elevated TSH. Likely iron deficiency given anemia on presentation (normal ferritin likely from shock liver). The patient was given iron supplementation. . 9. Cluster A personality (schizoid) with question underlying dementia. Patient had no close relationships prior to hospitalization and has been intermittently non-compliant with medications during her hospitalization. Psychiatry was involved in her care throughout her stay here and deemed her to have a prolonged delirium possibly with some underlying dementia. They said that her delirium may never fully resolve. Due to these factors and her lack of any family or close relationships, case management and social work helped obtain a court-appointed guardian for her to make medical decisions since she was deemed to persistently lack capacity. Once it was determined that she was not a surgical candidate and all medical therapies for her severe cardiomyopathy had been maximized/attempted, she was declared by the CCU attending to be "CPR-not-indicated" and her court-appointed guardian pursued a DNR/DNI order from the court. Due to her very poor prognosis, palliative care was consulted to help her obtain placement in a [**Hospital1 1501**] with hospice facilities. Due to her persistent delirium/?dementia, psychiatry recommended that she receive standing low-dose PO haloperidol; with this she remained mostly calm and cooperative. . 10. Adrenal mass: An adrenal mass was noted on CT abdomen. The patient should follow-up as outpatient for potential MRI. . 11. Back pain: Unclear etiology, could be secondary to deconditioning. There wre no obvious neurologic deficits. The pain responds to tylenol and oxycodone. The patient's urinalysis was negative. Spine XR shows only mild degenerative changes. . Code: DNR/DNI Medications on Admission: None. Discharge Medications: 1. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 2. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever/pain. 12. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 13. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 15. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 16. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for diarrhea. 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 18. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 19. Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 20. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare - [**Location (un) 620**] Discharge Diagnosis: Primary: 1. Cardiogenic shock 2. Atrial fibrillation 3. Leukocytosis 4. Thrombocytopenia 5. Cluster A personality 6. Osteoarthritis . Secondary: 1. Syncope 3 years ago 2. Neck pain, evaluated in 2/99 at [**Hospital1 336**] with some fibromyalgia points, occurred after viral syndrome 3. Fibromyalgia 4. Diverticulosis 5. Internal Hemorrhoids 6. Osteopenia 7. Schizophrenia 8. Gastritis 9. Bursitis Discharge Condition: Afebrile, vital signs stable. SBP 80s. Discharge Instructions: You were hospitalized with cardiogenic shock (your heart was not working well). You should take aspirin, plavix, metoprolol, and lasix for your heart. . You should continue amiodarone for your history of atrial fibrillation. For monitoring of the amiodarone, you will need yearly pulmonary function test, chest X-ray, and eye exam. You will also need liver function tests and thyroid function tests every six months. Followup Instructions: Please call [**Telephone/Fax (1) 62**] to schedule an appointment with cardiology within two months of discharge. . You should establish a relationship with a primary care physician. [**Name10 (NameIs) **] can call [**Telephone/Fax (1) 250**] to establish primary care at [**Hospital3 **] [**Hospital6 733**].

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icd9cm

[ [ [] ] ]

[ "38.93", "88.56", "00.40", "37.22", "37.61", "36.06", "00.17", "00.46", "00.66", "38.95", "96.6", "99.04", "89.64" ]

icd9pcs

[ [ [] ] ]

23887, 23971

14690, 21853

288, 349

24413, 24454

3250, 4135

24919, 25232

2691, 2696

21909, 23864

23992, 24392

21879, 21886

10538, 13487

24478, 24896

2711, 3231

9522, 10521

14422, 14667

7208, 9503

245, 250

377, 2226

13501, 14408

2248, 2476

2492, 2675

6,156

130,698

50935

Discharge summary

report

Admission Date: [**2108-11-28**] Discharge Date: [**2108-12-4**] Date of Birth: [**2047-2-3**] Sex: F Service: MEDICINE Allergies: Ambien / Percocet / Iodine; Iodine Containing Attending:[**First Name3 (LF) 7055**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization [**2108-11-29**] x 2 History of Present Illness: 61yo F w/ hx of HTN, hyperlipidemia, DM, CAD, s/p MI and CABG x 3 (LIMA-LAD, SVG-OM, SVG-RCA) in [**2097**], s/p known occluded vein grafts, s/p cardiac cath in [**2103**] c/b dissection of the LCx and s/p 2 Cypher DES placed. Pt is s/p prosthetic [**Year (4 digits) 1291**] in [**1-/2107**] for AS and underwent cath prior to that surgery and had a BMS to the left subclavian artery. Most recently [**2108-10-1**] had 80% ostial LAD lesions and got BMS to proximal LAD. . Patient reports worsening chest pain over the last few months, and reports using nitro multiple times a day. This pain occurs with rest and with activity. She describes intermittent chest pain over past 3 days which became constant, associated with diaphoresis. On the day of presentation, the patient had sudden onset of substernal chest pain while walking, and experienced associated shortness of breath, palpitations, diaphoresis. She denies any presyncopal symptoms, nausea, or vomiting. Despite [**3-31**] does of NTG, the pain was did not improve, and the patient activated EMS. . When EMS arrived in the field, HR was 210, BP 160/110. Pt was given SL NTG and Lopressor 5mg IV X 3 which brought rate to 140s-150s. On presentation to ED, initial vitals were BP 144/106, HR 85, RR 20, 98% on 2L. Pt received several mg IV morphine, nitro 0.4mg LS, ativan 0.5mg IV, then 1mg IV, dilauded 1mg X 2, ASA 325, Lopressor 5mg IV X 2. Was started on Nitro gtt which was increased to 200mcg/min. Despite these medications, the patient only had mild improvement of symptoms. Initial ECG showed afib with new LBBB pattern, ST depressions in V5, V6. Given unremitting chest pain and positive cardiac markers, the patient was admitted to the CCU for further monitoring with planned cath in the morning. Past Medical History: 1. CARDIAC RISK FACTORS:: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: Cath [**2108-10-1**]: R-dominant 3 vessel native disease. LMCA with dual ostia Ostial LAD had an 80% stenosis with poor perfusion of D1 and s1, got BMS to proximal LAD Stenosis in the LAD distal to the takeoff of D1 that impairs flow from D1 to the LAD LCX has a aproximal 40% stenosis SVGs were known to be occluded selective conduit arteriography revealed a patent LIMA to LAD The subclavian artery had a 30% in stent restenosis 3. OTHER PAST MEDICAL HISTORY: Hypothyroidism Osteoarthritis Rheumatoid arthritis Lap cholecystectomy on [**2108-7-9**] Iron deficiency anemia S/P appendectomy S/P total abdominal hysterectomy Depression Fibromyalgia Post-op Atrial Fibrillation Aortic Stenosis/ASD s/p Redo-Sternotomy s/p Aortic Valve Replacement ASD closure Social History: No tobacco or alcohol use. Lives alone, has 3 children. Family History: Mother with CABG at age 48, died of CAD at age 68. Father had diabetes and coronary artery disease and died of an MI vs. prostate cancer. Physical Exam: VS: T99.8 BP 136/57 HR 106 O2 98% on 2L GENERAL: WDWN female crying, anxious, but appears comfortable Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. No dentition. NECK: Supple with JVP of 11 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Irregularly, irregular rhytyth, tachycardic, normal S1, S2. [**2-1**] low pitched murmur heard best LLSB and apex. [**1-1**] slight higher pitched murmur at LUSB LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Slight crackles. 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: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2108-11-28**] 08:00PM BLOOD WBC-8.5# RBC-4.21 Hgb-10.0* Hct-30.6* MCV-73* MCH-23.7* MCHC-32.5 RDW-13.7 Plt Ct-380# [**2108-11-28**] 08:00PM BLOOD Neuts-67.7 Lymphs-25.5 Monos-4.6 Eos-1.5 Baso-0.6 [**2108-11-28**] 08:00PM BLOOD PT-30.2* PTT-33.6 INR(PT)-3.1* [**2108-11-28**] 08:00PM BLOOD Glucose-190* UreaN-12 Creat-0.9 Na-138 K-3.9 Cl-105 HCO3-24 AnGap-13 [**2108-11-28**] 08:00PM BLOOD CK-MB-5 cTropnT-0.40* [**2108-11-29**] 12:35AM BLOOD cTropnT-0.81* [**2108-11-29**] 06:21AM BLOOD CK-MB-70* MB Indx-8.3* cTropnT-1.97* [**2108-11-29**] 12:23PM BLOOD CK-MB-39* MB Indx-6.3* cTropnT-1.32* [**2108-12-3**] 07:05AM BLOOD calTIBC-372 Ferritn-21 TRF-286 [**2108-11-29**] 06:21AM BLOOD Hapto-47 [**2108-11-29**] 06:21AM BLOOD %HbA1c-6.3* [**2108-11-29**] 06:21AM BLOOD Triglyc-83 HDL-51 CHOL/HD-3.9 LDLcalc-129 . EKG [**2108-11-28**] on arrival to the CCU: AF at 90, new LBBb since [**18**]:51, ST depresions V5 + V6 1mm (new,) old ST demp and TW I in I + aVL (slighly worsened) . CXR [**2108-11-28**]: Cardiomegaly with mild congestion, possible small right pleural effusion. . Cardiac Cath [**2108-11-29**]: 1. Three vessel coronary artery disease. 2. In stent restenosis of proximal LAD bare metal stent. 3. Patent LIMA to LAD. . Cardiac Cath [**2108-11-29**] #2: 1. Three vessel coronary artery disease. 2. Successful stenting of the proximal LAD (ISRS) with a Xience DES. 3. Successful POBA pf the LAD into the diagonal branch distal to the stent. 4. Severe proximal external iliac stenosis. 5. The patient was pre-treated for her reported contrast allergy. . ECG [**2108-11-30**] (with chest pain): Junctional rhythm with A-V dissociation at an atrial rate of about 38 and a ventricular rate of 82. Right bundle-branch block. Left anterior fascicular block. Probable left ventricular hypertrophy. Lateral ST-T wave changes could be due to left ventricular hypertrophy and/or ischemia. Prolonged Q-T interval. Compared to the previous tracing of [**2108-11-29**] right bundle-branch block and left anterior fascicular block are new. Lateral ST segment depression is present. A-V dissociation is also present. . Stress Test [**2108-12-3**]: Questionable anginal symptoms with no additional ECG changes noted from baseline. Nuclear report sent separately. . Persatine Mibi [**2108-12-3**]: 1. Improvement of the previously described fixed inferior wall perfusion defect. No definite new or reversible perfusion defects identified, although the myocardium appears heterogeneous. 2. Global hypokinesis with an LVEF of 36%. Brief Hospital Course: 1. NON-ST ELEVATION MI The patient presented with chest pain, ST depressions on ECG and positive biomarkers consistent with an NSTEMI. She was initially placed on a nitro drip in the ED and given Morphine, then Dilaudid for pain control. Upon arrival to the CCU on [**2108-11-29**], she underwent cardiac catheterization during which an in-stent restenosis of her BMS to LAD was seen. She had distal filling via her LIMA graft and no intervention was performed. The patient continued to have chest pain post-procedure and was taken back to the cath lab later that day. She had a DES placed in the in-stent thrombosis of her prior BMS to LAD. She was able to be weaned off the nitro drip and chest pain subsided. She was transferred out of the CCU on [**2108-11-30**]. She continued to take her home doses of MS Contin and Morphine IR for pain control. She was chest pain free until the morning of [**2108-12-2**] when she developed an episode of chest pain similar to her anginal pain while walking to the bathroom. ECG showed a junctional rhythm with RBBB which had changed from admission. Pain was releived with rest and SL nitro X 1. The patient then developed chest pain later that same day of similar nature. Her isosorbide mononitrate was increased first to 60mg PO qday, then to 90mg PO qday. Her metoprolol was decreased due to the junctional rhythm. She underwent a persantine mibi study on [**2108-12-3**] during which she had some questionable anginal symptoms but imaging did not show any reversible ischemia. She walked with PT and was chest pain free. She was discharged on [**2108-12-4**] on aspirin, plavix, metoprolol, lipitor and imdur. . 2. COUGH, FEVER The patient spiked a temperature on [**2108-11-30**] and had a cough. She was started emperically on Levofloxacin for possible pneumonia. She was not hypoxic and CXR was without infiltrate. She completed a 5 day course of Levofloxacin for possible atypical pneumonia. . 3. JUNCTIONAL RHYTHM In the ED, the patient was tachycardic with HR in the 130. It was unclear if this was atrial fibrillation. She was initially control on her home dose of Toprol XL 100mg PO qday. Later in her hospital course, the patient developed a junctional rhythm with her chest pain with a HR in the 60s. Her metoprolol dose was decreased to 50mg PO TID due to this rhythm. She remained otherwise asymptomatic. . 4. HYPERTENSION Ms. [**Known lastname 13469**] was hypertensive at presentation and started on a nitroglycerin drip. She was able to be weaned off this drip and started on her home medications to control her blood pressure. She continued on Lisinopril and Metoprolol, and Amlodipine was added to her medication regimen. . 5. HX OF AORTIC VALVE REPLACEMENT The patient was therapeutic on her coumadin upon arrival. Due to interation with levofloxacin, she was supratherapeutic at 4.3 on [**2108-12-2**] and her coumadin dose was held this day. She was restarted at a lower dose on [**2108-12-3**] for an INR of 3.3. On discharge, her INR was 2.3 and she was told to take her home dose of Coumadin 7.5mg PO qday. She was instructed to have her INR checked in 3 days. She completed the Levofloxacin on [**2108-12-4**]. . 6. DEPRESSION: She was continued on Duloxetine for depression. . 7. HYPOTHYROIDISM Ms. [**Known lastname 13469**] was continued on Levothyroxine for her hypothyroidism. . On discharge, Ms. [**Known lastname 13469**] was given follow-up appointments with her cardiologist and primary care doctor. She was instructed to decrease her Metoprolol to 50mg PO TID. Her Crestor was changed to Lipitor 80mg PO qday. She was started on Amlodipine 5mg PO qday. Her Imdur was increased to 90mg PO qday. Her lasix was stopped. Medications on Admission: Lasix 20mg PO qday Omeprazole 20mg PO qday Rosuvastatin 20mg PO qday Levothyroxine 50mcg PO qday Imdur 120mg PO qday Duloxetine 60mg PO qday Colace 100mg PO BID Ferrous Sulfate 325mg PO qday Maalox 30ml PO q12hours PRN Morphine 15mg PO q12 hours Trazodone 150-200mg PO qHS PRN insomnia Ascorbic Acid 1000mg PO qday Clopidogrel 75mg PO qday Morphine 30mg PO q4 hours PRN X 10 days Lisinopril 80mg PO qday NTG 0.4mg SL 1-2 tabs q6hours PRN Toprol XL 300mg PO qday Warfarin 7.5 g PO qday Acetaminophen 325 - 650mg PO q6H PRN Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 4. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 5. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Known lastname **]:*30 Tablet(s)* Refills:*2* 7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO once a day. 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). [**Known lastname **]:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 11. Outpatient Lab Work Please check INR on Wednesday [**12-5**] and call results to Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 22972**] 12. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) ml PO once a day as needed for constipation. 13. Trazodone 100 mg Tablet Sig: 1-3 Tablets PO at bedtime as needed for insomnia. 14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Nitrostat 0.4 mg Tablet, Sublingual Sig: 1-2 tabs Sublingual q 5 minutes x3. 16. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. [**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*2* 17. Imdur 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Telephone/Fax (1) **]:*90 Tablet(s)* Refills:*2* 19. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day. 20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for headache. 21. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a day. 22. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ml PO Q6H (every 6 hours) as needed for constipation. [**Telephone/Fax (1) **]:*2 bottles* Refills:*1* 23. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 24. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. ST Elevation MI 2. Congestive Heart Failure 3. Community Acquired Pneumonia Secondary Diagnoses: 4. s/p Aortic Valve Replacement 5. Hypothyroidism 6. Coronary Artery Disease 7. Hypertension 8. Hyperlipidemia Discharge Condition: Hemodynamically stable without chest pain Discharge Instructions: You had a heart attack and a cardiac catheterization with a drug eluting stent to your left artery. You also had some fluid retention because your heart was weak, this was treated with furosemide and we adjusted your medicines. Your atrial fibrillation rate was fast and was treated with metoprolol. Finally, you underwent a cardiac stress test that did not show any new defects in your heart and no areas that could be improved by intervention. Please weight yourself every day. If your weight increases > 3lbs, please call your cardiologist. Please adhere to low salt, heart healthy diet. Medication changes: 1. Your Imdur was decreased to 90 mg 2. Your Omeprazole was increased to 40 mg daily 3. You were started on Norvasc to control your blood pressure. 4. Stop taking your Lasix 5. Please take 7.5 mg or Warfarin over the weekend. 6. You were found to be iron deficient and should take 325 mg of ferrous sulfate daily, however this may interact with your thyroid [**Last Name (LF) 87044**], [**First Name3 (LF) **] please discuss this with your primary doctor first. 7. Your Metoprolol was changed to 50mg three times daily. 8. You were started on Lipitor 80mg daily, your crestor was discontinued. . Please have your INR checked on Wednesday [**12-5**] and call results to Dr.[**Name (NI) 9388**] office, ([**Telephone/Fax (1) 22972**]. . Please call Dr. [**Last Name (STitle) **] if you have any further chest pain, trouble breathing, unusual fatigue, dark or tarry stools,palpitations, dizziness or any other concerning symptoms. Followup Instructions: Please have your INR checked on Wednesday [**12-5**] and call results to Dr.[**Name (NI) 9388**] office, ([**Telephone/Fax (1) 22972**]. Primary Care: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone [**Telephone/Fax (1) 17753**] Date/time Friday [**12-7**] at 11:15am. Cardiology [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], MD [**Last Name (Titles) 105861**] [**Telephone/Fax (1) 4105**] Date/time: Wednesday, [**12-19**] at 11:15am.

[ "401.9", "V45.82", "V43.3", "V45.79", "412", "715.90", "780.52", "729.1", "272.4", "440.8", "414.02", "414.2", "410.71", "250.00", "428.0", "486", "311", "414.01", "V58.61", "427.31", "714.0", "280.9", "426.3", "E878.1", "244.9", "996.72", "V88.01" ]

icd9cm

[ [ [] ] ]

[ "36.07", "88.56", "00.66", "00.40", "00.45", "37.22", "88.57" ]

icd9pcs

[ [ [] ] ]

13528, 13534

6848, 10576

317, 364

13809, 13853

4297, 6825

15445, 15939

3171, 3310

11149, 13505

13555, 13654

10602, 11126

13877, 14472

3325, 4278

13675, 13788

2276, 2753

14492, 15422

267, 279

392, 2171

2784, 3081

2193, 2256

3097, 3155

41,266

176,953

387

Discharge summary

report

Admission Date: [**2140-8-19**] Discharge Date: [**2140-8-29**] Date of Birth: [**2058-12-14**] Sex: M Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) / Zocor / aspirin Attending:[**First Name3 (LF) 1253**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: [**2140-8-20**] OPERATIONS PERFORMED: 1. Infrarenal inferior vena cava filter. 2. Coil embolization of branches of the left hypogastric artery. History of Present Illness: This is an 81-year-old gentleman with a past medical history of CAD s/p MI, MDS on cycle 2 Vidaza, anemia, severe COPD baseline home oxygen 2.5 L , hypertension, hyperlipidemia,also with bladder cancer status post TURBT and BCG treatment in [**2135**] presenting with retroperitoneal bleed. He presented to [**Location (un) 620**] ED this afternoon with left sided abdominal pain radiating to his left thigh. He had previously been hospitalized there from [**Date range (1) 3462**] for SOB and tachycardia during which he was found to have a PE and PNA and discharged to rehab on lovenox bridge to coumadin and levfloxacin. CT at [**Location (un) 620**] showed active extravasation on CTA abd/pelvis. HCT 23.9, received 1U PRBC and 10mg vitamin K and transferred to [**Hospital1 18**]. . On arrival to the ED his VS were T 97.6 HR 122 bp 126/66 RR 20 100% ON 5L NC. HCT at 24.3 from 30.5 on discharge [**2140-8-9**] (after transfusion). In ED Became hypotensive to 59/44 with 1U PRBC given, 1 U FFP, improving to 111/50 HR in 100s. ED EKG showed sinus tachycardia. Increasing pain ? tamponading vs worse managed with fentanyl boluses. Surgery consulted, noted LLQ/L groin pain c/w location of RP bleed on CT scan, recommended consulting interventional radiology for possible intervention and continued transfusion, resuscitation with plan to follow. IR consulted for angio,felt risks of angio outweighed benefits of resuscitation, watching. On arrival to the MICU patient denied pain. SOB with nasal canula and atrovent nebulizers given. Tachycardia to 140s. IVF bolus given. 2 18 guage peripherals in place. 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: - Retroperitoneal bleed s/p L hypogastric coil embolization - Removable IVC filter placed [**8-/2140**] (to be removed 6 months later) - DVT / PE ([**7-/2140**]) - MDS on Vidaza - CAD s/p MI - COPD on 2L NC - GI bleed [**2132**] - Bladder ca s/p BCG [**2135**] - HTN - HLD - AAA repair [**2120**] Social History: Lives with wife. Retired [**Name2 (NI) 3455**] [**Doctor Last Name 3456**]. Quit tobacco in [**2120**] with 2-3 ppd hx for over 50 years. No etoh or illicits. Family History: No family history of bledding disorders. Physical Exam: Admission Physical Exam: Vitals: T: BP: 144/80 P: 133 R: 18 O2: 96% General: Alert, oriented, no acute distress, HEENT: pale 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, non-tender, dis non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Discharge Physical Exam: VS Tc 97.8 Tm 98.0 HR 84-101 BP 137/67 (120s-150s/60s-70s) RR 18-20 O2 99-100% 2L NC (home O2 is 2.5 L) GEN Alert, oriented, no acute distress HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Diminished air movement, improved from prior, otherwise clear, no wheezes, rales, ronchi CV RRR normal S1/S2, distant heart sounds, no mrg ABD firm abdomen (not rigid) - consistent with exam throughout the week, NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, pitting edema in hands improved to baseline, 3+ lower extremity peripheral edema NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers or lesions, large ecchymosis on left flank Pertinent Results: Admission labs: [**2140-8-19**] 08:24PM BLOOD WBC-1.5*# RBC-2.51*# Hgb-8.1* Hct-24.3* MCV-97 MCH-32.4* MCHC-33.4 RDW-19.4* Plt Ct-319 [**2140-8-19**] 08:24PM BLOOD Neuts-71* Bands-0 Lymphs-24 Monos-4 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2* [**2140-8-19**] 08:24PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Target-OCCASIONAL Stipple-OCCASIONAL [**2140-8-19**] 11:13PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+ Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Burr-1+ Tear Dr[**Last Name (STitle) 833**] [**2140-8-19**] 08:24PM BLOOD PT-24.3* PTT-40.8* INR(PT)-2.3* [**2140-8-19**] 08:24PM BLOOD PT-24.3* PTT-40.8* INR(PT)-2.3* [**2140-8-20**] 10:15AM BLOOD Fibrino-165* [**2140-8-19**] 08:24PM BLOOD Glucose-167* UreaN-25* Creat-0.9 Na-137 K-5.0 Cl-103 HCO3-30 AnGap-9 [**2140-8-20**] 04:20AM BLOOD Calcium-7.1* Phos-5.9*# Mg-1.9 [**2140-8-20**] 10:20AM BLOOD Type-ART Temp-36 Rates-/12 Tidal V-500 FiO2-100 pO2-475* pCO2-51* pH-7.37 calTCO2-31* Base XS-3 AADO2-186 REQ O2-40 Intubat-INTUBATED [**2140-8-20**] 10:20AM BLOOD Type-ART Temp-36 Rates-/12 Tidal V-500 FiO2-100 pO2-475* pCO2-51* pH-7.37 calTCO2-31* Base XS-3 AADO2-186 REQ O2-40 Intubat-INTUBATED [**2140-8-20**] 10:20AM BLOOD Glucose-129* Lactate-2.0 Na-135 K-4.1 Cl-103 calHCO3-31* [**2140-8-20**] 10:20AM BLOOD freeCa-0.87* [**2140-8-19**] 08:42PM BLOOD Hgb-8.2* calcHCT-25 Discharge Labs: [**2140-8-29**] 07:15AM BLOOD WBC-3.0* RBC-3.33* Hgb-10.6* Hct-33.8* MCV-101* MCH-31.8 MCHC-31.4 RDW-19.1* Plt Ct-405 [**2140-8-29**] 07:15AM BLOOD PT-13.1* PTT-94.3* INR(PT)-1.2* [**2140-8-29**] 07:15AM BLOOD Glucose-96 UreaN-17 Creat-0.8 Na-136 K-4.5 Cl-99 HCO3-34* AnGap-8 [**2140-8-29**] 07:15AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.0 [**2140-8-21**] 05:33PM BLOOD freeCa-1.12 Studies: [**2140-8-20**] CHEST PORT. LINE PLACEM In comparison with the earlier study of this date, there is now a right jugular sheath in place without evidence of pneumothorax. Endotracheal tube tip lies approximately 8 cm above the carina. Little overall change in the appearance of the heart and lungs. [**2140-8-20**] CT ABD & PELVIS W/O CONTRAST Interval increase of left retroperitoneal hematoma, now with decompression into the peritoneal cavity. Small amounts of blood tracking around the liver, both paracolic gutters, and into the pelvis. [**2140-8-20**] CHEST (PORTABLE AP) In comparison with the study of [**8-13**], there is continued hyperexpansion of the lungs consistent with chronic pulmonary disease. There is associated decrease in markings at the apices with coarse interstitial markings in the lower lung zones. The possibility of supervening pneumonia would have to be considered in the appropriate clinical setting. Micro: [**2140-8-19**] Urine culture, final: negative [**2140-8-20**] MRSA screen x 2, final: negative Brief Hospital Course: 81M with CAD s/p MI, severe COPD (home oxygen 2.5 L), HTN, HL, MDS (on cycle 2 Vidaza), and bladder cancer (s/p TURBT and BCG treatment in [**2135**] was transferred from [**Hospital1 **] [**Location (un) **] [**2140-8-19**] with retroperitoneal bleed and is now s/p coil embolizatoin of left hypogastric artery and IVC filter placement. He remained hemodynamically stable post-operatively and has was called out of the CV ICU to the medicine floor. # Retroperitoneal bleed: Atraumatic bleed in the setting of anticoagulation for provoked DVT/PE with INR in therapeutic range of 2.3 at presentation. Initially presented to [**Location (un) 620**] where CT showed active extravasation on CTA abd/pelvis. HCT 23.9, INR 1.8, received 1U PRBC and 10mg vitamin K and transferred to [**Hospital1 18**]. Transferred to MICU for hypotension. In the MICU, IR was consulted and then vascular surgery. Iliac aneurysm was found and patient transferred to vascular surgery. He was continuing to have expansion of the RP hematoma. Had CT scan at 5am on [**8-20**] which showed expansion with decompression of peritoneal cavity and his hypogastric artery was coil embolized, achieving hemostasis. The bleeding was not related to his iliac aneurysm. He was then brought to the CV ICU post-operatively. Arbitrary transfusion goal of 30 (was in 28 range before this acute illness due to MDS). Only got 2 units in CV ICU. In total he was transfused 10 units since arrival to [**Hospital1 18**] (6 peri operatively) Last transfusion [**2140-8-21**] at 9pm with HCT 25 -> 30. Throughout his stay in the CVICU, he did not require pressors and has been hypertensive today with SBP~150. Peripheral access was obtained in the CV ICU and his cortis was pulled. Transferred from CV ICU to medicine on [**8-22**] and he remained hemodynamically stable with stable hematocrit in the 28-33 range. # PE: Diagnosed [**2140-8-13**] by CTA revealing subsegmental right lower lobe pulmonary embolus. Was anticoagulated with INR 2.3 on admission, and is now s/p reversal given RP bleed coil of hypogastric artery. On heparin drip bridging to coumadin. Started coumadin 5 mg daily on [**8-26**]. No evidence of bleeding and stable hematocrits. He had an IVC filter placed [**2140-8-20**] (Cook Select Filter). He will require a total of 6 months of anticoagulation and will follow up with his Hematologist for ongoing management of his DVT/PE. At the time of discahrge he was satting 99% on his home O2 (2L NC). # Elevated Bicarb: Bicarb peaked at 43. Likely multifactorial due to COPD with chronic renal compensation and retention of bicarb. Also likely component of contraction alkalosis secondary to aggressive diuresis. Started acetazolamide [**8-25**] through [**8-28**]. Bicarb was 34 at the time of discharge. His HCO3 should continue to be monitored as long as he is being actively diuresed. # LE edema: Patient with continued marked lower extremity edema likely from iatrogenic volume overload due to transfusion of 10U pRBCs. He was diuresed with Lasix 20mg IV qday for the duration of his course with marked improvement in his volume overload. He should continue to have his legs elevated at night and throughout the day when recumbent in bed. He should also continue Lasix 40mg PO qday for 3 days. He should have his electrolytes checked twice daily while receiving Lasix. # COPD: Patient has a history severe COPD with FEV1 of approximately 0.7 on 2.5L NC at home. His home medications were continued and there was no e/o COPD flare on this admission. At the time of discharge he was satting well on his home O2. # Ischemic Colitis: Diagnosed [**Hospital1 **] CT [**8-4**], involving descending/sigmoid colon area. Initially presumed infectious s/p 10 day course cipro/flagyll but in context of atherosclerotic disease and large volume bleed, ischemic seemed more likely. Pt was transfused per above and was having normal non bloody BMs at the time of discharge. # MDS: He is s/p Vidaza with continued pancytopenia. In consultation with outpatient oncologist, will hold off on additional chemotherapy for MDS at this time. He will f/u with his outpatient Oncologist for ongoing management of MDS. # Liver and renal hypodensities: seen on CT scan last [**Hospital1 **] admission likely cysts vs hemangiomas. - outpatient MRI/renal US to further evaluate # CAD s/p MI: His home Atorvastatin and Diltiazem were continued throughout his course. He is allergic to ASA. # GERD: His home omeprazole 20 mg PO daily was continued. # Hyperlipidemia: His home Atorvastatin 40mg PO daily was continued. # Transitional issues: - Patient will need IV heparin bridge to Coumadin (INR goal [**1-15**] for 6 months) - Will need daily INR checks until therapeutic - Patient scheduled for follow up with Vascular Surgery (Dr. [**Last Name (STitle) **] - Please ensure the patient follows up for interval IVC filter removal. The filter is a Cook Celect filter. - Patient scheduled for follow up with [**Name (NI) 3463**] [**Name (NI) 2274**] - Pt will need his Na, Cl, K, Cr and Mg checked twice daily for 3 days while being diuresed with Lasix. - Pt will need outpatient MRI/renal US to evaluate liver and renal hypodensities seen on CT Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from team census. 1. Enoxaparin Sodium 80 mg SC Q12H 2. Warfarin 5 mg PO DAILY16 3. Levofloxacin 500 mg PO Q24H 4. PredniSONE 10 mg po daily Duration: 2 Days 5. PredniSONE 5 mg po daily Duration: 2 Days Start: After 10 mg tapered dose. 6. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation [**Hospital1 **] 7. Albuterol-Ipratropium [**12-14**] PUFF IH Q6H:PRN wheeze 8. Omeprazole 20 mg PO DAILY 9. Cyanocobalamin 1000 mcg PO DAILY 10. Benzonatate 200 mg PO TID 11. Docusate Sodium 100 mg PO BID 12. Senna 1 TAB PO BID 13. Diltiazem Extended-Release 120 mg PO DAILY Hold for SBP < 100 14. Atorvastatin 40 mg PO HS 15. Bisacodyl 10 mg PO HS:PRN constipation 16. Ensure *NF* (food supplement, lactose-free) 120 ml Oral [**Hospital1 **] 17. Acidophilus *NF* (L.acidoph & sali-B.bif-S.therm;<br>lactobacillus acidophilus) 175 mg Oral [**Hospital1 **] 18. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Senna 1 TAB PO BID 3. Albuterol-Ipratropium [**12-14**] PUFF IH Q6H:PRN wheeze 4. Benzonatate 200 mg PO TID 5. Cyanocobalamin 1000 mcg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation [**Hospital1 **] 8. Warfarin 5 mg PO DAILY16 9. Heparin IV Sliding Scale 10. Diltiazem Extended-Release 120 mg PO DAILY Hold for SBP < 100 11. Atorvastatin 40 mg PO HS 12. Acidophilus *NF* (L.acidoph & sali-B.bif-S.therm;<br>lactobacillus acidophilus) 175 mg Oral [**Hospital1 **] 13. Bisacodyl 10 mg PO HS:PRN constipation 14. Ensure *NF* (food supplement, lactose-free) 120 ml Oral [**Hospital1 **] 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnoses: - Left Retroperitoneal Hematoma / expanding - Anemia requiring transfusion - Pulmonary emobolism / recent - Left Iliac Artery Aneurysm Secondary diagnoses: Severe COPD on home O2, coronary artery disease status post MI, hyperlipidemia, myelodysplastic syndrome, and bladder cancer status post TURBT 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 3457**], You were admitted to the hospital because you were bleeding internally (retroperitoneal hemeorrhage). You were given multiple blood transfusions. You required an endovascular procedure to stop the bleeding as well as to prevent a future blood clot in your lungs. Due to the recent blood clots in your leg and lungs, you were restarted on blood thinners (Heparin and Coumadin) and you should continue taking Coumadin as prescribed following discharge. You will need to have your blood drawn often to determine how much Coumadin you will need to take. Below are the instructions and expectations following the procedure: MEDICATION: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart with pillows every 2-3 hours throughout the day and night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication ACTIVITIES: ?????? When you go home, you may walk and use stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications CALL THE OFFICE FOR: [**Telephone/Fax (1) 3464**] ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. You will need to have the IVC filter removed after you complete your course of blood thinners. This should be scheduled through the office of Dr. [**Last Name (STitle) **] who placed the filter. Followup Instructions: You will also need to follow up with vascular surgery (Dr. [**Last Name (STitle) **] for removal of your IVC filter when you finish your course of blood thinners (6 months from discharge). Name: [**Name6 (MD) 3465**] [**Last Name (NamePattern4) 3466**], MD Specialty: Hematology/Oncology When: Thursday [**2140-9-1**] at 12:30pm Location: [**Hospital1 641**] Address: [**Street Address(2) 3467**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3468**] This appointment was already scheduled for you to see Dr. [**First Name (STitle) 3459**]. Department: VASCULAR SURGERY When: WEDNESDAY [**2140-9-28**] at 2:45 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3453**], MD Specialty: Primary Care Location: [**Location (un) 2274**] [**University/College **] Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 3471**] Phone: [**Telephone/Fax (1) 3472**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Completed by:[**2140-8-29**]

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Discharge summary

report

Admission Date: [**2193-12-17**] Discharge Date: [**2193-12-19**] Service: CCU HISTORY OF PRESENT ILLNESS: This is a 78 year old woman with a history of coronary artery disease, type 2 diabetes and COPD who presents to the coronary care unit after diagnostic cardiac cath complicated by growing hematoma and hypotension. She has a known history of coronary artery disease with long standing angina at rest and dyspnea on exertion. She had a cath done in [**2190-7-27**] at [**Hospital 1474**] Hospital for anginal symptoms which revealed 90% ostial lesion to a large ramus off of the left circumflex as well as mid-RCA lesion of 99% which was successfully treated with PTCA. She had done well subsequently, but for the past several months has begun to have increasing frequency of chest discomfort that lasts approximately 10 minutes in duration. One month ago this happened at rest once. She now has this chest pain about one time a week that resolves spontaneously. Additionally she has noted mild dyspnea on exertion as well as the fact that she sleeps on two to three pillows, although this is not clear if it is related to her dyspnea. She underwent a Persantine with Myoview on [**2193-9-30**], which revealed a small reversible anteroapical defect and normal LV function with EF of 76%. She had no chest pain or EKG changes during this test. She was then referred for cath. A diagnostic left heart cath was performed which revealed no change in her disease since [**2190-7-27**], so no intervention was performed. Angio-Seal was inserted, but failed to deploy to close. Hemostasis was achieved by manual pressure. She was then taken to the holding area where, after 10 minutes, she was noted to have an expanding right groin hematoma. Manual pressure was applied for 20 minutes and a clamp was placed for 40 minutes. During this episode she received 1 mg of atropine for a heart rate in the 40s as well as dopamine transiently. She quickly responded with an increase in her systolic blood pressure to 170s and heart rate to 160s while on dopamine. EKG at that time revealed new onset atrial fibrillation at 108 beats per minute. This reverted spontaneously to normal sinus rhythm. She also received one unit of packed red blood cells and vascular surgery was contact[**Name (NI) **]. [**Name2 (NI) 6**] ultrasound was done which showed no evidence of pseudoaneurysm and patent vessels. On arrival to the CCU she continued to have oozing from the groin. Manual pressure was applied yet again for 30 minutes. She was hemodynamically stable and awake and oriented during this period. Hemostasis was then achieved which lasted for two hours. She rebled again and 25 minutes of pressure was held at which point a fem-stat device was employed. She noted the use of three to four aspirin a day for the past few days for headaches, but had not received Plavix or heparin or Coumadin that day or recently. She had normal coagulations and normal platelet count before and after her procedure. PAST MEDICAL HISTORY: Coronary artery disease status post cardiac cath at [**Hospital 1474**] Hospital on [**2190-8-20**] revealing mild diffusely diseased LAD with a 30% to 40% diffusely diseased ramus intermedius branch. The first branch off the ramus had 90% ostial stenosis. She had 30% to 40% stenosis of OM2. She had 99% mid-RCA lesion that was PTCA'd open. COPD. Hypertension. Hypercholesterolemia. Type 2 diabetes mellitus with hemoglobin A1C of 7.9 in [**2193-8-26**]. Arthritis. Right sciatica. MEDICATIONS: Aspirin three to four q.day, Imdur 30 mg q.day, Lipitor 20 mg q.day, Zestril 40 mg q.day, atenolol 50 mg q.day, Lasix 80 mg q.day, Valium 10 mg t.i.d., 70/30 insulin 40 units q.a.m. and 20 units q.p.m., albuterol p.r.n., cod liver oil, garlic tablets, multivitamin. ALLERGIES: Penicillin causes a rash. SOCIAL HISTORY: She quit smoking 20 years ago. She lives with her daughter. PHYSICAL EXAMINATION: This was a pleasant woman in no acute distress who appeared younger than her stated age. She was afebrile, blood pressure 102/44, pulse 88, respiratory rate 18, oxygen saturation 99% on 4 liters nasal cannula. She was 5'1" tall and weighed 190 pounds. HEENT exam was unremarkable. She had no jugular venous distension. Lungs were clear to auscultation anteriorly. Heart was regular with no murmurs or gallops. Abdomen was soft and obese. Right groin had a firm ecchymotic hematoma. There was no bruit. Extremities were without edema and with 2+ distal pulses. LABORATORY DATA: On presentation white count was 11.9, hematocrit 38.5, platelet count 366. Hematocrit dropped to 37.1 immediately after the procedure. It was followed and settled out at around 35 after having received one unit of blood. Chem-7 was within normal limits except for glucose of 223. Creatinine rose from 0.9 to 1.1. INR was 0.9, PTT 29.3 before the procedure. Total cholesterol in [**2193-8-26**] was 195, HDL 45, LDL 97, triglycerides 286. As mentioned above, groin ultrasound was negative for pseudoaneurysm and showed patent vessels. Cardiac catheterization revealed normal LV function with an EF of 65%. Left main was normal. She had 50% ostial lesion of D1. She had a tortuous, but patent, LAD. She had 50% proximal stenosis of OM2. She had 50% stenosis of proximal upper pole of ramus intermedius and 60% proximal stenosis of lower pole of ramus intermedius. She had 40% mid-right coronary artery stenosis as well. HOSPITAL COURSE: The patient received one bag of platelets as it was believed that her continued oozing may have been secondary to platelet dysfunction from excessive aspirin. A fem-stat device was in place which led to control of the bleeding. After one hour the pressure was relieved, although the device was left in place. She remained hemodynamically stable for the rest of her hospital course. She had no further bleeding. She did not develop a bruit. The ecchymosis slowly evolved. The hematoma did not grow in size. After she was observed for 36 hours and after she was able to ambulate well in the [**Doctor Last Name **] with physical therapy, she was discharged home on her home medication regimen which was unchanged. To follow up with her primary cardiologist, Dr. [**First Name8 (NamePattern2) 20069**] [**Last Name (NamePattern1) **] at [**Hospital 1474**] Hospital, in one to two weeks. CONDITION ON DISCHARGE: Improved. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post cardiac cath without intervention complicated by right groin hematoma. 2. Hypertension. 3. Hypercholesterolemia. 4. Diabetes. 5. COPD. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Name8 (MD) 1552**] MEDQUIST36 D: [**2193-12-20**] 23:30 T: [**2193-12-21**] 17:52 JOB#: [**Job Number 38322**]

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icd9cm

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icd9pcs

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53,014

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43829

Discharge summary

report

Admission Date: [**2174-5-25**] Discharge Date: [**2174-8-10**] Date of Birth: [**2135-11-15**] Sex: F Service: MEDICINE Allergies: Prochlorperazine / Heparin Agents Attending:[**First Name3 (LF) 3918**] Chief Complaint: Altered Mental Status. Major Surgical or Invasive Procedure: Paracentesis Cardiac catheterization Broncheoalveolar lavage History of Present Illness: Ms. [**Known lastname **] is a 38 year old female with ALL s/p double cord blood SCT [**1-/2173**] c/b GVHD, severe left ventricular systolic dysfunction attributed to chemotherapy for ALL as well as XRT for [**Year (4 digits) 3242**] (EF 15-20%), embolic CVA now on coumadin, asthma, hypertension and chronic kidney disease who was sent in from onc floor today for confusion. Pt arrived for appointment with Dr. [**Last Name (STitle) **] today; she thought she was to go to 7F to see her MD. In actuality, she had no appointment today, and her appointment would have been in [**Hospital Ward Name 23**] had she had one. Per her father, she has been confused for 3-4 days with complaints of recurrent and chronic abdominal pain. She describes her abdominal pain as constant and nonradiating, the same as always. . In the ED, VS 97.1 77 135/105 16 100% RA. In ED, AOx2(not date) with c/o abdominal pain. Labs notable for creatinine 3.6, Lactate 8, K 6, ALT 210 AP: 173 Tbili: 4.7 AST: 144 LDH: 575 Dbili: 3.7 Lip: 154. AG 24. WB 14.9 plt 131 Hct 31 INR: 16.7. A right femoral line was placed. Head CT was negative. CXR was unremarkable. Given calcium Gluconate 1g/10mL, Sodium Kayexelate 30mg, Phytonadione 10mg/mL Amp, Vanc/Piperacillin-Tazob. She was afebrile in ED and prior to leaving 80 137/95 20 100% on RA. She received 1 amp d50, 10units of insulin. She received 1L NS. . Of note patient had recent admission to [**Hospital Ward Name 3242**] [**Date range (3) 94160**] where she presented with nausea, vomiting and abdominal pain in addition to acute on chronic renal failure. She was found to have peritonitis with lymphocytic predominance with unclear etiology but Tb vs malignancy was explored. It seems she was seen by cardiology for CHF (including ICU stay for diuresis with BP support), renal for ARF, psych for coping, ID for peritonitis and surgery for peritonitis. Surgery did not think it wise to do peritoneal biopsy. There is no discharge summary, but following medication changes appear to have occurred: start acyclovir, stop carvedilol and start Toprol, decrease torsemide to 40mg daily (from 40mg). . She was last seen by Dr. [**Last Name (STitle) **] on [**5-20**] at which point prednisone was decreased to 50 mg a day. She was continued on Cellcept despite a slight transaminitis at that time. She also had thrush and was started on fluconazole. Bactrim was continued for PCP [**Name Initial (PRE) 1102**]. Her torsemide was increased to 60mg qday due to worse lower extremity edema. . Upon arrival to the ICU, pt's father reports improvement in MS since interventions in ED. Past Medical History: ALL: - initially presented in [**2172-8-5**] right chest and right upper extremity pain and paresthesias and visual blurriness. WBC 149,000; received leukapheresis, started on hydroxyurea. Diagnosed with precursor B-cell ALL. - underwent phase I induction with daunorubicin, vincristine, dexamethasone, L-asparaginase, MTX; phase II with cyclophosphamide, cytarabine, mercaptopurine, MTX - Bone Marrow Aspirate/Biopsy on [**2172-10-26**] showed no morphologic evidence of residual leukemia - underwent allo double cord blood SCT [**2173-1-11**], course complicated by neutropenic fever and acute skin GVHD - subsequent course has been complicated by pseudomonas pneumonia in [**5-15**], empiric treatment of CMV pericarditis in [**7-15**], chronic nausea and vomiting which has been treated as GVHD with steroids though colonoscopies in [**8-14**] and [**11-14**] were negative for GVHD. . OTHER MEDICAL HISTORY: - Embolic stroke in [**3-/2174**] on coumadin - Asthma - Hypertension - Cervical Intraepithelial Neoplasia - C-section in [**2165**] - Cardiomyopathy due to early anthracycline-related cardiotoxicity [**10/2172**] - Chronic kidney disease stage III/IV, baseline creatinine ~2.0 - Chronic abdominal pain: Her workup so far has included EGD [**2173-9-5**], [**2173-11-5**] with mild signs of gastritis, no GVHD. Colonoscopy [**2173-8-5**], unremarkable with biospy negative for GVHD, CMV. UGI and SBFT [**4-/2174**] was mostly unremarkable. She has had multiple CT scans which have demonstrated moderate ascites with interval increase, no drainable fluid collection, diverticulosis, small fat-containing umbilical hernia with mild fat stranding, no bowel obstruction. RUQ ultrasound revealed ascites, gallbladder wall edema presumably from third spacing, and no biliary duct dilatation. Social History: She is single with a daughter and a son. Lives in [**Location 686**]. Previously employed at [**Company 59330**] though has not worked since her diagnosis. Lifelong nonsmoker, but not currently. Denies illicits or EtOH. Family History: Mother with history of gastric cancer, died at age 40. Father with hypertension. Physical Exam: Upon admission: Vitals: T: 96.4 BP: 143/113 P: 87 R: 19 O2: 97%(RA) General: Oriented xself, place, month/year and able to do DoW task forward (not backwards), but somnolence and need to re-arouse multiple times during exam. NAD. HEENT: Sclera anicteric, Dry MM, oropharynx clear no palatal findings Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, voluntary guarding, mild distension with diffuse TTP but worst in RUQ. Unable to assess fluid wave. No rebound tenderness GU: foley in place Ext: all extremities cool (but uncovered), cap refill wnl, 1+ pulses, trace LE edema Neuro: Non focal At discharge: Vitals: T: 99.1 BP 114/68 HR 105 RR 18 O2 Sat 94% RA General: Patient lying in bed in no acute distress HEENT: MMM. OP clear without erythema or exudate. Cushingnoid appearance. NECK: no LAD LUNGS: Clear to ascultation bilaterally. No crackles or wheezes. CV: RRR. No murmurs, rubs, or gallops. ABDOMEN: Normal active bowel sounds. Soft, non-distended. Liver tip appreciated. Mild tenderness to palpation over RUQ. EXT: Trace pitting edema in RLE. 1+ pitting edema in LLE. No clubbing or cyanosis. NEURO: CN II-XII intact bilaterally. Pertinent Results: ADMISSION LABS ============= [**2174-5-25**] 06:20PM BLOOD WBC-15.4* RBC-3.50* Hgb-10.8* Hct-34.5* MCV-99* MCH-30.9 MCHC-31.4 RDW-21.0* Plt Ct-138*# [**2174-5-25**] 06:20PM BLOOD Neuts-90.7* Lymphs-5.0* Monos-3.8 Eos-0.2 Baso-0.2 [**2174-5-25**] 06:20PM BLOOD PT-124.8* PTT-32.3 INR(PT)-15.5* [**2174-5-25**] 08:30PM BLOOD Glucose-148* UreaN-102* Creat-3.6*# Na-138 K-6.2* Cl-94* HCO3-20* AnGap-30* [**2174-5-25**] 08:30PM BLOOD ALT-210* AST-144* LD(LDH)-575* AlkPhos-173* TotBili-4.7* DirBili-3.7* IndBili-1.0 [**2174-5-26**] 11:40AM BLOOD CK-MB-8 cTropnT-0.04* proBNP-GREATER TH [**2174-5-26**] 01:40AM BLOOD Calcium-8.8 Phos-7.7*# Mg-2.8* UricAcd-11.4* [**2174-5-25**] 11:46PM BLOOD Lactate-8.7* K-6.0* . DISCHARGE LABS ============= . CHEMISTRY: 126/4.6 89/24 87/2.6 < 177 7.3/1.9/5.3 CBC: 4.4 > 8.5/23.4 <26 LFTS: ALT 17 AST 62 LDH 993 ALK PHOS 491 TBILI 1.4 INR: 1.1 . Micro: [**2174-6-29**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2174-6-29**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2174-6-28**] URINE URINE CULTURE-PENDING [**2174-6-24**] Immunology CMV Viral Load-FINAL [**2174-6-18**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2174-6-18**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2174-6-17**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL [**2174-6-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL [**2174-6-14**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL [**2174-6-13**] Immunology CMV Viral Load-FINAL [**2174-6-6**] Immunology CMV Viral Load-FINAL [**2174-5-28**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL [**2174-5-27**] PERITONEAL FLUID ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY [**2174-5-26**] IMMUNOLOGY HCV VIRAL LOAD-FINAL [**2174-5-26**] IMMUNOLOGY HBV Viral Load-FINAL [**2174-5-26**] Immunology (CMV) CMV Viral Load-FINAL [**2174-5-26**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB-FINAL [**2174-5-26**] URINE URINE CULTURE-FINAL [**2174-5-25**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2174-5-25**] BLOOD CULTURE Blood Culture, Routine-FINAL . BAL CULTURE: NGTD SPUTUM CULTURE: 1 COLONY OF ASPERGILLUS FUMIGATUS BLOOD CULTLURES: NGTD MYCOLYTIC AND AFB BLOOD CULTURES: NGTD . Imaging: ======= TTE [**2174-5-26**] The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with mild global free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. . IMPRESSION: Severely depressed left ventricular systolic function with elevated left ventricular filling pressure. Mild global free wall hypokinesis in the setting of right ventricular volume overload. Mild aortic and mitral regurgitation. Moderate tricuspid regurgitation. Indeterminate pulmonary artery systolic pressure. Very small pericardial effusion without echocardiographic evidence of tamponade. Compared with the prior study (images reviewed) of [**2174-5-16**], the global left ventricular systolic function is worse. Mild aortic and mitral regurgitation are new. The severity of pulmonary artery hypertension was not able to be determined on the current study, but was previously moderate. . TTE ([**2174-7-4**]) Normal left ventricular cavity size with regional and global systolic dysfunction. Right ventricular free wall hypokinesis. Pulmonary artery systolic hypertension. Mild mitral regurgitation. Moderate tricuspid regurgitation. Compared with the prior study (images reviewed) of [**2174-6-29**], global left ventricular systolic function is minimally improved (some regionality was suggested on review of the prior study) and the severity of tricuspid regurgitation is now reduced. The estimated pulmonary atery systolic pressure is similar. The pericardial effusion is minimally larger. . TTE [**2174-7-7**] LVEF: 40% to 45% The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the mid to distal inferior wall, inferior septum and inferolateral wall. Right ventricular chamber size is normal. with depressed free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] 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. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a small to moderate sized pericardial effusion without evidence of tamponade physiology. . Compared with the prior study (images reviewed) of [**2174-7-4**], overall function has increased slightly due to slight improvement in inferior/inferoseptal/inferolateral segments. The size and distribution of the pericardial effusion is similar. . CARDIAC MRI . Impression: 1. Mildly increased left ventricular cavity size with mild global hypokinesis. The LVEF was moderately depressed at 30%. The effective forward LVEF was severely depressed at 25%. There was a diffuse increase in signal intensity of the myocardium on the T2 images which may be consistent with edema or inflammation. The increase in signal intensity was relative to the skeletal muscle and liver. 2. Normal right ventricular cavity size with mild free wall hypokinesis. The RVEF was moderately depressed at 31%. 3. Mild mitral regurgitation. Moderate to severe tricuspid regurgitation. 4. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was mildly increased. 5. Biatrial enlargement. 6. Small pericardial effusion. . These findings are most consistent with myocarditis (subacute versus chronic). In the future, gadolinium enhanced images may be useful for the assessment of myocardial fibrosis (gadolinium was not given on the current study due to low eGFR). . CT CHEST WITHOUT CONTRAST: . There is a small non-hemorrhagic pericardial effusion, slightly decreased from [**2174-1-13**], without evidence of tamponade physiology. Heart is otherwise unremarkable. There is no significant coronary artery calcification. There is a right PICC extending to the low SVC. The esophagus is normal. The trachea and central airways are patent to the subsegmental level. There are no endobronchial lesions identified. . In the lungs, there are diffuse, multifocal ground-glass opacities, both in a peribronchovascular and peripheral distribution. These are new from prior study. There are no consolidative or cavitary opacities. There is no pleural abnormality; previous effusions have resolved. . This examination is not tailored to evaluation of subdiaphragmatic structures, except to note normal appearance of the included portions of the liver, spleen, and adrenal glands. There is no acute process identified. . No lytic or sclerotic osseous lesions identified. . IMPRESSION: . 1. Multifocal ground-glass opacities scattered throughout both lungs, compatible with multifocal pneumonia, though hemorrhage could have a similar appearance. If this is infectious, viral etiologies are favored, though bacterial pneumonia or PCP cannot be excluded. 2. Resolution of prior pleural effusions. Small pericardial effusion persists. . CHEST CT . FINDINGS: The visualized thyroid gland is normal. No axillary, mediastinal, or hilar lymphadenopathy meeting CT criteria for pathologic enlargement is present. A right-sided PICC follows normal course terminating at the cavoatrial junction. The heart size is normal with unchanged small pericardial effusion. . There is severe progressive peribronchial ground-glass opacity with septal thickening consistent with infection, most likely viral. The rapidly more widespread distribution--perihilar and lower lobe predominant--is atypical for a fungal infection. There is no pleural effusion or pneumothorax. . Visualized portion of the upper abdomen is unremarkable. . BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified. . IMPRESSION: . 1. Marked progression of peribronchovascular ground-glass opacity consistent with infection, most likely viral rather than fungal. . 2. Unchanged small pericardial effusion. . SINUS CT . The frontal sinuses are normally aerated. There is minimal mucosal thickening in the right and left ethmoid air cells. There is an air-fluid level in the right sphenoid sinus and minimum mucosal thickening in the left sphenoid sinus. There is mild circumferential mucosal thickening in the bilateral maxillary sinuses, with an air-fluid level seen on the left. There is no adjacent sclerosis to suggest chronicity of inflammation. There is no hyperdensity or calcification to suggest fungal colonization. There is no osseous erosion or adjacent soft tissue change to suggest invasive disease. . The ostiomeatal units are patent bilaterally, though narrowed by mucosal thickening. The nasal septum is midline. The lamina papyracea and cribriform plates are intact. The roofs of the ethmoids are symmetric in height. There is a single septum identified within the sphenoid sinus, inserting upon the left carotid groove. . The bony orbits and intraorbital contents are normal. There is no intraocular fat stranding or inflammatory change. . The visualized intracranial contents are normal. There is no extra-axial fluid collection. . The mastoid air cells are well aerated and clear, as are the middle ears. . IMPRESSION: . Mild pansinus mucosal disease, with air-fluid levels seen in the left maxillary and right sphenoid sinuses. Clinical correlation is recommended to exclude acute sinusitis. There is no hyperdensity or calcification to specifically suggest fungal colonization. There is no bony sclerosis to suggest chronicity of inflammation. There is no bony erosion or adjacent soft tissue change to suggest invasive disease. . ECHO [**2174-8-4**] The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. 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%). Right ventricular chamber size is normal. with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. . IMPRESSION: Mildly symmetric left ventricular hypertrophy with normal cavity size and borderline-normal global left ventricular systolic function. Mild pulmonary artery systolic hypertension. Small pericardial effusion without echocardiographic evidence of tamponade. . Compared with the prior study (images reviewed) of [**2174-7-27**], the previously mentioned wall motion abnormalities appear to have improved and the global left ventricular systolic function is now near-normal. Brief Hospital Course: 38-year-old female with ALL s/p double cord blood SCT [**1-/2173**] c/b GVHD, CHF secondary to anthracycline induced cardiomyopathy, embolic CVA on coumadin presented with altered mental status, ascites secondary to congestive hepatopathy, and acute on chronic systolic heart failure exacerbation presumed to be secondary to cardiac GVHD with initial EF <10%. . # AMS: Patient initially admitted to the [**Hospital Unit Name 153**] with altered mental status likely multifactorial in etiology from factors such as uremia and hepatic encephalopathy. There was no evidence of infection or substance abuse. Given INR of ~ 16, a CT head was performed not indicating an intracranial bleed. Paracentesis was performed on ascites that was not suggestive of peritonitis. Her mental status improved without clear change in potential underlying cause. She was started on broad-spectrum antibiotics including vancomycin and zosyn. Her outpatient cardiologist was contact[**Name (NI) **] and felt that the clinical picture could all be related to cardiac failure. She was subsequently transferred to the CCU. . # Acute on chronic congestive heart failure with systolic dysfunction: Patient presented with a depressed EF secondary to presumed GVHD. Her ECHO on admission was read as 20%, but upon further review by Dr. [**First Name (STitle) 437**] was <10% consistent with profoundly low cardiac output. She was volume overloaded on admission. Given the waxing and [**Doctor Last Name 688**] clinical course, the impression was that this did not represent anthracycline-based cardiomyopathy since this would be quite dramatic and irreversible at late stages. She had myocardial biopsies in the past not showing T-cell infiltration based on prior pathology records, however, it was theorized that her presentation was most likely a result of GVHD affecting the heart. In the CCU, she was diuresed with a combination of milrinone for inotropic support and furosemide with adjunctive metalozone. For presumed GVHD, she was pulsed with solumedrol 1 g followed by taper from 60 mg IV to 15 mg IV BID in addition to continuing mycophenolate. On transfer out the CCU, she was net negative 13.9 L. Repeat TTE showed LVEF 35%. After transfer out of the CCU, steroids were tapered and she was given a dose of ritxuan as a steroid sparing [**Doctor Last Name 360**]. Ejection fraction plummeted from 40 to 20%. She was again admitted to the CCU where she was diuresed and was taken for right heart cath which demonstrated pulmonary hypertension responsive to sildenafil. She was started on Nifedipine and Sildenafil with improvement in EF to 40%. Torsemide was resumed and titrated to maintain volume status even. *** Include discharge weight under CHF section: Admission: 64.86 kgs. (142.99 lbs) [**2174-4-19**] Discharge: 136.5 on [**2174-8-9**] . # Pulmonary HTN: Pulmonary HTN was investigated with RHC on [**6-30**]. Initial numbers: RA pressure of 20, wedge 12, CI of 1.2, pulm vasc resistence 560, PCP [**Last Name (NamePattern4) **] 38. With 100% FiO2: no change in wedge, PVR decreased to 480, wedge increased to 22. With inhaled NO: no significant change in PA pressures, wedge pressures increased to 31, PVR decreased further to 160 indicating significantly improved LV filling. With addition of milrinone: wedge decreased from 31 to 22, there was no change in cardiac output and PVR increased from 160 to 400. Sildenafil was started and was uptitrated to 80 mg TID. Nifedipine was also started at 30 mg per day and uptitrated to 60mg daily. . # Acute on chronic renal failure: Patient baseline creatinine 2.5 - 3.0 with admission Cr 3.8. Urine sediment with many hyaline casts and few granular casts. FeUrea 38% consistent with pre-renal state. Likely multifactorial - may be part of GVHD, drug side effect tacrolimus, poor output secondary to CHF. Renal ultrasound was negative for obstruction. Her creatinine trended down with diuresis. Throughout the remainder of her course, creatinine fluctuated as her cardiac output changed. . # Parainfluenza pneumonia: Patient developed new fever and pulmonary infiltrates on [**2174-7-7**], she was started IV vancomycin and cefepime for hospital acquired pneumonia coverage. Nasal swab returned positive for parainfluenza 3. Antibiotics were continued for a 14 day course given concern for bacterial suprainfection. A bronchoscopy with BAL sample collected in light of fevers. A sputum collection was also collected; 1 colony of aspergillus fumigatus grew out of the patient's culture. She also developed a nose bleed. There was concern that she had developed an invasive fungal infection of the sinuses that was perhaps dripping down through BAL samples had no growth to date on the day of discharge. . # Transaminitis: Worsened on admission compared to last set of outpatient labs on [**5-20**]. Secondary to congestive hepatopathy given CHF. Hepatology was consulted and felt that clinical picture represented cholestatic hepatitis, but may be having fulminant hepatic failure if INR not due to coumadin effect. LFTs were trended, multiple hepatic markers were checked and negative, and diagnostic paracentesis revealed SAAG >1.1. LFTs trended downward with diuresis. On day of discharge, patient's LFTs ALT: 17 AP: 491 Tbili: 1.4 AST: 62 LDH: 993. . # Coagulopathy: Supratherapeutic INR to ~16 on admission, reversed with Vit K and 2U FFP. Elevated INR is multifactorial and related to congestive hepatopathy and drug interaction between fluconazole and warfarin. Coumadin and Fluconazole were held, and INR trended down. On day of discharge, the patient's INR was 1.1. . # ALL: s/p double cord blood SCT [**1-/2173**] complicated by GVHD on immunosuppression with recent decrease in prednisone dose to 50mg prior to admission. She was continued on mycophenolate, bactrim, and acyclovir. Tacrolimus was discontinued given renal failure. She was treated with methylprednisolone as above. She was discharged home on CellCept 1000mg [**Hospital1 **] and methylprednisolone 60mg IV once daily. . #Left knee pain: While in hospital, patient developed acute onset of atraumatic left knee pain of unclear etiology. Arthrocentesis ruled out infection and crystalline disease. The joint fluid was sterile and contained a large number of marcrophages and lymphocytes as did the peritoneal fluid sampled during her last admission. This may be a sign of broad serositis secondary to GVHD. A left knee xray was performed to rule out AVN, but noted a periosteal reaction with bone mottled, which was concerning for early AVN. Rheumatology was consulted who recommended MRI of the knee. The patient repeatedly refused the MRI of the knee. Risks and benefits of undiagnosed AVN were discussed with her and she remained unwilling to undergo MRI. With time, the pain resolved, etiology remains unclear. . # Hyponatremia: Sodium trended down to mid-120s during diuresis likely from heart failure given decreased effective circulating volume in addition to usage of thiazide. TSH and cortisol were normal. Sodium eventually trended to normal after diuresis. . # Hypocalcemia: Likely secondary to bisphosphonate administration. Patient symptomatic with episodes of lock jaw. Her calcium was increased and was given IV when symptomatic. Vitamin D level was extremely low so patient was started on 50,000 units qweek. Ativan was given for muscle spasms for symptomatic relief. . # Thrombocytopenia: Patient noted to have decrease in platelets since recent [**5-20**] labs of unclear etiology. Hematology was following with impression of thrombotic microangiopathy from HIT, medication side effect, or other etiology based on blood smear and rising hemolysis markers. Tacrolimus TMA seemed less likely as LDH rise preceded tacrolimus initiation. Her HIT PF4 antibody returned weakly positive but a serotonin assay was negative. . # Normocytic anemia: Patient was admitted with Hct 34.5 that trended down to 22.8 requiring 2 units of pRBC. No signs or symptoms or acute blood loss. Etiology may be low grade hemolysis given insidious trend related to aforementioned thrombotic angiopathy. Coomb's was negative. . # Embolic stroke in [**3-/2174**]: Patient was on coumadin as an outpatient. Her INR was supratherapeutic at time of admission and was held. Neurologic exam was monitored and non-focal. In discussion with her primary oncologist and review of the MRI findings at the time of diagnosis, it was determined that embolic stroke was unlikely and Coumadin was discontinued. . # Abdominal pain: Extensive work-up in past with no clear etiology. Managed with MS contin and Morphine IR. . # Hyperglycemia: Secondary to steroid usage and tacrolimus. HISS was used for coverage. Medications on Admission: ACYCLOVIR - (Prescribed by Other Provider) - 400 mg Tablet - 1 Tablet(s) by mouth every twelve (12) hours ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA Aerosol Inhaler - 2 HFA(s) inhaled every four (4) hours as needed for sob or wheeze FLUCONAZOLE - 200 mg Tablet - 1 Tablet(s) by mouth daily LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for nausea METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 100 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth DAILY (Daily) MORPHINE - (Prescribed by Other Provider) - 15 mg Tablet - 1 Tablet(s) by mouth every twelve (12) hours as needed for pain MORPHINE - (Prescribed by Other Provider) - 15 mg Tablet Extended Release - 1 Tablet(s) by mouth every twelve (12) hours MYCOPHENOLATE MOFETIL - (Prescribed by Other Provider) - 500 mg Tablet - 2 Tablet(s) by mouth twice a day PREDNISONE - (Dose adjustment - no new Rx) - 20 mg Tablet - 2.5 Tablet(s) by mouth DAILY (Daily) SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) TORSEMIDE - (Dose adjustment - no new Rx) - 20 mg Tablet - 3 Tablet(s) by mouth DAILY (Daily) WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth once a day . Medications - OTC DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] - (Prescribed by Other Provider) - 400 mg/5 mL Suspension - 30 Suspension(s) by mouth every six (6) hours as needed for constipation MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day OMEPRAZOLE - (OTC) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily SIMETHICONE - (Prescribed by Other Provider) - 80 mg Tablet, Chewable - 1 Tablet(s) by mouth four times a day as needed for abdominal pain or gas Discharge Medications: 1. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*15 Tablet(s)* Refills:*2* 3. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (WE). Disp:*12 Capsule(s)* Refills:*2* 4. sildenafil 20 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*2* 5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 6. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QPM (once a day (in the evening)). Disp:*30 Tablet Extended Release(s)* Refills:*2* 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 8. voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety/nausea. Disp:*60 Tablet(s)* Refills:*0* 10. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. 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:*0* 12. MS Contin 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. Disp:*28 Tablet Extended Release(s)* Refills:*0* 13. methylprednisolone sodium succ 500 mg Recon Soln Sig: Sixty (60) mg Intravenous once a day. Disp:*1800 mg* Refills:*0* 14. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**2-6**] Tablet, Rapid Dissolves PO three times a day as needed for nausea. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 15. 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:*0* 16. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*24 Tablet(s)* Refills:*0* 17. torsemide 20 mg/2 mL (10 mg/mL) Solution Sig: Forty (40) mg Intravenous once a day. Disp:*120 mL* Refills:*0* 18. Home O2 Home oxygen @2 LPM continuous via nasal canula, conserving device for portability. Dx: CHF, pulmonary hypertension 19. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous twice a day: Please administer 10 units before breakfast and 10 units before dinner. . Disp:*600 mL* Refills:*0* 20. Insulin Syringe 1 mL 30 x [**6-20**] Syringe Sig: One (1) syringes Miscellaneous twice a day: Use to administer insulin NPH. Disp:*60 syringes* Refills:*0* 21. glucometer Please dispense one glucometer and test strips. Patient should check her fingersticks before giving herself insulin at breakfast and dinner. Discharge Disposition: Home With Service Facility: Care Group Discharge Diagnosis: Acute on Chronic Systolic Heart Failure Graft vs. Host Disease Pulmonary arterial hypertension Parainfluenza pneumonia Congestive hepatopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to care for you in your stay at [**Hospital1 771**]. . Your were brought to the hospital with confusion and found to be in heart failure. Your heart failure is very complex and related to Graft vs. Host Disease and high blood pressure in your lungs (pulmonary arterial hypertension). You underwent cardiac catheterization to diagnose pulmonary hypertension and were started on nifedipine and sildenafil to treat pulmonary hypertension. We also treated you with diuretics (torsemide) to remove the extra water that had accumulated in your lungs and legs as a result of the heart failure. With time, we removed the fluid and your breathing improved. You will continue the torsemide at home, receiving it through the PICC. . While in the hospital, you developed pneumonia and were found to have a viral infection called parainfluenza. Patients with this infeciton commonly have a bacterial infection in the lungs as well and we treated you with antibiotics. You also underwent bronchoscopy to collect samples for culture to identify a cause for your fevers. There have been no organisms that have been grown from your samples collected from the bronchoscopy. A sputum culture that was collected grew out a mold called Aspergillus fumigatus so you were started on Voriconazole for treatment. As part of the work-up to determine where this mold may have come from, you had a CT of your sinuses, which did not show evidence of infection. . We made the following changes to your home medication list: START Nifedipine for pulmonary hypertension START Sildenafil for pulmonary hypertension START Voriconazole for treatment of Aspergillus infection START Solumedrol (methyprednisolone) 60mg IV daily START digoxin for heart failure START omeprazole to protect your stomach while on steroids CHANGE torsemide to 40mg IV daily for heart failure STOP carvedilol. Instead, take metoprolol succinate (Toprol XL) 50mg once a day. STOP valsartan STOP coumadin STOP pentamidine monthly STOP fluticasone-salmeterol (Advair) inhaler STOP morphine. Instead, take MS Contin (long-acting pain medication) twice a day. Then, if you still have pain, take oxycodone as needed. . You will be seeing Dr. [**Last Name (STitle) **] tomorrow. You also have appointments [**Last Name (STitle) 1988**] with Dr. [**First Name (STitle) 437**] and Dr. [**Last Name (STitle) 724**] (infectious disease). . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. . Please check your finger sticks before you give yourself insulin before breakfast and diner. Please keep a journal of your numbers and bring them to your appointments. Followup Instructions: Department: [**Name8 (MD) 3242**]/ONCOLOGY UNIT When: THURSDAY [**2174-8-11**] at 11:30 AM [**Telephone/Fax (1) 447**] Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**] Campus: EAST Best Parking: Main GarageDepartment: [**Location (un) 3242**]/ONCOLOGY UNIT . When: FRIDAY [**2174-8-12**] at 12:00 PM [**Telephone/Fax (1) 447**] Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage . Department: HEMATOLOGY/[**Location (un) 3242**] When: THURSDAY [**2174-8-25**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: CARDIAC SERVICES When: [**Hospital Ward Name **] [**2174-8-29**] at 2:00 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: [**Hospital3 249**] When: THURSDAY [**2174-9-15**] at 11:20 AM With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]

[ "425.9", "279.52", "790.92", "E849.8", "573.0", "428.0", "789.59", "996.85", "789.09", "249.00", "416.8", "276.1", "E933.1", "428.23", "E932.0", "781.2", "480.2", "584.9", "276.3", "V58.69", "E879.8", "784.7", "585.4", "275.41", "V64.2", "403.90", "780.39", "285.9", "782.4", "785.0", "572.2", "204.01", "719.46" ]

icd9cm

[ [ [] ] ]

[ "38.97", "33.24", "99.14", "81.91", "99.10", "54.91", "89.64", "37.21" ]

icd9pcs

[ [ [] ] ]

32843, 32884

19234, 27952

318, 381

33070, 33070

6513, 19211

35892, 37574

5104, 5187

29921, 32820

32905, 33049

27978, 29898

33221, 35869

5202, 5204

5957, 6494

256, 280

409, 3026

5218, 5943

33085, 33197

3048, 4850

4866, 5088

9,750

130,665

16463

Discharge summary

report

Admission Date: [**2166-3-13**] Discharge Date: [**2166-3-17**] Date of Birth: [**2088-5-5**] Sex: M Service: PURPLE SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 77 year-old male with four days of right upper quadrant abdominal pain worse with eating and the pain persisted and the patient presented to an outside hospital and underwent an ultrasound study, which showed cholelithiasis and cholecystitis. The patient also had a CT scan done at the outside hospital,which showed an inflamed gallbladder with inflammatory changes in the right upper quadrant. PAST MEDICAL HISTORY: Coronary artery disease status post coronary artery bypass graft times two in [**2165-10-20**]. Hypertension, Barrett's esophagus and status post prostatectomy, herniated lumbar disc, renal stone, status post bilateral stent and status post right inguinal hernia repair. MEDICATIONS: 1. Lopressor 15 mg po b.i.d. 2. Aspirin 325 mg po q.d. 3. Protonix 40 mg po q.d. 4. Accupril 10 mg po q.d. ALLERGIES: Iodine. PHYSICAL EXAMINATION: The patient had a fever of 101.6 and elevated white count at 13. His liver function tests were elevated. Total bilirubin of 1.4. The patient also had [**Doctor Last Name 515**] sign on admission. The patient was taken by Dr. [**Last Name (STitle) **] to the Emergency Room on [**2166-3-13**] and underwent an open cholecystectomy and the patient also had the umbilical hernia, which was repaired at the same operation. Postoperatively, the patient had an nasogastric tube placed and the patient had a morphine PCA and Foley placed. Postoperatively, the patient did well. Nasogastric tube was discontinued on postop day number one and Foley catheter was discontinued on postop day number two. The patient was started on a clear diet on postoperative day number two. The patient tolerated diet well and has been passing flatus. The patient was deemed ready for discharge on postoperative day number four. Prior to discharge the patient was afebrile, vital signs were stable. Chest was clear. Heart was regular rate and rhythm. Abdomen was soft, nontender, nondistended. Incision was clean, dry and intact. The patient's pain was controlled on po pain medication and the patient was tolerating a regular diet prior to discharge and has been passing flatus and the patient has been ambulating prior to discharge. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po q.d. 2. Lopressor 50 mg po b.i.d. 3. Percocet one to two tabs po q 4 to 6 hours prn. 4. Levaquin 500 mg po q.d. 5. Flagyl 500 mg po t.i.d. for ten days. 6. Colace 100 mg po b.i.d. The patient is instructed to follow up with Dr. [**Last Name (STitle) **] in two weeks. DISCHARGE DIAGNOSES: 1. Cholelithiasis, cholecystitis status post open cholecystectomy and umbilical hernia repair. 2. Coronary artery disease status post coronary artery bypass graft times two. 3. Hypertension. 4. Barrett's esophagus. 5. Prostatectomy. 6. Herniated lumbar disc. 7. Renal stones status post bilateral stents. 8. Status post right inguinal hernia repair. [**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**] Dictated By:[**Last Name (STitle) 46794**] MEDQUIST36 D: [**2166-3-17**] 09:33 T: [**2166-3-17**] 09:54 JOB#: [**Job Number 46795**]

[ "553.1", "574.00", "401.9", "530.2", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "53.49", "51.22" ]

icd9pcs

[ [ [] ] ]

2718, 3357

2400, 2697

1053, 2377

175, 589

612, 1030

74,639

153,331

52491

Discharge summary

report

Admission Date: [**2170-10-29**] Discharge Date: [**2170-11-17**] Date of Birth: [**2088-11-13**] Sex: M Service: SURGERY Allergies: Celebrex / Glucotrol Xl / Lyrica / Gabapentin Attending:[**First Name3 (LF) 598**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Extensive lysis of adhesions. History of Present Illness: 81M presents with abd pain x 18 hrs and no BMs/flatus for 24 hrs. The patient has a history of SBOs - 2 of which were surgically managed many years ago, and 2 of which were non-operatively managed within the past 5 years. The patient reports that he had R sided abd pain at 2100 last night that quickly progressed to diffuse abd pain by midnight. He started dry heaving this morning and came to the ED. His last BM was yesterday and was hard and brown. He has had chills, no fevers. He reports some dysuria Past Medical History: - paroxysmal afib - dx [**2164**], s/p aflutter ablation ~[**2164**] on coumadin and amiodarone, 2-3 episodes/day. MIBI in [**3-25**] showed EF 60%, no EKG changes, nl perfusion. TTE [**2164**] with mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 108413**], mild symmetric LVH, nl EF. Followed by Dr [**Last Name (STitle) **] - htn - diabetes mellitus. insulin dependent. last hba1c 7.0 in [**3-25**] - pulmonary disease, ?COPD but PFTs in [**2164**] showed mild restrictive disease - duodenal ulcer, medically managed - spinal stenosis, s/p multiple spinal surgeries including lamenectomy, fusion; c/b "staph infection" requiring debridment - Crohns disease s/p sigmoidectomy with revision surgeries and multiple SBOs managed medicallly and surgically; last colonoscopy [**2166**]. Supposed to get annual colos, but insurance won't pay - hypercholesterolemia - kidney and bladder stones - CKD - presumed related to htn/diabetes, baseline Cr 1.5-1.8. Followed by Dr. [**Last Name (STitle) **] - BPH s/p TURP - s/p total L knee replacement. Uses cane/walker at baseline. - onchomycosis - Rosacia Social History: Lives at home with his wife in [**Name (NI) **]. Has not worked since [**2121**] due to disability related to his back; worked many odd jobs including bread delivery, insurance. Has 200 pack-year smoking hx, but quit 20 yrs ago. Drank years ago, none now. Denies drug use. Family History: non contributory Physical Exam: Afebrile, VSS NAD CTAB RRR Abd: soft, NT, ND, incision C/D/I, no erythema no drainage Ext: trace edema Pertinent Results: [**2170-11-13**] 05:00AM BLOOD WBC-8.2 RBC-3.07* Hgb-7.8* Hct-24.2* MCV-79* MCH-25.6* MCHC-32.4 RDW-15.3 Plt Ct-411 [**2170-11-12**] 05:32AM BLOOD PT-15.7* PTT-35.7* INR(PT)-1.4* [**2170-11-13**] 05:00AM BLOOD Glucose-110* UreaN-19 Creat-1.2 Na-144 K-4.1 Cl-109* HCO3-29 AnGap-10 [**2170-11-3**] 01:59PM BLOOD ALT-15 AST-24 AlkPhos-46 Amylase-28 TotBili-0.5 DirBili-0.2 IndBili-0.3 Brief Hospital Course: 82M admitted with abdominal pain and was found to have a small bowel obstruction. He was initially treated for a urine culture growing e.coli. While being observed the patient went into atrial fibrillation with a rate in the 130's which rate improved with lopressor. He has a history of atrial fibrillation. Patient was initially observed but failed to improve clinically, complaining of increased abdominal pain. He underwent exploratory laparotomy with lysis of adhesions, with repair of two enterotomies made during the operation. Neuro: Post-operatively there were periods where he was delerious and not oriented. This was attributed to narcotic analgesia and disrupted sleep. The narcotics were discontinued and a geriatrics consult was placed. Seroquel was recommended for sleep and his mental status has cleared off narcotics. He is on tylenol, ultram, and motrin for pain control. CV: He was hypotensive requiring pressor support in the immediate post-operative period. These were able to be weaned off and he has remained hemodynamically stable. He did require an amiodarone gtt for a-fib with rapid ventricular response. He has been transitioned to PO amiodarone and lopressor. He is currently rate controlled. He was transiently hypertensive requiring additional IV hydralzine. His blood pressure is now stable on his home antihypertensive regimen. Pulm: He remained intubated in the immediate post-operative period as he was resuscitated and supported through his septic episode. He was extubated without difficulty and on his outpatient regimen of combinvent. . GI: While he was NPO he was started on TPN and then tube feeds. He was then advanced to a regular cardiac/renal diet without difficulty. He is having normal BMs and passing flatus. He did have some spotting of BRBPR for 2 days. He was examined and there were no hemorrhoids seen. His spotting stopped. His hematocrit remained stable. . GU: He required lasix diuresis as his dry weight was up a number of kilograms. He is now voiding without difficulty. . FEN: He was on TPN for a few days post-operatively while waiting for bowel function to return. He is currently on a regular diet. . Heme: His hematocrit has remained stable post-operatively. His coumadin was held. He can resume his coumadin per his cardiologist's discretion. He has remained in good rate control on amiodarone and lopressor. . ID: He was treated with broad spectrum Vanc and Zosyn for sepsis. His cultures have ultimately grown no bacteria and no source was isolated. He complete a course of antibiotics and has remained afebrile with a normal WBC. . Dispo: Physical therapy was consulted and it was recommended that he be discharged to rehab for additional physical therapy services. Medications on Admission: amiodarone 100, Lasix 20, Combivent 2 puffs q6hrs prn, Metoprolol Succinate 75, Simvastatin 80, Coumadin 3 mg QSun,mon,[**Last Name (un) **],fri , Coumadin 4 mg q T/Th/Sat, Tylenol prn, aspirin 81, Calcium Citrate-Vitamin D, Insulin Novolin SS and lantus, Sulfasalazine 500, Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. 5. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for hypocalcemia. 7. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale units Injection ASDIR (AS DIRECTED): BS Insulin 120-160 2 units 161-200 4 units 201-240 6 units 241-280 8 units 281-320 10 units. 8. Metoprolol Tartrate 50 mg Tablet Sig: 1 and [**1-19**] Tablet PO DAILY (Daily). 9. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath. 11. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical APPLY 12 HOURS IN AM, REMOVE 12 HOURS IN PM (). 13. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)). Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: small bowel obstruction, intraperitoneal adhesions, atrial fibrillation, hypertension, diabetes mellitus, Duodenal ulcer, spinal stenosis, possible Crohn's disease, kidney stones, chronic kidney disease, benign prostatic hyperplasia,onychomycosis, rosacia Discharge Condition: Good Discharge Instructions: [**Name8 (MD) **] MD if temperature greater than 100.5, increased redness or drainage from incisions, pain not relieved with pain medication, uncontrolled nausea or vomiting. Keep dry sterile dreessing on incision. You may shower. Pat incision dry. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in 1 week. Call [**Telephone/Fax (1) 600**] for an appointment. Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB) Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2170-11-22**] 11:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]

[ "995.91", "555.1", "560.81", "532.70", "998.59", "038.9", "518.81", "E870.0", "599.0", "585.9", "V43.65", "E878.8", "583.81", "E849.7", "998.2", "427.31", "600.00", "496", "428.0", "041.4", "403.90", "250.40" ]

icd9cm

[ [ [] ] ]

[ "96.04", "46.73", "38.93", "99.15", "54.59", "96.72" ]

icd9pcs

[ [ [] ] ]

7431, 7474

2932, 5696

322, 384

7773, 7780

2526, 2909

8080, 8498

2370, 2388

6021, 7408

7495, 7752

5722, 5998

7804, 8057

2403, 2507

268, 284

412, 924

946, 2060

2076, 2354

75,156

174,610

27359

Discharge summary

report

Admission Date: [**2183-9-1**] Discharge Date: [**2183-9-3**] Date of Birth: [**2110-2-15**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 425**] Chief Complaint: syncope Major Surgical or Invasive Procedure: Transcutaneous pacemaker: DDD [**Company 1543**] Permanent pacemaker History of Present Illness: 73F w HTN HLD, retinal detachment who presented to the ED early this morning after syncopal event at home, was admitted to the floor and noted to have a brief episode of asymptomatic atrioventricular conduction dissociation x2. She had returned from [**Country 3587**] 2 days ago, noted feeling weak and fatigued starting last night. Around 4am this morning, when patient got up to go to bathroom at home, she started coughing, felt increased shortness of breath, became lightheaded, vision darkened around periphery, and she fell, losing consciousness briefly. She awoke on the floor and called her daughter; she was unclear of how long she was out, but she feels that it was brief. She denied chest pain/pressure, palpitations, headache, urinary incontinence, nausea, vomiting. She has been having loose stools today. She has not had prior episodes of syncope. She has had decreased po intake secondary reduced appetite. She does not recall any sick contacts. She was in [**Country 3587**] for 5 weeks until Saturday. She denies having fevers at home, though has had fevers on presentation to the ED this morning. She does report fatigue and malaise for the last two days. . In the ED, her vital signs were as follows: T 98.8, BP 121/73, HR 103, RR 16, and SpO2 100% on RA. Labs were notable for an elevated WBC count of 11.0 with neutrophil predominance and anion gap of 15. Her CXR was unremarkable. D-dimer was elevated to 897, so CTA was done which was negative for PE and also showed no consolidation. Head CT was negative. Patient later spiked a fever to 102.1 in the ED with no clear source. Blood and urine cultures were sent; no antibiotics were started because there was no clear source of infection. . On the floor, patient was monitored on telemetry with heart rates mostly in the 80s-90s. At 18:04, she was noted to have a transient AV dissociation lasting 6 seconds with regularly conducting p-waves and no ventricular escape, then another 4 second episode with 4 beats normal sinus rhythm in between. She then returned to her native rhythm with rate 80s. Patient was asymptomatic during this time and vital signs were stable. Cardiology was consulted, and patient was transfered to CCU for placement of temporary pacemaker wire. . Upon transfer to CCU, patient had a similar episode of transient 5s AV dissociation with regularly conducting p-waves and no ventricular escape during a coughing episode. Her rhythm quickly returned to baseline in 70s-80s. Patient complained of mild dizziness and fatigue, denied headache or visual symptoms on arrival to CCU. She admitted to new cough. Patient admitted to some mild chest tightness in last week. She denied abdominal pain, nausea, but admits to poor appetite x 1-2 days associated with the fatigue. Daughter did note that patient may have gotten a large bug bite on her right arm a few days ago, right before she left [**Country 3587**]. She believes that patient may have been worked up for hematuria as outpatient. . Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: Hypertension Hyperlipidemia - though reports of normal lipid panel recently w/o statin L retinal detatchment Social History: Originally from [**Country 3587**]. Speaks Portuguese Creole, very limited English. She lives alone and is able to carry out her ADLs at baseline. She has good support from her family. Her daughter, son, and sister are present with her today. Her daughter [**Name (NI) **] lives nearby and sees her frequently. Tobacco: No smoking history Alcohol: No alcohol Family History: No family history of seizure disorders or premature cardiac death. All of her siblings have diabetes. Brother with pacemaker. Physical Exam: PHYSICAL EXAMINATION on Admission: VS: T= 99.9 BP= 135/29 HR= 87 RR= 19 O2sat= 92%RA GENERAL: WDWN elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. EOMI, mmm NECK: JVP flat CARDIAC: RR, normal S1, S2. [**1-25**] Early systolic murmur at USB. LUNGS: lungs clear anteriorly bilaterally ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: + very trace lower extremity edema; DP and PT pulses intact . PHYSICAL EXAMINATION on Discharge: GENERAL: WDWN elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. EOMI, mmm NECK: JVP flat CARDIAC: RR, normal S1, S2. [**1-25**] Early systolic murmur at USB. LUNGS: lungs clear anteriorly bilaterally ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: + very trace lower extremity edema; DP and PT pulses intact Pertinent Results: [**2183-9-2**] 03:48AM BLOOD WBC-7.3 RBC-3.71* Hgb-11.1* Hct-32.7* MCV-88 MCH-29.8 MCHC-33.8 RDW-14.2 Plt Ct-274 [**2183-9-1**] 05:10AM BLOOD WBC-11.0# RBC-4.30 Hgb-12.7 Hct-37.7 MCV-88 MCH-29.6 MCHC-33.8 RDW-14.1 Plt Ct-329 [**2183-9-1**] 05:10AM BLOOD Neuts-91.7* Lymphs-5.6* Monos-1.9* Eos-0.4 Baso-0.4 [**2183-9-2**] 03:48AM BLOOD Plt Ct-274 [**2183-9-2**] 03:48AM BLOOD PT-14.0* PTT-32.0 INR(PT)-1.2* [**2183-9-1**] 05:10AM BLOOD Plt Ct-329 [**2183-9-1**] 05:10AM BLOOD PT-13.1 PTT-24.6 INR(PT)-1.1 [**2183-9-2**] 03:48AM BLOOD Parst S-NEGATIVE [**2183-9-2**] 12:39PM BLOOD Glucose-83 UreaN-11 Creat-0.7 Na-141 K-3.4 Cl-107 HCO3-24 AnGap-13 [**2183-9-2**] 03:48AM BLOOD Glucose-87 UreaN-12 Creat-0.7 Na-139 K-3.0* Cl-105 HCO3-24 AnGap-13 [**2183-9-1**] 05:10AM BLOOD Glucose-120* UreaN-23* Creat-0.9 Na-141 K-4.1 Cl-104 HCO3-22 AnGap-19 [**2183-9-2**] 03:48AM BLOOD ALT-13 AST-22 LD(LDH)-203 CK(CPK)-124 AlkPhos-54 TotBili-0.5 [**2183-9-1**] 05:10AM BLOOD CK(CPK)-246* [**2183-9-2**] 03:48AM BLOOD CK-MB-3 cTropnT-<0.01 [**2183-9-1**] 10:55AM BLOOD cTropnT-<0.01 [**2183-9-1**] 05:10AM BLOOD cTropnT-<0.01 [**2183-9-1**] 05:10AM BLOOD CK-MB-4 [**2183-9-2**] 12:39PM BLOOD Mg-3.0* [**2183-9-2**] 03:48AM BLOOD Albumin-3.4* Calcium-8.2* Phos-2.7 Mg-1.4* [**2183-9-1**] 06:49AM BLOOD D-Dimer-897* [**2183-9-1**] 05:10AM BLOOD TSH-1.4 [**2183-9-1**] 12:19PM BLOOD Lactate-1.4 [**2183-9-1**] 05:33AM BLOOD Lactate-1.6 [**2183-9-1**] 09:25AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.046* [**2183-9-1**] 09:25AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2183-9-1**] 09:25AM URINE RBC-[**11-8**]* WBC-0-2 Bacteri-FEW Yeast-OCC Epi-0-2 [**2183-9-1**] 09:25AM URINE Hours-RANDOM UreaN-555 Creat-69 Na-128 K-34 Cl-160 [**2183-9-1**] 09:25AM URINE Osmolal-694 . Parasite Smear Negative . Urine and Blood cultures Pending as of [**2183-9-2**] PM.... . ECG Study Date of [**2183-9-1**] 5:10:04 AM Normal sinus rhythm. Left axis deviation at minus 31 degrees. Q waves in leads I and aVL. Poor R wave progression in leads V2-V6. Left ventricular hypertrophy. Intraventricular conduction delay with QRS duration of 110 milliseconds. Compared to the previous tracing of [**2182-7-12**] no diagnostic interval change. Intervals Axes Rate PR QRS QT/QTc P QRS T 93 188 110 368/425 70 -31 75 . CHEST (PA & LAT) Study Date of [**2183-9-1**] 5:30 AM FINDINGS: The lungs are clear. There are no pleural effusions or pneumothorax. The cardiomediastinal contours demonstrate mild tortuosity of thoracic aorta, with mild cardiomegaly. Pulmonary vascularity is normal. Note is made of mild elevation of the right hemidiaphragm and non-specific mildly gaseously distended loops of small bowel in the upper abdomen. IMPRESSION: No acute cardiopulmonary process. Mild elevation of the right hemidiaphragm and non-specific mildly gaseous distended loops of small bowel in the upper abdomen. . CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2183-9-1**] 7:49 AM FINDINGS: Non-contrast imaging demonstrates no evidence of aortic intramural hematoma. Note is made of mild calcification along the left anterior descending coronary artery. Following the administration of IV contrast, opacification of the pulmonary arterial tree is suboptimal for evaluation of segmental and subsegmental vessels. However, the larger pulmonary arterial branches extending to the lobar level are well opacified without evidence of pulmonary embolism. The aorta is normal in course and caliber without evidence of dissection or aneurysm. There is no lymphadenopathy. The heart is normal in size and shape. . Lung windows demonstrate no worrisome nodule, mass, or consolidation. Bibasilar areas of atelectasis are noted. The imaged upper abdominal structures are unremarkable. No worrisome osseous lesions are seen. A vertebral body hemangioma is noted in the mid thoracic spine. . IMPRESSION: No large pulmonary embolism. Please note, evaluation limited for subsegmental or segmental level PE. . Brief Hospital Course: Pt is a 73 y/o female with HTN, HLD, retinal detachment who presented after a syncopal event with prodrome the morning of admission, found to have fever and paroxysmal AV disassociation. . # Paroxsymal AV disassociation: Etiology was unclear, but lesion was likely infranodal as the PR intervals are not increased and AV disassociation was complete. Temporary pacemaker was placed. Patient was conducting normally through native system at rate 80s. Given travel, fever and diarrhea, and time of year infectious etiologies including Lyme, malaria and myocarditis, were considered but infectious work-up is negative to date. Ischemic etiology was unlikely, given troponins were flat. Home atenolol was not likely to have contributed, as PR intervals and RR intervals are not prolonged, just sudden paroxysmal episodes of CHB with no ventricular escape. Based on EKG findings, it was felt that the episode of syncope was not vagal. Decision was made to place permanent pacemaker (dual chamber), which was successfully placed on [**2183-9-2**]. Pt did not experience any complications during procedure and was able to leave ICU and got to the floor. . # Syncopal event: Event was proceeded by a clear prodrome. There was conern that this may have been vagal micturition syncope, or orthostatic (poor PO intake and insensible losses with diarrhea). Although this may have been an initial contributory factor, EP felt that episode was likely due to of paroxsymal heart block that caused her to syncopize, given similar findings seen on telemetry today (suggestive of phase 4 block). CXR, CTA, and head CT in the ED were all unremarkable. Unlikely seizure as there was no post-ictal state and she has no history of epilepsy. As above, decision was made to place a permanent dual chamber pacemaker. . # Fever: Source unknown and infectious work-up was unrevealing to date. Patient just returned from a 5 week trip to [**Country 3587**]; infectious source most likely gastroenteritis. Stool studies were sent and are still pending; her primary care physician at [**Name9 (PRE) **] [**Name9 (PRE) **] will have access to the [**Hospital1 18**] records online. Patient did have new cough, but no pneumonia or cavitary lesions were seen on CXR. UA showed hematuria but no nitrites or leukocyte esterase. Fever curve downtrended and normalized by the time of discharge. . # HTN: HCTZ and atenolol were held on initial presentation; patient was continued home lisinopril. She was restarted on home atenolol dose post pacemaker. . # Anion gap: Anion gap of 15 upon admission was likely due to mild lactic acidosis in setting of syncope, fall and decreased PO intake over past few days related to diarrhea, fever. No signs of uremia, ETOH, DKA, or other toxic ingestion. Improved w/IVF and supportive care. . # Hematuria: Likely secondary to trauma from catheterization. UA negative for nitrites, leuk esterase. No casts. . Pt was full code during this admission. Pt is [**Name (NI) 67026**] speaking and interpreter was used for consent. . Medications on Admission: Aspirin 81 mg PO daily Atenolol 25 mg PO daily Hydrochlorothiazide 25 mg PO daily Lisinopril 20 mg PO daily Tylenol Arthritis 650 mg, 1-2 tabs [**Hospital1 **] PRN pain Simvastatin 20 mg PO daily -- no longer taking regularly Discharge Medications: 1. Tylenol Arthritis 650 mg Tablet Sustained Release Sig: [**12-21**] Tablet Sustained Releases PO twice a day as needed for pain. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 3 days. Disp:*24 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Paroxsymal atrio-ventricular disassociation Bradycardia Syncope Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 1001**], You were admitted to the hospital because you had a fainting spell. It was determined that this was caused by an irregular rhythm of your heart. In order to ensure that your heart maintained a normal rate and rhythm, it was determined that you needed a permanent pacemaker placed. You underwent placement of a dual chamber pacemaker without any complications during the procedure. You were able to be discharged in stable condition to complete your recovery at home. . The following changes were made to your medications: - Please START taking the antibiotic Clindamycin 300mg (2 tablets, 150mg each) every 6 hours x 3 days - Please STOP taking hydrochlorothiazide until seen by your primary care physician who can restart it as appropriate - Please continue to take all of your other home medications as prescribed Please be sure to take all medication as prescribed. . Please be sure to keep all follow-up appointments with your primary care physician and other healthcare providers. If you continue to have fevers or diarrhea, please contact your primary care physician. . It was a pleasure taking care of you and we wish you a speedy recovery. Followup Instructions: Please be sure to keep all follow-up appointments with your primary care physician and other [**Name9 (PRE) 67027**] providers. . Department: CARDIAC SERVICES When: WEDNESDAY [**2183-9-10**] at 10:30 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: CARDIAC SERVICES When: MONDAY [**2183-10-13**] at 1 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: [**Hospital1 7975**] ST. HLTH CTR-KCSS When: WEDNESDAY [**2183-11-12**] at 10:40 AM 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 . . Department: [**Hospital3 1935**] CENTER When: MONDAY [**2183-11-17**] at 1:45 PM With: EYE IMAGING [**Telephone/Fax (1) 253**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: [**Hospital1 7975**] INTERNAL MEDICINE When: WEDNESDAY [**2183-9-10**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Completed by:[**2184-1-19**]

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icd9cm

[ [ [] ] ]

[ "37.72", "37.83", "38.93", "37.78" ]

icd9pcs

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277, 348

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5002, 9046

14373, 16049

4036, 4164

12380, 12875

12925, 12991

12129, 12357

13163, 14350

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3443, 3501

4641, 4983

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376, 3363

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3532, 3643

3385, 3423

3659, 4020

65,582

194,117

44497

Discharge summary

report

Admission Date: [**2168-12-1**] Discharge Date: [**2168-12-16**] Date of Birth: [**2102-1-19**] Sex: M Service: MEDICINE Allergies: Tagamet / Ditropan / Penicillins / Lisinopril / Heparin Agents Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: respiratory distress, altered mental status Major Surgical or Invasive Procedure: tracheostomy PEG tube placement CVL placement and removal PICC line placement History of Present Illness: Mr. [**Known lastname **] is a 66 y/o man with PMH notable for type 2 DM, HTN, and chronic renal insufficiency with recent complicated history (see below in PMH) who presents from rehab with altered mental status, fever, and respiratory distress. The patient was discharged from our MICU yesterday afternoon. At [**Hospital 100**] Rehab last night, his wife reports that he was more oriented and able to converse, though he was speaking in a whisper. He did not appear in respiratory distress at that time. This morning, the staff at the rehab noted increased somnolence and respiratory rate (28-32). He also had increased nasal congestion and they were able to suction thick secretions from his airway. Oxygen saturation noted to be 83-89% on 1.5 L NC and Mr. [**Known lastname **] had a temperature of 99.5 degrees. They contact[**Name (NI) **] EMS to bring him to the [**Hospital1 18**] ER at that time for further evaluation. . In the ED, initial vitals were T 104.2 (rectal), HR 110s-120s, BP 135/80, RR 20, 100% on NRB. The patient was intubated due to respiratory distress and inability to protect his airway. Intubation with etomidate/succ was difficult and involved help of Anesthesia and glidescope; the ED team noted thick, yellow secretions immediately post-intubation with suctioning of the ET tube. He then received 2 mg versed and 10 mg vecuronium . Post-intubation he became hypotensive to the 70s systolic and was started on levophed gtt. He had a R IJ CVL placed. He underwent CT scan of the chest/abdomen/pelvis in order to determine a source of infection. He was treated with vancomcyin and zosyn as well as 1 g tylenol PR. His 3rd liter of NS was hanging as he was transferred to the ICU. . On arrival to the ICU, the patient is intubated and sedated. He is not opening eyes to voice. Past Medical History: - Morbid obesity - DM type 2 poorly controlled with complications - Chronic renal insufficiency (baseline Cr 1.6-2) - HTN - reactive airways disease - h/o asbestos exposure with pleural plaques - GERD - Parkinson's disease - detrusor instability - gout - hypothyroidism - aortic stenosis, valve area 0.9cm2, peak gradient 24, median gradient 48 - Anemia - h/o nephrolithiasis - Fall in [**8-12**] w/ R subdural hematoma, s/p strep bovis bacteremia and 6 wks Ceftriaxone, developed bacteremia after completion of tx with MRSA and enterococcus. line removed, tx with Vanco then d/c'd. Neg cx 3 consecutive days. [**11-4**] - febrile, blood cxs + enterococcus, [**Last Name (un) 36**] to PCN and Vanc. got Vancomycin due to PCN allergy. - Recent 2-week admission for altered mental status, found to have pneumonia, NSTEMI, embolic CVA (thought not contributing to mental status) and aortic valve endocarditis. Was intubated in the ED with difficult to wean vent. Eventually exctubated on [**11-28**]. Acinetobacter in sputum (? colonization versus VAP), treated with tobramycin and unasyn (plan to d/c on [**12-1**]). Also diuresed with lasix gtt for volume overload. Social History: no alcohol or tobacco use, currently resides at [**Hospital **] [**Hospital **] Rehabilitation Center, formerly owned pizzaria restuarants Family History: non-contributory Physical Exam: T: 102.6 orally BP: 93/59 HR: 119 RR: 23 O2 97% on vent Gen: sedated and intubated HEENT: No scleral icterus. MM slightly dry, OP clear, ET tube in place NECK: supple, no LAD, R IJ in place, no thyromegaly CV: RRR, 2/6 systolic murmur at the LUSB LUNGS: breat sounds diminished bilaterally, no wheezing, coarse breath sounds at right base ABD: obese, normoactive bowel sounds, soft with reducible small umbilical hernia, nontender throughout EXT: warm, dry skin on feet, DP and radial pulses 2+ bilaterally, no peripheral edema SKIN: No rashes/lesions, ecchymoses. NEURO: Intubated and sedated. No eye opening to voice or sternal rub. Oculocephalic reflex intact. Intermittent rhythmic tremor or left>right hand. Withdraws to pain in all four extremities. Toes mute bilaterally. Slight increase in tone in upper extremities>lower extremities. Pertinent Results: [**12-16**] creatinine 1.1 [**2168-11-30**] 03:01AM BLOOD WBC-9.8 RBC-4.14* Hgb-11.3* Hct-34.3* MCV-83 MCH-27.3 MCHC-33.0 RDW-16.5* Plt Ct-277 [**2168-12-1**] 01:26PM BLOOD WBC-19.2*# RBC-4.72 Hgb-12.6* Hct-39.2* MCV-83 MCH-26.7* MCHC-32.1 RDW-16.7* Plt Ct-262 [**2168-12-2**] 02:00AM BLOOD WBC-21.8* RBC-3.79* Hgb-10.1* Hct-31.1* MCV-82 MCH-26.8* MCHC-32.6 RDW-17.7* Plt Ct-255 [**2168-12-3**] 02:38AM BLOOD WBC-11.4* RBC-3.14* Hgb-8.4* Hct-26.2* MCV-84 MCH-26.7* MCHC-32.0 RDW-16.7* Plt Ct-166 [**2168-12-4**] 03:30AM BLOOD WBC-6.8 RBC-3.15* Hgb-8.4* Hct-26.2* MCV-83 MCH-26.7* MCHC-32.2 RDW-17.3* Plt Ct-136* [**2168-12-10**] 03:00AM BLOOD WBC-6.1 RBC-3.27* Hgb-8.9* Hct-26.3* MCV-81* MCH-27.1 MCHC-33.6 RDW-16.7* Plt Ct-219 [**2168-12-11**] 04:10AM BLOOD WBC-10.3# RBC-3.46* Hgb-9.0* Hct-27.8* MCV-80* MCH-26.1* MCHC-32.4 RDW-16.4* Plt Ct-225 [**2168-12-1**] 01:26PM BLOOD Neuts-91.1* Lymphs-5.6* Monos-2.4 Eos-0.8 Baso-0.2 [**2168-12-6**] 03:55AM BLOOD Neuts-72.0* Lymphs-18.2 Monos-5.0 Eos-4.3* Baso-0.5 [**2168-12-11**] 04:10AM BLOOD Neuts-89* Bands-0 Lymphs-7* Monos-3 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2168-12-11**] 04:10AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-3+ Polychr-OCCASIONAL [**2168-12-1**] 01:26PM BLOOD PT-18.5* PTT-45.1* INR(PT)-1.7* [**2168-12-2**] 02:00AM BLOOD PT-20.5* PTT-48.7* INR(PT)-1.9* [**2168-12-5**] 04:30AM BLOOD PT-15.1* PTT-42.3* INR(PT)-1.3* [**2168-12-6**] 03:55AM BLOOD PT-15.6* PTT-48.1* INR(PT)-1.4* [**2168-12-11**] 04:10AM BLOOD PT-17.5* PTT-49.5* INR(PT)-1.6* [**2168-12-2**] 02:00AM BLOOD Fibrino-691* D-Dimer-4095* [**2168-12-2**] 07:56AM BLOOD Fibrino-712* D-Dimer-3691* [**2168-11-30**] 03:01AM BLOOD Glucose-177* UreaN-26* Creat-1.7* Na-143 K-3.5 Cl-95* HCO3-39* AnGap-13 [**2168-12-1**] 01:26PM BLOOD Glucose-160* UreaN-33* Creat-1.9* Na-148* K-3.8 Cl-99 HCO3-37* AnGap-16 [**2168-12-2**] 02:00AM BLOOD Glucose-145* UreaN-40* Creat-2.4* Na-149* K-3.0* Cl-108 HCO3-30 AnGap-14 [**2168-12-2**] 02:56PM BLOOD Glucose-141* UreaN-40* Creat-2.4* Na-146* K-3.4 Cl-107 HCO3-32 AnGap-10 [**2168-12-3**] 02:38AM BLOOD Glucose-175* UreaN-39* Creat-2.3* Na-144 K-3.3 Cl-107 HCO3-31 AnGap-9 [**2168-12-7**] 02:31AM BLOOD Glucose-173* UreaN-37* Creat-1.8* Na-142 K-4.1 Cl-101 HCO3-34* AnGap-11 [**2168-12-7**] 06:33PM BLOOD Glucose-180* UreaN-40* Creat-1.7* Na-142 K-4.0 Cl-99 HCO3-35* AnGap-12 [**2168-12-8**] 02:47AM BLOOD Glucose-152* UreaN-41* Creat-1.6* Na-140 K-3.7 Cl-101 HCO3-33* AnGap-10 [**2168-12-11**] 04:10AM BLOOD Glucose-149* UreaN-33* Creat-1.4* Na-142 K-3.5 Cl-105 HCO3-29 AnGap-12 [**2168-12-1**] 01:26PM BLOOD CK(CPK)-32* [**2168-12-2**] 02:00AM BLOOD CK(CPK)-55 [**2168-12-2**] 07:55AM BLOOD CK(CPK)-44 [**2168-12-1**] 01:26PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2168-12-2**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.09* [**2168-12-2**] 07:55AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2168-11-30**] 03:01AM BLOOD Calcium-9.5 Phos-2.5* Mg-2.2 [**2168-12-11**] 04:10AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.1 [**2168-12-4**] 06:40AM BLOOD Vanco-24.2* [**2168-12-4**] 03:56PM BLOOD Vanco-22.4* [**2168-12-5**] 06:00AM BLOOD Vanco-25.7* [**2168-12-7**] 06:33PM BLOOD Vanco-18.4 [**2168-12-10**] 06:00AM BLOOD Vanco-20.6* [**2168-12-10**] 07:45PM BLOOD Vanco-15.6 [**2168-11-30**] 03:33PM BLOOD Type-ART pO2-63* pCO2-51* pH-7.50* calTCO2-41* Base XS-13 [**2168-12-1**] 04:25PM BLOOD Type-ART Rates-/18 Tidal V-500 PEEP-12 FiO2-100 pO2-315* pCO2-51* pH-7.42 calTCO2-34* Base XS-7 AADO2-362 REQ O2-63 -ASSIST/CON Intubat-INTUBATED [**2168-12-5**] 04:31PM BLOOD Type-ART Temp-37.8 Rates-/20 Tidal V-450 PEEP-8 FiO2-30 pO2-124* pCO2-45 pH-7.49* calTCO2-35* Base XS-10 Intubat-INTUBATED Vent-SPONTANEOU [**2168-12-6**] 03:48AM BLOOD Type-ART Temp-37.7 Rates-18/2 Tidal V-450 PEEP-5 FiO2-30 pO2-85 pCO2-43 pH-7.49* calTCO2-34* Base XS-8 -ASSIST/CON Intubat-INTUBATED [**2168-12-6**] 01:43PM BLOOD Type-ART Temp-38.0 Rates-/29 PEEP-5 FiO2-40 pO2-94 pCO2-45 pH-7.50* calTCO2-36* Base XS-9 Intubat-INTUBATED Vent-SPONTANEOU [**2168-12-10**] 03:40AM BLOOD Type-ART Temp-37.3 Rates-/18 Tidal V-500 PEEP-5 FiO2-30 pO2-100 pCO2-36 pH-7.55* calTCO2-32* Base XS-8 -ASSIST/CON Intubat-INTUBATED [**2168-12-10**] 05:05AM BLOOD Type-ART Temp-37.6 PEEP-5 pO2-97 pCO2-37 pH-7.51* calTCO2-31* Base XS-5 Intubat-INTUBATED [**2168-12-10**] 04:41PM BLOOD Type-ART Temp-38.8 Rates-/35 Tidal V-380 PEEP-10 FiO2-30 pO2-78* pCO2-38 pH-7.50* calTCO2-31* Base XS-5 Intubat-INTUBATED Vent-SPONTANEOU [**2168-12-1**] 01:34PM BLOOD Lactate-1.5 [**2168-12-1**] 06:44PM BLOOD Lactate-2.5* [**2168-12-6**] 01:43PM BLOOD Lactate-0.8 [**2168-11-30**] 03:33PM BLOOD freeCa-1.22 [**2168-12-4**] 12:30PM BLOOD HEPARIN DEPENDENT ANTIBODIES- positive [**2168-12-6**] 01:33PM BLOOD SEROTONIN RELEASE ANTIBODY- negative [**2168-12-1**] 03:39PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2168-12-1**] 03:39PM URINE RBC-[**11-24**]* WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0 [**2168-12-4**] 12:46PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2168-12-4**] 12:46PM URINE RBC-28* WBC-226* Bacteri-FEW Yeast-FEW Epi-0 [**2168-12-10**] 04:40PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD [**2168-12-10**] 04:40PM URINE RBC->50 WBC-21-50* Bacteri-OCC Yeast-MANY Epi-0-2 [**2168-12-11**] 05:15PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-SM [**2168-12-11**] 05:15PM URINE RBC-10* WBC-89* Bacteri-FEW Yeast-NONE Epi-<1 [**2168-12-1**] 03:39PM URINE CastHy-0-2 [**2168-12-10**] 04:40PM URINE CastGr-<1 . Microbiology: blood cx negative ([**12-1**], [**12-3**], [**12-4**], [**12-10**], [**12-13**]) MRSA nasal swab screen positive on [**12-13**] C diff toxin A & B negative [**12-11**], [**12-13**] Urine legionella antigen negative ([**12-1**]) [**2168-12-10**] RESPIRATORY CULTURE (Preliminary): OROPHARYNGEAL FLORA ABSENT. COLISTIN SUSCEPTIBILITY REQUESTED BY DR [**First Name (STitle) **] ([**Numeric Identifier 95354**]). COLISTIN SENT ON [**2168-12-14**]. ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". gram stain reviewed: 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S) were observed [**2168-12-11**]. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII COMPLEX | KLEBSIELLA PNEUMONIAE | | AMIKACIN-------------- 16 S AMPICILLIN/SULBACTAM-- 4 S =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 32 R R CEFTAZIDIME----------- =>64 R =>64 R CEFTRIAXONE----------- R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R =>16 R IMIPENEM-------------- =>16 R MEROPENEM------------- <=0.25 S PIPERACILLIN/TAZO----- 32 I TOBRAMYCIN------------ <=1 S =>16 R TRIMETHOPRIM/SULFA---- <=1 S =>16 R [**2168-12-1**] 6:03 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2168-12-5**]** GRAM STAIN (Final [**2168-12-1**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2168-12-5**]): OROPHARYNGEAL FLORA ABSENT. KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. SECOND MORPHOLOGY. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | KLEBSIELLA PNEUMONIAE | | AMIKACIN-------------- 16 S 16 S AMPICILLIN/SULBACTAM-- =>32 R =>32 R CEFAZOLIN------------- =>64 R =>64 R CEFEPIME-------------- R R CEFTAZIDIME----------- =>64 R =>64 R CEFTRIAXONE----------- R R CEFUROXIME------------ =>64 R =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R =>16 R MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- 8 S =>128 R TOBRAMYCIN------------ =>16 R =>16 R TRIMETHOPRIM/SULFA---- =>16 R =>16 R . [**2168-12-3**] 2:35 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2168-12-10**]** GRAM STAIN (Final [**2168-12-3**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2168-12-5**]): OROPHARYNGEAL FLORA ABSENT. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 95355**] FROM [**2168-12-1**]. LEGIONELLA CULTURE (Final [**2168-12-10**]): NO LEGIONELLA ISOLATED. . [**2168-12-4**] 12:46 pm URINE Source: Catheter. **FINAL REPORT [**2168-12-5**]** URINE CULTURE (Final [**2168-12-5**]): YEAST. 10,000-100,000 ORGANISMS/ML. . [**2168-12-10**] 4:40 pm URINE Source: Catheter. **FINAL REPORT [**2168-12-11**]** URINE CULTURE (Final [**2168-12-11**]): YEAST. 10,000-100,000 ORGANISMS/ML.. . Radiographic Data: . [**12-1**] Head CT: IMPRESSION: No hemorrhage. . [**12-1**] Chest/Abd/Pelvis CT: IMPRESSION: 1. Compared to prior exam from [**2168-11-15**] there is worsening consolidation of the right lower lobe. Streaky opacity within the left lung base is unchanged. 2. Extensive pleural thickening with calcified pleural plaques most compatible with prior asbestos exposure. 3. Small fat containing umbilical hernia. 4. Side port of NG tube is at the GE junction. Recommend advancing for optimal placement. . [**12-2**] CXR: Impression: Remaining findings within the lungs including bilateral consolidations, regions of pleural thickening, and pleural plaques, and positioning of right- sided central line, endotracheal tube, display no interval change. . [**12-11**] CXR: IMPRESSION: AP chest compared to [**12-5**] through 5: Large areas of lung are obscured by heavy asbestos-related pleural calcifications. Heterogeneous consolidation in the right lung appeared to develop between [**12-8**] and 5 and has subsequently improved. Tracheostomy tube in standard placement. Mediastinal contour is grossly unchanged since [**12-5**] prior to the tracheostomy. Left subclavian line passes to the low SVC but the tip is indistinct. Heart size normal. Lung volumes remain generally low. . Brief Hospital Course: This is a 66 y/o man with PMH notable for type 2 DM, HTN, recent subdural hematoma, recent strep bovis/MRSA/enterococcus bacteremia and recent admission to the MICU for altered mental status and pneumonia re-admitted to the MICU with respiratory distress and altered mental status. . # Septic Shock: Patient presented with fever and hypotension which started immediately after post-intubation medications were given and was likely a result of these medications as well as overall volume depleted status on presentation. BCx negative throughout MICU stay. Weaned off levophed within 24h of admission to MICU. CE negative and EKG unchanged from recent. He was treated for his aspiration pneumonia as described below. He was hemodynamically stable with appropriate urine output prior to discharge. . # Respiratory failure: Secondary to Aspiration PNA w/Klebsiella, sensitive to meropenem. Tracheostomy placed due to aspiration in setting of recent extubation and copious secretions w/poor cough strength. No complications with tracheostomy, tolerating trach mask with 30% FiO2 at time of discharge. He originally had bloody secretions in vent tube but they have decreased in quantity. Treated pneumonia w/meropenem and aggressive chest PT (completed a 12 day course of meropenem for Klebsiella). Also on IV vancomycin, for bacteremia/endocarditis (course completed on [**12-21**]). A followup sputum culture showed Acinetobacter sensitive for tobramycin and unasyn, which was initiated on [**12-12**] for a two week course (to end [**12-26**]). The patients respiratory status improved significantly after the change in his antibiotic regimen and he was tried on trach mask which he tolerated well. He was intermittently rested on pressure support and was maintained mostly on trach mask prior to discharge to rehabilitation. - Patient should be treated with tobramycin/unasyn until [**12-26**] for Acinetobacter pneumonia. Tobramycin peak (1 hour after dose) and trough (1 hour prior to dose) should be drawn every other day until course is complete with goal peak ([**7-14**]) and goal trough (< 2). - Patient should follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Infectious Disease within 3-4 weeks. Please call [**Telephone/Fax (1) 457**] to make this appointment. . # Altered mental status: Likely related to underlying infection/shock; of note he has had multiple prior similar episodes with recent infections (bacteremia, pneumonia). Head CT showed no acute changes and exam was nonfocal. Mental status improved significantly during stay. Neurology was consulted to ensure proper dosage of anti-parkinsonian medications, and recommended an increase in sinemet dosage as well as seroquel prn agitation (avoid benzodiazepines and typical antipsychotics). . # Acute on chronic renal insufficiency: ATN in setting of sepsis. Creatinine up to 2.4 shortly after admission but improved throughout stay. Creatinine was 1.1 at discharge. . # Thrombocytopenia: HIT antibody positive, off all heparin products, lines flushed yesterday. Platelets slowly recovered and in 200s at discharge. Serotonin release assay negative but was done 2 days after heparin d/c. Consulted hematology to discuss significance and whether patient should or should not carry a Dx of HIT. Hematology felt his presentation was not consistant with HIT but he should still carry an allergy allert to heparin so he is being treated as HIT positive. He should not have heparin products and is currently on Fondaparinux for prophylaxis. . # Fever: Likely secondary to his pneumonia, and possibly due to yeast in his urine. ID was consulted and noted that he is likely chronically colonized with yeast and does not need intervention with fluconazole unless he is symptomatic. His fevers resolved with antibiotic treatment of his pneumonia. . # Hypernatremia: Likely related to hypovolemia due to poor PO intake at rehab. Improved with volume repletion. . # INR elevation: Likely nutritional given protracted ICU stay. Up to 2.0 initially but resolved without vitamin K repletion. . # Type 2 DM: FS stabilized with 10 glargine and increased ISS. Sliding scale adjustment should be done at rehab as fingerstick blood sugars allow. . # Ectopy: Multiple PVCs, trigemony and bigemony on tele. Decreased ectopy after started metoprolol 25 [**Hospital1 **] but BP dropped severely after Metoprolol increased to TID, so decreased dose to 12.5 mg TID with good effect and good control of blood pressures. Since then has had intermittent PVCs on telemetry but hemodynamically stable. . # MRSA/Enterococcus bacteremia with aortic valve endocarditis: continue vanco 750mg IV q24 through [**12-21**], re-checking troughs with change in renal function. Trough levels should be drawn once weekly and faxed to Dr. [**First Name (STitle) **] as directed. *** Due to prior bacteremia with Streptococcus bovis, patient should have formal GI malignancy screening once stabilized and out of rehab facility. . # Parkinson's disease: Continue carbidopa/levodopa and ropinirole for now. Dose adjusted per neurology service recommendations and tremors have improved. Please avoid benzodiazepines and zyprexa as this may exacerbate his Parkinson's symptoms. Patient may receive bedtime dose of seroquel as needed for agitation. . # Hypothyroidism: Continue levothyroxine. . # FEN: Tube feeds via peg, which patient is toelrating well. Repleting electrolytes as needed. Receiving Multivitamin and vitamin D. . # PPx: PPI, bowel regimen, pneumoboots. Fondoparinux . # ACCESS: PICC. PIV. . # CODE: Full code, confirmed with wife. . # COMM: With patient and family. Wife [**Name (NI) **] is HCP. Phone # [**Telephone/Fax (1) 95356**]. Medications on Admission: tylenol 650 mg PO q6h ampicillin/sulbactam 3 g iv q6h aspirin 325 mg daily calcitriol 0.25 mcg daily carbidopa/levodopa 2 tabs 5X per day vitamin b12 [**2160**] mcg daily colace 100 [**Hospital1 **] ferrous sulfate 325 mg daily lasix 40 mg po bid hep 5000 u sc tid humalog sliding scale albuterol MDI prn bisacodyl prn senna prn miconazole powder prn pramoxine ointment prn tobramycin 300 mg every other day vancomycin 1g iv q24h atrovent MDI q6h levothyroxine 88 mcg daily metoprolol 25 [**Hospital1 **] mvi daily omeprazole 20 [**Hospital1 **] ropinirole 3 qid simvastatin 20 mg qhs neutra-phos 1 tid Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Hospital1 **]: One (1) Intravenous Q 24H (Every 24 Hours) for 5 days: Please discontinue on [**12-21**]. 2. Ampicillin-Sulbactam 3 gram Recon Soln [**Month (only) **]: Three (3) Recon Soln Injection Q4H (every 4 hours) for 10 days: until [**12-26**]. 3. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month (only) **]: Two (2) Tablet PO DAILY (Daily). 4. Carbidopa-Levodopa 25-250 mg Tablet [**Month (only) **]: One (1) Tablet PO every four (4) hours. 5. Quetiapine 25 mg Tablet [**Month (only) **]: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for agitation. 6. Metoprolol Tartrate 25 mg Tablet [**Month (only) **]: 0.5 Tablet PO TID (3 times a day). 7. Fondaparinux 2.5 mg/0.5 mL Syringe [**Month (only) **]: One (1) Subcutaneous DAILY (Daily). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 10. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 11. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: Five (5) ML PO DAILY (Daily). 12. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 13. Ropinirole 1 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO QID (4 times a day). 14. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6) Puff Inhalation QID (4 times a day). 15. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID (4 times a day) as needed for rash. 16. Levothyroxine 88 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 17. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 18. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 20. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 21. Tobramycin in NS 80 mg/100 mL Piggyback [**Hospital1 **]: Three Hundred (300) mg Intravenous every twenty-four(24) hours for 10 days: Please continue till [**2168-12-26**] for a 14 day course. Desired peak level is between 8 and 10. 22. Outpatient Lab Work Please draw weekly CBC with differential, BUN/creatinine, LFTs, and vancomycin trough and fax to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 432**]. Thank you. 23. Insulin Glargine 100 unit/mL Cartridge [**Telephone/Fax (1) **]: Twenty (20) U Subcutaneous at bedtime. 24. Insulin Lispro 100 unit/mL Cartridge [**Telephone/Fax (1) **]: As directed U Subcutaneous every six (6) hours: Please see attached sliding scale insulin every 6 hours. [**Month (only) 116**] be adjusted as necessary. . 25. Outpatient Lab Work Please check tobramycin trough (1 hour prior to dose) and peak (1 hour after dose) every other day. Fax result to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 432**]. If tobramycin trough > 1.7, please decrease dosing interval to q48h. If tobramycin peak < 5, please increase to 400 mg q24h. 26. PICC care PICC line care per protocol Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Klebsiella pneumonia, resolved Acinetobacter pneumonia, currently on treatment Respiratory failure s/p tracheostomy and PEG tube placement Acute renal failure, resolved Secondary: Parkinsons disease HIT antibody positive Type 2 Diabets mellitus Chronic renal insufficiency, creatinine on discharge 1.1 Hypothyroidisim Detrussor instability History of gout Aortic stenosis (valve area 0.9) History of subdural hematoma Discharge Condition: afebrile, normotensive, on trach mask Discharge Instructions: You were admitted for altered mental status and fevers. You were found to have pneumonia which was treated with antibiotics. Please ensure that you complete the antibiotic course as indicated. You were also found to be in acute renal insufficiency on admission which resolved prior to discharge. Due to respiratory failure, you had a tracheostomy tube placed; you are doing well on trach mask 30% FiO2. You also had a PEG tube placed. . You were found to be HIT antibody positive. You whould not get any heparin products in the future. Fondaparinux could be used as needed for anticoagulation/prophylaxis. Please call your PCP or return to the emergency room should you develop any of the following symptoms: fever > 101, chills, difficulty breathing, chest pain, abdominal pain, diarrhea, change in mental status, lower leg swelling, or any other concerns. Followup Instructions: Please make a follow up appointment with Dr. [**Last Name (STitle) **] within two weeks of discharge. Tel: [**Telephone/Fax (1) 1247**]. . Please call [**Telephone/Fax (1) 457**] make an appointment to see your infectious disease physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], in [**3-8**] weeks. . Other previously scheduled appointments: Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2168-12-27**] 11:00 Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2168-12-27**] 1:30 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2168-12-16**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

26415, 26481

16495, 18818

375, 455

26944, 26984

4549, 10471

27895, 28677

3652, 3670

22869, 26392

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27008, 27872

3685, 4530

10512, 15207

292, 337

483, 2291

15216, 16472

18833, 22215

2313, 3479

3495, 3636

26,170

187,323

13307

Discharge summary

report

Admission Date: [**2106-2-5**] Discharge Date: [**2106-2-19**] Service: [**Hospital1 **] HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old gentleman with a history of advanced prostate cancer who presented with obstructive jaundice from external lymph node compression. The patient has had frequent nausea and vomiting and was sent for an endoscopic retrograde cholangiopancreatography with Dr. [**Last Name (STitle) **] at [**Hospital1 69**], status post duodenal stenting today at the proximal common bile duct, and internal and external biliary drain placement. The patient was transferred to the floor after the percutaneous transhepatic cholangiography for observation. He reports that he felt fine without nausea or vomiting, with no appetite and mild abdominal pain. He complained of bilateral lower extremity swelling that was known to be chronic, but was otherwise free of complaints. PAST MEDICAL HISTORY: 1. Prostate cancer with diffuse metastatic disease; duodenal and biliary stents in place. Status post radiation therapy and transurethral resection of prostate. Diagnosed 30 years ago. Recently complicated by obstructive jaundice. 2. Lower extremity edema secondary to lymphadenopathy. 3. Right superficial femoral vein deep venous thrombosis on [**2106-2-2**]. 4. Gastric gastroesophageal reflux disease. 5. History of transient ischemic attack. 6. Status post appendectomy. 7. History of inferior vena cava stent placement in [**2105-12-12**] due to compressive lymphadenopathy. ALLERGIES: Allergies are to PERCOCET. MEDICATIONS ON ADMISSION: 1. Plavix 75 mg once per day. 2. Nexium 40 mg once per day. 3. Zofran as needed. 4. Ketoconazole 200 mg once per day. 5. Cortisone 20 mg once per day. 6. Multivitamin once per day. 7. Potassium chloride 20 mEq once per day. 8. Vitamin C 500 mg once per day. 9. Vitamin E 800 units once per day. 10. Psyllium two tablets once per day. SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] has a daughter and son that are very involved with his care. He is very close with his daughter, and he is ambulatory at baseline. PHYSICAL EXAMINATION ON PRESENTATION: The patient had a temperature of 95.1, his blood pressure was 130/80, his heart rate was 64, his respiratory rate was 18, and his oxygen saturation was 94% on room air. In general, the patient was a fatigue-appearing elderly male with yellow skin and in no apparent distress. Head, eyes, ears, nose, and throat examination revealed he had scleral icterus. The mucous membranes were moist. The oropharynx was clear. The neck was supple. He had no lymphadenopathy, and no bruits, and no elevation in jugular venous pressure. The lungs were clear to auscultation anteriorly. Cardiovascular examination revealed a regular rate. Normal first heart sounds and second heart sounds. There was a 3/6 systolic ejection murmur heard best in the axilla. The abdomen had positive bowel sounds. The abdomen was mildly distended and mildly tender diffusely. No guarding. Drains were in place. Extremities revealed 3+ pitting edema and stasis dermatitis (right greater than left). On neurologic examination, the patient was alert and oriented times three. He had no clear cranial nerve deficits. BRIEF SUMMARY OF HOSPITAL COURSE: The patient had emesis on the early morning of [**2106-2-13**] with frequent blood clots. A nasogastric tube was dropped and had return of frank blood. His hematocrit was noted to be dropped down to 26 from 32 that day, and the patient was transferred to the Intensive Care Unit for further monitoring and transfusions. The patient received 2 units of packed red blood cells, 2 units of fresh frozen plasma, nasogastric lavage of 2 liters did not clear at all. Throughout this event, the patient denied any shortness of breath, chest pain, or palpitations. The hematemesis was thought to be due to instrumentation. Before the patient had an esophagogastroduodenoscopy, he had an upper gastrointestinal study which revealed an obstructed duodenal stent. Contrast freely flowed into the biliary stent from the stomach. It was thought that the patient would never be able to take oral intake until this was corrected. This was confirmed with esophagogastroduodenoscopy. A Gastroenterology consultation felt that the upper gastrointestinal bleeding was likely due to the instrumentation and an ulceration in the region of the duodenal stent which was stable and did not require any treatment. The patient was transferred back to the floor. His hematocrits were stable. His blood pressure was stable. The patient was mentating well. His nausea persisted, and the patient continued to have emesis with scant blood and stable hematocrits. The patient became increasingly fatigued, and further interventions were discussed with the interventional radiologists and gastrointestinal consultants to evaluate the best treatment for the duodenal obstruction. The patient's primary oncologist was called to discuss indications for further treatment who reported that the patient's ketoconazole and hydrocortisone were used as palliative measures and that the patient understood from previous conversations that there was no further treatment available. To prevent further gastrointestinal ulcerations, the hydrocortisone was discontinued, and a family meeting was called to discuss plans for care. Dr. [**Last Name (STitle) **] placed a stent with a duodenal stent to open up the obstruction. The gastrointestinal tract was presumed to be patent. The patient started oral intake and had frequent coffee-grounds emesis. The patient had repeated hypotension to the 70s, mentating well, which improved to the 90s to 100 with a 1-liter intravenous fluid bolus. Repeat lower extremity Doppler studies revealed that the right-sided deep venous thrombosis was still present, and there was great concern over how to manage this best given the patient's need for anticoagulation, concern for pulmonary embolism given the presence of the deep venous thrombosis, unlikely benefit of an inferior vena cava filter, and the persistent inability for the patient take oral intake well and get adequate nutrition in the context of severe worsening metastatic disease. The patient's hypotension continued. A family meeting was called. The Palliative Care Service was seen in consultation. The patient discussed plans of care and determined that he wanted to go home to focus his care on comfort rather than painful treatment with unknown benefit or increased duration of life span. The patient was made comfort measures only and sent home with hospice services. DISCHARGE DIAGNOSES: 1. Prostate cancer. 2. Obstructive jaundice. 3. Hypotension. MEDICATIONS ON DISCHARGE: 1. Prochlorperazine 25-mg suppository q.12h. as needed (for nausea). 2. Scopolamine patch q.72h. 3. Tylenol as needed. 4. Ativan one tablet as needed (for anxiety). 5. Morphine 20 mg/mL solution as needed (for pain or shortness of breath). 6. Oxygen by nasal cannula (to keep saturations greater than 93% on 3 liters). 7. Oxygen condenser and nasal cannula and a face mask. 8. Biliary drain dressings and biliary drain bags. 9. Hospital bed. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient's oncologist (Dr. [**Last Name (STitle) 40508**] as well as the patient's primary care physician (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**]) were contact[**Name (NI) **] to discuss the patient being made do not resuscitate/do not intubate/comfort measures only status and sent home. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**] reported that she would follow up with the patient and continue care as an outpatient. CONDITION AT DISCHARGE: The patient was unable to ambulate at all, requiring oxygen 3 liters to have normal saturations. DISCHARGE STATUS: The patient was discharged to home with [**Hospital6 407**] and hospice services ([**Hospital **] hospice). [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 6374**] MEDQUIST36 D: [**2106-4-26**] 17:16 T: [**2106-4-27**] 13:06 JOB#: [**Job Number 40509**]

[ "507.0", "V10.46", "537.3", "578.1", "996.59", "591", "576.2", "197.6", "196.2" ]

icd9cm

[ [ [] ] ]

[ "39.90", "51.98", "88.51", "99.15", "97.05", "87.54", "45.13", "38.93", "99.04", "39.50" ]

icd9pcs

[ [ [] ] ]

6704, 6769

6795, 7247

1599, 1952

7281, 7781

3325, 6683

7796, 8289

128, 918

940, 1572

1969, 3295

31,670

117,294

31387

Discharge summary

report

Admission Date: [**2136-9-12**] Discharge Date: [**2136-9-14**] Date of Birth: [**2058-4-17**] Sex: M Service: NEUROSURGERY Allergies: Penicillins / Cephalosporins / Antihistamines Attending:[**First Name3 (LF) 1835**] Chief Complaint: Admitted from OSH after having seizure at home and found to have left frontal lobe and cerebellar hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: 78 y/o man with recent diagnosis of intracranial mass admitted from OSH after having seizure at home and found to have left frontal lobe and cerebellar hemorrhage. At OSH BS was 59. CT head showed ICH. He was transferred to the ED here. Pt intubated in ER for airway protection. At [**Hospital1 18**], he had MR head revealing a large left frontal intraparenchymal lesion that is predominantly hemorrhagic in nature. This lesion exhibits irregular contrast enhancement. There is significant edema associated with this lesion. There is also a lesion seen involving the cerebellum, also hemorrhagic in nature. This lesion exhibits more solid type enhancement. These findings are consistent with metastatic disease. He had a CT chest which revealed a dominant spiculated nodule in the medial aspect of the left upper lobe highly suspicious for a neoplasm. Additional scattered bilateral pulmonary nodules noted as well. He was admitted to the Neurosurg service in the SICU. Past Medical History: CAD, PVD, NIDDM, HTN Social History: Ex- smoker. No tobacco. Lives with wife. Family History: N/C Physical Exam: : T: 98 BP: / HR: R O2Sats Gen: somnolence, follow some commands but inconsistently HEENT: Pupils: PERRLA EOMs unable to follow Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: somnolence, speech incomprehensible. Only follow a few simple commands during exam. Orientation: incomprehensible answers. Language: see above Pertinent Results: [**2136-9-13**] 05:14AM BLOOD WBC-15.2*# RBC-3.18* Hgb-9.2* Hct-30.0* MCV-94 MCH-29.0 MCHC-30.7* RDW-16.0* Plt Ct-327 [**2136-9-11**] 10:30PM BLOOD Neuts-87* Bands-1 Lymphs-4* Monos-6 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 [**2136-9-13**] 05:14AM BLOOD Plt Ct-327 [**2136-9-13**] 05:14AM BLOOD Glucose-137* UreaN-20 Creat-0.8 Na-144 K-4.4 Cl-110* HCO3-21* AnGap-17 [**2136-9-11**] 10:30PM BLOOD Glucose-211* UreaN-18 Creat-0.7 Na-133 K-4.8 Cl-93* HCO3-27 AnGap-18 [**2136-9-13**] 05:14AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.2 [**2136-9-11**] 10:30PM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0 [**2136-9-12**] 02:26AM BLOOD PSA-1.1 [**2136-9-13**] 05:14AM BLOOD Phenyto-17.4 [**2136-9-12**] 02:26AM BLOOD Phenyto-23.3* [**2136-9-13**] 03:35AM BLOOD Type-ART pO2-258* pCO2-56* pH-7.20* calTCO2-23 Base XS--6 [**2136-9-12**] 09:57AM BLOOD Type-ART pO2-180* pCO2-52* pH-7.28* calTCO2-25 Base XS--2 [**2136-9-12**] 08:24AM BLOOD Type-ART pO2-169* pCO2-60* pH-7.27* calTCO2-29 Base XS-0 [**2136-9-12**] 06:37AM BLOOD Type-ART pO2-116* pCO2-55* pH-7.28* calTCO2-27 Base XS--1 [**2136-9-11**] 10:51PM BLOOD Type-ART Rates-/14 Tidal V-450 PEEP-5 FiO2-100 pO2-442* pCO2-59* pH-7.32* calTCO2-32* Base XS-2 AADO2-214 REQ O2-44 Intubat-INTUBATED Vent-CONTROLLED [**2136-9-12**] 09:57AM BLOOD Glucose-134* [**2136-9-11**] 10:37PM BLOOD Glucose-205* Na-134* K-4.6 Cl-95* calHCO3-29 . CT CHest: IMPRESSION: 1. Dominant spiculated nodule in the medial aspect of the left upper lobe highly suspicious for a neoplasm. Additional scattered bilateral pulmonary nodules as above. 2. Mediastinal and hilar lymphadenopathy. 3. Multiple hypoattenuating liver lesions, some of which likely represent cysts. The rest, however, cannot be accurately characterized on this study. 4. Cystic enhancing mass in the medial aspect of the spleen and the stomach. . CT HEAD: IMPRESSION: 1. Large 3.9 x 2.7 cm left frontal intraparenchymal hemorrhage with severe vasogenic edema. Resultant 7 mm rightward subfalcine herniation and mass effect on the left lateral ventricular body. Given marked vasogenic edema and second lesion in the cerebellum, hemorrhage is likely secondary to underlying neoplasm, probably metastatic. 2. 2.7 x 1.6 cm hyperdense lesion within the cerebellum, likely representing hemorrhagic metastasis, causing mass effect on the fourth ventricle, with no evidence of obstructive hydrocephalus. . MR [**Name13 (STitle) 430**]: IMPRESSION: 1. There is a large left frontal intraparenchymal lesion that is predominantly hemorrhagic in nature. This lesion exhibits irregular contrast enhancement. There is significant edema associated with this lesion. This is concerning for metastatic disease as noted on prior report from the CT scan from [**2136-9-12**]. 2. There is also a lesion seen involving the cerebellum, also hemorrhagic in nature. This lesion exhibits more solid type enhancement. These findings are consistent with metastatic disease. 3. There are no other enhancing lesions identified. Brief Hospital Course: 78 M hypoglycemic/sz. CT large multi IPH with edema, mild MLS, no hydrocephalus. Neuro exam: right side weakness, esp RUE. . # Intracranial lesions: Neurosurgery recommended an operation for fluid evacuation and debulking given mass effect from the tumors. Decadron and Dilantin were started IV to decrease edema in setting of tumors and to prevent seizures, respectively. His wife and grandaughter (HCP) both decided that he would not want an operation. On [**9-12**] he was extubated without event and remained on Bipap until [**9-13**]. He remained stable on bipap despite marked discomfort from the mask and on [**9-13**], he was transferred to the MICU team for further management. Upon transfer, a family meeting was held during which the patient confirmed his desire for comfort measures only and no operation with hospice at home if possible. . # Respiratory distress: Intubated initially for airway protection and extubated without event on [**9-12**]. On [**9-13**], he declined further bipap and the mask was removed. At this time, his breathing became labored and a morphine drip was begun at his and his family's request. . # Dispo: The MICU team consulted palliative care upon transfer who recommended home with hospice and discussed plans for transfer to home on [**9-14**]. However, upon discontinuing the Bipap mask, the patient's respiratory distress worsened and he required a morphine drip for comfort. Per palliative care recommendations, goals of care were switched for continuing in-hospital care while on the morphine drip titrating to comfort. The patient expired on the morning of [**2136-9-14**] with family at the bedside. Medications on Admission: Theophylline, Ferrous Gluyconate (Fergon), Protonix 40mg/d, Lisinopril, Atorvastatin, prednisone. unknwon dose. Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "162.3", "443.9", "496", "198.3", "401.9", "431", "250.00", "780.39" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

6874, 6883

5015, 6679

419, 425

6934, 6943

2021, 3838

6999, 7009

1552, 1557

6842, 6851

6904, 6913

6705, 6819

6967, 6976

1573, 1842

271, 381

453, 1432

3847, 4992

1857, 2002

1454, 1476

1492, 1536

5,060

126,476

24282

Discharge summary

report

Admission Date: [**2178-7-21**] Discharge Date: [**2178-7-22**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2297**] Chief Complaint: OD, ETOH intoxication Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 33 y/o M with h/o polysubstance abuse and Hep C who presented today s/p overdose of 90 tabs Klonapin and 30 tabs tylenol #3 today (per EMS). Pt arrived via ambulance today to [**Hospital1 18**] ED with slurred speech, unable to stand, and on arrival to ED was lethargic, somnolent. Per paramedics, pt went to [**Hospital1 2177**] this am and filled prescription for Klonapin (90 tabs) and tylenol #3 (30 tabs) and took these pills with a fifth of vodka. Pt was found in [**Hospital1 778**] staggering, brought to [**Hospital1 18**] ED. Pt only admits to taking 30 tabs tylenol and did not admit to Klonapin OD; stated that he took the pills with "a lot of beer" and a fifth of vodka. Initial VS in ED with T 99.4 BP 96/43 R 13 Sat 93-95%RA, decreased to 52% RA per nursing notes after pt became more somnolent and was minimally responsive to sternal rub, also dropped O2 sats with apneic episodes. Given 2 mg IV narcan x 2 with good effect, pt awoke. Also given charcoal 25 gm with sorbitol, placed on CIWA Valium 20 mg IV and Banana bag and given 2 L NS. On admission to MICU, was without complaints except c/o "crawling out of my skin" and begging for a drink. Past Medical History: PMH: 1. Hepatitis C, reportedly as result of IVDU 2. h/o compartment syndrome in RLE in [**2171**] 3. h/o OCD and anxiety since childhood 4. h/o depression: current psychiatrist is Dr. [**Last Name (STitle) 60521**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. H/o SI but never a plan or an attempt, only hospitalized at [**Doctor Last Name 1263**] once. 5. h/o polysubstance use including EtOH with h/o withdrawal seizures (daily vodka drinker 1 pint-1 liter), h/o heroin IVDU, Klonapin, last detox at [**Location (un) **] house in [**Hospital1 392**]. Drinks alcohol regularly since age 18 with h/o numerous detox treatments (over 9). Longest period of sobriety was 9 months when he was in jail for possession charges. Social History: SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.): Has been homeless for the past 16 yrs. He was born and raised in [**Location (un) 1157**] by his father. His mother left and his parents were divorced when the pt was 2 yrs old. He has 1 sister. [**Name (NI) **] has not been in contact with his sister or father since [**2162**]. His mother died from complications of diabetes in [**2162**]. He received his GED. He states he stopped going to school because he had a "fear of crowds." Legal history: Reports that he was in jail for 9 months due to possession charges. He also reports a history of almost every infraction due to substance abuse. Family History: mother died of complications of DM in '[**62**]; has not been in contact with sister or father since [**2162**], Father with depression and alcoholism Physical Exam: PE: T 98.6 BP 123/67 P 90 R 10 Sat 95%RA Gen: alert, oriented to person and place, slurred speech, NAD HEENT: PERRL, EOMI, OP clear with MMM Neck: supple, NT, no LAD Pulm: CTA bilaterally CV: reg rhythm, tachy, no m/r/g Abd: s/nt/nd +BS Ext: no edema, no CT, +2 DP pulses bilat Neuro: CN 2-12 intact, no focal deficits Pertinent Results: [**2178-7-21**] 04:59AM GLUCOSE-74 UREA N-11 CREAT-1.0 SODIUM-138 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-24 ANION GAP-13 [**2178-7-21**] 04:59AM ALT(SGPT)-182* AST(SGOT)-170* ALK PHOS-63 TOT BILI-0.4 [**2178-7-21**] 04:59AM CALCIUM-8.2* PHOSPHATE-6.3*# MAGNESIUM-2.1 [**2178-7-21**] 04:59AM OSMOLAL-339* [**2178-7-21**] 04:59AM ACETMNPHN-23.9 [**2178-7-21**] 04:59AM WBC-5.7 RBC-4.18* HGB-12.6* HCT-36.8* MCV-88 MCH-30.1 MCHC-34.2 RDW-13.4 [**2178-7-21**] 04:59AM PLT COUNT-269 [**2178-7-21**] 04:59AM PT-14.3* PTT-32.0 INR(PT)-1.3 [**2178-7-20**] 11:30PM ACETMNPHN-47.5* [**2178-7-20**] 09:38PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2178-7-20**] 09:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2178-7-20**] 08:35PM GLUCOSE-96 UREA N-11 CREAT-1.4* SODIUM-140 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16 [**2178-7-20**] 08:35PM ALT(SGPT)-190* AST(SGOT)-164* ALK PHOS-80 TOT BILI-0.4 [**2178-7-20**] 08:35PM ASA-NEG ETHANOL-309* ACETMNPHN-45.7* bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2178-7-20**] 08:35PM WBC-5.4 RBC-4.50* HGB-13.7* HCT-39.6* MCV-88 MCH-30.5 MCHC-34.7 RDW-13.2 [**2178-7-20**] 08:35PM NEUTS-42* BANDS-0 LYMPHS-38 MONOS-14* EOS-2 BASOS-0 ATYPS-4* METAS-0 MYELOS-0 [**2178-7-20**] 08:35PM PLT COUNT-298# [**2178-7-20**] 08:35PM PT-12.9 PTT-27.7 INR(PT)-1.1 ECG: sinus tachycardia Brief Hospital Course: Hospital Course: 33 y/o M with PMH hep C and polysubstance abuse now present with acute EtOH withdrawal. 1. EtOH withdrawal - Patient admitted to the ICU from the ED with tachycardia and tremulousness characteristic of withdrawal with EtOH level in 300s. Given h/o withdrawal seizures and current signs/symptoms, we decided to treat with standing Ativan and Ativan prn per CIWA >10 (decided Ativan instead of valium since shorter acting and less likely to cause benzo intoxication b/c long-lasting effects). He recieved 2 doses then we opted to change his benzodiazepine to Valium given that his respiratory status was stable and was requiring frequent doses of Ativan. On [**7-21**], pt recieved a total of 90mg of Valium in a 24 hour period with 4-6mg of Ativan. His symptoms improved significantly and his Valium dose has been decreased to 10 mg PO BID and valium 10 mg q2hr prn per CIWA scale>10. He currently has a mild tremor upon discharge. In addition to the benzodiazepines, pt was given IV fluids and MVI/thiamine/Folate. 2. s/p OD Klonapin and tylenol w/ somnolence - +benzos and opiates were noted on tox screen with tylenol level of 45 initially at 4 and 8 hrs and subsequent level decreased to 27. Given that the initial levels were <150, pt was deemed not to have tylenol hepatotoxicity and did not require NAC. It was thought that his somnolence was more likely secondary to opiate overdose in combination with EtOH since pt more responsive s/p narcan therapy. Pt had psych consult in house who did not feel that pt's overdose was a suicide attempt. He is being discharged to a detox facility to receive treatment for alcohol withdrawal and will benfefit from psych follow-up as well for his depression. 3. Acute renal insufficiency - This was likely prerenal secondary to dehydation and decreased PO intake and his creatinine improved back to baseline after IV hydration. 4. Tooth pain - Pt complained of tooth pain and this is likely the reason that pt has been on pain medications. Dental consult was called but they were unable to see the pt prior to his discharge to detox facility. Pt was started on Peridex mouthwash and viscous lidocaine for relief of tooth pain. He was also empirically started on clindamycin which he should complete for a [**8-16**] day course for treatment of a possible tooth infection. The pt should have dental follow-up for his tooth pain and likely X rays as outpatient. He remained afebrile with no elevation in his wbc count throughout his hospital course. 4. FEN - pt was maintained on a regular diet. His lytes remained stable. 5. Code - full 6. Dispo - pt will be discharged to a detox facility so he can receive adequate treatment for EtOH withdrawal. Medications on Admission: 1. Thiamine 100 mg daily 2. Folic acid daily 3. MVI daily 4. Atenolol 25 mg daily Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Diazepam 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please give additional valium q2hr prn as needed for acute detox. 3. Chlorhexidine Gluconate 0.12 % Liquid Sig: One (1) ML Mucous membrane TID (3 times a day). 4. Lidocaine HCl 2 % Solution Sig: 10 mL MLs Mucous membrane TID (3 times a day) as needed for tooth pain. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital3 8063**] - [**Location (un) **] Discharge Diagnosis: 1. Acute alcohol withdrawal 2. Benzodiapene and opiate overdose Discharge Condition: STable Discharge Instructions: Please continue to take all medications as prescribed. Please return to the ED or call your PCP if you experience any worsening fevers/chills, nausea or vomiting, confusion or any other concerning symptoms. Followup Instructions: You should follow-up with a dentist to obtain appropriate evaluation and X rays for your tooth pain. You should obtain a PCP [**Name Initial (PRE) **] [**Name Initial (NameIs) 138**] [**Telephone/Fax (1) 250**] ([**Hospital **]) for an appointment. Completed by:[**2178-7-22**]

[ "969.4", "E850.4", "522.4", "291.81", "965.4", "070.70", "276.5", "V60.0", "E853.2", "305.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8592, 8662

5087, 5087

294, 300

8770, 8778

3609, 5064

9034, 9315

3095, 3248

7944, 8569

8683, 8749

7838, 7921

5104, 7812

8802, 9011

3263, 3590

233, 256

328, 1509

1531, 2283

2299, 3079

26,172

164,243

18983

Discharge summary

report

Admission Date: [**2182-4-22**] Discharge Date: [**2182-4-26**] Date of Birth: [**2107-11-13**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Zantac / Bactrim Attending:[**First Name3 (LF) 922**] Chief Complaint: Admitted for elective cardiac surgery Major Surgical or Invasive Procedure: [**2182-4-22**] Two vessel coronary artery bypass grafting(vein grafts to diagonal and posterior descending artery), Aortic Valve Replacement(23 millimeter pericardial Magna with Thermafix), and Replacement of Ascending Aorta and Hemiarch(30 millimeter Gelweave Graft). History of Present Illness: Mr. [**Known lastname **] is a 74 year old male with known CAD and AS/bicuspid valve. He has a history of a positive stress test and recently underwent cardiac catheterization which showed right dominant coronary circulation with a 70% stenosis in the diagonal artery with 90% lesion in the mid right coronary artery. Left ventriculography revealed a preserved ejection fraction and very calcified aortic valve with reduced mobility. There was severe aortic stenosis with aortic valve gradient of 57 mmHg and valve area of 0.6 cm2. A recent chest CT scanz([**2182-4-19**]) found dilatation of the ascending thoracic aorta. The aorta measured 4.4 x 4.9 cm at the level of the sinus of Valsalva. The aorta returned to [**Location 213**] caliber at the location of the ligamentum arteriosum. Outside ECHO in [**2182-2-10**] showed [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.8 cm2 with a mean gradient of 43 mmHg. Based upon the above results, he was admitted for cardiac surgical intervention. Of note, the CT scan in [**2182-4-10**] was also notable for a focal abdominal aortic dissection at the level of the renal arteries extending over approximately 3.5 cm. All the mesenteric vessels and the renal arteries originate from the true lumen. There is no extravasation of contrast from the aorta. Past Medical History: Coronary artery disease, Bicuspid Aortic Valve, Aortic Stenosis, Ascending Aortic Aneurysm, Abdominal Aortic Dissection, Hypertension, Elevated cholesterol, BPH, History of C. diff, s/p Right TKR, s/p PTCA of RCA Social History: Widowed, lives alone. 20 pack year history of tobacco, quit 20 years ago. Denies ETOH. He has 3 children. Family History: Denies premature CAD. Physical Exam: Vitals: BP 130/69, HR 67, RR 22, SAT 97% on room air General: well developed male in no acute distress HEENT: oropharynx benign, edentulous, MMM, PERRL Neck: supple, no JVD, transmitted murmur vs bruit noted bilaterally Heart: regular rate, normal s1s2, harsh SEM noted Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [**2182-4-17**] Carotid Ultrasound: Minimal plaque with bilateral less than 40% carotid stenosis. [**2182-4-19**] Chest, Abd, Pelvic CT Scan: 1. Focal abdominal aortic dissection at the level of the renal arteries extending over approximately 3.5 cm. All the mesenteric vessels and the renal arteries originate from the true lumen. There is no extravasation of contrast from the aorta. 2. Ascending aortic aneurysm. The abnormal dilatation begins at the level of the sinus of Valsalva and extends to the ligamentum arteriosum. There is no abdominal aortic aneurysm. [**2182-4-11**] Cardiac Cath: 1.Selective coronary angiography revealed a right dominant system with one vessel coronary artery disease. LMCA was free of angiographically apparent disease, LAD had minimal disease except for a 70% origin of a small D2 branch. LCX was without obstructive disease. The RCA had a 90% mid-vessel lesion. 2. Left ventriculography revealed a preserved ejection fraction and very calcified aortic valve with reduced mobility. 3. Hemodynamic assessment showed mildly elevated right sided filling pressures and normal left sided filling pressures with mild pulmonary hypertension. There was severe aortic stenosis with Ao valve gradient of 57 mmHg and valve area of 0.6 cm2. There was no mitral stenosis. [**2182-4-25**] 05:40AM BLOOD Hct-29.8* [**2182-4-23**] 03:24AM BLOOD WBC-12.9* RBC-3.97*# Hgb-11.2*# Hct-31.6* MCV-80* MCH-28.3 MCHC-35.6* RDW-16.8* Plt Ct-187 [**2182-4-25**] 05:40AM BLOOD UreaN-21* Creat-1.0 K-3.9 [**2182-4-24**] 07:49AM BLOOD Glucose-114* UreaN-19 Creat-1.1 Na-133 K-4.8 Cl-98 HCO3-24 AnGap-16 [**2182-4-24**] 07:49AM BLOOD Mg-2.1 Brief Hospital Course: On the day of admission, Dr. [**Last Name (STitle) 914**] performed coronary artery bypass grafting along with an aortic valve replacment and replacement of his acending aorta and hemiarch. The operation was uneventful and he was transferred to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. He maintained stable hemodynamics as he weaned from inotropic support. His CSRU course was uncomplicated and he transferred to the SDU on postoperative day one. He remained in a normal sinus rhythm and tolerated beta blockade. All chest tubes were gradually removed without complication. Over several days, medical therapy was optimized and he continued to make clinical improvements with diuresis. The rest of his postoperative course was routine and he was medically cleared for discharge on postoperative day four. At discharge, his BP was 120-130/60-70 with a HR of 80. His oxygen saturation was 95% on room air and the discharge chest x-ray showed only small bilateral pleural effusions with associated bibasilar atelectasis. All surgical wounds were clean, dry and intact. Medications on Admission: Folate 1 qd, Lipitor 40 qd, Cartia XL 180 qd, Gemfibrozil 600 [**Hospital1 **], Vitamin E, Ecotrin 81 qd Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO Q12H (every 12 hours): take with lasix - adjust accordingly, maintain K > 4.0 - please stop when Lasix discontinued. 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days: titrate accordingly, adjust for goal weight 84 kg - please stop when goal weight is reached. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Coronary artery disease, Bicuspid Aortic Valve, Aortic Stenosis and Ascending Aortic Aneurysm - s/p AVR, CABG, Replacement of Ascending Aorta; Focal Abdominal Aortic dissection, Hypertension, Elevated cholesterol, BPH, History of C. diff, s/p Right TKR, s/p PTCA of RCA Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [**Last Name (STitle) 914**] in [**5-15**] weeks. Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1689**] in [**3-15**] weeks. Local cardiologist, Dr. [**Last Name (STitle) 5293**] in [**3-15**] weeks. Completed by:[**2182-4-26**]

[ "428.0", "V43.65", "V45.82", "401.9", "441.2", "746.4", "414.01", "272.0" ]

icd9cm

[ [ [] ] ]

[ "36.12", "38.44", "99.04", "39.61", "99.07", "35.21", "89.60" ]

icd9pcs

[ [ [] ] ]

6863, 6940

4481, 5607

335, 607

7254, 7261

2807, 4458

7579, 7851

2328, 2351

5762, 6840

6961, 7233

5633, 5739

7285, 7556

2366, 2788

258, 297

635, 1952

1974, 2189

2205, 2312

16,674

108,255

31033

Discharge summary

report

Admission Date: [**2115-4-5**] Discharge Date: [**2115-4-11**] Date of Birth: [**2046-2-16**] Sex: F Service: CARDIOTHORACIC Allergies: Atenolol / Codeine / Enalapril / Inderal Attending:[**First Name3 (LF) 281**] Chief Complaint: 59-year-old with postintubation tracheal stenosis to evaluate the airway patency. Major Surgical or Invasive Procedure: flexible and rigid bronchoscopies History of Present Illness: 69F s/p trach [**10-6**] during hospitalization for COPD/asthma exacerbation. In coma x5wks and trached -> weaned over ~3months. [**12/2114**] developed cough and progressive SOB, treated for PNA in [**2-6**] and has been hospitalized 4-5 times since [**2-6**] for respiratory distress. Ct scans showing tracheal stenosis down to 0.9cm from 1.6cm prox/distal. Past Medical History: COPD, CHF, vocal cord polyps, GERD, HTN, dyslipidemia, macular degeneration PSHx: s/p trach [**2111**], s/p hysterectomy, s/p ccy, s/p wedge resection Social History: 100 pk year smoker-quit 4 yrs ago lives independently Family History: non-contibutory Physical Exam: PE: 97.7-84-133/72, 97% 3L Sitting comfortably in bed in NAD. Chest: CTA. able to talk in full sentences. COR: RRR S1, S2 ABD: soft, NT, ND, +BS. extrem: LE warm, no edema. nauro: alert and oriented x3 Pertinent Results: CXR [**4-9**]: Heterogeneous opacification at the base of the left lung has improved. This may represent either residual atelectasis or aspiration, and acute pneumonia is certainly not excluded. Lungs are otherwise clear. Heart size is normal. Narrowing of the lower cervical trachea is better evaluated by recent chest CT. BAL [**2115-4-8**]: Staph coag positive mod growth. Brief Hospital Course: Pt was admitted on [**2115-4-5**] w/ tracheal stenosis mainatined on steriods. Noted to have thrush-placed on fluconazole, nystatin and PPI's. Placed on BIPAP. Airway CT done consistent w/ Moderate upper tracheal stenosis, severely malacia. Severe generalized tracheobronchomalacia, main, right upper, and intermediate bronchi. Nonincarcerated, subsegmental, post-thoracotomy transthoracic lung hernia, anterior segment, left upper lobe. Moderate to severe centrilobular emphysema. Flexible bronch done on HD#3 w/ thickened 2nd/3rd ring; triangular shaped stenosis immed distal and posterior-micro and path sent. Old tear also noted at left posterior-lateral gutter. CT trachea w/ focal narrowing to 9mm at 3cm below the cordsand distal malacia. Post bronch pt became acutely SOB and required ICU admit for CPAP. Pt improved w/ positive pressure ventilation. Taken to the OR on HD#4 for silicone stent (16x20) placement. BAL [**2115-4-8**] staph coag postive-started on levoflox for 2 week course. Medications on Admission: prednisone, norvasc, crestor, prilosec, meprobamate, mvi, citrucel, quinine sulfate, albuterol, combivent, pulmicort, advair, singulair, flonase, spiriva Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 9. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily). 12. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) as needed for gerd. 15. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for copd. 16. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 17. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 18. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 19. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) as needed for oral / laryngeal [**Female First Name (un) **] for 9 days. 20. Levofloxacin 25 mg/mL Solution Sig: Five Hundred (500) mg Intravenous once a day for 2 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 38**] Discharge Diagnosis: fractured second and third tracheal rings - subglotic narrowing - left lower lobe pneumonia - inflamed vocal cords - h/o COPD, CHF, vocal cord polyps, GERD, HTN, dyslipidemia, macular degeneration - s/p trach '[**11**], hysterectomy, cholecystectomy Discharge Condition: deconditioned requires CPAP prn Discharge Instructions: you should eat a regular diet - you should be up and moving daily - you should gradually increase your activity as tolerated - you should take pain medication as needed - every day you take pain medication you should take a stool softener: colace, senna, or dulcolax are all good options - you may shower - call the interventional pulmonology office at ([**Telephone/Fax (1) 73295**] if T>101.5, chills, nausea, vomiting, chest pain, shortness of breath, productive cough -> with colored sputum or blood, abdominal pain, swelling in extremities, or any other concern Followup Instructions: *it is very important to make/keep the following appointments* - you should call and schedule a follow-up appointment with the interventional pulmonology service in 6 weeks for bronchoscopy. Please call the office at ([**Telephone/Fax (1) 73296**] to make this appointment. - you should schedule a follow-up appointment with your primary care physician as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 41081**] visit. This will be important to re-evaluate your chronic medicaitons and overall health. **you will need to call and confirm all appointments** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2115-4-17**]

[ "492.8", "482.41", "519.19", "519.02", "493.20", "E878.8", "401.9", "112.0", "519.09", "464.00", "530.81", "272.4" ]

icd9cm

[ [ [] ] ]

[ "33.24", "96.05", "33.23" ]

icd9pcs

[ [ [] ] ]

4860, 4941

1729, 2728

388, 423

5236, 5269

1328, 1706

5893, 6585

1074, 1091

2933, 4837

4963, 5215

2755, 2910

5294, 5870

1106, 1309

266, 350

451, 812

834, 987

1003, 1058

15,910

150,857

23925

Discharge summary

report

Admission Date: [**2138-3-4**] Discharge Date: [**2138-3-7**] Date of Birth: [**2078-12-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: BRBPR, chest discomfort Major Surgical or Invasive Procedure: administration of activated charcoal History of Present Illness: 59m with HTN, CRI, and a recent admit [**Date range (1) 46888**] for PUD-related UGIB and NSTEMI who now re-presents with one day's worth of BRBPR and some mild non-radiating chest pain. He was feeling well after his last discharge. On the day prior to admit, he began to feel some sharp upper abdominal pain about 10-15min after eating. This lasted about 45min, then resolved. The next am, he had the sx again for approximately 35min, again self resolving. Around 2pm, he felt he needed to have a normal BM, no abdominal pain, particular urgency, cramps, etc. He looked in the toilet afterwards and noted a normal brown BM, but there was red blood filling the toilet. About two hours later, he passed a small, regular, brown BM with no blood. He continues to have the sharp, intermittent upper abdominal pain, but it usually lasts no longer than a few seconds. He denies any LH, chest pain, dyspnea, cough, n/v, dysuria, hematuria. . In ED, was guaiac positive with bright red blood, his hct was 34, down from 36 at discharge, and his Tn was 0.05, down from 0.19. His ECG showed no changes. NG-lavage was negative, though also non-bilious. Past Medical History: -HTN -CAD: NSTEMI at last admit in setting of hct of 26; MIBI [**2138-2-24**] with fixed inferior defect -PUD: Has UGIB and EGD at [**Hospital1 1474**]; recent UGIB here, EGD [**2138-2-21**] with PUD, H. pylori +, on 3x tx -CRI: baseline cr around 1.9-2.1 -Gout Social History: Denies Tob, EtOH, or Illicit drug use. He is from [**Country 16573**]. Family History: Father and mother died at a young age of unknown causes. Denies FH of CAD of cancer Physical Exam: t 98.7, bp 180/100, hr 69, rr 16, spo2 99%ra gen- pleasant, well appearing, easily getting around room, nad heent- anicteric, op clear with mmm neck- no jvd, lad, or thyromegaly cv- rrr, s1s2, no m/r/g pul- moves air well, no w/r/r abd- soft, nt, nd, nabs, no hsm back- no cva/vert tendrn extrm- trace minimally pitting edema over shins, warm/dry nails- no clubbing, no pitting/color changes/indentn neuro- a&ox3, no focal cn/motor defct Pertinent Results: ECG: nsr, nl axis, nl intervals, laa, borderline lvh, TWI in limb leads, twi v4-v6, 1-2mm st-elevtn v1-v3; no major change from prior. . EGD [**2138-2-21**]: Small hiatal hernia. Patch of gastric mucosa in the esophagus. Ulcer in the anterior bulb. Otherwise normal EGD to second part of the duodenum. . Brief Hospital Course: A/P: In summary this is a 59 yo man with HTN, CRI, and a recent admit for a PUD-related UGIB and NSTEMI, who presented with BRBPR and chest pain. His hematocrit was stable during the stay, he was ruled out for an MI by cardiac enzymes. On the day of discharge, however, he became bradycardic and hypotensive after adjustments were made to his antihypertensive regimen and was briefly admitted to the ICU. . #BRBPR: Pt initially admitted to [**Hospital1 18**] on [**2138-3-4**] with a GIB following a one day history of BRBPR. Recent EGD revealed one ulcer, otherwise WNL. His hematocrit was stable during the hospital stay. He will follow up with GI as an outpatient for a colonoscopy and continue the medications already prescribed for his PUD. . #Chest Pain: Had intermittent chest pain on the day of admission. He was ruled out by cardiac enzymes. . #Bradycardia/Hypotension: On [**2138-3-6**] Mr. [**Known lastname 60983**] received three anti-HTN (75mg Metoprolol, 120 mg Nifedipine CR, & 40mg Lisinopril) medications simultaneously at breakfast and developed bradycardia & hypotension. Toxicology was consulted and he was treated c IV hydration, PO Charcoal and IV Glucagon & Calcium Gluconate. He vomited s/p PO Charcoal intake and had a brief episode of unresponsiveness. During this event the pts EKG waveform changed from NSR to a junctional escape rhythm. The pt was then brought to MICU 6 for evaluation where he has had an uneventful night/morning. His blood pressure and heart rate remained stable. On the day of discharge he was started on a metoprolol 25 mg [**Hospital1 **] and tolerated the first dose. . Follow-up appointments include an episodic appointment in 4 days for BP check, appointment with a new primary care physician, [**Name10 (NameIs) **] GI follow-up. Medications on Admission: -Pantoprazole 40mg [**Hospital1 **] -Amoxicillin 500mg [**Hospital1 **] to finish [**3-10**] -Clarithromycin 500mg [**Hospital1 **] to finish [**3-10**] -Simvastatin 40mg daily -Metoprolol 50mg [**Hospital1 **] Discharge Medications: 1. Amoxicillin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days: Continue till [**3-10**] as previously prescribed. 2. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days: Continue till [**3-10**] as previously prescribed. 3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Lower gastrointestinal bleeding Hypertension Transient Hypotension related to medications (calcium channel blocker overdose) Discharge Condition: Good Discharge Instructions: You were admitted with bright red blood in your bowel movement. This absolutely needs to be followed up with a colonoscopy. You have been scheduled to have a colonoscopy at the [**Hospital1 771**] on [**3-13**] at 8:30 AM. . In order to prepare for the colonoscopy, you must drink a special fluid the day before. You will have a lot of liquid bowel movements during this time. This is necessary for the colonoscopy. You also should have nothing to eat after midnight (12AM) on the morning of the colonoscopy. . You also have high blood pressure. As we discussed, your high blood pressure is having damaging effects on your kidneys and your heart. It is extremely important that you take medications to control your blood pressure and that you check your blood pressure regularly. You were started on several new blood pressure medications, but they dropped your blood pressure too quickly and were stopped. You blood pressure medication is: Metoprolol 25mg twice a day . You have been prescribed other medications for your stomach ulcers which are listed below. . You have a follow-up appointment with Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 60984**], MD Phone:[**Telephone/Fax (1) 250**] on [**2138-3-11**] at 2:00 PM for a blood pressure check and to make any necessary adjustments to your medications. You have an appointment with Dr. [**Last Name (STitle) **] (your new primary care physician) on [**3-25**]. . Additional follow-up appointments are listed below. . You should contact your physician or go to the Emergency Department if you feel lightheaded, particularly when you stand, or dizzy, or have bloody stools. You should go to the Emergency Department if you lose consciousness, have chest pain or shortness of breath. Followup Instructions: Provider: [**Name10 (NameIs) 3816**] [**3-11**] with Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 8360**] at 2PM in [**Location (un) **] of [**Hospital Ward Name 23**], South Suite for follow up visit after your hospital stay. Please call [**Telephone/Fax (1) 250**] to reschedule or for directions. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 8360**] will not be your new primary care doctor. Your next appointment on [**3-25**] with Dr. [**Last Name (STitle) **] is to establish a new doctor. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 7091**] Date/Time:[**2138-3-13**] 9:30 Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2138-3-13**] 9:30 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 14712**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2138-3-25**] 1:30 ([**Hospital Ward Name 23**] Building)--please call prior to your appointment for directions Completed by:[**2138-3-7**]

[ "584.9", "E947.8", "458.29", "585.9", "578.9", "403.90", "410.72" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5445, 5451

2826, 4625

337, 376

5620, 5627

2497, 2803

7440, 8468

1938, 2023

4887, 5422

5472, 5599

4651, 4864

5651, 7417

2038, 2478

274, 299

404, 1547

1569, 1833

1849, 1922

57,081

141,047

52336

Discharge summary

report

Admission Date: [**2172-3-24**] Discharge Date: [**2172-4-6**] Service: MEDICINE Allergies: Lipitor / Amoxicillin / Erythromycin Base / Sulfa (Sulfonamide Antibiotics) / Procainamide / Zocor Attending:[**First Name3 (LF) 2290**] Chief Complaint: C. diff colitis Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is an 88 year-old gentleman with a history of prostate cancer currently undergoing hormonal therapy, diastolic CHF, atrial fibrillation not on aspirin/plavix only, PAD, who presents with a one-day history of feeling poorly and fever. He was recently admitted to [**Hospital1 18**] with dysuria/hematuria where he was in the ICU initially and called out to [**Hospital Ward Name **] hospitalist. He was found to have UTI with quinolone-resistant E. coli and proteus organisms and treated with 10-day course of cefepime which ended on [**2172-3-22**]. His PICC line was pulled [**2172-3-23**]. Early this morning he was noted by staff to be febrile to T 103. He began feeling "lousy" last night, at which time he had some transient SOB and chills (of note, he has recently been using O2 by NC at [**Hospital1 1501**] at nights). He also noticed dry cough this morning, although this has been "on and off" for several weeks. He had an episode of loose stool last week while on antibiotics, but last BM was yesterday and normal, no blood. He has occasional dysuria which has been attributed to pain from urethral strictures that occurs on occasion (brief episode yesterday, now resolved). He has an indwelling foley catheter given his prostate cancer. He also had some "aching" left upper arm pain that came on suddenly yesterday and has been off and on. He received 650 mg PO acetaminophen at [**Hospital1 1501**] prior to transfer to ED. Past Medical History: - Asbestosis with numerous pleural plaques (RUL mass seen on [**8-/2171**] admission, thoracic surgery recommended repeat CT scan) - Spinal stenosis, severe C3-C4 and C6-C7 - Atrial fibrillation (not on coumadin secondary to falls) - CAD - '[**52**] BMS to mid RCA, '[**64**] DES to mid RCA - Diastolic CHF - [**11-25**] EF 55%, LA mod dilated, mild LVH, RV normal, aortic root mildly dilated, no AS, no AI, trivial MR, mod pHTN - PAD - s/p stent to RLE SFA in [**12-25**] - H/o bladder cancer in [**2166**](s/p local resection) - hx of urethral stricture requiring permanent indwelling foley - h/o prostate CA (s/p external beam radiation and Lupron injections; undergoing treatment with Leuprolide Acetate 22.5 mg IM planned for Q12 weeks) - Recurrent UTIs - Patient has a h/o of MRSA & Proteus UTI in [**12-26**] as well as STENOTROPHOMONAS, sensitive to bactrim and ENTEROCOCCUS SP, [**Last Name (un) 36**] to vanco in [**8-26**]. Multiple pseudomonas UTIs in past, most were fairly sensitive. - COPD: Obstructive profile (emphysema) on PFTs [**2164**] Social History: He is widowed since the death of his wife two years ago. He now lives at a skilled nursing facility (Genesis in [**Location (un) **]; 932 [**Last Name (LF) **], [**First Name3 (LF) **] MA, [**Telephone/Fax (1) 90219**]). Denies current alcohol, IVDU, or smoking. He smoked cigarettes in the past, but quit 45 years ago. Had "slight" asbestos exposure during WWII. Previously worked as a foreman for the city of [**Location (un) 3146**] in plumbing/sewer. Has 3 children, son [**Name (NI) **] [**Name (NI) **]. (HCP), daughter [**Name (NI) 1439**], [**First Name3 (LF) **] [**Name (NI) **] who are all involved in his care. Family History: Mother: had heart problems Father: had heart problems Brother: died from prostate cancer Brother: died from MI Physical Exam: ADMISSION: VS: T 100.5, BP 114/39, HR 81, RR 24, 100% on 4L GEN: Elderly Caucasian gentleman awake in bed, NAD, weak with attempting to sit up, dozing off during conversation, mildly hard of hearing HEENT: PERRL, EOMI, dry mucous membranes including flaking skin on lips and roof of mouth (uses dentures but they are at [**Hospital1 1501**]) NECK: JVP difficult to assess given body habitus; appears to be above clavicle PULM: End-expiratory wheeze on exam at bases bilaterally, shallow inspirations, patient has difficulty complying with complete lung exam but there is questionable egophony at bases, dry crackles at left base CARD: RRR, no appreciable M/R/G ABD: Resolving ecchymoses over lower abdomen consistent with SQ heparin injections, mildly distended, non-tender, +NABS EXT: Weak left DP pulse, right DP difficult to palpate but clear with Doppler. Trace pedal edema. SKIN: Healing ulceration on medial aspect of right heel, skin is healing over (no open sore, no oozing). NEURO: Oriented x 3 (can name [**Hospital1 **], can state day of week) PSYCH: Appropriate mood and affect . DISCHARGE: VS: Tc 98.4; Tm 98.4; BP 114/58 (113-130/52-60); HR 88 (72-88); RR 18 (18-20); O2Sat 96% RA (88-96% RA) GEN: Well nourished elderly man; Alert and oriented; pleasant; NAD HEENT: NC/AT; no conjunctival pallor or injection; no scleral icterus; EOMI, PERRL, dry MM, OP clear NECK: JVP~10cm; no JVD; supple, trachea midline PULM: bibasilar crackles 1/3 up; good air movement throughout; no IWOB, speaking in full sentences CV: RRR, no appreciable m/r/g, nl S1 and S2 ABD: mildly distended but soft; tympanic; +BS; mild tenderness to deep palpation LLQ, no rebound EXT: no clubbing/cyanosis; scant pedal edema; no calf tenderness; passive dorsiflexion non-tender DERM: Healing ulceration on medial aspect of right heel NEURO: AAOx3; CN II-XII grossly intact; moving all limbs PSYCH: Appropriate mood and affect Pertinent Results: Admission Labs: [**2172-3-24**] 08:35AM WBC-5.4 RBC-3.09* HGB-9.0* HCT-27.6* MCV-89 MCH-29.0 MCHC-32.5 RDW-15.8* [**2172-3-24**] 08:35AM NEUTS-88.5* LYMPHS-4.4* MONOS-3.9 EOS-2.7 BASOS-0.5 [**2172-3-24**] 08:35AM GLUCOSE-98 UREA N-29* CREAT-1.7* SODIUM-141 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-29 ANION GAP-14 [**2172-3-24**] 08:35AM ALT(SGPT)-10 AST(SGOT)-19 ALK PHOS-76 TOT BILI-0.2 [**2172-3-24**] 09:03AM LACTATE-2.2* [**2172-3-24**] 09:31AM PT-13.4 PTT-26.1 INR(PT)-1.1 [**2172-3-24**] 09:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2172-3-24**] 09:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM [**2172-3-24**] 09:00AM URINE RBC-3* WBC-10* BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-<1 [**2172-3-24**] 09:00AM URINE GRANULAR-1* HYALINE-4* [**2172-3-24**] 09:00AM URINE MUCOUS-RARE [**2172-3-24**] 08:35AM proBNP-617 . Discharge Labs: [**2172-4-6**] 07:03AM BLOOD WBC-3.6* RBC-3.23* Hgb-9.7* Hct-28.4* MCV-88 MCH-30.1 MCHC-34.3 RDW-15.3 Plt Ct-235 [**2172-4-6**] 07:03AM BLOOD Glucose-96 UreaN-32* Creat-3.1* Na-140 K-4.3 Cl-101 HCO3-29 AnGap-14 [**2172-4-6**] 07:03AM BLOOD Calcium-8.4 Phos-5.2* Mg-2.2 . Urine: [**2172-4-4**] 02:26PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM [**2172-4-4**] 02:26PM URINE RBC-4* WBC-5 Bacteri-FEW Yeast-MANY Epi-<1 RenalEp-<1 [**2172-4-4**] 02:26PM URINE Hours-RANDOM Creat-99 Na-45 K-50 Cl-20 Creatinine trend: [**3-31**] 2.6 -> [**4-3**] 3.0 -> [**4-4**] 3.2 -> [**4-5**] 3.1 -> [**4-6**] 3.1 URINE CULTURE (Final [**2172-3-25**]): <10,000 organisms/ml. . Micro: [**2172-3-29**] CLOSTRIDIUM DIFFICILE TOXIN A & B: Positive URINE CULTURE (Final [**2172-3-25**]): <10,000 organisms/ml. Blood Cx [**2172-3-24**]: No Growth Blood Cx [**2172-3-28**]: No Growth . Studies: [**2172-3-24**] Portable AP CXR: IMPRESSION: No acute cardiopulmonary process. . [**2172-3-26**] Radiology CHEST (PA & LAT): IMPRESSION: Stable chest findings, no evidence of new acute infiltrates. . [**2172-4-4**] Radiology RENAL U.S.: IMPRESSION: No hydronephrosis. . Cards: [**2172-3-16**] Cardiology ECG: Sinus rhythm. Prolonged Q-T interval. Rate 74; PR 130; QRS 82; QT/QTc 448/472 [**2172-3-31**] Cardiology ECHO (TTE): The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. 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. Physiologic mitral regurgitation is seen (within normal limits). There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. Compared with the prior study (images reviewed) of [**2170-11-22**], findings are similar. Brief Hospital Course: Mr. [**Known lastname **] is an 88 year-old M with multiple medical problems including prostate cancer, dCHF, CAD s/p stents, PAD, COPD who presented with fever and hypotension concerning for early sepsis. He was initially admitted to the ICU, where blood pressure remained stable after 3L of IVF in the ED without the use of pressors. He was called out to the floor on [**2172-3-26**] (HOD3). On HOD5 the pt was found to be C. diff positive and started PO vancomycin. . #) C. Diff colitis The patient's initial presentation of hypotension in the setting of fever was concerning for possible sepsis. On arrival to the ED, respiratory rate was 24 and temperature in the ED was 101.1, meeting SIRS criteria. He received 3L of IVF in the ED, and on arrival to the ICU pressures were stable with SBPs > 100. He was begun on vancomycin and cefepime for emperic coverage of suspected infection (HOD1). Due to continued hemodynamic stability, the patient was transferred to the floor on HOD3. Urine cultures from admission were negative, and the pt's cefepime was discontinued on HOD3. The vancomycin was continued until blood cultures were negative for 48 hrs, and was discontinued on HOD4. On HOD5 the pt had his first BM in the hospital, which was found to be C. diff positive. C. diff infection unified the pt's LLQ tenderness, recent h/o antibiotics, recent h/o diarrhea, and episodic fevers. He improved quickly with PO vancomycin, and remained hemodynamically stable and afebrile for the remainder of this admission. - recommend continuing PO vancomycin to finish 14 day course (last day of treatment [**2172-4-12**]) - recommend C. Diff precautions - recommend serial abdominal exams and standing aggressive bowel regimen . #) Hypoxia: Review of records in OMR reveal PFTs with obstructive pattern consistent with emphysema in [**2164**]. Patient was not aware of this diagnosis nor is he on medications at home for COPD, so it seems that prior symptoms have been mild. Mr. [**Known lastname **] did not complain of subjective SOB and was able to maintain O2 sats in the mid-to-upper 90s on room air after admission to the ICU (was 92% on arrival to the ED). Given wheezing on exam, he received albuterol and ipratropium nebs PRN. On HOD3 the patient began to have an increasing O2 requirement. He was restarted on his home lasix therapy since it had been held since admission given hypotension. His dyspnea slowly improved with diuresis, and serial CXRs remained reassuring against pneumonia or florid pulmonary edema. He was also converted to standing ipratroprium/albuterol nebs. On HOD10 the patient reported return to his baseline, and he no longer required supplemental O2 during the days. By his report, the pt requires occasional supplemental O2 at his facility during nights. From HOD10 to discharge the patient's respiratory status remained stable at his baseline (O2 sats 88 to 97% on RA, 94 to 97% on 2L NC). - Recommend continuing albuterol and ipratropium nebs PRN for wheezing or shortness of breath . #) Acute on chronic renal failure Creatinine on admission was at the upper end (1.7) of recent baseline range of 1.3 to 1.7. This was likely secondary to poor forward flow in the setting of hypotension and chronic diastolic heart failure. The patient's home lasix was stopped in the MICU due to hypotension, and his creatinine trended down to 1.5 by HOD3. Due to worsening peripheral edema, crackles on exam, and increasing O2 requirement, lasix was restarted on HOD3. Given that the pt's respiratory status improved substantialy with diuresis, an increase in creatinine was tolerated. Creatinine increased to 3.2 by HOD12, and renal was consulted. It was felt that the pt was hypovolumic given bland sedement and low FeUrea. He was transfused 2 units of pRBC (HOD12-13) given his need for intravascular volume and pre-existing baseline anemia. Creatinine stabilized by HOD13, and trended down by discharge to 3.1. - Recommend checking creatinine weekly. Pt has scheduled follow-up with nephrology. . #) Anemia Hct was 27 on admission which is stable from his recent discharge. His Hct has ranged from 25 to 28 during this admission. He was transfused 2 units of pRBC on HOD13-14 per nephrology's recommendations. His crit was stable at 28 upon discharge. . #) Leukopenia Likely secondary to demargination in a setting of poor physiologic reserve. Given his h/o anemia, possible underlying component of MDS. Patient's WBC has ranged from 2.8 to 3.6. Was never neutropenic. Trending up at time of discharge to 3.6. . #) History of recurrent UTIs Will likely remain a problem with future care given indwelling foley. Followed by Dr. [**Last Name (STitle) **] of urology at [**Hospital1 18**]. Urology consult team was notified of patient's admission and recommended holding off on changing out the Foley in the setting of inactive infection. Patient will follow up as outpatient [**2172-4-16**] with Dr. [**Last Name (STitle) **]. . #) Diastolic CHF Last echo [**11/2170**] showed preserved EF > 55%. BNP last admission elevated at 2385 from baseline < 1000; this admission BNP was lower at 617. Lasix was initially held in the setting of fluid rescusitation and fever, as patient appeared dry on exam. Lasix was restarted on HOD3 at 40mg PO given worsening peripheral edema, crackles, and increase in O2 requirement. With diuresis the patient's hypoxia resolved, and his signs of heart failure improved. At the time of discharge, he appeared euvolemic by exam with baseline O2 requirement. He was given 2 units of pRBC HOD13-14 for ARF on CKD and tolerated the additional volume well. - Recommend continuing home dose of lasix after discharge. . #) Atrial Fibrillation Patient was in NSR on admission. He is not anticoagulated given his history of recurrent falls. He is not on any meds for rhythm or rate control at baseline at this time, though per family he may have been on rate-control agents in the past. He was continued on aspirin and Plavix and monitored on telemetry while in the ICU. On the floor he remained in NSR. - Consider beta blocker as an outpatient for rate control if needed . #) CAD Status post [**2152**] BMS to mid RCA, [**2164**] DES to mid RCA. No evidence of acute ischemic change on EKG. Has allergy to statin. He was continued on aspirin and Plavix during this admission. - Recommend adding beta blocker as an outpatient if patient can tolerate . #) Prostate Cancer On admission was day #20 of Leuprolide Acetate 22.5 mg IM planned for every 12 weeks x 2 cycles per OMR. Followed by Dr. [**Last Name (STitle) **] of oncology. He will follow up as outpatient. . #) Right Heal Ulcer Appears to be healing well. Wrapped as at [**Hospital1 1501**] with dry gauze. Waffle boots were used to minimize pressure sores on this admission. Medications on Admission: - Asbestosis with numerous pleural plaques (RUL mass seen on [**8-/2171**] admission, thoracic surgery recommended repeat CT scan) - Spinal stenosis, severe C3-C4 and C6-C7 - Atrial fibrillation (not on coumadin secondary to falls) - CAD - '[**52**] BMS to mid RCA, '[**64**] DES to mid RCA - Diastolic CHF - [**11-25**] EF 55%, LA mod dilated, mild LVH, RV normal, aortic root mildly dilated, no AS, no AI, trivial MR, mod pHTN - PAD - s/p stent to RLE SFA in [**12-25**] - H/o bladder cancer in [**2166**](s/p local resection) - hx of urethral stricture requiring permanent indwelling foley - h/o prostate CA (s/p external beam radiation and Lupron injections; undergoing treatment with Leuprolide Acetate 22.5 mg IM planned for Q12 weeks) - Recurrent UTIs - Patient has a h/o of MRSA & Proteus UTI in [**12-26**] as well as STENOTROPHOMONAS, sensitive to bactrim and ENTEROCOCCUS SP, [**Last Name (un) 36**] to vanco in [**8-26**]. Multiple pseudomonas UTIs in past, most were fairly sensitive. - Obstructive profile (emphysema) on PFTs [**2164**] Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. calcium carbonate-vitamin D3 600 mg(1,500mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for fever or pain. 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: Please alternate 1 tablet (20mg) and 2 tablets (40mg) every other day. 6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. [**Year (4 digits) **] 8.6 mg Capsule Sig: Two (2) Tablet PO at bedtime. 12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) PO twice a day as needed for constipation. 13. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 14. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 16. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 17. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for constipation. 18. trazodone 50 mg Tablet Sig: [**1-19**] Tablet PO at bedtime as needed for insomnia. 19. Cranberry Concentrate 500 mg Capsule Sig: One (1) Capsule PO twice a day. 20. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 21. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days: Last day of treatment [**2172-4-12**] to finish a 14 day course. 22. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: Primary: Cdiff colitis Secondary: h/o prostate cancer with urethral strictures A-fib CAD CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you in the hospital. You were admitted to the hospital because of fever and low blood pressure. You were initially admitted to the ICU for closer monitoring, but quickly tranferred to the General Medicine Service given your clinical improvement. You were found to have an infection in your colon by a bacteria called C. difficile. To treat this infection, you were started on a powerful oral antibiotic called vancomycin for a total course of 14 days. Also during this admission you had worsening kidney function which is likely a result of multiple causes including the infection in your colon, and the diureses you require for treatment of chronic heart disease. You were given two blood transfusions to help treat your heart condition, your kidney function, and to improve your anemia. At the time of discharge your renal function stabilized and began to improve. Given your heart condition, please maintain a low salt diet (less than 2 grams of sodium per day). Also, you should weigh yourself daily; call your doctor if your weight increases by more than 3 pounds. The following changes were made to your medications: 1) Oral vancomycin was ADDED to your regimen, 125mg capsule every 6 hours to finish a 14 day course (last day of treatment [**2172-4-12**]) 2) Your pantoprazole was STOPPED and you were started on famotidine, 20 mg by mouth daily. You have 4 scheduled appointments that you should keep for follow-up. Please see below for further details. Followup Instructions: You have 4 scheduled appointments: Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**] Date/Time:[**2172-4-16**] 11:30 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD,PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 22**] Date/Time:[**2172-5-28**] 10:30 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2172-6-23**] 9:00 Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2172-4-29**] at 4:30 PM With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage NOTE*****This date was the soonest they had available however they are searching for a sooner appt. When one becomes available, they will call you at home with an appt. Completed by:[**2172-4-6**]

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Discharge summary

report+report+addendum

Admission Date: [**2148-9-14**] Discharge Date: [**2148-9-19**] Date of Birth: [**2092-4-12**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 56-year-old female with past medical history of mast cell activation disorder, chronic abdominal pain, who presented with her typical symptoms. She began experiencing epigastric pain radiating to her back two days ago. This pain is very typical of previous episodes of her chronic pain syndrome. She was recently hospitalized from [**2148-8-25**] to [**2148-8-28**] with similar symptoms. She was treated with IV Dilaudid, was NPO, received antiemetics, and had good results. She complained of nausea, vomiting, no diarrhea with no shortness of breath, throat tightness, or symptoms of anaphylaxis. Denied any fevers, chills, or diarrhea. PAST MEDICAL HISTORY: 1. Patient has mast cell activation disorder manifesting as chronic abdominal pain status post multiple admissions in the past. Extensive workup: She has had ERCPs x5, is status post cholecystectomy, sphincterotomy, liver biopsy. 2. Raynaud's syndrome. 3. Hypertension. 4. Foot neuropathy. 5. History of salmonella enteritis. 6. History of non-ST-segment myocardial infarction from a prior hospitalization in which the patient received gadolinium, developed anaphylaxis, received Epinephrine, and developed a MI causing troponins to rise to 20. 7. Carpal tunnel syndrome. 8. Depression and anxiety. 9. Coronary artery disease with an ejection fraction under echocardiogram done on [**2147-11-3**] at 35%. FAMILY HISTORY: She has a family history of heart attacks, but no cancer or diabetes. SOCIAL HISTORY: She works as an Emergency Room technician at [**Hospital3 **], currently going through a divorce. Denies any tobacco or alcohol. ALLERGIES: 1. Compazine. 2. Droperidol. 3. Sulfa drugs. 4. Gadolinium. 5. Epinephrine causes vasospasm leading to a MI. 6. Demerol. 7. Morphine should be avoided because of degranulation of mast cells. MEDICATIONS ON ADMISSION: 1. Lisinopril 2.5 mg q.d. 2. Effexor 150 mg q.d. 3. Protonix 40 mg q.d. 4. Diltiazem 120 mg q.d. 5. [**Doctor First Name **] 180 mg q.d. 6. Ranitidine 300 mg q.d. 7. Colace 100 mg b.i.d. 8. Cromolyn 200 mg q.i.d. 9. Benadryl 25 mg prn. PHYSICAL EXAMINATION: On physical exam, she was afebrile at 98.3. Blood pressure was 145/100. Pulse was 103 and she was sating at 100% on room air. The patient was very somnolent, but easily arousable to voice. Her eyes were closed. She had been receiving IV Dilaudid for pain. Her pupils were equal and reactive. Her extraocular movement was intact and her mucous membranes were dry. Her neck is full, had no JVD and she had tenderness in her posterior scalp muscles and also tenderness around her deltoid muscles around the posterior of her neck. The pain appeared to be musculoskeletal in origin. Her lungs were clear bilaterally. She had no wheezes. She had a regular, rate, and rhythm with normal S1, S2, and a soft systolic flow murmur. Her abdomen was diffusely tender to percussion and palpation, but she had no rebound. No guarding was purely voluntary, no involuntary guarding, and she had no hepatomegaly or splenomegaly. Her extremities showed no edema and no rashes. Neurologic examination was nonfocal. LABORATORIES: The patient's initial laboratories were completely normal. She had a normal CBC, white count is 7.7. Her Chem-7 was completely normal. Her LFTs were normal and her urinalysis was normal. She had a x-ray of her abdomen, which found no free air, no obstruction. Chest x-ray showed no CHF and no infiltrates. HOSPITAL COURSE: The patient was started and continued with IV fluids at 1/2 normal saline at 100 an hour. The patient was given Dilaudid 1-4 mg IV q.4-6h. prn for pain, lorazepam 0.5 to 2 mg IV q.4h. for nausea, Zofran 4 mg IV q.8h. for nausea, famotidine 50 mg IV t.i.d., and methylprednisolone 100 mg IV q.8h. The patient continuously took IV Dilaudid and received adequate pain control. However, that evening the patient developed severe chest pain. Her EKG showed no changes and the pain subsided with additional Dilaudid. She was ruled out for MI using cardiac enzymes. The following day the patient's LFTs spiked. She had an ALT of 369, an AST of 313, an alkaline phosphatase of 145, amylase and lipase were 64 and 47. She had a T bilirubin of 0.3. After talking to the patient's attending, found out that this was typical of her abdominal pain in which she developed severe abdominal pain after admission and on admission day two, she develops high LFTs. The following day the patient once again reported feeling chest pressure radiating to her back. She was once again given IV Dilaudid and lorazepam and also nitroglycerin. Her EKG was normal. The pain subsided, but then the patient developed a bronchospasm in which she developed severe wheezes, and could not move air in and out of her lungs. However, she remained able to speak. The patient had diffuse itchiness and tightness in her throat. On physical exam, her lungs showed wheezes. She remained sating at 100%. She was given famotidine at 20 mg IV x1, Benadryl 50 mg IV x1, and hydrocortisol 100 mg IV x1. Soon, the patient began feeling much more comfortable and the wheezes greatly improved. The tightness in her throat resolved also. The patient's course in the MICU was uneventful. She was observed and had no events. The patient was once again brought to the floor and on the floor shortly after being admitted, she developed yet another episode of anaphylaxis. It was treated the same way as the first one. However, the patient self administered herself a shot from her EpiPen, and symptoms resolved. She was taken once again to the Intensive Care Unit. In the Intensive Care Unit, once again, she remained stable, and she was brought back to the floor. On the floor, her abdominal pain began improving using the coarse of IV Dilaudid, bowel rest, and the antiemetics. The patient's Gastrocrom was increased to 300 mg p.o. q.i.d., and she was started on a constant dose of Benadryl 25 mg q.6h. The patient's LFTs improved. Also of note, is a trend in her eosinophils upon admission they were 12.2% when they spiked up to 20% and at this point they were back down to 0.4%. The patient was changed from IV Dilaudid to p.o. Dilaudid on her final day of hospitalization. On her final day of hospitalization, her ALT was 211, AST was 63, LD was 167, alkaline phosphatase was 145, and amylase was 63. The patient was also started on prednisone at 40 mg q.d. The rest of the dictation will be done as an addendum later on tonight. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 21723**] Dictated By:[**Last Name (NamePattern1) 18596**] MEDQUIST36 D: [**2148-9-19**] 16:46 T: [**2148-9-23**] 09:36 JOB#: [**Job Number 23027**] Admission Date: [**2148-9-14**] Discharge Date: [**2148-9-20**] Date of Birth: [**2092-4-12**] Sex: F Service: Medicine Addendum to a discharge summary, the summary was interrupted because the patient was experiencing abdominal pain and anxiety complicating her discharge process. Concerning the patient's second episode of anaphylaxis on [**2148-9-17**], the patient had eaten a cheeseburger for dinner and shortly afterwards reported increasing abdominal pain followed by shortness of breath. She was given IV Benadryl, famotidine, self administered epinephrine from an Epi-Pen and was transferred to the ICU. The epinephrine from the Epi-Pen caused a stop of the attack of anaphylaxis. In the intensive care unit her prednisone was increased to 20 mg p.o. q.d. and her diet was changed to a lactose-free, red meat-free diet. She also had a triptase level sent out. The patient's stay in the intensive care unit was uneventful, although she was distraught over psychosocial stressors such as marriage discord regarding her separation from her husband. She was ordered back to the regular floor on [**9-19**] where here abdominal pain she graded as 2 to 3 out of 10, however, it still required Dilaudid 2 to 3 mg IV q2 to 3 hours. Soon after that because the pain was so well controlled it was decided that the patient should give a trial of p.o. Dilaudid 1 to 2 mg every 2 to 3 hours. The patient tolerated that well and was ready for discharge that afternoon. However, shortly before discharge the patient starting complaining of abdominal pain. She was given two tablets of Percocet and after 5 minutes she said the pain had gotten worse to 7 out of 10. The pain was radiating to her chest from back. She was nauseous, but no vomiting or diaphoresis. Blood pressure was 150/90, pulse 80 and respiratory rate 22. On physical examination she had a regular rate and rhythm with 2/6 systolic murmur, unchanged. Her lungs were clear bilaterally and her abdomen was tender to palpation, no rebound, no voluntary guarding. An EKG done showed no changes from previous exam and no ST changes. The patient began talking about her life was falling apart and began crying. She denied any suicidal ideation. The patient called her psychiatrist and then we were able to obtain the patient's consent to contact him [**Name2 (NI) 23028**]. His name is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21721**], and his phone number is [**Telephone/Fax (1) 21750**], pager number [**Telephone/Fax (1) 23029**]. We talked to Dr. [**Last Name (STitle) 21721**], who faxed an up to date listing of her psychiatric medications and advised that we do not let her sign out in a distraught state. He informed us that she is under many psychosocial stressors with a strong psychiatric history, so therefore she was a suicide risk, even she denied any suicidal ideation at the time. We called a stat psychiatric consult and the patient was put on one to one. Regarding her chest pain an EKG was done and it showed no changes from previous exam, so it was decided that this chest pain was not of cardiac origin, but merely referred pain from her abdomen. The psychiatric consult recommended that we re-start the patient's medications that she never informed us of, which include Klonopin 0.5 mg q.a.m. and q.afternoon with 1 mg of Klonopin before bedtime, also Remeron 15 mg p.o. q.h.s. and we increase her dose to her current dose of Effexor, which is should be of 225 mg p.o. q.h.s. We were instructed by the psychiatric consult that the patient should not be allowed to sign out that night without seeing the attending the next morning. That night the patient's pain was controlled with Percocet one to two tablets every 4 to 6 hours and breakthrough pain was controlled by 5 mg of Oxycodone every 4 to 6 hours, however, the Percocet was the first line medication. The patient slept well that night with the Remeron. The following morning the patient reported that her abdominal pain had resolved and graded it at a 1 to 2. The psychiatric attending stated that the patient was stable psychologically for discharge and had no suicidal ideation. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 21723**] Dictated By:[**Last Name (NamePattern1) 23030**] MEDQUIST36 D: [**2148-9-20**] 14:40 T: [**2148-9-23**] 19:26 JOB#: [**Job Number 23031**] Name: [**Known lastname 3624**], [**Known firstname 3625**] Unit No: [**Numeric Identifier 3626**] Admission Date: [**2148-9-14**] Discharge Date: [**2148-9-20**] Date of Birth: [**2092-4-12**] Sex: F Service: MEDICINE This is the continuation of the discharge summary started yesterday on [**9-19**]. The discharge summary was interrupted because the patient began experiencing abdominal pain with anxiety, and was called to see the patient. The patient's second episode of anaphylaxis during this admission, it was on the 16th, and she had eaten a cheeseburger for dinner. Shortly afterwards, she had increased abdominal pain followed by shortness of breath. She was given IV Benadryl, famotidine, self administered Epinephrine, and that caused the episode of anaphylaxis to subside. The patient was able to breathe without problem. [**Name (NI) **] lungs were clear. In the Intensive Care Unit, the patient was very sad about the psychosocial stressors in her life including the breakup of her marriage. However, there were no other events. The patient returned to the floor on [**9-18**], and did well. Her pain was controlled with IV Dilaudid 1-2 mg q.2-3h. The patient had a trial in which her IV Dilaudid was switched to p.o. Dilaudid 1-2 mg every 2-3 hours and she responded well. The patient was ready for discharge on [**9-19**], when a few minutes before she was scheduled to leave the hospital, she complained of growing abdominal pain. She was given two tablets of Percocet. After five minutes, she said the pain had gotten worse to [**7-11**]. She said the pain radiated to the chest, back. There was nausea, but no vomiting and no diaphoresis. Her vitals are 150/90, 80, and 22. On exam, she had a regular, rate, and rhythm. Her lungs were clear, and her abdomen was moderately tender to palpation, but no rebound or guarding. She had an EKG done, which showed there was no changes from previous examination. Soon after the chest pain, the patient began complaining of being very anxious and was crying about how her life was falling apart. However, she denied suicidal ideation. She called her psychiatrist, and with the patient's permission, we were able to contact him, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3900**] at telephone number [**Telephone/Fax (1) 3901**] or pager number [**Telephone/Fax (1) 3902**]. Dr. [**Last Name (STitle) 3900**] faxed us a copy of an up to date list of the patient's psychiatric medications, and advised us that we do not let her sign out in a distraught state. He informed us that she has been under many psychosocial stressors with a strong prior psychiatric history, so she is a suicide risk even if she denies suicidal ideation. He also advised us to call a psychiatric consult, which we did, and put the patient on one-on-one observation. The psychiatric consult advised us to continue the one on one, and to start Klonopin 0.5 mg q.a.m. and q afternoon with 1 mg before bedtime for a total of 2 mg throughout the day. Remeron 15 mg p.o. q.h.s. and her dose of Effexor at 225 mg p.o. q.h.s. up from the 150 that she was currently on. She advised us that we should not allow the patient to sign out that night and to wait for the patient to be cleared when she was seen by the psychiatric attending. That night the patient's pain was controlled with p.o. Percocet 1-2 tablets every 4-6 hours with breakthrough pain controlled with oxycodone 5 mg every 4-6 hours for breakthrough pain. We were advised not to allow the patient to have any IV pain medications as that would be inappropriate for discharge. That night the patient slept well and the following morning, her abdominal pain decreased to a level of around 2. She denied any chest pain or any pain in her back. The patient wanted very much to leave. She was seen by the psychiatric attending, which cleared the patient to leave the hospital. The patient was discharged on [**9-20**] with the following followup: To call Dr.[**Name (NI) 3903**] office for a follow-up appointment within two weeks at [**Telephone/Fax (1) 3904**]. To keep her appointment with Dr. [**Last Name (STitle) 3905**], her allergist to be seen within two weeks, and to keep her appointment with her psychiatrist, Dr. [**Last Name (STitle) 3900**]. She was told to make an appointment, she had the number within 1-2 weeks, and to call her PCP and make an appointment within two weeks. DISCHARGE MEDICATIONS: 1. Prednisone two tablets p.o. q.d. for one week, and then to discuss her taper with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 3905**]. She is advised not to stop her medication without discussing it with her doctor. 2. Effexor 75 mg three tablets q.d. 3. Lisinopril 5 mg [**1-4**] tablet q.d. 4. Diltiazem 120 mg one tablet q.d. 5. Chromelin 20 mg/mL 15 mL 4x a day. 6. Protonix 40 mg every day. 7. [**Doctor First Name 1866**] 180 mg every day. 8. Benadryl 25 mg one tablet every six hours. 9. Ranitidine 300 mg one tablet at night. 10. Colace 100 mg as needed for constipation. 11. Albuterol MDI 1-2 puffs q.4-6h. prn as needed for shortness of breath. 12. Zofran 4 mg one tablet b.i.d. prn as needed for nausea. 13. Mirtazapine 15 mg one tablet at bedtime. 14. Clonazepam one tablet in the morning 0.5 mg, clonazepam 0.5 mg one tablet at 2 p.m. and clonazepam 0.5 mg two tablets at bedtime. DISCHARGE STATUS: Stable. She was advised to continue to take her home medications as prescribed except to increase her Gastrocrom to 30 mg p.o. q.i.d., that her Benadryl was 25 mg q.i.d., but not to take it if feeling sedated. She was advised to take prednisone as directed, and to discuss it with her doctors if she [**Name5 (PTitle) **] any questions, to stop. The medication only after speaking to her doctor, and to not stop it prematurely, and do not decrease from 20 mg to 10 mg until discussing with Dr. [**Last Name (STitle) 3905**], her allergist. Also on discharge, she had a urinalysis and she was told that she would be called if the urinalysis was positive. She was told that if she had symptoms of urinary frequency, pain with urination, fevers, chills, and nausea, call her doctor. She was advised that she may continue her estrogen patch, to make sure to take no dairy in her diet until she sees Dr. [**Last Name (STitle) **]. She was told that because she told the house staff she had plenty of EpiPens, she is all set, but if she ever gets low, to call her doctor [**First Name (Titles) **] [**Last Name (Titles) 3906**], to take Zofran up to twice a day for nausea as needed. If she has any concerning symptoms or she cannot eat, to call her doctor or go to the Emergency Room, and it is important to keep her appointment on Monday with her therapist, however, we were not able to get a hold of her psychiatrist and to please call me and make an appointment to see him as soon as possible. DISCHARGE DIAGNOSES: 1. Mast cell activation syndrome. 2. Abdominal pain. 3. Allergic reaction versus anaphylaxis. 4. Bronchospasm. 5. Urinary tract infection. 6. Raynaud's. 7. Hypertension. 8. History of myocardial infarction. 9. Depression. 10. History of nephrolithiasis. 11. Anxiety/depression. CODE STATUS: Full. DISCHARGE FOLLOWUP: Is as said above. [**Name6 (MD) 1118**] [**Name8 (MD) **], M.D. [**MD Number(2) 3907**] Dictated By:[**Last Name (NamePattern1) 3034**] MEDQUIST36 D: [**2148-9-20**] 15:03 T: [**2148-9-24**] 07:04 JOB#: [**Job Number 3908**]

[ "401.9", "355.8", "412", "995.67", "599.0", "443.0", "300.4", "202.60", "414.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

1568, 1639

18283, 18583

15828, 18262

2015, 2252

3630, 15805

2275, 3612

18604, 18867

166, 821

843, 1551

1656, 1989

47,788

186,787

834

Discharge summary

report

Admission Date: [**2198-5-31**] Discharge Date: [**2198-6-6**] Date of Birth: [**2125-10-3**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5831**] Chief Complaint: Seizures Major Surgical or Invasive Procedure: Intubation and ventilation at [**Hospital **] Hospital Lumbar puncture History of Present Illness: cc: Seizures versus syncope transferred from [**Hospital1 **] at around 3 am, [**Hospital1 112**] was at maximal capacity therefore could not accept the transfer. 72 yo man with an extensive past medical history, and of note: End Stage Renal Disease(started on hemodialysis one month ago), dialysis days Tue/[**Doctor First Name **]/Sat Normal pressure hydrocephalus & Parkinsonism (s/p VP [**Hospital1 5832**] Hakim programmable shunt placed at the [**Hospital1 756**] in Han [**2198**], on [**5-25**] setting changed from 9-->11 cm of water). He has had no previous seizures and he presented with 2 episodes that were thought to be seizures (note in [**2183**] at [**Hospital1 18**] prior to his L CEA he had 2XEEGs), intubated at OSH. Wife reports that his mental status has waxed and waned for the past years, however, she noticed that he has been more confused for the past 1 week than usual. For over a week he has felt light headed. He was feeling dizzy all day long yesterday. She reports a mild fall backwards on the toilet without hitting his head or any loss of consciouness. Of note, he had been having more frequent headaches recently and he had his shunt re-adjusted 5 days ago. At 6:30pm his wife found him on the floor, unresponsive, with blood coming out of his mouth as he had bit his tongue. She called 911 and he was taken to [**Hospital **] Hospital. He had an event where he arched his head, eyes rolled back and there was extensor posturing of his arms and legs, and this lasted minutes. He received morphine 2 mg, dilaudid 0.5 mg, ativan 2 mg, Etomidate 20, Succ 150 and he was intubated for airway protection and so it is unclear which [**Doctor Last Name 360**] aborted the event. He was then transferred here. Neurosurgery were consulted on the patient, and as per Neurosurgery mentioned that if the shunt required tapping they would do it, but left no recs. He received ceftriaxone 2g, vancomycin 1g and acyclovir 700mg empirically in ER. He also received 500mg dilantin in ER. On contacting Dr [**Last Name (STitle) **] [**Last Name (NamePattern4) **], he mentioned that he had seen the patient last Friday and was concerned about syncopal events for over a week. Post HD his SBP had been dropping and he was on a number on anti-HTN agents. During his in patient stay at [**Hospital1 18**], it became clear that these episodes were syncopal related to his severe orthostatic hypotension. Past Medical History: -renal failure (started on HD one month ago), -NPH (s/p VP shunt placed at B&W on [**Month (only) **]/09), -HTN, -Left iliac and femoral disease secondary to hypertension. -Left lower extremity bypass. -Bilateral hip replacement -Left endarterectomy -Orthiostatic Hypotension -CHF -?Parkinson's disease Social History: Ex-smoker, at least 30 pack years. In the past, heavy alcohol intake, past few years one cocktail per night, stopped alcohol when he had ESRD and was on HD. Retired RH businessman, owned a hardware store. No IV drug abuse. Family History: Mother had [**Name (NI) 2481**] disease. Son had ESRD-->probably secondary to Lithium (died of thrombocytopenia&massive hemorrhage, he had schizophrenia and bipolar disorder) Physical Exam: T-98.8 BP-166/76 HR-79 RR- O2Sat Gen: intubated HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: rhonchi BL aBd: +BS soft, nontender ext: pitting edema BL Neurologic examination: Mental status: intubated, sedated, grimaces to noxious stimuli. Cranial Nerves: Pupils equally round and reactive to light, myotic, 3 to 2 mm bilaterally. Facial movement symmetric. Hearing intact to finger rub bilaterally. Tongue midline. Corneal and gag relex positive. Normal Doll's Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor He retracts all extremities symetrically to noxious stimuli Sensation: He retracts all extremities symetrically to noxious stimuli Reflexes: B T Br Pa Pl Right 1 1 1 1 1 Left 1 1 1 1 1 Toes were downgoing bilaterally. Pertinent Results: [**2198-5-31**] EEG IMPRESSION: This portable EEG shows fairly regular alpha frequencies throughout, in anterior and posterior areas. This is most suggestive of widespread medication effect, likely obscuring other background features. There were no areas of focal (or generalized) slowing, and there were no epileptiform features. Cardiology Report ECG Study Date of [**2198-5-31**] 3:29:46 AM Sinus rhythm Consider left atrial abnormality Prominent precordial lead QRS voltage suggests left ventricular hypertrophy Prolonged Q-Tc interval Modest ST-T wave changes CXR [**5-31**] Findings: The endotracheal tube distal tip projects 2.9 cm above the carina. The distal tip of NG tube is not well visualized. The VP shunt is noted. The left central line distal tip projects in the cavoatrial junction. The mediastinal and hilar contours are prominent, most likely due to vascular congestion. However attention to the mediastineal contour inthe follow up imaging is recommended. The right lung is clear. Small left pleural effusion and left basilar atelectasis is noted. CThead [**5-31**] IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. Status post placement of the VP shunt. Mild prominence of the lateral ventricles with no transependymal migration of CSF. [**2198-6-3**] CT L-spine IMPRESSION: 1. No evidence of acute vertebral compression fracture or paravertebral hematoma. 2. Transitional anatomy at the lumbosacral junction, as described. 3. Multilevel lumbar spondylosis with multifactorial moderately severe spinal canal stenosis, from the L2-L3 through L4-5 levels, as detailed above. 4. Extensive atherosclerosis of the abdominal aorta and its branches. Rib series X-Ray, hip X-ray, R gleno-humeral X-rays showed no new fractures or dislocations [**2198-5-31**] 06:00AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-2* Polys-0 Lymphs-90 Monos-10 [**2198-5-31**] 06:00AM CEREBROSPINAL FLUID (CSF) TotProt-59* Glucose-68 [**2198-5-31**] 09:31AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.030 [**2198-5-31**] 09:31AM URINE Blood-LG Nitrite-NEG Protein->300 Glucose-NEG Ketone-15 Bilirub-MOD Urobiln-NEG pH-5.0 Leuks-TR [**2198-5-31**] 09:31AM URINE RBC-46* WBC-3 Bacteri-FEW Yeast-RARE Epi-1 [**2198-5-31**] 09:31AM URINE CastHy-8* [**2198-6-6**] 05:10AM BLOOD WBC-3.2* RBC-2.98* Hgb-10.1* Hct-32.0* MCV-107* MCH-33.8* MCHC-31.5 RDW-20.4* Plt Ct-83* [**2198-6-5**] 05:25AM BLOOD WBC-2.9* RBC-3.21* Hgb-10.6* Hct-34.0* MCV-106* MCH-33.1* MCHC-31.2 RDW-19.2* Plt Ct-86* [**2198-5-31**] 02:25AM BLOOD Neuts-76.5* Lymphs-14.5* Monos-6.5 Eos-2.5 Baso-0.1 [**2198-6-6**] 05:10AM BLOOD Plt Ct-83* [**2198-6-6**] 05:10AM BLOOD Glucose-86 UreaN-24* Creat-3.6* Na-140 K-3.8 Cl-103 HCO3-26 AnGap-15 [**2198-6-4**] 04:50AM BLOOD ALT-2 AST-21 AlkPhos-124* [**2198-6-5**] 05:25AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.4* Brief Hospital Course: [**5-30**] He was transferred to the TICU, and was successfully weaned off the ventilator. [**Date range (1) 5833**] He had visual hallucinations (people with guns) on Rivastigmine, therefore it was discontinued. [**6-2**] He continued to be orthostatic, Sinemet stopped, and most of his anti-hypertensive medication doses were either stopped or reduced. [**6-4**] He was started on Aricept 5 mg in the mornings with breakfast and Clonazepam 0.25 mg at night (for REM sleep disturbances - nightmares). During his admission, he had hemodialysis on Tuesday/Thursday and Saturday. He was reviewed by Dermatology, who suggested topical treatment for his psoriasis, and this has been explained in his discharge planning. He was reviewed by the Autonomics team who advised follow-up in the outpatient setting for autonomic testing, and they also recommended Midodrine 2.5 mg prn on hemodialysis days, if the patient was walking (not when he was lying down). He could not have an MRI because the neurosurgical team at [**Hospital1 18**] did not have the device required to reprogram his shunt if needed after the MRI. Medications on Admission: Rivastigmine patch 9.5 mg once daily Metoprolol ER 50 mg daily Norvasc 10 mg daily Doxazosin 2 mg daily Clonidine patch 1 mg topical weekly Allopurinol 100 mg every 2 days B12 injections once a month Procrit 30 000 depending on hematocrit Ambien prn Folate 1 mg daily Sertraline 50 mg daily Sinemet 25/100 tid (on this med for a year and a half) Phoslo 1334 mg tid Nephrocaps once daily Zetia 10 mg daily Protonix 40 mg daily Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ezetimibe 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. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO Q48H (every 48 hours). 6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime) as needed for 18:00 h. 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Bacitracin-Polymyxin B Ointment Sig: One (1) Appl Topical TID (3 times a day) for 7 days. 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 11. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical DAILY (Daily). 12. Cortisone 1 % Cream Sig: One (1) Appl Topical DAILY (Daily) as needed for dermatitis. 13. Donepezil 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for [**2189**]. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: 1. [**Last Name (un) 309**] Body Dementia 2. Orthostatic hypotension 3. Psoriasis with terafirma on the shins Discharge Condition: He was still orthostatic on walking. However, he did not have any visual hallucinations for over 48 h. Discharge Instructions: You have had syncopal episodes because your blood pressure is too low when you stand up. You have also been diagnosed with [**Last Name (un) 309**] Body Disease, which is why you have visual hallucinations and features of Parkinsonism. Medications aggravating your condition have been stopped. Followup Instructions: Neurology: [**7-13**] - Dr [**Last Name (STitle) **] [**Last Name (NamePattern4) **] at 8:30 am, [**Hospital Ward Name 860**] Building [**Location (un) **], Rm 253 Autonomic testing and follow-up: Please call [**Telephone/Fax (1) 5834**], to organize an appointment. Please call: PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 5835**] to organize a follow-up with him. Completed by:[**2198-6-6**]

[ "331.82", "V45.2", "V43.64", "331.5", "294.10", "599.0", "458.0", "696.1", "403.91", "585.6" ]

icd9cm

[ [ [] ] ]

[ "03.31", "39.95", "96.71" ]

icd9pcs

[ [ [] ] ]

10351, 10434

7455, 8568

324, 396

10588, 10693

4580, 7432

11036, 11481

3430, 3607

9044, 10328

10455, 10567

8594, 9021

10717, 11013

3622, 3936

276, 286

424, 2846

4041, 4561

3975, 4025

3960, 3960

2868, 3173

3189, 3414

75,054

170,546

39590

Discharge summary

report

Admission Date: [**2159-12-12**] Discharge Date: [**2159-12-17**] Date of Birth: [**2111-6-29**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: 48 y/o male s/p MVA and closed head injury who had undergone a craniectomy on his last admission returns on this admission for replacement of bone flap. Major Surgical or Invasive Procedure: Cranioplasty History of Present Illness: s/p TBI returns for elective cranioplasty Past Medical History: previous right craniectomy TBI Social History: construction worker, married, 2 children in college. + etoh Family History: non-contributory Physical Exam: On admission the patient barely verbalizes. He is able to respond to occasional questions. Pupils are equal and reactive to light. Extraocular movements are intact. Face is symmetric. He does have a pronator drift on his left side. He moves all extremities without any focal weakness. ON DISCHARGE: Patient is awake, confused interactive Pupils are 4mm to 3mm bilaterally Left sided neglect and some paresis ( degree difficult to assess with specific muscle group testing, given patient's agitation and confusion) Able to move all extremities, right greater than left. Cranial incision is clean and dry with staples and sutures in place. Pertinent Results: Radiology Report CT HEAD W/O CONTRAST Study Date of [**2159-12-13**] 6:59 PM NON-CONTRAST HEAD CT: There has been interval right cranioplasty. There is no underlying hemorrhage. A drain is seen in the overlying soft tissues. Small foci of air are compatible with recent surgery. Intracranially, there is no significant change. There is persistent ex vacuo dilatation of the right lateral ventricle, with extensive overlying cystic encephalomalacia, which is stable in extent and appearance compared to [**2159-11-15**]. There is no evidence of acute territorial infarction. There is no mass effect. Midline structures demonstrate no shift, and the basal cisterns are patent. There are no abnormal extra-axial fluid collections. Accounting for postoperative changes, the bones are unremarkable. There is partial opacification of the right mastoid air cells. The remainder of the paranasal sinuses and left mastoids are normally aerated. IMPRESSION: 1. Expected postoperative changes following right cranioplasty. No intracranial hemorrhage or other complication is identified. 2. Stable extensive encephalomalacia in the right frontoparietal temporal lobes, with associated ex vacuo dilatation of the adjacent ventricle. Cardiology Report ECG Study Date of [**2159-12-14**] 8:07:54 AM Sinus tachycardia. Possible inferior wall myocardial infarction of indeterminate age. Compared to the previous tracing of [**2159-9-18**] there is no significant diagnostic change. Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**] Intervals Axes Rate PR QRS QT/QTc P QRS T 103 162 94 328/403 45 -19 62 Display/Print ECG (Requires a Software Download) ([**-9/8374**]) Brief Hospital Course: Mr. [**Known lastname 87367**] returned to the [**Hospital1 18**] from [**Hospital6 **] for a cranioplasty. Operative course was uncomplicated. Post operatively he was transferred to the floor with a foley catheter and a subgalial JP drain. POD #1 patient was slightly agitated and recieved a small dose of haldol with good effect. Post operative CT showed expected post operative changes. Patient's agitation and aggression continued to escelate and he was placed on Seroquel around the clock. We asked Psychiatry to consult and help in the care of this patient. They recommended continuing standing Seroquel with a larger dose in the evening before bedtime. The patient's behavior improved while on Seroquel. He continued to improve and was calm enough to participate with PT OT for dispo planning. His diet and activity were advanced and foley removed. He was discharged to rehab in stable condition and will follow up in the office for suture removal and general follow up in 6 weeks. Medications on Admission: Heparin 5000 UNIT SC TID Quetiapine Fumarate 25 mg PO/NG Q6H agitation Lisinopril 5 mg PO/NG DAILY Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **] Vitamin D 1000 UNIT PO/NG DAILY Oxcarbazepine 600 mg PO BID Famotidine 20 mg PO/NG [**Hospital1 **] OxycoDONE (Immediate Release) 5-10 mg PO/NG Q4H:PRN pain LeVETiracetam Oral Solution 1000 mg PO/NG [**Hospital1 **] Discharge Medications: 1. levetiracetam 100 mg/mL Solution Sig: Ten (10) ml PO BID (2 times a day). 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. oxcarbazepine 300 mg/5 mL Suspension Sig: Ten (10) ml PO BID (2 times a day). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for agitation. 9. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). 10. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO Q NOON (). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 12. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-30**] Tablets PO Q4H (every 4 hours) as needed for headache. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: TBI Confusional state Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office by [**2159-12-22**] for removal of your staples & sutures and wound check. This appointment can be made with the Nurse Practitioner [**First Name (Titles) **] [**Last Name (Titles) **] [**Name Initial (PRE) 19158**]. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. [**Name10 (NameIs) **] can also be done at the rehab facility. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Known firstname **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast at that time. Completed by:[**2159-12-18**]

[ "738.19", "294.9", "907.0", "342.90", "293.0", "E929.0", "781.94" ]

icd9cm

[ [ [] ] ]

[ "02.06" ]

icd9pcs

[ [ [] ] ]

5607, 5654

3146, 4143

461, 476

5720, 5720

1395, 1486

7356, 8113

695, 713

4564, 5584

5675, 5699

4169, 4541

5898, 7333

728, 1020

1034, 1376

269, 423

504, 547

1496, 3123

5735, 5874

569, 601

617, 679

63,405

122,284

2911

Discharge summary

report

Admission Date: [**2200-4-22**] Discharge Date: [**2200-4-28**] Date of Birth: [**2124-7-16**] Sex: M Service: NEUROSURGERY Allergies: Spironolactone / Levaquin Attending:[**First Name3 (LF) 1271**] Chief Complaint: s/p unwitnessed fall with SDH, SAH< and IPH as well as C1 and C3 fx's Major Surgical or Invasive Procedure: none History of Present Illness: 75 yo man s/p unwitnessed fall around 10:30 found 3 hrs later. Was awake and unconfused. Found to have L SDH, RAH, and bilateral intraparenchymal hemorrhages left > right with shift. Also has C1 ring and atlas fractures and C3 vert body fracture. Past Medical History: 1. Hepatitis B w/cirrhosis: Last VL undetectable. Grade II esophageal varices. 2. h/o HCC: tx'd with RFA. Not biopsy proven. 3. Diabetes: last A1c 7.6% 4. COPD: Last PFT's FEV1/FVC 95%, FEV1 60% 5. Thyroid nodule: Ultrasound showed multinodular goiter with two nodules in right lobe that plan to be biopsied. 6. Mitral regurgitation 7. Coronary artery disease 8. Chronic Kidney Disease - Stage III w/hyperparathyroidism Social History: confirmed with patient: Cantonese speaking only. Smokes approximately 1 cigaretter per day, occasional ETOH, no IVDU. Has 3 daughters closely involved in his care. Married. No Nursing services. Family History: No known family history of pulmonary disease Physical Exam: PE: VS: 136/76 P 54 R 18 100%2L Neck: Hard collar. No tenderness. Back: No T/L spine tenderness. Cards: RRR no click/rubs/mumurs. Abd: soft. non tender. Ext: WWF, no edema. Neuro: MS: Eyes closed, somewhat somnolent but responds and follows commands. Oriented to [**2-21**] and no year. Follows simple commands only. Inattentive. speech intact per daugther who translates. CN: Cannot assess VF. Does not blink to threat. Pupils [**1-14**] bilaterally. Tracks with endgaze nystagmus bilaterally. Face symemtric. Tongue/palate midline. Motor: Difficult to do full exam given inattention. Full strength in triceps/grasp/IP/DF bilaterally. Tone nl. Reflexes: Reflexes difficult to obtain. Toes mute. Sensory: intact to LT x 4. Coord: could not assess. Discharged Exam: Expired Pertinent Results: CT C-Spine [**4-22**] 1. Fracture of the right anterior arch of C1 extending into the right lateral mass. 2. Fracture of the anteroinferior corner of C3. 3. Extensive prevertebral soft tissue swelling concerning for ligamentous injury. Recommend MRI for further evaluation. 4. Multilevel degenerative changes, most prominent at C4-C5, C5-C6 and C6-C7 with severe central canal narrowing. 5. Heterogenous enlarged right thyroid lobe which is relatively unchanged from prior ultrasound. CT HEAD [**4-22**] 1. Massive subarachnoid hemorrhage most prominent within the right sylvian fissure but also seen within both frontal and right parietal sulci. 2. Left subdural hematoma with 3-mm of rightward shift of midline structures. 3. Bifrontal hemorrhagic parenchymal contusions left greater than right. Hemorrhagic contusion within the right parietal lobe parallel to the falx cerebri. 4. Right posterior parietal subgaleal hematoma. CT Head [**4-22**] #2 Interval increase in parenchymal, subarachnoid, and subdural hemorrhage as described above. [**2200-4-28**] 07:00AM BLOOD WBC-6.9 RBC-3.96* Hgb-10.8* Hct-36.0* MCV-91 MCH-27.4 MCHC-30.1* RDW-14.7 Plt Ct-85* [**2200-4-22**] 02:05PM BLOOD WBC-7.6# RBC-4.79 Hgb-12.8* Hct-42.4 MCV-89 MCH-26.8* MCHC-30.3* RDW-13.7 Plt Ct-87* [**2200-4-22**] 02:05PM BLOOD Neuts-81* Bands-0 Lymphs-9* Monos-9 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2200-4-28**] 07:00AM BLOOD PT-14.3* PTT-27.1 INR(PT)-1.2* [**2200-4-28**] 07:00AM BLOOD Plt Ct-85* [**2200-4-22**] 06:32PM BLOOD PT-13.4 PTT-26.5 INR(PT)-1.1 [**2200-4-22**] 02:05PM BLOOD Plt Smr-LOW Plt Ct-87* [**2200-4-28**] 07:00AM BLOOD Glucose-227* UreaN-48* Creat-1.7* Na-159* K-4.4 Cl-126* HCO3-23 AnGap-14 [**2200-4-22**] 02:05PM BLOOD Glucose-273* UreaN-29* Creat-1.6* Na-139 K-4.5 Cl-104 HCO3-30 AnGap-10 [**2200-4-28**] 07:00AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.0 Brief Hospital Course: Patient presented to [**Hospital1 18**] s/p unwitnessed fall at home on [**2200-4-22**]. In the ER he was evalauted and admitted to the ICU after beign foudn to have a L SDH, R SAH, and Bialteraly IPH's left > right. On [**4-23**] there was a family meeting to discuss hisprognosis which was grim. no more Head CT's were planned to be done per family wishes and secodnary to prognosis. On [**4-24**] he was transferred to the floor. At that time he had no eye openeing, his pupils weer sluggish and he had no corneal reflexes. his RUE minimally localized which was a change in exam as he had been spontaneously moving it prior. His LUE was 0/5 throughout, his RLE was triple flexion, and his LLE minimally responded to stimulation. On [**4-25**] his blood sugars were up to 330 and a sliding scale was initiated. The family at this time also communicated that they would not want him to get tube feedings or TPN. Social work met with the family and recommneded palliative care see the pt. Pallaitive care recommended hospice vs nursing home. The family initially seemed open to the idea of hospice but on [**4-26**] when the representative from [**Hospital **] arrived they did not wish to meet with them. Also on [**4-26**] another meeting was held between socail work and neurosurgery with the family to reiterate the grim prognosis and attempt to better devise a plan of care as we moved forward. they relayed they wanted to wait for family to arrive to maker any final decisions and would keep him DNR/DNI and make decisions of care as they arose. On [**4-27**] his sodium was elevated to 153 and discussion as to the required itnervention, nasogastric tube placement with free water and tube feed administration, was discussed and the family decided that they were not interested in this therapy. On the mornign fo [**4-28**] the family decided to make him comfort measures only and palliative care was contact[**Name (NI) **] to meet with the family. After discussion of plan of care to aid in keeping him comfortbale the emasures were initiated. very shortly there after he was turned on his side to aid in positioning and a moderate amount of secretions came out of his mouth. he shortly there after passed away quietly with his family at the bedside. Medications on Admission: AMILORIDE - 5 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day FLUTICASONE - 50 mcg Spray, Suspension - [**11-16**] sprays each nostril qd GLUCAGON (HUMAN RECOMBINANT) [GLUCAGON EMERGENCY] - 1 mg Kit - inject contents of one vial SC once, as needed for as needed for emergency hypoglycemia INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 13 u at bedtime IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90 mcg)/Actuation Aerosol - 2 (Two) puffs inhaled four times a day as needed for cough KETOCONAZOLE - 2 % Cream - apply to area twice daily twice a day Large tube size please. LACTULOSE [ENULOSE] - (Prescribed by Other Provider) - 10 gram/15 mL Solution - 30 mL(s) by mouth twice a day Dispense 2 (480mL) bottles NADOLOL - 20 mg Tablet - one half Tablet(s) by mouth once a day - No Substitution NOVOLOG - 100 U/ML Solution - AS PER DR [**Last Name (STitle) **] [**Name (STitle) **] [XIFAXAN] - 200 mg Tablet - 2 Tablet(s) by mouth twice a day TENOFOVIR DISOPROXIL FUMARATE [VIREAD] - 300 mg Tablet - 1 Tablet(s) by mouth once a day - No Substitution ULTRAFINE SHORT NEEDLE SYRINGES - - as directed Medications - OTC ASPIRIN [ASPIRIN LOW-STRENGTH] - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily BLOOD SUGAR DIAGNOSTIC [FREESTYLE TEST] - Strip - use to test sugars five times daily using sliding scale Novolog 4-5 times daily based on sugars CALCIUM CARBONATE [CALCIUM 500] - 500 mg (1,250 mg) Tablet, Chewable - 1 (One) Tablet, Chewable(s) by mouth twice a day CYANOCOBALAMIN [VITAMIN B-12] - 1,000 mcg Tablet - 1 Tablet(s) by mouth daily ERGOCALCIFEROL (VITAMIN D2) - 400 unit Capsule - 1 (One) Capsule(s) by mouth twice a day with calcium supplement LANCETS - Misc - Free style lancets use as directed to check blood sugar qid and prn testing 4-5 times daily to dose Novolog insulin QID Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2200-4-28**]

[ "493.20", "155.2", "403.90", "287.5", "805.03", "250.00", "588.81", "E888.9", "414.01", "276.0", "851.00", "456.21", "780.2", "305.1", "V58.67", "805.01", "571.5", "446.29", "241.1", "585.3", "070.32" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8240, 8249

4077, 6355

360, 366

8300, 8309

2196, 4054

8365, 8498

1320, 1366

8270, 8279

6381, 8217

8333, 8342

1381, 2177

251, 322

394, 644

666, 1088

1104, 1304

31,217

119,143

32769

Discharge summary

report

Admission Date: [**2110-7-30**] Discharge Date: [**2110-8-5**] Date of Birth: [**2066-8-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 5188**] Chief Complaint: Pheochromoyctoma Major Surgical or Invasive Procedure: Right adrenalectomy and excision of retroperitoneal paraganglioma. History of Present Illness: The patient is a 44-year-old man who presents with newly-diagnosed pheochromocytoma and a workup has revealed a large (8 x 10 cm) mass in the right adrenal gland. The patient also has an approximately 4 cm in diameter paraganglioma, measuring just below the left renal vein in the retroperitoneal area. The patient has been also managed in endocrinology and the patient now presents for adrenalectomy and excision of the paraganglioma after adequate preoperative alpha and beta blockade. Past Medical History: Diabetes, h/o EtOH abuse Social History: Recently immigrated to here from [**Country 3587**]. Denies smoking. Former alcohol use but sober for 7-8 years. Denies illicit drugs. Living with his brother. Formerly worked at a fish market. Now looking for work. Family History: No family hx of CAD or heart disease Physical Exam: Vitals signs stable Gen: AAOx3, NADS HEENT: NCAT, EOMi, MMM Pulm: CTA, no RRW Cardio: RRR, no rmg Abd: soft, firm, NT, ND, act BS Incision: tranverse abdominal OTA with staples, CDI. Ext: No C/C/E, palp extremity pulses bilaterally Pertinent Results: [**2110-7-30**] 04:35PM BLOOD WBC-14.8*# RBC-3.86* Hgb-11.1* Hct-32.1*# MCV-83 MCH-28.7 MCHC-34.6 RDW-13.5 Plt Ct-160 [**2110-7-30**] 10:24PM BLOOD Hct-30.5* [**2110-7-31**] 02:07AM BLOOD WBC-14.2* RBC-3.62* Hgb-10.6* Hct-30.3* MCV-84 MCH-29.2 MCHC-35.0 RDW-13.7 Plt Ct-153 [**2110-8-1**] 02:04AM BLOOD WBC-13.5* RBC-3.31* Hgb-9.4* Hct-27.6* MCV-83 MCH-28.5 MCHC-34.2 RDW-13.8 Plt Ct-141* [**2110-8-2**] 09:20AM BLOOD WBC-13.5* RBC-3.77* Hgb-10.6* Hct-32.2* MCV-85 MCH-28.1 MCHC-32.9 RDW-13.5 Plt Ct-146* [**2110-7-30**] 04:35PM BLOOD Plt Ct-160 [**2110-7-31**] 02:07AM BLOOD Plt Ct-153 [**2110-8-1**] 02:04AM BLOOD Plt Ct-141* [**2110-8-2**] 09:20AM BLOOD Plt Ct-146* [**2110-7-30**] 04:35PM BLOOD Glucose-118* UreaN-11 Creat-0.7 Na-138 K-3.7 Cl-106 HCO3-26 AnGap-10 [**2110-7-31**] 02:07AM BLOOD Glucose-113* UreaN-13 Creat-0.8 Na-137 K-4.3 Cl-107 HCO3-25 AnGap-9 [**2110-8-1**] 02:04AM BLOOD Glucose-108* UreaN-13 Creat-0.8 Na-139 K-3.5 Cl-105 HCO3-30 AnGap-8 [**2110-7-30**] 12:52PM BLOOD Type-ART pO2-254* pCO2-44 pH-7.36 calTCO2-26 Base XS-0 Intubat-INTUBATED [**2110-7-30**] 01:58PM BLOOD Type-ART pO2-251* pCO2-48* pH-7.34* calTCO2-27 Base XS-0 Intubat-INTUBATED [**2110-7-30**] 04:47PM BLOOD Type-ART pO2-211* pCO2-49* pH-7.34* calTCO2-28 Base XS-0 Intubat-NOT INTUBA [**2110-7-30**] 12:52PM BLOOD Glucose-137* Lactate-1.7 Na-137 K-3.8 Cl-108 [**2110-7-30**] 01:58PM BLOOD Glucose-120* Lactate-2.5* Na-137 K-3.8 Cl-105 . [**2110-7-30**] Pathology Tissue: pheochromocytoma, [**2110-7-30**] [**Doctor Last Name **],[**Doctor First Name **] J. Not Finalized Brief Hospital Course: Patient was admitted to Dr.[**Name (NI) 6045**] surgical service and was taken to the operating room on [**2110-7-30**] for right arenalectomy and excision excision left paraganglioma. A pulmonary artery catheter was provided for closer intraoperative and postoperative cardiac output and therapeutic monitoring. He did experience a short period of slight hypotension during dissection and mobilization of the right adrenal tumor, where bleeding was encountered. The total operative blood loss was 1200 ml. His blood pressure responded with crystalloid fluid and remained hemodynamically stable throughout procedure. Both specimen were sent to pathology for analysis. After the procedure, the patient was extubated and taken directly to the intensive care unit for posotoperative monitoring. Given history of pheochromocytoma and with excision of tumor, patient's blood pressure were monitored closely. Aside from brief episodes of hypotension, patient remained hemodynamically stable. He was transferred to the surgical floor on POD2. He began with clears and tolerated his diet advancement to regular food. His pain was controlled by PCA which also transitioned to oral pain medications. Physical therapy consulted to help patient with ambulation. He ambulated with minimal assist, and ws cleared from Physical Therapy needs. There were no complications to patient's postoperative course. He received a suppository on POD5, and moved bowels. Reported decreased abdominal cramping and gas pains.Tolerating oral pain medication, and oral Motrin. Pain <[**4-5**]. Discharge instruction was reviewed with patient via Creole interpreter. Patient was picked up per family. He was discharged on POD6, no services required. He was advised to follow-up with Dr. [**Last Name (STitle) 5182**] in [**11-27**] weeks. Appointment was arranged. Staples were removed at bedside prior to discharge, and steri strips were applied. Incision CDI. Medications on Admission: Prilosec 20', phenoxybenzamine 10' Discharge Medications: 1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:*60 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. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for fever or pain: Do not exceed 4000mg in 24hours. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain for 2 weeks: do not drink alcohol or drive while on medication. Disp:*50 Tablet(s)* Refills:*0* 6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain for 2 weeks: Take with FOOD. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Pheochromocytoma (right adrenal mass) and retroperitoneal paraganglioma . Secondary: HTN, Diabetes, h/o EtOH abuse Discharge Condition: vss tolerating regular food ambulating pain control with oral medications hemodynamically stable 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 staples will be removed at your follow-up appointment with Dr. [**Last Name (STitle) 5182**]. Steri Strips will be applied. -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -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: 1. Follow-up with Dr [**Last Name (STitle) 5182**] 1-2 weeks, [**Telephone/Fax (1) 5189**]. 2. Follow-up with PCP Dr [**Last Name (STitle) **] 1-2 weeks [**Telephone/Fax (1) 7976**]. . Previous appointments: 1. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2110-8-13**] 3:40 [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**] Completed by:[**2110-8-5**]

[ "458.29", "250.00", "227.0", "235.4", "305.00", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "54.4", "07.22", "89.64" ]

icd9pcs

[ [ [] ] ]

5974, 5980

3113, 5046

331, 400

6148, 6247

1521, 3090

7904, 8399

1216, 1254

5131, 5951

6001, 6127

5072, 5108

6271, 7413

7428, 7881

1269, 1502

275, 293

428, 918

940, 966

982, 1200

78,505

177,489

47822

Discharge summary

report

Admission Date: [**2183-4-20**] Discharge Date: [**2183-4-25**] Date of Birth: [**2129-6-20**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: Perianal pain Major Surgical or Invasive Procedure: Perianal abcess incision and drainage History of Present Illness: 53F with DM c/o peri-anal pain x 5 days. She denies a history of peri-anal abscess. She has not had any hard bowel movements. She had diarrhea 3 days ago and then no bowel movements since. She has had upper respiratory symptoms with cough and sputum production this week. She has also had fevers and chills and emesis. The emesis is preceded by nausea. She has been tolerating liquids but hasn't eaten much food because of the rectal pain. Past Medical History: 1. Renal failure with a baseline creatinine of 2.8. 2. Type 2 diabetes. 3. Hypertension. 4. Anemia secondary to blood loss and iron deficiency 5. G16 P7. 9 miscarriages 6. Adenomyosis with menorrhagia: First Lupron dose [**2180-12-7**] with good effect. s/p admission [**11-18**] for anemia and she received 1 unit of red blood cells. 7. D&C. 8. Bilateral tubal ligation. 9. Bilateral surgery on her legs as a child Social History: Stay at home mom. Denies tobacco, alcohol or drug use. Family History: None contributory Physical Exam: PE: 98.5 88 215/68 15 99 RA NAD RRR CTAB Abd - soft, nttp, no hernias Rectal - large abscess to the right of her perineum with fluctuance. No tenderness or extension into the rectum. No surrounding cellulitis. Ext - warm, 2+ pulses Pertinent Results: [**2183-4-20**] 11:10PM GLUCOSE-216* UREA N-36* CREAT-3.2* SODIUM-136 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-17 [**2183-4-20**] 11:10PM CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-2.1 [**2183-4-20**] 12:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-75 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2183-4-20**] 10:20AM GLUCOSE-869* UREA N-42* CREAT-3.6* SODIUM-125* POTASSIUM-4.4 CHLORIDE-87* TOTAL CO2-20* ANION GAP-22* [**2183-4-20**] 10:20AM WBC-12.6*# RBC-3.55* HGB-9.5* HCT-30.4* MCV-86 MCH-26.7* MCHC-31.1 RDW-14.9 [**2183-4-20**] 10:20AM NEUTS-89.1* LYMPHS-6.7* MONOS-3.6 EOS-0.4 BASOS-0.3 [**2183-4-20**] 10:20AM PLT COUNT-293 Brief Hospital Course: Ms. [**Known lastname **] was admitted to the SICU after having an I+D of a perianal abscess. She was admitted to the SICU for control of hyperglycemia and started on an insulin drip which was transitioned to Lantus and SSI. Once Ms. [**Known lastname 6237**] blood sugar was controlled her diet was advanced. Her wound was packed and freely draining. She was discharged on insulin after achieving adaquate blood glucose control. Her wound was left open and she was instructed to follow up in clinic. Medications on Admission: calcitriol 0.5mg lasix 20mg daily insulin unknown dose iron 325mg daily lisinopril 40mg daily lupron 11.25 q 3 months\ oxybutynin 5mcg daily simvastatin 80mg daily vit D. Discharge Medications: 1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 7 days. Disp:*40 Tablet(s)* Refills:*0* 6. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Insulin Syringe 1 mL 28 X 1 Syringe Sig: One (1) syringe as directed Miscellaneous five times a day as needed for as directed per sliding scale. Disp:*100 syringe as directed* Refills:*0* 8. Insulin Glargine 100 unit/mL Solution Sig: Thirty Two (32) U Subcutaneous once a day. Disp:*2 vials* Refills:*2* 9. Insulin Lispro 100 unit/mL Solution Sig: One (1) dose Subcutaneous four times a day as needed for per sliding scale. Disp:*2 vials* Refills:*20* 10. Senna 8.6 mg Capsule Sig: [**12-14**] Capsules PO twice a day. Disp:*30 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Perianal Abcess Hyperglycemia requiring ICU admission and insulin infusion. Discharge Condition: Good Discharge Instructions: You will need to monitor your blood sugars diligently. You have been discharged with a new insulin sliding scale, Please follow it. While you were in hospital your creatinine was elevated suggesting your kidney were not working well. Please follow-up with your PCP with regards to restarting your lisinopril, a blood pressure pill that may affect your kidneys. Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. Followup Instructions: Please call Dr.[**Name (NI) 1482**] office for ([**Telephone/Fax (1) 1483**] for follow up appointment in [**12-14**] weeks. Please call your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 7538**] for follow-up appointment as soon as you get home. Issues that need to be addressed include restarting your lisinopril in the context of your renal insufficieny and your blood glucose control (you have been started on a new regimen [**First Name8 (NamePattern2) **] [**Last Name (un) **] Diabetes). Please call nephrologist Dr. [**Last Name (STitle) **], nephrology, ([**Telephone/Fax (1) 76788**] for follow-up appointment in [**2-13**] weeks regarding your kidney function.

[ "V58.67", "585.4", "584.9", "566", "583.81", "250.52", "362.01", "250.42", "280.0", "403.90" ]

icd9cm

[ [ [] ] ]

[ "49.01" ]

icd9pcs

[ [ [] ] ]

4249, 4306

2355, 2862

328, 368

4425, 4432

1659, 2332

6446, 7168

1372, 1391

3083, 4226

4327, 4404

2888, 3060

4456, 5800

1406, 1640

5832, 6423

275, 290

396, 843

865, 1283

1299, 1356

12,419

145,251

1100

Discharge summary

report

Admission Date: [**2167-1-13**] Discharge Date: [**2167-1-17**] Date of Birth: [**2124-6-8**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Chocolate Attending:[**First Name3 (LF) 7141**] Chief Complaint: left lower quadrant pain Major Surgical or Invasive Procedure: Exploratory laparotomy, left salpingo-oophorectomy History of Present Illness: 42 y/o G0 w/ LMP 6 yrs ago s/p endometrial ablation presents w/ 3d h/o LLQ pain. Pt w/ h/o ovarian cysts followed w/ similar pain. Pt reports intense pain on L side associated w/ nausea/dry heaves x 3 days & w/ diarrhea x 1 day. No further N/V/D today. No F/C/dysuria. Continues to have sharp pain in LLQ, does not radiate, better w/ rest, worse w/ sitting up/activity. Initially [**6-25**] pain but now [**3-25**] s/p Morphine 2mg IV at 9:30 am. Past Medical History: ObHx: G0 Gyn Hx: - Gyn MD -> Dr. [**Last Name (STitle) **] [**Name (STitle) **] (Gyn Onc) at [**Hospital1 2025**] (followed for cervical dysplasia) - h/o Ovarian Cysts x 2 yrs - Menarche age 12, No h/o OCPs - h/o Menorrhagia s/p endometrial ablation in [**2160**] w/ no further menses after that point - No h/o STDs - h/o Abn Pap - s/p Colpo/Bx -> LEEP [**2164**] w/ persistent dysplasia - Recent [**Last Name (un) **] [**12-21**] wnl - Colonoscopy [**12-19**] yrs ago wnl PMHx: 1. Focal Segmental Glomerulosclerosis s/p Living unrelated donor renal tranplant in [**2159**] c/b acute rejection treated with OKT3 (most recently [**10-20**]) 2. Osteonecrosis of b/l hips/shoulders/knees requiring replacements at each site (2/t long term steroid tx) 3. h/o CMV infection, s/p transplant treated with Gancyclovir 4. Bilateral cataracts 5. HTN 6. Nephrolithiasis 7. Gout PSHx: 1. Appendectomy 2. s/p Bilateral Hip/Shoulder/Knee replacements 3. s/p Endometrial Ablation Social History: Works at [**Hospital1 18**] in radiology, no alcohol use, non smoker Family History: Family Hx: - Sister w/ FSGS s/p Renal Transplant - Paternal Aunt d of Breast/Ov CA at 52 y/o - No other h/o Breast/Ov CA - h/o HTN/DM Physical Exam: 97.3 160/86 76 16 100%RA NAD RRR CTAB Breasts - No masses, no nipple discharge Abd - Soft, mild ttp in LLQ, ND, + BS, + Implanted kidney in RLQ palpable on exam (NT) Ext - NT, No edema Pelvic (by Dr. [**First Name8 (NamePattern2) 7142**] [**Last Name (NamePattern1) **]) - SSE - NEFG, Normal Vagina, GC/Chlam collected, Nulliparous Os w/ no discharge - BME - AV Uterus, nml size, 5cm L adnexal mass w/ mod ttp, No R adnexal mass, no CMT Pertinent Results: Urine: [**2167-1-13**] 01:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2167-1-13**] 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Chem 10 [**2167-1-13**] 09:30AM GLUCOSE-103 UREA N-37* CREAT-1.9* SODIUM-143 POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-26 ANION GAP-13 HCG/tumor markers [**2167-1-13**] 09:30AM HCG-<5 [**2167-1-13**] 09:30AM CEA-1.5 CA125-62* CBC [**2167-1-13**] 09:30AM WBC-7.0 RBC-4.10* HGB-11.6* HCT-33.1* MCV-81* MCH-28.4 MCHC-35.1* RDW-14.8 [**2167-1-13**] 09:30AM NEUTS-72.9* LYMPHS-20.3 MONOS-4.1 EOS-1.2 BASOS-1.3 [**2167-1-13**] 09:30AM PLT COUNT-254# Brief Hospital Course: The pt was admitted to the gyn/oncology service on [**2167-1-13**] and on [**2167-1-14**], underwent an exploratory laparotomy and left salpingo-oophorectomy. Please see the operative report for full detail on the procedure. The pt's postoperative course was complicated by the following: 1) Oversedation: On the evening of POD#0, the pt was noted to be quite somulent upon transfer to the floor after having received both IV morphine and dilaudid for pain control. She was thus transferred to the [**Hospital Ward Name 332**] ICU for close monitoring overnight. The pt's somulence resolved overnight and she was tranferred to the floor the next morning. The pt was transitioned to po vicidin that day and had no further issues w/ somulence. 2) Pain: NSAIDS were avoided given the pt's hx of renal transplant. 3) Renal: The pt's renal status remained at baseline throughout her hospital course. Her creatinine was measured daily and found to range from 1.8 - 2.0. The pt's blood levels of tacrolimus and rapamycin were also checked and found to be within the therapeutic range. The pt's postoperative course was otherwise uncomplicated. On POD#3, her pain was well-controlled w/ oral pain medication, she was tolerating a full diet and able to ambulate and void without difficulty. The pt was thus discharged to home on POD#3 in stable condition and will follow-up with Dr. [**First Name (STitle) 1022**] in 4 weeks. Medications on Admission: 1. Sirolimus 2mg QD 2. Tacrolimus 2mg qam, 1mg qhs 3. Celexa 40 mg QD 4. Ambien 5mg prn 5. Terazosin 5mg qhs 6. Lasix 40mg qam 7. Diltiazem SR 240mg QD 8. Lopressor 100mg [**Hospital1 **] Discharge Medications: 1. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q3-6H () as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Left adnexal mass Discharge Condition: good Discharge Instructions: - Please call Dr. [**First Name (STitle) 1022**] if you experience fever > 100.5, chills, nausea and vomiting, worsening or severe abdominal pain, or if you have any other questions or concerns. Please call if you have redness and warmth around your incision, if you have pus draining from your incision, or if your incision reopens. - No heavy lifting or exercise for six weeks. No driving for 2 weeks and while taking vicodin as it can make you drowsy. Nothing per vagina (no tampons, intercourse, douching) until you see Dr. [**First Name (STitle) 1022**] in follow-up. - Please keep all follow-up appointments as outlined below. Followup Instructions: Please call Dr.[**Name (NI) 2989**] office at [**Telephone/Fax (1) 5777**] to set up a follow-up appointment to be seen in 4 weeks.

[ "V43.61", "733.49", "V43.64", "780.09", "E932.0", "V42.0", "V43.65", "585.9", "274.9", "401.9", "620.1", "E937.8" ]

icd9cm

[ [ [] ] ]

[ "65.49" ]

icd9pcs

[ [ [] ] ]

5284, 5290

3258, 4692

307, 360

5352, 5359

2551, 3235

6042, 6177

1937, 2073

4931, 5261

5311, 5331

4718, 4908

5383, 6019

2088, 2532

243, 269

388, 842

864, 1834

1850, 1921

31,627

168,542

31097

Discharge summary

report

Admission Date: [**2176-7-16**] Discharge Date: [**2176-7-21**] Date of Birth: [**2131-10-11**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: dyspnea, chest pain, fatigue Major Surgical or Invasive Procedure: 7/24 min. inv. MV repair History of Present Illness: 44 yo male with h/o MVP/MR with increasing dyspnea over the past year. Stress echo was positive for ischemic changes. Past Medical History: MR/MVP,Depression,Anxiety,R finger amp Social History: works as sheet metal mechanic livees with girlfriend no tobacco no etoh Family History: no premature cad Physical Exam: Admission: HR 78 RR 12 BP 136/80 NAD Chest Lungs CTAB RRR 3/6 systolic murmur Abdomen benign Extrem warm, no edema, right groin ecchymosis, No varicosities Pertinent Results: [**2176-7-21**] 10:45AM BLOOD Hct-29.1* [**2176-7-20**] 04:50AM BLOOD WBC-7.7 RBC-2.99* Hgb-9.5* Hct-26.4* MCV-89 MCH-31.8 MCHC-35.9* RDW-14.6 Plt Ct-205 [**2176-7-20**] 04:50AM BLOOD Plt Ct-205 [**2176-7-20**] 04:50AM BLOOD Glucose-110* UreaN-26* Creat-0.9 Na-139 K-4.5 Cl-101 HCO3-31 AnGap-12 Brief Hospital Course: On [**7-16**] he was taken to the operating room where he underwent a minimally invasive mitral valve repair with a 32 mm annuloplasty band. He was transferred to the ICU in critical but stable condition on neosynephrine and propofol. He awoke and was extubated later that same day. His chest tubes were pulled and he was transferred to the floor on POD #1. He was transfused 2 units for an HCT of 20. A left chest tube was inserted for a hemothorax. The hemothorax resolved and his hematacrit stabilized. His chest utbe was removed, and he was ready for discharge on POD #5. Medications on Admission: lexapro, MVI, prilosec Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. 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* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Escitalopram 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 2 weeks: then take as needed for pain/discomfort. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: MR Discharge Condition: good Discharge Instructions: no creams, lotions or powders to any incisions no driving while taking narcotics shower daily, no bathing or swimming for 1 month Followup Instructions: with Dr. [**Last Name (STitle) 73419**] in [**1-27**] weeks with Dr. [**Last Name (STitle) 73420**] in [**1-27**] weeks with Dr. [**Last Name (STitle) **] in [**3-28**] weeks needs follow-up with PCP for nodule on ct scan in [**2-27**] months Completed by:[**2176-7-22**]

[ "424.0", "E878.8", "998.11", "300.4", "511.8" ]

icd9cm

[ [ [] ] ]

[ "35.12", "34.04", "39.61", "99.04" ]

icd9pcs

[ [ [] ] ]

3586, 3669

1221, 1798

351, 378

3716, 3723

902, 1198

3901, 4175

692, 710

1871, 3563

3690, 3695

1824, 1848

3747, 3878

725, 883

283, 313

406, 525

547, 587

603, 676

11,851

106,183

29421

Discharge summary

report

Admission Date: [**2191-10-16**] Discharge Date: [**2191-10-18**] Date of Birth: [**2127-1-9**] Sex: F Service: MEDICINE Allergies: Adhesive Attending:[**First Name3 (LF) 1973**] Chief Complaint: Transfer from outside hospital for bilateral Pulmonary Emboli, elevated troponins and ST elevations in inferolateral leads (found to be similar to old ekg changes) Major Surgical or Invasive Procedure: Bilateral lower extremity dopplers: The bilateral common femoral, superficial femoral, greater saphenous, and popliteal veins are widely patent and demonstrate normal compressibility, augmentation, and phasic flow. No evidence of intraluminal thrombus. History of Present Illness: Mrs. [**Known lastname 70644**] is a 64 year old female nurse with a history of smoking and thrombophlebitis who presents with an intense left chest pain. On Friday, patient noticed an increased pain in her right thigh and a decrease in sensation in her right fingers. Patient woke up on Saturday ([**2191-10-15**]) to a [**9-13**] pain that began on the top of her left shoulder and radiated down to her midline. She describes the pain as a ??????vice-like?????? tightening as it traveled down. Nothing seemed to make it better or worse and she claimed she had done nothing unusual the day before. She has not been on any prolonged trips, had any recent surgeries, been immobilized recently, and has never felt a pain similar to this one. She has no dyspnea, cough, hemoptysis, tachypnea, tachycardia, nausea, emesis, dizziness, fevers, or chills associated with this chest pain. She believed it was ??????neuromuscular?????? pain and tried to ignore it. Her husband drove her to the local [**Hospital 18**] [**Hospital3 **] two hours later. She was found to have ST elevations on her EKG, which were consistent with previous findings, a positive D-dimer, and an initial Troponin of 0.8. A CT angio showed bilateral pulmonary emboli. She was given aspirin and started on heparin for anticoagulation and nitroglycerin for prophylaxis. She was then transferred to the [**Hospital1 18**] main campus for further workup. In the emergency room, she was given a bedside echo and seen by cardiology. Past Medical History: 1.)Thrombophlebitis 2.)Gastritis Social History: Patient is a former operating room nurse with a 10 pack-year history of smoking. She still smokes off and on but has not had a cigarette in the past two weeks. She occasionally drinks alcohol. She has no history of blood transfusions or illicit drugs. She has two children, both married with one child each. Patient has some financial concerns and helps small businesses out to make ends meet. Her husband is an electric engineer who still works three days a week. She really enjoys [**Location (un) 1131**]. Family History: She believes one of her aunt had a ??????clot??????, probably a venous thromboembolism. Her mother had extensive heart disease and died of a myocardial infarction at 65. Her other aunt had a dissected cerebral aneurysm. She states that there is an extensive cancer history in her family. Physical Exam: General: Vitals: Temp: 98.8 BP: 111/51 HR: 79 RR: 13 Oxygen Sat: 98 on room air HEENT: Eyes: Visual fields are normal, extraocular muscles are normal, fundoscopic exam not performed Ears: Hearing intact bilaterally to whispering, Otoscopic exam not performed. Nose: Septum is in the midline. No swollen turbinates. Mouth: No tongue deviation. Teeth and tongue are normal Throat: Bilateral palatal elevation Neck: No swollen nodes, no thyroidmegaly Cardiac: Carotid, radial, and DP Pulse all 2+ Midclavicular PMI along the 5th costal-vertebral line. Normal S1 and S2 clear, no murmurs Respiratory: Wheezes are auscultated in bilateral lungs, more so on the right base. No cyanosis, clubbing, no increased AP diameter No fremitus Normal resonance No egophony Abdominal Test: Abdomen not distended Auscultation demonstrates increased bowel sounds Percussion demonstrates no enlarged organs. No CVA tenderness Cranial Nerves: I: Not tested II: Peripheral vision normal Pupils reactive III, IV, VI: Extra-ocular movements are fully intact Lid elevation normal Pupillary reaction normal to light V: Jaws clench well, unable to be opened Pin prick to three regions of face are normal and symmetrical VII: Facial expressions are normal and symmetrical VIII: Can hear finger rubbing bilaterally IX, X: Uvula elevates symmetric [**Doctor First Name 81**]: Shrug normal Can turn head against resistance well to both side XII: Tongue protrudes in the midline. Tongue can push out checks Neurological Exam: Muscle bulk and tone are normal symmetrically No fasciculations or tremors. Strength test: [**4-8**] bilaterally on all extremities Sensory of sharp versus dull normal Joint Position sense is normal bilaterally Light touch is normal on each side Pertinent Results: [**2191-10-16**] 11:48PM CK(CPK)-134 [**2191-10-16**] 11:48PM CK-MB-8 cTropnT-1.01* [**2191-10-16**] 11:48PM PT-12.8 PTT-55.2* INR(PT)-1.1 [**2191-10-16**] 03:45PM GLUCOSE-118* UREA N-11 CREAT-0.8 SODIUM-137 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15 [**2191-10-16**] 03:45PM CK(CPK)-141* [**2191-10-16**] 03:45PM cTropnT-0.96* [**2191-10-16**] 03:45PM CK-MB-11* MB INDX-7.8* [**2191-10-16**] 03:45PM WBC-10.5 RBC-3.85* HGB-12.5 HCT-35.4* MCV-92 MCH-32.4* MCHC-35.2* RDW-13.5 [**2191-10-16**] 03:45PM NEUTS-69.9 LYMPHS-23.5 MONOS-4.7 EOS-1.7 BASOS-0.1 [**2191-10-16**] 03:45PM PLT COUNT-201 [**2191-10-16**] 03:45PM PT-13.5* PTT-133.7* INR(PT)-1.2* [**2191-10-18**] 05:40AM BLOOD WBC-7.9 RBC-3.59* Hgb-11.4* Hct-34.1* MCV-95 MCH-31.8 MCHC-33.5 RDW-13.3 Plt Ct-227 [**2191-10-18**] 05:40AM BLOOD Glucose-97 UreaN-7 Creat-0.9 Na-143 K-4.1 Cl-106 HCO3-28 AnGap-13 [**2191-10-17**] 02:21PM BLOOD CK(CPK)-106 [**2191-10-18**] 05:40AM BLOOD CK(CPK)-23* [**2191-10-17**] 07:19AM BLOOD CK-MB-5 cTropnT-0.96* [**2191-10-17**] 02:21PM BLOOD CK-MB-4 cTropnT-0.86* [**2191-10-18**] 05:40AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.4 Brief Hospital Course: Patient was transferred from [**Hospital1 **] [**Location (un) 620**] for bilateral pulomonary emboli seen on CTA and elevated troponins in the setting of ST elevations in the inferolateral leads (found to be consistent with old ekg's). The patient was on a heparin gtt and nitro gtt. In the ED at [**Hospital1 18**], a bedside echo was performed and did not show significant heart strain. (ED ECHO: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a fat pad.) The patient was admitted to the MICU for continued nitro and heparin gtt. Cardiology recommended telemetry, trending of the troponins, discontinuing nitro drip on hospital day 2 and if asymptomatic, transfer to the floor. The patient tolerated the discontinuation of nitro without complaints. She was transferred to the floor on HD 2. Her heparin gtt was continued. On HD 3 she was bridged to lovenox, bilateral lower extremity ultrasounds showed no evidence of clots, and she was prepared for discharge. Important outpatient issues discussed with the primary MD: outpatient stress test recommended by cardiology, outpatient hypercoaguability workup (protein c and S and free protein S), follow up with Thoracic surgery at scheduled appointment for workup of right upper lobe 6mm spiculated nodule. Medications on Admission: Aspirin 81mg PO qDay Calcium Discharge Medications: 1. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous twice a day. Disp:*14 syringes* Refills:*0* 2. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Right upper lobe 6 mm spiculated pulmonary nodule Bilateral pulmonary emboli Discharge Condition: Stable, Improving Discharge Instructions: Follow up at your scheduled appointments with thoracic surgery and Dr [**Last Name (STitle) 5292**]. (dates specified below). You should continue to take the lovenox injections twice a day for the next three days. Also, you should take one tablet (5mg) of coumadin every night. You should follow up with Dr [**Last Name (STitle) 5292**] on Friday to determine if your coumadin level is therapeautic. Followup Instructions: You have an appointment scheduled with Dr [**Last Name (STitle) **], a thoracic surgeon, on [**10-25**] at 10 AM to discuss the right lung nodule that was seen on CT scan. His office is located in the [**Hospital Ward Name 23**] building on the [**Location (un) **]. This appointment is very important. If you should have a conflict, please call the office at [**Telephone/Fax (1) 11763**]. Follow up with Dr [**Last Name (STitle) 5292**] on Friday at 1PMat [**Street Address(2) **] [**Apartment Address(1) 70645**], [**Location (un) 620**] MA. An outpatient stress test should be scheduled and a future hypercoaguability workup should be completed. Dr [**Last Name (STitle) 5292**] will also follow up with the lab tests ordered in the hospital (protein C, S and free protein S). Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] Date/Time:[**2191-10-25**] 10:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5294**] [**2194-10-21**] 1:00PM

[ "305.1", "518.89", "415.19", "535.50", "E935.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8610, 8616

6081, 8126

435, 690

8737, 8756

4913, 6058

9206, 10254

2833, 3126

8205, 8587

8637, 8716

8152, 8182

8780, 9183

3141, 4052

4646, 4894

231, 397

719, 2227

4068, 4627

2249, 2284

2300, 2817

25,879

115,996

3350

Discharge summary

report

Admission Date: [**2116-5-2**] Discharge Date: [**2116-5-8**] Date of Birth: [**2067-9-11**] Sex: M Service: VASC [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 15537**] is a 48 year old male who is status post aortobifemoral bypass grafting as well as right sided femoral to popliteal artery bypass grafting, right sided iliac stenting and aortohepatic bypass grafting with erosion of his graft into his duodenum requiring repair approximately four months ago, as well as a history of a left sided axillary femoral artery with fem-[**Doctor Last Name **] bypass grafting in [**2116-1-17**], and redo of his left femoral popliteal bypass in [**Month (only) 958**] of this year with a left sided toe amputation, who presented complaining of two days of drainage of his left groin incision and tenderness. HOSPITAL COURSE: This was diagnosed as a wound infection and he was placed on broad-spectrum antibiotics and had wound management performed at this time. He was admitted to the Floor and was doing well up until hospital day number three where he was noted to have a large amount of bloody emesis, approximately two liters, with hypotension. He was subsequently transported into the Intensive Care Unit, had large bore intravenous access obtained, and had an esophagogastroduodenoscopy performed showing a large duodenal blood clot. He continued to require large amounts of blood and went down to Angiography the next morning. In the Angio Suite, it was found that his axillary to femoral bypass graft was thrombosed, requiring TPA administration. He also had evidence of active bleeding requiring multiple coil embolization of multiple aortic branches. He returned to the Intensive Care Unit following this procedure in very critically ill condition. He was maintained on high inotropic support and aggressive fluid and blood products administration. However, he went into liver failure that morning and given the poor prognosis, a discussion was carried out with the family and they felt that continuing further support was against his wishes and made the patient comfort measures only. Following this, all inotropic support was removed, and the patient expired at 09:51 a.m. on [**2116-5-8**]. No post-mortem examination was to be performed by the family's request. DISCHARGE DIAGNOSES: 1. Massive upper gastrointestinal bleed of unknown origin. 2. Thrombosed axillary femoral bypass graft. 3. Sepsis. 4. Multi-organ failure. 5. Status post multiple vascular bypass procedures. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**] Dictated By:[**Name8 (MD) 15538**] MEDQUIST36 D: [**2116-5-8**] 11:25 T: [**2116-5-11**] 11:28 JOB#: [**Job Number 15539**]

[ "998.3", "570", "263.9", "E878.2", "998.59", "038.9", "532.40", "996.74", "441.9" ]

icd9cm

[ [ [] ] ]

[ "99.10", "39.79", "45.13", "88.42" ]

icd9pcs

[ [ [] ] ]

2356, 2820

873, 2335

188, 854

9,040

128,304

28099

Discharge summary

report

Admission Date: [**2122-8-6**] Discharge Date: [**2122-8-9**] Service: MEDICINE Allergies: Levaquin / Penicillins / Nifedipine Attending:[**First Name3 (LF) 2704**] Chief Complaint: Transfer for cardiac cath Major Surgical or Invasive Procedure: Cardiac cath x2 Hemodialysis History of Present Illness: 88 yo male with h.o CAD, STEMI in [**2113**] with angioplasty of LCX, CKD stage IV, close to hemodialysis, who presented to OSH with chest pain on [**2122-8-1**]. He described the pain as L side of chest and substernal, aching in quality, nonradiating, [**3-9**] in intensity at its worst. The pain was worse with activity. The pain improved with sublingual NTG on arrival to OSH. His ECG at that time showed NSR, rate 70's, LAD, RBBB, LAFB, STD and TWI in v3-v6. His enzymes were negative (CK 87, 92, trop I 0.1. 0.15)at OSH. He was started on heparin and loaded with plavix. Of note, he had a supposed allergy to plavix but has tolerated this dose. His hematocrit was dropping (34->26.7) over 2 days and had some nosebleeding so heparin and plavix were stopped. He had cardiac cath there that showed LAD with 80% calcified lesion, plan to transfer to [**Hospital1 18**] for treatment. Cath here showed LM with 30 distal stenosis, LAd with ostial 80% calcified lesion, 40% LCX, RCA not engaged as known to be nondominant and without disease. He had rotablation of LAD and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] placed in distal LM to LAD, then LCX looked hazy it was balloon angioplastied in a kissing fashion. During procedure, he experienced some chest pain similar to what brought him into hospital. He was started on nitroglycerine with some relief in the pain. He was sent to F6 and had persistent chest pain [**2126-1-3**] with borderline Bp's 80-100/50-60. ECG was essentially unchanged with STD inferiorly but a new 1 mm STE in V2. He was transferred to CCU for monitoring. On transfer to CCU, he c/o [**3-9**] CP, ECG showed resolution of the STE in V2, worsening STD laterally. CP decreased to [**12-9**] with more nitrolgycerine and morphine. Of note his hemotcrit dropped to 27.6 from 31.3 prior to cath. He was guiac positive but denied any h/o dark stool or BRBPR. Past Medical History: CKD, secondary to glomerulonephritis, followed by Dr. [**Last Name (STitle) 68100**], s/p R arm fistula in [**11-3**]. CAD s/p STEMI in [**2113**] with PTCA of LCX Glaucoma DMII Gout S/P T&A L ear squamous cell carcinoma Social History: Widowed, lives in [**Location **], used to work as carpenter and farmer, no tobacco, no ETOH Family History: Brother with "heart problems", DM, PVD Physical Exam: VS- 96.5, 94/50, 75, 16, 98% 4L GEN- Anxious appearing elderly gentlman sitting up in bed HEENT- JVP elevated to 7 cm above sternal angle at 80 degrees LUNGS- decreased BS R base. + crackles b/l bases HEART- S1, S2, [**2-2**] SM loudest at inferior portion of sternum ABD- soft, ND, NT, BS+, no abdominal bruit, masses, pulsatility EXT- L leg warm to touch, R foot cooler. trace pitting edema b/l. 2+ R femoral pulse, cath site unremarkable NEURO- A*O*3, able to name objects, difficulty with naming months backward, remembering presidents Pertinent Results: [**2122-8-6**] 05:31PM WBC-9.1 RBC-2.92* HGB-9.3* HCT-27.6* MCV-95 MCH-32.0 MCHC-33.8 RDW-16.5* [**2122-8-6**] 05:31PM CK(CPK)-56 [**2122-8-6**] 05:31PM CK-MB-NotDone cTropnT-0.26* proBNP-[**Numeric Identifier 68330**]* [**2122-8-9**] 07:30AM BLOOD WBC-14.6*# RBC-2.72* Hgb-8.7* Hct-25.8* MCV-95 MCH-31.9 MCHC-33.7 RDW-16.6* Plt Ct-151 [**2122-8-9**] 07:30AM BLOOD Glucose-305* UreaN-113* Creat-6.3* Na-137 K-4.6 Cl-95* HCO3-15* AnGap-32* [**2122-8-9**] 12:50AM BLOOD CK-MB-19* MB Indx-10.5* cTropnT-1.34* [**2122-8-9**] 08:17AM BLOOD Type-ART FiO2-100 pO2-80* pCO2-41 pH-7.23* calTCO2-18* Base XS--9 AADO2-595 REQ O2-97 Brief Hospital Course: Mr. [**Known lastname **] was transfered to [**Hospital1 18**] for concern for ACS; [**Hospital1 18**] cath showed LM c 30% distal stenosis, LAD c 80% ostial lesion, LCX 40% lesion. Rotablation of LAD done [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] placed in distal LM to LAD. LCX balloon angioplastied in kissing fashion. Post cath had CP c new 1 mm STE V2; transferred to CCU monitoring. STE resolved on transfer to CCU; pain resolved. Cardiac enzymes bumped but this was thought to be secondary to rotablation. He was then transferred back to the floor team for further management. The patient again began to complain of chest pain. Reported pain over epigastrium and inferior portion sternum radiating to back bilaterally. There was no associated SOB, diaphoresis. This started at rest. He was started on nitro drip but ability to uptitrate limited by low blood pressure in high 80-low 90 range. He received total of 8 mg IV morphine for pain and was transferred back to the CCU. Upon arrival to the CCU the patient was hypotensive and acutely distressed. He rapidly deteriorated into a PEA arrest. ACLS was performed, and he was successfully revived and emergently transferred to the cath lab for PCA to investigate whether a new ischemic event had triggered his rapid deterioration. While in the cath lab the patient again developed PEA arrest. ACLS was performed unsuccessfully and the patient was pronounced dead. His family was made aware of the events as they were happening via telephone and arrived at the hospital shortly after his death. Medications on Admission: Allopurinol Actos 1 mg QD Edacryne ASA 81 mg QD Centrum Alphagam eye drops Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: End-stage renal disease Coronary artery disease Myocardiac infarction Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A

[ "785.51", "274.9", "276.2", "458.29", "V45.82", "403.91", "276.7", "V10.83", "250.00", "414.01", "412", "585.6", "427.5", "410.81", "275.3", "285.1", "271.3" ]

icd9cm

[ [ [] ] ]

[ "00.66", "99.04", "00.41", "37.61", "99.60", "36.07", "37.22", "39.95", "88.56", "00.45" ]

icd9pcs

[ [ [] ] ]

5636, 5645

3868, 5482

267, 298

5759, 5769

3214, 3845

5821, 5827

2597, 2637

5608, 5613

5666, 5738

5508, 5585

5793, 5798

2652, 3195

202, 229

326, 2227

2249, 2471

2487, 2581

28,160

184,274

32814

Discharge summary

report

Admission Date: [**2179-2-7**] Discharge Date: [**2179-2-23**] Date of Birth: [**2100-5-24**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1283**] Chief Complaint: asymptomatic Major Surgical or Invasive Procedure: CABGx2(LIMA-LAD,SVG-OM)AVR(19mm [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])[**2-9**] History of Present Illness: 78 yo M with known AS, recent admission for respiratory distress, mild CHF. Cath showed 2VD, [**Location (un) 109**] 1, referred for surgery. Past Medical History: AS, HTN, PAF, DM, ^lipids, PVD, carotid stenosis Social History: retired government worker tobacco - quit a few months ago, ~1pack/week no etoh x 1 month Family History: None Physical Exam: Admission VS:HR 82 RR 20 BP 140/60 Gen:NAD Skin:few superficial skin tears Lungs: CTAB Heart: RRR, 3/6 SEM Abdomen: benign Extrem: warm, no edema, superficial varicosities Carotids with transmitted murmur v. bruit Pertinent Results: [**2179-2-23**] 05:20AM BLOOD WBC-17.2* RBC-3.38* Hgb-9.9* Hct-31.1* MCV-92 MCH-29.4 MCHC-32.0 RDW-14.9 Plt Ct-798* [**2179-2-22**] 05:20AM BLOOD WBC-20.6* RBC-3.43* Hgb-10.1* Hct-31.5* MCV-92 MCH-29.4 MCHC-32.1 RDW-14.3 Plt Ct-748* [**2179-2-21**] 04:14AM BLOOD WBC-16.0* RBC-3.27* Hgb-10.0* Hct-29.8* MCV-91 MCH-30.4 MCHC-33.5 RDW-14.5 Plt Ct-572* [**2179-2-20**] 04:18AM BLOOD WBC-17.6* RBC-3.31* Hgb-9.7* Hct-30.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-14.4 Plt Ct-476* [**2179-2-23**] 05:20AM BLOOD PT-27.5* INR(PT)-2.8* [**2179-2-22**] 05:20AM BLOOD PT-34.0* PTT-32.5 INR(PT)-3.6* [**2179-2-21**] 04:14AM BLOOD PT-36.6* INR(PT)-3.9* [**2179-2-20**] 04:18AM BLOOD PT-39.4* INR(PT)-4.3* [**2179-2-19**] 05:36AM BLOOD PT-36.4* INR(PT)-3.9* [**2179-2-18**] 05:40AM BLOOD PT-28.8* PTT-29.6 INR(PT)-2.9* [**2179-2-17**] 06:25AM BLOOD PT-21.8* PTT-69.9* INR(PT)-2.1* [**2179-2-16**] 04:14AM BLOOD PT-18.1* PTT-55.8* INR(PT)-1.7* [**2179-2-15**] 03:39AM BLOOD PT-18.1* PTT-43.3* INR(PT)-1.7* [**2179-2-23**] 05:20AM BLOOD Glucose-223* UreaN-29* Creat-1.5* Na-135 K-4.7 Cl-96 HCO3-31 AnGap-13 [**2179-2-22**] 05:20AM BLOOD Glucose-71 UreaN-29* Creat-1.4* Na-138 K-4.7 Cl-98 HCO3-33* AnGap-12 [**2179-2-21**] 04:14AM BLOOD Glucose-91 UreaN-32* Creat-1.3* Na-141 K-4.7 Cl-100 HCO3-33* AnGap-13 [**2179-2-20**] 04:18AM BLOOD Glucose-42* UreaN-33* Creat-1.1 Na-141 K-4.2 Cl-100 HCO3-32 AnGap-13 [**2179-2-7**] 02:15PM BLOOD Glucose-376* UreaN-40* Creat-1.3* Na-139 K-5.2* Cl-103 HCO3-25 AnGap-16 CHEST (PA & LAT) [**2179-2-19**] 10:04 AM CHEST (PA & LAT) Reason: eval for pleural effusions [**Hospital 93**] MEDICAL CONDITION: 74 year old woman s/p AVR/CABG/PFO closure REASON FOR THIS EXAMINATION: eval for pleural effusions REASON FOR EXAMINATION: Followup of a patient after aortic valve replacement, CABG and patent foramen ovale closure. PA and lateral upright chest radiograph compared to [**2179-2-16**]. Patient was extubated in the meantime interval with removal of the NG tube and Swan-Ganz catheter. The moderate cardiomegaly is stable. The bibasal opacities are consistent with post-surgical atelectasis, improved. Small amount of pleural effusion is demonstrated, bilateral. There is no evidence of failure. There is no pneumothorax. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76413**] (Complete) Done [**2179-2-8**] at 4:49:10 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] 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: [**2100-5-24**] Age (years): 78 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: CABG, AVR ICD-9 Codes: 424.1 Test Information Date/Time: [**2179-2-8**] at 16:49 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.6 cm <= 5.2 cm Left Ventricle - Ejection Fraction: 55% >= 55% Left Ventricle - Lateral Peak E': 0.40 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 3 < 15 Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Arch: 2.3 cm <= 3.0 cm Aortic Valve - Peak Velocity: *2.3 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *21 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 12 mm Hg Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2 Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 1.57 Mitral Valve - E Wave deceleration time: *410 ms 140-250 ms Findings Please this TEE was done on [**2179-2-9**] during the surgery LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global 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 ascending aorta. Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Moderate AS (AoVA 1.0-1.2cm2) Moderate (2+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild to moderate ([**12-9**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. 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 dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-9**]+) mitral regurgitation is seen. There is a moderate aortic regurgitation with moderate aortic stenosis. There is no pericardial effusion. Dr. [**Last Name (Prefixes) **] was notified of the findings in the operating room. Post_Bypass: Preserved biventricular normal systolic function. LVEF 55%. Ascending aortic contour is well preserved. Mild to Moderate regurgitation is seen. There is a mechanical valve in the native aortic position, stable and moving well with residual gradients of a peak of 12 and a mean of 5mm of Hg. Brief Hospital Course: He was admitted to cardiac surgery for IV heparin after stopping his coumadin in preparation for surgery. He was taken to the operating room on [**2-9**] where he underwent a CABG x 2 and AVR. He was transferred to the ICU in stable condition. He was extubated on POD #1. He was transfused. He returned to rate controlled atrial fibrillation. He was started on coumadin for his mechanical valve and afib. He developed complete heart block and was seen by electrophysiology. His complete heart block resolved and he again had atrial fibrillation. He was started on IV heparin while his INR was subtherapeutic. He was transferred to the floor on POD #6. He was noted to cough while drinking thin liquids and was seen by speech and swallow and did not aspirate upon bedside examination. He continued to require aggresive pulmonary toilet. He was started on vanoc, cipro and flagyl for ? of aspiration pna. His INR became supratherapeutic and his coumadin was held for several days. Video swallow performed on [**2-22**] showed no aspiration but he continued to be high risk for aspiration. He was re-started on thin liquids and soft solids, and aspiration precautions. He improved, his CXR improved, white count decreased, and INR decreased and was ready for discharge to rehab on POD #14. Medications on Admission: Coumadin, zocor 80', HCTZ 50', Lantus 30', Toprol XL 150QA/ 100QP, Felodipine 10', lisinopril 40', zetia 10', humalog Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days: then reassess need for diuresis. 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days: with lasix. 10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**3-14**] hours as needed for pain. 13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: Check INR [**2-24**] and dose accordingly. . 14. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous at bedtime. 15. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding scale Subcutaneous four times a day. Discharge Disposition: Extended Care Facility: [**Hospital3 15644**] Long Term Health - [**Location (un) 47**] Discharge Diagnosis: CAD/AS now s/p CABG/AVR HTN, PAF, DM, ^lipids, PVD, carotid stenosis Discharge Condition: Stable Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) 5051**] 2 weeks Dr. [**Last Name (Prefixes) **] 4 weeks Completed by:[**2179-2-23**]

[ "414.01", "997.1", "250.00", "428.0", "E878.2", "426.0", "427.31", "507.0", "424.1", "401.9", "276.2", "272.4", "584.9" ]

icd9cm

[ [ [] ] ]

[ "36.11", "99.04", "38.93", "36.15", "39.61", "35.22" ]

icd9pcs

[ [ [] ] ]

10636, 10726

7726, 9014

290, 434

10839, 10848

1055, 2635

799, 805

9182, 10613

2672, 2715

10747, 10818

9040, 9159

10872, 11138

11189, 11340

820, 1036

238, 252

2744, 7703

462, 605

627, 677

693, 783

28,776

192,923

33233

Discharge summary

report

Admission Date: [**2105-11-30**] Discharge Date: [**2105-12-4**] Date of Birth: [**2026-3-27**] Sex: F Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11304**] Chief Complaint: vaginal bleeding Major Surgical or Invasive Procedure: turbt History of Present Illness: This is a 79 year-old female with a history of PVD, AF, who presents with vaginal bleeding. The patient reports being in her usual state of health until this AM when she started to bleed. Per report the patient had ongoing vaginal bleeding with passing large clots. She then went to dialysis but continued to have bleeding. She then went to the ER with this ongoing bleeding . In the ED, initial vitals were T 97 BP 109/54 HR 112, RR 16 02 97% RA. Patient was reportedly seen by urology and is to be admitted to the [**Hospital Unit Name 153**] for evaluation of the bleeding. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: 1. PVD with Right Lower Extremity non-healing ulcers 2. hypercholesterolemia 3. ESRD on HD 4. atrial fibrillation 5. DM 6. depression 7. hypothyroidism 8. Bladder CA 9. Constipation 10. Anemia PSH: R fem-AK [**Doctor Last Name **] BPG (6 years ago); R groin exploration with R EIA/profunda/fem-[**Doctor Last Name **] BPG thrombectomy, R CFA & EIA Dacron patch angioplasty, RLE 4 compartment fasciotomies [**2105-1-7**]; R PFA & fem-[**Doctor Last Name **] [**Doctor Last Name **] thrombectomy, fem-[**Doctor Last Name **] angioplasty x 2, fem-[**Doctor Last Name **] stent x 2 [**2105-1-8**]; hysterectomy, C-section Social History: Has daughter and son, smoked 1 ppd, stopped 8 years ago, lives alone but currently at [**Name (NI) **], HCPs are son [**Doctor First Name **] [**Telephone/Fax (1) 77205**]) and daughter ([**Telephone/Fax (1) 77206**]) Family History: Non-contributory Physical Exam: GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2105-11-30**] 03:40PM PT-13.4 PTT-31.1 INR(PT)-1.1 PLT SMR-NORMAL PLT COUNT-320 HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL PAPPENHEI-OCCASIONAL ENVELOP-1+ NEUTS-84.3* BANDS-0 LYMPHS-10.7* MONOS-3.1 EOS-1.6 BASOS-0.3 WBC-7.5# RBC-3.05* HGB-9.3* HCT-29.4* MCV-96 MCH-30.5 MCHC-31.6 RDW-20.1* CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-1.9 GLUCOSE-183* UREA N-19 CREAT-3.0* SODIUM-140 POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-32 ANION GAP-14 HGB-11.2* calcHCT-34 CT ABDOMEN W/CONTRAST Study Date of [**2105-11-30**] 6:37 PM CONCLUSION: 1. Urinary bladder tumor and likely hemorrhage. It is technically difficult to assess the exact extent of the tumor due to surrounding hemorrhage, though the mass approximately measures 52 x 31 mm, previously 40 x 26 mm. 2. Air within the urinary bladder, if no recent instrumention fistulous communication is a concern. 3. Multiple cystic lesions in the pancreas likely representing side branch IPMNs. No associated pancreatic ductal dilatation. An MRCP would be helpful for further characterization. 4. Extensive atherosclerosis in the coronary arteries as well as the abdominal and pelvic vasculature with an occluded right superficial femoral artery [**Date Range **] as well as occlusion of the native right superficial femoral artery. 5. Indeterminate tiny hepatic hypodensities were barely visualized on the prior examination due to different phase of contrast. A liver ultrasound would be helpful for further characterization of these or alternatively these can be assessed at the time of the MRCP. Brief Hospital Course: This is a 79 year-old female with a history of PVD, bladder cancer, a fib, ESRD who presents with persistent vaginal bleeding . # Vaginal bleeding/Tachycardia/hypotension:: Based on history the patient was reported to lose a significant amount of blood. Initial repeat hct stable at 29. Nonetheless, the patient had ongoing blood loss, hypotension and intermittent tachycardia and was admitted to the. Coag studies were WNL. CT scan showed bladder mass which was considered the cause of bleeding. The patient recieved a total of 3U RBC and was subsequently stable. Tachcardia and hypotension improved with transfusion of blood and was likely secondary to blood loss. Hematocrit was ********the day of discharge. # Bladder Mass: The patient's bleeding was suspectd to be due to a bladder mass eroading through the bladder wall. The patient underwent cystoscopy with subseqent biopsy of the bladder mass. Pathology results were pending at the time of discharge. # PVD/ s/p debridement: Pt has wound appears to be healing with good granulation tissue and minimal evidence for infection. Will have wound care evaluate the patient in AM. Will consider plastics consult if worsening. Holding aspirin for now given . # Atrial fibrillation: patient is rate controlled without meds currently. Given the patient's hypotension, will not add betablockers at this time, but will add back when bleeding stable. Not currently on anticoagulation . # Diabetes: patient reports having diet controlled diabetes. Will give patient insulin sliding scale at this point and diabetic diet. [**11-30**] Hypotensive with SBPs in the 80's. Mentating well. Did not respond to fluids. Had post transfusion Hct with minimal increase. Recieved 1U RBC with Hct from 29-->30 [**12-1**] - Urology - npo mn, plan for proecedure - PICC line placed - Renal - HD tommorow, ? PRBC during HD (per ICU team) - Hct - 29 > 30 (s/p 1 UPRBC) > 24.1 > 23.8 > 25.1 (post-transfusion 1 u prbc) - Anesthesia contact[**Name (NI) **] re: procedure and aware of pt for tommorow's procedure - [**Name (NI) **] contact[**Name (NI) **] and aware of pt (no official consult requested) - 1.44 second sinus pause on telemetry (astymptomatic) o/n [**12-2**] TURBT procedure, transferred back to ICU in stable condition [**12-3**] Transferred to floor [**12-4**] Discharge Medications on Admission: Albuterol [**Hospital1 **] Aspirin 81 mg daily Atorvastatin 10 mg daily Brimodine Carvediolol 12.5 [**Hospital1 **] Furosemide 60 mg [**Doctor First Name **],tu,th,sa Insulin sliding scale metoclopramide micanazole mvi scopolamine sevelamer 800 TID Vit B Percocet 1 tab this PM Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 3. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 7. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO SUNDAY, TUESDAY, THURSDAY, SATURDAY (). 9. Bactrim 1 tab po bid Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: bladder tumor Discharge Condition: stable Discharge Instructions: - resume home medications - keep foley catheter in until Saturday at which point it can be removed - return to emergency room for further bleeding, vomitting, or other concerns - f/u with Dr. [**Last Name (STitle) 3748**] Followup Instructions: 2 weeks Completed by:[**2105-12-4**]

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icd9cm

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Discharge summary

report

Admission Date: [**2132-11-25**] Discharge Date: [**2132-12-2**] Date of Birth: [**2064-6-20**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4095**] Chief Complaint: Fever Major Surgical or Invasive Procedure: TEE History of Present Illness: 68 yo male with history of mental retardation and recurrent UTIs [**2-20**] urethral stricture with chronic Foley admitted from group home for [**10-27**] lower abdominal pain since this AM. His pain was accompained by fever to 104 (decreased to 100.9 with tylenol), chills, nausea and vomiting, also decreased urine output. Patient last had foley changed on [**11-10**]. He has a history of playing with his foley and manipulating the placement. . In the ED inital vitals were 97.6 91 114/60 16 90% RA. His exam in the ED was concerning for a distended lower abdomen/suprapubic area. His foley was replaced with improvement in pain to [**5-27**], and immediate UOP of 1.4L. He received a total of 5L NS with BP remaining 96/53 with HR 61. Since placement of foley, he has had an additional 3L of urine output. Labs were remarkable for WBC 11.8 with left shift and creatinine of 1.6 (baseline 1.1), lactate 1.2. His UA showed positive nitirite, large leuks, >182 WBC, moderate bacteria. He had a CT abdomen without contrast which revealed chronic hydronephrosis (L>R), thickening of the bladder (suggestive of chronic obstruction), could not rule out/in pyelo b/c no IV contrast. He had a chest xray which was not concerning for any acute processes. He was started empirically on vanc/ceftriaxone for history of E. coli and MRSA UTI, and flagyl for possible other intra-abdominal processes. . Of note, pt was recently discharged on [**11-4**] for similar complaints of UTI and urinary retention. Urine cultures at that time revealed E. Coli resistant to cipro and bactrim. He was initially treated with ceftriaxone, and transitioned to PO cefpedoxime to complete a 10 day course. He was seen by urology on [**11-10**] who recommended intermittent catheterization, thought it is unclear if this is a plausible option for this patient given his mental capacity. Per notes, his group home is not equiped to help with intermittent catheterization. On the floor, pt is still complaining of lower abdominal pain. He is complaining of being very hungry. . Review of systems: (+) Per HPI, chronic pelvic pain per previous notes, occasional blood stools, none recently (-) Denies 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 diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -recurrent urethral stricture: followed by Dr. [**Last Name (STitle) **], s/p cystoscopy, direct-vision internal urethrotomy and fulguration of a bladder lesion on [**2132-10-14**] -Mental Retardation: mild to moderate, independent in ADLs -Traumatic R knee inflamatory arthritis -hx of eczema in the past rx with hydrocortisone cream, -dx with open angle glaucoma R eye [**2121**] -chronic onychomycosis of b/l toe nails -diabetes, based on HbA1c 6.7% -hypertension -elevated PSA -hyperlipidemia: [**3-26**] t chol 192, LDL 118, HDL 64, TG 51 -ECHO [**2130-7-7**] EF 60-70% normal sytolic function -Diverticulosis: [**Last Name (un) **] [**12/2130**] -B 12 Defic Social History: lives in a group home; Bay Cove Human Services. Worked at a Recycling Center few hours daily, retired '[**30**]. Denies tobacco, alcohol or drugs. Family History: Father: unknown Mother: unknown Physical Exam: Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, pupils equal and reactive to light, 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 with lower abdominal distension, diffusely tender to palpation worse in lower abdomen, bowel sounds present, no rebound tenderness or guarding, no organomegaly, no CVA tenderness though does have diffuse lower back pain, no spinal tenderness GU: foley draining cloudy yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge Exam: AVSS CV: No M/R/G Abdomen: soft NT ND GU: yellow clear urine. Pertinent Results: [**2132-11-25**] 05:30PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011 [**2132-11-25**] 05:30PM URINE BLOOD-MOD NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [**2132-11-25**] 05:30PM URINE RBC-16* WBC->182* BACTERIA-MOD YEAST-NONE EPI-0 [**2132-11-25**] 03:13PM UREA N-31* CREAT-1.6* [**2132-11-25**] 03:13PM estGFR-Using this [**2132-11-25**] 03:13PM ALT(SGPT)-18 AST(SGOT)-21 CK(CPK)-31* ALK PHOS-99 TOT BILI-0.5 [**2132-11-25**] 03:13PM LIPASE-22 [**2132-11-25**] 03:13PM CK-MB-2 cTropnT-0.13* [**2132-11-25**] 03:13PM PH-7.51* COMMENTS-GREEN TOP [**2132-11-25**] 03:13PM GLUCOSE-111* LACTATE-1.2 NA+-135 K+-4.4 CL--101 TCO2-23 [**2132-11-25**] 03:13PM freeCa-1.09* [**2132-11-25**] 03:13PM WBC-11.8*# RBC-3.93* HGB-11.3* HCT-33.7* MCV-86 MCH-28.7 MCHC-33.5 RDW-13.5 [**2132-11-25**] 03:13PM NEUTS-93.5* LYMPHS-4.3* MONOS-1.0* EOS-0.9 BASOS-0.2 [**2132-11-25**] 03:13PM PLT COUNT-395 [**2132-11-25**] 03:13PM PT-13.7* PTT-25.0 INR(PT)-1.2* EKG: new TWI in II, III, AVF Blood Culture, Routine (Preliminary): ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Aerobic Bottle Gram Stain (Final [**2132-11-26**]): Blood Culture, Routine (Final [**2132-11-29**]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 334-3294R [**2132-11-25**]. STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S Aerobic Bottle Gram Stain (Final [**2132-11-26**]): GRAM NEGATIVE ROD(S). GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by [**First Name8 (NamePattern2) 251**] [**Last Name (un) **] (4I) @ 0956 [**2132-11-26**]. Anaerobic Bottle Gram Stain (Final [**2132-11-26**]): GRAM POSITIVE COCCI IN CLUSTERS. [**2132-11-25**] 5:30 pm URINE Site: CATHETER **FINAL REPORT [**2132-11-26**]** URINE CULTURE (Final [**2132-11-26**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. [**2132-11-26**] 12:05 pm SWAB Source: Urethral. **FINAL REPORT [**2132-11-27**]** Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final [**2132-11-27**]): Negative for Chlamydia trachomatis by PCR. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final [**2132-11-27**]): Negative for Neisseria Gonorrhoeae by PCR. [**2132-11-28**] Transthoracic ECHO: IMPRESSION: Normal left ventricular cavity size and regional systolic function. Mild pulmonary artery hypertension. Dilated ascending aorta. No valvular pathology or pathologic flow identified. Compared with the prior study (images reviewed) of [**2130-7-7**], global left ventricular systolic function is less vigorous (and the heart rate is much slower). . [**2132-12-2**] TEE: No spontaneous echo contrast or thrombus is seen in the body of the left or right atrium. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta to 40 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No vegetations or clinically-significant valvular disease seen. Brief Hospital Course: 68M history of mental retardation and recurrent UTI secondary to urethral stricture admitted for recurrent UTI, urinary retention and resulting in urosepsis, fluid responsive hypotension. . ACTIVE ISSUES: # MRSA and E. Coli Septicemia: Pt presented with fever to 104, SBPs to 90s that was responsive to 5L of IVF. Likely due to urinary track infection in etiology. Pt presented in severe sepsis that was responsive to IVF and antibiotics. BCx (last + [**11-27**]) revealed E.Coli and Staph Aureus. TTE and TEE unrevealing for vegetations. I.D. consutled and agreed with CTX and Vancomycin until [**2132-12-11**]. Vanco trough should be rechecked, as well as labs, on [**2132-12-5**]. The I.D. team does not need to follow-up with the patient per team. . # Bacterial UTI: Pt has history of recurrent UTI secondary to urethral stricture. UA had >182 WBC and the source of his sepsis was thought to be likely GU. Pt was maintained with foley in place during admission and will be due to follow-up in Dr. [**Last Name (STitle) **] (urology clinic) on [**2132-12-18**]. . # Hyperglycemia - nor prior diagnosis of DM2: A1c 6.7 in 2/[**2132**]. Not on any medications at home. Repeat check of HbA1c in house was <6.0. . # Positive troponins - thought to be due to demand ischemia in the setting of hypotension. Upon transfer to he floor, routine EKG was obtained that showed new TWI. Cardiac enzymes continue to downtrend. Pt otherwise asymptomatic and recommend outpatient follow-up. - Consider rechecking ECG as outpatient to look for resolution of TWIs in inferior leads. Pt otherwise asymptomatic. . INACTIVE ISSUES: # h/o Hypertension: not on any antihypertensives - confirmed with group home. . # Depression: confirmed with group home, pt is on sertraline. . # Glaucoma: Patient with a known history of open angle glaucoma, - continue eye drops . TRANSTIONAL ISSUES: - Patient will be discharged to [**Hospital 100**] Rehab on [**12-2**]. Accepting physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will be emailed the summary above. - Direct verbal signout was provided to pt's PCP via phone on [**12-2**]. PCP recommends [**Name Initial (PRE) **]/u following discharge from [**Hospital 100**] Rehab. - Full Code - Patients Visting Nurse Medications on Admission: colace 100 mg po bid aspirin EC 81 mg po daily zoloft 25 mg po q hs vitamin B12 1000 mcg q day lumigan 0.03% 1 gtt each eye q hs Alphagan 0.2% 1 gtt each eye [**Hospital1 **] Tinactin power q hs to toes robitussin 100 ml/5ml q 4 hrs prn cough Tylenol 325-650 mg po q 6 prn pain, fever, Discharge Medications: 1. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours): Continue through [**2132-12-11**]. 2. ceftriaxone 1 gram Piggyback Sig: One (1) Intravenous once a day: Continue through [**2132-12-11**]. 3. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. Outpatient Lab Work Please check Basic Metabolic Panel and Vanco trough Friday [**2132-12-5**] Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary Diagnosis - E.Coli Septicemia - MRSA Septicemia - Urinary Retention 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 and were found to have a urinary track infection and were found to have a bacterial infection in your blood. . The following changes have been made to your medications: 1) Vancomycin 1gm every 12 hours until [**12-11**] 2) Ceftriaxone 1gm every day until [**12-11**] Followup Instructions: Department: SURGICAL SPECIALTIES When: THURSDAY [**2132-12-18**] at 2:30 PM With: PELVIC FLOOR UNIT [**Telephone/Fax (1) 274**] 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: MONDAY [**2133-5-18**] at 3:00 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 9420**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

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39416

Discharge summary

report

Admission Date: [**2192-9-14**] Discharge Date: [**2192-10-4**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2192-9-10**] CT-guided drainage of multiple abscesses in the abdomen with 2 pigtail catheters. [**2192-9-16**] Left PICC History of Present Illness: 88 M w/ advanced dementia is brought by his sons from his nursing home with 2 weeks of abdominal pain. Approximately two weeks ago the patient developed nausea and vomiting without a clear cause. He was treated as an ileus, given bowel rest for 2 days and then diet was restarted. He did not vomit, but had a very low appetite and often rubbed his stomach as though he had pain. His sons were concerned and pursued a CT scan. He had the scan today which showed a likely duodenal perforation, partially contained. He was brought to the [**Hospital1 18**] for further workup. His sons, [**Name (NI) **] and [**Name (NI) **], note recently he has become lethargic and withdrawn. Normally he ambulates with a cane and eats well. They deny blood per rectum. ROS: elicited from family (+) per HPI (-) Denies chills, night sweats, current nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: Past Medical History: 1. Advanced dementia 2. Recent pneumonia 3. IDDM 4. High Cholesterol Past Surgical History: none Social History: Social History: Lives in nursing home. Two sons live locally. [**Doctor First Name **]: [**Telephone/Fax (1) 87115**]; [**Doctor First Name **] [**Telephone/Fax (1) 87116**] 2 weeks PTA he was eating and walking with a cane. Family History: Family History: NC Physical Exam: On Admission: Physical Exam: 98.7 F 104 148/66 18 98% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes dry CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, mildly tender in midepigastrium to deep palpation, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No LE edema, LE warm and well perfused Pertinent Results: [**2192-9-15**] CT-guided drainage of multiple abscesses in the abdomen as described, with two pigtail drainage catheters deployed within the left mid abdomen paraduodenal area along with the left flank. [**2192-9-16**] PICC Line No previous images. The left subclavian PICC line extends to the mid portion of the SVC. There are relatively low lung volumes. Cardiac silhouette is within normal limits, and there is no definite vascular congestion. Opacification at the bases is consistent with regions of atelectasis and possible small effusions. [**2192-9-19**] CT Abd : 1. No significant change in size of the intra-abdominal/pelvic loculated abscess. The pigtail catheters are in a unchanged position. 2. Large left-sided and small right-sided pleural effusion. Near total collapse of the left lower lobe of the lung. 3. Two small gallstones within the gallbladder. [**2192-9-27**] CT Abd : 1. No interval change in the size of large intra-abdominal abscesses. There is no evidence of new collections. There continues to be no definite fistulous communication between these collections and the bowel. There is no active arterial extravasation. Two drains are unchanged in position compared to the prior. 2. Persistent bilateral pleural effusions with the larger on the left compared to the right, which are slightly increased in size with associated compressive atelectasis [**2192-9-13**] 08:15PM WBC-16.1* RBC-3.20* HGB-8.9* HCT-28.0* MCV-88 MCH-27.7 MCHC-31.7 RDW-14.6 [**2192-9-13**] 08:15PM NEUTS-85.7* LYMPHS-9.7* MONOS-3.1 EOS-1.0 BASOS-0.4 [**2192-9-13**] 08:15PM PLT COUNT-902* [**2192-9-13**] 08:15PM PT-14.8* PTT-27.1 INR(PT)-1.3* [**2192-9-13**] 08:15PM GLUCOSE-113* UREA N-28* CREAT-0.9 SODIUM-138 POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-25 ANION GAP-15 [**2192-9-13**] 08:15PM ALT(SGPT)-41* AST(SGOT)-31 ALK PHOS-142* TOT BILI-0.2 [**2192-9-15**] 4:50 pm ABSCESS PARADUODENAL LEFT UPPER. **FINAL REPORT [**2192-9-21**]** GRAM STAIN (Final [**2192-9-15**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): BUDDING YEAST. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Final [**2192-9-21**]): YEAST, PRESUMPTIVELY NOT C. ALBICANS. SPARSE GROWTH. ANAEROBIC CULTURE (Final [**2192-9-21**]): NO ANAEROBES ISOLATED. Brief Hospital Course: Mr. [**Known lastname 4886**] was evaluated by the Acute Care service in the Emergency Room and admitted to the hospital for further work up of his abdominal pain. He was initially admitted to the Surgical floor but upon further evaluation he was transferred to the ICU with altered mental status and some hypotension. After some fluid resuscitation his blood pressure normalized and his hemodynamics remained stable. His abdominal CT revealed some loculated collections in the left abdomen and left flank. He was taken to Interventional radiology for drainage on [**2192-9-15**] and 2 drainage catheters were left in place. The initial consistency was described as purulent and 70 cc was aspirated and sent for culture. In the interim he was placed on Cipro and Flagyl. Due to his debilitated state and possible need for long term antibiotics a PICC line was placed on [**2192-9-16**]. Many discussions with his sons took place in case surgery was necessary. They did not want any surgery but wanted as much done as possible to try to get him back to his baseline. He was made a DNR/DNI. Final cultures on the abdominal abscess was sparse growth of yeast and gram positive cocci. Fluconazole was added to his regime. Following transfer back to the Surgical floor he was started on TPN as he was taking minimal amounts orally and certainly not enough to maintain his nutritional needs. His sons agreed to a PEG tube placement so as to wean the TPN and again hopefully get him to take a regular diet. He had no dysphagia but simply no interest in eating. Marinol was also started. His PEG tube was placed on [**2192-10-3**] without difficulty and tube feeding were started later that evening. His TPN was weaned off on [**2192-10-4**] and his PICC line remains for antibiotics. As far as his abdominal abscess goes, repeat imaging was done on [**2192-9-19**] and [**2192-9-27**] without much change although the drainage catheters were in the proper place and patent. The daily drainage was 0-20 cc/day. His antibiotics were stopped after a ten day course on [**2192-9-26**] and he subsequently spiked a temperature of 101.6 on [**2192-9-27**]. Blood cultures were done which were negative and a chest Xray showed some bilateral small effusions and atelectasis. He was restarted on Fluconazole and Zosyn. He has since remained afebrile although his WBC is in the 12-16 range. He has no abdominal tenderness and will remain on antibiotics until [**2192-10-17**]. After a difficult course he returns to rehab on tube feedings which can be gradually increased to a goal of 60 cc/hr, IV antibiotics and abdominal drains to bulb suction. He will return to the [**Hospital 2536**] Clinic in 4 weeks for evaluation and possible removal of the drains. It is our hope that he will be able to get back to his nursing home at his pre admission baseline. Medications on Admission: rocephin, flagyl, asa 81', prilosec 20', metformin 500", tylneol, zocor 10', insulin Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 6. Pantoprazole 40 mg IV Q24H 7. Fluconazole in NaCl (Iso-osm) 200 mg/100 mL Piggyback Sig: Two Hundred (200) mg Intravenous once a day: thru [**2192-10-17**]. 8. Zosyn 4.5 gram Recon Soln Sig: 4.5 Gm Intravenous every eight (8) hours: thru [**2192-10-17**]. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Duodenal perforation Severe nutritional deficiency 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: * You were admitted to the hospital with an abdominal abcess requiring drainage thru 2 small tubes in your abdomen. * You will have these drains removed when you come back for a 2 weeks appointment as long as the surgeon sees fit. * You also had a feeding tube placed to try to improve your nutrition and ultimately get stronger. * You will need to remain on antibiotics for 2 more weeks. Followup Instructions: Call the [**Hospital 2536**] clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in 4 weeks. Please bring with you a record of the daily drainage from the tubes. Completed by:[**2192-10-4**]

[ "250.00", "569.83", "269.9", "567.22", "574.20", "294.8", "511.9", "V85.1", "599.0", "041.19" ]

icd9cm

[ [ [] ] ]

[ "38.93", "43.11", "54.91", "99.15" ]

icd9pcs

[ [ [] ] ]

8552, 8618

4735, 7604

277, 403

8712, 8712

2264, 4712

9300, 9508

1846, 1851

7739, 8529

8639, 8691

7630, 7716

8887, 9277

1563, 1570

1895, 2245

222, 239

431, 1426

1880, 1880

8727, 8863

1470, 1540

1602, 1814

5,196

106,963

24081

Discharge summary

report

Admission Date: [**2206-7-27**] Discharge Date: [**2206-8-8**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2751**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: n/a History of Present Illness: [**Age over 90 **]F w/PMHx of suspected bronchoalveolar carcinoma, CKD [**2-16**], CHF, Afib, DM2 on insulin, renal artery stenosis, brought in by EMS from nursing home due to respiratory distress. The patient was noted to have progressive respiratory distress with a sat of 88% on nasal cannula, as well as a fingerstick blood sugar in the 500s this morning with poor response to 10 units of insulin. Notably, patient was admitted at [**Hospital 3278**] medical center [**Date range (1) 61239**] for dyspnea, a-fib with RVR, COPD exacerbation, CHF exacerbation In the ED, initial VS were: 98.8 77 145/57 26 99% 15L. Patient was found to be hypoxic with poor response to full face mask. He also spiked to [**Age over 90 **]F, given tylenol with good response. He was tachypneic, with increased work of breathing and started empirically on vanc/zosyn for HAP. PE could not be ruled out with a CT chest as patient had elevated Cr (1.9) so he was started on a heparin drip. He was given 10 units of insulin at rehab, and 10 more units in the ED with subsequent fingersticks in the 200s. On arrival to the MICU, patient was on BIPAP, saturating 98% on minimal settings. Past Medical History: CHF with diastolic dysfunction, EF 55% in [**2-/2206**] CAD w/ h/o positive stess test Afib HTN [**1-16**] renal artery stenosis DM2, not on insulin COPD Renal artery stenosis s/p stent to R RA Duodenal ulcer H/o c. diff colitis Social History: Came from [**Location (un) **] Health rehab facility, gets most of his care at [**Hospital 3278**] Medical center. Per [**Hospital1 3278**] records, no history of EtOH or illicit drug use. Remote significant tobacco use. Family History: [**Name (NI) **] sister with colorectal cancer Physical Exam: Exam on Admission: Vitals: T:97.1 BP:126/51 P:67 R:26 O2:98 on BIPAP General: Alert, no acute distress HEENT: Sclera anicteric, injected with hemmorhage on left, on BIPAP Neck: supple, distended neck veins CV: Irregular rate, non-tachy, normal S1 + S2, no murmurs, rubs, gallops Lungs: Crackles bilaterally at bases Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: Onychomycosis present b/l at toes, DP present, no edema Neuro: Catontonese speaking, moving all 4 extremities Discharge exam - unchanged from above, except as below: Neck: No JVD CV: Irregular rhythm, normal rate Lungs: CTAB Neuro: Cantonese speaking, appropriate and follows commands with interpreter Pertinent Results: Labs on Admission: [**2206-7-27**] 06:40PM BLOOD WBC-9.9 RBC-4.99 Hgb-13.9 Hct-42.8 MCV-86 MCH-27.8 MCHC-32.4 RDW-15.2 Plt Ct-241 [**2206-7-27**] 06:40PM BLOOD Neuts-82.2* Lymphs-14.8* Monos-2.4 Eos-0.2 Baso-0.3 [**2206-7-27**] 09:00PM BLOOD PT-12.1 PTT-26.1 INR(PT)-1.1 [**2206-7-27**] 06:40PM BLOOD Plt Ct-241 [**2206-7-27**] 06:40PM BLOOD Glucose-470* UreaN-32* Creat-1.9* Na-134 K-4.0 Cl-94* HCO3-20* AnGap-24 [**2206-7-27**] 06:40PM BLOOD estGFR-Using this [**2206-7-27**] 06:40PM BLOOD CK(CPK)-72 [**2206-7-27**] 06:40PM BLOOD CK-MB-1 proBNP-6839* [**2206-7-27**] 06:40PM BLOOD cTropnT-0.04* [**2206-7-27**] 06:40PM BLOOD Calcium-8.7 Phos-3.7 Mg-2.2 [**2206-7-27**] 07:01PM BLOOD pO2-68* pCO2-31* pH-7.44 calTCO2-22 Base XS--1 Comment-GREEN TOP [**2206-7-27**] 07:01PM BLOOD Lactate-5.7* Labs on Discharge: [**2206-8-8**] 04:42AM BLOOD WBC-8.6 RBC-4.49* Hgb-12.6* Hct-38.9* MCV-87 MCH-28.2 MCHC-32.5 RDW-16.1* Plt Ct-175 [**2206-8-8**] 04:42AM BLOOD Glucose-112* UreaN-17 Creat-1.2 Na-139 K-3.6 Cl-107 HCO3-23 AnGap-13 Imaging: Chest XRay ([**2206-7-27**]): "Left basilar opacification likely reflects a combination of a small pleural effusion and adjacent atelectasis. Infection, however, is not excluded. Hazy opacification within the mid lung fields bilaterally is nonspecific, and could reflect an infectious or inflammatory process. Mild pulmonary edema is considered less likely." [**Month/Day/Year **] ([**2206-7-28**]): "The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (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 no pericardial effusion." Bilateral lower extremity ultrasound ([**2206-7-28**]): "No evidence of deep vein thrombosis in either right or left lower extremity." Microbiology: BC ([**2206-7-27**]): No growth Urine legionella antigen ([**2206-7-28**]): No growth MRSA screen ([**2206-7-28**]): Negative [**2206-8-6**] 2:13 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2206-8-7**]** C. difficile DNA amplification assay (Final [**2206-8-7**]): CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). Brief Hospital Course: [**Age over 90 **] year old male with a history of diastolic heart failure, atrial fib/flutter, and chronic obstructive pulmonary disease who was admitted with dyspnea likely secondary to an exacerbation of his heart failure in the setting of atrial flutter with rapid ventricular response. # Acute on chronic diastolic heart failure: The patient presented in acute hypoxic respiratory failure, for which he initially required supplemental oxygen with 15L nasal cannula and was later transitioned to BiPAP, for which he was admitted to the MICU. Possible etiologies for his respiratory failure were thought to include CHF exacerbation, pneumonia, PE, COPD exacerbation, or progression of his underlying cancer. CHF exacerbation was considered the most likely diagnosis given his elevated BNP, pulmonary congestion on x-ray, known diastolic dysfunction, and respiratory distress. CXR found evidence of pulmonary congestion. [**Age over 90 **] showed an LEVF of >55%, unchanged from prior. He initially presented with an elevated lactate, which improved after a 500cc bolus. However, he continued to be volume overloaded, and was diuresed with IV lasix with improvement in his symptoms. Over the first 24 hours, his oxygen requirement decreased and he was successfully weaned from bipap. Afterload reduction was achieved with diltiazem (initially via a diltiazem drip). Health care associated pneumonia was also considered considered as a source of his symptoms given that he had an isolated fever to 101F in the ED. He was started empirically on vancomycin/zosyn/azythroycin, but this was discontinued after four days because he remained afebrile and did not have a leukocytosis or findings suggestive of PNA on CXR. To evaluate for PE, he underwent LENIs and [**Age over 90 **], both of which were negative. Given his elevated Cr, we did not pursue a CTA. He was given standing atrovent nebulizers for a possible COPD exacerbation. After transfer to the floor, the patient had an episode of hypertension, tachycardia and flash pulmonary edema and required IV lasix and his diltiazem was increased for further rate control and blood pressure control. His diltiazem was restarted and titrated to achieve a heart rate of <100, as discussed below. Furosemide was restarted at 20mg PO daily prior to discharge. Given his renal function and adequate blood pressure control on diltiazem alone, ACEi and [**Last Name (un) **] were not initiated. # A fib: He was started on a diltiazam drip and metorprolol IV to optimize rate control. His HR remained stable in the 70-100s on this regimen. He was eventially weaned off of the diltiazam drip and transitioned to metoprolol 25mg po BID. However, he did not tolerate this well, and IV diltiazem was required for rate control. He was transitioned to PO diltiazem with IV pushes as necessary, before adequate rate control was obtained. His discharge dose was diltiazem extended-release 240mg daily. He persistently remained in atrial flutter this admission. He does not appear to be chronically anticoagulated at home given his high risk for falls, this was discussed with his PCP. [**Name10 (NameIs) **] found no evidence of thrombus, normal cardiac output, and normal atrial size. TSH was also normal. #Clostridium difficile colitis: Patient had loose watery stools this admission and C. diff PCR was positive. He was started on metronidazole and will be discharged on a 14 day course of this antibiotic. # Supraventricular Tachycardia (SVT): On [**2206-7-31**] the patient developed tachycardia to 130's with no visible P waves and a narrow complex QRS that was interepreted as SVT. He was given beta blockers and two doses of adenosine with subsequent conversion into atrial flutter with variable conduction. Diltiazem was then continued with good rate and rhythm control. # Hypertension: His hypertension was initially managed with nitroglycerin drip, which was eventenually weaned. He was started on captopril while in the hospital for afterload reduction, and was stopped due to renal impairment. He was restarted on half of his home dose of furosemide on the floor for diuresis and afterload reduction. Of note, the patient developed SBPs in the 190s when agitated, which often resulted in flash pulmonary edema. His blood pressure was well controlled on diltizazem and Lasix at discharge. # [**Last Name (un) **]: His creatinine wasi nitially near his baseline of 1.6-1.8, as documented in [**Hospital1 3278**] records. His kidney function was monitored during diuresis, and he required repletion of potassium and phosphate. At discharge, creatinine had improved to 1.2. # Diabetes mellitus: Initially had blood glucose 500 at rehab facility. He received 20units total on the day of admission, which decreased his blood sugar to the 200s. He was maintiained on an insulin sliding scale with no adverse effects. At discharge, he was restarted on glipizide 2.5mg PO daily, with instructions for his family members to check his glucose before breakfast and after dinner daily until visiting his PCP. # Rule out Tuberculosis: On admission, the patient's x-ray was concerning for miliary TB. Records from [**Hospital1 3278**] were obtained that confirmed that he had been ruled out for TB via broncioalveolar lavage and sputum culture. # Goals of care: The primary team, along with a Cantonese translator, met with the patient, health care proxy, and family, and confirmed the patient's desire to be DNR. He would like to continue to have the option to be intubated at this time. Their primary goal was for the patient to return home and the appropriate services were arranged to facilitate this. # HTN/Renal Artery Stenosis s/p stent placemement: Hypertension was managed with diltiazem. He was discharged with diltiazem and Lasix, he did not require any other blood pressure agents. # Incidental findings: There is some displacement of the lower cervical trachea to the left, suspicious for thyroid mass on the right. Upon reviewing records from [**Hospital1 3278**], the patient has a known thyroid mass. After discussion with his PCP, [**Name10 (NameIs) **] had been a discussion about this and the decision was made not to intervene on this mass. #Code status: The patient was DNR but OK to intubate throughout his admission. #Transitions of care: - will need further titration of his diltiazem for rate control - continue to discuss the indication for anticoagulation givenhis atrial fibrillation - will continue a 14 day course of Flagyl as an outpatient - follow up on [**Hospital1 **] finger stick blood sugars and titrate oral hypoglycemics for further diabetes management - follow up on thyroid mass with possible biopsy, if within goals of care Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from [**Location (un) **] health rehab. 1. Aspirin 81 mg PO DAILY 2. Diltiazem Extended-Release 240 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. Ipratropium Bromide MDI 1 PUFF IH Q4H:PRN wheeze 5. GlipiZIDE 2.5 mg PO BID 6. Mirtazapine 7.5 mg PO HS Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Timolol Maleate 0.25% 1 DROP BOTH EYES [**Hospital1 **] RX *timolol maleate 0.25 % 1 drop both eyes twice daily [**Hospital1 **] #*5 Milliliter Refills:*0 3. Ipratropium Bromide MDI 1 PUFF IH Q4H:PRN wheeze 4. Mirtazapine 7.5 mg PO HS 5. Medical equipment Hospital bed. Diagnosis: chronic diastolic heart failure(ICD-9 428.32) 6. Diltiazem Extended-Release 240 mg PO DAILY 7. Furosemide 20 mg PO DAILY Hold for SBP <100 8. GlipiZIDE 2.5 mg PO DAILY Hold for blood sugar <80 9. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 13 Days RX *metronidazole 500 mg 1 tablet(s) by mouth Three times daily [**Hospital1 **] #*39 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Primary: Acute on chronic diastolic heart failure Atrial flutter with rapid ventricular response Clostridium difficile colitis Secondary: Diabetes Mellitus Type 2 Coronary artery disease Hypertension Chronic obstructive pulmonary disease Renal artery stenosis Duodenal ulcer Glaucoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 3443**], You were recently admitted to [**Hospital1 18**] with difficulty breathing. While you were here, we performed tests that suggest that your heart failure was worsened by a fast heart rate. We restarted you on your home diltiazem to get better control of your heart rate, and we gave you medications to control your blood pressure and remove the fluid from your lungs. You were also started on an antibiotic for an infection of your colon, which you should take as prescribed. This will be expected to cause a lot of diarrhea for the next 1-2 weeks. It is important to NOT TAKE medications such as Imodium, loperamide or Lomotil during this time. While you are at home, please make sure to weigh yourself daily, and if you notice a 3 pound increase in weight, contact your primary care physician. In addition, we changed your oral diabetes medication, and you will now take glipizide 2.5 miligrams every day. Please be sure to check your fingerstick blood sugar before breakfast and after dinner everyday until you see your primary care physician. [**Name10 (NameIs) **] your doctor if the numbers are consistently over the 200 in the morning or over 300 after meals. It was our sincere pleasure to take care of you while you were in the hospital. Please do not hesitate to contact us with any questions, comments or concerns. With Warm Regards, Your Inpatient Medicine Team Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] K. Address: [**Last Name (un) 4805**], [**Location (un) **],[**Numeric Identifier 2900**] Phone: [**Telephone/Fax (1) 4806**] ***I have left a message with the office stating you need a follow up appt and to call you with an appt. If you dont hear from them by tomorrow, please call them directly to book.

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icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "38.97", "93.90" ]

icd9pcs

[ [ [] ] ]

13575, 13650

5780, 12076

258, 264

13979, 13979

2777, 2782

15599, 15961

1976, 2025

12885, 13552

13671, 13958

12528, 12862

14157, 15576

2040, 2045

211, 220

3591, 5757

292, 1467

2796, 3572

13994, 14133

12097, 12502

1489, 1720

1736, 1960

30,349

109,699

45645

Discharge summary

report

Admission Date: [**2108-12-9**] Discharge Date: [**2108-12-18**] Date of Birth: [**2046-9-8**] Sex: M Service: SURGERY Allergies: Haloperidol Attending:[**First Name3 (LF) 371**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Exploratory laparotomy History of Present Illness: This man has had abdominal pain. He did not have peritoneal findings and KUB demonstrated dilated small bowel. CT scan demonstrated air in the portal system as well as possibly in the small bowel wall itself. He was therefore taken to the Operating room and placed in the supine position. He was given general anesthetic. The abdomen was prepped and draped using Betadine solution. The patient's previous midline abdominal incision was reopened. It was deepened down to subcutaneous tissue to the level of the fascia. The fascia was opened. In the lower end of this fascial closure, we found separate blue sutures which were not present in the upper end of the incision, suggesting that he, in fact, probably had 2 operations in the past. The patient did not give that history. Past Medical History: PMH: Schizophrenia, Depression, DM PSH: Ex lap and splenectomy s/p GSW [**2074**] Social History: B&[**Initials (NamePattern4) **] [**Location (un) 669**], middle of 6 kids, dad was an abusive alcoholic. Pt. attended prep school. After graduation worked for Turnpike for several years. He's been on disability for >20yrs. Pt said he has been living in a group home in [**Location (un) **] for the past five years. Family History: denies mental illness, suicides Physical Exam: ED Vitals: T-100.7, HR-100, BP-120/54, RR-16, O2 sat-98% on RA Const: NAD, A/Ox3 Head/Eyes: NCAT Resp: CTAB CV: RRR, + systolic murmur ABD: distended, decreased bowel sounds GU: no CVAT Extrem: No edema B/L Pertinent Results: [**2108-12-17**] 05:28AM BLOOD WBC-12.5* RBC-3.98* Hgb-12.1* Hct-34.6* MCV-87 MCH-30.3 MCHC-34.8 RDW-14.6 Plt Ct-264 [**2108-12-17**] 05:28AM BLOOD Neuts-83.5* Lymphs-11.2* Monos-4.8 Eos-0.4 Baso-0.1 [**2108-12-9**] 01:45PM BLOOD WBC-25.9* RBC-4.91 Hgb-15.1 Hct-42.5 MCV-87 MCH-30.8 MCHC-35.6* RDW-14.0 Plt Ct-208 [**2108-12-10**] 03:21AM BLOOD PT-13.1 PTT-25.4 INR(PT)-1.1 [**2108-12-9**] 01:45PM BLOOD PT-13.5* PTT-25.3 INR(PT)-1.2* [**2108-12-17**] 05:28AM BLOOD Plt Ct-264 [**2108-12-17**] 05:28AM BLOOD Glucose-180* UreaN-7 Creat-0.7 Na-140 K-4.1 Cl-108 HCO3-26 AnGap-10 [**2108-12-9**] 01:45PM BLOOD Glucose-226* UreaN-30* Creat-1.0 Na-142 K-4.2 Cl-105 HCO3-25 AnGap-16 [**2108-12-13**] 07:44PM BLOOD CK(CPK)-417* [**2108-12-13**] 08:18AM BLOOD CK(CPK)-548* [**2108-12-13**] 12:42AM BLOOD CK(CPK)-688* [**2108-12-11**] 02:28AM BLOOD ALT-21 AST-23 AlkPhos-75 Amylase-14 TotBili-0.3 [**2108-12-13**] 07:44PM BLOOD CK-MB-3 cTropnT-<0.01 [**2108-12-9**] 09:36PM BLOOD CK-MB-4 cTropnT-<0.01 [**2108-12-17**] 05:28AM BLOOD Calcium-7.7* Phos-2.7 Mg-1.9 [**2108-12-9**] 09:36PM BLOOD Calcium-7.9* Phos-3.7 Mg-1.9 [**2108-12-9**] 01:45PM BLOOD Albumin-4.2 [**2108-12-13**] 12:38AM BLOOD Lactate-1.4 [**2108-12-9**] 01:56PM BLOOD Lactate-2.2* . Blood cultures-negative Urine cultures-negative MRSA cultures-negative . RADIOLOGY Final Report CT PELVIS W/CONTRAST [**2108-12-9**] 5:18 PM [**Hospital 93**] MEDICAL CONDITION: 62 year old man with sbo on xray, abd pain and elevated wbc IMPRESSION: Large amount of diffuse portal venous gas seen within the liver, out of proportion to possible small amount of pneumatosis. Multiple abnormally dilated loops of small bowel with decompressed bowel distally. Findings are consistent with ischemic bowel, possibly from obstruction. Possible transition point is seen in the right lateral abdomen at the distal ileum. Findings were discussed with the clinical team immediately following completion of the study. . RADIOLOGY Final Report ABDOMEN (SUPINE & ERECT) PORT [**2108-12-9**] 1:17 PM [**Hospital 93**] MEDICAL CONDITION: 62 year old man with upper abd pain, ?ekg changes REASON FOR THIS EXAMINATION: eval for SBO (upright, please) IMPRESSION: Markedly distended small bowel loops that may be secondary to an SBO, likely distal in origin given the number of distended small bowel loops. Ileus is also a consideration. Clinical correlation and/or cross-sectional imaging is recommended. . [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 97323**]Portable TEE (Complete) Done [**2108-12-9**] at 9:24:43 PM FINAL Conclusions The left atrium is mildly dilated. No mass/thrombus is seen in the left atrium or left atrial appendage. . Color-flow imaging of the interatrial septum raises the suspicion of an atrial septal defect, but this could not be confirmed on the basis of this study. Left ventricular wall thicknesses are normal. 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%). Right ventricular chamber size is mildly dilated, free wall motion are normal. The aortic valve leaflets are moderately thickened. Significant aortic stenosis may be present (not quantified) due to technical limitations .Bicuspid aortic valve cannot be ruled out . No aortic regurgitation is seen.Ascending aorta is mildly dilated ,descending thoracic aorta normal in diameter. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. . [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 97323**]Portable TTE (Complete) Done [**2108-12-10**] at 10:30:27 AM FINAL Conclusions The left atrium is normal in size. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Transmitral Doppler and tissue velocity imaging are consistent with normal LV diastolic function. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (area 1.0-1.2cm2). The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild left ventricular hypertrophy with overall normal function. Moderate aortic stenosis. . RADIOLOGY Final Report CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2108-12-13**] 1:43 AM Reason: r/o PE [**Hospital 93**] MEDICAL CONDITION: 62 year old man s/p ex lap for ischemic bowel POD #4, with intra-op ST depressions; now with new onset mental status changes, hypoxia, tachypnea. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Bibasilar infiltrates, consistent with aspiration. 3. Small amount of portal venous gas remains. . RADIOLOGY Final Report ABDOMEN (SUPINE & ERECT) [**2108-12-16**] 1:51 PM [**Hospital 93**] MEDICAL CONDITION: 62 year old man s/p ex lap for ischemic bowel, no resection, now with abdominal distension IMPRESSION: Non-specific bowel gas pattern. While the findings can be seen with ileus, differential air-fluid levels are atypical for ileus. Close clinical followup is recommended. Brief Hospital Course: Mr. [**Known lastname 496**] presented to ED via ambulance from group home for evaluation of abdominal pain w/ N/V x 6 days. EKG in ED revealed T wave inversions. CT scan revealed small bowel obstruction, and extensive portal venous air. Due to clinical presentation, elevated WBC, and no recent h/o colonoscopy, surgery intervention was deemed necessary per General Surgery Service. . Mr. [**Known lastname **] operative course was complicated by ST segment changes via EKG. He was stabilized,and surgery was successfully completed. . POD1/ICU: Transferred to ICU due to noted bowel changes intra-op and cardiac instability where he remained intubated. His cardiac enzymes were cycled with no increase in troponin levels, and was ruled out for a myocardial infarction. In addition, an Echocardiogram revealed no thrombus or wall motion abnormality. BP elevation 140-150 systolic was managed briefly with IV Nitro, discontinued once BP's stabilized. Cardiology was consulted. Continued with beta-blockade. Bowel ischemia thought to be vascular in nature. No abdominal cause for obstruction/hypoprofusion noted via Ex/Lap. He was started on IV Levo & Flagyl. . POD2/ICU: Extubated with no event. Pain managed with IV Dilaudid PCA. Received LR boluses for low urine output. Started on sips for comfort. His condition remained stable, and he was transferred to [**Hospital Ward Name **] for post-op care. Psych was consulted for management of medications. Recommended continuation of home regimen, and cleared for discharge back to group home once stable. . POD3/FA9/ICU: NGT was removed. He was confused overnight with complaints of pain. His O2 sats decreased to 80-90's resulting in a "Trigger". ABG revealed PO2-64, and EKG with ST depressions once again. He was transferred back to ICU. CT was obtained which was negative for PE. CXR revealed mild fluid overload. He was transferred back to the ICU for management of possible ischemic cardiac episode. Enzymes were flat, and patient was asymptomatic during event. CT was negative for PE. . POD4/ICU/FA9: He was monitored overnight in ICU, remained stable, and was transferred back to [**Hospital Ward Name **]. . POD5-Discharge [**2108-12-18**]: His diet was advanced to regular food as tolerated. He resumed all his home medication, and tolerated oral pain medication. Due to his cardiac event, cardiology recommended continuation of Lopressor and aspirin. Prescriptions were faxed to pharmacy, and regimen changes was discussed with [**Doctor First Name **] & [**Doctor Last Name **] from Bay Cove group home. His Foley catheter was removed, and he was able to urinate without difficulty. His abdomen is large, appropriately tender with active bowel sounds. His incision is OTA with staples which will be removed at his follow-up appointment with Dr. [**Last Name (STitle) **]. Distention decreased, and he reported passing flatus, and bowel movement prior to discharge. He ambulated the halls independently. No need for PT/OT. VNA was arranged for home visit upond discharge to assess incision and blood pressure. He was advised to follow-up with his PCP for further management of blood pressure & CV status. THis was also discussed with [**Doctor First Name **] from group home. Medications on Admission: clozaril, zocor, klonopin, flomax, terazosin, humalog 75/25 18qAM 28qPM Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:*35 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 months. Disp:*60 Capsule(s)* Refills:*0* 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. Disp:*15 Tablet(s)* Refills:*0* 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 7. Clozapine 100 mg Tablet Sig: Five (5) Tablet PO HS (at bedtime). 8. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: 27 units Subcutaneous QPM. 9. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: 18 units Subcutaneous QAM. 10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO three times a day. 13. Invega 3 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 14. Trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: pneumatosis Small bowel obstruction Ischemic bowel Post-op pulmonary edema . Secondary: Schizophrenia, Depression, DM Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your staples will be removed at your follow-up appointment. -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: 1. Please make a follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) **] in [**1-13**] weeks. 2. Follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12806**], [**Telephone/Fax (1) 97324**] in 1 week or as needed. Completed by:[**2108-12-18**]

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icd9cm

[ [ [] ] ]

[ "54.11", "88.72" ]

icd9pcs

[ [ [] ] ]

12358, 12416

7475, 10711

285, 310

12586, 12664

1850, 3234

14044, 14389

1575, 1608

10833, 12335

7178, 7452

12437, 12565

10737, 10810

12688, 13729

13744, 14021

1623, 1831

231, 247

3997, 6731

338, 1117

1139, 1223

1239, 1559

43,484

172,124

49467

Discharge summary

report

Admission Date: [**2166-6-26**] Discharge Date: [**2166-7-19**] Date of Birth: [**2090-4-4**] Sex: M Service: MEDICINE Allergies: Darvocet-N 100 Attending:[**First Name3 (LF) 3565**] Chief Complaint: Malaise Major Surgical or Invasive Procedure: Intubation PEG placement Tracheostomy History of Present Illness: 76YOM presents with increasing fatigue, weakness over past several days. Does have a history of MS (followed by neuro here), but states that this does not feel like his usual flares. Was on the toilet today and felt like he couldn't get up from the commode because he was too weak. Family attempted to get him up, but couldn't easily move him, so called EMS. EMS reports he was found on the commonde, no AC and was extremely hot in the apartment/bathroom, patient was diaphoretic, but drastically improved in the ambulance. In the ED he was found to have initial vitals of 98.6 80 84/44 16 97% and triggered for hypotension. A CXR demonstrated profoundly diminshed lung volumes, no acute process. CT Abdomen negative. His lactate was elevated to 4.2 and he received 3L of fluid, normalizing to 1.1. Guaiac positive in ED and received 1 unit of blood. BP stabilized with fluids and blood. Admitted for LGIB. Vitals on transfer 112/60 p78 rr 16 t98.3 sat 100. ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - Multiple sclerosis with Parkinsonian elements (followed by Dr. [**Last Name (STitle) **] at [**Hospital1 **]) - Anemia - Coronary artery disease status post multiple PCI. - cath [**6-13**] showed progression of diffuse disease: Mid LAD: 40 %, 1st Diagonal: focal 80 %, 2nd diagonal: 95% proximal, Proximal Circumflex: focal 100 % in distal third, 2nd Marginal: focal 70 % in proximal third, Ramus: Occluded at site of prior stenting, Mid RCA: long and irregular 30 % stenosis, PDA: irregular 80 % mid-vessel stenosis, overall no intervention - Heart failure with preserved systolic function. - Hyperlipidemia. - Hypertension. - Chemosis with left eyelid swelling, followed at MEEI. - Osteoarthritis, right knee. - s/p total knee replacement R [**9-13**] - History of UTI. - neurogenic bladder Social History: Lives at home with wife. Wife and son help him with medications. Family History: Patient unable to provide. Physical Exam: On Admission: VS: 97.0 110/68 73 12 100RA GENERAL: Well-appearing man in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, conjunctivitis L> R. NECK: Supple, HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh. Slightly decreased sounds at bases bilaterally. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. Guaiac positive ED per report. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&O x1 On Discharge: VS: 98.0 113/50 78 22 97%trach mist GENERAL: NAD, comfortable HEENT: NCAT, PERRL, EOMI, conjunctivitis L> R. NECK: Supple, +trach c/d/i HEART: RRR, no MRG, nl S1-S2. LUNGS: mild ronchi at bases, otherwise CTA ABDOMEN: Soft/NT/ND, +PEG c/d/i, no rebound/guarding EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox1-2 Pertinent Results: Blood Counts [**2166-6-26**] 05:13PM BLOOD WBC-4.9 RBC-2.82* Hgb-9.2* Hct-26.0* MCV-92 MCH-32.6* MCHC-35.4* RDW-11.7 Plt Ct-163 [**2166-6-30**] 03:00AM BLOOD WBC-14.3*# RBC-3.10* Hgb-10.1* Hct-28.2* MCV-91 MCH-32.7* MCHC-36.0* RDW-12.2 Plt Ct-137* [**2166-7-10**] 03:05AM BLOOD WBC-8.9 RBC-2.67* Hgb-8.6* Hct-25.2* MCV-94 MCH-32.3* MCHC-34.3 RDW-12.9 Plt Ct-254 [**2166-7-17**] 04:30AM BLOOD WBC-13.4*# RBC-3.27* Hgb-10.5* Hct-29.3* MCV-90 MCH-32.0 MCHC-35.8* RDW-13.0 Plt Ct-237 [**2166-7-18**] 09:00PM BLOOD WBC-19.4* RBC-3.03* Hgb-9.9* Hct-28.0* MCV-92 MCH-32.5* MCHC-35.3* RDW-13.2 Plt Ct-252 [**2166-7-19**] 03:20AM BLOOD WBC-18.0* RBC-2.92* Hgb-9.5* Hct-27.1* MCV-93 MCH-32.4* MCHC-35.0 RDW-13.3 Plt Ct-261 . Chemistry [**2166-6-26**] 05:13PM BLOOD Glucose-142* UreaN-37* Creat-1.5* Na-140 K-4.0 Cl-102 HCO3-24 AnGap-18 [**2166-6-27**] 10:14PM BLOOD Calcium-7.2* Phos-3.4 Mg-2.2 [**2166-7-2**] 06:00AM BLOOD Glucose-126* UreaN-10 Creat-0.6 Na-133 K-3.4 Cl-101 HCO3-27 AnGap-8 [**2166-7-19**] 03:20AM BLOOD Glucose-115* UreaN-34* Creat-1.1 Na-140 K-3.8 Cl-106 HCO3-25 AnGap-13 [**2166-7-19**] 03:20AM BLOOD Calcium-8.2* Phos-2.0* Mg-2.4 . IMAGING TTE [**2166-7-9**] The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with near akinesis of the basal to mid inferior and inferolateral segments. Doppler parameters are indeterminate for left ventricular diastolic function. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Small to moderate pericardial effusion, located mostly over the right ventricular free wall. Regional LV systolic dysfunction consistent with prior inferior infarction. No significant valvular abnormality. Mild pulmonary artery systolic hypertension. . CXR [**2166-7-19**] 1. Slight interval worsening of findings at the right base, with more confluent opacity and new small right effusion. 2. Minimal patchy retrocardiac opacity and blunting of the left costophrenic angle are stable. Brief Hospital Course: HOSPITAL COURSE 76 year old M PMHx multiple sclerosis, CAD s/p stent who presented with increasing fatigue, was found to have an aspiration PNA, and had a hospital course complicated by recurrent aspirations, now status post tracheostomy and gtube placement, hemodynamically stable, on antibioitics for recurrent pneumonia, being discharged to [**Hospital 100**] Rehab MACU. . ACTIVE ISSUES: # Respiratory Failure [**1-8**] Aspiration Pneumonia and Heart Failure On day after admission, pt w rising leukocytosis and increasing oxygen requirements, CXR demonstrating RLL consolidation. Patient was transferred to ICU where he was intubated for hypoxic respiratory failure. Patient was treated with 1wk vanc/zosyn with subsequent improvement. Patient was also found to have evidence of pulmonary vascular congestions and was diuresed. Patient was subsequently extubated. Swallow study demonstrated aspiration. Patient required reintubation several days later after development of respiratory distress attributed to recurrent aspiration. Spoke with patient's neurologist Dr. [**Last Name (STitle) **] who felt that patient had been losing weight for the past year and while his difficulty swallowing could be a reversible symptom of worsened MS in the setting of acute illness, more perminent enteral access was recommended. PEG tube was placed. Given recurrent aspiration pneumonias and difficulty extubating, patient underwent tracheostomy. He tolerated tube feeds well. As of time of discharge, patient remained with signs of a RLL pneumonia, cultures growing pan-sensitive enterobacter, which was being treated with PO cipro ( to be continued until [**2166-7-25**]). He remained w secretions, but was otherwise stable off of the ventilator on trach-mist >48hrs. Continued nebs standing. Patient will need eval for pauci-muir valve in future. . # Chronic Lower GI Bleed - The patient was anemic to hgb 9.2 on admission with guiac + stools. His PCP at [**Name9 (PRE) 2025**] reported that the patient has had significant weight loss of 40lbs over the past 6 months with decreased appetite and worsening anemia over that time period. No known etiology and colonoscopy clean in [**2157**]. He received 1 unit of PRBC in the ED and hct remained stable during the rest of hospitalization. Outpt colonoscopy should be considered after d/c. Started IV Pantoprazole. . INACTIVE # CAD s/p stent - Per discussion w PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) 4532**], continued ASA. . # HTN - Home atenolol, isosorbide, and losartan held in setting of fluctuating BP. Will need to be evaluated for restarting prn. . #CHF - In setting of acute illness, had standing lasix held. At time of discharge, was being dosed 20mg IV lasix prn, will need to have fluid status reassessed with lasix dosed appropriately . # DM - Continued sliding scale insulin . # MS - Continued baclofen, scopolamine patch. Bethanachol and gabapentin held, can be restarted prn. . # BPH - Held uroxatral, can be restarted at rehab prn . TRANSITIONAL ISSUES: Pt is full code. He will need antibiotics until [**2166-7-25**]. He will require frequent suctioning for management of his secretions. He will also likely need intermittent lasix dosing to maintain euvolemia. He should also have a colonoscopy to evaluate BRBPR, weight loss and constipation. He should remain NPO and be fed via tube feeds. Medications on Admission: - Uroxatral 10 mg daily - atenolol 12.5 mg daily - baclofen 10 mg b.i.d. - bethanechol 25 mg three times a day - [**Month/Day/Year **] 75 daily - diazepam 5 mg at bedtime - folic acid 1 mg daily - furosemide 20 mg b.i.d - Gabapentin now only at 200 h.s. - isosorbide 120 mg extended release daily - losartan 50 mg daily - Prilosec 20 mg b.i.d. - Seroquel 12.5 mg h.s. - Ecotrin 325 daily - Colace 100 mg p.o. b.i.d. Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. docusate sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2 times a day). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. insulin lispro 100 unit/mL Solution Sig: asdirected Subcutaneous ASDIR (AS DIRECTED): sliding scale as attached. 6. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. baclofen 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for sleep. 9. Pantoprazole 40 mg IV Q12H 10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 11. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Four Hundred (400) mg Intravenous Q12H (every 12 hours) for 7 days. 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every six (6) hours. 13. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation every six (6) hours. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: PRIMARY Recurrent Aspiration Pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. [**Known lastname 1661**], It was a pleasure taking care of you during your hospitalization at [**Hospital1 69**]. You were hospitalized with malaise and weakness. While you were here we noticed that food was going down the wrong tube into your lung. You had recurrent issues with your breathing and required a tracheostomy to help with your breathing. You also had a gastric tube placed to help with your feeding. You are now ready for discharge to an extended care facility. Please see the attached sheet for your updated medications Followup Instructions: Department: NEUROLOGY When: TUESDAY [**2166-9-16**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD [**Telephone/Fax (1) 5434**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "96.71", "96.72", "31.1", "43.11", "96.6" ]

icd9pcs

[ [ [] ] ]

11055, 11121

5973, 6350

282, 321

11203, 11203

3444, 5950

11954, 12275

2491, 2519

9827, 11032

11142, 11182

9386, 9804

11383, 11931

2534, 2534

3038, 3425

9014, 9360

235, 244

6365, 8993

349, 1562

2548, 3024

11218, 11359

1584, 2392

2408, 2475

12,660

120,060

51103

Discharge summary

report

Admission Date: [**2163-7-22**] Discharge Date: [**2163-7-25**] Date of Birth: [**2110-12-14**] Sex: M Service: SURGERY Allergies: Codeine / Penicillin G Attending:[**Last Name (NamePattern1) 4659**] Chief Complaint: RECTAL BLEEDING Major Surgical or Invasive Procedure: BIOPSY OF INTERNAL ANAL WART History of Present Illness: PT IS A 52 YEAR-OLD HIV+ MALE, ON PLAVIX, ADMITTED FOR RECTAL BLEEDING AFTER BIOPSIES OF INTERNAL ANAL WARTS WERE OBTAINED. Past Medical History: HIV CORONARY ARTERY DISEASE S/P STENTS X 3 HYPERLIPIDEMIA KAPOSIS SARCOMA S/P CHEMO HEP B BRONCHIECTASIS BASAL CELL CARCINOMA ANXIETY Physical Exam: NO DISTRESS ALEART AND ORIENTED X 3 CRANIAL NERVES [**2-19**] INTACT HEART REGULAR RATE RHYTHM. 2/6 SEM LUNGS CLEAR TO ASCULTATION ABDOMEN IS SOFT, NON-TENDER, NON-DISTENDED RECTAL: HEMATOCHEZIA Pertinent Results: [**2163-7-21**] 09:30PM WBC-3.8* RBC-3.07* HGB-10.8* HCT-30.7* MCV-100* MCH-35.2* MCHC-35.2* RDW-13.3 [**2163-7-22**] 01:12AM PT-14.5* PTT-25.0 INR(PT)-1.4 [**2163-7-22**] 01:52AM HGB-6.7*# HCT-19.1*# [**2163-7-22**] 05:20AM HGB-9.2*# HCT-25.9*# [**2163-7-22**] 08:42AM HCT-26.9* [**2163-7-22**] 01:04PM BLOOD Hct-25.9* [**2163-7-22**] 04:38PM BLOOD Hct-25.0* [**2163-7-23**] 01:29AM BLOOD Hct-29.5* [**2163-7-23**] 05:38AM BLOOD WBC-2.0* RBC-3.43* Hgb-11.5* Hct-31.2* MCV-91# MCH-33.3* MCHC-36.7* RDW-16.5* Plt Ct-128* [**2163-7-23**] 01:04PM BLOOD Hct-27.8* [**2163-7-24**] 02:37AM BLOOD Hct-34.7* [**2163-7-24**] 04:15PM BLOOD Hct-31.3* [**2163-7-25**] 05:15AM BLOOD Hct-36.8* Brief Hospital Course: The patient was emergently seen in the ER. Anoscopy was performed by Dr. [**Last Name (STitle) **] and copious anal bleeding was encountered. Two surgicel packs were placed with good control of the bleeding. PATIENT WAS ADMITTED FOR RECTAL BLEEDING. HE WAS CLOSELY OBSERVED IN THE INTENSIVE CARE UNIT. HIS HEMATOCRIT DROPPED TO 19.1 AND WAS TRANSFUSED 2 UNITS OF PACKED RED BLOOD CELLS. WE WAS SUBSEQUENTLY TRANSFUSED ANOTHER UNIT. He passed the anal packing and his bleeding do NOT resume. His PLAVIX WAS not HELD after discussion with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] - the significant risks of clotting his recent cardiac stent were too great, especially in light of the fact taht his bleeding had stopped. HE RESPONDED WELL TO THE TRANSFUSIONS WITH A HEMATOCRIT OF 26.9 ON HOSPITAL DAY 2. HIS HEMATOCRIT HAS BEEN STEADILY INCREASING FOR 3 DAYS SINCE THEN. HE WAS TRANSFERRED TO THE FLOOR. He had several bowel movements without blood. PT WILL BE DISCHARGED WITH A HEMATOCRIT OF 36.8. Discharge Medications: 1. Lopinavir-Ritonavir 133.3-33.3 mg Capsule Sig: Three (3) Cap PO BID (2 times a day). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: RECTAL BLEEDING Coronary Atery Disease Anticoagulated secondary to medications. Post-operative anemia. Discharge Condition: STABLE Discharge Instructions: IF BLEEDING RECURS OR SYMPTOMS WORSEN, INCLUDING LIGHTHEADEDNESS, PALOR SKIN, OR WEAKNESS, PLEASE CALL OR GO TO THE EMERGENCY ROOM. OTHERWISE PLEAE FOLLOW UP WITH DR. [**Last Name (STitle) **] (BELOW) IN [**1-9**] WEEKS. Continue taking your Plavix. Followup Instructions: PLEASE CALL FOR A FOLLOW UP APPOINTMENT WITH DR. [**Last Name (STitle) **] IN [**1-9**] WEEKS. ([**Telephone/Fax (1) 15665**] ([**Telephone/Fax (1) 19177**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**] Completed by:[**2163-7-25**]

[ "042", "070.30", "998.11", "272.4", "494.0", "078.10", "E878.8", "V45.82", "414.01" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

3457, 3463

1594, 2638

307, 338

3609, 3617

880, 1571

3917, 4248

2661, 3434

3484, 3588

3641, 3894

664, 861

252, 269

366, 491

513, 649

32,316

195,043

18861

Discharge summary

report

Admission Date: [**2111-11-3**] Discharge Date: [**2111-11-4**] Date of Birth: [**2075-2-22**] Sex: M Service: MEDICINE Allergies: Bactrim Ds Attending:[**First Name3 (LF) 3326**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: None History of Present Illness: 36 year old male with HIV not on HAART, HepB, HepC, PSA presenting with several episodes of coffee ground emesis one night prior to admission. He presented to hospital in [**Hospital1 6687**] and was admitted. His Hct on admission was 23, he was given 2 units pRBCs, 2 units FFP, 1 bag of platelets and Hct recheck was 19. Unclear when blood was rechecked in relation to blood transfusion. He was transferred to [**Hospital1 18**] where he receives his GI and Hepatology care. He states that he had a similar episode a couple of months ago requiring admission. . Of note, he has had endoscopies in [**Hospital1 6687**] by Dr. [**First Name (STitle) 572**] but none in OMR. He is not sure whether he has varices. Past Medical History: HIV/AIDS dx'ed [**2097**] HepB HepC (no cirrhosis or portal HTN by CT scan but no liver bx in past) thrombocytopenia, baseline 10-17K splenomegaly and possible bone marrow suppression) polysubstance abuse chronic anemia, baseline 30-33 med non-compliance epistaxis occasional hematochezia small squamous cell carcinoma on face s/p excision '[**04**] s/p right hip replacement in [**2110**] for OA osteoarthritis seizures (related to past cocaine) h/o suicude attempt [**7-28**] - OD on pills h/o depression Social History: Lives on [**Hospital1 6687**] with grandmother. [**Name (NI) 1351**], no children. Employed as handyman. Occasional EtOH. Denies recent drug use. Multiple tattoos. Incarcerated in past. History of being homeless and ivdu. Family History: Mother with [**Name (NI) **] disease. Father died of a self-inflicted gunshot wound. Physical Exam: V: 99.1F HR 93 BP 115/61 RR 14 98%RA Gen: awake, alert, no jaundice, NAD, thin male HEENT: PERRL, EOMI, OP clear, MM sl dry Neck: supple. no LAD CV: RRR, normal S1, S2, soft systolic murmur, mildly displaced [**Name (NI) 51627**] Pulm: CTAB Abd: Normoactive BS, soft, mild distension, mild TTP RUQ, hepatosplenomegaly appreciated, no rebound or guarding Ext: WWP, no edema skin: spider angiomas on trunk Pertinent Results: [**10-27**] HIV VL: 59,200 copies/ml. CD4 18 [**10-27**] HBV VL: 149,000 IU/mL [**9-1**] HCV VL (genotype 1): 1,980,000 IU/mL [**11-1**] CD4 4%, abs 18. . ON ADMISSION TO MICU AS TRANSFER OSH [**2111-11-3**] 04:40PM BLOOD WBC-2.6* RBC-2.53* Hgb-8.1* Hct-23.8* MCV-94# MCH-32.2* MCHC-34.1 RDW-19.6* Plt Ct-50*# [**2111-11-3**] 04:40PM BLOOD Neuts-63.6 Lymphs-25.3 Monos-9.4 Eos-1.3 Baso-0.4 [**2111-11-3**] 04:40PM BLOOD PT-15.9* PTT-38.1* INR(PT)-1.4* [**2111-11-3**] 04:40PM BLOOD Glucose-75 UreaN-17 Creat-0.8 Na-143 K-3.4 Cl-115* HCO3-23 AnGap-8 [**2111-11-3**] 04:40PM BLOOD ALT-66* AST-142* LD(LDH)-194 AlkPhos-82 TotBili-2.1* DirBili-1.3* IndBili-0.8 [**2111-11-3**] 04:40PM BLOOD Albumin-2.5* Calcium-7.2* Phos-2.4* Mg-1.7 . WHEN PATIENT LEFT AMA [**2111-11-4**] 04:13AM BLOOD WBC-2.2* RBC-2.61* Hgb-8.8* Hct-24.9* MCV-96 MCH-33.5* MCHC-35.1* RDW-18.7* Plt Ct-45* [**2111-11-4**] 04:13AM BLOOD PT-16.3* PTT-40.5* INR(PT)-1.5* [**2111-11-4**] 04:13AM BLOOD Glucose-105 UreaN-13 Creat-0.7 Na-141 K-3.5 Cl-114* HCO3-22 AnGap-9 [**2111-11-4**] 04:13AM BLOOD ALT-66* AST-151* AlkPhos-72 TotBili-2.7* [**2111-11-4**] 04:13AM BLOOD Calcium-7.0* Phos-2.3* Mg-1.6 . CXR [**11-4**] FINDINGS: There is borderline cardiomegaly. There is elevation of the right hemidiaphragm. There is right lower lobe atelectasis. There is no evidence of pneumothorax or pleural effusions. The soft tissues and osseous structures are unremarkable. IMPRESSION: Area of right lower lobe atelectasis. Borderline cardiomegaly. . ECHO [**11-4**]:IMPRESSION: Normal study. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. No valvular pathology or pathologic flow identified. Brief Hospital Course: A/P: 36 year old male with HIV/AIDS, HepB, HepC, PSA presenting with upper GI Bleed. . 1) GI Bleed - Improved overall status, no hematemesis, hemosynamically stable, not orthostatic. On admission transfused two units pRBC, two units fresh frozen plasma, and one bag of platelets. Patient underwent EGD which revealed, one 7 mm none-bleeding ulcer in the pre-pyloric region, mild portal hypertensive gastropathy, and esophageal candidiasis. Patient initially on octreotide drip for presumed variceal bleed, but this was discontinued after the EGD showed no varices. Liver consulted and feels patient has no active liver issues at this time. Patient to follow-up as an outpatient. - Consented and two units of blood on reserve at blood bank. - Maintain 2 large bore ivs - PPI iv bid - Follow HCT [**Hospital1 **], transfuse HCT <21 . 2) Thrombocytopenia - Episode of epistaxis this am. Patient had been pursuing an outpatient work-up for ITP vs splenic sequestration vs bone marrow suppression. Work-up complicated by patient living on [**Hospital1 6687**]. Tranfusion yesterday did not raise patient's platelet counts. Liver has seen as outpatient and will not follow while in hospital. - Consult Heme/Onc: ? further work-up, bone marrow biopsy - ID: Dr. [**Last Name (STitle) 51628**] following, not ID consult service. He will see the patient [**11-5**]. . 3) Respiratory Infiltrates - Patient afebrile with no change in baseline WBC levels, denies cough, sputum, SOB. CXR RLL infiltrate concerning for aspiration chemical pneumonitis vs community acquired or aspiration pneumonia. patient is on PJP prophylaxis. - Monitor symptoms - If patient symptomatic, consider sputum cx and empiric therapy with levofloxacin and flagyl. . 4) HIV - followed by Dr. [**First Name (STitle) **] in [**Hospital **] clinic here. Not currently on HAART. Patient has history of intolerance to HAART therapy. Dr. [**Last Name (STitle) 51628**] plans to try Truvada in approx one month time as an outpatient. Dr. [**Last Name (STitle) 51628**] does not recommend starting it now as an inpatient. Patient currently on telbivudine as a transition to Truvada. CD4 count 18 on [**11-1**]. - Dr. [**Last Name (STitle) 51628**] to follow while in hospital. To see [**11-5**] am. - MAC proph with azithro - PCP [**Name9 (PRE) **] with dapsone - Fluconazole for esophageal candidiasis on ECG on day [**3-11**]. - Ensure patient got ordered pneumococcal vaccine and flu shot. . 5) HepB/HepC - has never received treatment for HepC. Recently started on telbivudine for chronic HepB by ID (Hep Be Ag positive consistent with active replicating infection). Liver consulted and feel patient has no active liver issues at this time. - Cont telbivudine - Cont to follow LFTs, esp T.Bili as it is slightly higher today . 6) Displaced [**Name (NI) 51627**] - unclear cardiac history, CXR demonstrates enlarged cardiac silhouette, systolic mumur at left sternal border. Concerned for HIV cardiomyopathy, no ECHO on file. ECHO wnl. . 7) s/p Right hip replacement - patient one month ago dislocated his replaced right hip. Patient currently wears brace to prevent re-dislocation. - Cont to use brace - Activity as tolerated . 8) FEN - Regular diet as tolerated, replete electrolytes as needed. . 9) Prophylaxis - Pneumoboots, patient able to ambulate, PPI iv bid, bowel regimen prn . 10) FULL CODE . 11) Dispo - called out for transfer from [**Hospital Ward Name 332**] ICU to 11 [**Hospital Ward Name 1827**] for further work up of thrombocytopenia. . This was the hospital course to date and the plan for the day the patient left AMA. Hematology will still leave a note in OMR regarding patient's thrombocytopenia. Patient was provided with fluconazole to complete 14 day course for oral candidiasis, and protonix 40 mg twice a day to treat his recent upper gastrointestinal bleed. Patient was strongly encouraged to follow-up with his primary care practitioner and to keep all of his outpatient appointments. Medications on Admission: Dapsone 100 mg p.o. daily Azithromycin 600 mg two tabs weekly Tyzeka (telbuvidine) 600 mg p.o. daily. Discharge Medications: 1. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (MO). Disp:*10 Tablet(s)* Refills:*2* 3. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 12 days. Disp:*24 Tablet(s)* Refills:*0* 4. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). Disp:*60 Recon Soln(s)* Refills:*2* 5. Telbivudine 600 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Upper Gastrointestinal Bleed Thrombocytopenia HIV HBV HCV Discharge Condition: No evidence of active bleeding, needs further hospital work-up but refuses Discharge Instructions: You were admitted for an upper gastrointestinal bleed. You were found to have a gastric ulcer. You were started on a proton pump inhibitor twice a day. You need to still be in the hospital to monitor your blood levels. You also have low platelets that need transfusions. You are currently being seen in the hospital by blood specialist. It is strongly recommended that you stay in the hospital to complete this work-up and receive any potential treatments. . You have decided to leave against medical advice. If you experience any fevers, chills, nausua, vomiting, bleeding please call 911 or go to the local emergency room. Please take your protonix twice a day as directed, please also take the fluconazole for oral candidiasis as directed Followup Instructions: Please call your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] to follow-up. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 7621**] CLINIC Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2111-12-1**] 1:20 Provider: [**First Name8 (NamePattern2) 1037**] [**First Name8 (NamePattern2) 1052**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2111-12-1**] 1:20 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 7621**] CLINIC Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2111-12-29**] 1:00

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icd9cm

[ [ [] ] ]

[ "99.04", "45.13" ]

icd9pcs

[ [ [] ] ]

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4085, 8069

280, 287

8891, 8968

2358, 4062

9763, 10333

1824, 1911

8221, 8760

8810, 8870

8095, 8198

8992, 9740

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232, 242

315, 1034

1056, 1564

1580, 1808

32,707

128,977

7336

Discharge summary

report

Admission Date: [**2128-2-12**] Discharge Date: [**2128-2-15**] Service: MEDICINE Allergies: Lisinopril / Aspirin Attending:[**First Name3 (LF) 19836**] Chief Complaint: Weakness and Dizziness Major Surgical or Invasive Procedure: Upper Endoscopy/Enteroscopy History of Present Illness: 85F with CHF, aortic stenosis, known jejunal AVMs and history of ?colonic plasmacytoma presenting with one day of dizziness and leg weakness. Yesterday doing fine. Got up today and was very lightheaded with standing, felt presyncopal. Felt generalized weakness when upright, okay when supine. Family members also thought she looked more pale than usual. No abdominal pain, N/V, diarrhea. Last bowel movement this morning, describes as black pellets which she has attributed to iron pills. No hematochezia or melena. No hematemesis. No syncope or vertigo. No CP, palps, dyspnea. Has not noted any hematuria since recent admission. No vaginal bleeding. No NSAIDs other than 81 mg ASA (started about 2 weeks ago), no EtOH. She was recently admitted to [**Hospital1 18**] from [**Date range (1) 27076**] for CHF exacerbation and was diuresed. She was also treated with a 5 day course of levofloxacin for ?pneumonia. Aspirin and lasix were started with this admission. In the ED, initial vs were: T97.3 P86 121/49 R18 93% RA. She was found to be guaiac positive. Neurologically intact. Hct returned at 23 - 11.5 points lower than value from 11 days ago. Lactate 3.5. Remained hemodynamically stable. Patient was given protonix 40 mg IV, 40 mEQ potassium, 1 L NS started. On the floor, patient feeling well lying supine. No abdominal pain or current dizziness. Review of systems: (+) Per HPI. Thinks she may have lost a few pounds since recent hospital discharge attributed to poor appetite. (-) Denies fever, chills, recent weight gain. Denies headache, visual changes, cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, nausea, vomiting, 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: Past Medical History: - Congestive heart failure, diasystolic and valvular dysfunction - Aortic stenosis - moderate in [**1-/2128**] echo. - AVMs - jejunal, cauterized in [**2126**] - Fe deficiency anemia - MGUS - plasma cell infilatrate/mass on colonoscopy in [**2125**]; SPEP showing MGUS. repeat biopsy not c/w plasmacytoma. - History of ischemic colitis x 2 episodes. - Gout - HTN - Hyperlipidemia - Hematuria of unclear etiology - [**Name (NI) 19917**] disease involving L iliac bone Social History: The patient is a retired [**Company 2676**] worker. She has worked both in electronic assembly and in the office, although she denies either radiation or toxin exposure. She reports + EXPOSURE to asbestos, though. She had about 5- or 8-pack-year history of smoking, does not drink alcohol. Lives with a lot of family in a 13 bedroom home. Family History: Mother died of [**Name (NI) 2481**] disease. Father died of unknown form of cancer. She had a brother who had a melanoma. Another brother died of a myocardial infarction. Physical Exam: General: Alert, oriented, no acute distress, very pleasant and well appearing HEENT: Sclera anicteric, conjunctiva pale, MMM, oropharynx clear, no dried blood. Neck: supple, JVD flat, no LAD. Lungs: Clear to auscultation bilaterally with exception of L base, with few inspiratory crackles, improve slightly with cough. CV: Regular rate and rhythm, 3/6 systolic murmur best at RUSB with radiation to carotids. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Rectal: external hemorrhoids present, no rectal masses, no stool present. Ext: warm, well perfused, no clubbing, cyanosis or edema. Neuro: CN II-XII intact, strength 5/5 in distal uppers and all lowers, oriented x 3. Pertinent Results: Labs on Admission: [**2128-2-12**] 12:30PM WBC-10.9 RBC-2.57*# HGB-6.9*# HCT-23.0*# MCV-89 MCH-27.0 MCHC-30.3* RDW-16.6* [**2128-2-12**] 12:30PM PLT COUNT-263 [**2128-2-12**] 12:30PM PT-13.0 PTT-20.8* INR(PT)-1.1 [**2128-2-12**] 12:30PM HAPTOGLOB-305* [**2128-2-12**] 12:30PM CALCIUM-9.0 PHOSPHATE-2.8 MAGNESIUM-1.6 [**2128-2-12**] 12:30PM ALT(SGPT)-27 AST(SGOT)-30 LD(LDH)-197 CK(CPK)-42 ALK PHOS-115* TOT BILI-0.2 [**2128-2-12**] 12:30PM cTropnT-<0.01 [**2128-2-12**] 12:30PM CK-MB-NotDone proBNP-1723* Labs on Discharge: [**2128-2-15**] 07:15AM BLOOD WBC-7.2 RBC-3.30* Hgb-9.6* Hct-28.9* MCV-88 MCH-29.2 MCHC-33.3 RDW-17.7* Plt Ct-200 [**2128-2-15**] 07:15AM BLOOD Glucose-103* UreaN-20 Creat-1.0 Na-142 K-3.7 Cl-101 HCO3-33* AnGap-12 [**2128-2-15**] 07:15AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8 Studies: CXR [**2128-2-12**]: Findings compatible with mild congestive heart failure. ECG [**2128-2-12**]: Sinus rhythm. Left bundle-branch block. Compared to the previous tracing there is no significant change. Enteroscopy [**2128-2-13**]: Please see procedure note for full details. Brief Hospital Course: 85 year old female with small bowel AVMs, aortic stenosis, CHF, admitted with weakness and acute decrease in Hct due to a GI Bleed. #. GI Bleed: She most likely had a GI bleed causing acute blood loss and her presenting symptoms of lightheadedness and dizziness. She had an enteroscopy that showed an angioectasia of the stomach and the duodenum that was the most likely source and both sites were cauterized. She was also recently started aspirin which was held during this hospitalization and she was instructed to discuss with her outpatient PCP whether or not to restart it. She may need an outpatient colonoscopy in the future given her history of questionable GI tract plasmacytoma and her ongoing anemia. After the enteroscopy, her hematocrit remained stable and her dizziness had resolved. She was discharged on a po PPI [**Hospital1 **]. #. Congestive heart failure: She had a BNP below previous numbers in the system and she appeared generally hypovolemic. Her Lasix and beta blocker were held initially but restarted prior to discharge. #. Hyperglycemia: She was managed on an insulin sliding scale and should have PCP [**Name9 (PRE) 702**] regarding hyperglycemia. #. Code Status: Full code, confirmed Medications on Admission: - allopurinol 150 mg daily - atenolol 25 mg daily - ASA 81 mg daily - lasix 40 mg daily - pantoprazole 40 mg [**Hospital1 **] - iron 325 mg [**Hospital1 **] - psyllium daily - vitamin D 400 units daily Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 40 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 twice a day. 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 6. Psyllium Oral 7. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis GI bleed AV malformations in stomach and small bowel Secondary Diagnosis: Anemia Aortic stenosis Congestive Heart Failure 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 weakness and dizziness. You also were found to have a low blood count and you were given blood. It was felt that you had a bleed from your GI tract and you had a scope placed in your GI tract to look for sources of bleeding. You had areas of abnormal vessels and the bleeding was stopped. You should also follow-up with your gastroenterologist regarding whether you also should have a colonoscopy as an outpatient. CHANGES to your medications: Stopped aspirin Followup Instructions: You should call and schedule an appointment with a gastroenterologist in the next 1-2 weeks. Dr. [**Last Name (STitle) **] saw you in the hospital. Please call [**Telephone/Fax (1) 27077**] to schedule an appointment. You also have the following appointments scheduled: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2128-2-24**] 11:00 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2128-2-26**] 1:30 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2128-4-5**] 11:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]

[ "424.1", "428.32", "455.3", "274.9", "790.29", "599.70", "426.3", "276.8", "285.1", "428.0", "272.4", "280.9", "401.9", "731.0", "537.83" ]

icd9cm

[ [ [] ] ]

[ "44.43", "99.04" ]

icd9pcs

[ [ [] ] ]

7122, 7128

5130, 6354

252, 281

7313, 7313

4004, 4009

7988, 8833

3055, 3227

6607, 7099

7149, 7221

6380, 6584

7461, 7919

3242, 3985

7948, 7965

1707, 2168

190, 214

4545, 5107

309, 1688

7242, 7292

4023, 4526

7328, 7437

2212, 2681

2697, 3038

25,256

144,551

12435

Discharge summary

report

Admission Date: [**2162-3-22**] Discharge Date: [**2162-4-2**] Date of Birth: [**2123-3-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Fever, chronically vented patient Major Surgical or Invasive Procedure: PICC placement Dobhoff repositioning Dobhoff replacement History of Present Illness: 38M with NHL s/p alloSCT [**2155**] and DLI [**2156**], in remission but with chronic GVHD including bronchiolitis obliterans and severe restrictive lung disease. He was recently discharged on [**3-16**] after 2 month hospital stay complicated by repeated respiratory failure ultimately requiring trach and VAP. At the time of discharge from the [**Hospital Unit Name 153**] last week, he was not tolerating trach collar mask, but was off all antibiotics except for prophylactic antibiotics. . Patient is sent in today from [**Hospital1 **] for Fever to [**Age over 90 **] yesterday and increased work of breathing. At rehab, he was tolerating 6 hours a day off the vent, until yesterday when he had a fever. Per patient, he was given Vanco/[**Last Name (un) **] at rehab. Upon arrival to the ED, his vitals were T 100.0, HR 107, BP 90/59, RR 28. He was initially hypoxic upon arrival here to low 90s on the vent, but improved with suctioning. A chest CT performed here showed worsening pulmonary infiltrates suggestive of a VAP and was negative for PE. Urine culture was sent at [**Hospital1 **]. In the ED, he was briefly hypotensive to the 80s, which improved with 500 cc normal saline bolus. . Upon arrival to the floor, he denies abdominal pain, diarrhea, dysuria, pain. He reports coughing for the past few days. Past Medical History: Past Oncologic History: - [**4-/2154**] p/w fevers, night sweats, and weight loss in the setting of a left inguinal lymph node. - CT scan: 15x14x10cm mass in the LUQ. - Bx grade II/III follicular lymphoma. - Treated with six cycles of CHOP/Rituxan with good response, but showed evidence for relapse in [**12/2154**] and was treated with MINE chemotherapy for two cycles. - [**3-/2155**]: Underwent stem cell mobilization with Cytoxan followed by autologous stem cell transplant in - [**7-/2155**]: Noted for disease recurrence. He was initially treated with a course of Rituxan without response followed by Zevalin with - [**3-/2156**]: Noted progression of his disease. He was treated with one cycle of [**Hospital1 **] followed by one cycle of ESHAP. - [**2156-7-29**]: Nonmyeloablative allogeneic stem cell transplant with a [**5-30**] HLA-matched unrelated donor with Campath conditioning - Six-month follow-up CT noted for disease progression. - [**1-/2157**]: Received donor lymphocyte infusion in , complicated by acute liver/GI GVHD grade IV, for which [**Known firstname **] required a prolonged hospitalization in the summer of [**2156**]. - Multiple GI bleeds requiring ICU admissions and multiple transfusions and embolization of his bleeding. - Noted to have CNS lesions felt consistent with PTLD and this was treated with a course of Rituxan. No evidence for recurrence of the PTLD. - Acute liver GVHD, on CellCept, prednisone, and photophoresis. - [**2157-12-28**] Photophoresis was d/c'd due to episodes of bacteremia and eventual removal of his apheresis catheter. - [**2158-6-13**] restarted photopheresis on a weekly basis on , but then discontinued this again on [**2158-9-7**] as this was felt not to be making any impact on his liver function tests. - undergone phlebotomy due to iron overload with corresponding drop in his ferritin. He has continued with transient rises in his transaminases and bilirubin and has remained on varying doses of CellCept and prednisone which has been slowly tapered over the time. - [**2160-1-10**] CellCept discontinued. - [**2159-1-19**] admission due to increasing right hip pain. MRI revealed edema and infiltrating process in the psoas muscle bilaterally. After extensive workup, this was felt related to an infection and required several admissions with completion of antibiotics in 03/[**2158**]. - [**7-/2160**]: Last scans showed no evidence for lymphom and he has remained in remission. - [**2160-10-20**]: URI and treatment with course of Levaquin. - [**2160-11-13**] completed a 4 week course of Rituxan to treat his GVHD. -In [**5-/2161**], noted to have tiny echogenic nodule on abdominal [**Year (4 digits) 950**]. MRI of the liver also showed this nodule but was not as concerning on review and he is due to have a repeat MRI imaging in early [**Month (only) **]. -- GI varices and attempts at banding have been unsuccessful due to difficulty with passing the necessary instruments. He has been on a low dose beta blocker as well as simvastatin, which was started on [**2161-7-7**] to help with medical management of his varices. -On [**2161-8-3**], worsening cough and was noted to have a small new pneumothorax in the left apical area. This has essentially resolved over time - Issues with weight loss (followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]); multiple tests done with no etiology found; question malabsorption related to GVHD - Has on and off respiratory infections and has been treated with antibiotics with possible pneumonia. Question underlying exacerbations of pulmonary GVHD in setting of his URIs. - Currently receives IVIG every month. . Other Past Medical History: 1. Non-Hodgkin's lymphoma s/p allo SCT 2. Grade 4 Acute GVHD of GI/liver following DLI with GI bleed, chronic transaminitis, portal HTN with esophageal varices (not able to band) 3. History of intracranial lesions felt consistent with PTLD. 4. Extensinve chronic GVHD of lung, liver, skin, mucous membranes. 5. Grade II esophageal varices, intollerant to beta blockade. 6. HSV in nasal washing [**11/2159**](completed course of Valtrex) 7. Hypothyroidism 8. hx of Psoas muscle infection . Social History: Smoke: never EtOH: none currently; occassional use prior to NHL dx Drugs: never Born in [**Country **] and moved to the U.S. for college ([**Hospital1 **]). Married in [**2160-8-25**] and lives in [**Location **]. No children. Stays at home and writes (currently writing a book on being diagnosed with cancer at young age). Family History: Without history of lymphoma or other cancers in the family No FHx of DM or HTN Mother: Alive, Thyroid disease Father: [**Name (NI) 38646**] cardiac cath with angioplasty of 2 vessels, asthma 2 older brothers: alive and well Physical Exam: Gen: Cachectic male, +Trach present, + NGT HEENT: sclera anicteric CV: Tachycardic, no m/r/g Pulm: coarse breath sounds bilaterally, no wheezes, crackles Abd: soft, NT, ND, bowel sounds present Ext: no peripheral edema Pertinent Results: [**2162-3-23**] 03:42AM BLOOD WBC-7.1 RBC-2.55* Hgb-7.6* Hct-23.5* MCV-92 MCH-29.8 MCHC-32.3 RDW-16.6* Plt Ct-218 [**2162-3-23**] 03:42AM BLOOD Neuts-68 Bands-8* Lymphs-18 Monos-4 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1* [**2162-3-23**] 03:42AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-OCCASIONAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL MacroOv-OCCASIONAL [**2162-3-23**] 03:42AM BLOOD PT-15.7* PTT-49.1* INR(PT)-1.4* [**2162-3-23**] 03:42AM BLOOD Glucose-79 UreaN-9 Creat-0.4* Na-136 K-3.8 Cl-101 HCO3-26 AnGap-13 [**2162-3-23**] 03:42AM BLOOD ALT-30 AST-37 LD(LDH)-178 AlkPhos-239* TotBili-1.2 [**2162-3-23**] 03:42AM BLOOD Albumin-2.6* Calcium-7.8* Phos-1.9* Mg-1.6 Iron-12* [**2162-3-23**] 03:42AM BLOOD calTIBC-190* VitB12-1810* Folate-15.8 Hapto-336* Ferritn-250 TRF-146* [**2162-3-23**] 03:42AM BLOOD TSH-4.0 [**2162-3-22**] 01:16PM BLOOD IgG-197* [**2162-3-22**] 01:18PM BLOOD Type-[**Last Name (un) **] Temp-37.8 pO2-179* pCO2-47* pH-7.44 calTCO2-33* Base XS-7 -ASSIST/CON Comment-TRACH CTA Chest [**2162-3-23**]. IMPRESSION: 1. No evidence of pulmonary embolism. No acute aortic pathology. 2. Bilateral small pleural effusions with associated atelectasis, decreased on the left and increased on the right since [**2162-3-4**]. 3. Persistent lower lobe pulmonary consolidations with interval increased conspicuity of bilateral associated tree-in-[**Male First Name (un) 239**] abnormalities and layering lower lobe bronchus secretions, highly suggestive of aspiration superimposed on infection. 4. Mild improvement of left lower lobe consolidations. Less confluent central consolidations on the right with new peripheral opacities in the right lower lobe as well as in the right upper lobe, concerning for worsening infection. Right upper lobe opacities also demonstrate equivocal tiny cavitary foci, possibly related to patient's immunocompromised state. 4. Cirrhosis with ascites, as characterized previously on [**Male First Name (un) 950**] from [**2162-3-15**]. . [**2162-3-31**]: INDICATION: 39-year-old male with left PICC placement. COMPARISON: [**2162-3-27**]. CHEST, AP: A new left PICC terminates in the inferior SVC. Other monitoring and support devices are unchanged in course and position. There is no pneumothorax. Bibasilar atelectasis, left greater than right, is unchanged. The cardiomediastinal and hilar contours are normal. A trace left pleural effusion persists. IMPRESSION: Left PICC placement, without complications. RESPIRATORY CULTURE (Final [**2162-3-29**]): SPARSE GROWTH Commensal Respiratory Flora. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: Mr. [**Known lastname 38598**] is a 38 yo male with NHL, s/p allo [**Known lastname 3242**] complicated by multi-organ GVHD and bronchiolitis obliterans, now trached for repeated hypercarbic respiratory failure admitted with Klebsiella pneumonia and bacteremia. . Klebsiella pneumonia and bacteremia. Patient presented with fevers, increased pulmonary secretetions and increased ventillator requirements. His blood cultures and sputum cultures were possitive for Klebsiella. He was initially treated with Vancomycin/Meropenem/Bactrim (for concern for stenotrophomonas or acinetobacter), but this was later tailored to Meropenem and Tobramycin for ESBL Klebs double coverage. He was later transitioned to ceftriaxone monotherapy when further lab investigation confirmed sensitivity. He was discharged on a 21 course to end on [**4-12**]. He has a follow up appt with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] on [**2162-5-4**] Respiratory failure. Patient has broncholitis obliterans and muscle weakness, and is now trached. He was tolerating up to 6 hours of trach collar mask at [**Hospital1 **] prior to admission. There was some concern for a component of aspiration. His dobhoff was repositioned under IR. In the ICU, he was initially ventiallated with assist control, and discharged on trach collar with pressure support. he has a follow up appointment on [**2162-7-19**] with Dr. [**Last Name (STitle) **] Hypotension. Patient has low normal BP, which was monitored and did not require pressors in house. We held his metoprolol and spironolactone because of systolics in low 100's. These can be restarted at the discretion of physicians at [**Hospital1 **]. Elevated INR. Likely due to malnutrition and prologned antibiotic use. He was given vitamin K x1 in house. This resolved. GVHD: Resulting in elevated LFTs and broncholitis oblietans. Continued prednisone and mycophenolate mofetil; ppx with bactrim, acyclovir, voriconazole. Given IvIG for low IgG levels. The patient had an elevated Beta glucan level which was thought to be spurious. This should be rechecked on [**4-7**], with results communicated with dr.[**Doctor Last Name 3930**] office at [**Telephone/Fax (1) 3237**], ext 1. # Non-Hodgkin's lymphoma s/p allo [**Telephone/Fax (1) 3242**]: Most recent PET scan with no evidence of recurrent disease and he remains in remission. # Hyperlipidemia: continue simvastatin # Hypothyroidism: continued on Levothyroxine # Anemia. At baseline - normocytic anemia, workup showed anemia of chronic inflammation. Patient received one unit and returned to baseline at 30's. He was started on Iron supplementation. Medications on Admission: Bactrim DS MWF Simvastatin 20 mg daily Levothyroxine 125 mg daily Atrovent PRN Tylenol PRN Bisacodyl prn HSQ Vitamin D 50,000 weekly Glycopyrrolate 1 mg TID Phenol spray prn throat pain Mycophenolate Mofetil 200 mg/mL PO BID (2 times a day) Saline nasal spray for nasal dryness Acyclovir 400 q 12 hours Albuterol prn wheezing Metoprolol 12.5 [**Hospital1 **] Guiafenesin [**5-3**] ml q 12 hour Trazodone 50 mg qhs prn PNA Fluticasone nasal spray [**Hospital1 **] Voriconazole 200 mg [**Hospital1 **] Colace [**Hospital1 **] Prednisone 20 mg daily Pantoprazole 40 mg daily MVI daily Spironlactone 50 mg [**Hospital1 **] Discharge Medications: 1. Acyclovir 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12 hours). 2. Ascorbic Acid 500 mg/5 mL Syrup [**Hospital1 **]: One (1) dose PO DAILY (Daily). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [**Hospital1 **]: One (1) Capsule PO 1X/WEEK (WE). 4. Therapeutic Multivitamin Liquid [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Prednisone 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime). 7. Zinc Sulfate 220 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily). 8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB, wheeze. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB, wheeze. 11. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Sodium Chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**12-26**] Sprays Nasal QID (4 times a day) as needed for dry nares. 13. Trazodone 50 mg Tablet [**Month/Day (2) **]: .[**4-24**] Tablet PO HS (at bedtime) as needed for insomnia. 14. Voriconazole 200 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO Q12H (every 12 hours). 15. Acetaminophen 500 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 16. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (3) **]: One (1) dose PO BID (2 times a day). 17. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 18. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Last Name (STitle) **]: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 19. Lipase-Protease-Amylase 8,000-30,000- 30,000 unit Tablet [**Last Name (STitle) **]: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 20. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO BID (2 times a day). 21. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 22. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (STitle) **]: One (1) dose PO DAILY (Daily). 23. Levothyroxine 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 24. Ondansetron 8 mg IV Q8H:PRN nausea 25. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback [**Last Name (STitle) **]: One (1) dose Intravenous Q24H (every 24 hours) for 10 days. 26. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 27. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution [**Last Name (STitle) **]: Two [**Age over 90 1230**]y (250) mg PO twice a day. 28. Fluticasone 50 mcg/Actuation Spray, Suspension [**Age over 90 **]: One (1) spray Nasal once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Klebsiella Pneumonia with Bacteremia GVHD BOOP Protein-Energy Malnutrition Hypogammaglobulinemia Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: You were admitted with fevers and low blood pressure. You were found to have pneumonia and a blood infection. Your fevers resolved and your blood pressure normalized atfer you were given antibiotics. Additionally, you had a new PICC and feeding tube placed. As always, it was a pleasure to meet you and participate in your care. You will need to continue ceftriaxone for ten more days, ending on [**4-12**]. Your metoprolol and spironolactone were held because of low blood pressure. These can be restarted at [**Hospital1 **] at the discretion of their physicians. You were started on Viokase as well to help with digestion. Your protonix was switched to lansoprazole. Iron supplements were started for anemia. Followup Instructions: [**Doctor Last Name **]: Please call [**Telephone/Fax (1) 3237**] to schedule an appointment with Dr. [**Last Name (STitle) **] within two weeks. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2162-9-23**] 2:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2162-5-4**] 9:00 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2162-7-19**] 9:00 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2162-7-19**] 8:40 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2162-4-4**]

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Discharge summary

report

Admission Date: [**2135-9-27**] Discharge Date: [**2135-10-7**] Date of Birth: [**2104-8-11**] Sex: M Service: MEDICINE Allergies: Ibuprofen Attending:[**First Name3 (LF) 949**] Chief Complaint: Fever, tachycardia Major Surgical or Invasive Procedure: Temporary hemodialysis catheter placement Tunnelled hemodialysis catheter placement [**Last Name (un) 1372**] intestinal tube placement History of Present Illness: This is a 31 yo male with biliary atresia s/p liver [**Last Name (un) **] in [**2110**], s/p small bowel resection [**8-/2135**], recent staph bacteremia [**12-27**] infected HD line who was transferred from OSH for fevers and tachycardia. At home, patient complained of two weeks of fatigue, productive cough, progressive lower extremity edema, and fevers/chills. At a VNA visit he was noted to be tachycardic and taken to an OSH. . At OSH, he was febrile and noted to be in SVT, which broke with adenosine. He was started on levofloxacin for suspected LLL PNA on CXR. This was broadened empirically to vanc/pip-tazo given concern for SBP, as well. Patient was transferred to [**Hospital1 18**] ICU. . In the ICU, all cell lines of his CBC were trending down, hct drop from 27 to 19, given 2U PRBC with appropriate increase to 26. No clear source of blood loss. He also c/o myalgias/arthralgias, with multiple sick contacts, so flu swab was sent. This came back positive, so he was started on oseltamivir. Diagnostic para was negative for SBP and CXR did not show PNA, so vanc/pip-tazo were stopped. His vitals have shown mild tachycardia from the 90s to low 100s, current BP 136/90. . Currently, patient c/o fevers, chills, night sweats, myalgias, arthralgias, dyspnea, cough productive of greenish sputum, and hematuria. He denies CP, sore throat, n/v/d, abd pain, melena, hematochezia, dysuria, frequency, urgency. Past Medical History: -biliary Atresia s/p liver [**Hospital1 **] at age 4 (25 years ago) -asthma, well-controlled -right hip avascular necrosis, per ortho may need THR -postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**] showed IgG dominent exudative proliferative GN, c/w postinfectious GN -nephrotic syndrome (4.1g proteinuria), hypoalbuminemia -small bowel resection Social History: denies any tobacco, EtOH or illict drug use. Lives at home with parents, engaged. Has one child with a prior girlfriend. Does not work. Family History: NC Physical Exam: PHYSICAL EXAM: Vitals - T: 101.1 (current) BP: 136/92 HR: 110 RR: 22 02 sat: 94% 3L GENERAL: Tachypneic, diaphoretic, mild resp distress, alert and cooperative HEENT: NCAT, no scleral icterus, MM dry, no JVD CARDIAC: +S1/S2, no M/R/G, slightly tachycardic, regular rhythm LUNG: Rhonchi throughout right lung, exp wheezing on left, good air mvmt ABDOMEN: NABS, several abdominal scars, soft, distended, no TTP. Dependent flank edema. EXT: 2+ LE edema, WWP. Pertinent Results: *** CBC [**2135-9-27**] WBC-7.8 RBC-2.99* Hgb-9.1* Hct-26.9* MCV-90 MCH-30.3 MCHC-33.8 RDW-16.6* Plt Ct-169# [**2135-10-7**] WBC-9.6 RBC-3.40* Hgb-9.8* Hct-29.5* MCV-87 MCH-28.9 MCHC-33.2 RDW-16.7* Plt Ct-187 [**2135-9-27**] Neuts-84.2* Lymphs-7.2* Monos-3.4 Eos-4.8* Baso-0.4 [**2135-9-27**] PT-16.0* PTT-35.2* INR(PT)-1.4* . *** Chemistries [**2135-9-27**] Glucose-87 UreaN-23* Creat-2.5* Na-137 K-4.2 Cl-109* HCO3-21* AnGap-11 [**2135-9-28**] Glucose-105 UreaN-24* Creat-2.5* Na-136 K-4.0 Cl-110* HCO3-19* AnGap-11 [**2135-9-28**] Glucose-98 UreaN-28* Creat-2.6* Na-136 K-4.1 Cl-110* HCO3-20* AnGap-10 [**2135-9-29**] Glucose-80 UreaN-30* Creat-2.8* Na-138 K-4.1 Cl-112* HCO3-20* AnGap-10 [**2135-9-30**] Glucose-78 UreaN-38* Creat-3.6* Na-137 K-3.8 Cl-111* HCO3-17* AnGap-13 [**2135-10-1**] Glucose-95 UreaN-45* Creat-4.2* Na-137 K-3.8 Cl-110* HCO3-17* AnGap-14 [**2135-10-2**] Glucose-82 UreaN-52* Creat-5.5*# Na-135 K-3.9 Cl-110* HCO3-16* AnGap-13 [**2135-10-3**] Glucose-80 UreaN-57* Creat-6.6*# Na-138 K-4.3 Cl-110* HCO3-15* AnGap-17 [**2135-10-4**] Glucose-83 UreaN-66* Creat-7.6* Na-139 K-4.6 Cl-111* HCO3-15* AnGap-18 [**2135-10-5**] Glucose-92 UreaN-51* Creat-6.9* Na-140 K-3.8 Cl-108 HCO3-20* AnGap-16 [**2135-10-6**] Glucose-98 UreaN-35* Creat-5.7*# Na-141 K-3.7 Cl-107 HCO3-26 AnGap-12 [**2135-10-7**] Glucose-139* UreaN-22* Creat-4.3*# Na-140 K-3.8 Cl-105 HCO3-28 AnGap-11 . *** Liver Function Tests: [**2135-9-27**] ALT-33 AST-79* LD(LDH)-399* CK(CPK)-310* AlkPhos-371* TotBili-0.4 [**2135-9-28**] ALT-25 AST-63* LD(LDH)-319* CK(CPK)-305* AlkPhos-265* TotBili-0.6 [**2135-9-28**] LD(LDH)-364* [**2135-9-29**] ALT-20 AST-62* LD(LDH)-403* AlkPhos-267* TotBili-1.0 [**2135-9-30**] ALT-18 AST-68* LD(LDH)-504* AlkPhos-336* TotBili-0.5 [**2135-9-30**] CK(CPK)-387* [**2135-10-1**] ALT-15 AST-56* LD(LDH)-442* AlkPhos-329* TotBili-0.6 [**2135-10-2**] ALT-14 AST-56* LD(LDH)-469* AlkPhos-321* TotBili-0.5 [**2135-10-4**] ALT-12 AST-48* AlkPhos-310* TotBili-0.5 [**2135-10-5**] ALT-13 AST-39 AlkPhos-275* TotBili-0.5 [**2135-10-6**] ALT-10 AST-40 AlkPhos-301* TotBili-0.5 [**2135-10-7**] ALT-14 AST-48* AlkPhos-327* TotBili-0.4 [**2135-9-30**] Lipase-119* . *** Albumin, Calcium, Phosphorus, Magnesium [**2135-9-27**] Albumin-1.1* Calcium-6.3* Phos-3.2 Mg-0.8* [**2135-9-28**] Calcium-6.0* Phos-3.2 Mg-1.4* [**2135-9-28**] Calcium-6.5* Phos-3.7 Mg-1.8 [**2135-9-29**] Calcium-6.7* Phos-4.3 Mg-1.8 [**2135-9-30**] Albumin-1.5* Calcium-6.8* Phos-4.3 Mg-1.7 [**2135-10-1**] Calcium-7.3* Phos-4.4 Mg-1.7 [**2135-10-2**] Calcium-7.4* Phos-4.4 Mg-1.7 [**2135-10-3**] Calcium-7.3* Phos-4.6* Mg-1.8 [**2135-10-4**] Albumin-1.2* Calcium-7.2* Phos-5.0* Mg-1.9 [**2135-10-5**] Calcium-7.2* Phos-4.4 Mg-1.8 [**2135-10-6**] Albumin-1.1* Calcium-7.0* Phos-4.0 Mg-1.7 Iron-22* [**2135-10-7**] Calcium-6.9* Phos-3.1 Mg-1.7 . *** Other Lab Tests: [**2135-10-6**] calTIBC-55* Ferritn-1367* TRF-42* [**2135-9-28**] TSH-0.18* [**2135-9-30**] Free T4-0.48* [**2135-10-4**] T3-50* [**2135-10-7**] C3-70* C4-26 [**2135-10-6**] Vanco-21.5* . *** Serum tacrolimus level: [**2135-9-28**] tacroFK-2.2* [**2135-9-29**] tacroFK-3.5* [**2135-9-30**] tacroFK-5.5 [**2135-10-1**] tacroFK-11.5 [**2135-10-2**] tacroFK-8.6 [**2135-10-3**] tacroFK-10.2 [**2135-10-4**] tacroFK-8.7 [**2135-10-5**] tacroFK-6.9 [**2135-10-6**] tacroFK-8.8 [**2135-10-7**] tacroFK-5.0 . *** Urine [**2135-9-28**] 11:44AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018 [**2135-9-28**] 11:44AM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2135-9-28**] 11:44AM URINE RBC->50 WBC-[**10-14**]* Bacteri-FEW [**Month/Year (2) **]-MANY Epi-0 [**2135-9-28**] 11:44AM URINE Hours-RANDOM UreaN-339 Creat-73 Na-58 URINE CULTURE (Final [**2135-9-29**]): NO GROWTH. . [**2135-10-2**] 11:10AM URINE Color-Brown Appear-Cloudy Sp [**Last Name (un) **]-1.020 [**2135-10-2**] 11:10AM URINE Blood-LG Nitrite-NEG Protein->300 Glucose-NEG Ketone-15 Bilirub-MOD Urobiln-0.2 pH-5.5 Leuks-NEG [**2135-10-2**] 11:10AM URINE RBC->50 WBC-[**1-27**] Bacteri-MANY [**Month/Day (1) **]-NONE Epi-[**1-27**] [**2135-10-2**] 11:10AM URINE Hours-RANDOM UreaN-195 Creat-157 Na-32 K-63 [**2135-10-2**] 11:10AM URINE Osmolal-295 URINE CULTURE (Final [**2135-10-2**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . *** Peritoneal Fluid. [**2135-9-28**] 08:10AM ASCITES WBC-25* RBC-50* Polys-1* Lymphs-7* Monos-0 Eos-3* Macroph-89* GRAM STAIN (Final [**2135-9-28**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 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 [**2135-10-1**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2135-10-4**]): NO GROWTH. Transthoracic Echcardiogram: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. No vegetation identified (but cannot exclude). . Abdominal Ultrasound: INDINGS: Postsurgical anatomy and inability of patient to cooperate with breathing instructions limits this examination. No evidence of focal lesions. Echogenic linear structures are seen in the liver, likely due to pneumobilia. Limited views of the pancreas, due to overlapping bowel gas. Gallbladder not seen, likely surgically absent. There is no intrahepatic biliary duct dilatation. IVC, right main and left hepatic vein are patent. The main portal vein and right portal vein are patent and show normal hepatopetal flow. Flow was seen in the splenic veins, however, difficult to obtain splenic vein waveform. The SMV was not imaged. The left portal vein is not definitely identified. The right hepatic artery, main hepatic artery, are patent with normal waveforms. The left hepatic artery was not seen. Ascites is seen in the left lower quadrant. IMPRESSION: 1. Main and right portal veins have appropriate flow and directionality; the left portal vein difficult to visualize, and unable to assess. 2. Left hepatic artery not clearly visualized; remainder of the arteries and veins of the liver appear patent. 3. Gallbladder not seen, likely surgically removed. 4. Trace ascites. . Renal U/S: Both kidneys are echogenic throughout with poor corticomedullary differentiation. They are of a good size, measuring 11.3 cm longitudinally on the left, and 11.7 cm longitudinally on the right. No hydronephrosis or focal abnormality is seen in relation to either kidney. Both main renal veins and main renal arteries are patent. There are normal resistive indices on both sides varying from 0.59 to 0.66. Views of the urinary bladder are unremarkable. Incidental note is made of a small amount of ascites. CONCLUSION:. The kidneys are of increased echogenicity bilaterally with poor corticomedullary differentiation, in keeping with chronic renal disease, from the patient's known post-infectious glomerulonephritis. There is no hydronephrosis. There is good perfusion of the kidneys. Brief Hospital Course: #. Multifocal Pneumonia. On arrival to the floor, patient had significant rhonchi bilaterally, and had an oxygen saturation of 94% on 3L of oxygen by nasal cannula. Serial blood cultures were negative and an echocardiogram demonstrated no vegetations suggestive of endocarditis. A repeat chest x-ray was obtained which demonstrated multifocal opacities sugeestive f pneumonia. He was restarted in IV vancomycin, piperacillin-tazobactam, and levofloxacin for treatment of multifocal pneumonia in the setting of influenza, in a immunosupressed patient. Antibiotics were dosed renally and adjusted to match his changing renal function. His respiratory symptoms and pulmonary exam improved with treatment and he was successfully weaned from supplemental oxygen. Per the recommendation of infectious disease, he was treated for a total of 8 days of antibiotics with complete resolution of symptoms. . #. H1N1 Influenza. On admission, his influenza swab tested positive for H1N1 swine like influenza. He was treated with five days of oseltamivir 150mg PO bid and kept on droplet precautions. He defervesced on hospital day 4, and droplet precautions were removed, and droplet precautions were removed 24 hours later, with the completion of antiviral therapy. . #. Acute on Chronic Renal Failure. On admission, serum creatinine was 2.5, which was increased over his baseline of 1.9 at his last discharge. Urinalysis was X, and FeNa was 1.46%. He was given IV fluid boluses and his creatinine did not decrease. He later was treated with IV albumin, with no improvement of his renal function. His serum creatinine subsequently began to increase to a peak of 7.6, with a concomitant decrease in urine output. [**Month/Day/Year 1326**] nephrology was consulted, and a urinalysis, urine chemistries were repeated. Urinalysis was significant for muddy brown casts, and acute tubular necrosis was diagnosed. A temporary hemodialysis catheter was placed on [**2135-10-3**], and hemodialysis was initiated on [**2135-10-4**]. The temporary catheter was exchanged for a tunneled catheter on [**2135-10-6**]. By discharge, serum creatinine had improved to 4.3, but he was still oliguric with under 100cc of urine output per day. He was relisted for kidney [**Date Range **], and follow-up will be arranged with [**Date Range **] nephrology. Infectious disease was consulted regarding infectious causes of renal failure, and recommended CMV, HIV, BK virus, HBV and HCV viral load tests, which were pending at the time of discharge. . #. Chronic liver disease s/p liver [**Date Range **]. On admission, patient had a mild transamititis with an ALT and AST of 33 and 79, an elevated alkaline phosphatase of 371, low albumin of 1.1 and an INR of 1.4, all of which were at his baseline. An ultrasound guided paracentesis was performed, revealing mild ascites, but paratoneal fluid analysis demonstrated no SBP. Patient was continued on his home doses of tacrolimus 0.5mg PO bid and lactulose 30ml PO tid. Daily serum tacrolimus levels were drawn, and doses were held as his renal function worsened. On the day of discharge, his serum tacrolimus level had decreased to 5.0, and he was restarted on tacrolimus 0.5mg daily. Serum tacro levels will be drawn at [**Date Range 2286**] on [**2135-10-11**] and faxed to the liver [**Date Range **] center. MELD on discharge was 23. Follow-up was arranged with the liver [**Date Range **] center on [**2135-10-19**]. . #. Hyperthyroidism. On admission, serum TSH was low at 0.18. Free T4 was low at 0.4 and T3 low at 50. This was thought to be due to sick euthyroid and was on uncertain significance in a patient with acute illness. Repeat TSH levels are recommended 4-6 weeks after discharge. Medications on Admission: OxycoDONE 2.5 mg Q4H:PRN pain Oseltamivir Phosphate 75 mg PO BID Sarna Lotion 1 Appl TP TID:PRN itching DiphenhydrAMINE 25 mg Q6H:PRN itching Ipratropium Bromide 1 NEB IH Q6H SOB Ondansetron 4 mg IV Q8H:PRN nausea Acetaminophen 325-650 mg PO/NG Q6H:PRN fevers, pain Tacrolimus 0.5 mg PO Q12H Pantoprazole 40 mg PO Q24H Lactulose 30 mL PO/NG TID 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. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). Disp:*1 bottle* Refills:*2* 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). Disp:*1 bottle* Refills:*2* 5. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO once a day. 6. Outpatient Lab Work Please draw serum tacrolimus level with [**Date Range 2286**] next tuesday [**2135-10-11**] and fax the result to Dr. [**Last Name (STitle) 497**] at the liver [**Last Name (STitle) **] center. Discharge Disposition: Home With Service Facility: vna southeastern [**State **] Discharge Diagnosis: Acute on Chronic Renal Failure H1N1 Influenza Multifocal Pneumonia s/p liver [**State **] Discharge Condition: Stable, alert and oriented to person, place and time. Discharge Instructions: You were admitted for high heart rate and fevers. Laboratory testing revealed you had H1N1 swine like influenza. A chest x-ray showed pneumonia. Fluid was taken from your abdomen and demonstrated no infection. You were treated with antiviral medications for your flu. You were treated with intravenous antibiotics for your pneumonia. Your kidney function deteriorated and hemodialysis was initiated. With hemodialysis, your laboratory values improved. While here your blood level of thyroid stimulating hormone (TSH) was low. This is not surprising in the case of an acute illness, but your primary doctor may want to recheck you TSH valcue is 4-6 weeks. Please make the following changes in your medications: Please CHANGE your dose of tacrolimus to 0.5mg by mouth daily Please STOP taking lasix Please START Pantoprazole 40mg by mouth daily You will require hemodialysis for the forseeable future. Your first hemodialysis session will be on [**2135-10-8**]. Please adhere to your follow-up appointments. They are important for managing your long-term health. . Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. Followup Instructions: Please follow up with the following appointments: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2135-10-8**] 7:30 Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2135-10-19**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **],[**MD Number(3) 13795**]:[**Telephone/Fax (1) 37766**] Date/Time:[**2135-10-26**] 9:00 Please make an appointment with your primary care doctor within the next two weeks.

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icd9cm

[ [ [] ] ]

[ "39.95", "38.95", "54.91" ]

icd9pcs

[ [ [] ] ]

15354, 15414

10429, 14171

288, 426

15548, 15604

2932, 10406

16969, 17521

2435, 2439

14566, 15331

15435, 15527

14197, 14543

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2469, 2913

230, 250

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24,480

140,383

27174

Discharge summary

report

Admission Date: [**2189-9-15**] Discharge Date: [**2189-9-24**] Date of Birth: [**2138-5-13**] Sex: F Service: CARDIOTHORACIC Allergies: Milk Attending:[**First Name3 (LF) 281**] Chief Complaint: tracheal stenosis w/ t-tube in place. Admitted for removal of T-tube and evaluation of airway post removal. Major Surgical or Invasive Procedure: rigid bronchoscopy, t-tube removal with subsequent T-Tube replacement for critical airway stenosis. flexible bronchoscopy x2. Speech and swallow evaluation History of Present Illness: 51 yo Laiotian F (resides in FLA) w/ hx of Tracheal stenosis s/p intubation after suicide attempt [**2186**]. Had metallic stent placed in [**2186**]. Metal stent removed by [**Doctor Last Name **] [**5-12**] w/ post membranous tracheal injury so, T-tube placed. [**7-12**]- eval of injury-90% healed and t-tube replaced d/t degree of manipulation from microdebridement. [**9-15**]-F/U bronch- paresis left vocal cord, granulation tissue proximal. Past Medical History: tracheal stenosis -multiple dilitations, s/p metal tracheal stent placement '[**86**]. depression w/ suicide attempt- intubation, Social History: She lives with family. She denies alcohol or tobacco use. Family History: n/c Physical Exam: general: well appearing feamle in NAD. Vitals: 98.4 71 131/85 16 100 room air HEENT: T-tube in place Chest: lungs CTA bilat COR: RRR S1, S2 extrem: no c/c/e neuro: Alert and approp. Pertinent Results: [**2189-9-23**] 07:30AM BLOOD WBC-6.7 RBC-5.11 Hgb-13.0 Hct-39.4 MCV-77* MCH-25.4* MCHC-32.9 RDW-16.3* Plt Ct-307 [**2189-9-23**] 07:30AM BLOOD Glucose-93 UreaN-11 Creat-0.7 Na-142 K-3.5 Cl-105 HCO3-29 AnGap-12 [**2189-9-23**] 07:30AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.2 . CHEST (PORTABLE AP) [**2189-9-16**] 1:45 PM REASON FOR THIS EXAMINATION: ?pneumothorax PORTABLE CHEST 2:03 P.M. on [**9-16**]: FINDINGS: Compared with [**2189-7-29**], the tracheostomy tube has been removed. The lungs are well expanded and clear. No pneumothorax is seen. No acute process identified. . VIDEO OROPHARYNGEAL SWALLOW [**2189-9-18**] 11:56 AM REASON FOR THIS EXAMINATION: eval swallow per Sp/ Sw recommendation INDICATION: 31-year-old woman with tracheal stenosis status post tracheal stent placement and removal and t-tube replacement. Evaluate swallow. FINDINGS: A video oropharyngeal swallow exam was performed in conjunction with the speech and swallow therapy department. Various consistencies of barium were administered under constant video fluoroscopic monitoring. No pharyngeal residue was appreciated. No aspiration or penetration of solids or liquids was observed. Vocal cord movement was difficult to appreciate and left vocal cord paresis cannot be fully appreciated. Brief Hospital Course: The patient is a 51 year-ol female admited to Dr. [**Last Name (STitle) **] Interventional Pulmonology service on [**2189-9-15**] with c/o shortness-of-breath for 2 weeks s/p T-tube placement at an OSH. On HD 1, she was taken to the OR where her T-tube was removed. Postoperatively she developed stridor and was monitored in the PACU and later placed on a heliox and transferred to the TICU. On PPD 2, the patient underwent a flex bronch for evaluation of vocal cord paralysis and showed left vocal cord paralysis. She alsounderwent a swallow evaluation at the bedisde and later a video swallow study, which demonstrated the no difficulty. A repeat flex bronch on [**2189-9-21**] demonstrated tracheal stenosis 2cm below cords with a diameter of 7cm for 0.5cm. On PPD 7 from removal of her T-tube, Dr, [**Name (NI) **] replaced her T-tube. On PPD 1 of replacement of her T-tube, the patient was deemed stable for discharge back home to [**State 108**]. She was discharge home with instructions to follow-up with Dr. [**Last Name (STitle) **] in 8 weeks and a pulmonologists in [**State 108**] in 2 weeks. Medications on Admission: prednisone 20', pepcid, metoprolol 25". Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 4. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). Disp:*120 Tablet Sustained Release(s)* Refills:*2* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) vial Injection as directed: administer as directed per sliding scale- see attached. 9. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day) as needed. Disp:*120 ML(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: tracheal stenosis, s/p suicide attempt- [**2186**], s/p metal stent placement, s/p posterior membranous tracheal injury, s/p t-tube placement, left vocal cord dysfunction. Discharge Condition: good. T-Tube in place Discharge Instructions: Call [**Doctor First Name **]/ [**Name8 (MD) **], MD Interventional Pulmonary [**Telephone/Fax (1) 3020**] for: fever, shortness of breath, chest pain, coughing up small amounts of blood. YOU MUST follow up with your primary care doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 108**] for blood sugar control. Follow with Pulmonologist in [**State 108**] for any acute issues. Diet-you may eat whatever consistancy food you wish, no concentrated sweets, cakes, cookies. Medications- take medications as directed. Followup Instructions: Follow up with Pulmonologist in [**State 108**] as directed by Interventional Pulmonary. YOU MUST follow up with your primary care doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 108**] for blood sugar control. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]

[ "478.31", "401.9", "786.1", "997.3", "519.02" ]

icd9cm

[ [ [] ] ]

[ "33.22", "97.23", "31.99", "31.5", "97.37", "31.74" ]

icd9pcs

[ [ [] ] ]

4960, 4966

2778, 3889

378, 536

5182, 5206

1487, 1803

5783, 6103

1261, 1266

3981, 4937

4987, 5161

3915, 3958

5230, 5760

1281, 1468

231, 340

2145, 2755

564, 1014

1036, 1168

1184, 1245

29,219

128,173

46042

Discharge summary

report

Admission Date: [**2176-10-8**] Discharge Date: [**2176-11-3**] Date of Birth: [**2109-5-15**] Sex: F Service: MEDICINE Allergies: Ampicillin / Penicillins / Bactrim / Lisinopril / Shellfish Attending:[**First Name3 (LF) 5552**] Chief Complaint: Shortness of Breath with Increased Oxygen Requirement Major Surgical or Invasive Procedure: 1. Intubation 2. Red blood cell transfusion 3. Chemotherapy treatment with irinotecan. History of Present Illness: Briefly, patient is 67 year old female with known history of sigmoid colon adenocarcinoma and sarcoidosis, who presents to the hospital for worsening shortness of breath and increased oxygen demand. . She relates that Sunday night, she awoke from sleep feeling more short of breath. She usually wears 1.5 L Ox at home, and turned her oxygen up to 4L and then felt comfortable. She had no other symptoms at that time--no [**First Name3 (LF) **], fever, chills, night sweats, chest pain, palpitations. . She has kept her oxygen at 4L, and knew she would follow up at clinic yesterday, at which time her oxygen saturation was 88% on 3L. She was sent to the ED, where a CTA was negative for PE, but did show increased grown opacification. . ROS: Negative for fever, chills, rigors, night sweats, chest pain, palpitations, N/V/D. Patient reported one episode of diarrhea one week ago. No PND, orthopnea, no weight changes. Leg swelling is chronic and unchanged. No increase in abdominal girth. No bone or joint pain, skin changes, rashes. No sick contacts. [**Name (NI) **] [**Name2 (NI) **] or sputum. . Allergy: ampicilin/penicillins/bactrim/lisinopril/shellfish . Past Medical History: 1. Asthma 2. HTN 3. Osteopenia 4. Hypercholesterolemia 5. Sarcoidosis/Pulm HTN - She remains on 1.5 L/min of O2. She remains on Revatio 40 mg TID. She continues on prednisone 10 mg QD. 6. History of elevated calcium 7. Decreased T4 s/p thyroid adenoma resection 8. History of steroid induced hyperglycemia 9. Sigmoid colon adenocarcinoma, s/p L hemicolectomy with stapled colorectal anastomosis [**2175-6-9**]: mucinous adenocarcinoma (>50%) which was pT3, pN2 and M1 (stage IV) with metastatic disease to omentum and peritoneal implants. Received FOLFOX (oxaloplatin, FU, LV). Now receiving Iritotecan Social History: Lives with daugther who is 47 in [**Location (un) **]. Quit smoking 25 yrs ago (10 pack years). No ETOH/drugs. Family History: NC Physical Exam: Tm/c 100.5, BP 128/72 P 97 RR 18 sats 94% on 4l General: Pleasant female appearing stated age, resting in bed comfortably, in no apparent distress Neck: Supple, no jvd, no LAD Cardiac: RRR, nl S1, S2, no m/r/g Lungs: good air entry and movement, scattered bilateral mild rhonchi, no wheezes, rales, no dullness to percussion Abdomen: soft, NT, ND, +BS, no HSM appreciated. Extr: trace edema bilaterally, no clubbing/cyanosis Neuro: A&Ox3, no focal findings Psych: Appropriate Pertinent Results: CXR: Diffuse fibrotic changes secondary to sarcoid without superimposed acute cardiopulmonary process. No lesions worrisome for metastatic spread. . CT chest: 1. New, diffuse ground-glass opacities with multifocal areas of more confluent opacities. Findings are non-specific and diagnostic considerations include pulmonary edema, pulmonary hemorrhage, or possibly infection. 2. No evidence of pulmonary embolism. 3. Fibrosis, traction bronchiectasis, hilar and paraaortic lymph nodes consistent with known sarcoidosis again seen, not significantly changed from prior. 4. Evidence of pulmonary arterial hypertension. [**2176-10-10**]: ECHO The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the findings of the prior report (images unavailable for review) of [**2174-2-21**], moderate pulmonary hypertension is now evident. The tricuspid regurgitation is increased. ADMISSION LABS: Brief Hospital Course: 67 yo female with pulmonary sarcoidosis, and known history of stage IV sigmoid colon [**Hospital 97993**] transferred from oncology floor for CPAP due to hypoxia and increased carbon dioxide by ABG. Patient initially presented to hospital from clinic for hypoxia. . 1) Respiratory Distress . Patient was admitted for respiratory distress and hypoxia. She received a CTA out of concern for pulmonary embolism. The CTA was negative for pulmonary embolism, but demonstrated bilateral focal area of ground glass opacification. Patient low grade temperature on arrival to floor, and given CTA findings the oncology team initiated coverage for community acquired and atypical PNA. Echo showed no signs of heart failure or strained right ventricle, therefore, heart failure was not thought to be a significant contributing factor. The patient's respiratory status did not improve and she spiked a temperature > 101. At this time pulmonary was consulted and broad spectrum antibiotic therapy was initiated with Vancomycin, Aztreonam, Levofloxacin and Pentamidine. The patient continued to have respiratory decline on [**10-10**] 9.32/75/51, then [**10-11**] 7.27/82/82. MICU was called to evaluate and the patient was felt to have increasing mental confusion, increased fatigue, increased work of breathing, tachypnea (to 40s) and increasing hypercarbia. Patient was transferred to the MICU for CPAP and further work-up. . Upon Arrival to MICU, patient was placed on CPAP with no appreciable change in mental status, but slight decrease in tachypnea to 30s. Repeat gas after an hour on CPAP (10/5/100%O2)revealed 7.23/88/99. Given patient's clinical picture it was felt that intubation was necessary. Patient was intubated for hypercarbia. . MICU reviewed patient's rapid decline in pulmonary status and felt it was likely due to infection vs congestive heart failure vs pneumonitis based on new bilateral ground glass opacity by CT. Unlikely congestive heart failure as patient with nl ECHO, no signs of RV overload, only moderate pulm HTN, proBNP 1214. Irinotecan can cause interstitial lung disease, last dose was [**9-24**]; however, more concerned that fever, new infilatate represents pulmonary infection. She was continued on Vancomycin, Aztreonam, Levofloxacin and Pentamidine. Increased patient's steroids to treat possible PJP. Initial concern for ARDS as pt initally required high platuea pressures > 30; however, ARDSnet protocol was started and tidal volumes decreased. The patient tolerated this intervention very well and her platuea pressures decreased while her ventilation improved. . Patient was successfully extubated. Sputum from BAL remains negative including for PJP. All blood cultures remain negative. . She completed a 10 day course of antibiotics with vancomycin and levofloxacin. She also was started on increased doses of steroids and tapered back to her home dose at time of discharge, to assist with any inflammatory component. Outpatient follow up with Dr. [**First Name (STitle) **], her pulmonologist at [**Hospital1 2177**], was also coordinated. She continued her home medication of revatio for pulmonary hypertension. She was discharged on 2 L of nasal cannula, and may benefit from outpatient consult for sleep study (patient was noted to need more oxygen at night and reason for intubation was hypercarbia, so she could potentially benefit from CPAP, although her oxygen saturations stabalized during her stay). . #) Acute Renal Failure: Patient developed acute renal failure, thought to be secondary to hypotension as well as potentially nephrotoxic medeications. Her renal function returned to baseline prior to her discharge. The renal consult team also followed and assisted with her management. . #) Small bowel obstruction: Patient noted crampy abdominal pain at time of her irinotecan treatment, with much dirrahea. It was felt that her abdominal pain was likely secondary to chemotherapy effect initially, however then was unable to pass any flatus and had no bowel movements, with increasing distention. Imaging at that time was consistent with a small bowel obstruction. Sugery was consulted and every attempt was made to manage her small bowel obstruction conservatively. A nasogastric tube was placed for decompression, and she was kept NPO. Somatastatin was administrated. After several days, she began to again have flatus and eventually bowel function returned. She was tolerating a regular diet at time of discharge without any discomfort, and having normal bowel movements. She received TPN during the time she was kept NPO, and morphine was used for pain control. . #) Adenocarcinoma, Stage IV: Patient underwent her 6th cycle of irinotecan on [**2176-10-18**] while hospitalized, and tolerated it overall very well. Outpatient follow up with oncology was arranged. . #) Hypertension: Patient was noted to have widely flucuating blood pressures, depending on whether she was in pain or had intravenous fluids running. Many of her home medications were decreased in dose, and she was changed from atenolol to metoprolol as atenolol is more renally cleared. She was discharged on nifedipime 30 mg daily; metoprolol was held due to persistently low blood pressure. . #) Hypothyroidism: Continued home dose levothryoxine. . #) Hypercholesterolemia: Patient relates she was not currently on any treatment at this time. This will need to be re-addressed as an outpatient. . #) Hyperglycemia: Patient had elevated blood sugars in setting of likely infection as well as steroids used for respiratory distress and chemotherapy. As her steroids were tapered, her blood sugars trended downward closer to the normal range. She has testing supplies for blood sugar monitoring at home, and was instructed, and expressed understanding, to monitor her blood sugars closely after discharge and follow up with her primary care physician. . #) Anemia: Patient's baseline HCT was 30-32, and she was noted to have worsening of her chronic anemia while hospitalized. This was felt to be in part due to chemotherapy effect, as well as dilutional in nature. - Continued iron supplementation while taking POs. - Patient received red blood cell transfusions for her anemia while hospitalized. . #) Code status: Full Code. Many discussions took place with patient and her family regarding her code status, which was initially DNR/DNI. Patient and daughter very clear that she does not want to be intubated for a long period of time; however, if it was felt there was a reversible cause patient would want intubation. She remained full code during her admission. . #) Disposition: At time of discharge, patient was tolerating a regular diet with full return of bowel function. She was cleared by physical therapy for a safe return to her home, and was ambulating without difficulty. Her family was present and supportive regaring her return home. VNA services were set up for post-discharge assistance. She had follow up appointments with both oncology and pulmonology in place within 1-2 weeks of discharge. Medications on Admission: nifedipine 90mg daily atenolol 50mg daily levothyroxine 0.025mg daily plaquenel 200mg [**Hospital1 **] prednisone 10mg daily ferrous sulfate 324mg daily revatio 40mg tid--> clarified with outpatient pulmonologist Discharge Medications: 1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily): Note change in dosing, previous dose was 90 mg. Disp:*30 Tablet Sustained Release(s)* Refills:*2* 4. Revatio 20 mg Tablet Sig: Two (2) Tablet PO tid (). 5. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed: For Nausea, as needed. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Prednisone 5 mg Tablet Sig: As directed. Tablet PO once a day: Please take 3 tablets (15mg) for 2 days, then resume dosing of 2 tablets (10mg) daily (pre-hospitalization dosing). Disp:*62 Tablet(s)* Refills:*2* 8. Finger sticks Please check your blood sugar with finger sticks 2-3 times daily, and bring in your blood sugars to your follow up appointments. Please call your primary care physician if your sugar is above 300. 9. Home oxygen Nasal cannula, 2L titrate to oxygen saturation 94-100%. 10. Medication changes Medications STOPPED: 1. Plaquenil 200mg daily--held until follow up appointment in pulmonary with Dr. [**Last Name (STitle) **]. 2. Atenolol 50 mg daily. Medications CHANGED: 1. Nifedipime: Changed to 30 mg daily (from 90mg). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: - Pneumonia Secondary Diagnoses: - Small bowel obstruction - Pulmonary Sarcoidosis - Sigmoid adenocarcinoma - Pulmonary hypertension - Anemia Discharge Condition: Stable. Ambulating safely, seen by physical therapy and determined to be safe for discharge. Breathing without difficulty, using nasal cannula oxygen. Discharge Instructions: You were admitted due to worsening shortness of breath, increasing need for oxygen, and fevers. A number of tests, including blood, sputum, urine, and imaging studies were completed. It was thought that you likely had an infection and that was the cause of your increased oxygen, and you were supported by intubation, on a ventilator, and monitored closely in the intensive care unit. You also were given your chemotherapy for your cancer while you were admitted. You developed a bowel obstruction, which resolved with medical management. . Please continue to take all medications as prescribed and follow up with your appointments as noted below. . Please contact your oncologist, primary care doctor, or go to the emergency room if you experience any fevers (greater than 100.4), chills, abdominal pain, chest pain, difficulty breathing, worsening nausea/vomiting/diarrhea, lack of bowel movement or ability to pass gas for more than one day, or other concerning symptoms. Followup Instructions: Please follow up at your scheduled appointments as noted below: 1. Oncology: - You have an appointment with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] on [**11-5**], at 9:00 am. Phone:[**0-0-**] - You have an appointment with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5556**], RN, on [**11-5**] at 9:30 am. Phone: [**Telephone/Fax (1) 22**] 2. Pulmonary: - You have an appointment at [**Hospital6 **] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2176-11-14**] at 10:40 am. The office has arranged the 'Ride' to pick you up prior to your appointment. The number for the office is ([**Telephone/Fax (1) 79185**].

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icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "33.24", "99.25", "96.71", "99.15" ]

icd9pcs

[ [ [] ] ]

13394, 13452

4631, 11670

374, 463

13657, 13810

2944, 4591

14834, 15518

2429, 2433

11933, 13371

13473, 13473

11696, 11910

13834, 14811

2448, 2925

13525, 13636

281, 336

491, 1656

4608, 4608

13492, 13504

1678, 2284

2300, 2413

27,780

163,984

34753

Discharge summary

report

Admission Date: [**2121-7-11**] Discharge Date: [**2121-7-17**] Date of Birth: [**2038-6-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: VT and ICD shocks Major Surgical or Invasive Procedure: Electrophysiology study and VT ablation History of Present Illness: The patient is an 83 year old man with CAD s/p CABG (23yrs ago), ischemic cardiomyopathy (EF 20-25%), hx of afib and SSS, and VT s/p ICD implantation presenting with syncope. The patient initially presented to [**Hospital6 33**] on [**2121-7-10**] after 2 episodes of syncope. He has had pre-syncopal events that have been associated with a wave of dizziness often lasting [**3-4**] seconds while standing. On the day of admission he was out to breakfast with a friend and while riding in the care he started to feel lightheaded and lost consciousness. Per report of the friend, the patient was unconscious for ~3-5 seconds. About [**5-10**] minutes later he had a second event. . On arrival to [**Hospital6 33**] he was afebrile with stable vital signs. His EKG was v-paced. His initial CK was 86, Tn <0.02, and serum potassium was 3.2. He was admitted to the telemetry floor. His ICD was interrogated and per report multiple episodes of Vt usually cycle lenghth of 2 different rates, multiple episodses at 150-160 bpm with termination by ATP and muliple episodes at 190 bpm terminted by ATP. VT episodes on the day of admission were sustained with rates of 197 bpm which failed to terminate with 3 cycles of ATP and required 26 j shock. On the morning of [**2121-7-11**] he was found by the nurses nauseated, diaphoretic and telemetry reported showed VT that was treated by his ICD. He was started on an amiodarone bolus then gtt (~930am) and transferred to [**Hospital1 18**]. En route to [**Hospital1 18**] he had 3 more events with subsequent ICD discharges and restoration of sinus rhythm. . 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. He denies dysuria but has 1/night nocturia. 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, ankle edema. Past Medical History: CAD s/p MI and CABG (c. [**2097**]) Ischemic cardiomyopathy (EF 20-25%) Atrial fibrillation Sick sinus syndrome s/p ppm (Guidant) VT s/p ICD placement (Guidant Prism VR) Hypertension Peptic ulcer disease sleep apnea (home CPAP = unknown cmH2O) Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. He was widowed last [**Month (only) 359**] after his wife died of complications of ovarian cancer. He lives at home, and a son from [**Name (NI) 622**] is staying with him, his daughter is a PA and a second daughter lives in the same town. Family History: There is no family history of premature coronary artery disease or sudden death Physical Exam: VS: T 98.7, BP 129/72, HR 60, RR 12, O2 95% on 4L Gen: WDWN 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 with non elevated JVP. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: bilateral pacer pockets. No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. faint bibasilar crackles Abd: no surgical scars. Obese, soft, NTND, No HSM or tenderness. No abdominal bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Neuro: Mental status - CN II-XII Motor: moving all 4 extremities [**Last Name (un) **]: light touch intact to fac/hands/feet Pertinent Results: [**2121-7-11**] 02:20PM WBC-8.9 RBC-4.20* HGB-14.1 HCT-41.4 MCV-99* MCH-33.7* MCHC-34.1 RDW-14.0 [**2121-7-11**] 02:20PM PLT COUNT-182 [**2121-7-11**] 02:20PM PT-18.0* PTT-29.7 INR(PT)-1.6* [**2121-7-11**] 02:20PM GLUCOSE-125* UREA N-26* CREAT-1.5* SODIUM-139 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14 CXR - There is substantial enlargement of the cardiac silhouette in a patient with multiple clips and midline sternal sutures from CABG. The defibrillator leads are seen extending to the general region of the right atrium and apex of the right ventricle. No definite pleural effusion, vascular congestion, or acute pneumonia, though the area behind the heart cannot be properly evaluated for possible atelectasis or consolidation. Brief Hospital Course: 83 year old man with history of CAD s/p CABG, ischemic cardiomyopathy (EF 20%), paroxysmal atrial fibrillation (on amiodarone and coumadin), s/p ICD implantation and pacemaker, presenting with syncope, found to have multiple episodes of prolonged VT. Now s/p VT ablation on [**7-14**] showing inducible ventricular tachycardia on right side. . # Rhythm: The patient has a known history of PAF and VT. He presented to an outside hospital with episodes of VT with syncope and ICD discharges. Interrogation of ICD showed multiple episodes of ventricular tachycardia CL 310 msec (all of which had a warm up phase - automatic or triggered), some requiring ATP and requiring ICD discharge. Home dose of digoxin was discontinued on admission as it likely contributed to NSVT. Amiodarone was discontinued as the patient's ICD continued to discharde despite amiodarone bolus and drip. He was instead started on a lidocaine drip. As his telemetry remained without any further events other than occasional short runs of NSVT, his lidocaine drip was discontinued. An EP study on [**2121-7-14**] showed VT most inducible on R side near pacer wire; likely due to wires or old scar. Ventricular ablation was stopped prematurely secondary to fluoroscopy failure. Following the ventricular ablation the patient had occasional PVCs, and afib and was restarted on amiodarone for rhythm control. Following the EP study, amiodarone was increased to 200mg daily to maintain NSR and prevent atrial fibrillation. The patient was transitioned to warfarin on a heparin bridge with a goal INR [**2-2**], currently 1.9. . # Hematoma: The patient developed a large ecchymosis after sheath was pulled on right groin site, with extension to right scrotum and laterally to right hip. Following sheath removal pressure was held for 30 minutes. Pt continues to have good pulses with no bruit; hematoma has spread superficially but is not indurated. Hematocrit remained stable. . # Hypotension: Pt developed hypotension with SBPs in 70s following the VT ablation. This was presumed to be due to dehydration and not a bleed from the right groin catheter site as hematocrit was stable and the groin ecchymosis was superficial. It was not determined to be due to tamponade as no clinical signs or symptoms (no JVD, crisp heart sounds, pulsus 6, not tachycardic, good UO) were present. Pt's blood pressure improved with fluids and oral intake. . # CAD/Ischemia: The pt has known disease and risk factors but there was no evidence of active ischemia on this admission. The patient was not on aspirin due to a history of PUD but he was continued on atorvastatin, carvedilol and losartan. . # CHF: Pt was clinically euvolemic and sans evidence of decompensation on physical exam throughout this admission. He was continued on his home doses of carvedilol 6.25 [**Hospital1 **] and losartan 25mg QD. His lasix was continued at 20 mg QAM and the evening lasix was discontinued. His home spironolactone 25mg daily was continued. . # Sleep apnea: Patient did well on home CPAP machine. . # Hypothyroidism: TSH was checked and was within normal limits. The patient was continued on home dose levothyroxine. . # Anxiety/Depression: The patient was continued on home dose paroxetine (confirmed). The patient also reported long-term use of librium (confirmed by pharmacy) for anxiety, which was continued. Medications on Admission: Paxil 10 mg daily Fosamax 70mg qweek Cozaar 25 mg daily Tricor 48 mg daily Synthroid 100 mcg daily Mag-oxide 400 mg tid Aldactone 25 mg daily Bentyl 10 mg TID Zantac 150 mg [**Hospital1 **] Coreg 6.25 mg [**Hospital1 **] Amiodarone 200 mg daily Lipitor 80 mg qhs Librium 5 mg TID Coumadin 2.5 qTWThSaSu, 1.25 mg MoFr Lasix 20 mg qAM, 10 mg qPM Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Librium 5 mg Capsule Sig: One (1) Capsule PO three times a day. 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*2* 7. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day. 9. Bentyl 10 mg Capsule Sig: One (1) Capsule PO four times a day. 10. Warfarin 2 mg Tablet Sig: 1-2 Tablets PO at bedtime: Please take two tablets tonight ([**2121-7-17**]) and tomorrow [**Doctor Last Name **] the nurse at Dr.[**Last Name (STitle) 79629**] clinic will tell you how many tablets to take. Disp:*50 Tablet(s)* Refills:*2* 11. Paxil 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Uroxatral 10 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 14. Aldactone 25 mg Tablet Sig: [**1-1**] Tablet PO once a day. 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Primary: Ventricular tachycardia s/p ICD placement and ablation . Secondary: Paroxysmal atrial fibrillation CAD s/p MI and CABG (c. [**2097**]) Ischemic cardiomyopathy (EF 20-25%) Sick sinus syndrome s/p pacemaker Hypertension Sleep apnea (home CPAP = unknown cmH2O) Hypothyroidism Peptic ulcer disease Discharge Condition: Stable Discharge Instructions: You presented with syncope and ventricular arrhythmia. You have undergone electrophysiology investigation of your heart. You have been treated for ventricular arrythmia. . Please note the following changes to your medications: Amiodarone was increased to 300 mg daily Furosemide PM dose was discontinued; you will take 20 mg in AM only Warfarin was increased to 4 mg every night; your dose will be adjusted by [**Doctor Last Name **] at Dr.[**Last Name (STitle) 79629**] office. Please continue all other medications as prescribed. . Please be sure to make it to all of your follow-up appointments. Please get your INR checked on [**7-18**] at 1:30pm at Dr. [**Last Name (STitle) 79630**] office. Your nurse [**Doctor Last Name **] will tell you what coumadin dose to take tomorrow. . If you develop any recurrent chest pain, shortness of breath, weakness, loss of consciousness of any other general worsening of condition, please call your PCP or come directly to the ED. Followup Instructions: Primary Care Physician: [**Name10 (NameIs) **] Grape MD: Phone: [**Telephone/Fax (1) 79631**]. [**7-24**] at 4:45pm. INR checked at his office on [**7-18**] . Cardiology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23651**] MD: ([**Telephone/Fax (1) 64863**]. Date/Time: [**7-31**] at 2pm.

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icd9cm

[ [ [] ] ]

[ "37.34" ]

icd9pcs

[ [ [] ] ]

10174, 10233

5069, 8443

332, 374

10580, 10589

4291, 5046

11611, 11922

3191, 3272

8837, 10151

10254, 10559

8469, 8814

10613, 10812

3287, 4272

10841, 11588

275, 294

402, 2542

2564, 2810

2826, 3175

21,668

197,645

22720+57385

Discharge summary

report+addendum

Admission Date: [**2179-1-28**] Discharge Date: Date of Birth: [**2102-11-11**] Sex: M Service: VSU CHIEF COMPLAINT: Abdominal aortic aneurysm. HISTORY OF PRESENT ILLNESS: This is a patient who has been followed by Dr. [**Last Name (STitle) 1391**] with an abdominal aortic aneurysm presents for elective repair. PAST MEDICAL HISTORY: No known drug allergies. MEDICATIONS: 1. aspirin 2. Celebrex, which is discontinued. 3. Folic acid 200 mg daily 4. Glipizide 10 mg daily 5. Lisinopril 10 mg daily 6. Zocor 80 mg daily. MEDICAL HISTORY: The patient has known history of ischemic heart disease, stable angina, coronary artery bypass graft x3 in [**2167**]. The patient was evaluated by Dr. [**Last Name (STitle) **], his cardiologist on [**2179-1-26**] and was determined he would proceed with surgery. History of hypertension controlled. Type 2 diabetes on oral agents. History of osteoarthritis of the hips, status post bilateral hip replacements. The patient has history of smoking. He does admit to alcohol use like wine. PHYSICAL EXAMINATION: General appearance: This adult male intubated, distended abdomen. The patient is responsive to stimulation. Head, eyes, ears, nose and throat examination is unremarkable. Heart is regular rate and rhythm. No murmur. Lungs clear to auscultation. Abdomen is distended. Extremities: Pink, warm feet with Doppler DP and PT. HOSPITAL COURSE: The patient was admitted to the preoperative holding area. He underwent an open abdominal aortic repair with an aortobifemoral bypass graft. He was transferred to the Post Anesthesia Care Unit in stable condition. He did require blood intraoperatively. The patient in the Post Anesthesia Care Unit was noted to have postoperative hematocrit was 27, BUN 21, creatinine 0.9. INR 1.3, chest x-rays was no acute cardiopulmonary processes. The abdominal wall showed significant amount of serosanguineous oozing. The patient remained intubated in the Post Anesthesia Care Unit. About 8:30 PM it was noted the bowel protruding from the abdominal incision. The patient returned to the O.R. at 10 PM and underwent exploratory laparotomy, abdominal closure with retention sutures. The patient tolerated the procedure well and was transferred back to the Post Anesthesia Care Unit in stable condition on Neo at 0.7 mg's per kg per minute. Postoperative hematocrit on return was 29.5, BUN 20, creatinine 0.9. The patient remained in the Post Anesthesia Care Unit overnight. The patient had an epidural catheter placed intraoperatively for analgesic control. The patient was then transferred to the SICU for continued monitoring. On postoperative day 1 there were no overnight events. The patient remained on Neo drip for systolic hypotension. The patient remained intubated. The patient was placed on Piptaz secondary to wound dehiscence. Postoperative day 2 the patient was weaned from his Neo and extubated. Hematocrit was 30.2. BUN 18, creatinine 1.2. Liver function tests were obtained which were normal. Incision was clean, dry and intact. The patient had palpable pulses. Cardiac examination was unremarkable. The Piptaz was changed to Ancef. Postoperative day 3 the patient continued to do well. Vent weaning was continued. The patient remained NPO with a nasogastric tube. He requires a diuresis. There was some thrombocytopenia noted on his serial CBC's and the Heparin was held. Epidural catheter was discontinued on postoperative day 3. Postoperative day 4 the patient's hematocrit, echocardiogram done demonstrated left ventricle in flow pattern period of relaxation with a dilated left atrium and normal ventricle, left ventricular ejection fraction of 50 to 55%. Physical examination was unremarkable. A HIP panel was sent because of the thrombocytopenia. The patient was transfused and maintained hematocrit greater than 30. He was transferred to the SICU for continued monitored care. Postoperative day 5 he remained afebrile. Post transfusion crit was 25.1, BUN 18, creatinine 0.8. physical examination was unremarkable. He was begun on tea and toast after the nasogastric tube was discontinued. The patient was diuresed and maintained a negative balance of 1 liter. Postoperative day 6, the patient's T-max was 99.5 to 98.9. He had on respiratory exam, some mild diminished breath sounds with mild crackles. Abdomen was clean, dry and intact. He did have bowel sounds. He has not passed flatus. His edema continues to improve. He has a palpable dorsalis pedis. The day before they had anticipated starting p.o. but this was withheld. Kefzol was continued. The patient was ambulated to chair and he remained in the PICU. Postop day 5 the team member of the service was called to see the patient regarding left shoulder pain. The examination demonstrated point tenderness at the acromioclavicular and humeral joint. There was no warmth of the distal arm and hand showed 2 to 3+ edema. The patient was aware of increasing pain in the left shoulder after being manipulated by physical therapy. He had diminished adduction. An electrocardiogram was obtained which was without acute changes. A left shoulder x-rays was obtained which was negative for a fracture displacement. More inflammatory process. Physical therapy re- evaluated the patient, he will require rehabilitation prior to being discharged to home. Postoperative day 7, the patient's T-max was 100.6. ambulation was encouraged. Electrolytes were repleted. His diet remained tea and toast, continued ambulation and incentive spirometry were encouraged. Postoperative day 8, the patient's T-max was 100.4 to 98.4. His diet was advanced as tolerated. He was given low dose of Lasix for continued diuresis. Postoperative crit was 28.7, BUN 10, creatinine 0.5. Remaining hospital course was unremarkable. The patient will be discharged when medically stable, tolerating p.o.'s, ambulating. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg daily 2. Lisinopril 10 mg daily 3. Glipizide 10 mg daily 4. Fimostatin 80 mg daily 5. Protonix 40 mg daily 6. Metoprolol tartrate 50 mg twice a day DISCHARGE DIAGNOSIS: 1. Abdominal aortic aneurysm status post open abdominal aortic repair with aortobifemoral graft on [**2179-2-2**]. 2. Abdominal incisional wound dehiscence status post abdominal exploration with abdominal closure with retention sutures on [**2179-2-2**] 3. Postoperative blood loss anemia, transfused. 4. Postoperative volume overload diuresed. 5. Postoperative atelectasis improved. 6. Type 2 diabetes mellitus controlled. 7. Hypertension. 8. Postoperative hypotension requiring vasopressor support, resolved. POSTOPERATIVE INSTRUCTIONS: The patient should follow-up with Dr. [**Last Name (STitle) 1391**] in 2 weeks time. Skin clips to remain in place until seen in follow-up. He may shower but no tub baths. He may ambulate essential distances. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2179-2-4**] 13:32:59 T: [**2179-2-4**] 14:41:25 Job#: [**Job Number 58831**] Name: [**Known lastname 1012**],[**Known firstname 63**] Unit No: [**Numeric Identifier 11110**] Admission Date: [**2179-1-28**] Discharge Date: [**2179-2-8**] Date of Birth: [**2102-11-11**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 231**] Addendum: patient remained in hospital awaiting bed for rehab. D/c [**2179-2-8**] stable. Discharge Disposition: Extended Care Facility: [**Hospital3 **] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2179-2-8**]

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icd9cm

[ [ [] ] ]

[ "99.04", "39.25", "38.93", "54.61", "99.07", "38.44" ]

icd9pcs

[ [ [] ] ]

7634, 7833

5906, 6079

6100, 7611

1423, 5883

1084, 1405

139, 167

196, 338

361, 1061

27,485

121,620

31239

Discharge summary

report

Admission Date: [**2108-7-4**] Discharge Date: [**2108-7-5**] Date of Birth: [**2052-2-4**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Penicillins Attending:[**First Name3 (LF) 2485**] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 56 yo F with recent diagnosis of Sarcoidosis ([**Month (only) 216**] [**2106**])on steroids admitted with c/o UGI bleed. She had an EGD today at [**Hospital1 **] for low HCT obtained on monday; HCT 32 @ PCP x1wk ago, was 23.8 today in ED. . She denies any hematochezia, melena or hematemesis; describes her stools as brownish yellow. She reports chronic daily use of Advil in the past(4mo ago), however reports taking 2 pills twice a week in the last couple of months. Reports vague abd pains x 1wk upon awakening, however relieved with food. Also denies CP, SOB, N/V/D, lightheadedness or dizzinies. Actually denies any accompanying symptoms prior to EGD, however did c/o being more tired & weak a few days PTA. Denies fevers, chills, just rhinorrhea. Does report wt.loss ~15lbs since diagnosis of Sarcoidosis [**5-/2107**], however wt has been stable for the last 2 months. . ED COURSE: VS T 98.8F BP 170/P HR 80 RR 16. Rectal exam with guaiac neg stools. Lopressor 5mg IV x 3 & Atenolol 50mg PO x 1, BP remained elevated ranging 150- 210/70-110's. 1 unit PRBC initiated in the ED. EKG in ED: NSR, nml axis, no ST elevation or TWI noted. Past Medical History: - Sarcoidosis (diagnosed by lung biopsy [**5-/2107**]) - Vaginal herpes Social History: Social Hx - Lives with husband - Uses a cane to ambulate because of weakness - Denies tobacco use currently (quit 15yrs ago); EtoH use [**5-18**] glasses of wine daily, until diagnosis of sarcoid; rarely uses EtoH now. No illicit drug use - Works as manager at a restaurant. Family History: Family hx - Mum: HTN, CVA, MI died age 77 - Father: Gastric CA with mets to liver, died age 62 Physical Exam: VS: T 99.4 BP 156/99 HR 67 RR 19 O2sats 100% on 2l NC Gen: Pleasant lady, in NAD HEENT: Oropharynx cl; PEERL with pupils ~5 Heart: RRR, no m/g/r Lungs: CTA bilaterally, no rhonchi or wheezing Abdomen: Soft, +bs, nttp Ext: warm to touch, cachectic with muscle wasting Skin: No rashes or lesions noted Neuro: no focal deficits noted, generalized weakness Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2108-7-4**] 04:05PM 8.0* 23.8* [**2108-7-4**] 03:10PM 9.9 2.31* 7.7* 22.7* 98 33.3* 33.9 22.3* 353 [**2108-7-5**] 04:46AM 11.7* 3.90 12.9 36.0 92 33.1* 35.9* 19.7* 318 . CXR [**2107-7-5**] No acute cardiopulmonary process . EGD (at [**Hospital1 **]) [**2108-7-4**]: - 2cm very deep cratered ulcer with white base but a possible vessel seen, small amount of oozing; fibrotic margins - 5cc of epinephrine injected around the ulcer - 7 Endoclips applied with almost complete seal of the ulcer, there's minimal ooozing from the clips but there is no obvious bleeding from the ulcer. Brief Hospital Course: A/P: 56 yo F with Sarcoidosis, chronic steriod use & recent NSAID use admitted with UGIB, s/p EGD [**2108-7-4**], for observation overnight. . # UGIB: Probably [**1-13**] NSAID use in combination with chronic steroid use. HCT 23.8 in the ED. s/p EGD [**2108-7-4**] with intervention, where oozing ulcer was clipped, however no bleeding vessel. She denied any associated symptoms of hematochezia, melena, lightheadness, dizziness, abd pain during hospitalizaion. Recieved 2U PRBC over night, HCT increased from 23.3 to 36. Restarted pt on home medications on day of discharge as BP was elevated & GI did not plan any interventions for pt. . # Hypertension: Although family hx, on no meds prior to diagnosis of Sarcoid & initiation of prednisone. SBP 150-180's on arrival to the floor. She received 2 doses of Hydralazine 10mg IV for elevated BP; Initiated home BP regimen on day of discharge. . # Sarciodosis: Diagnosed [**2107-7-12**]; on multiple medications including steroids; restarted home regimen on day of discharge. . CODE STATUS: Full . Medications on Admission: - Prednisone 50mg total daily - Mepron 1500mg - Fexofenadine 180mg - Amitriptyline 30mg qhs - Alprazolam 0.5mg PRN - Valtrex 500mg - Combipatch 50/140 change 2x weekly - Prilosec q day - B complex + c q daily - Atenolol 75 mg total q day - Plaquenil 300mg daily Discharge Medications: No new medications; Pt was instructed to continue home medications Discharge Disposition: Home Discharge Diagnosis: Primary: - Upper GI bleed secondary to duodenal bulb ulcer Secondary: - Sarcoidosis - Hypertension Discharge Condition: Stable, hematocrit, blood pressure stable. Discharge Instructions: You were admitted to the intensive care unit at [**Hospital1 18**] for upper GI bleed. Your hematocrit was found to be 22.7. Your stool, however, was negative for blood. You received 2 units of red blood cells and your hematocrit responded well and remained stable on subsequent checks (hematocrit 36 on discharge). Gastroenterology saw you here and, given your recent intervention (with Dr. [**Last Name (STitle) 17466**] and stability of your hematocrit after transfusion, you will be discharged with close follow up with your primary care doctor, GI doctor, rheumatologist and endocrinologist. Please be sure to follow up at your primary care doctor's office tomorrow morning for repeat labs. Please also be sure to avoid medications such as ibuprofen, naproxen, aspirin. I have discussed your case with Dr. [**Last Name (STitle) **] and you should decrease your prednisone to 15mg twice daily and continue your imuran and plaquenil. Please discuss with your rheumatologist at your upcoming appointment the continued tapering of your prednisone. Be sure to continue mepron while taking steroids. . You may resume your medications as you were taking prior to your admission, EXCEPT, please note that you should decrease your prednisone dose to 15mg twice daily. You should continue to have you calcium monitored closely (as it has been elevated) in this setting, beginning tomorrow at Dr.[**Name (NI) 73713**] office. Followup Instructions: Please follow up with your primary care doctor, Dr. [**Last Name (STitle) **], on Monday, [**7-9**]. You will hear from Dr.[**Name (NI) 73713**] office regarding time of your appointment on Monday. In the meantime, you will need to have labs drawn tomorrow at Dr.[**Name (NI) 73713**] office in order to follow up your hematocrit. . Please also follow up with your gastroenterologist, Dr. [**Last Name (STitle) 17466**], [**Telephone/Fax (1) 17468**] on [**8-6**] at 10am. Depending on your follow up hematocrits, Dr. [**Last Name (STitle) **] may recommend sooner follow and can help you to arrange for this. . Please follow up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 73714**] as previously scheduled and note that you should decrease your prednisone dose to 15mg twice daily.

[ "285.1", "V58.65", "E935.9", "135", "532.00" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

4551, 4557

3099, 4147

307, 313

4700, 4745

2379, 3076

6222, 7022

1893, 1990

4460, 4528

4578, 4679

4173, 4437

4769, 6199

2005, 2360

253, 269

341, 1488

1510, 1584

1600, 1877

28,721

144,718

48488

Discharge summary

report

Admission Date: [**2164-9-27**] Discharge Date: [**2164-10-11**] Date of Birth: [**2096-6-9**] Sex: F Service: MEDICINE Allergies: Latex / Oxaliplatin / Iodine; Iodine Containing / Fluconazole / Ace Inhibitors Attending:[**First Name3 (LF) 5141**] Chief Complaint: Hypotension, GI bleed Major Surgical or Invasive Procedure: Central Line placement and removal (internal jugular line) PICC line placement History of Present Illness: Ms. [**Known lastname 69629**] is a 68-year-old woman with a history of stage IV metastatic colon cancer complicated by an enterocutaneous fistula and extensive spread of carcinoma into the osotomy bag who presents with acute on chronic bleeding into her ostomy. She is well known to this ICU team. . She was recently hospitalized at [**Hospital1 18**] from [**9-11**] - [**2164-9-20**] after presenting similarly with bleeding from her enterocutaneous fistula. Patient had been on ASA and lovenox as outpatient, was given protamine and 4U pRBCs. She was discharged off aspirin and lovenox due to the risk of bleeding. The patient's last admission was also complicated by a multi-organism bacteremia (Enterococcus and E. Coli; CoNS felt to be contaminant) and her PICC was changed, but placed in the same spot due to difficult with access. She has been taking vancomycin and ceftriaxone at rehab (day [**8-25**]; vanco was to be held today due to high trough). Today, she had recurrence of bright red blood (approx 200cc) in her ostomy bag yesterday afternoon. She is asymptomatic. On arrival to the ED, initial VS were: 97.9 102 90/56 16 100% ra. On arrival to the ED, she triggered for hypotension initially, but was mentating well and asymptomatic. Her SBP dropped down to 70s in the ED. Her ostomy had some maroon colored liquid, but she had brown stool on probing the ostomy. She received 4 L of crystaloid, 1 unit of uncrossed PRBC and was started on levofed for her hypotension. Due to concern re: sepsis physiology, she also received vancomycin and zosyn. Surgery was consulted in the ED. They openned her ostomy and infused surgicel to stop generallized oozing that is felt to be source of bleeding. For IV access, she has a right-sided PICC, which flushed but dose not draw per ED, and a left IJ was placed in ED. Of note, her Hct is slightly lower than her Hct on discharge, but her coags are elevated with a PTT of 150. She has been getting heparin SC TID at rehab. In the ED, she confirmed that she was full code. VS prior to transfer were: 88/40, 120 15 100% 2L. . Review of systems: (+) Per HPI (-) Denies fever, chills, body aches. Denies headaches, sinus pressure, sore throat. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, lightheadeness/dizziness or weakness. Denies nausea, vomiting, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Metastatic colon ca (known mets to lungs) - Right colectomy with ileo-colic anastamosis - Depression - Pulmonary Embolism - lovenox d/c'ed in past r/t high risk of recurrent bleeding. - Recurrent SBO - SVC syndrome - ? DM, patient historically denies Oncological history (per outpatient oncology note): Metastatic colon cancer to the lung and pancreaticmass in addition to a large fungating enterocutaneous fistula. The patient was originally diagnosed in [**2156-3-12**] with a T3, N0, M0 ulcerating adenocarcinoma of the ascending colon. In [**2157-9-12**], she developed metastatic disease in the porta hepatitis. She is status post multiple systemic chemotherapies, most recent regimen included 33 cycles of infusional 5-FU and leucovorin, and most recently she has been started on single [**Doctor Last Name 360**] panitumumab, she received her first dose on [**2164-6-1**]. The patient has received oxaliplatin, Xeloda, cetuximab, irinotecan, and erlotinib. The patient developed angioedema secondary to erlotinib. She has also had a reaction to oxaliplatin in the past. Lastly, the patient had intolerance of cetuximab and irinotecan due to allergic reaction to cetuximab. The patient has KRAS wild type disease. She is not currently a candidate for chemotherapy per recent d/c summary. Social History: Husband died of multiple myeloma in [**9-20**]. She is Spanish speaking from [**Country 5976**]. Lives in extended care facility, [**Location (un) 582**] in [**Location (un) 583**], MA. 3 sons. On disability but worked in housekeeping at [**Hospital3 1810**]. No alcohol, tobacco or illicit drugs at any time. Has 3 sons, [**Name (NI) **] who lives in [**Last Name (LF) 1727**], [**Name (NI) **] who lives in [**Location 86**] and [**Doctor Last Name **] who lives in [**State 38104**]. Family History: father w/ prostate ca; grandma w/ liver ca Physical Exam: Vitals: T 98.6, HR 111, BP 109/64, RR17, SpO2 98% 3L NC General: Sleepy but easily arousable, oriented x3, no acute distress HEENT: NCAT, PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD, LIJ in place. Lungs: dullness and decreased breath sounds bilat, rales bilat. no wheezes, ronchi CV: rapid rate, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: left colostomy in place with fungating mass protruding, no red blood in bag and modertate amount of brown fecal material in ostomy, normal active bowel sounds, abdomen soft, non-tender, non-distended, no rebound tenderness or guarding. Back: 12 cm area of erythema c/w fungal rash on upper left back. Ext: cool extremities, 2+ pulses DP and left radial pulses, no clubbing, cyanosis or edema Pertinent Results: [**2164-9-27**] 02:02AM GLUCOSE-97 LACTATE-1.2 NA+-135 K+-4.3 CL--112 TCO2-20* [**2164-9-27**] 02:04AM WBC-16.6* RBC-2.98* HGB-8.7* HCT-26.4* MCV-89 MCH-29.3 MCHC-33.0 RDW-17.0* [**2164-9-27**] 02:04AM NEUTS-81.5* LYMPHS-11.9* MONOS-3.6 EOS-2.4 BASOS-0.6 [**2164-9-27**] 02:04AM GLUCOSE-100 UREA N-18 CREAT-1.6* SODIUM-137 POTASSIUM-4.6 CHLORIDE-112* TOTAL CO2-17* ANION GAP-13 [**2164-9-27**] 02:04AM ALT(SGPT)-7 AST(SGOT)-13 ALK PHOS-85 TOT BILI-0.2 [**2164-9-27**] 05:36AM ALBUMIN-1.4* CALCIUM-6.4* PHOSPHATE-3.1 MAGNESIUM-1.2* [**2164-9-27**] CXR 1. New left internal jugular approach venous catheter with tip in mid SVC. No evidence of pneumothorax. 2. New small bilateral effusions. 3. Stable right lower lobe pulmonary nodule compatible with known metastatic colon cancer. 4. Right PICC is slightly more proximal, a finding sometimes seen with thrombus formation; recommend clinical correlation for patency. ECG: ST 117 rightward axis and nl intrevals, low voltageno ST changes. TWF stable from previous EKG [**2164-9-18**] TTE: [**2164-9-28**] The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mild pulmonary hypertension CXR [**2164-9-28**]- FINDINGS: In comparison with study of [**9-27**], the central catheters remain in place. There is diffuse haziness of both hemithoraces consistent with substantial layering pleural effusions. This obscures the appearance ofthe underlying pulmonary metastasis at the right base. No definite vascular congestion or acute focal pneumonia. RENAL U/S [**2164-9-29**]- FINDINGS: Evaluation is limited due to patient's body habitus and presence of a large ostomy bag. The right kidney measures 10.1 cm. The left kidney measures 9.8 cm. There is no hydronephrosis. Further evaluation for masses or stones is very limited, however, none were seen. IMPRESSION: No evidence of hydronephrosis. CXR [**2164-9-30**]- There are lower lung volumes. Large bilateral pleural effusions associated with adjacent atelectasis have worsened. Cardiac silhouette is obscured by the pleural effusions. Right PICC remains in place. CXR [**2164-10-2**]- The PICC line is identified within the proximal basilic vein on the right side. There is a duplex brachial and basilic vein noted on the right side. Normal flow and compression identified in this and indeed surrounding the PICC line. The right cephalic vein, axillary vein, subclavian and right internal jugular vein are all patent and demonstrates normal flow and compressibility. IMPRESSION: No evidence for RIGHT UPPER EXTREMITY DVT Brief Hospital Course: Ms. [**Known lastname 69629**] is a 68-year-old woman with a history of stage IV metastatic colon cancer complicated by an enterocutaneous fistula and extensive spread of carcinoma into the osotomy bag who presents from a rehab center with with acute on chronic bleeding into her ostomy and hypotension. # Acute GI bleed with coagulopathy: Patient with intermittent brisk bleeding into ostomy bag in the setting of cutaneous extension of carcinoma. Seen by surgery who recommended surgicel and said no role for surgical intervention. Initial PTT/INR elevated, thought some effect from prophylactic heparin SC patient was getting at [**Hospital1 1501**]. 25mg IV Protamine given one time. Pt received 1 unit PRBC in the ED for Hct 26.4. Pt was started on empiric PPI. Another 2 units PRBC were given on [**9-28**] for decrease in Hct and concerns for presisting bleeding in context of hypotension. Pt also had evidence of coagulopathy with elevated INR. Pt did not respond to PO Vitamin K so one dose of IV vit K given and INR came down. INR remained elevated during hospitalization, and patient was not administered during admission due to this. Bleeding resolved on its own and pt had no further bleeding for several days prior to discharge. . # Hypotension: Thought most likely secondary to acute GI bleeding as above. However, septic etiology was also in question. She was most recently being treated with Vanco/Ceftriaxone at her [**Hospital1 1501**] for pan-sensitive Entercoccal & E. Coli bacteremia (still getting course of therapy when admitted). Vanco trough was high at [**Hospital1 1501**] before admit but patient was given a dose of Vancomycin in the ED. ID added Metronidazole as well for anaerobic coverage. Antibiotics were switched to Vanco/Cefepime with Vanco held for high trough (was 50.6 on [**9-28**] AM draw). Patient was still orthostatic after fluid so albumin infusion was given along with 2 units PRBC as noted above and urine output picked up. Briefly, patient was given stress dose steroids for random cortisol of 12.4. ID stated that antibiotics course could be stopped after doses given on [**10-2**], however, patient had evidence of UTI at that time, and cefepime was continued. PICC line was left in place from previous admission, which was the patient's only source of access. . # Altered mental status: there was concern for patient having waxing and [**Doctor Last Name 688**] mental status after she left the ICU. There was concern for infectious etiology, for which patient was at the time being treated with cefepime for UTI. Goals of care discussion was had with patient, and she revealed that she would like to be DNR/DNI, with focus on comfort measures. She wished that her family would visit, because she thought as if she was dying. Patient was determined to be competent at the time of this discussion. Further tests to determine the patient's altered mental status were not pursued. Pt's mental status improved during her hospital course likely [**2-14**] family visits from her children and grandchildren. . # Right arm swelling: patient was noted to have and erythematous right upper extremity after leaving the ICU. Ultrasound was performed revealing no evidence of DVT. Area around PICC insertion was slightly erythematous, but since this was the patient's only IV access, the line was not pulled. . # Metastatic Colon Cancer: Pt not felt to be candidate for further chemotherapy. Pain was controled with fentanyl, morphine IR & MS contin. Ostomy nurse saw after ICU arrival and gave [**Month/Day (2) **] care recs. Pt started back on diet [**9-28**] when became clear she was not briskly bleeding from GI tract. There was likely some element of poor GI absorption in nutrition status and contributing to coagulopathy. Patient stopped eating for many days after leaving the unit due to being weak and having no desire for food. Goals of care discussions were had at that time, and patient revealed that she would prefer to be DNR/DNI, with focus on comfort measures. This was communicated w/ her family and per discussion w/ son [**Name (NI) **] who is her [**Hospital 79534**] transfer to [**Name (NI) 582**] in [**Name (NI) 583**], where the pt had lived for several years was thought to be the best option for this pt. . # Acute Kidney injury: Cr up to 1.6 from baseline of 0.7 in the setting of GI bleed and hypotension. Thought to be pre-renal initially although question of interstitial injury from vancomycin. Vancomycin was held while in ICU and troughs were followed but never became sub-threrapeutic before floor transfer. Vancomycin was discontinued after transfer from ICU per ID recommendations, with remaining supratherapeutic levels. Cr drifted up to 2.0 and then stayed at 2.0 until pt left ICU. There was no hydronephrosis on renal u/s. Patient was given fluids after leaving the ICU, for which her kidney function slowly recovered. . # Hypoxia/Pleural Effusions: Patient had a history of lung nodule and bilateral effusions in the past. On most recent CXR patient with recurrence of effusions. ECHO on [**9-28**] done for concern over cardiac systolic decompensation with volume overload. Showed normal global and regional biventricular systolic function. Mild pulmonary hypertension that had not previously been present. Pt was given IV lasix on [**9-30**] as mentioned above. She did not require further diuretic administration. . Medications on Admission: Morphine SR (MS Contin) 100 mg PO Q12H Ondansetron 8 mg IV Q8H:PRN nausea Acetaminophen 325-650 mg PO/NG Q6H:PRN fever/pain Opium Tincture 15 DROP PO/NG Q 12H CefePIME 1 g IV Q24H Pantoprazole 40 mg IV Q24H Ferrous Gluconate 325 mg PO TID Prochlorperazine 10 mg PO Q6H:PRN nausea Lorazepam 0.5 mg PO/NG TID Psyllium Wafer 1 WAF PO TID Megestrol Acetate 40 mg PO QID Rifaximin 200 mg PO/NG TID MetRONIDAZOLE (FLagyl) 500 mg PO/NG Q8H Miconazole 2% Cream 1 Appl TP [**Hospital1 **] Duration: 14 Days Apply to rash on back. Sodium Bicarbonate 650 mg PO/NG TID Mirtazapine 15 mg PO/NG HS Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN apply to folds and groin as needed Morphine Sulfate 4-6 mg IV Q4H:PRN pain Discharge Medications: 1. Mirtazapine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 2. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Hospital1 **]: Two (2) mL Injection Q8H (every 8 hours) as needed for nausea. 3. Morphine 100 mg Tablet Sustained Release [**Hospital1 **]: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 4. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every six (6) hours as needed for fever or pain. 5. Pantroprazole 40 mg IV [**Hospital1 **]: One (1) once a day. 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1) Tablet PO three times a day. 7. Prochlorperazine Maleate 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six (6) hours as needed for nausea. 8. Lorazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a day. 9. Morphine sulfate 4-6 mg IV [**Hospital1 **]: One (1) every four (4) hours as needed for pain. 10. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) application Topical twice a day. 11. Megace Oral 400 mg/10 mL (40 mg/mL) Suspension [**Hospital1 **]: One (1) PO twice a day. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: Primary Diagnoses: Gastrointestinal bleed Acute Renal Failure urinary tract infection Secondary Diagnoses: Metastatic Colon Cancer Anxiety Depression Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: Ms. [**Known lastname 69629**]: You were admitted to [**Hospital1 18**] with a gastrointestinal bleed into your ostomy and evidence of damage to your kidneys as well as a urinary tract infection. You received fluids and some blood products and improved. Your gastrointestinal bleed slowly resolved and your kidney function improved. During this admission you also completed your course of antibiotics from a gastrointestinal infection from a prior hospitalization. The following changes were made to your medications: -- STOP Cefepime 1 g intravenously every 24 hours: you completed the course of this antibiotic this hospitalization -- STOP Flagyl 500 mg by mouth every eight hours: you completed the course of this antibiotic this admission -- STOP Miconazole 2% Cream, one application to the skin: you completed your 14-day course during this hospitalization Followup Instructions: No follow-up Completed by:[**2164-10-14**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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26,043

100,395

47345

Discharge summary

report

Admission Date: [**2164-10-7**] Discharge Date: [**2164-11-15**] Date of Birth: [**2107-3-17**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 57 year old woman with a history of viral myocarditis at age 11 as well as a history of multiple abdominal surgeries including a Billroth II procedure, partial vagotomy and partial gastrectomy in [**2153**]. She had a Roux-en-Y gastrojejunostomy for poor gastric emptying in [**2156**]. In [**2160**] she had transverse colon volvulus and had a hemicolectomy with an ileosigmoid anastomosis. In [**2161**] she had a procedure for lysis of intra-abdominal adhesions and was admitted to the Cardiac Medicine Service on [**10-7**] with chest pain. The patient also presented with eight days of nausea, vomiting and weakness as well as decreased p.o. intake. On electrocardiogram at the time of admission she had marked ST elevations of 5 cm in V3 through V6. She was taken to the Cardiac Catheterization Laboratory on [**10-7**] which revealed angiographically normal coronary arteries. Her left ventriculogram showed an ejection fraction of 35% of unknown origin although the patient has a history of viral myocarditis at age 11. The patient had multiple echocardiograms during her admission which showed an ejection fraction of around 20 to 22% with severe global hypokinesis and a normal left ventricular size, also 3+ tricuspid regurgitation. After this, the patient continued to have nausea, vomiting and developed abdominal pain. Then she began to have peritoneal signs as well as coffee ground emesis. She had a computerized tomography scan of the abdomen which showed free air as well as free fluid in the abdominal cavity. The patient was taken to Surgery on [**10-9**]. At that time they noted a perforation of her previous jejunojejunostomy secondary to an adhesive obstruction. Procedure performed was a small bowel resection with reanastomosis of various parts of the small bowel as well as adhesiolysis. During the procedure, there were some small bowel contents filled into the intra-abdominal cavity and a Swan-Ganz catheter was placed. Postoperatively the patient had a long course in the Surgery Intensive Care Unit of approximately one month prior to being transferred to the Medicine Intensive Care Unit on [**2164-11-9**]. The Surgery Intensive Care Unit course was notable for worsening cardiomyopathy as well as a large fluid requirement. Then the patient began to develop ascites, bilateral pleural effusions as well as congestive heart failure. She was diuresed. They performed thoracentesis of both the left and right pleural space, both which were sterile without evidence of infection. The patient completed a course of Ampicillin, Ceftriaxone and Flagyl after the operation. The patient also has been followed throughout her course by Infectious Disease as well as Cardiology. The patient had several courses of pneumonia. She first developed a pneumonia with Senna Trepomonas. On [**10-18**], her sputum culture revealed 2+ Senna Trepomonas which was Levofloxacin sensitive as well as 2+ yeast. She was treated for two weeks with Levofloxacin. After that she was extubated, however, ended up being reintubated three days later because of increasing secretions. They did more sputum cultures on [**10-22**] and then she grew out Senna Trepomonas as well as Methicillin-resistant Staphylococcus aureus. She was treated for two weeks with a two week course of Vancomycin. The patient also began to have some diarrhea. They did multiple Clostridium difficile samplings. On [**10-23**], her Clostridium difficile toxin was positive and she was treated with a course of Flagyl. The patient was again extubated after she seemed to be improving at the end of [**Month (only) **]. However, after several days she again began to fail and had to be reintubated on [**11-8**]. At that time she was transferred to the Medicine Intensive Care Unit Service. PAST MEDICAL HISTORY: 1. Multiple abdominal surgeries as in history of present illness. 2. Migraines. 3. Agoraphobia. 4. Panic disorder. 5. Sinusitis, status post surgery. 6. Cardiomyopathy with an ejection fraction of 22%. 7. Migraines. 8. Hypothyroidism. 9. Peptic ulcer disease. 10. Hypertension. 11. Viral myocarditis at age 11. 12. Phototoxicity from Gentamicin. MEDICATIONS ON ADMISSION: 1. Toprol XL 25 mg q. day 2. Prozac 3. Klonopin 4. Levoxyl 5. Prilosec 6. Prempro 7. Compazine 8. Seroquel 9. Fioricet ALLERGIES: The patient is allergic to Sulfa and gentamicin. SOCIAL HISTORY: She is a clinical psychologist and has a history of eating disorders as well as possible abuse of psychotropic medications. PHYSICAL EXAMINATION: Physical examination on [**2164-10-8**], at the time of admission revealed the patient was afebrile, pulse was 85, her blood pressure was 117/62, she was sating 96% on room air. Generally, she is cachectic. Neck had a jugulovenous pressure of 6. Chest was clear to auscultation bilaterally. Cardiovascular: She had a normal S1 and S2, regular rate and rhythm. No murmurs, rubs or gallops. Abdomen: She has decreased bowel sounds, however, she was soft, nondistended with mild left lower quadrant tenderness. No rigidity or guarding. Extremities: She had no edema and 2+ pulses bilaterally. LABORATORY DATA: Labs at the time of admission included a white count of 21.9, hematocrit 49.6, platelets 567. Chem-7 Sodium was 129, potassium 3.1, chloride 85, bicarbonate 19, BUN 52, creatinine 4.1 and glucose 111. Calcium was 6.5, magnesium 1.3, CK 509, trended down to 350. Her chest x-ray was negative. Electrocardiogram showed sinus with a rate of 100, left axis deviation, ST elevations inferiorly as well as V3 through V6 of up to [**Street Address(2) 32524**] depression V1 through V2. Right side leads were negative. Echocardiogram showed an ejection fraction of 25%, severe global hypokinesis, decreased left ventricular function and 1+ mitral regurgitation. HOSPITAL COURSE: [**Hospital Unit Name 196**] and Surgical Intensive Care Unit course as above. The patient was transferred to Medicine Intensive Care Unit on [**11-9**]. At the time of transfer to our service the patient was afebrile. She had a pulse of 79, blood pressure 100/56 sating 100% on a ventilator set with pressure support of 18 and positive end-expiratory pressure of 5, FIO2 40%. Arterial blood gases at that time on those settings was 7.49, 3.8, 156, 30. Her labs at the time of transfer to us were white count 17.4 which was trending down from 22.5. Her hematocrit was 29.3, platelets 350, sodium 134, potassium 4.3, chloride 99, bicarbonate 27, BUN 38, creatinine 0.8, glucose 128, calcium 8.5, phosphorus 3.0 and magnesium 2.2. Her micro-data summarized for hospital course, basically all her blood cultures were negative. She had cultures done [**10-7**] times two, [**10-17**] times three, [**10-18**] times two, [**10-20**] times two and [**11-8**] times three. Her sputum cultures as in history of present illness on [**10-18**] grew Senna Trepomonas sensitive to Levofloxacin and yeast. [**10-21**] was normal oropharyngeal Flora, [**10-22**] was Senna Trepomonas Methicillin-resistant Staphylococcus aureus, [**11-4**] Senna Trepomonas Methicillin-resistant Staphylococcus aureus, [**11-8**] she had 2+ gram negative rods and 1+ gram positive cocci. Urine cultures had evidence of yeast and her stool was positive for Clostridium difficile on [**10-23**], negative for Clostridium difficile times five on all other testings. Pleural fluid samples on [**10-19**] had polys no organisms, on [**11-3**] had neither polys nor organisms. The patient was transferred to us with her main issue being failure to wean from ventilator as well as question of how to best manage her congestive heart failure and cardiomyopathy. She also at that time was reported to have increased white count and glucose as well as a history of anxiety and benzodiazepine addiction. Medications on transfer included intravenous Lasix prn, Lopressor, Captopril, subcutaneous Heparin, Fioricet, Prozac, Levoxyl, Klonopin, Haldol, TUMS, magnesium oxide, iron, Prevacid and after transfer to our service we titrated up her Captopril, we added Aldactone and we also added Digoxin. Throughout her six days on our service her heart failure remained very well compensated with no evidence of pulmonary congestion or lower extremity edema. We tried to wean down her pressure support over the first several days, however, the patient was not able to successfully be weaned. On [**11-12**], the patient had a tracheostomy placed at the bedside without any complications. She continued to receive her tube feeds. She had some slightly liquid stools, therefore we changed her tube feeds to a tube feed with more fiber. Physical therapy and occupational therapy interviewed the patient. It was decided that after the tracheostomy the patient would need time to let that heal so it was decided to just continue the tube feeds and let her have a swallow evaluation and otorhinolaryngology evaluation after discharge to a rehabilitation facility. After tracheostomy was placed, we checked mechanics, her NIF was 10, her vital capacity was 750, title volume 400 and her RISB was 42.5. She received some Ultram from the tracheostomy pain. We weaned off her Haldol. The patient remains stable and plan to change her Lopressor and Captopril to a q. day medication. DISCHARGE STATUS: Discharge to rehabilitation with tracheostomy and nasogastric tube for tube feedings. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Toprol XL 25 mg per gastrostomy tube q. day 2. Vasotec 20 mg q. day 3. Aldactone 25 mg q. day 4. Lasix 40 mg q. day 5. Digoxin 0.125 mg q. day 6. Prozac 60 mg q. day 7. TUMS 2 tablets b.i.d. 8. Magnesium oxide 400 mg b.i.d. 9. Prevacid 30 mg q. day 10. Heparin 5000 units subcutaneously b.i.d. 11. Iron elixir 325 mg t.i.d. 12. Klonopin 1 mg q. 6 hours prn 13. Levoxyl 150 mcg q. day 14. Fioricet prn pain 15. Tube feeds with Ultracal at 55 cc/hr 16. Tylenol 650 mg prn DISCHARGE DIAGNOSIS: 1. Small bowel resection on reanastomosis for small bowel perforation 2. Cardiomyopathy with ejection fraction of 22% 3. Panic disorder and agoraphobia 4. Hypertension 5. Hypothyroidism 6. Peptic ulcer disease 7. Hypertension 8. Congestive heart failure 9. Migraine DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-761 Dictated By:[**Last Name (NamePattern1) 1203**] MEDQUIST36 D: [**2164-11-14**] 16:23 T: [**2164-11-14**] 16:54 JOB#: [**Job Number **]

[ "560.81", "482.83", "425.4", "263.9", "511.9", "008.45", "789.5", "569.83", "428.0" ]

icd9cm

[ [ [] ] ]

[ "45.62", "31.1", "88.55", "96.6", "45.91", "34.91", "96.72", "88.53", "37.22" ]

icd9pcs

[ [ [] ] ]

9627, 9636

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4752, 6031

161, 3983

4006, 4370

4604, 4729

69,206

188,764

39934

Discharge summary

report

Admission Date: [**2188-11-28**] Discharge Date: [**2188-12-2**] Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 2569**] Chief Complaint: Left intraventricular hemorrhage. Major Surgical or Invasive Procedure: None. History of Present Illness: [**Age over 90 **] year old male presents with left intraventricular hemorrhage. On [**2188-10-30**], he had a fall secondary to high grade AV block with syncope; CT head was negative at that time and the patient was admitted for pacemaker placement. He was discharged to [**Hospital 38**] rehab, where he has been since [**2188-11-4**]. Today, staff at [**Location (un) 38**] noted altered mental status and a right visual field cut. CT head showed the left IVH, and he was transferred to [**Hospital1 18**] for further management. Past Medical History: High grade AV block s/p pacemaker HTN Hyperlipidemia Dementia CAD S/p cardiac stent [**2180**] Rheumatoid arthritis Osteoarthritis in the neck Prostate cancer C. Diff S/p multiple surgeries Social History: Retired machinist. Has son and daughter. Girlfriend is health care proxy: [**Name (NI) 41028**] [**Name (NI) **] [**Telephone/Fax (1) 87808**]. Family History: NC Physical Exam: 98.6 109 130/76 18 98% 2L RA Gen: Lying in bed, NAD HEENT: There is a bruise under the left eye. Mucous membranes moist. Neck: In C-collar CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: +BS soft, nontender Ext: LUE erthematous and warm. Neurologic examination: Mental status: General: Asleep, awakens easily to voice. Orientation: Oriented to person, place = "[**Location (un) **]," date = "[**Month (only) 404**]." Attention: Unable to to say days of the week backwards Executive Function: Intermittently follows simple axial and appendicular commands, easily confused and perseverative. Does not follow complex commands. Memory: Recall 0/3 at 5 minutes. Speech/Language: Names objects incorrectly (pen = "[**Location (un) 6151**]"). Praxis: When asked to demonstrate how to brush teeth, the patient brushes his C-collar. Calculations: Unable to calculate 9 quarters = $2.25 Cranial Nerves: II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Right homonymous hemianopia. III, IV, VI: Extraocular movements intact without nystagmus. V1-3: Sensation intact V1-V3. VII: Facial movement symmetric. VIII: Hearing grossly intact. IX & X: Palate elevation symmetric. Uvula is midline. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius full strength bilaterally. XII: Good bulk. No fasciculations. Tongue midline, movements intact. Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor. Unable to lift the L arm/shoulder - prior injury? Delt; C5 Bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7 Left 3 5 5 5 5 Right 5 5 5 5 5 IP: Quad: Hamst: Dorsiflex: [**Last Name (un) 938**]:Pl.flex Left 5 5 5 5 5 5 Right 5 5 5 5 5 5 Deep tendon Reflexes: Biceps: Tric: Brachial: Patellar: Achilles Toes: Right 1 1 1 1 0 UPGOING Left 1 1 1 1 0 DOWNGOING Sensation: Intact to light touch throughout. No extinction to double simultaneous stimulation. Coordination: RAMs normal. Reaches for finger without dysmetria, but frequently perseverates on touching his nose. Gait: Not tested Pertinent Results: [**2188-12-1**] 12:40PM BLOOD WBC-10.5 RBC-3.31* Hgb-10.7* Hct-32.7* MCV-99* MCH-32.3* MCHC-32.7 RDW-13.2 Plt Ct-361 [**2188-11-28**] 06:40PM BLOOD Neuts-77.7* Lymphs-15.7* Monos-4.2 Eos-1.8 Baso-0.6 [**2188-12-1**] 05:50AM BLOOD PT-14.2* PTT-34.5 INR(PT)-1.2* [**2188-12-1**] 12:40PM BLOOD Glucose-96 UreaN-9 Creat-0.8 Na-135 K-3.7 Cl-103 HCO3-20* AnGap-16 [**2188-11-30**] 06:00AM BLOOD ALT-13 AST-21 AlkPhos-55 TotBili-0.6 [**2188-12-1**] 05:50AM BLOOD Calcium-7.5* Phos-2.6* Mg-1.7 [**2188-11-29**] 01:09AM BLOOD %HbA1c-5.3 eAG-105 [**2188-11-29**] 01:09AM BLOOD Triglyc-69 HDL-36 CHOL/HD-2.6 LDLcalc-43 [**2188-11-28**] 06:48PM BLOOD Lactate-0.9 EKG Ventricular pacing. Underlying rhythm is difficult to determine due to baseline artifact but it is probably atrial fibrillation. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 111 0 174 376/465 0 -70 86 CT Head FINDINGS: There is large acute hemorrhage in the posterior left lateral ventricle, involving the atrium, occipital [**Doctor Last Name 534**], and left temporal [**Doctor Last Name 534**], without significant change in size as compared to the prior study. Small amount of intraventricular hemorrhage is also seen layering dependently along the posterior [**Doctor Last Name 534**] of the right lateral ventricle, without significant interval change. Slight increase in prominence of the right temporal [**Doctor Last Name 534**] may be positional; however, developing hydrocephalus is not excluded. The ventricles and sulci are prominent, consistent with age-related atrophy. There is no midline shift or evidence of acute large vascular territory infarct. No acute fracture is seen. The paranasal sinuses and the mastoid air cells are clear. IMPRESSION: Bilateral intraventricular hemorrhage, large in the posterior left lateral ventricle, as above, and small layering along the dependent portion of the posterior right lateral ventricle, size unchanged. Slight increase in prominence of the right temporal [**Doctor Last Name 534**] may be positional, although developing hydrocephalus is not excluded. CT Head [**2188-11-28**] FINDINGS: There is large acute hemorrhage in the posterior left lateral ventricle, involving the atrium, occipital [**Doctor Last Name 534**], and left temporal [**Doctor Last Name 534**], without significant change in size as compared to the prior study. Small amount of intraventricular hemorrhage is also seen layering dependently along the posterior [**Doctor Last Name 534**] of the right lateral ventricle, without significant interval change. Slight increase in prominence of the right temporal [**Doctor Last Name 534**] may be positional; however, developing hydrocephalus is not excluded. The ventricles and sulci are prominent, consistent with age-related atrophy. There is no midline shift or evidence of acute large vascular territory infarct. No acute fracture is seen. The paranasal sinuses and the mastoid air cells are clear. IMPRESSION: Bilateral intraventricular hemorrhage, large in the posterior left lateral ventricle, as above, and small layering along the dependent portion of the posterior right lateral ventricle, size unchanged. Slight increase in prominence of the right temporal [**Doctor Last Name 534**] may be positional, although developing hydrocephalus is not excluded. CT Head [**2188-11-30**] Stable appearance of predominantly left lateral intraventricular hemorrhage with involvement of the occipital [**Doctor Last Name 534**] and atrium of the right lateral ventricle. Brief Hospital Course: Patient is a [**Age over 90 **]yo RHM with hx of HTN, hypercholesterolemia who had a syncope last month from a have high grade block. He underwent pacemaker placement and was at acute rehab ([**Location (un) 38**]) when he was found to have acute change in mental status and possible visual field cut. He was initially brought to an OSH where he did have elevated BP including SBP up to 200mmHg and was found to have intraventricular hemorrhage on head CT hence transferred here for further care. Due to the pacemaker, he was not able to undergo MRI evaluation to assess for possible underlying pathology leading to the intraventricular hemorrhage. Its primarily L posterior [**Doctor Last Name 534**] and appears to be primary intraventricular hemorrhage. He was intially admitted to the ICU but remained stable including repeat imaging hence transferred out to the floor. 1. Primary intraventricular hemorrhage - Unclear etiology but possibly hypertensive. Ordered for repeat MRI in 6 weeks prior to his follow-up appointment with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] as outpatient. Goal SBP < 160. 2. LUE cellulitis - Found to have edematous and erythematous L arm. He had an ultrasound which showed no evidence of DVTs. Given the erythema, cellulitis was concerning hence IV vancomycin was started then switched to Clindamycin which is to be continued for 5 more days for total 7 days. 3. C.diff - patient continued to have foul-smelling, loose stools with leukocytosis. C.diff was tested and was positive hence he was started PO vancomycin to be continued for 2 weeks. Patient is discharged back to acute rehab and will need inpatient physical and occupational therapy. He has follow-up appts and head CT scheduled/ordered. Medications on Admission: ferrous sulfate 325 mg (65 mg Iron) Tab Oral 1 Tablet(s) Once Daily finasteride 5 mg Tab Oral 1 Tablet(s) Once Daily folic acid 1 mg Tab Oral 1 Tablet(s) Once Daily hydroxychloroquine 200 mg Tab Oral 1 Tablet(s) Once Daily lactobacillus acidophilus Tab Oral 1 Tablet(s) Twice Daily omeprazole 20 mg Cap, Delayed Release Oral 1 Capsule, Delayed Release(E.C.)(s) Once Daily potassium chloride SR 10 mEq Tab Oral 1 Tablet Sustained Release(s) Three times daily simvastatin 40 mg Tab Oral 1 Tablet(s) Once Daily acetaminophen 650 mg Tab Oral 1 Tablet(s) Every 6-8 hrs, as needed Bimatoprost 1 drop to each eye daily Oscal-D 2 tabs PO BID Lactinex (lactobacillus) 1 tab PO BID Cholestyramine (Questra) 1 tab Po BID Lovenox 40mg/0.4mL 1 tab SC qam Discharge Medications: 1. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for Pain. 6. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 7. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day). 10. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for C.diff for 2 weeks. 11. clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 5 days. 12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Primary Primary ntraventricular hemorrhage Secondary C.diff cellulitis of left arm Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Presently benefiting from assistance. Decreased ROM of L shoulder and weak L arm. Also, edematous L arm with some erythema but normal pulses. Discharge Instructions: You came to the hospital after having a bleed in your brain. You were found to be confused and initially went to an outside hospital where head CT revealed intraventricular hemorrhage and transferred here for further evaluation. Because you have a pacemaker, MRI evaluation was not possible. Initially you were admitted to the ICU but given stable exam and head CT (imaging), you were transferred to the floor. You were evaluated per occupational and physical therapists and you have been recommended to be discharged to acute rehab. Followup Instructions: You have been scheduled for follow-up with the neurologist. You are also scheduled to have repeat head CT prior to the appointment. Please get the head CT before coming to [**Hospital1 18**] to follow-up as scheduled below: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2189-1-12**] 1:00 [**Hospital Ward Name 23**] Building Floor 8 Please also follow-up with your PCP [**Name Initial (PRE) 176**] 2~3 weeks of discharge from rehab. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2188-12-2**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10816, 10961

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255, 262

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182, 217

290, 828

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850, 1041

1057, 1204

31,455

199,866

34467

Discharge summary

report

Admission Date: [**2128-7-13**] Discharge Date: [**2128-7-18**] Date of Birth: [**2051-5-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2128-7-14**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA) History of Present Illness: 77 y/o male with known CAD with recent increase in shortness of breath and fatigue. Stess echo notable for new septal wall ischemia. Subsequent cardiac cath showed left main and rca disease. Referred for surgical intervention. Past Medical History: Coronary Artery Disease, Hypertension, Hypercholesterolemia, Paroxysmal Atrial Fibrillation, Asthmatic bronchitis, right arm cellulitis [**2122**], left wrist fracture, s/p PPM placement [**2122**], s/p TKR Social History: Smoked pipe for 20 yrs. Quit 25 yrs ago. Approx. 2 ETOH drinks/day. Family History: NC Physical Exam: VS: 60 152/70 5'[**30**]" 200# Gen: NAD Skin: Recent abrasions bilat arms HEENT: PERRL, EOMI, anicteric Neck: Supple, FROM -JVD, -carotid bruit Chest: CTAB Heart: Irregular rhythm, -murmur Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -edema, mild bilat. varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**7-13**]: CNIS/Vein Mapping: 1. Patent greater saphenous veins bilaterally with the measurements as above. 2. Less than 40% stenosis of the internal carotid arteries bilaterally. [**7-13**] Chest CT: 1. No calcifications identified within the ascending aorta, up to the level of the aortic arch. 2. Right lung nodules measuring up to 5 mm as described above. Followup chest CT within one year is recommended. [**7-14**] Echo: 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 miold anterior and inferior wall hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 45=50 %). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-3**]+) mitral regurgitation is seen at a SBP 100mm Hg. When the SBP was increased to 150 mm Hg with phelylephrine and Trendelenburg position the MR increased to moderate (2+).. There is no spontaneous echo contrast or thrombus in the left atrial appendage. POSTBYPASS: No aortic dissection noted. Mitral regurgitation remains mild to moderate. EF 45-50%. Remaining exam unchanged. All findings discussed with surgeons at the time of the exam. [**2128-7-17**] 07:20AM BLOOD WBC-9.6 RBC-3.51* Hgb-10.8* Hct-31.2* MCV-89 MCH-30.9 MCHC-34.8 RDW-13.0 Plt Ct-176 [**2128-7-18**] 07:25AM BLOOD PT-12.7 INR(PT)-1.1 [**2128-7-17**] 07:20AM BLOOD Glucose-102 UreaN-16 Creat-0.8 Na-130* K-4.0 Cl-94* HCO3-30 AnGap-10 [**2128-7-13**] 08:44PM BLOOD ALT-31 AST-24 LD(LDH)-200 AlkPhos-53 Amylase-29 TotBili-0.6 [**2128-7-13**] 08:44PM BLOOD Albumin-4.6 Calcium-9.6 Phos-2.8 Mg-2.0 [**Known lastname **],[**Known firstname **] [**Medical Record Number 79214**] M 77 [**2051-5-10**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2128-7-16**] 1:21 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2128-7-16**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79215**] Reason: s/p ct removal ? ptx [**Hospital 93**] MEDICAL CONDITION: 77 year old man with s/p cabg REASON FOR THIS EXAMINATION: s/p ct removal ? ptx Final Report HISTORY: Chest tube removal, to evaluate for pneumothorax. FINDINGS: In comparison with study of [**7-14**], all of the support-monitoring devices have been removed. No convincing evidence of pneumothorax. Right IJ sheath remains in place. Low lung volumes with probable atelectasis and pleural fluid at the left base. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: FRI [**2128-7-16**] 3:46 PM Brief Hospital Course: Mr. [**Known lastname 32142**] was admitted 1 day prior to surgery secondary to being on Coumadin and to undergo more pre-operative testing. He was brought to the operating room on [**7-14**] where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he appeared to be doing well and was transferred to the telemetry floor for further management. His pacer was interrogated by EP and his epicardial pacing wires were d/c'd. His chest tubes were d/c'd on POD 2 and the pt. progressed well. He was restarted on his coumadin and discharged to home on POD 4 in stable condition. Dr.[**Name (NI) 79216**] office was called on [**7-19**] for coumadin follow up. Medications on Admission: Verapamil 240mg qd, Lisinopril 20mg qd, Vytorin 10/80mg qd, Indapamide 1.25mg qd, Coumadin 5mg qd, Toprol XL 25mg qd, MVI, Hydrocodone 5/500mg prn, Alprazolam 0.5mg prn, Albuterol 2 puffs [**Hospital1 **], Azmacort 2 puffs [**Hospital1 **], Flunisolide nasal spray Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 MDI* Refills:*2* 7. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*1 MDI* Refills:*2* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). Disp:*90 Tablet(s)* Refills:*2* 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-7**] hours as needed. Disp:*50 Tablet(s)* Refills:*0* 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): for 5 days, then 400 daily for 1 week, then 200 mg daily until discontinued by cardiologist . Disp:*120 Tablet(s)* Refills:*2* 13. Vytorin [**9-/2100**] 10-80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Community VNA, Inc. Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 PMH: Hypertension, Hypercholesterolemia, Paroxysmal Atrial Fibrillation, Asthmatic bronchitis, right arm cellulitis [**2122**], left wrist fracture, s/p PPM placement [**2122**], s/p TKR Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 2912**] in [**1-4**] weeks Dr. [**Last Name (STitle) **] in [**12-3**] weeks Completed by:[**2128-7-19**]

[ "V58.61", "458.29", "401.9", "493.90", "413.9", "V43.65", "427.31", "414.01", "272.0", "V45.01" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.13", "89.45", "39.64", "36.15" ]

icd9pcs

[ [ [] ] ]

7264, 7314

4354, 5261

341, 441

7605, 7611

1367, 3715

8122, 8296

1028, 1032

5576, 7241

3755, 3785

7335, 7584

5287, 5553

7635, 8099

1047, 1348

282, 303

3817, 4331

469, 697

719, 927

943, 1012

10,791

179,165

17510

Discharge summary

report

Admission Date: [**2158-4-9**] Discharge Date: [**2158-4-11**] Date of Birth: [**2119-9-1**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 38-year-old male with a past medical history significant for bipolar disorder as well as a previous suicide attempt by carbon monoxide poisoning, who was started on lithium one month prior to admission, who took 90 tablets of sustained lithium on the day of admission. The patient stated he had been feeling quite depressed concerning his wife and was concerned that she had been unfaithful to him. The patient states he took the lithium at about 7 a.m. on the morning of admission and was found by his father around 3 p.m. At that time, he was lethargic but arousable. He was then taken to [**Hospital3 **] Hospital at 4 p.m. where his lithium level was 5 mEq per liter. The patient vomited times three. There were pill fragments noted. He was given 2 liters of normal saline, 1 liter of GoLYTELY by nasogastric tube, and was then transferred to [**Hospital1 346**]. The patient was seen by both Toxicology and Renal who decided that emergent dialysis would be safest option. PAST MEDICAL HISTORY: 1. Bipolar disorder. 2. Attention deficit disorder. 3. Suicide attempt times one in the past. 4. Carbon monoxide poisoning attempt in the past. MEDICATIONS ON ADMISSION: Lithium 300 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is a smoker. He lives with his father. FAMILY HISTORY: Depression in mother and father. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission to the Medical Intensive Care Unit revealed vital signs with a blood pressure of 105/48, heart rate was 89, oxygen saturation was 95%, respiratory rate was 18, and oral temperature was 98.1. Neurologic examination revealed alert and oriented times three. No sensory or motor deficits. Lethargic with 5/5 strength. No nystagmus. Deep tendon reflexes were 2+. Head, eyes, ears, nose, and throat examination revealed mucous membranes were moist. No jugular venous distention. Cardiovascular examination revealed tachycardic. Lungs were clear to auscultation bilaterally. The abdomen was benign. Extremity examination revealed no edema. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories revealed white blood cell count was 9, hematocrit was 40.7, and platelets were 265. Differential with 86% neutrophils, 4% bands, 6% lymphocytes. Sodium was 139, potassium was 3.9, chloride was 106, bicarbonate was 25, blood urea nitrogen was 20, creatinine was 1.3, and blood glucose was 82. Lithium level was 5.5. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed sinus tachycardia. HOSPITAL COURSE: This is a 38-year-old gentleman with acute lithium intoxication secondary to a suicide attempt. The patient was admitted for close observation, placed on telemetry, and lithium levels were checked every two to three hours. On presentation, the patient received emergent hemodialysis with a resultant lithium level of 1.2. On a follow-up lithium check, it had elevated to approximately 1.5. Due to concern of a fluid shift, the patient received hemodialysis for a second time. The dialysis courses were approximately six hours a piece. The patient was also continued on half normal saline of approximately 4 liters to increase urine output. Goal urine output was 2 cc/kg per hour. The patient was also continued on GoLYTELY. There was concern for diabetes insipidus due to lithium. Osmolalities were checked. First was in the 400s and the second was in the 500s; thus, this concern was put to rest. A urine toxicology screen was also sent which was negative. Due to the suicide attempt, the patient was put on a one-to-one sitter while an inpatient. Due to a concern of Haldol interactions, this was not used. Since the patient did well status post dialysis with lithium levels returning to a therapeutic range, and symptoms of confusion and gastrointestinal toxicity had resolved, the patient was transferred to the floor where he continued to be monitored for another 24 hours. The patient continued to improve symptomatically. His lithium level continued to decrease at 0.7. Thus, the patient was medically cleared for discharge to a psychiatric facility for treatment of his bipolar disorder, depression, and suicide attempt. MEDICATIONS ON DISCHARGE: The patient was discharged on only docusate 100 mg p.o. b.i.d. and Protonix 40 mg p.o. q.d. CONDITION AT DISCHARGE: Condition on discharge was stable and improved. DISCHARGE STATUS: Discharge status was to inpatient psychiatry facility. DISCHARGE DIAGNOSES: 1. Lithium overdose. 2. Suicide attempt. 3. Depression. 4. Bipolar disorder. [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**MD Number(1) 28963**] Dictated By:[**Name8 (MD) 8876**] MEDQUIST36 D: [**2158-4-11**] 13:05 T: [**2158-4-11**] 13:46 JOB#: [**Job Number 48874**]

[ "296.7", "E950.3", "969.8", "584.9", "314.00" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

1496, 2702

4656, 5009

4393, 4496

1353, 1417

2720, 4366

4511, 4635

158, 1155

1177, 1326

1434, 1478

58,948

112,578

5926+55710

Discharge summary

report+addendum

Admission Date: [**2159-8-30**] Discharge Date: [**2159-9-6**] Date of Birth: [**2078-5-19**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2777**] Chief Complaint: Lt groin pain Major Surgical or Invasive Procedure: [**8-31**]: OPERATIONS PERFORMED: Excision of left limb of aortofemoral bypass graft, and vein patch angioplasty of left superficial femoral artery at distal anastomosis with distal right greater saphenous vein. [**9-4**]: PROCEDURE: Debridement and delayed primary closure of left flank and left groin incision. History of Present Illness: 81M who presents w left groin pain for approx 24 hours. He is s/p aorto bifem in [**2148**]. In [**2152**] I and D of his left groin for infection and he underwent exploration of the left groin, detachment of left the limb from the common femoral artery, vein patch angioplasty of common femoral artery, excision of left limb, and reconstruction with interposition new graft segment for proximal left aortobifemoral graft to superficial femoral artery with rifampin impregnated 8 mm Dacron graft. He had a duplex at local hospital showing fluid around left limb of ABF graft approx 1 month ago. Now w the new left groin pain there is concern that the graft could be infected. He denies fevers/chills, rash, SOB, CP, abd pain, changes in bowel habits, N/V, or other complaints. Past Medical History: PMH: Hypercholesterolemia, PVD, hypothydroidism, BPH . PSH: appendectomy and hernia repair, aorto bifem ([**2148**]), [**2152**] - I and D of his left groin for infection w exploration of the left groin, detachment of left the limb from the common femoral artery, vein patch angioplasty of common femoral artery, excision of left limb, and reconstruction with interposition new graft segment for proximal left aortobifemoral graft to superficial femoral artery with rifampin impregnated 8 mm Dacron graft Social History: smokes 10 cigs/day for decades. Social drinker. Lives with wife at home Family History: n/c Physical Exam: PHYSICAL EXAM: VS: T 97.0, HR 75, BP 139/57, RR 19, 95%3L NC General: pleasant elderly man, NAD HEENT: PERRL, EOEMI, sclerae anicteric OP: MMM, no ulcers/lesions/thrush Neck: supple, no LAD, no thyromegaly Cardiovascular: RRR, normal S1, S2, no M/G/R Respiratory: CTA bilat w/o wheezes/rhonchi/rales Abdomen: surrounding area clean, dry, nonerythematous, minimally tender, not swollen Musculoskeletal: moving all extremities Ext: Warm and well perfused, no edema. L thigh wound closed, nonerythematous, slightlytender Lymph: no cervical, axillary, inguinal lymphadenopathy Skin: no rashes, no jaundice Neurological: aaox3 Psychiatric: non-anxious, normal affect Pertinent Results: [**2159-9-6**] 06:00AM BLOOD WBC-8.8 RBC-3.22* Hgb-10.0* Hct-29.6* MCV-92 MCH-31.1 MCHC-33.9 RDW-14.5 Plt Ct-270 [**2159-9-6**] 06:00AM BLOOD Plt Ct-270 [**2159-9-6**] 06:00AM BLOOD Glucose-108* UreaN-26* Creat-1.6* Na-139 K-3.8 Cl-110* HCO3-21* AnGap-12 [**2159-9-6**] 06:00AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.3 [**2159-9-6**] 06:00AM BLOOD Vanco-19.9 [**2159-8-30**] 09:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.018 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2159-8-31**] 11:45 am SWAB PERI GRAFT H ILIAC. GRAM STAIN (Final [**2159-8-31**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2159-9-2**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [**2159-8-30**] 9:30 am URINE Site: CLEAN CATCH URINE CULTURE (Final [**2159-8-31**]): <10,000 organisms/ml. [**2159-8-31**] 2:17 pm MRSA SCREEN Site: NARIS (NARE) MRSA SCREEN (Final [**2159-9-3**]): No MRSA isolated. [**2159-8-31**] 12:10 pm FOREIGN BODY LEFT FEMORAL GRAFT. WOUND CULTURE (Final [**2159-9-5**]): NO GROWTH. FINDINGS: New right PICC terminates within the mid to lower superior vena cava. Cardiomediastinal contours are within normal limits. Left retrocardiac opacity probably reflects atelectasis, but developing pneumonia should also be considered in the appropriate clinical setting. The study and the report were reviewed by the staff radiologist. US: Ultrasonography of the left upper extremity is negative for DVT but the entire cephalic vein is occluded around the PICC site ECHO: Conclusions The left atrium and right atrium are normal in cavity size. A patent foramen ovale is present. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (mobile) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are complex (>4mm) atheroma in the abdominal aorta. The aortic valve leaflets (3) are mildly thickened. The study is inadequate to exclude significant aortic valve stenosis. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild mitral regurgitation is seen. Brief Hospital Course: On admission: Pt did have elevated creatinine. He was hydrated before CTA. Was given PO mucomyst and IV Bicarb. Also Gentle hydration. On DC creatinine is stable. I CTA IMPRESSION: 1. Large 7.7 x 5.8 x 27.1-cm fluid collection surrounding the left aortofemoral graft with inferior components of higher attenuation that is most compatible with hematoma. In addition, on post-contrast images, some evidence of active extravasation. Overall, these findings have characteristics compatible with pseudoaneurysm. Superinfection cannot be excluded. Recommend clinical correlation. 2. 17 x 10-mm hypoattenuating lesion within the uncinate process of the pancreas incompletely characterized, could either represent pancreatic cystic neoplasm or side branch IPMN, with interval growth since [**1-9**]. Recommend MRCP on non- urgent basis for further evaluation. Mr. [**Known lastname **], [**Known firstname 1955**] was then admitted on [**8-30**] with Infected aortobifemoral artery bypass graft. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. Broad spectrum Antibiotics given. ID consult obtained. Pt to have 6 weeks ov Vancomycin, PO Cipro, PO Flagyl. He does have follow-up in [**Hospital **] clinic. He will probably need long term PO suppression therapy. It was decided that she would undergo a: O7/24. PERATIONS PERFORMED: Excision of left limb of aortofemoral bypass graft, and vein patch angioplasty of left superficial femoral artery at distal anastomosis with distal right greater saphenous vein. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. He was then transferred to the CVICU for further recovery. While in the CVICU he recieved monitered care. He had a VAC placd. JP bulbs to suction. Extubated POD # 2. Pt did have post op anemia secondary to blood loss. Transfused 2 units PRBC. On DC HCT is stable. He was transfered to the VICU for further care. He was delined. His diet was advanced. A PT consult was obtained. PICC line placed. Wound Vac taken down, it was then decided to primary close the wound. Pt pre-op'd. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. [**9-4**]: PROCEDURE: Debridement and delayed primary closure of left flank and left groin incision. He tolerated the proceure well without complications. He was then transfered to the PACU for further care. Once recovered from anesthesia. He was transfered to the VICU. for further care. [**Last Name (un) **] in the VICU, it was noticed that he had swelling in his LUE. An US revealed cephalic vein thrombois. His PICC was Dc'd. Another PICC was placed in his RUE. A CXR revealed tip in the SVC. Once stabl from the VICU setting, he was transfered to the Floor. On the floor, he remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged to a rehabilitation facility in stable condition. He has an appointmentwith ID in 5 weeks and Vascular in 2 weeks Medications on Admission: synthroid 0.15mg/daily flomax 0.4mg/daily simvastatin 20mg QD, fludrocortisone0.1mg/daily Discharge Medications: 1. PICC LINE Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 2. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 5 weeks: Follow trough and creatinine. 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 weeks. 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 5. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO four times a day: prn. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): DC when ambulatory. 10. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 weeks. 12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Outpatient Lab Work Please draw weekly LFT, CBC with Diff, Vanco trough, BUN and creatinine. Fax the results to [**Telephone/Fax (1) 432**]. Dr [**Last Name (STitle) 23383**] Office. Discharge Disposition: Extended Care Facility: [**Hospital 392**] Rehabilitation & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: Infected aortobifemoral artery bypass graft Hypercholesterolemia, PVD, hypothydroidism, BPH Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**3-13**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2159-9-20**] 4:10. This is in the [**Last Name (un) **] building. [**Doctor First Name **]. [**Location (un) 442**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2159-10-16**] 11:30. This is in the [**Last Name (un) **] building. [**Doctor First Name **]. Basement Completed by:[**2159-9-6**] Name: [**Known lastname **],[**Known firstname 133**] Unit No: [**Numeric Identifier 3982**] Admission Date: [**2159-8-30**] Discharge Date: [**2159-9-6**] Date of Birth: [**2078-5-19**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 726**] Addendum: pt arrived with increase in creatiine from his basline. Pt had to get a CTA to evaluate previous fluid collection from surgery. He was hydrated with bicarb and given PO mucomyst. On DC pt creatinine improved to baseline. ARF on chronic renal failure. 2.6 on arrival. On DC 1.4. Discharge Disposition: Extended Care Facility: [**Hospital 3983**] Rehabilitation & Nursing Center - [**Hospital1 3983**] [**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 730**] MD [**MD Number(2) 731**] Completed by:[**2159-10-11**]

[ "272.0", "584.9", "244.9", "442.3", "996.62", "997.2", "600.00", "440.20", "305.1", "285.1", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "86.22", "88.72", "39.56", "38.93", "39.49" ]

icd9pcs

[ [ [] ] ]

14691, 14951

5292, 5292

327, 645

10639, 10648

2803, 3589

13485, 14668

2099, 2105

8901, 10380

10523, 10618

8786, 8878

10672, 13052

13078, 13462

2135, 2784

274, 289

673, 1461

5307, 8760

3625, 5269

1483, 1993

2009, 2082

31,880

192,262

32449

Discharge summary

report

Admission Date: [**2123-2-18**] Discharge Date: [**2123-2-27**] Date of Birth: [**2055-5-31**] Sex: F Service: SURGERY Allergies: Vicodin Attending:[**First Name3 (LF) 6346**] Chief Complaint: Rectosigmoid colonic stricture, chronic partial large bowel obstruction Major Surgical or Invasive Procedure: Exploratory laparotomy, lysis of adhesions, splenic flexure takedown, left colectomy, colonic lavage, low anterior resection, re-resection of anastomosis, rigid sigmoidoscopy, [**Doctor Last Name 406**] drain placement, nasogastric tube; central venous access; transesophageal echocardiogram History of Present Illness: 67 year old female with spina bifida and spine scoliosis presented to the outpatient clinic where on workup she was found to have colonic stricture. She had an open cholecystectomy 3 years prior for complications of gallstones. Recent colonoscopy showed a stricture which was very tight but the pediatric scope could be passed across it. She was on multiple stool softeners and a bowel regimen. She was offered surgical resection and anastomosis. Past Medical History: PMH: Spina bifida, Seizure disorder, Gallstone, hypertension,Anxiety Osteoarthritis PSH: Left breast excision, ERCP/stent placement, Open CCY Social History: Denies current tobacco, smoked previously ? 1PPD for several years, quit several years ago, occasional etoh (unspecified), denies illicit drug use. Family History: Father deceased - MI at age 75, sister deceased [**3-2**] CAD at age 78 Physical Exam: Morning Rounds [**2123-2-17**] Tm: 99.2 Tc: 97.5 HR: 106 BP: 124/62 RR: 20 93% 2L Gen: Patient lying in bed in non-acute disteress, dysmorphic positioning secondary to spina bifida noted. Awake, with dopoff tube in place, CR: RRR, slightly Tachy. Res: No respiratory distress Abd: moderatly protruberant within limits for patient, soft, appropriately tender to palpation, no guarding, no masses. Ext: No clubbing, cyanosis, Edema, patient compliant with venogyne boots Pertinent Results: Labs On admission post operative [**2123-2-18**] 10:27PM HCT-21.7* [**2123-2-18**] 08:54PM POTASSIUM-3.8 [**2123-2-18**] 08:54PM ALBUMIN-2.7* MAGNESIUM-1.3* [**2123-2-18**] 08:54PM PHENYTOIN-2.1* [**2123-2-18**] 08:54PM HCT-25.3*# [**2123-2-18**] 07:27PM TYPE-[**Last Name (un) **] PH-7.33* INTUBATED-INTUBATED VENT-CONTROLLED [**2123-2-18**] 07:27PM GLUCOSE-63* LACTATE-3.0* NA+-137 K+-4.2 CL--105 TCO2-23 [**2123-2-18**] 07:27PM HGB-15.6 calcHCT-47 [**2123-2-18**] 07:27PM freeCa-1.34* [**2123-2-26**] Day prior to expiration: 05:05AM BLOOD WBC-10.9 RBC-3.67* Hgb-11.1* Hct-34.5* MCV-94 MCH-30.3 MCHC-32.3 RDW-15.8* Plt Ct-188 [**2123-2-27**] Morning of expiration: 04:51AM BLOOD WBC-13.8* RBC-3.48* Hgb-11.0* Hct-33.4* MCV-96 MCH-31.8 MCHC-33.1 RDW-15.8* Plt Ct-220 [**2123-2-27**] 12:28PM Prior to expiration: BLOOD WBC-9.3# RBC-3.86* Hgb-12.5 Hct-38.3 MCV-99* MCH-32.5* MCHC-32.8 RDW-16.8* Plt Ct-121* Imaging [**2123-2-27**] TT Echo The left atrium is normal in size. Overall left ventricular systolic function is normal (LVEF>55%). The left ventricle appears to be underfilled. The right ventricular cavity is probably mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. Trace aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is no pericardial effusion. [**2123-2-27**] CXR ET tube in standard placement. Nasogastric feeding tube passes into a distended stomach and out of view. Large area of new right perihilar consolidation could be pneumonia or pulmonary hemorrhage but in the presence of a mild degree of left perihilar opacification could be a markedly asymmetric pulmonary edema. Heart size normal. No pneumothorax. [**2123-2-21**] TEE The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-30**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2120-12-23**], the severity of mitral regurgitation and the estimated pulmonary artery systolic pressure are higher. The right ventricular cavity is now dilated with mild free wall hypokinesis. Global left ventricular systolic function remains [**2123-2-19**] EKG Normal sinus rhythm, rate 89. RSR' pattern with QRS duration of 82 milliseconds. Decreased precordial voltage in leads V4-V6 with flat T waves in leads II, III, aVF and V3-V6. Compared to the previous tracing of [**2123-2-19**] there is no diagnostic interim change. Brief Hospital Course: Patient present to [**Hospital1 **] [**2123-2-18**] for surgical repair colonic stricture. She was identified in the pre-operative area where her history, physical and consent was reviewed. She was given intravenous antibiotics, subcutaneous heparin and taken to the operating room in the appropriate fasion. Please see operative report for details. Of note, 3400 mL of crystalloid, albumin 250 mL was administered during the operation, the patient made 130 mL of urine output an there was an estimated blood [**Last Name (un) 940**] of 400 mL. The patient was initially extubated in the OR and transferred to the PACU. While in the PACU she required pressors post-operatively and was sent to the surgical intensive care unit for recovery for acute respiratory faluire and hypotension. Her hospital course in the SICU on day of transfer to the floor can be summarized by the following review of systems: Neurologic: Dilantin 100q8 for seixure prophylaxis, Morphine for pain on day of transfer to the floor [**2123-2-25**] she was following commands with intermittent confusion/delenrium. Cardiovascular: Diuresisng with lasix; goal of 1L negative, on metoproloed 25 [**Hospital1 **]. Pulmonary: Sating 90's on NC, on albuterl/Atrovent nebs and recieving chest PT GI: NGT in place with tubefeeds at goal on a bowel regimen. Consults: Speech and swallow recommended NPO until mental status improves. Renal: Lasix 20mg [**Hospital1 **] Hematoloty: HCT of 36.7%, Endocrine: RISS; ID: afebrile WBC decreasing, off antibiotics. Wound: midline Prophylaxis: SQH, Boots and proton pump inhibitor FID Full Code status requiring proxy consent. The patient was transferred to the floor the in the evening on [**2123-2-25**] and remained stable on [**2123-2-26**]. she was monitored on telemetery for tachycardia, her blood labs were monitored and electrolytes appropriately replaced. [**2123-2-27**] Patient was seen by the surgery team on am rounds and was in stable conditon. At approximately 10:10am the patient was coded for PEA arrest after an episode of emesis. She underwent prolonged CPR requiring femoral line and endotracheal tube placement. She appropriately recieved epinephrine, atropine, several liters of fluid for low BP and 2 unites of PRBCs. She was started on Norepinephrine and vasopressin for BP support and was tranferred to the MICU intubated on AC 100%/24x300/+10 settings. A TTE and CXR was performed and workup initiated. The patient's family was allowed to visit the patient at 1:15pm whereby [**Name8 (MD) **] MD informed them of the patient's grave prognosis. At 1:23pm her heart rate was seen to brady down and PEA arrest followed. CPR was immediately initiated. The patient remained unresponsive and CPR was stopped ending the code per the SICU Attending who pronounced the patient as deceased. The Family was again allowed to see the patient and elected to have a post mortum. All necesssary paperwork was completed and the patient belonging were taken home by the family. Medications on Admission: alprazolam .25prn, atenolol 50', protonix 40", dilantin XR 200", darvocet N-100 prn, Super B, MVI, Miralax Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Patient Expired Partial Large Bowel Obstruction Respiratory Failure Post operative congestive heart failure PEA Arrest, Cardiogenic shock Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: NA Completed by:[**2123-3-2**]

[ "518.5", "562.10", "428.0", "737.30", "458.29", "741.90", "997.1", "276.0", "785.51", "560.9", "427.5", "345.90" ]

icd9cm

[ [ [] ] ]

[ "96.04", "47.09", "45.75", "96.71", "96.6", "99.60", "89.64", "48.23", "89.68", "48.63" ]

icd9pcs

[ [ [] ] ]

8393, 8402

5196, 6087

339, 632

8583, 8592

2038, 5173

8643, 8675

1457, 1530

8366, 8370

8423, 8562

8234, 8343

8616, 8620

1545, 2019

6107, 8208

228, 301

660, 1109

1131, 1275

1291, 1441

16,717

112,700

30182

Discharge summary

report

Admission Date: [**2160-3-5**] Discharge Date: [**2160-3-12**] Date of Birth: [**2119-9-25**] Sex: M Service: MEDICINE Allergies: Haldol / Trazodone Attending:[**First Name3 (LF) 465**] Chief Complaint: Seizure in setting of 3 days N/V/D Major Surgical or Invasive Procedure: None History of Present Illness: 40 yo male with a history of depression and seizures presented [**2160-3-4**] to [**Hospital 5871**] Hospital ED with c/o nausea, vomiting, diarrhea, and headache x 3 days. In [**Name (NI) **], Pt experienced chest pain x 2 hours, felt shaky and chilled. He became agitated, then dazed, then had a witnessed grand-mal seizure approximately 2 minutes in duration. . History obtained from patient's wife. Patient's history is not reliable [**12-21**] mental status changes. Reports that sxs began on Sunday [**2160-3-2**] when he had profuse, watery, foul-smelling diarrhea, accompanied by nausea and vomiting. For the next two days, he was unable to take any POs, was having diarrhea 4x/day, and hydrating with only water and ice chips. Sick contacts include his 5-yr-old son who had similar symptoms that resolved spontaneously in [**1-20**] days. ROS significant for low-grade fever, shaking, chills, severe migraine. Denies unusual foods, undercooked foods, recent travel, abdominal pain. . Wife reports that Pt was very pale, shaky, and acting unusual since Monday [**2160-3-3**]; she stated that he was "out of it". She brought him to the [**Hospital 5871**] Hospital ED on Tuesday, [**2160-3-4**] for further evaluation. While in the [**Name (NI) **], Pt had a 2 min grandmal seizure. Pt has had one similar episode in the past, approximately 3 yrs ago. He reports that it was similarly preceded by a flu-like illness with nausea, diarrhea, migraine. Prior to the seizure, he experienced shaking/tremor/agitation, followed by loss of consciousness and convulsions. At the time, he was evaluated at [**Hospital1 498**] with CT, MRI, MRA, and EEG, all of which were normal. He was started on Dilantin, experienced myoclonus, and stopped the Dilantin after 9 mos of treatment. Since then, has had no seizure activity prior to this episode. Pt reports no alcohol or drug use. . ROS is significant for h/o multiple head traumas [**12-21**] work in construction business - none of which have required further evaluation. Wife also reports that Pt filled his Ambien prescription on [**2160-3-1**] (sixty - 10 mg tabs). On [**2160-3-4**] there were 20 tabs missing from the bottle. Pt reports that he does not remember taking the pills. He has no h/o drug overdose, and ususally takes 1-2 tabs (10-20 mg) at night. Other ROS include impaired memory (unable to recall events between Saturday, [**2160-3-1**] and awakening in the ED) and difficulty starting urine stream. . At [**Hospital 5871**] [**Hospital 12018**] Medical Center: Pt given Ativan 1 mg, Morphine 4 mg, Tylenol 975 mg, Ativan 1 mg prior to transfer to [**Hospital1 18**]. Head CT: negative, no bleed, no masses, no acute changes CXR: negative, no infiltrates, no PTX, no hemothorax, no masses, no effusion, no free air, no CHF, no cardiomegaly. LP: CSF protein 30, Glu 66, 1 WBC, 2 RBC - negative CK MB 2.5, CPK 201, [**Doctor First Name **] 44, lip 14 Alb 4.5, Tprot 7.2, alk phos 73, AST 18, ALT 15, Tbili 0.8, Dbili 0.1 Chem 7: 135/4.2/98/27/6/0.8/93 Ca 9.4 CBC: 7.6/14.5/40.3/357 Past Medical History: 1. Seizure - 1 prior episode in [**2156**]. Similar flu-like illness preceding. Similar pre-ictal shaking, chills, agitation. Grand-mal with loss of consciousness, post-ictal confusion. 2. Depression - dx 9 yrs ago. 1 prior suicide attempt in [**2152**] (slit wrists). Followed by psychiatrist, Dr. [**Last Name (STitle) **], at [**Hospital **] Health Center in [**Hospital1 1559**], MA. Sees Dr. [**Last Name (STitle) **] q 3-6 mos for 15 mins. 3. Migraines - controlled with Excedrin pm. 4. Hypercholesterolemia - untreated. Pt does not like to go to the doctor. 5. h/o kidney stones. . ALLERGIES: NKDA Social History: Pt lives with his wife and 2 children, 7 yr old Max, and 16 yr old [**Last Name (un) 61509**], in [**Location (un) 5871**], MA. He owns a construction business, but has been working less in past couple years, and spending more time home with the kids. He denies any history of tobacco, alcohol, or illicit drug use. Family History: FH: NC. No history of seizure disorder. Physical Exam: Physical Exam on admission [**2160-3-5**]: T 100.1 BP 116/60 HR 69 RR 20 02sat 99RA Gen: Thin male, tired-appearing, slightly confused, lying comfortably in bed, in NAD HEENT: NC/AT. EOMI. PERRLA. MM dry, OP clear Neck: supple, no LAD, no tenderness to palpation, no JVD Chest: CTAB, no wheezes, rales, rhonchi CV: RRR, nl S1 S2, no murmurs, rubs gallops Abd: soft, NT, ND, NABS. No peritoneal signs. No organomegaly. Ext: cold hands and feet, o/w well-perfused with 2+ DP, PT, radial and ulnar pulses. No cyanosis or clubbing. Neuro: Motor - generalized weakness, with strength 4/5 bilaterally upper and lower extremities Sensation - intact Reflexes - 2+ and symmetric, downgoing Babinski Finger-nose testing, Romberg, and gait WNL Mental status - Poor attention (Pt could only recite 2 of 12 mos of yr backwards, then started coutning). Difficulty maintaining task. Perseveration even with redirection. Poor recall (0 of 3 objects). Poor long-term memory (did not know street name or age of child). Visual/sensory misperceptions (calling ceiling lights [**Last Name (un) 3625**] DVDs, getting concerned about ceiling mildew and water leaking into room). Pertinent Results: At [**Hospital 5871**] [**Hospital 12018**] Medical Center: Pt given Ativan 1 mg, Morphine 4 mg, Tylenol 975 mg, Ativan 1 mg prior to transfer to [**Hospital1 18**]. Head CT: negative, no bleed, no masses, no acute changes CXR: negative, no infiltrates, no PTX, no hemothorax, no masses, no effusion, no free air, no CHF, no cardiomegaly. LP: CSF protein 30, Glu 66, 1 WBC, 2 RBC - negative CK MB 2.5, CPK 201, [**Doctor First Name **] 44, lip 14 Alb 4.5, Tprot 7.2, alk phos 73, AST 18, ALT 15, Tbili 0.8, Dbili 0.1 Chem 7: 135/4.2/98/27/6/0.8/93 Ca 9.4 CBC: 7.6/14.5/40.3/357. . EEG ABNORMALITY #1: Occasional bursts of generalized 3 Hz rhythmic spike and slow wave discharges, occurring in runs up to 3 seconds were noted in the waking state. During one episode, the patient appeared to stare off. ABNORMALITY #2: With photic stimulation, asymmetric arhythmic muscle jerks were noted, producing large amplitude movement artifact. It was difficult to determine whether any underlying discharges were seen within the movement artifact, although at 4 Hz photic stimulation, generalized spike and polyspike and slow waves were noted. BACKGROUND: A 9 Hz posterior predominant rhythm was noted in the waking state, which attenuated with eye opening. The normal anterior to posterior voltage gradient was seen. HYPERVENTILATION: Contraindicated due to patient's mental status. INTERMITTENT PHOTIC STIMULATION: As above. SLEEP: The patient progressed from the waking to drowsy state, but did not attain stage II sleep. CARDIAC MONITOR: A generally regular rhythm was noted with an average rate of 54 beats per minute. IMPRESSION: This is an abnormal EEG in the waking and drowsy states due to the bursts of 3 Hz generalized rhythmic spike and wave discharges and the arhythmic jerks with photic stimulation, with likely underlying spike and polyspike and wave discharges. The first abnormality suggests a primary generalized epilepsy. The muscle jerks with photic stimulation represent a photoconvulsive response, although the movement artifact obscured the background rhythm. A photoconvulsive response may be seen with primary generalized epilepsies. . [**2160-3-10**] 04:50AM BLOOD WBC-6.5 RBC-4.30* Hgb-13.6* Hct-38.0* MCV-89 MCH-31.7 MCHC-35.8* RDW-13.1 Plt Ct-348 [**2160-3-7**] 10:19PM BLOOD WBC-5.7 RBC-4.22* Hgb-13.7* Hct-37.6* MCV-89 MCH-32.4* MCHC-36.4* RDW-13.1 Plt Ct-270 [**2160-3-5**] 01:05AM BLOOD WBC-9.3 RBC-4.25* Hgb-13.7* Hct-39.0* MCV-92 MCH-32.2* MCHC-35.1* RDW-13.2 Plt Ct-336 [**2160-3-7**] 10:19PM BLOOD Neuts-73.6* Lymphs-19.4 Monos-6.1 Eos-0.5 Baso-0.4 [**2160-3-5**] 01:05AM BLOOD Neuts-84.9* Lymphs-9.5* Monos-5.0 Eos-0.2 Baso-0.4 [**2160-3-10**] 04:50AM BLOOD Plt Ct-348 [**2160-3-5**] 01:05AM BLOOD Plt Ct-336 [**2160-3-5**] 01:05AM BLOOD PT-12.5 PTT-28.9 INR(PT)-1.1 [**2160-3-10**] 04:50AM BLOOD Glucose-93 UreaN-8 Creat-0.5 Na-140 K-3.9 Cl-101 HCO3-31 AnGap-12 [**2160-3-5**] 01:05AM BLOOD Glucose-88 UreaN-6 Creat-0.7 Na-140 K-3.9 Cl-105 HCO3-23 AnGap-16 [**2160-3-10**] 04:50AM BLOOD ALT-23 AST-12 CK(CPK)-102 [**2160-3-9**] 05:00AM BLOOD CK(CPK)-175* [**2160-3-7**] 10:19PM BLOOD ALT-16 AST-16 CK(CPK)-426* AlkPhos-60 TotBili-0.5 [**2160-3-6**] 04:40AM BLOOD ALT-15 AST-13 LD(LDH)-133 AlkPhos-63 TotBili-0.3 [**2160-3-5**] 01:05AM BLOOD CK(CPK)-390* [**2160-3-5**] 01:05AM BLOOD cTropnT-<0.01 [**2160-3-5**] 01:05AM BLOOD CK-MB-4 [**2160-3-10**] 04:50AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.1 [**2160-3-6**] 04:40AM BLOOD Albumin-4.0 Calcium-9.0 Phos-2.2* Mg-2.1 [**2160-3-6**] 04:40AM BLOOD VitB12-257 Folate-8.5 [**2160-3-6**] 04:40AM BLOOD TSH-0.44 [**2160-3-5**] 01:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2160-3-6**] 02:53PM URINE bnzodzp-NEG barbitr-POS opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG. . RPR (-) Blood cultres (-)/NGTD at time of discharge Brief Hospital Course: This 40 year old white male preseted from outside hospital for work-up of grand-mal seizure in the setting of four days of mausea, vomiting, and diarrhea, who while hospitalized had significant worsening delerium and suspected drug overdose withdrawal. . 1. Seizure - Initial inquiry was to etiology of seizures: withdrawal vs organic disease, likely thought due to withdrawal presentation given negative LP and CT at outside hospital and with return to baseline after acute delirium state. Neurology followed the patient while in house. Patient's EEG showed abnormalities, as noted above, and patient was initiated on Keppra. As per neurology recommendations, patient will need an outpatient MRI for follow-up. . 2. Change in MS - Initially upon transfer, showed minimal signs of hallucinations and/or abnormal behavior, but on hospital day two, became acutely combative, hyperactive requiring restraint codes, haldol, and ativan, and eventually, transfer to the unit for hemodynamic monitoring and possible further work up. Patient had a dystonic-type reaction to the haldol and was treated with cogentin, ativan, and benadryl. By report, there was concern patient had overdosed on either ambien, fiorcet, or ativan, or all of the above. Patient's TSH, B12, RPR, and serum toxicologies were negative, while the urine toxicologies were positive for barbs. By hospital day number four, patient returned to what appeared to be his baseline with coherent thought processes and without agitation. . 3. Depression - Patient had a nine year history of depression with two suicidal attempts - one by "cutting" his wrists. By report, patient had previously been apathetic, had decreased interest in daily activities, and was eating much less. When lucent, patient admitted to a rough work year and to stressors with his wife, but denied suicidal ideations or homicidal ideations. He denied that this event was an attempt to commit suidice. He is followed by phsyciatrist, Dr. [**Last Name (STitle) **] - [**Hospital **] Health Center, [**Hospital1 1559**]. Patient reports he has tried multiple anti-depressants, but does not like to take medications or see doctors, and is currently not taking any medication for his depression. Psychiatry followed the patient throughout his stay.- Followed by Dr. [**Last Name (STitle) **] in [**Hospital1 1559**], MA [**Telephone/Fax (1) 71915**]. Due to patient's multiple suicidal attempts/ideations and psychiatry evaluation, patient was discharged to inpatient psychiatric unit here at [**Hospital1 **]. . 4. Contact: [**Name (NI) 402**] [**Name (NI) 71916**] (wife) - [**Telephone/Fax (1) 71917**] or [**Telephone/Fax (1) 71918**] (cell). Request by wife and approved by Pt that [**Name (NI) 1094**] mother does not get information about Pt care if she calls. . 5. Code. Presumed full . 6. Left elbow wound - tetanus shot was administered. Medications on Admission: Meds on Admission: 1. Ambien 10-20 mg qhs - sleep 2. Clonazepam 2 mg [**Hospital1 **] - anxiety 3. Excedrin pm prn - migraine Discharge Medications: 1. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 doses. 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 doses. 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). Discharge Disposition: Extended Care Discharge Diagnosis: Primary: 1. seizure . Secondary: 1. Seizure - 1 prior episode in [**2156**]. Similar flu-like illness preceding. Similar pre-ictal shaking, chills, agitation. Grand-mal with loss of consciousness, post-ictal confusion. 2. Depression - dx 9 yrs ago. 1 prior suicide attempt in [**2152**] (slit wrists). Followed by psychiatrist, Dr. [**Last Name (STitle) **], at [**Hospital **] Health Center in [**Hospital1 1559**], MA. Sees Dr. [**Last Name (STitle) **] q 3-6 mos for 15 mins. 3. Migraines - controlled with Excedrin pm. 4. Hypercholesterolemia - untreated. Pt does not like to go to the doctor. 5. h/o kidney stones. Discharge Condition: Good condition. Vital signs stable. Tolerating POs with no nausea, vomiting, or diarrhea. Able to ambulate independently. Discharge Instructions: You were evaluated for a grandmal seizure in the setting of 3 days of nausea, vomiting, diarrhea. The etiology of your grandmal seizure is unknown. Seizure etiologies include alcohol withdrawal, drug or medication withdrawal, brain tumor, head trauma, cerebrovascular disease, infectious, and electrolyte abnormalities. Highest on the differential was medication withdrawal. Patient should: 1. Take all medications as prescribed. 2. Keep all follow-up appointments. 3. Seek medical attention if you acquire chest pain, shortness of breath, nausea, vomiting, fevers greater than 101, or any other issue that is out of the ordinary for him. Followup Instructions: 1. Primary care physician. [**Name10 (NameIs) **] have an appointment scheduled with Dr. [**First Name (STitle) **] ([**Company 191**] at [**Hospital1 18**]) on Friday, [**2160-3-28**] at 1:30pm. [**Location (un) **] [**Hospital Ward Name 23**], South Suite. Phone [**Telephone/Fax (1) 250**] 2. Psychiatry - our psychiatrists here spoke with your outpatient psychiatrist. This appointment has already been arranged - please call to verify. 3. [**Hospital 875**] clinic - You are scheduled for an appointment with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] on Thursday [**2160-3-27**] at 9:00 am. This is in the [**Hospital Unit Name **] on the [**Hospital Ward Name **] of [**Hospital1 18**] [**Location (un) 6332**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

[ "292.0", "345.10", "305.41", "787.91", "346.90", "272.0", "311", "787.01" ]

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Discharge summary

report

Admission Date: [**2129-6-17**] Discharge Date: [**2129-6-29**] Date of Birth: [**2068-10-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2279**] Chief Complaint: Intracranial Hemorrhage Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: Mr. [**Known lastname **] is a 60 year-old right-handed man with a past medical history including hypertension, hyperlipidemia, polycystic kidney disease and alcohol abuse who was initially evaluated at [**Hospital3 **] after he was found unresponsive by his some at his home on [**6-16**] and was transferred to the [**Hospital1 18**] for further evaluation and care when imaging revealed a right temporal hemorrhage. He was initially intubated for airway protection and admitted to the Neuro ICU. Head CT on [**2129-6-19**] was stable. Hospital course was c/b T1 fracture, hepatic mass, aspiration PNA rx with Vanc/Zosyn and re-intubation due to hypercapneic respiratory failure. Patient was also treated for EtOH withdrawal. He was seen by cardiology for + troponins, tachycardia, and depressed (EF 35%) which were thought to be due to his time unresponsive, alcohol, and dehydration/infection. He was not started on anticoagulation given his head bleed. He was re-extubated on [**2129-6-20**] and called out to the medicine service the evening of [**2129-6-21**]. CTA on [**2129-6-21**] showed small subsegmental PEs and GGO c/w multilobar pna and pleural effusions. . The evening of [**2129-6-21**] the pateint was noted to be hypoxic to the 80s on room air. He was placed on nasal canula which improved his sats to the mid 80s and then placed on NRB with imporvement to the 90s. He appeared comfortable on the nonrebreather and ABG showed 7.49/37/183/29. He was then placed on shovel mask and maintained sats in the 90s. However, he was tachypneic to the 30s and noted that he was "tired." MICU was called to evaluate the pt for possible intubation due to respiratory failure. . The patient appeared calm with sats in the high 90s on shovel mask. However, he was exhibiting paridoxical abdominal breathing and use of accessory muscles. He was tachycardic to the 150s and hypertensive to the 150s. Given his known underlying lobar PNA and PEs he was transferred to the ICU for possible intubation. . In the ICU the pt was placed back on non-rebreather and looked more comfortable. The decision was made to monitor his respiratory status and hold off on intubation. He was noted to have a sluggish and dilated right pupil and was sent for STAT head CT. Otherwise exam was notable for mild scattered wheezes. . Review of systems: (+) Per HPI (-) Denies fever, chills, headache, sinus tenderness, rhinorrhea or congestion, 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: EtOH abuse (1.5L hard EtOH/day) Tobacco use HTN PCKD Depression Diverticulosis Hypogonadism Hyperglycemia Chronic rib fractures Social History: Lives alone. EtOH Abuse. Ongoing tobacco use. Question of IVDU. Family History: unkown Physical Exam: Vitals: T:99.3 BP:144/84 P:97 R:18 O2:95% on 4L NC 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: tachycardic regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2129-6-17**] 01:00AM BLOOD cTropnT-0.39* [**2129-6-17**] 07:56AM BLOOD CK-MB-10 MB Indx-0.3 cTropnT-0.42* [**2129-6-17**] 04:02PM BLOOD CK-MB-7 cTropnT-0.29* [**2129-6-18**] 12:11AM BLOOD CK-MB-5 cTropnT-0.29* [**2129-6-19**] 02:22PM BLOOD cTropnT-0.25* . . [**2129-6-17**] 01:00AM BLOOD ALT-23 AST-110* CK(CPK)-4733* AlkPhos-62 TotBili-1.4 [**2129-6-17**] 07:56AM BLOOD ALT-20 AST-89* LD(LDH)-446* CK(CPK)-3522* AlkPhos-54 Amylase-55 TotBili-1.1 [**2129-6-17**] 04:02PM BLOOD CK(CPK)-2585* [**2129-6-18**] 12:11AM BLOOD ALT-19 AST-65* CK(CPK)-1885* AlkPhos-53 TotBili-1.0 [**2129-6-19**] 12:51AM BLOOD ALT-22 AST-49* CK(CPK)-926* . . [**2129-6-19**] 1:01 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2129-6-22**]** GRAM STAIN (Final [**2129-6-19**]): [**9-12**] PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. RESPIRATORY CULTURE (Final [**2129-6-22**]): SPARSE GROWTH Commensal Respiratory Flora. MORAXELLA CATARRHALIS. HEAVY GROWTH. . . [**2129-6-17**] CT Abdomen IMPRESSION: 1. Partially fatty liver with numerous hypodense hepatic lesions. Though some of these may be cysts, others show evidence of delayed enhancement and overall these lesions are not well characterized. These findings as well as the dilated biliary ducts would be best assessed via MR [**First Name (Titles) 10139**] [**Last Name (Titles) 10015**] appropriate. 2. Scattered poorly marginated pulmonary nodular opacities. While these may represent areas of aspiration or inflammation, underlying neoplastic nodularity is not excluded. We would recommend a repeat dedicated CT of the chest after appropriate treatment and when [**Last Name (Titles) 10015**] stable in order to document resolution or stability of these findings. 3. Innumerable bilateral renal cysts, possibly PCKD. 4. Atherosclerotic disease. 5. Sigmoid diverticulosis. 6. Multiple chronic rib fractures. . . [**2129-6-17**] CT Head IMPRESSION: Intracerebral hematoma in the right temporal and occipital lobes with extension into the posterior [**Doctor Last Name 534**] of right lateral ventricle as seen on the recent CT head of [**2129-6-16**] 20:57 hours. Bilateral low-density extra-axial collections in keeping with CSF hygroma unchanged. No new hemorrhage. No evidence of AV malformation on the CTA study. . . [**2129-6-17**] MR [**Name13 (STitle) 430**] IMPRESSION: Right temporal hematoma with intraventricular extension. There is suggestion of associated enhancement which may be seen in the setting of a subacute hematoma or a metastatic lesion. Recommend followup study after resolution of acute blood products. Chronic subdural hygromas bilaterally. Brief Hospital Course: ICU Course - patient was admitted after being found down at home for an unknown period of time. According to his brother he had recently been in 3 automobile accidents involving head trauma. His son had been unable to reach him at home for 2 days and when landlord opened apartment they found him on the ground with a bookcase collapsed near him, and an empty bottle of Captain [**Doctor Last Name **]. In the ICU he was noted to have ecchymosis around his left eye and some dried blood near his nose. While intubated he was able to follow commands and had intact cranial nerves as well as sensation in all 4 extremities. CT revealed a large temporal hemorrhage on the right side. He was extubated and there were no obvious neurologic deficits on exam. Troponins had been elevated in-house, and he peaked at 0.42. A TTE was performed which showed hypokineses. He started to withdraw from EtOH and was having elevated systolics in the 160s, agitation and delerium. He required large IV doses of Ativan and was then reintubated for concern of airway protection. The patient was then re-extubated without issues and started on antibiotics for concern of pneumonia. He was sent to the stroke team for continued care. . Neuro ICU . SIRS . MICU [**Location (un) **] Course: The patient presented to MICU after respiratory distress/increasing O2 requirement and possible impending respiratory failure. He was placed on non-rebreather mask and stabilized. He was on Zosyn and vancomycin was dc'd based on speciation of moraxella from sputum. He was gently diuresed as it was felt that his acute respiratory distress was likely secondary to flash pulmonary edema. He was given nebulizer treatments as needed. A CT of the head showed interval expected evolution of right temporal parenchymal hemorrhage with surrounding edema and local mass effect, and extension into the right lateral ventricle. His neuro exam remained stable. His blood pressure was controlled with a goal of SBP < 160. Neurosurgery was consulted and felt that no intervention was warranted but that he should have a follow-up head MRI on [**2129-7-2**]. The results from a CTA of the chest came back and showed small subsegmental PE's. He was not anticoagulated given his ICH. Bilateral LENIs were performed and negative for DVT. The patient was maintained on a CIWA scale with valium. His C-Collar was removed per trauma team recommendations. His HTN was controlled with uptitrating of metoprolol to his home dose of 50 mg [**Hospital1 **] adn continuation of his Norvasc. Given slight rise in creatinine, his ACE-I was held but should be restarted soon given his TTE which showed of EF which cardiology thought was likely due to EtOH cardiomyopathy. At time of transfer he was tolerating a regular heart healthy diet and had pneumoboots for prophylaxis. He spiked a fever on the morning of transfer and had several loose stools, so a UA was sent in addition to a C.Diff test. . Medical Floor Hospital Course: Mr. [**Known lastname **] was a 60 year old man with PMH of alcohol abuse who was found down and discovered to have right temporal parenchymal hemorrhage and has had hospital course complicated by multilobar pneumonia, and etoh withdrawal and was transfered from the MICU with with a stable T1 fracture, stable temporal intraparenchymal hematoma, stable bifrontal subdural hematomas, liver mass identified on CT, subsegmental PEs, and multilobar PNA that was treated with 8 days of IV Zosyn. . # Respiratory distress: His respiratory distress was likely caused by agitation in the setting of etoh withdrawal and poor underlying repiratory function with multilobar PNA, PEs, and pleural effusions. On arrival to the medical floor he was sating well on 3L NC and appeared comfortable. He was continued on IV Zosyn and completed an 8 day course of antibiotics on [**2129-6-25**] for his multilobar PNA that had developled in the setting of mechanical ventillation. His oxygen requirement was titrated to RA with O2 sats ranging from 95-98%. . # R temporal hematoma: Initial etiology remained unclear, although AV malformation and malignancy remained possiblities. Neurosurgery recommended a BP goal of <160. He is scheduled to have outpatient repeat MRI and [**Hospital 87099**] clinic appointment ot follow resolution. . # PE: RML and RLL sub-segmental pulmonary emboli on CT scan. No anticoagulation was started because of head bleed. Biateral LENIs were found to be negative. His respiratory status was supported and improved throughout his hospital course. He may be anti-coagulated once cleared by neurosurgery. . # Etoh Withdrawal: He was continued on CIWA with valium 5 mg PO Q2H with no valium requirement on [**2129-6-23**] through [**2129-6-25**] with dicontinuation of CIWA on [**2129-6-25**]. A social work consult was obtained to evaluate for resources and EtOH abuse conseling. . #. T1 FRACTURE: Ok to discontinue the c-collar per trauma surgery . #. LIVER MASS: CT A/P showed numerous hypodense hepatic lesions and dilated biliary ducts. MRI was obtained revealing a 4.2 cm left liver lobe mass and CBD dilitation with suggestion of ampulary stricture. He will need outpatient liver tumor clinic follow up and ERCP as an outpatient follow-up. . #. HTN: Goal SBP<160 per neurosurgery. Metoprolol was increased from home dose of 50 [**Hospital1 **] to 150mg of Metoprolol Succinate to maintain blood pressure under 160. Norvasc 5 mg daily was continued. Lisinopril 5mg was also started to maintain his blood pressure. . #. EF 35%, global dysfunction seen on Echo: Etiology included PE versus alcoholic cardiomyopathy versus ischemic cardiomyopathy. Beta blocker therapy continued and ACEI was started once renal status returned to baseline. Medications on Admission: Metop 50 [**Hospital1 **] Nifedipine xl 60 Questran light miralax altrazolam 1mg [**Hospital1 **] fluoxetine 20 qd androdern patch2.5 mg qhs Vit D 3K units qd Discharge Medications: 1. Testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours). 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital 5503**] Health care center Discharge Diagnosis: Right Temporal Parenchymal Hemorrhage Bilateral Frontal Subdural Hemorrhages T1 Vertebral Fracture Subsegmental RML and RLL Pulmonary Emboli Liver Mass on CT Scan NSTEMI Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with a head bleed and fracture of your spine. You were evaluated and treated by the neurosurgery and medicine services. Your hospital course was complicated and required intensive care. You have ongoing serious medical problems that include 1.) a brain bleed, 2.) a T1 vertebral fracture, 3.) blood clots in your lungs, 4.) a mass that was discovered in your liver, and 5.) a heart attack. Each of these problems will need a follow-up appointment with a specialist. Follow-up appointments with neurosurgery, cardiology, a liver specialist and your primary care doctor have been arranged on your behalf. You should take your home medications as described in this discharge document and keep your outpatient appointments. The following changes have been made to your outpatient medicaitons: 1.)Your Alprazolam has been STOPPED 2.)Your Nifedipine has been STOPPED 3.)Your Miralax has been STOPPED 4.)Your Questran light has been STOPPED 5.)Your Metoprolol 50mg [**Hospital1 **] was INCREASED to Metoprolo XL 150mg Daily 6.)You were STARTED on Amlodipine 5mg daily 7.)You were STARTED on Lisinopril 5mg daily 8.)You were STARTED on Simvastatin 80mg daily 9.)You were STARTED on Folic Acid, Thamine and a Multivitamin supplement Followup Instructions: 1.) Neruosurgery: Department: RADIOLOGY When: THURSDAY [**2129-7-7**] at 3:00 PM With: XMR [**Telephone/Fax (1) 327**] Building: CC [**Location (un) 591**] [**Hospital 1422**] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Please arrive for this appointment at 2:45pm. . . Department: NEUROSURGERY When: THURSDAY [**2129-7-7**] at 4:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . . 2.)PCP: [**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) 275**] Address: [**Street Address(2) 87100**], [**Location (un) **],[**Numeric Identifier 62441**] Phone: [**Telephone/Fax (1) 75244**] Appointment: Tuesday [**2129-7-12**] 2:30pm . . 3.)Cardiology: Department: [**Last Name (un) 12214**] [**Doctor Last Name **] MED GRP When: THURSDAY [**2129-7-14**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD [**Telephone/Fax (1) 5068**] Building: [**Location (un) **] ([**Location (un) 86**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking . . 4.)Hepatology: You should see the Liver Specialists within two week of leaving the hospital. If you are not called within one week with an earlier appointment please call 1-[**Telephone/Fax (1) 10431**] to verify appointment for next week. Department: LIVER TUMOR SERVICE/TRANSPLANT When: FRIDAY [**2129-8-12**] at 10:20 AM With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . . Outpatient ERCP Procedure is being scheduled for you please call [**Telephone/Fax (1) 87101**] or [**Telephone/Fax (1) 87102**] to confirm this appointment. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]

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icd9cm

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Discharge summary

report+report

Admission Date: [**2130-3-16**] Discharge Date: [**2130-3-28**] Date of Birth: [**2096-8-16**] Sex: M Service: MEDICINE Allergies: Penicillins / Tetracycline / Sulfa (Sulfonamide Antibiotics) / Bee Pollen / Gadolinium-Containing Agents Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: transferred for evaluation of fevers, chills, and lymphadenopathy, and hepatosplenomegaly Major Surgical or Invasive Procedure: Cycle 1 [**Doctor Last Name **]-dexamethasone History of Present Illness: 33 year old man with 3-4 months of chills, fevers, and drenching night sweats. His symptoms started shortly after he quit drinking and abusing narcotics, about 3 months ago, and he initially attributed the chills and fevers to withdrawal. However, the nightsweats have continued. He has also noticed an abdominal mass, more prominent on the left side, which is diffusely painful and which prevents him from taking a deep breath if he lies down. . On arrival to [**Hospital **] Hosp ([**2130-3-6**]), he was febrile to 102.3, pancytopenic with WBC 3.2, 17 bands, Hgb 7.7, as well as an LDH of 700. He was transfused and a thoracentesis was performed for pleural effusion (500 cc drained) and then spleen biopsy was performed to evaluate his pancytopenia and lymphadenopathy. He was then transferred to [**Hospital1 18**] for further evaluation and management of suspected lymphoproliferative disorder. . In our ED, vital signs were T103 P103 BP114/71 R20 Sat95% ra. . REVIEW OF SYSTEMS: (+) 13 lb weight gain in the last 2 months. (-) Denied 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. Denied recent change in bowel or bladder habits. Denied dysuria. Denied arthralgias or myalgias. Denied pruritus. Past Medical History: - h/o MRSA cellulitis of the right lower extremity - eczema - h/o depression - pyloric sphincterotomy as an infant Social History: Incarcerated from [**Month (only) 404**] to [**Month (only) 958**] of this year, previously worked in construction, smoked one pack of cigarettes daily prior to going into prison, endorses h/o marijuana use and also reports that he has had problems with opioid addiction, using over 80mg of oxycontin several times a day, ending 2 years ago. He was treated with suboxone for several months, but prior to this hospitalization, he had not taken any narcotics in the last 2.5 months. Denies IV drug use. Family History: Mother with diabetes. No family history of cancer in first degree relatives. Physical Exam: T 99.3 BP140/80 HR99 RR22 96% RA General - Resting comfortably in bed, no acute distress HEENT - Sclera anicteric, MMM, oropharynx clear Neck - Supple, JVP not elevated, no LAD Pulm - CTA bilaterally; no wheezes, rales, or rhonchi CV - tachy, normal S1/S2; no murmurs, rubs, or gallops Abdomen - Well-healed midline epigastric surgical scar. Normoactive bowel sounds; firm, mildly tender mass in the LUQ extending along the left flank and to the pelvis, non-distended. Ext - Small, appropriately tender incision in the right axilla. Warm, well perfused, radial and DP pulses 2+; no clubbing, cyanosis or edema Neuro - CN II-XII intact in detail, full strength throughout. Pertinent Results: [**2130-3-16**] 12:10PM PT-15.1* PTT-30.6 INR(PT)-1.3* PLT SMR-LOW PLT COUNT-118* HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-2+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-1+ BURR-1+ STIPPLED-OCCASIONAL TEARDROP-2+ BITE-OCCASIONAL NEUTS-40* BANDS-9* LYMPHS-42 MONOS-2 EOS-0 BASOS-1 ATYPS-0 METAS-1* MYELOS-4* PLASMA-1* WBC-3.7* RBC-3.66* HGB-9.3* HCT-29.0* MCV-79* MCH-25.5* MCHC-32.2 RDW-19.8* [**2130-3-16**] 12:10PM LIPASE-30 ALT(SGPT)-118* AST(SGOT)-103* LD(LDH)-702* TOT BILI-0.7 [**2130-3-16**] 12:10PM GLUCOSE-109* UREA N-18 CREAT-0.8 SODIUM-139 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15 [**2130-3-16**] 12:36PM LACTATE-1.3 [**2130-3-16**] 02:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.029 [**2130-3-16**] 03:01PM BONE MARROW IPT-D CD23-D CD45-D HLA-DR[**Last Name (STitle) **] [**Name (STitle) 7736**]7-D KAPPA-D CD2-D CD7-D CD10-D CD19-D CD20-D LAMBDA-D CD5-D [**2130-3-16**] 09:00PM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-2.0 URIC ACID-5.1 LD(LDH)-580* GLUCOSE-89 UREA N-16 CREAT-0.7 SODIUM-136 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-26 ANION GAP-13 Diagnostics and Imaging: Bone Marrow Cytogenetics [**3-17**]: Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by a non-Hodgkin lymphoma are not seen in specimen. Correlation with clinical findings and morphology (S09-[**Numeric Identifier 12953**]) is recommended. Flow cytometry immunophenotyping may not detect all lymphomas as due to topography, sampling or artifacts of sample preparation. TTE [**3-17**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal. Quantitative (3D) LVEF = 63%. Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. CT TORSO [**3-17**]: Several enlarged lymph nodes within the axilla, mediastinum, and abdomen. The largest of these are located within the axilla. There is massive splenomegaly. Additionally, there are numerous small liver lesions as described above. Overall, these findings are consistent with lymphoma. BM IMMUNOPHENOTYPING [**3-18**]: RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. B cells comprise 9% of lymphoid-gated events, are polyclonal, and do not express aberrant antigens. T cells comprise 68% of lymphoid gated events, express mature lineage antigens. INTERPRETATION Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by a Non-Hodgkin lymphoma are not seen in specimen. Correlation with clinical findings and morphology (see S09-[**Numeric Identifier 12953**]; ) is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. PATHOLOGY: SPECIMEN #1: RIGHT AXILLARY LYMPH NODE, EXCISIONAL BIOPSY (SLIDES LABELED S09-1787 FROM [**Hospital3 **], [**Location (un) **], MA; FROM PROCEDURE DATE [**2130-3-8**]) DIAGNOSIS: HODGKIN LYMPHOMA, NODULAR LYMPHOCYTE PREDOMINANT TYPE, SEE NOTE. Note: H&E sections show nodal tissue with a vaguely nodular infiltrate and abundant sclerosis. The infiltrate consists of a background of small lymphocytes, plasma cells, and histiocytes harboring many large atypical cells with abundant vesicular chromatin, multiple nuclear lobulations, multiple nucleoli, and scant pale cytoplasm (L&H or popcorn cells). By immunohistochemistry performed at [**Hospital1 18**], CD45 is panreactive. CD20 stains the expanded follicles and highlights L&H cells, as well as remaining germinal center and interfollicular B cells. CD15 and CD30 are largely negative within the infiltrate, with positive internal controls. Both [**9-8**] and Bob1 are expressed by the L&H cells. CD21 highlights few expanded follicular dendritic cell meshworks. CD3, CD4, CD5, and CD8 all highlight background expanded T lymphocytes. LMP-1 stain highlights rare positive cell. MIB-1 highlights germinal centers - where the proliferation fraction is high - as well as scattered large cells within the expanded B cell nodules. SPECIMEN #2: SPLEEN, NEEDLE BIOPSY (SLIDES LABELED S09-1874 FROM [**Hospital3 **], [**Location (un) **], MA) DIAGNOSIS: SPLENIC PARENCHYMA WITH MULTIPLE GRANULOMAS. DEFINITIVE MORPHOLOGIC OR IMMUNOPHENOTYPIC EVIDENCE OF LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA IS NOT SEEN. Note: H&E sections show several small cores of splenic tissue with multiple lymphohistiocytic aggregates, which in some areas coalesce into well-formed granulomas with occasional giant cells. There are scattered large atypical cells in a background of lymphocytes, plasma cells, and histiocytes. However, L&H cells are not identified. Special stains for acid fast bacteria and fungus (AFB, PAS, GMS, Giemsa) are all negative for microorganisms with adequate controls. Of note, splenic involvement by lymphocyte predominant Hodgkin lymphoma is infrequent and when present it is usually not a cause of splenomegaly, let alone massive splenomegaly. Rarely, however, LP HL can behave clinically in a more aggressive manner with widespread dissemination to bone marrow and other sites. Please correlate with other clinical, laboratory and imaging findings. MICRO: CRYPTOCOCCAL ANTIGEN (Final [**2130-3-24**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. HIV-1 Viral Load/Ultrasensitive (Final [**2130-3-21**]): HIV-1 RNA is not detected. HCV VIRAL LOAD (Final [**2130-3-20**]): HCV-RNA NOT DETECTED. CMV Viral Load (Final [**2130-3-19**]): CMV DNA not detected. HBV Viral Load (Final [**2130-3-27**]): HBV DNA not detected. BRUCELLA IGG 0.03 BRUCELLA IGM 0.06 REFERENCE RANGE: <0.80 COCCIDIOIDES ANTIBODY, ID NEGATIVE EBV PCR: NA EBV genomes/10(5) lymphocytes Remarks: Expected Results: ----------------- Using a modified protocol, the copy number of EBV genomes in latently infected adults has been estimated to be 0.1 copies/10(5) lymphocytes. Therefore, latency falls below the sensitivity of this assay. The expected result for a normal healthy adult with latent EBV infection is "not detected" (nd). Note: Failure to amplify is reported as "Not Amplifiable" (NA) and differs from "not detected". Histoplasma Quantitative Antigen EIA Result: None Detected ng/ml(-) Brief Hospital Course: 33M with a history of narcotic abuse who presented w 3 months of fevers, nightsweats, LAD and splenomegaly found to be pancytopenic upon presentation and subsequently diagnosed with Hodgkins Lymphoma. . # Nodular Lymphocyte Predominant Hodgkins Lymphoma. Review of path from OSH axillary LN biopsy was consisitent with nodular LP HL. Bone marrow biospy was not consistent with bone marrow involvement. The patient was placed on steroids and then received one cycle of [**Doctor Last Name **]-dexa. He tolerated this regimen without significant complication although he became quite uncomfortable once steroids were stopped. As a result, he was placed on a steroid taper which he was instructed to continue to taper at his time of discharge. His nightsweats had largely resolved and he was afebrile for >48 hours at the time of discharge. . # Hepatosplenomegaly. Patient had a splenic biospy at the OSH which was reviewed by [**Hospital1 18**] pathology and found to contain granulomas which were concerning for infectious vs lymphoma-related process. Infectious Disease was consulted and recommended several viral PCRs as well as serologies be sent. These results were all negative for a particular etiology and are contained in the results section of this document. Given concern for non-specific infectious process status-post chemotherapy, the patient was started empirically on fluconazole and levofloxacin. He developed worsening LFT abnormalities as well as hyperbilirubinemia which improved when fluconazole was stopped. He was discharged on levofloxacin and asked to continue taking it until further discussion with his outpatient oncologist. The patient's LFTs remained elevated throughout his hospitalization but were trending toward normal at his time of discharge. This was also thought to be related to infectious vs lymphoma-related process but was not entirely clear at his time of discharge and was to be closely followed up on as an outpatient. . # Fevers. The patient had daily fevers until after completion of chemotherapy during which time he defervesced until his time of discharge. He was asked to return should he become febrile again at home. Given his defervescence after chemotherapy in the setting of multiple negative cultures, it was felt that his initialy fevers were related to his lymphoma. . # Pain. Given patient's history of narcotic abuse, care was taken to limit narcotic medications. The patient clearly had significant pain related to his abdominal distention from his spleen which required low dose morphine SR with IR for breakthrough pain. He was discharged with a limited script for these medications with a plan for down-titration with resolution of his HSM in the setting of lymphoma treatment. . On [**3-28**], the patient was afebrile and otherwise hemodynamically stable with a plan for close follow up in place. He was therefore discharged to home. Medications on Admission: Klonipin 1mg TID. Discharge Medications: 1. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks. Disp:*42 Tablet(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*0* 5. Prednisone 5 mg Tablet Sig: ASDIR Tablet PO once a day for 5 days: Take 4 pills (20mg) on [**3-29**]. Take 2 pills (10mg) on [**3-30**] and [**3-31**]. Take 1 pill (5mg) on [**4-1**] and [**4-2**]. . Disp:*10 Tablet(s)* Refills:*0* 6. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tablet Sustained Release(s)* Refills:*0* 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 8. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for 3 weeks. Disp:*25 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Lymphocyte Predominant Hodgkin Lymphoma with massive hepatosplenomegaly Secondary: History of Narcotic Abuse Discharge Condition: Hemodynamically stable with normal vitals and plan for follow up in place. Discharge Instructions: You were admitted to the hospital for diagnosis and further management of your fever, nightsweats, and abdominal swelling. You were found to have lymphocyte-predominant Hodgkin lymphoma causing expansion of your liver and spleen. A bone marrow biopsy showed that your bone marrow was not involved. You had 1 cycle of chemotherapy targeted toward your type of lymphoma. You will need to have 5 more cycles of treatment. These treatments last a couple of hours and can be done as an outpatient. Each treatment is 3 weeks from the prior. You will however need more frequent monitoring of your blood counts and liver function. Medication changes: You should take levofloxacin (an antibiotic) daily to prophylax against infection. You should take morphine sustained release twice per day to prevent pain. You may take morphine immediate release for breakthrough pain not adequately controlled by the sustained release medication. You should complete a steroid taper as outlined in the prescription provided for you. You should take protonix while on steroids to protect your stomach. You should take a stool softener while taking narcotic medications to prevent constipation. Please call your primary doctor or Dr. [**First Name (STitle) **] or go to the ED should you experience fevers >100.4, cough, nightsweats, chest pain, shortness of breath, worsening abdominal pain, pain with urination, changes to your bowels, or any other concerning symptoms. Because your spleen is so enlarged, you are at increased risk for splenic rupture. You should not engage in any heavy labor or sports. Followup Instructions: Please follow up at the following appointments: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Location (un) 436**] [**Hospital Ward Name 1826**] Building [**2130-3-30**] 11:30 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], RNC [**Location (un) 436**] [**Hospital Ward Name 23**] Building ([**Telephone/Fax (1) 3241**]) [**2130-4-3**] 1:00pm (this appointment is for blood work) [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD [**Location (un) 436**] [**Hospital Ward Name 23**] Building ([**Telephone/Fax (1) 3237**]) [**2130-4-3**] 1:00 Admission Date: [**2130-3-31**] Discharge Date: [**2130-4-30**] Date of Birth: [**2096-8-16**] Sex: M Service: MEDICINE Allergies: Penicillins / Tetracycline / Sulfa (Sulfonamide Antibiotics) / Bee Pollen / Gadolinium-Containing Agents Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Splenectomy History of Present Illness: This 33 yo male with new diagnosis of lymphocyte predominant Hodgkin's Lymphoma who presented on day 11 status post CHOP with one day of fever to 101.4 F and chills. The patient reported worsening of his chronic abdominal pain from [**2131-5-14**] to [**9-16**] over the preceding days but denied any other localizing symptoms particularly denying shortness of breath, cough, nausea, vomiting, dysuria, hematuria, or skin changes. He continued to have normal bowel movements including one on the morning of admission. Generally, he reported feeling anxious and agitated on being back in the hospital. In the ED, initial vitals were Tmax 102.2, BP: 153/103, HR: 120, O2sat: 98%RA . Labs were notable for ANC of 36 and elevated liver enzymes with ALT 243, AST 78, AP 260, and a normal T Bili of 1.1 (stable from daily outpatient labs). Hct was 24.9 and platelets 35K which are also stable from his recent discharge. In the ED blood cultures were drawn and he was given 2 gm IV cefepime as well as 3 L of IVF . He underwent CXR which showed atelectasis and question of pneumonia per ED read. CT abdomen/pelvis was performed given his chronic abdominal pain and demonstrated stable splenomegaly and LAD. It also showed mildly dilated loops of small bowel which contained oral contrast, which could possibly represent early partial SBO vs early ileus. He received acetaminophen, ondansetron, and hydromorphone as well and was admitted for further management. REVIEW OF SYSTEMS: As per HPI he reported agitation, chills, and fever. He denied cough, dyspnea, chest pain, palpitations, change in bowel or bladder habits, melena, hematochezia, dysuria, hematuria, or rashes. Past Medical History: ONCOLOGIC HISTORY ================== Lymphocyte Predominant Hodgkin's Lymphoma -[**2129-12-8**]: Developed B symptoms (chills, fevers, and night sweats) and left sided abdominal mass while incarcerated -[**2130-2-5**]: presented to [**Hospital **] Hosp with fever, pancytopenia, and elevated LDH, He had a thoracentesis for effusion and a spleen biopsy prior to being transferred to [**Hospital1 18**] for further management -[**2130-3-16**]: Arrived at [**Hospital1 18**], pathology found to be consistent with lymphocyte predominant Hodgkin's Lymphoma, He received his first cycle of CHOP starting on [**2130-3-20**] and discharged on [**2130-3-26**] PAST MEDICAL HISTORY: ==================== - History of MRSA cellulitis of the right lower extremity - Eczema - Depression - Pyloric sphincterotomy as an infant Social History: Incarcerated from [**Month (only) 404**] to [**Month (only) 958**] of this year, previously worked in construction, smoked one pack of cigarettes daily prior to going into prison, endorses h/o marijuana use and also reports that he has had problems with opioid addiction, using over 80mg of oxycontin several times a day, ending 2 years ago. He was treated with suboxone for several months, but prior to this hospitalization, he had not taken any narcotics in the last 2.5 months. Denies IV drug use. Family History: Mother with diabetes. No family history of cancer in first degree relatives. Physical Exam: On Admission: Vitals - T: 98.4 BP: 122/79 HR: 114 RR: 16 02 sat: 98% on RA GENERAL: NAD, mildly anxious but easily consoled SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: increased rate, regular rhythm, normal S1/S2, no mrg LUNG: CTAB ABDOMEN: distended, hyperactive BS, mildly tender in all quadrants, no rebound/guarding, massive splenomegaly M/S: moving all extremities well, no cyanosis, clubbing, +1 non-pitting edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact Pertinent Results: LABORATORY RESULTS ================== Admission labs: WBC-0.5* RBC-3.20* HGB-8.8* HCT-26.3* MCV-82 RDW-20.3* --N 12*, LYMPHS-80* MONOS-6 BASOS-2 NUC RBCS-8* Na 136, K 4.4, Cl 100, HCO3 25, BUN 24*, Cr 0.7 ALT-301* AST-105* LD(LDH)-392* AlkPhos-262* TotBili-1.1 On Discharge: WBC-5.8 RBC-3.09* Hgb-8.8* Hct-27.3* MCV-89 RDW-19.8* Plt Ct-470* ---Neuts-94* Lymphs-1* Monos-4 Promyel-1* Na 139, K 4.5, Cl 103, HCO3 24, BUN 48*, Cr 1.8*, Glu 108* -Calcium-8.8 Phos-4.8* Mg-2 ALT-125* AST-55* LD(LDH)-444* AlkPhos-391* TotBili-0.3 MICROBIOLOGY ============ -Numerous blood and urine cultures negative. -CMV Viral Load [**2130-4-5**], [**2130-4-18**], [**2130-4-27**]: Not detected -Blood cryptococcal antigen [**2130-4-7**]: Not accepted -EBV PCR [**2130-4-5**]: Not detected -B Glucan [**4-3**], [**4-7**], [**4-18**]: Negative -Galactomannan [**4-3**], [**4-7**], [**4-18**]: Negative -Bartonella Antibody Panel [**2130-4-4**]: Negative -Human Herpes Virus 6 PCR [**2130-4-27**]: Not detected -HSV 1 and 2 IgG and IgM Ab test [**2130-4-21**]: Negative -Coxiella Antibody Screen [**2130-4-5**]: Negative PATHOLOGY ========== Shave Biopsy of Left Ring Finger [**2130-4-7**]: DIAGNOSIS: Skin, left ring finger: - Verruca vulgaris, see note. Note: There is superimposed bacterial infection. Spleen, Omentum, and Liver [**2130-4-11**]: DIAGNOSIS: I. Splenule (A): Nodule of splenic tissue with extramedullary hematopoiesis and prominent interstitial histiocytes. II. Omentum (B-C): Unremarkable fibroadipose tissue. III. Spleen, total splenectomy ([**2105**] grams) (D-I, M-U) and VI. Splenic tissue, biopsy (L): Massive splenomegaly with extensive red pulp congestion, fibrosis and extramedullary hematopoiesis (see note 1). Multiple vascular thrombi. Focal splenic infarction and geographic necrosis. Lymphohistiocytic aggregates and necrotizing granulomas. Hilar lymph node with atypical lymphoid infiltrate (see note 2). -Note 1: H&E sections of splenic tissue demonstrate marked red pulp congestion with extensive interstitial fibrosis. There is extensive extramedullary hematopoiesis throughout with megakaryocytes as well as erythroid islands; erythroid precursors are markedly dyspoietic with asymmetric nuclear budding noted. Additionally, sections from the grossly visible necrotic area shows a large area of geographic necrosis. In many areas, blood vessels with thrombi, including organizing thrombi are noted; some are recanalized. The white pulp is attenuated with occasional scattered larger lymphoid cells noted in a background of smaller lymphocytes and histiocytes. Scattered histiocytes with ingested hematopoietic precursors (hemophagocytic histiocytes) are seen. Several scattered ill-defined lymphohistiocytic aggregates are seen with prominent central karyorrhectic debris (also noted in perihilar connective tissue). Some form focal granulomas, including an occasional large necrotizing one with palisading histiocytes (slide M). Gamna-Gandy bodies are also noted. Special stains for microorganisms (acid fast bacilli, fungal and parasite: AFB, GMS, and Giemsa) are negative with adequate controls. By immunohistochemistry performed on block from splenic section H, LCA (CD45) highlights scattered lymphoid cells. B-cell markers CD20, PAX-5, and CD79a highlight few scattered, and occasional loosely clustered B-cells, including a few larger forms. A subset express bcl-6. The cells do not express CD30 or CD15. CD3 highlights numerous reactive small T lymphocytes, which are a mixed population of CD4 and CD8 positive cells (ratio of [**1-10**]:1). CD57 highlights few scattered germinal center T cells. CD21 (DRC) is negative. CD31 and Factor 8 highlight vascular endothelia. CD8 highlights dilated sinusoids, which are focally widely separated with extensive fibrosis in the intervening areas. MPO highlights numerous granulocytes, while CD68 stains histiocytes. The proliferation fraction, measured by Ki-67 (MIB-1) ranges from 10 to 50%, overall 30%. Overall, the findings are of congestive splenomegaly with extensive extramedullary hematopoiesis. Several thrombosed vessels are also noted, and concurrent radiology reports show nodal masses encompassing portal venous system. The exact etiology of the splenomegaly and vascular thromboses is uncertain but possibilities include chronic portal venous congestion either due to external compression from nodal masses, or alternatively the possibility of an underlying thrombophilic condition leading to vascular thromboemboli needs to be evaluated. The finding of extensive extramedullary hematopoiesis, which along with fibrosis appears to be the dominant cause of splenomegaly, is unusual, and correlation with clinical, cytogenetic, and bone marrow findings to exclude a possible underlying myeloproliferative disorder is needed. -Note 2: Sections of hilar lymph nodes show extensive sclerosis with only scattered lymphoid nodules remaining. By immunohistochemical staining performed on lymph node block S, a focal are of large atypical cells with markedly convoluted nuclei and prominent nucleoli are noted on CD20 immunostaining. These are CD30 negative (occasional immunoblasts staining). CD15 highlights neutrophils with no aberrant staining seen. Given the patient's known history of recently diagnoses, partially treated, nodular lymphocyte predominant Hodgkin lymphoma, the findings are suspicious for residual involvement by the same. IV. Liver, left lobe, needle core biopsy (J) (reviewed by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 10165**]): 1. Moderate portal and lobular lymphoid infiltrate with prominent sinusoidal pattern with cells consistent with extramedullary hematopoiesis. 2. Lobular regeneration with microscopic foci of necrosis with hemorrhage. 3. Minimal steatosis. 4. Trichrome stain shows mild portal fibrosis. 5. Iron stains shows moderate iron deposition in hepatocytes and Kupffer cells. 6. No micro organisms seen on special stains (AFB, GMS, PAS-D). V. Liver, right lobe, needle core biopsy (K) (reviewed by Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10165**]): 1. Moderate portal and lobular lymphoid infiltrate with prominent sinusoidal pattern with cells consistent with extramedullary hematopoiesis. 2. Lobular regeneration with microscopic foci of necrosis with hemorrhage. 3. Minimal steatosis. Note: The findings in both biopsies are similar. There are some atypical lymphoid cells which have been evaluated by (see hematopathology note). The main finding in these biopsies is the finding of extra-medullary hematopoiesis. However, there are microscopic foci of necrosis, the etiology of which cannot be determined. Clinical correlation is suggested. Dr. [**Last Name (STitle) **]. [**Doctor Last Name 10165**] reviewed Parts IV and V. Hempath note (for liver biopsy): Diagnostic features of lymphoma are not seen. See note. Note: Although several periportal and lobular lymphoid infiltrates are seen, no large cells or L&H variants are noted. By immunohistochemistry CD20 and PAX5 highlight few scattered, predominantly small B lymphocytes. A majority of the lymphocytes are CD3 positive T cells. No CD57 positive germinal center T cells are present. CD30 is not aberrantly expressed. CD45 is diffusely immunoreactive in lymphoid cells. Spleen Immunophenotyping [**2130-4-11**]: RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. B cells are scant in number. T cells comprise 97% of lymphoid gated events and express mature lineage antigens. -INTERPRETATION Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by B-cell non-Hodgkin lymphoma are not seen in specimen. Correlation with clinical findings and morphology (see S09-[**Numeric Identifier 82514**]) is recommended. Flow cytometry immunophenotyping may not detect all lymphomas as due to topography, sampling or artifacts of sample preparation Bone Marrow Biospy [**2130-4-21**]: ============== DIAGNOSIS ============ SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: DIAGNOSIS: HYPERCELLULAR BONE MARROW WITH MYELOID AND MEGAKARYOCYTIC HYPERPLASIA AND FREQUENT HEMOPHAGOCYTIC HISTIOCYTES HIGHLY SUGGESTIVE OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HEMOPHAGOCYTIC SYNDROME). THERE IS NO MORPHOLOGIC EVIDENCE OF LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA. SEE NOTE Native Renal Biopsy [**2130-4-27**]: DIAGNOSIS: Renal biopsy, needle: Consistent with acute tubular injury ("ATN"), see note. Note: Light Microscopy: The specimen consists of renal cortex and medulla, containing approximately 22 glomeruli, of which 0 are globally sclerotic. Some [**Hospital1 **] show ischemic type changes, the remainder are within normal limits. Patchy widespread interstitial edema is present. There is minimal interstitial fibrosis and tubular atrophy. Minimal chronic inflammation accompanies the scarring. Tubules show vacuolar change, as well as intralumenal necrotic debris and red blood cells; other signs of acute injury, including occasional single-cell necrosis are also seen. Arteries show minimal-mild intimal fibroplasia. Arterioles show mild mural thickening, with prominent hyaline change. -Immunofluorescence: The specimen consists of renal cortex, containing approximately 4 glomeruli, of which 0 are globally sclerotic. There is 0-trace mesangial staining for IgA, IgM, C3, fibrin, Kappa, and Lambda. IgG and C1q are negative. 2+C3 is seen along tubular basement membranes and in vessels. Albumin is non-contributory. -Comment: 1. The amount of deposition is too limited for a diagnosis of IgA nephropathy. 2. The degree of arteriolar hyalinosis is noteworthy. 3. Clinical correlation is necessary to determine the cause(s) of this process. OTHER STUDIES ============== Chest Radiograph [**2130-3-31**]: IMPRESSION: Linear area of increased opacity at the left lung base. By morphology this is likely atelectasis though an early infectious process is not excluded and should be correlated to the clinical presentation CT Abdomen and Pelvis W/Contrast [**2130-3-31**]: IMPRESSION: 1. Overall, minimal change since [**2130-3-17**] with massive splenomegaly and lymphadenopathy, which was better demonstrated on the previous study, compatible with lymphoma. Previously noted hypodensities within the liver are not as well imaged on the current study due to different phase of imaging. 2. Mildly dilated loops of small bowel which contain oral contrast. This finding may represent a pseudo- obstruction, but early or partial small bowel obstruction is not completely excluded. Repeat imaging can be performed to assess for passage of oral contrast into the colon. CT Chest W/O Contrast [**2130-4-3**]: IMPRESSION: 1. Bibasilar atelectasis and interval development of new ground-glass nodular opacities in the right upper lobe which are worrisome for infection. Viral or atypical bacterial pneumonia is favored. 2. Stable mediastinal lymphadenopathy and slightly improved right axillary lymphadenopathy. 3. Interval enlargement of 3-cm well-circumscribed fluid collection in the right axilla which may represent a necrotic lymph node versus a post-biopsy seroma. Clinical correlation is recommended. 4. Hepatosplenomegaly and a small amount of perisplenic fluid, unchanged MRI Abomen W and W/O Contrast [**2130-4-5**]: IMPRESSION: 1. Hepatosplenomegaly with heterogeneous signal and enhancement of both liver and spleen probably due to lymphoma. No focal liver or splenic mass or evidence of abscess is seen. 2. Dropout of signal in both liver and spleen on longer echo gradient echo imaging, likely due to iron overload from blood transfusions. 3. Nodal mass surrounding portal vein and celiac access is as previously seen. 4. Left lower lobe consolidation/atelectasis persist. 5. Given the patient's multiple other medication allergies as well as development of rash immediately after administration of gadolinium, premedication for allergic reaction would be recommended should the patient again receive IV gadolinium. This was discussed with Dr. [**Last Name (STitle) 4369**]. Ankle Radiograph [**2130-4-9**]: IMPRESSION: 1. Diffuse soft tissue swelling about ankle. 2. Extreme posterior calcaneus is excluded from the film. Allowing for this, no fracture or suspicious bone lesion detected involving the left ankle. 3. Minimal spurring of the distal tibia without other evidence of degenerative change. Chest Radiograph [**2130-4-10**]: FINDINGS: In comparison with the study of [**4-2**], there is some progressive decrease in opacification at the left base. Blunting of both costophrenic angles and bibasilar atelectasis persists in this patient with low lung volumes. Bilateral Lower Extremity Ultrasounds [**2130-4-10**]: IMPRESSION: No lower extremity DVT. Chest Radiograph [**2130-4-17**]: FINDINGS: In comparison with the study of [**4-10**], there is now increasing opacification at the left base. This appears to be consistent with pleural effusion and some underlying atelectasis. The possibility of superimposed pneumonia can certainly not be excluded. Streak of atelectasis overlying the cardiac border on the lateral view is unchanged. Transthoracic Echocardiogram [**2130-4-18**]: Conclusions Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. Chest Radiograph [**2130-4-18**]: IMPRESSION: AP chest compared to [**4-17**]: Left lower lobe is still consolidated but volume loss is not as severe. Mild pulmonary edema, progressive moderate cardiomegaly and small-to-moderate bilateral pleural effusions are new indicating cardiac decompensation. CTA of Chest W and W/O Contrast [**2130-4-18**]: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Moderate-sized bilateral pleural effusions and compressive atelectasis, new since the prior study. 3. Stable enlarged mediastinal, internal mammary, and right axillary lymph nodes consistent with the patient's history of Hodgkin's lymphoma. 4. 3.3-cm fluid-filled structure in the right axilla, slightly enlarged compared to the prior study and may represent a necrotic lymph node versus a post-biopsy seroma. 5. Interval increase in abdominal ascites status post splenectomy. CT Abdomen and Pelvis W/Contrast [**2130-4-19**]: IMPRESSION: 1. New right pleural effusion and increased left pleural effusion with associated relaxation atelectasis; pneumonia cannot be excluded. 2. Interval splenectomy with splenic vein clot. Fluid collectionin splenic bed. 3. Focal hypodense hepatic lesions likely secondary to lymphoma although another process such as disseminated fungal infection cannot be excluded. See the MR of [**2130-4-5**] for further details. 4. Mildly dilated loops of contrast-filled small bowel likely due to pseudo- obstruction. If clinically indicated could consider reimaging later to assure expected progression of contrast. Liver/GB Ultrasound [**2130-4-20**]: IMPRESSION: 1. Slight prominence of the common duct, measuring 8 mm. However, the extrahepatic common bile duct remains normal in caliber, measuring 6 mm, and there is no intrahepatic biliary ductal dilatation seen. The gallbladder is unremarkable, without evidence of stones. 2. Trace perihepatic ascites. 3. Innumerable hypodense liver lesions not visualized son[**Name (NI) 5326**]. Chest Radiograph [**2130-4-22**]: FINDINGS: Cardiomediastinal contours are unchanged. Slight improved aeration at the right lung base but no significant change in patchy and linear opacities at the left base. These findings favor atelectasis as reported on recent chest CT. Persistent small bilateral pleural effusions. Brief Hospital Course: 33 year male with new diagnosis of lymphocyte predominant Hodgkin's Lymphoma now status post one cycle of CHOP presenting with fever and persistent abdominal pain now dramatically improved status post splenectomy. 1) Fevers of Unknown Origin: The patient presented with neutropenic fevers and worsening abdominal apin. Given he was neutropenic at the time he was admitted to the oncology service and treated with multiple broad spectrum antimicrobials including cefepime, aztreonam ([**Date range (1) 27094**]), vancomycin([**Date range (1) 22023**]), metronidazole ([**Date range (1) 82515**]), azithromycin ([**Date range (1) 82516**]), and voriconazole ([**Date range (1) 82517**]) and never had abatement of his fevers. His neutropenia resolved on [**2130-4-7**]. All blood cultures were benign and there was no clear urinary or pulmonary source of infection. Work up did reveal multiple liver hypodensities but work up for granulomatous diseases was similarly negative. Eventually, given the largely negative work-up primary suspicion was for non-infectious sources of fever. Therefore, the patient was started on a steroid taper and had a splenectomy as his splenomegaly was thought to be contributing to his persistent abdominal pain and intraoperative biopsies would help with diagnostic evaluation. Therefore, he had a splenectomy on [**2130-4-11**]. Following splenectomy and while on steroid taper the patient did well and from [**Date range (1) 82518**] he was afebrile (antibiotics had been stopped on [**2130-4-14**]). Unfortunately, on [**2130-4-17**] he once again had fevers and was restarted on broad spectrum antibiotics (aztreonam/vancomycin then levofloxacin). From [**2130-4-17**] to [**2130-4-21**] the patient once again was persistently febrile with no localizing signs of acute infection and persistently negative cultures (though pneumonia was suspected due to his respiratory issues). On [**2130-4-21**], however, the patient had an abrupt increase in his LFT's as well as acute kidney injury. When he developed yet another episode of acute respiratory distress later in the day he was transferred to the intensive care unit where he had a repeat bone marrow biopsy, which along with the returning path from his splenectomy, and the results of his labs (including a greater than assay ferritin level) led to a diagnosis of hemophagocytic lymphohistiocytosis. 2) Hemophagocytic lymphohistiocytosis: A presumptive diagnosis of hemophagocytic lymphohistiocytosis was made on [**2130-4-21**] from bone marrow biopsies showing hemophagocytosis and splenectomy results as well as fulminant hepatic injury and the elevated ferritin. The patient was started on high dose steroids and etoposide per protocol and after first doses, which were adjusted for hepatic and renal dysfunction, was put on twice weekly etoposide and a steroid taper. With initiation of therapy liver enzymes rapidly declined and fevers resolved. With the initiation of transplant lab results dramatically improved with liver enzymes and LDH trending downward. He tolerated the steroid therapy and etoposide well. Work up for causes of HLH included assays for HHV5, HSV1, HSV2, EBV, and CMV and all were negative. Ultimately, most likely cause of HLH was considered to be due to a paraneoplastic process from his underlying Hodgkin's lymphoma. Given his improvement he was discharged to continue twice a week etoposide and steroid taper as an outpatient. Plan is to start cyclosporin per protocol as renal function improves. 3) Acute Kidney Injury: On the evening of [**2130-4-25**] the patient reported dark colored urine*1. Subsequent urinalysis revealed large heme but no RBC's. Initial concern was for rhabdomyolysis but CK was normal. The following day as the patient was diagnosed with HLH and his hemoglobinuria was presumed to be due to the massive hemolysis precipitated by that syndrome. From [**Date range (1) 82519**] Cr also increased from 0.7 to 2. Presumed etiology was thought likely to be contrast induced nephropathy and/or pigment nephropathy from hemoglobinuria leading to acute tubular necrosis. This was confirmed by urine sediment analysis, which showed muddy brown casts. Cr improved improved to 1.8 at the time of discharge with conservative management (primarily avoidance of nephrotoxins). The patient did have some issues with hyperkalemia after developing renal failure but never any ECG changes and this resolved as renal function trended back toward normal and the patient was put on a low K diet. Of note, the patient's initial urine studies did show an increased protein/Cr ratio suggesting significant proteinuria, which would be atypical for acute tubular necrosis. Therefore, he had a renal biopsy but the results of this were pending as of discharge. Repeat urine protein/Cr measurement was improved. 4)Respiratory Distress: The patient had two episodes of acute respiratory distress on the floor on [**4-17**] and [**2130-4-21**]. These were each in the context of rigoring from fever and reported anxiety. During the first work up showed hypoxia and chest radiograph showed volume loss perhaps suggesting a collapsed lobe. The patient improved from both these incidents with minimal direct management and his oxygen requirements simply decreased to baseline each time. The ultimate etiology of his hypoxia remained unclear. 5) Lymphocyte Predominant Hodgkin's Lymphoma: The patient received one cycle of CHOP prior to presentation. Initially, given that this is generally a rather indolent disease it was thought likely the cause of his splenomegaly but thought unlikely to be the cause of his fevers and hemophagocytic lymphohistiocytosis. As his hospitalization progressed and other etiologies of HLH were ruled out this was considered a possible precipitant of the HLH. Ultimately, etoposide does have activity against Hodgkin's Lymphoma as well. Further specific treatment for his Hodgkin's lymphoma will be pending treatment of his HLH. 6) Pain: The patient has a history of opioid abuse and chronic abdominal pain thus complicating his pain management. In consultation with the pain management service in the context of his splenectomy he was on PCA, which was then transitioned to extended release morphine and hydromorphone PRN. With these interventions his pain steadily improved after his splenectomy and he was discharged just on scheduled morphine SR for his chronic abdominal pain. 7) Anxiety: The patient did complain of anxiety particularly with uncertainty about his plan of care or medical situation but also just in general from being hospitalized. This responded well to standing and PRN clonazepam with minimal sedation or other side effects. He received SC heparin for DVT prophylaxis and PPI for GI prophylaxis. He was full code. He was tolerating a full diet as of the time of discharge. Medications on Admission: 1. Clonazepam 1 mg PO TID 2. Pantoprazole 40 mg daily 3. Docusate Sodium 100 mg [**Hospital1 **] 4. Levofloxacin 500 mg daily 5. Prednisone 10 mg [**3-31**] (steroid taper), due for 5mg [**Date range (1) 82520**] 6. Morphine 30 mg SR q12h 7. Simethicone 80 mg qid prn 8. Morphine 15 mg PO Q8H prn 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. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release(s)* Refills:*0* 3. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ML PO DAILY (Daily). Disp:*300 ML* Refills:*2* 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Dexamethasone 4 mg Tablet Sig: Five (5) Tablet PO once a day: For the first 2 weeks the dose is 20 mg/day so you have one more week on this dose. The dose will be adjusted per protocol by Dr. [**First Name (STitle) **] and [**Doctor First Name **]. Disp:*150 Tablet(s)* Refills:*2* 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours for 10 days. Disp:*30 Tablet(s)* Refills:*0* 7. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: -Hemophagocytic Lymphohistiocytosis -Lymphocyte Predominant Hodgkin's Lymphoma -Non-oliguric acute kidney injury (due to contrast nephropathy and/or hemoglobinuria) -Status post splenectomy -Acute on Chronic abdominal pain Discharge Condition: Stable, not hypoxic on room air, with decreased abdominal pain, without fevers. Discharge Instructions: You were admitted to the hospital because your spleen was enlarged and you had fevers while your counts were low. You went on to have a splenectomy and briefly improved before having fevers again and worsening liver enzymes. This was caused by your hemophagocytic syndrome. We treated this with chemotherapy and steroids. You will need continued treatment as an outpatient. This is a rare syndrome and we are not entirely sure what caused it, though we suspect it may be related to your Hodgkin's Disease. Your kidneys were also damaged while you were in the hospital probably by a combination of the IV contrast dye you were given and the pigment hemoglobin, which was released in large amounts when your hemophagocytic syndrome was accelerating. These have begun to improve on their own and we expect them to make a full recovery. The nephrologists did a kidney biopsy to make sure there was not another process going on in your kidneys. The results of this biopsy were still pending at the time of discharge but can be managed as an outpatient. Your medications have been changed. Please take your medications exactly as prescribed. Please call your doctors and [**Name5 (PTitle) **] be seen in either the office or the ED if you have fevers, chills, night sweats, progressive abdominal pain, decreased urine output, shortness of breath, or any other concerning changes in your health. Followup Instructions: Please follow up on 7 [**Hospital Ward Name **] outpatient on Tuesday at 3:30 pm for Etoposide. Dr. [**First Name (STitle) **] will be the doctor on service at that time. Follow up on Friday for Etoposide will also need to be scheduled at that time.

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icd9cm

[ [ [] ] ]

[ "50.12", "54.4", "99.25", "55.23", "41.5", "99.05", "41.31", "99.04", "34.91", "38.93" ]

icd9pcs

[ [ [] ] ]

45624, 45630

37433, 44314

17371, 17385

45916, 45998

21244, 21282

47447, 47700

20460, 20538

44662, 45601

45651, 45895

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46022, 47424

20553, 20553

21520, 37410

18891, 19087

15406, 16349

17326, 17333

17413, 18872

21298, 21506

20567, 21225

19785, 19925

19941, 20444

23,706

121,358

46533

Discharge summary

report

Admission Date: [**2199-12-31**] Discharge Date: [**2200-1-4**] Date of Birth: [**2134-1-20**] Sex: F Service: MEDICINE Allergies: Codeine / Bactrim / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 905**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: This is a 65 yo f with a PMH significant for COPD (last FEV1 in [**10-20**] 0.31 L; followed by pulm at [**Hospital1 18**]), morbid obesity, OSA (on nightly BiPAP), HTN and GERD with a recent admission for acute respiratory distress attributed to COPD, who presents today after becoming acutely dyspneic at home without benefit from her bronchodilators. She called EMS, who documented O2 sats in the 80's. They placed her on a NRB and she subsequently became lethargic. The NRB was removed and in the ED, she was placed on NIPPV, with good result, sats came up to mid-90's and MS improved. Vitals in the ED: T 97.5, HR 80, BP 152/74 RR 30, sats 97% on CPAP. She was given nebulizers, 1 dose of solumedrol IV, 1 dose each of CTX and azithromycin and was sent to the MICU for further management. CXR was interpreted in the ED as low lung volumes. . ROS: The patient denies chest pain, cough, fevers/chills, n/v/d, recent illnesses or sick contacts. She notes that she feels much better on the NIPPV than she did this morning. She is slightly confused and doesn't remember the events leading up to her admission. She had to be oriented to place and time. Last admission for COPD exacerbation was [**10-20**]. Past Medical History: Obstructive Sleep Apnea (on BiPAP at night) COPD (last [**Month/Year (2) 1570**]'s [**12-20**] - FVC 0.77L (37%) FEV1 0.31L (21%) FEV1/FVC 57%. Last intubation [**8-19**]. Multiple ICU admissions for BiPAP. On [**3-16**].5 L by NC at home and BiPAP at night ([**10-18**]).) Possible diastolic HF DM2 HTN GERD Hyperlipidemia Morbid Obesity (BMI 51) Schizophrenia Depression s/p R ankle ORIF Social History: 40 pack-year history of smoking, quit 10 years ago, no alcohol, no drug use. Was discharged to [**Doctor First Name **] house for rehab after last admission on [**10-20**]. Family History: non-contributory Physical Exam: VS: Temp 97.9: BP: 158/83 HR: 102 RR: 18 O2sat: 98% on PS 10/5 GEN: obese woman appearing older than her stated age, with NIPPV mask in place, mild respiratory distress. HEENT: PERRL, EOMI, anicteric, op not evaluated at this time [**2-15**] mask NECK: no supraclavicular or cervical lymphadenopathy, unable to assess jvd secondary to habitus, no carotid bruits RESP: poor air movement, likely low lung volumes with inspiratory and expiratory wheezes and faint bibasilar rales. CV: RR, S1 and S2 wnl, II/VI SEM at LLSB nonradiating. PMI diffuse. ABD: obese, nd, +b/s, soft, nt EXT: 1+ pitting edema to mid-calf. no c/c, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx1. 5/5 strength throughout. No sensory deficits to light touch appreciated. RECTAL: deferred URO: foley in place, draining clear yellow urine. Pertinent Results: Admission labs: [**2199-12-31**] 10:20AM WBC-13.3* RBC-4.75 HGB-11.9* HCT-38.4 MCV-81* MCH-25.0* MCHC-30.9* RDW-16.0* [**2199-12-31**] 10:20AM NEUTS-84.7* BANDS-0 LYMPHS-8.5* MONOS-4.7 EOS-1.5 BASOS-0.6 [**2199-12-31**] 10:20AM GLUCOSE-179* UREA N-13 CREAT-0.7 SODIUM-140 POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-34* ANION GAP-13 [**2199-12-31**] 03:42PM TYPE-ART TEMP-36.6 PO2-95 PCO2-70* PH-7.37 TOTAL CO2-42* BASE XS-11 INTUBATED-NOT INTUBA [**2199-12-31**] 03:42PM LACTATE-1.0 K+-3.8 [**2199-12-31**] 10:20AM cTropnT-<0.01 [**2199-12-31**] 10:18AM LACTATE-2.0 . CXR: Portable film showing bibasilar haziness obscuring the diaphrams bilaterally. Evidence of cephalization and perihilar fluffy infiltrates suggestive of pulmonary edema. Consolidation in the lower lobes is difficult to entirely excluded. No large effusion is evident; however, small effusions cannot be excluded. There is no pneumothorax. The cardiomediastinal silhouette remains stable in size, with a markedly enlarged heart. Brief Hospital Course: Summary: 65 yo F with severe COPD and history of multiple admissions for acute respiratory distress attributed to COPD flares, admitted to ICU for management of acute respiratory distress. . 1. COPD exacerbation: Patient improved greatly on NIPPV [**10-18**] in the MICU. She was initially treated steroids but this was discontinued as she improved quickly. She was also placed on standing albuterol nebulizers. She was transferred to the wards the next hospital day. Her SOB resolved by discharge. . 2. Community-acquired pneumonia: Pt had a mild leukocytosis on admission. CXR could not entirely exclude consolidation in the lower lobes. She was started on ceftriaxone, which was transitioned to cefpodoxime, and azithromycin x 5 days. . 3. Acute on chronic diastolic dysfunction: Pt was noted to have pulmonary edema on CXR. She was diuresed in the MICU and her home dose of furosemide was increased to 40 mg daily. . 4. OSA: Patient's obesity is likely the major contributing factor to OSA. Her BiPap regimen was increased to PS 14, PEEP 10. . 5. Hyperlipidemia: Pt was continued on home atorvastatin. . 6. HTN: Pt's BP was controlled on home regimen of amlodipine, hydralazine, and lisinopril. . 7. DM: Pt was placed on humalog ISS during hospitalization. . 8. Schizophrenia/Depression: Pt was continued on home Fluoxetine and risperadone. Medications on Admission: Albuterol Advair Calcium Dulcolax Fluoxetine Heparin subcut Hydralazine 50mg Q8hours Lasix 20mg qdaily Lipitor 20mg qdaily Lisinopril 40mg qdaily Norvasc 10mg qdaily Risperidone 2mg qdaily Novolog sliding scale Prilosec OTC Senna Tiotropium Trazadone Vitamin D Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 2. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-15**] Inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 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 DAILY (Daily). 6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Fluoxetine 40 mg Capsule Sig: Two (2) Capsule PO once a day. 11. Risperidone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 17. Insulin Regular Human 100 unit/mL Solution Sig: 1-10 units Injection ASDIR (AS DIRECTED): Please see sliding scale. 18. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 1 days. 19. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 1 days. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Chronic obstructive pulmonary disease . Secondary: Obstructive sleep apnea Diastolic congestive heart failure Hyperlipidemia Hypertension Diabetes mellitus Schizophrenia Depression Discharge Condition: Stable Discharge Instructions: You were admitted for difficulty breathing and confusion while your oxygen level was low. This was due to COPD (chronic obstructive pulmonary disease) exacerbation plus a possible pneumonia. You were treated with steroids, nebulizers, and antibiotics. You were also thought to have some fluid in your lungs. Your dose of Lasix (furesomide) was increased to help you get rid of the excess fluid. . Your BiPap was also adjusted to pressure support of 14, PEEP of 10. . Please take your medications as prescribed. Please finish your course of antibiotics. Your dose of Lasix has been increased to 40 mg daily. . If you develop confusion, shortness of breath, chest discomfort, palpitations, or any other worrisome symptoms, please call your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 693**]. Followup Instructions: Please see your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2200-1-29**] at 1PM. For any questions, please call [**Telephone/Fax (1) 693**]. . Please also keep the following appointments: Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2200-6-2**] 2:40 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2200-6-2**] 3:00 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 2515**] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2200-6-2**] 3:00 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

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icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

7557, 7614

4083, 5440

308, 314

7848, 7857

3043, 3043

8763, 9523

2169, 2187

5751, 7534

7635, 7827

5466, 5728

7881, 8740

2202, 3024

261, 270

342, 1549

3059, 4060

1571, 1962

1978, 2153

26,868

195,153

52921

Discharge summary

report

Admission Date: [**2164-1-8**] Discharge Date: [**2164-1-10**] Date of Birth: [**2090-1-9**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30201**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: None. History of Present Illness: 73F h/o DM, PVD s/p bilateral BKA, ESRD Afib and diastolic CHF with multiple admissions for acute pulmonary edema (most recent [**2164-1-4**]) who presents with acute SOB, 1 hour prior to admission. She was sitting at home watching a football game when the SOB came on suddenly; she denied CP, palpitations, cough, F/C, N/V, abd pain. EMS found that she was unable to speak in full sentences and BP was 220; they put her on CPAP (10) and gave NG x 3 with improvement in sx. By arrival to the ED, SBP was 130's; she was kept on CPAP for high RR (36) and started on a nitro drip and ASA 325 mg. TWI were noted on EKG in V5-V6 (though these were old compared to [**2164-1-4**] EKG). She was afebrile. (In addition, she was given ceftriaxone 1 g IV x 1 for a UTI; UCx from [**1-4**] grew Klebsiella, though returned after discharge so she has not received tx yet.) By arrival to the MICU, she was weaned to a NRB and quickly to 3LNC (home night O2 requirements). VS were T 96.0, HR 65, BP 115/46, RR 12, 100% on 3LNC. She was no longer ont he nitro drip. She said her sx were considerably improved. She denied missing her medications this morning; she lives alone at home, but a visting nurse normally arranges her medications for her. Of note, she has frequent hospitalizations for similar symtoms, the most recent of which was this last week [**1-4**] - [**1-5**]. Past Medical History: # CKD V on hemodialysis; qMWF schedule at [**Location (un) **] [**Location (un) **] # DM2 on insulin # HTN # Chronic diastolic CHF (LVEF >75%) with a history of tachycardia-induced acute LVOT obstruction # Hyperlipidemia # PVD s/p bilateral BKAs (left in [**2156**]; right in [**2157**]) # Paroxysmal a-flutter s/p failed ablation with subsequent atrial fibrillation; on warfarin # Chronic nighttime hypoxemia on 3 L/min nc # Secondary hyperparathyroidism # No occlusive coronary disease on cardiac cath [**12/2162**] # Left eye blindness # Mild functional mitral stenosis # GERD # Tobacco abuse-- still smokes [**12-23**] PPD as of [**12-30**] # h/o VRE UTI's # H/o Tibial fracture Social History: The patient denies alcohol and IV drug use. She states that she smokes approximately 3 cigarettes daily and has history of ~30 pack-year. She lives in a senior citizen center; her daughter lives with her. Family History: Her father died in his 90s of complications of DM2 and mother at the age of 102 of a stroke. Patient had a sister who died in her 70s of cancer (unknown type and site) and 2 brothers that died stroke and brain cancer. She has 7 children who are healthy. Her family history is significant for coronary artery disease, cancer, and diabetes. Physical Exam: Vitals: T 98.4, 134/48, 68, 18 98% on room air. Tm 98.8, 114-134/48, 68-74, 18, 93-98% on RA General: Alert, oriented, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no JVD Lungs: Clear in bilateral upper fields with crackles in bilateral lower fields. CV: Regular, II/VI SEM at R/LUSB w/o radiation to the neck; no rubs or gallops; left arm AV fistula with strong palpable thrill and continuous machine-like murmur. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: b/l BKA; no evidnee of cellulitis; WWP; no edema Neuro: AA, OX3; CN II-XII; moving all limbs Pertinent Results: Labs on admission: [**2164-1-8**] 07:20PM BLOOD WBC-11.4* RBC-3.76* Hgb-10.7* Hct-34.9* MCV-93 MCH-28.4 MCHC-30.6* RDW-19.3* Plt Ct-276 [**2164-1-8**] 07:20PM BLOOD Neuts-86.9* Lymphs-8.6* Monos-2.9 Eos-1.4 Baso-0.2 [**2164-1-8**] 07:20PM BLOOD PT-27.5* PTT-35.8* INR(PT)-2.8* [**2164-1-8**] 07:20PM BLOOD Glucose-168* UreaN-44* Creat-6.8*# Na-138 K-3.9 Cl-97 HCO3-28 AnGap-17 [**2164-1-8**] 07:20PM BLOOD CK(CPK)-47 [**2164-1-8**] 07:20PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 5405**]* [**2164-1-8**] 07:20PM BLOOD cTropnT-0.06* [**2164-1-9**] 05:46AM BLOOD Albumin-3.3* Calcium-8.1* Phos-4.7* Mg-2.0 [**2164-1-9**] 05:46AM BLOOD TSH-0.43 [**2164-1-9**] 05:46AM BLOOD Free T4-1.3 Labs on discharge: [**2164-1-10**] 06:35AM BLOOD WBC-7.8 RBC-3.89* Hgb-11.5* Hct-36.0 MCV-92 MCH-29.6 MCHC-32.0 RDW-20.0* Plt Ct-266 [**2164-1-10**] 06:35AM BLOOD PT-26.8* PTT-34.1 INR(PT)-2.7* [**2164-1-10**] 06:35AM BLOOD Glucose-69* UreaN-29* Creat-5.2*# Na-141 K-3.9 Cl-101 HCO3-30 AnGap-14 [**2164-1-10**] 06:35AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.8 Chest x-ray [**2164-1-8**]: 1. Slight interval improvement in pulmonary edema which is now mild-to-moderate in extent, with small bilateral pleural effusions. 2. More focal nodular opacities within the right upper lobe and right lower lobe which raise suspicion for superimposed infectious process. Brief Hospital Course: This is a 73 year old female with a history of DM, PVD s/p bilateral BKA, ESRD Afib and diastolic CHF with multiple admissions for acute pulmonary edema (most recent [**2164-1-4**]) who presented with acute SOB. EMS found that she was unable to speak in full sentences and BP was 220; they put her on CPAP (10) and gave NG x 3 with improvement in SBP to 130's. In the MICU, she was maintained on CPAP overnight; in the morning, she became subjectively dyspneic though her oxygen sats were 100%. She asked for BIPAP until HD, and she was able to be taken off BIPAP support when she initiated her HD run. During her period of dyspnea, she was also hypertensive with systolics in the high 100s where she was briefly given nitropaste until HD. # SOB: There is likely some degree of flash pulmonary edema in the setting of high BP. She had a significant improvement in symptoms with NG/afterload reduction. She denied medical non-compliance, however she seems to come in for similar symptoms often. She was easily weaned back to [**Month/Day/Year 5348**] O2 requirements (3LNC) with better BP control without lasix. Renal team followed the patient and she received HD on her regular schedule. Of note, she often experiences these symptoms on Sunday due to the extra day before dialysis (she normally has HD MWF). The extra day between Fri and Mon dialysis was addressed by providing the patient a low dose calcium channel blocker to take on Sundays. In addition, changing her Friday dialysis to the afternoons may be helpful in helping her make it through the extra time to Monday dialysis. #. HTN: She was continued on her home valsartan, lisinopril, metoprolol (tartrate 75 mg [**Hospital1 **] rather than home succinate 150 mg QD while in-patient). #. UTI: The patient has a positive urine culture from [**1-4**] admission, though the patient left before the culture returned. She was given one dose ceftriaxone in the ED, and was treated with a 3 day course of ceftriaxone. Medications on Admission: 1. Valsartan 160 mg QD 2. Lisinopril 10 mg QD 3. Metoprolol Succinate 150 mg QD 4. Simvastatin 40 mg QD 5. Amiodarone 200 mg PO QD 6. Warfarin 2 mg MO,WE,FR 7. Warfarin 1 mg [**Doctor First Name **],TU,TH,SA 8. Pantoprazole 40 mg QD 9. Albuterol MDI 2 puffs Q4 hours PRN 10. Brimonidine 0.15 % Drops 1 drop [**Hospital1 **] 11. Dorzolamide-Timolol 2-0.5 % Drops 2 drops [**Hospital1 **] 12. Folic Acid 1 mg QD 13. Latanoprost 0.005 % Drops 1 drop QHS 14. Sevelamer Carbonate 800 mg TID 15. Calcium Acetate 667 TID with meals 16. Aspirin 81 mg QD 17. Insulin NPH 4 U [**Hospital1 **] + Humalog SSI Discharge Medications: 1. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 7. Warfarin 1 mg Tablet Sig: One (1) Tablet PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H (Every 12 Hours). 10. Dorzolamide-Timolol 2-0.5 % Drops Sig: Two (2) Drop Ophthalmic Q12 HOURS. 11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. Insulin NPH 4U [**Hospital1 **] + Humalog SSI 17. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO every Sunday morning. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 18. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: Take after dialysis for the next two days. Disp:*2 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] [**Location (un) 269**] Discharge Diagnosis: - Acute on chronic diastolic congestive heart failure (CHF), LVEF >80% - Chronic Kidney Disease (CKD) on hemodialysis. - Diabetes Mellitus II on insulin. - Hypertension. Discharge Condition: Stable, afebrile. Discharge Instructions: You were admitted for shortness of breath. This improved greatly with hemodialysis. You have a very difficult balance of fluids to maintain. It is important to adhere to your sodium (salt) and fluid restriction in order to prevent fluid from building up in your body. Please be careful to take all of your medications and maintain your dialysis schedule. You have an additional two days of CEFPODOXIME to take for treating your urinary tract infection. Please take this medication after your dialysis on Wednesday. You are being given an additional medication called Imdur. You should take this medication (30mg by mouth) on Sunday morning. This medication is to help prevent hig blood pressure and fluid build-up on Sundays, prior to your hemodialysis on Monday. Your other medications were not changed. Please resume taking them as before. Please adhere to your follow-up appointments. They are important for managing your long-term health. Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. Followup Instructions: You have the following follow-up appointments: Cardiology: -Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2164-1-16**] 3:40 Primary care: -Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2164-1-19**] 12:40 Completed by:[**2164-1-23**]

[ "588.81", "428.33", "250.00", "305.1", "427.31", "V58.67", "V49.75", "496", "403.11", "428.0", "599.0", "585.6" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

9351, 9428

5081, 7058

335, 342

9642, 9661

3710, 3715

10897, 10920

2687, 3027

7705, 9328

9449, 9621

7084, 7682

9685, 10874

3042, 3691

10945, 11294

275, 297

4422, 5058

370, 1740

3729, 4403

1762, 2446

2462, 2671

5,014

153,891

22965

Discharge summary

report

Admission Date: [**2136-5-2**] Discharge Date: [**2136-5-7**] Date of Birth: [**2089-5-1**] Sex: F Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 16920**] Chief Complaint: Acquired right breast deformity status post mastectomy for breast cancer. Major Surgical or Invasive Procedure: s/p right total mastectomy and right breast construction with [**Last Name (un) 5884**] flap s/p right breast hematoma evacuation and exploration History of Present Illness: The patient recently had two operative procedures, with the resultant diagnosis of two separate sites of intraductal carcinoma. One site was extensive. The second site had positive margins. After discussing results with the patient, it was decided that a total mastectomy with excision of a few lower axillary nodes would be the appropriate choice. Past Medical History: HTN UC PUD arthritis s/p TAH Social History: NA Family History: NA Physical Exam: afebrile 92 110/70 16 97% RA HEENT: NCAT, EOMI Chest: CTA bil, right breast with some edema, but good doppler flow;, inc c/d/i CV: RRR ABD; soft NTNS< TRAM incision c/d/i EXT: no edema, pneumoboots Pertinent Results: [**2136-5-6**] 05:05AM BLOOD WBC-8.4 RBC-3.00* Hgb-8.9* Hct-25.7* MCV-86 MCH-29.8 MCHC-34.8 RDW-13.3 Plt Ct-184 [**2136-5-4**] 10:22PM BLOOD WBC-8.8 RBC-2.18* Hgb-6.4* Hct-18.5* MCV-85 MCH-29.5 MCHC-34.8 RDW-12.7 Plt Ct-168 [**2136-5-4**] 04:01AM BLOOD WBC-9.0 RBC-2.55* Hgb-7.5* Hct-21.8* MCV-85 MCH-29.5 MCHC-34.6 RDW-13.4 Plt Ct-154 [**2136-5-3**] 05:46PM BLOOD WBC-8.3 RBC-2.42* Hgb-7.2* Hct-20.5* MCV-85 MCH-29.6 MCHC-34.9 RDW-13.4 Plt Ct-161 [**2136-5-3**] 02:40AM BLOOD WBC-12.0* RBC-2.44*# Hgb-7.4*# Hct-20.6*# MCV-85 MCH-30.4 MCHC-36.0* RDW-12.9 Plt Ct-177 [**2136-5-2**] 09:30AM BLOOD WBC-9.5 RBC-4.68 Hgb-13.8 Hct-40.3 MCV-86 MCH-29.5 MCHC-34.2 RDW-12.9 Plt Ct-297 Brief Hospital Course: This pleasant female, was admitted to the plastic surgery service under the care of Dr. [**First Name (STitle) 3228**] after undergoing a right total mastectomy and right breat coonstruction with [**Last Name (un) 5884**]. The patient was noted to have low blood pressure post op and was fluid bolused which responded to fluid. She was noted to have low hematocrit as well on post op day 1 and was monitored over the next day. Since no obvious hematoma was appreciated on physical exam at this time, patient was transferred to the ICU for hemodynamic monitoring. She however finally was noted to have hematocrit of 18 and a ACW hematoma on post-op day 2. She was taken back to the operating room on [**5-4**] for evacuation of the heamtoma and was folllowed with hematocrits post-op. Her Hct leveled at approximately 25-27 and she was not continued on aspirin or heparin. Since her initial operation, she was continued on ancef and the head of the bed remained at elevated. She began to ambulate on pod 2 and was tolearting a regular diet. She was discharged on [**5-7**] to home with the drain in place and with duricef for 2 weeks. Medications on Admission: protonix 40 mg po qd atenolol 40 mg po qd vit D colazol 6MP hydrocort evenma 100 mg qd, vicodin prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while taking narcotic pain medication, do not take if having watery bowel movements or diarrhea. Disp:*60 Capsule(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day for 2 weeks. Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: s/p right total mastectomy and right breast construction with [**Last Name (un) 5884**] flap post-op bleeding Discharge Condition: Good Discharge Instructions: Please keep incision clean and dry. You may shower. Do NOT wear a bra or any other tight clothing. Please record your JP output. Followup Instructions: follow up with Dr. [**First Name (STitle) 3228**] in the next week. Please call to schedule an appointment Completed by:[**2136-5-7**]

[ "401.9", "174.4", "458.0", "998.12" ]

icd9cm

[ [ [] ] ]

[ "85.7", "85.43", "99.00", "85.0" ]

icd9pcs

[ [ [] ] ]

3813, 3871

1943, 3080

387, 536

4025, 4031

1243, 1920

4208, 4345

1004, 1008

3230, 3790

3892, 4004

3106, 3207

4055, 4185

1023, 1224

273, 349

564, 915

937, 968

984, 988

4,836

119,670

8435+8436+8437

Discharge summary

report+report+report

Admission Date: [**2107-3-29**] Discharge Date: [**2107-3-31**] Service: Briefly this is an 82-year-old woman with an extensive past medical history of peripheral vascular disease and multiple bypass surgeries who presented with a known thoracoabdominal aneurysm. She was planned for a repair on [**2107-3-29**] and was taken to the Operating Room. Please see operative report for further details. PAST MEDICAL HISTORY: Significant for multiple bypass surgeries including a bilateral fem-[**Doctor Last Name **] subclavian bypass, renal vein bypass. She is also status post myocardial infarction in [**2082**] with severe mitral valve regurgitation. She is also status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. MEDICATIONS ON ADMISSION: 1. Aspirin 325 p.o. q.d. 2. Nifedipine 30 p.o. q.d. 3. Lasix 40 p.o. q.d. 4. Ativan. 5 Quinine. 6. Hydrocodone. 7. Pinazepam. PHYSICAL EXAMINATION: She was afebrile with stable vitals, well appearing lady with clear lungs. Her heart was regular rate and rhythm with a 4 out of 6 systolic murmur. Her abdomen was soft and mildly obese, nontender and nondistended. Extremities were warm and well perfused. She had doppler pulses peripherally. On [**2107-3-29**], the patient was taken to the Operating Room for her thoracoabdominal aortic aneurysm repair, please see operative report for details. Postoperatively, she was transferred to PACU, intubated with Swan-Ganz catheter in place. She required significant resuscitation and her hematocrit was slowly decreased. It was found that she was bleeding internally and required significant resuscitation on that first postoperative day. Her hematocrit continued to drop and her abdomen became more and more distended. It was decided that the patient should return to the Operating Room for an exploratory laparotomy and wash out. She was taken to the Operating Room for this procedure. There was no clear identifiable bleeding site, however, there was significant oozing. All of this oozing was stopped. The anastomoses were inspected, again new sutures were placed to stop any further bleeding from the anastomotic site and the patient was transferred back to the PACU. Again, the patient required significant fluid resuscitation and her bladder pressures continued to increase. Her pulmonary pressures also continued to increase and became more and more difficult to ventilate the patient including her airway pressures rising to 50's and 60's. Again, her belly began to become more and more distended and it was decided that the patient would return to the Operating Room again for another exploratory laparotomy and wash out. The second wash out was also found to be benign with no active sites of bleeding. However, it was decided that because of the bowel edema and significant fluid resuscitation, that the abdomen would be left open. The belly was packed and Iodoform dressing was placed with two JP's. The JP's were hooked to wall suction. The patient continued to require a significant fluid resuscitation through the day. The patient was transferred to the trauma Intensive Care Unit after the second operation. The patient continued to require fluid resuscitation and also needed cardiac pressors in order to keep an adequate blood pressure. It was decided at that time that the patient continued to be stable and she would return to the Operating Room on the 18th for a second look and the decision would be made about whether or not the abdomen could be closed. On the 17th night, she began dropping her blood pressure which did not respond to fluid resuscitation and the patient was started on vasopressin. The patient was also on Levophed and dobutamine at the time. The dobutamine was weaned off and Levophed was continued. During the original operation, a transesophageal echocardiogram was performed and found that the patient had severe MR and also had moderate aortic wall motion abnormality and severe [**Male First Name (un) **]. The patient continued to have a severe acidosis and required significant fluid resuscitation. The patient was then taken back to the Operating Room on [**2107-3-31**] for a second look wash out. Upon taking down the dressing in the Operating Room, it was found that a significant amount of her bowel was ischemic and dead. Both arterial anastomoses were quickly inspected. The celiac artery reimplantation was completely opened and a good strong palpable pulse was felt. The SMA was also opened. However, the pulses was Dopplerable and the renal artery was also opened as well. At this time, the patient's abdomen was closed and she was transferred back to the Intensive Care Unit. Discussion was carried out with the family as to the findings of the operation and the likelihood that the patient would not survive this hospital stay. It was decided at this time, that the patient would have fluid withdrawn and made comfortable. The patient endotracheal tube was removed and the patient was given morphine for pain control and her cardiac pressors were stopped. The patient shortly expired thereafter. The patient died at 1:55 p.m. on [**2107-3-31**] with family being present. Upon discussion with the family, postmortem was refused and the medical examiner. The patient died on [**2107-3-31**]. DR.[**Last Name (STitle) 1111**],[**First Name3 (LF) 1112**] 002-287 Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2107-3-31**] 14:31 T: [**2107-3-31**] 14:42 JOB#: [**Job Number 29739**] Admission Date: [**2107-3-29**] Discharge Date: [**2107-3-31**] Service: Briefly this is an 82-year-old woman with an extensive past medical history of peripheral vascular disease and multiple bypass surgeries who presented with a known thoracoabdominal aneurysm. She was planned for a repair on [**2107-3-29**] and was taken to the Operating Room. Please see operative report for further details. PAST MEDICAL HISTORY: Significant for multiple bypass surgeries including a bilateral fem-[**Doctor Last Name **] subclavian bypass, renal vein bypass. She is also status post myocardial infarction in [**2082**] with severe mitral valve regurgitation. She is also status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. MEDICATIONS ON ADMISSION: 1. Aspirin 325 p.o. q.d. 2. Nifedipine 30 p.o. q.d. 3. Lasix 40 p.o. q.d. 4. Ativan. 5 Quinine. 6. Hydrocodone. 7. Pinazepam. PHYSICAL EXAMINATION: She was afebrile with stable vitals, well appearing lady with clear lungs. Her heart was regular rate and rhythm with a 4 out of 6 systolic murmur. Her abdomen was soft and mildly obese, nontender and nondistended. Extremities were warm and well perfused. She had doppler pulses peripherally. On [**2107-3-29**], the patient was taken to the Operating Room for her thoracoabdominal aortic aneurysm repair, please see operative report for details. Postoperatively, she was transferred to PACU, intubated with Swan-Ganz catheter in place. She required significant resuscitation and her hematocrit was slowly decreased. It was found that she was bleeding internally and required significant resuscitation on that first postoperative day. Her hematocrit continued to drop and her abdomen became more and more distended. It was decided that the patient should return to the Operating Room for an exploratory laparotomy and wash out. She was taken to the Operating Room for this procedure. There was no clear identifiable bleeding site, however, there was significant oozing. All of this oozing was stopped. The anastomoses were inspected, again new sutures were placed to stop any further bleeding from the anastomotic site and the patient was transferred back to the PACU. Again, the patient required significant fluid resuscitation and her bladder pressures continued to increase. Her pulmonary pressures also continued to increase and became more and more difficult to ventilate the patient including her airway pressures rising to 50's and 60's. Again, her belly began to become more and more distended and it was decided that the patient would return to the Operating Room again for another exploratory laparotomy and wash out. The second wash out was also found to be benign with no active sites of bleeding. However, it was decided that because of the bowel edema and significant fluid resuscitation, that the abdomen would be left open. The belly was packed and Iodoform dressing was placed with two JP's. The JP's were hooked to wall suction. The patient continued to require a significant fluid resuscitation through the day. The patient was transferred to the trauma Intensive Care Unit after the second operation. The patient continued to require fluid resuscitation and also needed cardiac pressors in order to keep an adequate blood pressure. It was decided at that time that the patient continued to be stable and she would return to the Operating Room on the 18th for a second look and the decision would be made about whether or not the abdomen could be closed. On the 17th night, she began dropping her blood pressure which did not respond to fluid resuscitation and the patient was started on vasopressin. The patient was also on Levophed and dobutamine at the time. The dobutamine was weaned off and Levophed was continued. During the original operation, a transesophageal echocardiogram was performed and found that the patient had severe MR and also had moderate aortic wall motion abnormality and severe [**Male First Name (un) **]. The patient continued to have a severe acidosis and required significant fluid resuscitation. The patient was then taken back to the Operating Room on [**2107-3-31**] for a second look wash out. Upon taking down the dressing in the Operating Room, it was found that a significant amount of her bowel was ischemic and dead. Both arterial anastomoses were quickly inspected. The celiac artery reimplantation was completely opened and a good strong palpable pulse was felt. The SMA was also opened. However, the pulses was Dopplerable and the renal artery was also opened as well. At this time, the patient's abdomen was closed and she was transferred back to the Intensive Care Unit. Discussion was carried out with the family as to the findings of the operation and the likelihood that the patient would not survive this hospital stay. It was decided at this time, that the patient would have fluid withdrawn and made comfortable. The patient endotracheal tube was removed and the patient was given morphine for pain control and her cardiac pressors were stopped. The patient shortly expired thereafter. The patient died at 1:55 p.m. on [**2107-3-31**] with family being present. Upon discussion with the family, postmortem was refused and the medical examiner. The patient died on [**2107-3-31**]. DR.[**Last Name (STitle) 1111**],[**First Name3 (LF) 1112**] 02-287 Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2107-3-31**] 14:31 T: [**2107-3-31**] 14:56 JOB#: [**Job Number 29739**] Admission Date: [**2107-3-29**] Discharge Date: [**2107-3-31**] Service: Briefly this is an 82-year-old woman with an extensive past medical history of peripheral vascular disease and multiple bypass surgeries who presented with a known thoracoabdominal aneurysm. She was planned for a repair on [**2107-3-29**] and was taken to the Operating Room. Please see operative report for further details. PAST MEDICAL HISTORY: Significant for multiple bypass surgeries including a bilateral fem-[**Doctor Last Name **] subclavian bypass, renal vein bypass. She is also status post myocardial infarction in [**2082**] with severe mitral valve regurgitation. She is also status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. MEDICATIONS ON ADMISSION: 1. Aspirin 325 p.o. q.d. 2. Nifedipine 30 p.o. q.d. 3. Lasix 40 p.o. q.d. 4. Ativan. 5 Quinine. 6. Hydrocodone. 7. Pinazepam. PHYSICAL EXAMINATION: She was afebrile with stable vitals, well appearing lady with clear lungs. Her heart was regular rate and rhythm with a 4 out of 6 systolic murmur. Her abdomen was soft and mildly obese, nontender and nondistended. Extremities were warm and well perfused. She had doppler pulses peripherally. On [**2107-3-29**], the patient was taken to the Operating Room for her thoracoabdominal aortic aneurysm repair, please see operative report for details. Postoperatively, she was transferred to PACU, intubated with Swan-Ganz catheter in place. She required significant resuscitation and her hematocrit was slowly decreased. It was found that she was bleeding internally and required significant resuscitation on that first postoperative day. Her hematocrit continued to drop and her abdomen became more and more distended. It was decided that the patient should return to the Operating Room for an exploratory laparotomy and wash out. She was taken to the Operating Room for this procedure. There was no clear identifiable bleeding site, however, there was significant oozing. All of this oozing was stopped. The anastomoses were inspected, again new sutures were placed to stop any further bleeding from the anastomotic site and the patient was transferred back to the PACU. Again, the patient required significant fluid resuscitation and her bladder pressures continued to increase. Her pulmonary pressures also continued to increase and became more and more difficult to ventilate the patient including her airway pressures rising to 50's and 60's. Again, her belly began to become more and more distended and it was decided that the patient would return to the Operating Room again for another exploratory laparotomy and wash out. The second wash out was also found to be benign with no active sites of bleeding. However, it was decided that because of the bowel edema and significant fluid resuscitation, that the abdomen would be left open. The belly was packed and Iodoform dressing was placed with two JP's. The JP's were hooked to wall suction. The patient continued to require a significant fluid resuscitation through the day. The patient was transferred to the trauma Intensive Care Unit after the second operation. The patient continued to require fluid resuscitation and also needed cardiac pressors in order to keep an adequate blood pressure. It was decided at that time that the patient continued to be stable and she would return to the Operating Room on the 18th for a second look and the decision would be made about whether or not the abdomen could be closed. On the 17th night, she began dropping her blood pressure which did not respond to fluid resuscitation and the patient was started on vasopressin. The patient was also on Levophed and dobutamine at the time. The dobutamine was weaned off and Levophed was continued. During the original operation, a transesophageal echocardiogram was performed and found that the patient had severe MR and also had moderate aortic wall motion abnormality and severe [**Male First Name (un) **]. The patient continued to have a severe acidosis and required significant fluid resuscitation. The patient was then taken back to the Operating Room on [**2107-3-31**] for a second look wash out. Upon taking down the dressing in the Operating Room, it was found that a significant amount of her bowel was ischemic and dead. Both arterial anastomoses were quickly inspected. The celiac artery reimplantation was completely opened and a good strong palpable pulse was felt. The SMA was also opened. However, the pulses was Dopplerable and the renal artery was also opened as well. At this time, the patient's abdomen was closed and she was transferred back to the Intensive Care Unit. Discussion was carried out with the family as to the findings of the operation and the likelihood that the patient would not survive this hospital stay. It was decided at this time, that the patient would have fluid withdrawn and made comfortable. The patient endotracheal tube was removed and the patient was given morphine for pain control and her cardiac pressors were stopped. The patient shortly expired thereafter. The patient died at 1:55 p.m. on [**2107-3-31**] with family being present. Upon discussion with the family, postmortem was refused and the medical examiner. The patient died on [**2107-3-31**]. DR.[**Last Name (STitle) 1111**],[**First Name3 (LF) 1112**] 02-287 Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2107-3-31**] 14:31 T: [**2107-3-31**] 14:42 JOB#: [**Job Number 29740**]

[ "441.4", "998.11", "441.7", "286.6", "995.92", "518.5", "998.2", "557.0", "038.9" ]

icd9cm

[ [ [] ] ]

[ "39.25", "89.64", "99.06", "54.59", "38.44", "54.12", "38.16", "99.04", "99.05", "38.45", "56.82", "99.07" ]

icd9pcs

[ [ [] ] ]

11859, 11993

12016, 16615

11512, 11833

11,613

168,054

24807

Discharge summary

report

Admission Date: [**2178-9-8**] Discharge Date: [**2178-9-12**] Date of Birth: [**2107-6-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9569**] Chief Complaint: chest pain, tnt leak, ?NSTEMI Major Surgical or Invasive Procedure: NG lavage Upper endoscopy, [**2178-9-9**]. History of Present Illness: 71 yo female with DM, HTN, hypercholesterolemia, known CAD s/p LAD stent [**2-/2176**] in [**Male First Name (un) 1056**] who presented initially to [**Hospital6 3105**] with SSCP which radiated to her back and was associated with SOB, N/V. Pain started while she was walking in a store, was similar to the pain she felt from her prior MI. She called an ambulance which took her to [**Hospital 487**] [**Hospital **] Hosp, where an EKG there showed ST depressions in II, III, aVF, V4-V6. She was given ASA, Plavix 600, IV heparin, IV Integrilin, IV TNG. Labs from OSH: CPK = 277, TnI = 0.04. She was then transferred to [**Hospital1 18**] for consideration for cath. While in the ED, she received nitro gtt, hep gtt, integrillin gtt, lasix 20mg iv, bicarb-containing fluid, mucomyst. Cards fellow evaluated and discussed with Cards Attd. Patient to be admitted to [**Hospital Unit Name 196**] with likely cath in AM. Past Medical History: Primary: CAD s/p MI in [**Male First Name (un) 1056**], received LAD stent [**2-/2176**] GI bleed Gastritis HTN Secondary: DM2 hypercholesterolemia Anemia TAH Social History: Pt lives with her family, occ etoh, no smoking, no other drugs Family History: CAD - MI in 70s Physical Exam: PE Vitals: 98.1-98.4 156-255/33-80 54-75 18-20 97-100%(RA) 1640(in)/700(out) Gen: pleasant, NAD HEENT: NCAT, EOMI, MMM, anicteric Neck: supple, no LAD, no JVD though large neck makes exam difficult, no bruit, no masses CV: RRR, nl s1 s2, [**2-1**] syst murmur at LUSB without rads. No R/G. Lungs: decreased air mvmt throughout, bibasilar rales, no wheeze, no rhonchi Abd: obese, soft, nt, nd, +bs Ext: no c/c/e, no edema Skin: multiple nevi over shoulders, neck Neuro: AOx3. Moves ext x 4. CN 2-12 intact grossly. Pertinent Results: Reports: CTA [**9-8**]: No PE. Cardiomegaly and bilateral perihilar ground glass opacities and septal thickening likely due to CHF. No pleural or pericardial effusions. EKG [**9-8**]: sinus brady @ 53bpm, stable LBBB, TWI in I,aVL,V6 CXR [**9-8**]: IMPRESSION: Improving pulmonary congestion, probably persisting cardiomegaly, no evidence of chest infiltrates on portable single view chest examination. Gastric Lavage [**9-8**]: bright red clots EGD [**9-9**]: Impression: Erythema and multiple superficial linear erosions in the stomach body and antrum compatible with gastritis Pink filmy material was found in the lower third of the esophagus. It is unclear if this is from food or other process (ie [**Female First Name (un) **]). . Recommendations: The erosions may account for the patient's GI bleed. The patient should continue PPI [**Hospital1 **] for 6 weeks and then get a f/u EGD. Avoid NSAIDs. Given patient's recurrent ulcers and negative H.pylori serology, would check a serum gastrin level. The patient should be scheduled for a colonoscopy if she hasn't had one recently (within past 1-2yrs). [**2178-9-8**] 11:20AM CREAT-1.6* [**2178-9-8**] 11:20AM CK(CPK)-120 [**2178-9-8**] 11:20AM CK-MB-4 cTropnT-0.02* [**2178-9-8**] 11:20AM WBC-9.8 RBC-3.11* HGB-7.9* HCT-24.3* MCV-78* MCH-25.3* MCHC-32.4 RDW-20.1* [**2178-9-8**] 11:20AM PT-15.5* PTT-93.5* INR(PT)-1.6 [**2178-9-8**] 11:20AM PLT COUNT-194 [**2178-9-8**] 03:30AM GLUCOSE-233* UREA N-28* CREAT-1.3* SODIUM-137 POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-23 ANION GAP-20 [**2178-9-11**] 07:00AM BLOOD WBC-10.6 RBC-3.89* Hgb-11.0* Hct-32.4* MCV-83 MCH- 28.4 MCHC-34.1 RDW-17.3* Plt Ct-155 [**2178-9-11**] 07:00AM BLOOD Plt Ct-155 [**2178-9-11**] 07:00AM BLOOD Glucose-212* UreaN-24* Creat-1.1 Na-136 K-3.9 Cl- 104 HCO3-23 AnGap-13 Brief Hospital Course: A/P: 71 yo F with known CAD s/p MI, LAD stent [**2-/2176**], p/w unstable angina to OSH, transferred here for possible cath. . 1. CP/CAD: Pt was admitted to cardiology service no longer in chest pain. At the OSH, she was started on heparin gtt, nitroglycerin gtt, integrillin, and plavix. This was stopped in the setting of GI bleed. She had a CK that went from 178 down to 120 on day of admission and TropT that was 0.02 x 2. She experienced no more chest pain or shortness of breath. Chest pain and troponin leak may have been in the setting of demand, given her GI bleed. Her medical regimen was optimized, and she will follow up with her outpatient cardiologist and PCP. 2. GI bleed: On day of admission, patient experienced a frank GI bleed with hematocrit dropping as low as 23.1. She was transported to the MICU, where she received 4 units pRBCs and an upper endoscopy which showed gastritis as outlined above. Her hematocrit stabilized in the MICU to 35, and she was transported back to the cardiology floor, where her hematocrit remained stable at about 32-36. H. pylori antibody was positive, and gastrin was pending at time of dishcharged. Her Protonix was increased to 40 [**Hospital1 **] (for 1-2 weeks) and ASA/NSAIDS avoided. She may restart aspirin in [**12-28**] weeks if hematocrit remains stable. She will follow up with her outpatient PCP for Colonoscopy and repeat EGD. 3. HTN: Upon admission, pt was not significantly hypertensive as she was on NTG ggt. When she returned to the cardiology floor, she was hypertensive to SBP above 200. Her lisinopril and metoprolol were titrated up, she was begun on Imdur and amlodipine, and she was restarted on her HCTZ. Renal ultrasound with doppler showed normal kidneys without evidence of renal artery stenosis. Blood pressure was 140-150's (systolic) at time of discharge. 4. Renal: Pt with DM2 and received a dye load with CTA. She was likely volume depleted as well and BUN/Cr ration > 20. Her HCTZ was held. Her Cr trended back to normal by day of discharge. She was restarted on her ACEI and HCTZ at time of discharge. 5. Disposition: She was discharged in good condition, to follow up with her PCP and cardiologist. Medications on Admission: Meds at home: Insulin 70/30: 50 units qAM, 30 units qPM Atenolol 50mg qd Iron 325mg qd ASA 81mg qd Benazepril 20mg qd Protonix 40mg qd Levoxyl 100mcg qd Metformin 500mg [**Hospital1 **] HCTZ 25mg qd Lipitor 40mg qd Add'l meds on transfer: Nitro gtt Integrillin gtt Heparin gtt Plavix 600mg x once . All: NKDA Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig: One (1) ML Injection ONCE (once) for 1 doses. Disp:*1 ML(s)* Refills:*0* 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Insulin NPH-Regular Human Rec 70-30 unit/mL Suspension Sig: One (1) 30 Subcutaneous at bedtime. 12. Insulin NPH-Regular Human Rec 70-30 unit/mL Suspension Sig: One (1) 50 Subcutaneous qam. 13. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Chest Pain; CAD s/p stent to LAD [**2175**] in [**Male First Name (un) 1056**] 2. GI bleed/Gastritis 3. HTN Secondary Diagnoses: 1. Diabetes mellitus 2. Hypothyroidism Discharge Condition: good Discharge Instructions: 1. If you experience chest pain, shortness of breath, lightheadedness/dizziness, blood in your stool or black tarry stools, abdominal pain, nausea/vomiting, bloody vomit, please contact you primary care physician, [**Name Initial (NameIs) 138**] 911, or go to your nearest emergency department. 2. Please continue the medications you were on in the outside hospital with the following exceptions: -your lisinipril has been increased to 40 mg daily. -we have added Imdur (isosorbide mononitrate, extended release) 90 mg daily to your regimen. -your Protonix (pantoprazole) has been increased to 40 mg twice a day. Take this for 2 weeks. After this, return to taking protonix once daily - Please continue with 100 mg daily of atenolol - We added Amlodipine 10 mg daily - We are holding your aspirin for 2 weeks given your GI bleed. Please restart this in 2 weeks. Please do not take any ibuprofen, alleve; these could cause further GI bleeding. 3. Please follow up as outlined below. Followup Instructions: Please see your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 71**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 59225**]) within the next 1 week. He should follow up your blood pressure and change your medications if necessary. Please follow-up with colonoscopy and repeat upper endoscopy in the next 6 weeks. Talk to your PCP about scheduling follow up with a gastroenterologist in your area.

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icd9cm

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Discharge summary

report+report

Admission Date: [**2146-7-23**] Discharge Date: [**2146-7-29**] Date of Birth: [**2084-5-9**] Sex: M Service: Transplant Surgery HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 62-year-old male with type 2 diabetes, hypertension, end-stage renal disease (on hemodialysis since [**2145-5-5**]), and has been on the kidney transplant list for the past three months. The patient reports doing well without any complaints. He does have a left arteriovenous graft which is working well. In his workup, the only abnormality noted was in [**2146-5-5**]. A thallium study showed a small area of ischemia in the high lateral wall. The patient saw his cardiologist (Dr. [**Last Name (STitle) 34313**] earlier this week who said the patient was cleared for transplant (per patient report). The patient presented on [**2146-7-23**] for a cadaveric renal transplant. PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus since the age of 40. 2. Left arteriovenous graft; working well. He has been on hemodialysis since [**2145-5-5**] at the [**Location (un) 4265**] [**University/College **] Dialysis Center two times per week. 3. Kidney stones. 4. Hypertension. 5. Neuropathy. 6. Retinopathy. 7. Right Charcot foot. 8. Status post appendectomy. 9. Pilonidal cyst. ALLERGIES: INTRAVENOUS CONTRAST DYE (some nausea). MEDICATIONS ON ADMISSION: 1. Regular insulin 20 units subcutaneously q.a.m. and 10 units subcutaneously q.p.m. 2. NPH 30 units subcutaneously q.a.m. and 28 units subcutaneously. 3. Avandia 8 mg by mouth every day. 4. Zestril 40 mg by mouth once per day. 5. Nephrocaps. 6. Neurontin. 7. Diovan 20 mg by mouth four times per day as needed. 8. Elavil. SOCIAL HISTORY: A 35-pack-year tobacco history; quit eight years ago. Occasionally drinks alcohol. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 99.2, blood pressure was 135/80, heart rate was 104, respiratory rate was 22, and oxygen saturation was 100% on room air. In general, in no acute distress. Skin was warm and dry. Head, eyes, ears, nose, and throat examination revealed the oropharynx was clear. Sclerae were anicteric. The neck was supple. No jugular venous distention. No lymphadenopathy. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. The lungs were clear to auscultation bilaterally. The abdomen was obese. Bowel sounds were present. Soft, nontender, and nondistended. No hepatosplenomegaly. Back revealed there was no costovertebral angle tenderness or spinal tenderness. Extremity examination revealed there was no edema. There were venous stasis changes. The left arm had an arteriovenous graft thrill. Neurologic examination revealed alert and oriented. Normal neurologic examination. Cranial nerves were intact. Decreased reflexes bilaterally symmetrically in the lower extremities. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories revealed white blood cell count was 6.6, hematocrit was 34.3, and platelets were 218. Sodium was 138, potassium was 3.8, chloride was 93, bicarbonate was 32, blood urea nitrogen was 21, creatinine was 5.4, and blood glucose was 253. ALT was 23, AST was 26, alkaline phosphatase was 96, and total bilirubin was 0.3. The urinalysis showed 3 to 5 white blood cells, 0 to 2 epithelial cells, trace leukocyte esterase, and negative nitrites. Negative hepatology serologies. PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed some fullness around the mediastinum. There were no infiltrates. Electrocardiogram revealed a normal sinus rhythm at 95. Normal axis and normal intervals. There were small Q waves in leads I and aVL. Echocardiogram in [**2145-12-5**] revealed an ejection fraction of 55% with trace mitral regurgitation. A stress thallium in [**2145-12-5**] by Dr. [**Last Name (STitle) 34313**] indicated a small area of ischemia in the high lateral wall. A colonoscopy was normal in [**2146-2-5**]. A chest computed tomography indicated mediastinal fullness secondary to adipose tissue. No lymphadenopathy. SUMMARY OF HOSPITAL COURSE: Mr. [**Known lastname **] is a 62-year-old male with end-stage renal disease secondary to diabetes and hypertension who presented on [**2146-7-23**] for a cadaveric renal transplant. Consent was obtained, and the patient was taken to the operating room. The operation went without any complications. Postoperatively, in the Recovery Room, the patient became hypotensive with systolic blood pressures running in the 70s to 90s. He was bolused several times. An electrocardiogram revealed no ischemic changes. Cardiac enzymes were sent. The patient was placed on a dopamine drip running between 2 mcg/kg and 5 mcg/kg per minute with minimal resolution of hypotension and anuria/oliguria. Neo-Synephrine was added (by the request of the Transplant fellow). Additionally, continuous positive airway pressure was started given the patient's history of sleep apnea. The patient's blood pressure stabilized in the 120s to 130s/50s to 60s. The patient was eventually weaned off both the Neo-Synephrine and dopamine. Repeat arterial blood gases showed marked improvement. In the Recovery Room, his potassium was 5.8. The patient was hemodialyzed. The patient was started on thymoglobulin, CellCept, Solu-Medrol, and the usual prophylaxis with Bactrim and Valcyte. The patient remained in the Vascular Intensive Care Unit during dialysis for closer monitoring given his cardiac enzymes which were sent. His troponin T had slightly risen from 0.07 to 0.14, and Cardiology was consulted. The patient was started on Lopressor 12.5 mg by mouth twice per day as well as aspirin 81 mg by mouth once per day. Cardiology did not believe that the patient had a myocardial infarction, but they continued to monitor him closely. The patient remained on telemetry throughout his hospital course. Given the patient's delayed graft function, slight increase in troponin level were not unexpected by the Renal team. The patient's urine output was carefully monitored as well as his electrolytes. The patient was requiring 2 liters to 3 liters of oxygen via nasal cannula daily to maintain saturations in the 90s. A chest x-ray revealed bilateral pleural effusions, a moderate-sized pleural effusion on the right side. At that point, we decided to diurese the patient with Lasix. We sent the patient home on Lasix 60 mg by mouth twice per day. The patient's primary care physician was [**Name (NI) 653**], and we were informed that the patient regularly has an oxygen saturation in the 80s. Given his saturation of 72% on room air with ambulation, the patient was discharged with oxygen as well as pulse oximetry with teaching provided by Respiratory Therapy. The patient had a short course of levofloxacin. Given his x-ray with a significant pleural effusion, we could not rule out an infiltrate. This antibiotic was discontinued by the time of discharge, and his chest x-ray showed marked improvement. The patient received five doses of thymoglobulin as well as a Solu-Medrol taper. He was discharged on tacrolimus at a dose of 6 mg by mouth twice per day and CellCept [**Pager number **] mg by mouth twice per day. The patient continued to do well. He was tolerating solids and ambulating regularly. To improve his pulmonary condition, chest physical therapy and pulmonary toilet were provided. The patient's urine output continued to improve, and he did not require any further dialysis. On postoperative day six, the patient was thought to be stable for discharge with home oxygen and pulse oximetry. The patient was scheduled to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] at the Transplant Center on [**8-1**] and with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**8-9**]. The patient was discharged with prescription for Percocet, potassium, Lasix, and oxygen. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE DIAGNOSES: 1. End-stage renal disease secondary to diabetes and hypertension. 2. Status post cadaveric renal transplant; delayed graft function with marked improvement by the time of discharge. 3. Hypotension most likely secondary to anesthesia. 4. Neuropathy. 5. Sleep apnea. 6. Postoperative hypoxemia. 7. Postoperative hyperkalemia; resolved after dialysis. 8. Ruled out for a myocardial infarction. MEDICATIONS ON DISCHARGE: 1. Bactrim-SS one tablet by mouth once per day. 2. Valcyte 450 mg one tablet by mouth every other day. 3. Pantoprazole 40 mg by mouth once per day. 4. Colace 100 mg by mouth twice per day. 5. Amitriptyline 50-mg tablets one tablet by mouth once per day. 6. Nystatin swish-and-swallow. 7. CellCept [**Pager number **]-mg tablets two tablets by mouth twice per day. 8. Aspirin 81 mg by mouth once per day. 9. Albuterol inhaler 1 to 2 puffs inhaled q.6h. as needed. 10. Metoprolol 25 mg by mouth twice per day. 11. Percocet one to two tablets by mouth q.4-6h. as needed (for pain). 12. Avandia 8 mg by mouth every day. 13. Insulin sliding-scale as provided for the patient. 14. Furosemide 60 mg by mouth twice per day. 15. Tacrolimus 6 mg by mouth twice per day. 16. Potassium chloride 10-mEq tablets one tablet to be taken once per day when the patient takes Lasix. 17. Oxygen 2 liters to 3 liters continuous with respiratory therapy instructing the patient on use of pulse oximetry. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] at the Transplant Center in the [**Last Name (un) 2577**] Building (telephone number [**Telephone/Fax (1) 673**]) on [**2146-8-1**] at 11:30 a.m. 2. The patient was also to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**Last Name (un) 2577**] Building on [**2146-8-9**] at 9:20 a.m. 3. The patient was also to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2146-8-15**] at 9:20 a.m. at the Transplant Center. [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**] Dictated By:[**Last Name (NamePattern1) 28937**] MEDQUIST36 D: [**2146-7-29**] 21:40 T: [**2146-8-10**] 08:55 JOB#: [**Job Number 34314**] Admission Date: [**2146-7-23**] Discharge Date: [**2146-7-29**] Date of Birth: [**2084-5-9**] Sex: M Service: Transplant Surgery HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 62-year-old male with type 2 diabetes, hypertension, end-stage renal disease (on hemodialysis since [**2145-5-5**]), and has been on the kidney transplant list for the past three months. The patient reports doing well without any complaints. He does have a left arteriovenous graft which is working well. In his workup, the only abnormality noted was in [**2146-5-5**]. A thallium study showed a small area of ischemia in the high lateral wall. The patient saw his cardiologist (Dr. [**Last Name (STitle) 34313**] earlier this week who said the patient was cleared for transplant (per patient report). The patient presented on [**2146-7-23**] for a cadaveric renal transplant. PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus since the age of 40. 2. Left arteriovenous graft; working well. He has been on hemodialysis since [**2145-5-5**] at the [**Location (un) 4265**] [**University/College **] Dialysis Center two times per week. 3. Kidney stones. 4. Hypertension. 5. Neuropathy. 6. Retinopathy. 7. Right Charcot foot. 8. Status post appendectomy. 9. Pilonidal cyst. ALLERGIES: INTRAVENOUS CONTRAST DYE (some nausea). MEDICATIONS ON ADMISSION: 1. Regular insulin 20 units subcutaneously q.a.m. and 10 units subcutaneously q.p.m. 2. NPH 30 units subcutaneously q.a.m. and 28 units subcutaneously. 3. Avandia 8 mg by mouth every day. 4. Zestril 40 mg by mouth once per day. 5. Nephrocaps. 6. Neurontin. 7. Diovan 20 mg by mouth four times per day as needed. 8. Elavil. SOCIAL HISTORY: A 35-pack-year tobacco history; quit eight years ago. Occasionally drinks alcohol. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 99.2, blood pressure was 135/80, heart rate was 104, respiratory rate was 22, and oxygen saturation was 100% on room air. In general, in no acute distress. Skin was warm and dry. Head, eyes, ears, nose, and throat examination revealed the oropharynx was clear. Sclerae were anicteric. The neck was supple. No jugular venous distention. No lymphadenopathy. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. The lungs were clear to auscultation bilaterally. The abdomen was obese. Bowel sounds were present. Soft, nontender, and nondistended. No hepatosplenomegaly. Back revealed there was no costovertebral angle tenderness or spinal tenderness. Extremity examination revealed there was no edema. There were venous stasis changes. The left arm had an arteriovenous graft thrill. Neurologic examination revealed alert and oriented. Normal neurologic examination. Cranial nerves were intact. Decreased reflexes bilaterally symmetrically in the lower extremities. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories revealed white blood cell count was 6.6, hematocrit was 34.3, and platelets were 218. Sodium was 138, potassium was 3.8, chloride was 93, bicarbonate was 32, blood urea nitrogen was 21, creatinine was 5.4, and blood glucose was 253. ALT was 23, AST was 26, alkaline phosphatase was 96, and total bilirubin was 0.3. The urinalysis showed 3 to 5 white blood cells, 0 to 2 epithelial cells, trace leukocyte esterase, and negative nitrites. Negative hepatology serologies. PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed some fullness around the mediastinum. There were no infiltrates. Electrocardiogram revealed a normal sinus rhythm at 95. Normal axis and normal intervals. There were small Q waves in leads I and aVL. Echocardiogram in [**2145-12-5**] revealed an ejection fraction of 55% with trace mitral regurgitation. A stress thallium in [**2145-12-5**] by Dr. [**Last Name (STitle) 34313**] indicated a small area of ischemia in the high lateral wall. A colonoscopy was normal in [**2146-2-5**]. A chest computed tomography indicated mediastinal fullness secondary to adipose tissue. No lymphadenopathy. SUMMARY OF HOSPITAL COURSE: Mr. [**Known lastname **] is a 62-year-old male with end-stage renal disease secondary to diabetes and hypertension who presented on [**2146-7-23**] for a cadaveric renal transplant. Consent was obtained, and the patient was taken to the operating room. The operation went without any complications. Postoperatively, in the Recovery Room, the patient became hypotensive with systolic blood pressures running in the 70s to 90s. He was bolused several times. An electrocardiogram revealed no ischemic changes. Cardiac enzymes were sent. The patient was placed on a dopamine drip running between 2 mcg/kg and 5 mcg/kg per minute with minimal resolution of hypotension and anuria/oliguria. Neo-Synephrine was added (by the request of the Transplant fellow). Additionally, continuous positive airway pressure was started given the patient's history of sleep apnea. The patient's blood pressure stabilized in the 120s to 130s/50s to 60s. The patient was eventually weaned off both the Neo-Synephrine and dopamine. Repeat arterial blood gases showed marked improvement. In the Recovery Room, his potassium was 5.8. The patient was hemodialyzed. The patient was started on thymoglobulin, CellCept, Solu-Medrol, and the usual prophylaxis with Bactrim and Valcyte. The patient remained in the Vascular Intensive Care Unit during dialysis for closer monitoring given his cardiac enzymes which were sent. His troponin T had slightly risen from 0.07 to 0.14, and Cardiology was consulted. The patient was started on Lopressor 12.5 mg by mouth twice per day as well as aspirin 81 mg by mouth once per day. Cardiology did not believe that the patient had a myocardial infarction, but they continued to monitor him closely. The patient remained on telemetry throughout his hospital course. Given the patient's delayed graft function, slight increase in troponin level were not unexpected by the Renal team. The patient's urine output was carefully monitored as well as his electrolytes. The patient was requiring 2 liters to 3 liters of oxygen via nasal cannula daily to maintain saturations in the 90s. A chest x-ray revealed bilateral pleural effusions, a moderate-sized pleural effusion on the right side. At that point, we decided to diurese the patient with Lasix. We sent the patient home on Lasix 60 mg by mouth twice per day. The patient's primary care physician was [**Name (NI) 653**], and we were informed that the patient regularly has an oxygen saturation in the 80s. Given his saturation of 72% on room air with ambulation, the patient was discharged with oxygen as well as pulse oximetry with teaching provided by Respiratory Therapy. The patient had a short course of levofloxacin. Given his x-ray with a significant pleural effusion, we could not rule out an infiltrate. This antibiotic was discontinued by the time of discharge, and his chest x-ray showed marked improvement. The patient received five doses of thymoglobulin as well as a Solu-Medrol taper. He was discharged on tacrolimus at a dose of 6 mg by mouth twice per day and CellCept [**Pager number **] mg by mouth twice per day. The patient continued to do well. He was tolerating solids and ambulating regularly. To improve his pulmonary condition, chest physical therapy and pulmonary toilet were provided. The patient's urine output continued to improve, and he did not require any further dialysis. On postoperative day six, the patient was thought to be stable for discharge with home oxygen and pulse oximetry. The patient was scheduled to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] at the Transplant Center on [**8-1**] and with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**8-9**]. The patient was discharged with prescription for Percocet, potassium, Lasix, and oxygen. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE DIAGNOSES: 1. End-stage renal disease secondary to diabetes and hypertension. 2. Status post cadaveric renal transplant; delayed graft function with marked improvement by the time of discharge. 3. Hypotension most likely secondary to anesthesia. 4. Neuropathy. 5. Sleep apnea. 6. Postoperative hypoxemia. 7. Postoperative hyperkalemia; resolved after dialysis. 8. Ruled out for a myocardial infarction. MEDICATIONS ON DISCHARGE: 1. Bactrim-SS one tablet by mouth once per day. 2. Valcyte 450 mg one tablet by mouth every other day. 3. Pantoprazole 40 mg by mouth once per day. 4. Colace 100 mg by mouth twice per day. 5. Amitriptyline 50-mg tablets one tablet by mouth once per day. 6. Nystatin swish-and-swallow. 7. CellCept [**Pager number **]-mg tablets two tablets by mouth twice per day. 8. Aspirin 81 mg by mouth once per day. 9. Albuterol inhaler 1 to 2 puffs inhaled q.6h. as needed. 10. Metoprolol 25 mg by mouth twice per day. 11. Percocet one to two tablets by mouth q.4-6h. as needed (for pain). 12. Avandia 8 mg by mouth every day. 13. Insulin sliding-scale as provided for the patient. 14. Furosemide 60 mg by mouth twice per day. 15. Tacrolimus 6 mg by mouth twice per day. 16. Potassium chloride 10-mEq tablets one tablet to be taken once per day when the patient takes Lasix. 17. Oxygen 2 liters to 3 liters continuous with respiratory therapy instructing the patient on use of pulse oximetry. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] at the Transplant Center in the [**Last Name (un) 2577**] Building (telephone number [**Telephone/Fax (1) 673**]) on [**2146-8-1**] at 11:30 a.m. 2. The patient was also to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**Last Name (un) 2577**] Building on [**2146-8-9**] at 9:20 a.m. 3. The patient was also to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2146-8-15**] at 9:20 a.m. at the Transplant Center. [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**] Dictated By:[**Last Name (NamePattern1) 28937**] MEDQUIST36 D: [**2146-7-29**] 21:40 T: [**2146-8-10**] 08:55 JOB#: [**Job Number 34314**]

[ "458.2", "403.91", "276.7", "250.40", "996.81" ]

icd9cm

[ [ [] ] ]

[ "39.95", "55.69" ]

icd9pcs

[ [ [] ] ]

18441, 18842

18869, 19877

11744, 12076

19910, 20741

14523, 18369

18384, 18420

10546, 11260

11282, 11718

12093, 14494

9,190

147,850

2417

Discharge summary

report

Admission Date: [**2164-10-9**] Discharge Date: [**2164-10-18**] Date of Birth: [**2086-2-24**] Sex: F Service: SURGERY Allergies: Percocet / Naprosyn / Darvocet A500 Attending:[**First Name3 (LF) 1781**] Chief Complaint: She is a 78-year-old woman with an infrarenal abdominal aneurysm and bilateral leg claudication left worse than right at 10 feet distance. Major Surgical or Invasive Procedure: Retroperitoneal tube graft repair of abdominal aortic aneurysm History of Present Illness: 78-year-old woman with a history of non-insulin dependent diabetes and ex-75 pack year smoker who presents to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] service, with a history of bilateral lower extremity claudication, left greater than right as stated previously associated with no clear ischemic rest pain however, this is now debilitating in nature. Also on workup of CT was found to have an infrarenal abdominal aneurysm as well as extensive aortoiliac atherosclerotic disease. The aneurysm at its maximum diameter was 5x3x5x4 cm. Past Medical History: PMH: DM, HTN, GERD, AAA, Hyperchol, HyopTH PSH: appendectomy, TAH, R-breast bx Social History: She is an ex-smoker of 75 pack years, she does not smoke currently, she does not drink outside of socially. She uses no recreational drugs. She is a country music singer. Family History: Non contributary Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness, INC: c/d/i EXT: rle - palp fem, [**Doctor Last Name **], / dop pt, dp lle - palp fem, [**Doctor Last Name **], / dop pt, dp Pertinent Results: [**2164-10-17**] WBC-18.6* RBC-4.24 Hgb-12.5 Hct-36.8 MCV-87 MCH-29.4 MCHC-33.9 RDW-15.6* Plt Ct-394 [**2164-10-13**] Neuts-85.5* Bands-0 Lymphs-9.5* Monos-2.6 Eos-2.3 Baso-0.1 [**2164-10-14**] PT-13.6* PTT-29.5 INR(PT)-1.2 [**2164-10-17**] Glucose-118* UreaN-18 Creat-0.8 Na-136 K-3.9 Cl-98 HCO3-25 AnGap-17 [**2164-10-17**] Calcium-7.6* Phos-2.5* Mg-1.9 [**2164-10-13**] freeCa-1.12 [**2164-10-9**] 2:52 PM CHEST PORT COMMENTS: A single supine AP view of the chest was reviewed and compared with PA and lateral chest radiographs from [**2164-8-29**]. Tip of an endotracheal tube is located 5 cm above the level of the carina. A right-sided Swan-Ganz catheter is seen with its tip projecting over the right main pulmonary artery. The heart size is normal. The mediastinal and hilar contours are unchanged. The lungs are clear. No pleural effusions or pneumothoraces are identified. The pulmonary vasculature is within normal limits. IMPRESSION: 1. Tip of right Swan-Ganz catheter located in the right main pulmonary artery. 2. No pneumothorax. [**2164-10-9**] ECHO MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.1 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm) Left Ventricle - Ejection Fraction: 45% to 50% (nl >=55%) Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm) Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.5 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A Ratio: 0.83 Mitral Valve - E Wave Deceleration Time: 294 msec INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild regional LV systolic dysfunction. No resting LVOT gradient. LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterolateral - hypo; mid anterolateral - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. AORTIC VALVE: Aortic valve not well seen. No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Indeterminate PA systolic pressure. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal image quality as the patient was difficult to position. Suboptimal image quality - ventilator. Based on [**2156**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the anterolateral wall. The remaining segments contract well. 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 appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. IMPRESSION: Mild regional left ventricular systolic dysfunction c/w CAD. Based on [**2156**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**2164-10-9**] 1:27:06 PM ECG Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing of [**2164-8-29**]. TRACING #1 Intervals Axes Rate PR QRS QT/QTc P QRS T 67 132 80 [**Telephone/Fax (2) 12458**] 85 [**2164-10-16**] 10:26 am STOOL CONSISTENCY: WATERY Source: Stool. FINAL REPORT [**2164-10-17**] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2164-10-17**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. [**2164-10-15**] 12:19 pm URINE - CATHETER FINAL REPORT 09/13/0 URINE CULTURE (Final [**2164-10-16**]): NO GROWTH GENERAL URINE INFORMATION Color Appear Sp [**Last Name (un) **] Yellow Clear 1.007 DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks NEG NEG NEG NEG NEG NEG NEG 7.0 NEG Brief Hospital Course: Pt admitted [**2164-10-9**] Pt undergoes a Retroperitoneal tube graft repair of abdominal aortic aneurysm. She tolerates the procedure well. There are no complications. Pt is intubated. Transfered to the PACU in stable condition. She did require post operaritive drips for hemodynamics. Once recovered from anesthesia. Pt is transfered to the SICU in stable condition.She is still intubated [**2164-10-10**] - [**2164-10-14**] Pt emained in the SICU She required IV drips for BP control / and gentle diuresis. Pt extubated [**2164-10-12**] After extubation, pt still required gentlee diuresis. Pt did experience some confusion, Narcotics DC'd. Pt mental status did improve. Diet was advanced as tolerated. [**2164-10-15**] Pt transfered to the VICU Case management and PT were consulted. Pt diet was advanced Foley removed, PT delined. Pt with slight increase in WBC, low grade temp - UTI, tx with antibiotics. [**2164-10-16**] - [**2164-10-18**] Pt transfered to the floor. Pt stable On discharge pt is taking PO, ambulating, pos BM, urinating. Pt did have multiple stools. C- Diff neg. Medications on Admission: 1. Metformin 500 TID 2. Atenolol 75 QD 3. Ranitidine 4. Fosamax 5. Lipitor 20 QD 6. ASA QD 7. Nifedipine SR 90 QD 8. Levoxyl 725 mcg QD Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours) as needed. 9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-5**] Puffs Inhalation Q4H (every 4 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. 13. Insulin Insulin SC (per Insulin Flowsheet) Sliding Scale QACHS, QPC2H, HS, QAM Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-50 mg/dL 4 oz. Juice 51-150 mg/dL 0 151-200 mg/dL 2 Units 201-250 mg/dL 4 Units 251-300 mg/dL 6 Units 301-350 mg/dL 8 Units 351-400 mg/dL 10 Units > 400 mg/dL Notify M.D. 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Abdominal aortic aneurysm Discharge Condition: Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING AORTIC SURGERY . 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 no specific restrictions on activity other than no lifting an object heavier than twenty-five (25) pounds for the first three (3) months. Gradually increase your level of activity back to normal depending on how you feel. Fatigue is normal, especially for the first month postoperative. Resume driving when you feel strong enough and comfortable enough without needing pain medication. . PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: . Severe and worsening abdominal pain . . Pain or swelling in one of your legs. . Increasing pain, redness or drainage related to your incision(s) . . 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 8 weeks. . Resume driving when you feel strong enough and comfortable enough without needing pain medication . . No heavy lifting greater than 20 pounds for 8 weeks. . Avoid excessive bending at the hips and stooping for 4 weeks. . BATHING/SHOWERING: . You may shower immediately if the incision is dry upon coming home. No baths until sutures / staples are removed. Dissolving sutures may have been used. In either case, you can wash your incision gently with soap and water. . WOUND CARE: . Suture / 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 / staples 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 two weeks after surgery. . MEDICATIONS: . You may resume taking medication you were on prior to your surgery unless specifically instructed otherwise by your physician [**Name9 (PRE) **] will be given a new prescription for pain medication, which should 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 heavy lifting (over 20 pounds) for 8 weeks after surgery. . No strenuous activity for 4-6 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: Follopw up with Dr [**Last Name (STitle) **] in two weeks. She can be reached at [**Telephone/Fax (1) 2395**]. Completed by:[**2164-10-18**]

[ "458.29", "244.9", "250.00", "440.0", "511.9", "441.4", "401.9", "440.21", "272.0", "599.0", "530.81" ]

icd9cm

[ [ [] ] ]

[ "99.07", "38.93", "96.71", "38.44", "89.64", "99.04" ]

icd9pcs

[ [ [] ] ]

9527, 9599

6617, 7727

436, 501

9669, 9678

1943, 6594

15200, 15343

1404, 1422

7913, 9504

9620, 9648

7753, 7890

9702, 11462

1437, 1924

257, 398

11475, 14493

14517, 15177

529, 1094

1116, 1200

1216, 1388

28,934

160,959

33785

Discharge summary

report

Admission Date: [**2178-4-29**] Discharge Date: [**2178-5-9**] Date of Birth: [**2135-11-14**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 148**] Chief Complaint: Biliary Stricture Major Surgical or Invasive Procedure: Right extended Hemi-Hepatectomy, IOUS, Redo-Roux-en-Y hepaticoojejunostomy for CBD stricture Central Bile Duct Excision History of Present Illness: This is a 42-year-old woman with a biliary stricture. Her story begins with a laparoscopic cholecystectomy performed in [**2160**] in [**Male First Name (un) 1056**]. This was complicated by a bile duct injury and she required an immediate operative repair in the setting of bile peritonitis. A hepaticojejunostomy was performed due to a high bile duct injury. I personally reviewed the operative note which was sent to me from the original surgeon from [**Male First Name (un) 1056**] and realized that there was a single anastomosis created with 4-0 silk sutures on the bile duct. Furthermore, an omega limb drainage procedure was created rather than a Roux-en-Y. Recently the patient has presented with a right upper quadrant pain. This was worked up and it was found that she had right-sided ductal dilation. This was pursued with a PTC cholangiogram, at which time, a stricture of the right ductal system was identified. Unfortunately, this could not be balloon-dilated. Brushings and biopsies were negative. The cholangiogram was performed and no drainage was achieved. Subsequent to this she developed a full rip roaring cholangitis, and it was in the setting of this that she was referred to me for further care. We found her in good shape, actually, and treated her with antibiotics and continued the investigation of this biliary stricture situation. Also of very important interest here is the fact that her CA19-9 has been high, starting at 700 a month and a half ago and elevated up to [**2169**] within the last 2 weeks. I performed an MRCP, as well as a CTA, at our institution to try and understand if malignancy was in play here. I had a very real concern that this was the case. Her CT scan showed a general hypodensity of the whole right anterior right drainage system, and there were enhancing features on the MRI, as well. Furthermore, it was clear from the CTA that there was no evidence of a right hepatic artery in play, and I surmised that this was injured at the original operative endeavor 17 years ago. Past Medical History: PMH: biliary stricture, asthma, depression PSH: Lap CCY '[**60**] in [**Male First Name (un) 1056**], bile leak, Hepaticojejunosotmy '[**60**], also C-section x1 Social History: Lives with husband and daughter Family History: NAD Physical Exam: AVSS Gen: NAD, anicteric Abd: soft, nontender, and nondistended with positive bowel sounds. She has no masses or hernias in her prior incision site, which is well healed. Ext: warm and well perfused. Pertinent Results: [**2178-5-4**] 05:17AM BLOOD WBC-12.8* RBC-3.42* Hgb-9.5* Hct-29.0* MCV-85 MCH-27.7 MCHC-32.7 RDW-15.4 Plt Ct-225 [**2178-5-3**] 11:51AM BLOOD Glucose-108* UreaN-9 Creat-0.6 Na-137 K-3.6 Cl-99 HCO3-27 AnGap-15 [**2178-5-4**] 05:17AM BLOOD ALT-87* AST-47* AlkPhos-128* Amylase-28 TotBili-1.1 [**2178-5-4**] 05:17AM BLOOD Lipase-16 [**2178-5-4**] 05:17AM BLOOD Albumin-2.9* . LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2178-4-29**] 6:18 AM CONCLUSION: 1. Scans show mild dilatation of the central left hepatic duct and marked dilatation of all of the peripheral and central ducts in the anterior right lobe. The trunks of the right and left bile ducts could not be joined together but were separated by 1 cm of soft tissue near the anastomotic bowel loop. This could represent neoplastic or fibroinflammatory tissue. Small intraductal stones were also noted on the right side. 2. Color flow and pulse Doppler assessment demonstrates what appears to be occlusion of the right hepatic artery with numerous collaterals in the right porta hepatis. A small accessory left hepatic artery is also noted. . CHEST (PORTABLE AP) [**2178-5-2**] 8:37 AM IMPRESSION: Retrocardiac airspace disease, atelectasis versus developing pneumonia. Postoperative changes in the abdomen. . BILAT LOWER EXT VEINS PORT [**2178-5-3**] 3:08 PM IMPRESSION: No evidence of bilateral DVT. . CT ABDOMEN W/CONTRAST [**2178-5-7**] 2:09 PM IMPRESSION: 1. Small fluid collection near the surgical bed in which an external drain is appropriately placed. 2. Dilated small bowel loops up to 4.1 cm suggestive of an ileus. 3. Small bilateral pleural effusions, right greater than left, with associated atelectasis. 4. Left adnexal lesion which likely represents a dermoid (2, 79). 5. Fibroid uterus. . [**2178-5-7**] 06:15AM BLOOD WBC-19.7* RBC-3.08* Hgb-8.5* Hct-27.0* MCV-88 MCH-27.7 MCHC-31.6 RDW-15.7* Plt Ct-261 . Brief Hospital Course: This is a 42 year old female with biliary stricture who went to the OR on [**4-29**] for: 1. Takedown of biliary drainage limb. 2. Conversion of omega limb drainage to Roux-en-Y. 3. Right extended hemihepatectomy. 4. Intraoperative ultrasound. 5. Biliary reconstruction consisting of hepaticojejunostomy to left ductal system. Pain: She had an epidural for pain control. She was followed by APS and the epidural was removed on POD 5. She was started on a PCA and once tolerating a diet, she was switched to PO meds. CV: She had post-op tachycardia. On [**5-3**], she had LENIs that were negative. She received several fluid boluses for Post-op Hypotension, and had an appropriate HR and BP response. GI/Abd: She was NPO, with IVF and a NGT. The NGT was removed on POD 3. The JP was sent for culture on POD4 and showed 2+ GNRs. It then grew out ESCHERICHIA COLI and ENTEROCOCCUS SP. She was started on Flagyl and already being treated with Cefepime. Her abdomen was soft and nontender. Erythema was noted on the right side of the incision and 4 staples were removed and the incision packed. Her WBC climbed to 19.7 and a CT was ordered. CT showed Small fluid collection near the surgical bed in which an external drain is appropriately placed. Dilated small bowel loops up to 4.1 cm suggestive of an ileus. The drain was removed and dressing changes were continued. WBC was 23.7 on [**5-8**] and UCx, BCx and CXR orderded. Her CXR was negative for Pneumonia. She had Ecoli in her Urine Cx and Wound culture. She was sent home on PO antibiotics. Her WBC on [**5-9**] was stable at 23.7. She was afebrile. She had occasional post-op emesis. We awaited return of bowel function. We slowly increased her diet and she was tolerating regular diet at time of. Post-op Blood Loss Anemia: On POD 1, She received 2 units pRBCs for a HCT of 20. Her INR was also elevated to 1.7 and she received 2 Units of FFP. Her HCT was stable at 29 and INR recovered to 1.2. Post-op UTI: E. coli was found in her urine. She was treated with Cefepime. She was discharged home to complete a course of Augmentin to cover both the urine and the wound culture. Medications on Admission: Tylenol, Percocet, albuterol MDI Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB/wheeze. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 3. Prilosec 20 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* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 6. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Multicultural Home Care Discharge Diagnosis: Biliary Stricture Wound Infection Leukocytosis Discharge Condition: Good Continue wound care [**Hospital1 **] Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new or worsening abdominal pain. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily. * No heavy lifting (>[**9-30**] lbs) until your follow up appointment. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. Call [**Telephone/Fax (1) 1231**] to schedule an appointment.

[ "560.1", "576.2", "E878.6", "599.0", "311", "458.29", "220", "285.1", "511.9", "493.90", "998.59", "041.4", "518.0", "576.1", "218.1" ]

icd9cm

[ [ [] ] ]

[ "50.3", "51.37", "99.04", "51.94", "51.69" ]

icd9pcs

[ [ [] ] ]

7837, 7891

4879, 7029

288, 410

7982, 8026

2966, 4856

9449, 9578

2724, 2729

7112, 7814

7912, 7961

7055, 7089

8050, 9426

2744, 2947

231, 250

438, 2473

2495, 2659

2675, 2708

109

136,572

14860

Discharge summary

report

Admission Date: [**2142-6-18**] Discharge Date: [**2142-6-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 2145**] Chief Complaint: Acute Onset Dyspnea Major Surgical or Invasive Procedure: Dialysis History of Present Illness: Please see MICU note for full details. In brief this is a 24 y.o. woman with SLE, ESRD on HD, hx malignant HTN, h/o SVC syndrome, h/o posterior reversible encephalopathy syndrome (PRES) and prior intracerebral hemorrhage, frequently admitted with hypertensive urgency/emergency who was admitted with acute onset dyspnea after 2 weeks without dialysis given to unable to get transportation ? despite Dr. [**Last Name (STitle) 7473**] attempting to arrange transport for her (? refused to come). She was admitted therefore on [**6-18**] to micu with VS: T 100.4 HR 108 BP 240/180 RR 28 POx100 RA. She was treated with nitro gtt, labetolol gtt and dilaudid-these gtts were stopped at 0700. In the micu she was dialyzed with 1.7L fluid removal (though + 300cc given tranfusion). Her SOB is improved. Her hct was also noted to be low (18->from 22 [**2142-6-5**]) so transfused 2 units PRBC's, recent EGD with gastric ulcer [**5-29**], guaiac negative in ED, no BM in unit, hemolysis w/u negative. BP in icu 140/106 currently but of note was hypotensive on HD to 86/62. She notes sob improved rapidly on arrival. ROS: Currently she has no complaints. She notes at home her abdominal pain is at baseline for her, felt mid epigastric, for which she takes dilaudid 4mg up to [**Hospital1 **]. She has been getting HD via right femoral catheter which is not painful, no discharge from the sight. She denies HA, visual changes, cough, chest pain or pressure, orthostatic changes, palpitations, nausea, vomiting, constipation, diarrhea, melena, brbpr, dysuria, hematuria, rash, swelling, orthopnea, pnd. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Physical Exam: Vitals - T: 97.7, BP: 140/99 P: 88 R: 19 O2: 98% on RA General: Sleeping comfortably but awakens easily, alert, oriented x3 HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, nonerythematous, MMM, moon facies Neck: supple, JVP flat, no LAD, full ROM, left EJ in place Lungs: coarse BS throughout, no W/R/R, no decreased BS at bases CV: S1, S2 nl, no m/r/g appreciated Abdomen: Firm, non-tender to palpation, no masses or organomegally Ext: Warm, well perfused, 1+ DP/PT, no clubbing, cyanosis or edema Neuro: a&o x3, motor [**5-15**] UE/LE bilaterally Pertinent Results: [**2142-6-18**] 05:28PM HCT-26.0*# [**2142-6-18**] 11:38AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL [**2142-6-18**] 05:04AM GLUCOSE-85 UREA N-72* CREAT-10.4* SODIUM-139 POTASSIUM-5.5* CHLORIDE-109* TOTAL CO2-14* ANION GAP-22* [**2142-6-18**] 05:04AM LD(LDH)-264* TOT BILI-0.2 [**2142-6-18**] 05:04AM CALCIUM-6.6* PHOSPHATE-6.5* MAGNESIUM-1.6 [**2142-6-18**] 05:04AM HAPTOGLOB-142 [**2142-6-18**] 05:04AM WBC-3.4* RBC-1.93* HGB-5.8* HCT-17.0* MCV-88 MCH-30.0 MCHC-34.2 RDW-18.4* [**2142-6-18**] 05:04AM PLT COUNT-97* [**2142-6-18**] 01:34AM GLUCOSE-84 UREA N-70* CREAT-10.5*# SODIUM-136 POTASSIUM-5.6* CHLORIDE-108 TOTAL CO2-14* ANION GAP-20 [**2142-6-18**] 01:34AM estGFR-Using this [**2142-6-18**] 01:34AM ALT(SGPT)-10 AST(SGOT)-39 ALK PHOS-108 TOT BILI-0.2 [**2142-6-18**] 01:34AM LIPASE-115* [**2142-6-18**] 01:34AM ALBUMIN-3.2* CALCIUM-6.6* PHOSPHATE-6.8* MAGNESIUM-1.7 [**2142-6-18**] 01:34AM WBC-4.5 RBC-2.08* HGB-6.0* HCT-18.3* MCV-88 MCH-28.6 MCHC-32.5 RDW-18.6* [**2142-6-18**] 01:34AM NEUTS-78.5* LYMPHS-16.5* MONOS-3.0 EOS-1.4 BASOS-0.6 [**2142-6-18**] 01:34AM PLT COUNT-104* [**2142-6-18**] 01:34AM PT-15.0* PTT-33.6 INR(PT)-1.3* Brief Hospital Course: # Dyspnea: Pt's dypsnea improved on admission to the ED prior to HD. Based on her imaging studies her dyspnea was likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. Upon transfer to the floor she was continued on her dialysis regimen and discharged on room air. # Anemia: Pt's baseline 1 month ago noted to be low 30s, since then her Hct has trended down to 22 several week prior to admission. As she missed dialysis she was not able to reserve her Eopgen which likely complicated her anemia. Pt underwent hemolysis workup in the ICU which was ultimately negative. She was given several units of PRBC and bumped her Hct appropriately. She was noted to be guaiac negative on examination. # Hypertension: Pt was initially admitted with hypertension. Following transition to the floor she was placed on her home regimen. She was noted to be hypotensive in dialysis which is likely due to her being on Labetalol, Nitro gtt on dialysis. Pt was discharged on her home BP regimen with follow up with her nephrologist. # Chronic Abdominal Pain: Pt had noted some intermittent abdominal pain which has been chronic. Lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. Pt was able to tolerate a PO diet prior to her discharge. Pt was continued on her outpatient regimen of Dilaudid, Fentanyl patch, Neurontin. # GE junction Ulcer: Pt was continued on her PPI regimen [**Hospital1 **]. # SLE: Pt was continued on her home regimen of Prednisone 4mg daily # History of DVT: Pt had a sub-therapeutic INR on admission. She was discharged on Warfarin 3mg daily. # ESRD on HD: Pt was admitted for dyspnea in the setting of missing 2 weeks of HD. The renal team followed Ms. [**Known lastname **] during her hospitalization and she was continued on her outpatient regimen of hemodialysis. Pt was continued on Sevelamer and Epogen. # Seizure D/O: Pt was continued on her home regimen of keppra. # Depression: Pt was continued on her home regimen of Celexa. Medications on Admission: 1. Nifedipine 90 mg Tablet Sustained Release PO QAM 2. Nifedipine 60 mg Tablet Sustained Release PO QHS 3. Lidocaine 5 % transdermal one daily 4. Aliskiren 150 mg PO BID 5. Citalopram 20 mg PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch Q72H (every 72 hours). 7. Prednisone 4mg PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Transdermal QSAT 9. Clonidine 0.3 mg/24 hr Patch Weekly Transdermal QSAT 10. Sevelamer HCl 400 mg Four (4) Tablet PO TID W/MEALS 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID 13. Hydralazine 100 mg PO Q8H 14. Hydromorphone 2 mg 1-2 Tablets PO Q6H as needed for pain. 15. Pantoprazole 40 mg PO Q12H 16. LeVETiracetam 1,000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24 H (). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK (TU,TH,SA). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Malignant HTN, ESRD on HD, Shortness of breath Secondary: Lupus Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to the hospital after you noticed some shortness of breath. Whilst in the hospital you were noted to have a low blood level (anemia) and you some fluid in your lungs. We think your blood level was low because you were not receiving your Epo shots, we think the fluid is from not receiving dialysis. Before you were discharged from the hospital your breathing was better. We recommend that you continue going to dialysis. We made no changes to your medications. If you notice any fevers, chills, nausea, vomiting, shortness of breath, lightheadedness please return to the ED. Followup Instructions: Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 Provider: [**First Name4 (NamePattern1) **] [**Name Initial (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-6-27**] 2:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

[ "403.01", "V12.51", "338.29", "276.6", "789.09", "V45.12", "585.6", "423.9", "710.0", "531.90", "285.29", "458.9", "276.7", "425.4", "311", "345.90" ]

icd9cm

[ [ [] ] ]

[ "39.95", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

9873, 9930

5602, 7643

313, 324

10047, 10066

4299, 5579

10710, 11058

3666, 3696

8443, 9850

9951, 10026

7669, 8420

10090, 10687

3711, 4280

254, 275

352, 1947

1969, 3518

3534, 3650

5,554

168,435

50125

Discharge summary

report

Admission Date: [**2192-11-26**] Discharge Date: [**2193-1-2**] Date of Birth: [**2130-10-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3913**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: 1. Platelet transfusions 2. Bronchoscopy 3. Blood transfusion 4. Bone marrow biopsy History of Present Illness: Mr. [**Known lastname 2031**] is a 62 y/o male with MM s/p allo-BMT and DLI [**8-16**] with GVHD of skin recently admitted on [**10-14**] for [**Month/Day/Year **] and shortness of breath concerning for pneumonia or restrictive airway disease such as BOOP. He was seen and evaluated by pulmonary at that time. PFT's revealed a slightly restrictive pattern, but pulmonary felt that the clinical evidence was not too suggestive for BOOP. Since discharge, he was on levaquin, which was subsequently switched to azithromycin by his outpatient oncologist. In addition, his prednisone was increased to 60 QD. . Today, he notes feeling increased SOB and DOE to the point that he can no longer shave without feeling SOB. He does note continued post-nasal drip and [**Month/Day/Year **] productive of white sputum. His [**Month/Day/Year **] is worse while sitting up, and better while lying down. He denies any hemoptysis. He denies any recent sick contacts, fevers, chills, nausea, vomiting. . ROS is negative for HA, F/C, CP, SOB, Abd pain. He does complain of bilateral shoulder discomfort R>L, an increasing level of fatigue, and also severe mouth pain from oral ulcers Past Medical History: 1. Multiple myeloma - s/p MUD nonmyeloablative allogeneic transplant [**7-16**] with Campath conditioning. Past treatment modalities include: s/p auto PBSCT in [**2188**],DC vaccine, Thalidomide, Velcade/Doxil, Cytoxan/Doxil. He has most recently been treated with radiation therapy and velcade in preparation for this DLI treatment. His [**2191**] transplant was complicated by mucositis with HSV infection, c. diff and enterococcus bacteremia. HSV has been resistant to oral valtrex and acyclovir but has improved with IV foscarnet, which was most recently restarted on [**2191-11-30**]. He has had recurrent diarrhea with rectal biopsies showing no evidence of GVHD, and c. diff was negative. 2. Ortho: Pt has extensive skeletal involvement with myeloma. Recent hospital amission for prophylactic rod placement in L femur with XRT (discharged6/24/06), also with recent radiation to his right clavicle and right calf as well. Known lesions of Rt clavicle, L humerus, recent fracture of L 4th metacarpal. Has had pamidronate treatments monthly. 3. steroid-induced DM, resolved 4. CHF, [**3-15**] diastolic dysfunction Echo [**10-23**]: Overall left ventricular systolic function is normal(LVEF>55%). 5. HTN for 15 years 6. Osteoarthritis 7. Atrial flutter, s/p ablation '[**88**] 8. CRI: thought secondary to myeloma vs HTN Social History: Married, 7 children, no tobacco for 35 yrs, 10 packyears hx, occasional alcohol. Family History: no history of malignancies, hx of CVAs and diabetes. Physical Exam: VS: 96.6 127/59 72 20 98%RA GEN: NAD, AAOx3, speaking full sentences, slightly short of breath while talking, no excessory muscle use HEENT: MMM, multiple apthous ulcers on sides of mouth COR: RRR, no M/R/G PULM: ins and exp crackles heard throughout ABD: soft, NT/ND, +BS SKIN: diffuse erythematous rash with whitish scales even on face [**3-15**] GVHD. Pertinent Results: Admission labs: [**2192-11-26**] 12:50PM GLUCOSE-253* UREA N-29* CREAT-1.6* SODIUM-136 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-21* ANION GAP-17 [**2192-11-26**] 12:50PM ALT(SGPT)-44* AST(SGOT)-48* LD(LDH)-327* ALK PHOS-184* TOT BILI-0.4 DIR BILI-0.2 INDIR BIL-0.2 [**2192-11-26**] 12:50PM ALBUMIN-2.5* CALCIUM-7.5* PHOSPHATE-3.2 MAGNESIUM-2.1 [**2192-11-26**] 12:50PM WBC-4.9 RBC-2.81* HGB-10.1* HCT-30.9* MCV-110* MCH-36.2* MCHC-32.8 RDW-24.6* [**2192-11-26**] 12:50PM NEUTS-79* BANDS-6* LYMPHS-7* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* [**2192-11-26**] 12:50PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2192-11-26**] 12:50PM PLT SMR-RARE PLT COUNT-22*# [**2192-11-26**] 12:50PM PT-11.2 PTT-23.2 INR(PT)-0.9 . IMAGING: [**11-9**] CHEST CT: 1. Evolving radiation fibrosis right apex, status post radiation therapy to a pathological fracture of the medial right clavicle. 2. Bronchial wall thickening, mild bronchial dilation and small airways disease within the dependent portions of the lower lobes. Infectious small airways disease or chronic aspiration should be considered. 3. Diffuse skeletal involvement by multiple myeloma. Destruction of posterior aspect of the vertebral body at approximately T11, for which it is difficult to evaluate for spinal canal involvement on routine CT. Spine MR could be obtained for more complete assessment if warranted clinically. 4. Diffuse coronary artery calcifications. . [**2192-11-12**] PFT's Please see OMR records from [**2192-11-12**] for complete values. Brielfy, lung volumes appear unchanged, DLCO decreased slightly, FEV1/FVC also decreased suggestive of restrictive disease. . CT chest [**2192-11-26**]: IMPRESSION: 1. Worsening diffuse bronchial wall thickening, new nodules with ground glass "halos," and new ground glass wedge opacities in the upper lobe are concerning for a progressive infectious process. In an immunocompromised patient, Aspergillus is the leading diagnosis. If the patient is immunocompetent, mucormycosis is most likely. Atypical pneumonias such as mycoplasma or viral infection are less likely. Findings were communicated to Dr. [**Last Name (STitle) **]. 2. Evolving right apical post-radiation changes. 3. Widespread bone lesions did not change appreciably, the evaluation of the D11 vertebral body lesion is difficult on the chest CT. If warranted clinically, further evaluation with MRI is recommended. 4. Diffuse coronary artery calcifications. . [**12-5**] right shoulder xray: IMPRESSION Displaced fracture of the mid clavicle, more apparent than prior study. . chest ct [**12-18**]: 1. New extensive ground-glass opacities and focal areas of consolidation, predominantly in the upper and mid lungs. Associated extensive traction bronchiectasis. These findings raise the possibility of an evolving acute interstitial pneumonia with areas of organizing fibrosis. The differential also includes a hypersensitivity reaction to drugs (or other antigen) or possibly eosinophilic pneumonia. Coexisting infection is likely, although bronchiolitis seen on the previous exam has improved. 2. New, bilateral pleural effusions. Mild smooth septal thickening consistent with hydrostatic edema. 3. Lytic lesions within the right side of the T12 vertebral body and left eighth rib. Pathologic fracture of the right clavicle. 4. Tracheobronchomalacia. . [**12-25**] cxr: IMPRESSION: No improvement in bilateral diffuse opacities likely representing bilateral pneumonias . [**12-31**] cxr: IMPRESSION: AP chest compared to [**12-14**] through 18: Substantial progression of consolidation has continued relative to [**12-26**] and 18 with greater involvement of the lower lungs. There is no pneumothorax or appreciable pleural effusion. The heart is normal size. Tip of the left PIC catheter projects over the mid SVC. A 3.5 cm wide round opacity projecting over the right hilus could be a fissural pleural fluid collection or a growing lung abscess. Brief Hospital Course: Mr. [**Known lastname 2031**] is a 62 year-old male with multiple myeloma status post allo-BMT and donor lymphocyte infusion [**8-16**] with GVHD of skin, who was admitted for dyspnea. . 1) Hypoxia/Pneumonia: The patient was admitted on [**11-26**] after being evaluated in outpatient clinic. He noted he was feeling increasingly SOB with exertion. He had a chest CT that showed "worsening diffuse bronchial wall thickening, new nodules with ground glass "halos," and new ground glass wedge opacities in the upper lobe" which were concerning for a progressive infectious process, such as aspergillus. He was initially started on vancomycin, levaquin, cefepime and caspofungin. A bronch was done and BAL showed growth of aspergillus. Sputum culture showed growth of pseudomonas (resistant to cipro and intermediate to cefepime). Antibiotics were changed to ceftazidime, voriconazole and ambisome. During the patient's course he had an episode of desaturation to the low 80s on 2L NC O2. His oxygen was increased to 5L NC, but he continued to be tachypneic and oxygenation ranged from 88%-98% on 5L. ABG was done and was 7.4/36/57/26. CXR appeared consistent with worsening opacities/volume overload. He was treated with 40 IV lasix and transferred to the [**Hospital Unit Name 153**] for hypoxic respiratory distress secondary to aspergillus and pseudomonal pneumonia. In the [**Hospital Unit Name 153**], the patient's prednisone was decreased from 60 mg to 15 mg QD. His antibiotics were adjusted ultimately to caspofungin and voriconazole for aspergillus, meropenam for pseudomonas, and atovaquone for PCP [**Name Initial (PRE) 1102**]. Patient's hyypoxia improved daily and by [**2192-12-10**] weaned down to 4-6L NC satting between 92-98%. He was still occasionally using a face mask at night, but this was more for humidification. There was some suggestion of occasional fluid overload and he noted that his SOB felt better after diuresis. He required occasional diuresis with lasix. The patient never required intubation and his respiratory status improved with antibiotics and diuresis. Once stable, he was transferred out of the [**Hospital Unit Name 153**], on [**4-15**] L O2 via nasal cannula, meropenem for pseudomonas and voraconazole and caspofungin for aspergillus. On the floor the patient remained stable, but still requiring 4-5 L of NC and on one occassion 7L face mask. He remained on nebs and advair for symptom improvement. Was diuresed for a fluid goal of -500 cc/day He continued treatment with caspofungin and voriconazole for aspergillus, meropenem for coverage of pseudomonas and atovaquone for PCP [**Name Initial (PRE) 1102**]. The infectious disease team followed the patient as well, and agreed with his care. A repeat CT scan was more worrisome for BOOP so the patient was treated with cellcept and steroids. He improved slightly, but later decompensated and went from 4L NC to face mask and later non-rebreather. The patient's BOOP, GVHD, aspergillus pneumonia and later presumed PCP pneumonia were all insults leading to his poor pulmonary status. To maximize his treatement at this point he was started on doxycycline for atypicals, given stress dose steroids (for BOOP/GVHD), given meropenum (pseudomonas), vancomycin (pneumonia coverage), primaquine (PCP) and clindamycin (pcp). Per pulmonary and ID recommendations his amiodorone was also stopped as this could contribute to pulmonary fibrosis. Patient remained on NRB, and then continued to decline and was only 70-80% saturation on 100% NRB, the patient was DNR/DNI and continued to decline at this point with antibiotics, lasix, nebs and inhalers. At this point he was started on a morphine drip for comfort. . 2. Aspiration precautions: During his course, the patient had one episode of aspiration while lying completely flat to eat. Afterwards, he was placed on NPO and then thick liquid diet. He was advanced back to regular on [**12-6**]. Speech and swallow passed him for regular foods, and he had no further episodes of aspiration. . 3. Skin GVHD grade 4: The patient has a diffuse rash from skin GVHD and receiving prednisone for this. As an outpatient he had recently had increased prednisone to 60 QD and this was decreased to 40 mg daily on [**11-29**]. Given the increased risk for infection, prednisone was again decreased to 15 QD. Later in his course, his prednisone was increased again to 60 mg daily, as the patient likely has some pulmonary GVHD that could benefit from steroids. Around that time the patient was also started on cellcept to improve his GVHD. Based on his Chest CT his steroids were increased and on [**12-26**] he received 3 days of high dose steroids to improve his pulmonary status. This was decreased, and while his pulmonary status worsened, the oral steroids and topical steroids helped the patient's skin GVHD. . 4. Oral Ulcers: The patient has a history of chronic resistant HSV mucositis. Viral swab from oral ulcers showed HSV-1 at this admission. He was started on oral cedofovir and continued pain control with magic mouthwash. His lesions improved and his pain remained controlled. . 5. Multiple myeloma: The patient has extensive skeletal involvement and is status-post allo transplant in '[**81**] and DLI in [**8-16**]. His course has been complicated by skin GVHD and mucositis. During his last admission, MRI revealed enhancing lesion on thoracic vertebrae. He has had a BM biopsy at this admission. BM biopsy revealed no recurrenece of disease. His counts were closely followed and he was given blood for hematocrit < 25 and platelets for platelets < 30. With the aspergillus he was at risk for pulmonary bleeding, so his platelets were kept > 30. His bony lesions were treated with fentanyl patch and oxycodone for breakthrough pain. The patient's malignancy was stable during the course. . 6. Right shoulder pain/swelling: Patient complained of this earlier in admission. Was seen and evaluated by orthopedics with no indication for acute surgery. He had a RUE ultrasound that was negative for DVT. Pain control with percocet, but on [**12-5**] evening complained of worsening pain. Shoulder films revealed unchanged non-[**Hospital1 **], but did not fully evaluate entire right arm. Further imaging subsequently revealed a lytic lesion in his right radius. Orthopedic oncology was consulted and recommeneded OT consult as well as a splint, which they fitted for him. His pain was controlled with fentanyl patch and oxycodone for breakthrough pain. . 7. Steroid induced Diabetes: Initially his sugars remained very well controlled most likely because his prednisone dose was low. At this time his insulin was stopped, but as his steroids were increased he was restarted on SSI, and his insulin was adjusted as needed. . 8. Atriatl flutter: The patient was admittien on amiodarone, given his history of atrial fibrillatin. During his course he had intermittent episodes of atrial fibrillation, but would spontaneously convert back to sinus rhythm. He never required intervention and as his was post-ablation, given his poor pulmonary status and risk for increased pulmonary fibrosis his amiodorone was stopped per infectious disease and pulmonary recommendations. The patient was followed closely and had no further issues. . 9. Hypertension: The patient was continued on his metoprolol. His bumax was stopped in the ICU for borderline low blood pressure. As he remained normotensive on th metoprolol his bumex was not restarted. . 10. Hematuria: The patient had intermittent hematuria during his course that was attributed to his low platelets and trauma from the follow. He had urine cultures followed, and as he was not infected was given platelets as needed and medications to control bladder spasms. . 11. Dispo: The patient expired on [**2193-1-2**] on morphine drip. Medications on Admission: Amiodarone 200 mg qd Zolpidem 5 mg po qhs Folic Acid 1 mg qd Levothyroxine 200 mc qd Pantoprazole 40 mg qd Gabapentin 300 mg TID Valacyclovir 500 mg TID Metoprolol Succinate 50 mg qd Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for GVHD on skin. Bumetanide 1 mg qd Fluconazole 200 mg qd Prednisone 60 mg qd Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO Q4-6H PRN Azithromycin Benzonatate 100 mg TID Fluticasone 50 mcg/Actuation Aerosol, one spray nasally [**Hospital1 **] Fluticasone-Salmeterol 250-50 mcg/Dose, one inhalation [**Hospital1 **] Maalox/Diphenhydramine/Lidocaine 15-30 ml PO QID PRN mouth pain. Fentanyl 75 mcg/hr Patch 72HR Colace 100 mg qd Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

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icd9cm

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[ "99.05", "38.93", "33.24", "41.31" ]

icd9pcs

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47166

Discharge summary

report

Admission Date: [**2165-2-18**] Discharge Date: [**2165-2-22**] Date of Birth: [**2115-11-1**] Sex: F Service: Blue Surgery HISTORY OF PRESENT ILLNESS: Patient is a 49-year-old African-American female who underwent a sigmoid colectomy in [**2163-10-5**] for adenocarcinoma of the colon with one positive lymph node. She also received chemotherapy adjunctive to the surgery of 5FU and leucovorin. She has had [**2165-1-2**]. A CT scan of the abdomen was performed on [**2165-1-4**], which demonstrated two lesions in the liver, a 3.2 cm lesion in segment for a 4.3 x 2.5 cm lesion in the inferior aspect of the right lobe near the liver edge. She was then referred to Dr. [**Last Name (STitle) **] for consideration of hepatic resection for this metastatic disease to the liver. 1. Hypertension. 2. Atrial fibrillation. 3. Congestive heart failure. 4. IHSS status post pacemaker placement DDD in [**2157**]. 5. Colon adenocarcinoma with positive lymph node and status post surgery and adjuvant chemotherapy. 6. Sleep apnea. 7. Diabetes. Past surgical history is significant for status post sigmoid colectomy in [**2152**] and status post brain tumor resection in [**2145**], status post uvulectomy and sinus surgery. MEDICATIONS ON ADMISSION: Coumadin 2.5 mg po taken as directed, verapamil HCL 180 mg po q day, triazolam 25 mg po q hs prn, ranitidine 150 mg po bid, Micro-K 20 mEq q am, lactulose two tablespoons [**Hospital1 **], hydrochlorothiazide 25 mg po q day, Glyburide 5 mg po q day, Glucophage 1000 mg po bid, Flonase one spray each nostril q day, Diovan 80 mg po q day, atenolol 50 mg po q day, [**Doctor First Name **] 60 mg po bid prn. ALLERGIES: She is allergic to sulfa and penicillin which cause rash. SOCIAL HISTORY: She denies any alcohol or smoking history. No history of IV drug use. Family history is significant for a mother who died of cerebrovascular accident. Her father died of a myocardial infarction and question of IHSS at age 45. Sister died at age 47 of a myocardial infarction and question of IHSS. PHYSICAL EXAMINATION: Patient is moderately obese female in no acute distress. Temperature is 99.0, pulse 84. Blood pressure is 140/84, respirations 20, and weight is 246 lb. Skin has keloids under both mandibles and several scars on the torso. HEENT: No scleral icterus. Oropharynx is clear. No uvula. Neck is supple. No lymphadenopathy and no thyromegaly. Lungs are clear to auscultation. Cardiac examination is normal, S1 loud, split S2, there is a 3/6 systolic ejection murmur along the left sternal border. Regular, rate, and rhythm with pacemaker. Abdomen is soft, nontender, normal bowel sounds, and no masses. Extremities have no peripheral edema. Neurologically she is intact. LABORATORIES: Hemoglobin 12.6, hematocrit 37.7, white count of 12.3, platelets 176,000. Sodium 139, potassium 4.5, chloride 102, bicarbonate 23, glucose of 305, BUN of 12, creatinine of 0.7, AST of 17, ALT of 27, alkaline phosphatase of 88, total bilirubin of 0.2, direct bilirubin of 0.1, CEA of 34. She underwent a cardiac catheterization by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], which is only significant for an elevated pulmonary capillary wedge pressure of 18-20, but her coronary arteries were open, which is a moderate surgical risk. Electrocardiogram showed paced rhythm with a rate of 78. CTA showed one liver lesion in segment six of the right lobe measuring 2.7 x 5.2 cm. Second lesion in segment 4A measuring 3.8 x 4.6 cm. There are two additional low attenuation foci. They were too small to characterize. HOSPITAL COURSE: On the date of admission, the patient was taken to the operating room where she underwent a segment six and segment 4B resection, cholecystectomy, and intraoperative ultrasound. She tolerated this procedure well and received 3,000 Crystalloid and estimated blood loss of 400 and urine output of 640. She was transferred to the PACU in stable condition. She spent the first postoperative night in the Intensive Care Unit for close monitoring where she remained hemodynamically stable, and postoperative day #1, she was transferred to the floor for remainder of recovery. Neurologically her pain was controlled with epidural for the first postoperative day. The epidural was discontinued and patient was placed on IV Morphine prn. Her pain has appropriately decreased and her use of pain medications has appropriately decreased. She has remained alert and oriented, and neurologically intact. Respiratory status has remained stable. Her O2 saturations have been in the high 90s to 100%, and has been weaned off oxygen successfully. Cardiovascular status has remained stable. She is remaining hemodynamically stable. She did have an episode on postoperative day #3 where she described a "her throat was closing." Due to the history of diabetes, it is unknown if this was an atypical chest pain versus perhaps some laryngeal edema secondary to intubation. She had an electrocardiogram which showed paced rhythm which was unchanged from a previous electrocardiogram. She also had a set of cardiac enzymes sent which were negative with a troponin less than 0.3, CPK of 639, MB fraction of 1. She had one other episode, but has denied having any other episodes of her throat closing. Much of her symptoms have been focused only around her airway. During this period also she did not have any periods of desaturation and remained hemodynamically stable. Her diet was advanced to a diabetic diet which she has been tolerating. Her wound has remained clean, dry, and intact. Her JP has continued to drain moderate amounts up to 50 cc/day of a darkly colored fluid. She will be discharged with a JP in place with followup in clinic for evaluation and then possible removal. Her Foley was discontinued. She has been voiding without any problems. Endocrine wise, the patient's blood glucose levels have remained in the 200s ranging anywhere from as low as 172 to as high as 288. Josalin consult was obtained and patient was recommended to be started on insulin injections for better hyperglycemic control. She was placed on NPH insulin 16 units in the morning and 12 units before bedtime in an adjusted sliding scale. She received diabetic teaching while in the hospital. She will be going home with VNA for injections of NPH in the morning and in the evening. Will follow up with Dr. [**Last Name (STitle) 82897**] in the [**Hospital 99937**] Clinic on Monday, [**2165-2-25**]. She was restarted on oral hypoglycemic medication once she was taken off the diabetic diet. Hematologically, the patient's hematocrit has remained stable. Has gone from 29 to 25. Her platelet count had dropped down to 105 on postoperative day two from 151 on postoperative day #0. Her Zantac was stopped. She is placed on Protonix for gastrointestinal prophylaxis. Her Heparin injections were continued and antibody was sent to the laboratory. The patient has been ambulating, stable, and ready for discharge with followup with Dr. [**Last Name (STitle) **] on [**2165-2-27**] in the clinic. Pathology has returned on the specimen with negative margins 0.9 cm. The section 6 and 4 resection were positive for metastatic adenocarcinoma of the colon. DISCHARGE DIAGNOSES: 1. Status post liver resection of sections 4B and 4A, cholecystectomy, and intraoperative ultrasound. 2. Metastatic colon adenocarcinoma to the liver. 3. Hypertension. 4. Diabetes mellitus. 5. IHSS. 6. Coronary artery disease. 7. Atrial fibrillation. DISCHARGE MEDICATIONS: Verapamil 180 mg po q day, Zantac 150 mg po bid, hydrochlorothiazide 25 mg po q day prn, Glyburide 5 mg po q day, Glucophage 1000 mg po bid, Flonase one spray each nostril q day, Diovan 80 mg po q day, atenolol 50 mg po q day, [**Doctor First Name **] 60 mg po bid, NPH insulin 16 units am, 12 units q pm, lactulose two tablespoons po bid, oxycodone 5 mg po q 4-6 hours prn, and Calor 20 mEq po q am. CONDITION ON DISCHARGE: Stable. DISCHARGE INSTRUCTIONS: The patient will go home with VNA services for wound care, JP care, and insulin teaching, NPH administration [**Hospital1 **]. Patient has been taught appropriately to empty and record JP outputs. The patient has had diabetic teaching for insulin shots. Patient will follow up with Dr. [**Last Name (STitle) 82897**] on [**2-25**] and followup with Dr. [**Last Name (STitle) **] on [**2-27**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D 02-366 Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2165-2-22**] 15:04 T: [**2165-2-25**] 11:17 JOB#: [**Job Number 99938**]

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icd9cm

[ [ [] ] ]

[ "51.22", "50.22" ]

icd9pcs

[ [ [] ] ]

7315, 7567

7591, 7993

1266, 1744

3641, 7294

8052, 8717

2085, 3623

169, 1239

1761, 2062

8018, 8027

32,681

156,883

34091

Discharge summary

report

Admission Date: [**2108-6-1**] Discharge Date: [**2108-7-14**] Date of Birth: [**2047-6-9**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 7591**] Chief Complaint: Cognitive decline Major Surgical or Invasive Procedure: Frontal Brain biopsy with Right craniotomy [**2108-6-16**] PICC line placement [**2108-6-19**] Percutaneous JG tube placement [**2108-6-13**] Ultra Sound guided liver biopsy [**2108-6-5**] Lumbar puncture [**2108-6-4**] History of Present Illness: 60 yo F h/o Hodgkin's disease, ITP, hypothyrodisim p/w cognitive decline. The patient's care has been at outside institutions prior to this month. She has had a progressive decline in cognition and general health beginning in [**7-12**], at which point she had recurrent ITP. In [**9-11**] she was treated with rituximab and her ITP seemed to respond. However, she felt fatigued, had night sweats, and experienced weight loss, all of an unclear etiology. She was thought to perhaps have URIs but eventually went to her PCP who found that her LFTs were elevated. Imaging revealed multiple small nodules in her liver worrisome for metastatic malignancy. However, CT guided biopsy in [**2-11**] was w/o evidence of malignancy. . At this point, she was transfused due to worsening anemia. This temporarily improved her symptoms. Then in [**3-13**], she began to notice a decline in her cognitive function. This was marked to the patient at her work in human resources. She found that she was having difficulty "connecting" with people and completeing tasks. . She was admitted to [**Hospital1 498**] for an extensive workup. Initial thought was that she had MS, given white matter changes on an MRI in [**Month (only) 116**], but the diagnosis was not definite. She continued to decline and presented to [**Hospital1 **] in early [**5-13**] for a second opinion by Dr. [**Last Name (STitle) 8760**]. . Dr. [**Last Name (STitle) 8760**] felt at that time that her exam and history were most consistent with PML. Also on the differential were tertiary syphilis, B12 deficiency, and Hashimoto encephalopathy. Evaluation at that time was notable for: WBC of 15.5, 93% neutrophils, Hct 28.7, MCV 91, plts of 448, Cr of 0.7, TSH of 0.50, neg HIV, neg EBV and [**Male First Name (un) 2326**] virus PCR in CSF, negative viral/fungal/cryptococcal Ag in CSF. LP: cell count 1 WBC, 4 RBC, 3% polys, 70% lymphs, 27% monos, TP 28, glu 68. [**Male First Name (un) 2326**] virus was re-checked by Dr. [**Last Name (STitle) 2340**] in neurology and found her test to again be negative. . Over the past 2 days the patient has become more confused at home. She has also had difficulty coordinating her swallow with new-onset hiccups. The patient's neurologists were contact[**Name (NI) **] and it was decided to admit the patient electively to the neuro service for brain biopsy. The patient was seen in the ED and admitted to neurology. The patient had a number of abnormalities on her ED labwork further complicating her presentation. She was transferred to medicine for further management. Past Medical History: # h/o recurrent Hodgkin's disease - initially presented as stage II - tx w/ XRT in [**2083**] - recurred then treated w/ ABVD - followed by splenectomy and autoBMT in [**2092**] - disease free since # recurrent ITP - first dx in [**2105**] - recurred in [**9-11**] - tx w/ IVIG, prednisone, rituximab (last given [**10-12**]) # h/o hypothyroidism since XRT # h/o SVT in [**2105**] - now on beta-blocker # asymptomatic carotid bruit # chronic anemia since [**7-/2107**] - required transfusion on at least 1 occassion Social History: Former HR manager, had to leave due to her present illness. Denies etoh/tob/illicits. Family History: Father with parkinson's otherwise no neuro history. Physical Exam: Temp 99 BP 104/62 Pulse 103 Resp 18 O2 sat 99% ra Gen - Alert, oriented x3, no acute distress HEENT - anicteric, mucous membranes slightly dry Neck - no JVD, no cervical lymphadenopathy Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, systolic murmur heard best at the LLSB Abd - Soft, nontender, nondistended, with normoactive bowel sounds Extr - No edema. 2+ DP pulses bilaterally Neuro - [**12-8**] words at 5 minutes, unable to spell world backwards cranial nerves [**1-17**] intact 4+/5 in [**Hospital1 **]/triceps b/l, o/w full strength throughout reflexes intact and symmetric sensation grossly intact Skin - No rash Pertinent Results: [**2108-6-1**] 10:46PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2108-6-1**] 10:46PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2108-6-1**] 10:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [**2108-6-1**] 10:46PM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[**2-8**] [**2108-6-1**] 09:03PM URINE HOURS-RANDOM CREAT-113 SODIUM-57 [**2108-6-1**] 09:03PM URINE OSMOLAL-608 [**2108-6-1**] 08:25PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2108-6-1**] 08:25PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2108-6-1**] 08:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-8.0 LEUK-NEG [**2108-6-1**] 08:25PM URINE RBC-[**2-8**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2108-6-1**] 06:49PM PT-14.5* PTT-28.8 INR(PT)-1.3* [**2108-6-1**] 06:20PM GLUCOSE-158* UREA N-14 CREAT-0.7 SODIUM-127* POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-20* ANION GAP-17 [**2108-6-1**] 06:20PM estGFR-Using this [**2108-6-1**] 06:20PM ALT(SGPT)-50* AST(SGOT)-92* LD(LDH)-248 ALK PHOS-297* TOT BILI-1.4 DIR BILI-0.7* INDIR BIL-0.7 [**2108-6-1**] 06:20PM ALBUMIN-2.4* IRON-17* [**2108-6-1**] 06:20PM calTIBC-135 VIT B12-502 FOLATE-7.9 HAPTOGLOB-590* FERRITIN-GREATER TH TRF-104* [**2108-6-1**] 06:20PM OSMOLAL-262* [**2108-6-1**] 06:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2108-6-1**] 06:20PM WBC-18.3* RBC-2.85* HGB-7.6* HCT-23.7* MCV-83# MCH-26.7* MCHC-32.0 RDW-17.5* [**2108-6-1**] 06:20PM NEUTS-84* BANDS-3 LYMPHS-6* MONOS-5 EOS-1 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2108-6-1**] 06:20PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-2+ TARGET-1+ SCHISTOCY-1+ BURR-1+ [**2108-6-1**] 06:20PM PLT SMR-NORMAL PLT COUNT-351 PLTCLM-1+ ANC nadir of 1312 on [**2108-7-5**] WBC nadir of 1.1 on [**2108-7-1**] Discharge labs- Glucose UreaN Creat Na K Cl HCO3 AnGap [**2108-7-14**] 03:26AM 253* 16 0.4 139 4.8 109* 23 12 WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2108-7-14**] 03:26AM 10.5 3.26* 10.3* 30.7* 94 31.5 33.5 19.9* 417 [**2110-7-13**].0 28.7 385 PT 12.9 INR 1.1 (from 1.2) PTT 26.4 AST 15 ALT 20 LDH 186 (from 138) AP 166 (from 144) . IMAGING: OLD IMAGING (per OMR note of Dr. [**Last Name (STitle) 8760**] [**2108-5-21**]): 1. MRI scan of the head [**2108-4-15**] reviewed today. There are bihemispheric confluent areas of increased signal within the centrum semiovale extending into the white matter of the cortical gyri without involvement of the cortex. In addition, there are extensive paraventricular white matter changes. Many of the extensive confluent white matter changes are oriented parallel to the long axis of the ventricle. There is a solitary 9-mm round oval area of increased signal within the right deep cerebellar white matter with feathery edges and no mass effect. There is no enhancement and only mild atrophy. There is no significant evidence of leukomalacia at this time. Diffusion weighted studies appear normal with no evidence of hemorrhage. 2. MRI scan of the spine [**2108-4-15**] shows no intramedullary signal changes. There are degenerative changes at C5-C6 with some impingement of the thecal sac on the left side. There is mention of submandibular and subclavicular lymph node enlargement on this study. [**2108-6-2**] Final Report EXAM: MRI brain. IMPRESSION: 1. Mild-to-moderate hyperintense signal in the subcortical and periventricular white matter could be due to small vessel disease and/or associated therapy-related changes. 2. Mild brain atrophy. 3. No evidence of abnormal brain parenchymal enhancement or acute infarcts. 4. Mild diffuse pachymeningeal enhancement is a nonspecific finding and could be related to previous lumbar punctures. . CT torso [**2108-6-2**] INDICATION: History of cognitive decline, history of liver nodules concerning for metastatic disease on outside hospital imaging. TECHNIQUE: Axial volumetric images have been obtained through the abdomen and pelvis without IV contrast. Arterial, portal venous, and delayed venous phases were also obtained after administration of IV contrast. Coronal and sagittal reformats were also obtained. FINDINGS: There are multiple innumerable hypoechoic nodules. The largest is in segment VI measuring 5 cm. Overall, there is enhancement of these nodules that appear to be more conspicuous on the portal venous phase. The background liver parenchyma appears unremarkable. No evidence of intra-hepatic biliary duct dilatation. The pancreas appears unremarkable. The stomach appears within normal limits. There are multiple retroperitoneal lymph nodes, all of which measure subcentimeter except for three portal lymph nodes measuring 1 cm in short axis. There has been previous splenectomy with surgical clips seen in the left upper quadrant. Bilateral adrenal glands are within normal limits. The bilateral kidneys appear unremarkable with no evidence of hydronephrosis or nephrolithiasis. No evidence of free fluid or free air in the abdomen. No evidence of abnormality. There is an 8 mm pericardial lymph node. There is basal atelectasis within the bilateral lower lobes. There are bilateral small pleural effusions. No evidence of suspicious bony lesions. There is a 2 mm lung nodule in the right lower lobe. IMPRESSION: 1. Innumerable hepatic nodules with an appearance mostly in keeping with multiple metastases with the largest in segment VI measuring 5 mm. 2. Multiple subcentimeter retroperitoneal lymph nodes with 1 periportal lymph node measuring 1 cm. No evidence of gastric, colonic, or pancreatic visible tumors. ----------------- [**2108-6-3**] MR of thoracic and cervical spine MRI SCAN OF THE CERVICAL AND THORACIC SPINE CONCLUSION: Relatively minor changes of cervical spondylosis, and a small T2-3 disc protrusion. Multiple nerve root diverticula as described. Moderate-size pleural effusions. Heterogeneous marrow signal pattern. Please see above report for additional discussion regarding the latter observation. [**2108-6-5**] Liver, needle core biopsies: Classical Hodgkin Lymphoma, see note: Note: Tissue cores reveal predominantly a lymphohistiocytic/granulomatoid background with scattered large, atypical [**Doctor Last Name **]-Sternberg cells and variants (monolobated Hodgkin cells) with a small fragment of residual intact hepatic tissue at the edges. By immunohistochemistry neoplastic cells express CD30, CD15 (dim/partial) and PAX5; CD20 and CD45 is negative (Block A). The CD30 and CD15 expression is confirmed in block B. Overall morphologic and immunohistochemical stains are in keeping with recurrence of patient's know classical Hodgkin lymphoma. The findings were communicated with the care providing team. ADDENDUM: [**Last Name (un) **] was performed: this revealed an increased number of EBV incorporated large cells. This is consistent with the above diagnosis. The overall impression remains unchanged. [**2108-6-5**] CXR HISTORY: Dyspnea, possibly related to aspiration. FINDINGS: In comparison with the earlier study of this date, the medial aspect of the left hemidiaphragm is not well seen. This raises the possibility of left basilar opacification consistent with atelectasis or, in view of the clinical history, possibly aspiration. ultra sound liver biopsy [**2108-6-5**] TARGETED ULTRASOUND-GUIDED LIVER BIOPSY: A limited ultrasound examination of the liver was performed, demonstrating numerous lobulated hypoechoic masses within the liver, consistent with lymphoma. A lobulated lesion in the left lobe measuring 3.7 cm was deemed most amenable to biopsy. IMPRESSION: Successful ultrasound-guided targeted liver biopsy of one lesion in the left lobe as described. CT chest [**2108-6-5**] INDICATION: Mental status change and liver nodules. Evaluate for aspiration. TECHNIQUE: MDCT axial images through the chest were obtained without intravenous contrast and displayed at 5 and 1.25 mm of collimation. A set of sagittal and coronal images were reformatted for review. COMPARISON: None. CT CHEST WITHOUT INTRAVENOUS CONTRAST: When compared to the prior CT abdomen of [**2108-6-2**], small bilateral pleural effusions, left greater than right, have increased in size. There is no evidence of aspiration or focal parenchymal consolidation. Microscopic apical subpleural nodules are too small to characterize. There is right apical scarring. Subtle nodular thickening of the right major fissure and right lower lobe intersitium could suggest lymphangitic tumor spread. Scattered mediastinal lymph nodes do not meet CT criteria for enlargement. The largest is a precarinal lymph node measuring 8 mm. There is a 6-mm pericardial lymph node. The airways are patent to the level of the subsegmental bronchi bilaterally, although there is generalized bronchial wall abnormality. While not tailored for infradiaphragmatic evaluation, multiple liver hypodensities concerning for metastases are best characterized on the recent CT abdomen scan. The patient is status post splenectomy. A 16 x 14 mm lytic lesion within the right humeral head disrupts the cortex. LP [**2108-6-6**] Cerebrospinal fluid: NEGATIVE FOR MALIGNANT CELLS. Shoulder xray [**2108-6-6**] HISTORY: Lytic humeral lesion seen on CT showing liver disease. IMPRESSION: Nonspecific lytic lesion humeral head is consistent with metastasis. Bone Scan [**2108-6-7**] IMPRESSION: No definite osseous metastases. Symmetrically increased tracer uptake in both shoulders is likely degenerative. No definite photopenia in the right humeral head to correspond to the patient's known lytic lesion. Video swallow [**2108-6-11**] HISTORY: Lymphoma recurrence, concern for aspiration. Comparison is made to report from prior examination dated [**2108-6-4**]. OROPHARYNGEAL SWALLOW STUDY Prior to the initiation of the study, the patient had an episode of seizure beginning with tonic stiffening of the upper extremities and slight rightward deviation of the head for approximately 30 seconds followed by generalized clonic activity of both upper and lower extremities, which lasted approximately 1-1/2 minutes. The patient was kept in an upright position to minimize aspiration risk and 2 mg of IV Ativan were administered just after termination of the clonic activity. Patient's hemodynamic parameters remained stable, and a blood sugar of over 100 was noted. The primary ordering team was contact[**Name (NI) **] and came to the department to further manage the patient's care. The findings were discussed with the caring resident, Dr. [**Last Name (STitle) **], immediately after the episode. IMPRESSION: Unsuccessful swallow study due to seizure. [**2108-6-11**] cxr HISTORY: Aspiration pneumonia. FINDINGS: In comparison with the study of [**6-9**], there is increased opacification at the right base silhouetting the hemidiaphragm, consistent with aspiration involving the right middle lobe. The area of opacification in the right upper zone is again seen though not as clearly. There is also some increased opacification in the left perihilar region and possibly at the left base. [**2108-6-12**] HISTORY: Aspiration pneumonia. FINDINGS: In comparison with the study of [**6-9**], there is increased opacification at the right base silhouetting the hemidiaphragm, consistent with aspiration involving the right middle lobe. The area of opacification in the right upper zone is again seen though not as clearly. There is also some increased opacification in the left perihilar region and possibly at the left base. CXR [**2108-6-13**] FRONTAL CHEST RADIOGRAPH: There has been interval placement of a nasogastric tube, which is appropriately positioned. Right perihilar and right upper lobe opacities are resolving. There remains left retrocardiac atelectasis and a small left-sided pleural effusion. [**2108-6-13**] IMPRESSION: Successful percutaneous transgastric jejunal tube placement. The tube is ready for use. The T-fastener skin sutures can be cut and released in seven to ten days. [**2108-6-15**] MR of HEAD with and without contrast IMPRESSION: 1. No interval change in degree of mild diffuse pachymeningeal enhancement, which is a non-specific finding and may be related to previous lumbar punctures, this appearance is not typical of lymphoma or PML. 2. Mild-to-moderate hyperintense signal in the subcortical and periventricular white matter is non-specific and could be due to small vessel ischemia and/or post-treatment changes. brain bx [**2108-6-16**] I. Dura, biopsy (A): Focal perivascular cuff of macrophages, see note. II. Right frontal lobe, biopsy (B): Cortical [**Doctor Last Name 352**] and white matter with minimal changes, see note. Note: Special stains on the dura (block A) reveal no organisms (gram stain, PAS, GMS, and AFB). By immunohistochemistry, the perivascular macrophages demonstrate positive staining with CD68, CD3, CD4, and CD8 highlight scattered T-lymphocytes. Special stains on the frontal lobe section (block B) show no organisms (gram stain, PAS, GMS, and AFB). Immunohistochemical stains show that CD68 highlights scattered macrophages and CD3, CD4, and CD5 stains rare T-lymphocytes. No microglial nodules are observed. No viral inclusions are detected. The inflammatory cell infiltrate is minimal and does not suffice for a diagnosis of meningoencephalitis. -------------------- [**2108-6-16**] Sinus tachycardia. Compared to the previous tracing of [**2108-6-9**] the rate has increased. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] Intervals Axes Rate PR QRS QT/QTc P QRS T 108 104 94 374/458 73 23 13 Head CT without Contrast [**2108-6-17**] INDICATION: 61-year-old female status post right frontal biopsy. Please evaluate for postoperative bleed, edema, and pneumocephalus. COMPARISON: MRI from [**2108-6-15**] and CT from [**2108-6-11**]. TECHNIQUE: Non-contrast head CT. IMPRESSION: Minimal, likely hemorrhage within right frontal cortex and pneumocephalus in the right frontal lobe, consistent with post- surgical change. ECHO [**2108-6-18**] Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal to mid inferior and inferolateral segments. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Mild focal LV systolic dysfunction. Probable diastolic dysfunction. Mild aortic stenosis. Moderate mitral regurgitation. [**2108-6-19**] PICC replacement by IR IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new double lumen PICC line. Final internal length is 51 cm, with the tip positioned in the SVC. The line is ready to use. [**2108-6-21**] cxr FINDINGS: In comparison with the study of [**6-20**], there is again a diffuse infiltrate of pulmonary process presenting as marked prominence of the interstitial markings. Moderate bilateral pleural effusions are again seen. The cardiac silhouette remains within normal limits and the right subclavian catheter again extends to the lower portion of the SVC. [**2108-6-28**] chest CT with contrast IMPRESSION: 1. Increased, almost complete left lower lobe atelectasis with mucus filling multiple segmental and subsegmental bronchi without visible focal lesion. 2. Right PICC line installed in good position. 3. Scattered non-enlarged mediastinal lymph nodes except for one 11 mm precarinal lymph node. 4. Left small pleural effusion improved. No residual right pleural effusion. 5. Multiple liver hypodensities worrisome for metastases from lymphoma or other primary should be compared with same technique of prior abdominal CT. 6. Post-splenectomy. 7. Stable lytic lesion of the right humeral head disrupting the cortex. 8. Unchanged biapical scarring and right lateral meningoceles or dural diverticula. [**2108-6-29**] echo IMPRESSION: Suboptimal image quality. Mild aortic stenosis. Low normal global left ventricular systolic function. Technically limited to exclude regional wall motion abnormality. Mild mitral regurgitation. Compared to prior study (images reviewed) of [**2108-6-18**], the regional left ventricular dysfunction cannot be assessed on the current study. The mitral regurgitation appears less prominent [**2108-6-29**] MR head with and without contrast IMPRESSION: 1. Subacute hematoma in the right frontal lobe at the biopsy site, with moderate surrounding edema. Superimposed infection within the hematoma cannot be excluded by imaging if the patient has infectious symptoms. 2. Diffuse pachymeningeal enhancement, unchanged compared to the preoperative study of [**2108-6-15**], which is of uncertain etiology but unlikely to be related to lymphoma. 3. Persistent fluid in the sphenoid sinus. Opacification of the right lateral mastoid air cells. CT Head with contrast [**2108-7-3**] IMPRESSION: 1. Rim-enhancing area in the right frontal cortex in the site of previous biopsy. This may be an evolving hematoma; however, an abscess is not entirely excluded. MRI is recommended to document evolution of blood products and to aid in the discrimination of an abscess MR head with contrast [**2108-7-4**] IMPRESSION: 1. Essentially unchanged appearance of the abnormality in the right frontal cortex. This may still be an evolving hematoma. Underlying infectious process is not excluded as suggested before in the appropriate setting. 2. Unchanged mild pachymeningeal enhancement. 3. New area of susceptibility in the left globe causing adjacent artifact. This may be secondary to metal overlying the left eye, and clinical correlation is recommended. [**2108-7-5**] EEG FINDINGS: IMPRESSION: Abnormal EEG due to the persistently slow background and due to the mixed frequency slowing in the left temporal region. The first abnormality signifies a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. The focal slowing indicates a focal subcortical dysfunction in the left hemisphere, but the tracing cannot specify the etiology. There were no epileptiform features. [**2108-7-5**] CT torso with constrast IMPRESSION: 1. Unchanged appearance of innumerable hepatic nodules in keeping with multiple metastases, grossly unchanged. 2. Marked increase in left pleural effusion and slight increase in the right pleural effusion. 3. Increased number of peribronchial ground-glass and consolidative opacities suggests more prominent multifocal airspace disease. 4. No evidence of pathologically enlarged nodes. The study and the report were reviewed by the staff radiologist. Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study Date of [**2108-7-11**] 10:59 AM SPIROMETRY 10:59 AM Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 1.94 3.39 57 FEV1 1.56 2.50 63 MMF 1.52 2.74 55 FEV1/FVC 81 74 109 LUNG VOLUMES 10:59 AM Pre drug Post drug Actual Pred %Pred Actual %Pred TLC 3.56 5.49 65 FRC 2.67 3.13 85 RV 1.77 2.10 85 VC 1.88 3.39 55 IC 0.89 2.36 38 ERV 0.90 1.04 87 RV/TLC 50 38 131 He Mix Time 0.00 DLCO 10:59 AM Actual Pred %Pred DSB 10.85 19.61 55 VA(sb) 3.38 5.49 61 HB 10.00 DSB(HB) 12.37 19.61 63 DL/VA 3.66 3.57 103 [**2108-7-12**] CXR Small left pleural effusion is comparable in volume to [**7-3**]. Opacification of the base of the left lung could represent either pneumonia or residual atelectasis. An intervening chest CT, on [**7-5**], when there was more left lower lobe consolidation was equivocal in this regard. Peribronchial opacification in the right mid lung is another candidate for pneumonia, unchanged since [**7-3**], and alternatively could be residual edema improved since [**7-1**]. Upper lungs are clear. There is no right pleural effusion. Heart size is normal. No pneumothorax. Right PICC line ends in the lower SVC. Mirco reports [**2108-7-12**] 9:40 pm STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT [**2108-7-13**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2108-7-13**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [**2108-7-8**] 5:17 pm SPUTUM Source: Induced. **FINAL REPORT [**2108-7-9**]** Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2108-7-9**]): NEGATIVE for Pneumocystis jirvovecii (carinii). [**2108-7-5**] 4:45 pm BLOOD CULTURE Source: Line-picc #2. **FINAL REPORT [**2108-7-11**]** Blood Culture, Routine (Final [**2108-7-11**]): NO GROWTH. [**2108-7-5**] 4:45 pm URINE Source: Catheter. **FINAL REPORT [**2108-7-6**]** URINE CULTURE (Final [**2108-7-6**]): NO GROWTH. [**2108-6-27**] 8:06 am URINE Source: Catheter. **FINAL REPORT [**2108-6-29**]** URINE CULTURE (Final [**2108-6-28**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 ORGANISMS/ML.. [**2108-6-16**] 9:00 pm TISSUE DURA ALSO R/O CMV AND HSV. VIRAL CULTURE (Preliminary): No Virus isolated so far. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final [**2108-6-20**]): NEGATIVE FOR CYTOMEGALOVIRUS EARLY ANTIGEN. REFER TO CULTURE RESULTS. [**2108-6-16**] 9:00 pm TISSUE Site: BRAIN DURA MIDDLE LOBE. FUNGAL, TISSUE, [**Doctor First Name **] AND GRAM STAIN REQUESTED BY DR.[**First Name (STitle) **],[**First Name3 (LF) **] ([**Numeric Identifier 78639**]), [**2108-6-18**]. GRAM STAIN (Final [**2108-6-18**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. POTASSIUM HYDROXIDE PREPARATION (Final [**2108-6-18**]): NO FUNGAL ELEMENTS SEEN. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. TISSUE (Final [**2108-6-21**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2108-6-24**]): NO GROWTH. [**2108-6-6**] 2:00 pm CSF;SPINAL FLUID TUBE 3. **FINAL REPORT [**2108-6-9**]** GRAM STAIN (Final [**2108-6-6**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 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 [**2108-6-9**]): NO GROWTH. Time Taken Not Noted Log-In Date/Time: [**2108-6-4**] 5:14 am Blood (EBV) **FINAL REPORT [**2108-6-4**]** [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2108-6-4**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2108-6-4**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2108-6-4**]): 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. Time Taken Not Noted Log-In Date/Time: [**2108-6-4**] 5:14 am Blood (CMV AB) **FINAL REPORT [**2108-6-5**]** CMV IgG ANTIBODY (Final [**2108-6-5**]): NEGATIVE FOR CMV IgG ANTIBODY BY EIA. < 4 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final [**2108-6-5**]): NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: NO ANTIBODY DETECTED. Greatly elevated serum protein with IgG levels >[**2099**] mg/dl may cause interference with CMV IgM results. Brief Hospital Course: 60yo female with a very prolonged and complicated hospital course. She has a past history of Hodgkin's' lymphoma in [**2092**] now with recurrence and was admitted for diagnostic work-up of cognitive decline. She initially has seen by the neurology service and there was concern for PML or other brain pathology. She had a liver bx that diagnosed Hodgkin's disease. She then had a brain bx which did not show any pathology. During her admission she developed dysphagia and problems speaking. She has a swallow study with a seizure. And then was treated for aspiration pneumonia. She then began treatment for her cancer. She developed orthostatic hypotension with syncope. She had ICU stays on [**8-7**] for hypoxia and syncope and [**Date range (1) 5489**] for aspiration PNA. Her mental status improved and she was able to receive additional chemotherapy before discharge. # Hodgkin's lymphoma - on [**6-2**] she had a abdominal CT that showed innumerable liver nodules. She has a ultra sound guided liver biopsy on [**6-5**], and the patient was found to have a recurrence of HD. She was then transferred to the BMT service. Her LP on [**6-6**] and brain bx on [**6-16**] was negative for CNS involvement. It was thought her mental decline was due to a paraneoplastic syndrome, since other causes were ruled out. Her dysphagia was also likely to neuropathy secondary to her disease. After she was stable, she received a PICC line and had treatment on [**6-21**] with gemcitabine 1400mg, vinorelbine 26mg, and Decadron 20mg. Then on [**6-17**] she received the same tx plus liposomal doxorubicin 20mg. Her WBC nadir was on [**7-1**] at 1.1 and her ANC nadir was on [**7-5**] at 1312. She had G-CSF treatment on [**8-1**] and [**Date range (1) 20550**]. She had a follow up torso CT with contrast on [**2108-7-5**] that did not show significant change in her disease, however, her mental status had improved. Therefore, she was restarted on chemotherapy with Doxil 17mg, Vinorelbine 26mg, and Gemcitabine 1400mg, Decadron 20mg on [**2108-7-13**], and will need her next treatment in [**5-15**] days after discharge depending on her nadir. She will also likely need treatment with G-CSF as her ANC falls on [**7-16**] and [**7-17**]. Her out patient Oncologist Dr. [**Last Name (STitle) 78640**] at [**Hospital3 15054**] will be contact[**Name (NI) **] and informed about her hospitalization and will likely administer her next dose of chemotherapy. If her oncologist is unable to be contact[**Name (NI) **] she will need her next treatment as an outpatient at the [**Hospital3 **] clinic. # Seizure - Just prior to a video swallowing exam on [**2108-6-11**], the patient was observed to have a tonic clonic seizure lasting approximately 30 seconds to 1 minute. She had post-ictal confusion, no fecal or urinary incontinence, and her vital signs were stable during and after her seizure. She was evaluated by neurology and she was started on levetiracetam 1500 mg daily, this was later changed on 500mg TID. She had an EEG on [**7-5**] that only showed diffuse slowing consistent with encephalopathy consistent with her paraneoplastic syndrome. . # Aspiration pneumonia - The [**Hospital 228**] hospital course was complicated transient hypoxemia that was believed to be aspiration PNA she was treated with levofloxacin and Flagyl initially. She went to the ICU in setting of hypoxia from 714/-[**6-20**] after her brain bx. Aspiration PNA and pulmonary edema were the leading diagnoses. She was diuresed with Lasix 20 IV with brisk response. She was net neg 3.7 L during ICU stay. Her resp status improved and she was on 2L. She was transferred back to the oncology floor for chemo if indicated per heme/onc. Then again after chemo on [**6-30**] that pt had orthostatic hypotension with syncope and temporary hypoxia believed to be a mucus plug. Her resp status improved with nebulizers and she was treated with levofloxacin. Then after her last CT scan on [**7-5**] showed bilateral increased pleural effusions (worse on left) and bilaterally lower lobe consolidations she was switched to vancomycin and aztreonam. She is on day 9 of both, she will need treatment for 6 more days, or until her cell counts recover. She has had no resp sx since her last ICU stay. # Cognitive decline: After full neurology work up including brain bx, her mental decline was likely secondary to paraneoplastic syndrome from her Hodgkin's causing encephalopathy. Pt has had evidence of memory difficulties and hallucinations on multiple exams here at [**Hospital1 **]. Her decline has been rapid. She has had gait changes, but otherwise minimal disordered movement before admission. She had a seizure on [**2108-6-11**], however, her EEG later during admission did not show continued seizure activity. The brain biopsy was on [**6-16**] and was inconsistent with lymphoma or PML. While in the ICU, head imaging showed edema around her biopsy site that was concerning for infection, but MRI was not consistent with this. Neuro felt that the amount of edema was consistent with post-biopsy. Cultures, EBV PCR, and [**Male First Name (un) 2326**] Virus PCR from CSF were all negative. HSV PCR was negative. Her mental status slowly improved after her chemotherapy which reenforced the diagnosis of a paraneoplastic syndrome. # Dysphagia: Daughter gives history of difficulty swallowing liquids and solids. Had a during this hospitalization of aspiration pneumonia. She was evaluated multiple times by speech and swallow, and was determined to be at serious aspiration risk. On [**2108-6-13**] she was refluxing tube feeds through her nasogastric tube, and thus had a gastric-jejunostomy tube placed and tube feeds were initiated. Then after improvement in her mental status, she had another video swallow test on [**2108-7-13**], which did not show aspiration. Therefore she was restarted on pureeded solids and thickened liquids, she will need follow up swallow study with video in [**12-7**] weeks. She should slowly increase her PO intake and decrease her tube feeds. # Hypotension: patient was transiently hypotensive to the 80's on [**2108-6-30**] when she stood up and had brief syncope, she had not been taking good PO's in prior 24 hours, secondary to nausea. She has since had multiple episodes of orthostatic hypotension, always responsive to fluids. These episodes have decreased since starting on fludrocortisone. # Tachycardia: History of SVT, baseline HR appears to be 90-110 for last several days. Sinus tachy on EKG. Tachycardia may also be worsening her diastolic dysfunction leading to increased pulmonary congestion. Her home Lopressor was held due to orthostatic hypotension. Once her BP has improved would benefit from restarting anti nodal [**Doctor Last Name 360**]. # Anemia: Low MCV anemia, suggesting either chronic blood loss or iron deficiency. Of note, patient must get irradiated blood due to previous stem cell transplant. Goal HCT is >25, now 30.7. # h/o ITP: Has been on a long taper of home prednisone. Steroid therapy was discontinued per oncology recommendations at the beginning of her hospital stay and her platelets progressively fell to below 100,000. Platelets are now 417. # hypothyroidism: Was continued on home dose of Synthroid. Patient will have follow up with Dr. [**Last Name (STitle) 78640**] at [**Hospital3 15054**], if she can not follow the patient she will be seen at [**Hospital1 18**]. She will need more chemotherapy in [**5-15**] days. She will be transferred to rehab for more physical therapy and treatment. Her CBC, ANC, electrolytes, coags, and LFT's should be followed. She will need a follow up video swallow test in [**12-7**] weeks. Medications on Admission: MEDS: tylenol 325-650 PO Q6 prn FeSO4 325mg PO BID levothyroxine 88mcg PO QD metoprolol XL 25mg PO QD pantoprazole 40mg PO QD prednisone 5mg PO QD sertraline 50mg PO QD vitamin D 400u PO QD colace 100mg PO BID ciprofloxacin 250mg PO Q12 - started on [**5-29**], for total 7 days Discharge Medications: 1. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Year (2) **]: 3-5 MLs Intravenous PRN (as needed) as needed for line flush: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. . 2. Aztreonam 1 gram Recon Soln [**Month/Year (2) **]: 500mg Recon Solns Injection Q8H (every 8 hours) for 6 days: started on [**2108-7-6**]. Recon Soln(s) 3. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Date Range **]: One (1) Intravenous Q 12H (Every 12 Hours) for 6 days: Started on [**2108-7-6**]. 4. Levothyroxine 88 mcg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 5. Thiamine HCl 100 mg/mL Solution [**Date Range **]: One (1) Injection DAILY (Daily). 6. Levetiracetam 100 mg/mL Solution [**Date Range **]: Five (5) PO Q 8H (Every 8 Hours). 7. Ipratropium Bromide 0.02 % Solution [**Date Range **]: One (1) Inhalation Q6H (every 6 hours) as needed. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Date Range **]: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Fluconazole 200 mg Tablet [**Date Range **]: One (1) Tablet PO Q24H (every 24 hours) as needed for yeast on culture. 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] every twelve (12) hours: give in G TUBE . 11. Fludrocortisone 0.1 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 12. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: One (1) Injection Q8H (every 8 hours) as needed for nausea for 7 days. 13. Filgrastim 300 mcg/0.5 mL Syringe [**Last Name (STitle) **]: One (1) Injection once a day for 2 days: Please give on [**7-16**] and [**7-17**]. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: -recurrent hodgkin's disease -orthostatic hypotension -paraneoplastic syndrome causing neuropathy and encephalopathy -bilateral pleural effusions -bilateral pneumonia -tonic clonic seizure -dysphagia secondary to neuropathy Discharge Condition: Hemodynamically stable, can ambulate a few steps with assistance, afebrile. Discharge Instructions: You were admitted to [**Hospital1 69**] due to mental decline and peumonia. You were found to have recurrent Hodgkin's Disease, this was found on a liver biopsy. You were treated with chemotherapy, you will need more chemotherapy after discharge in [**5-15**] days since you still have significant disease. You also had a brain biopsy which did not show cancer in your brain. You have complications that required going to the ICU for pneumonia and having a feeding tube since for a time you could not swallow properly. Before discharge your swallowing improved and you were restarted on foods. You are still being treated for a pneumonia with antibiotics. You also had problems with your blood pressure dropping when you stood up, this has been improved with medication. You will require more physical therapy after your discharge. Your swallowing will also be retested in [**12-7**] weeks. You will be going to a rehab center for more treatment. Please keep your follow up appointments. Please take your medications as perscribed. If you have shortness of breath, chest pain, increased confusion, rash, fever, chills, diarrhea or any other concerning symptom please seek medical attention or go to the ER. Followup Instructions: You will need to call your hemetologist/oncologist Dr. [**Last Name (STitle) 78640**] on Monday to set up an appointment in the next week. She will determine your next chemotherapy cycle. You will also need treatment with GCSF as your white blood drops. Video Swallow study in [**12-7**] weeks, should be arranged by rehab facility. Completed by:[**2108-7-14**]

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Discharge summary

report

Admission Date: [**2132-7-6**] Discharge Date: [**2132-7-16**] Date of Birth: [**2047-7-25**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1185**] Chief Complaint: Subarachnoid hemorrhage Major Surgical or Invasive Procedure: PICC catheter placement History of Present Illness: The patient is an 84 year old male with a history of CLL being treated with Rituxan who fell from bed early yesterday morning. He was found by his wife, and was reportedly awake and alert at the time. Per his wife, he was having fevers for several days prior, without any localizing symptoms. He was initially seen at [**Hospital3 **], where CT head showed extensive subarachnoid hemorrhage. He was febrile to 101.1 and noted to be hypokalemic and given oral potassium repletion. He was then transferred to [**Hospital1 18**] for further Neurosurgery evaluation. On arrival to [**Hospital1 18**], the patient denied chest pain, shortness of breath, or abdominal pain. . In the ED, initial vital signs were T 96.4, BP 120/59, HR 100, RR 18, SpO2 99% on 2L NC. The patient was seen by Neurosurgery, and CTA head was performed to evaluate for aneurysm. This showed extensive bilateral subarachnoid hemorrhage as on prior from OSH, with no evidence of intracranial aneurysm and patent major vessels. He was noted to have neutropenia with ANC <1 and hypokalemia with K 2.7. He was given Potassium choride PO for repletion. Infection workup was started with blood cultures, urinalysis, urine cultures, and CXR. His urinalysis was bland with WBC 1, few bacteria, negative nitrite, and negative leukocyte esterase. CXR showed bibasilar opacities likely atelectasis though aspiration could not be excluded. He was given a dose of Cefepime for empiric febrile neutropenia coverage. He was admitted to the ICU for further management. . Once in the ICU, the patient denied chest pain, cough, or sputum production. He does report feeling somewhat feverish over the last few days. He denies any abdominal pain, nausea, or vomiting. He does recall that he had a single day of diarrhea about 3-4 days previous, which he says is very atypical for him. He does not remember falling out of his bed, but does remember the trip to the hospital afterwards. He is unsure of his medications and says that his wife has a list that she can bring. . Review of systems: (+) Per HPI (-) 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: # Hypertension # Seizures # CLL -- currently undergoing treatment with bendamustine/rituximab # BPH # Restless legs Social History: # Home: He lives with his wife. # Tobacco: None # Alcohol: None # Illicits: None Family History: Noncontributory Physical Exam: ADMITTING PHYSICAL EXAM: Vitals: T 102.7, BP 134/57, HR 117, RR 23, SpO2 97% on RA General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated Lungs: Clear to auscultation bilaterally. No wheezes, rales, rhonchi CV: Regular tachycardia. Normal S1 and S2. No murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended. Bowel sounds active. No rebound tenderness or guarding. GU: No foley Ext: Warm, well perfused, 2+ pulses. No lower extremity edema. Nodes: Enlarged axillary nodes bilaterally. Neuro: CN II-XII grossly intact. Strength 5/5 in all extremities. . At the time of discharge, he has been afebrile for 4 days, normotensive with BPs in the 130/80 range, HR in the 80-100 range (sinus), sat ~95 on room air. His respirations are unlabored. He has difficulty communicating when he is not wearing his dentures and hearing aide. He becomes intermittently confused, but not agitated, overall delirium has been clearing the last 2 days. Pertinent Results: ADMISSION LABS: [**2132-7-6**] 12:37AM COMMENTS-GREEN TOP [**2132-7-6**] 12:37AM GLUCOSE-121* LACTATE-0.9 K+-2.9* [**2132-7-6**] 12:30AM GLUCOSE-125* UREA N-37* CREAT-1.0 SODIUM-142 POTASSIUM-2.7* CHLORIDE-103 TOTAL CO2-26 ANION GAP-16 [**2132-7-6**] 12:30AM estGFR-Using this [**2132-7-6**] 12:30AM CALCIUM-8.5 PHOSPHATE-2.6* MAGNESIUM-2.0 [**2132-7-6**] 12:30AM WBC-1.6* RBC-3.97* HGB-10.6* HCT-31.7* MCV-80* MCH-26.8* MCHC-33.5 RDW-15.5 [**2132-7-6**] 12:30AM NEUTS-31* BANDS-8* LYMPHS-30 MONOS-24* EOS-0 BASOS-0 ATYPS-6* METAS-1* MYELOS-0 NUC RBCS-1* [**2132-7-6**] 12:30AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ [**2132-7-6**] 12:30AM PLT SMR-LOW PLT COUNT-141* [**2132-7-6**] 12:30AM PT-13.1 PTT-28.3 INR(PT)-1.1 [**2132-7-6**] 12:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2132-7-6**] 12:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2132-7-6**] 12:30AM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-1 [**2132-7-6**] 12:30AM URINE GRANULAR-1* HYALINE-5* [**2132-7-6**] 12:30AM URINE MUCOUS-RARE ================= MICRO: ================= Blood culturesx4: GRAM POSITIVE RODS (Listeria), cleared after one day of antibiotics. Urine cultures: <10,000 organisms (FINAL) Stool cultures: negative C.diff assay: negative . [**2132-7-13**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2132-7-12**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2132-7-12**] URINE URINE CULTURE-FINAL INPATIENT [**2132-7-12**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2132-7-11**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2132-7-10**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2132-7-10**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2132-7-10**] URINE URINE CULTURE-FINAL INPATIENT [**2132-7-9**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2132-7-8**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2132-7-7**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2132-7-6**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2132-7-6**] BLOOD CULTURE Blood Culture, Routine-FINAL {LISTERIA MONOCYTOGENES}; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] [**2132-7-6**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **] [**2132-7-6**] BLOOD CULTURE Blood Culture, Routine-FINAL {LISTERIA MONOCYTOGENES}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL EMERGENCY . ================= IMAGING: ================= CTA HEAD ([**2132-7-6**]): WET READ: Extensive bilateral subarachnoid hemorrhage as on prior from OSH. No evidence of intracranial aneurysm with patent major vessels. . CHEST PA&LAT ([**2132-7-6**]):FINDINGS: Elevated left hemidiaphragm is noted. Bibasilar opacities likely reflect atelectasis. Cardiomegaly is noted; however, this could be reflective of low lung volumes. No pleural effusion or pneumothorax seen. IMPRESSION: Bibasilar atelectasis. . CT HEAD ([**2132-7-7**]): SAH grossly unchanged with small amount of hemorrhage in occipital [**Doctor Last Name 534**] of right lateral ventricle, likely redistribution of blood. No shift of midline structures or central herniation . ECHO ([**2132-7-7**]): The left atrium is elongated. 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 regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are moderately thickened. No masses or vegetations are seen on the aortic valve. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is a small to moderate sized pericardial effusion (mainly posterior). There are no echocardiographic signs of tamponade. . CT head ([**7-13**]): Interval mild decrease in bilateral subdural and subarachnoid and prenchymal hemorrhages. No new areas of hemorrhage. A subcm. lucent lesion in the left parietal bone- attention on followup. . ================== DISCHARGE LABS: ================== [**2132-7-16**] 04:51AM BLOOD WBC-7.1 RBC-3.53* Hgb-9.3* Hct-28.4* MCV-81* MCH-26.3* MCHC-32.6 RDW-15.4 Plt Ct-177 [**2132-7-14**] 05:05AM BLOOD Neuts-69 Bands-0 Lymphs-25 Monos-1* Eos-1 Baso-0 Atyps-0 Metas-4* Myelos-0 [**2132-7-14**] 05:05AM BLOOD Gran Ct-4271 [**2132-7-15**] 06:28AM BLOOD Glucose-80 UreaN-12 Creat-0.8 Na-138 K-3.5 Cl-100 HCO3-28 AnGap-14 [**2132-7-13**] 05:14AM BLOOD ALT-7 AST-14 LD(LDH)-201 AlkPhos-99 TotBili-0.3 [**2132-7-15**] 06:28AM BLOOD Mg-1.9 [**2132-7-11**] 04:20AM BLOOD calTIBC-231* VitB12-753 Folate-13.0 Ferritn-119 TRF-178* . Brief Hospital Course: 84 yo M with CLL admitted with SAH/SDH and fevers after fall from home. Hospital course complicated by neuropenia, listeria bacterimia, and delirium. Outlined by problem below: . # Febrile Neutropenia, Bacteremia, CLL He was reportedly febrile for several days prior to his presentation, and was febrile to 102.7 on arrival in the ICU. ID was consulted. Treatment with vancomycin and cefepime was initiated. Blood cultures eventually grew Listeria. Antibiotic was switched to ampicillin, then to pencillin for ease of dosing. Surveillance cultures were drawn, blood cultures cleared after the first day. Given the presence of a murmur on exam and bacteremia, patient underwent TTE, which revealed no vegetations. . He has a hx of temporal lobe seizures and seized on [**7-13**]. Because penicillin is thought to be more eliptogenic than ampicillin, he was swtiched bact to ampicillin q4h with the intention of treating for a total course of 4 weeks starting the day his neutropenia resolved ([**Date range (1) 91546**]). Surveillance labs should be done weekly and faxed to ID at [**Hospital1 18**] and his oncologist--instructions attached in discharge plan. He will follow-up with ID at [**Hospital1 18**] in two weeks as scheduled. . Oncology was consulted regarding management of CLL and neutropenia. Neupogen was started on [**7-9**], his counts rose and on [**7-13**] he was no longer neutropenic. He has a history of CLL treated with Rituxan, Prednisone, and Treanda (Bendamustine). Patient's primary oncologist was contact[**Name (NI) **]; per him, patient takes a long time to recover counts. He gets 50% dose reduction of chemotherapy. His last treatment was [**2132-5-15**]. . # Subarachnoid Hemorrhage: He developed an extensive SAH and SDH after fall from his bed at home with headstrike. CTA brain did not show evidence of an aneurysm. Neurosurgery did not feel that surgery was indicated at this time; they were actively involved in his care. Patient was continued on Felbamate, his home antiepileptic regimen. Neuro checks were done q1hour and then increased to q4hours. Three repeat head CTs showed a grossly unchanged SAH with no shift of midline structures or central herniation. He will have f/u head CT and appointment with neurosurgery in [**5-21**] weeks. . # Seizure disorder: continued felbamate. As above, he had one seizure this admission which was brief, sel-terminating, and did not recur after he was swwitched back to ampicillin. . # Hypertension, Benign: initially held triamterene/HCTZ in setting of febrile neutropenia, then restarted at home dose. Acetozolamide was held throughout admission. . # Urinary retention: Had somewhat high post-void residuals. Started Flomax with good effect. Dutasteride was discontinued. . # Delirium: After the bulk of the medical issues above stabilized, the patient became delirious on [**7-13**] and [**7-14**], this largely resolved 48 hours prior to discharge. He was seen by the geriatrics consult service, but had largely improved by then. They suggested that if he should become confused again that carbidopa/levodopa be discontinued as he takes this only for RLS and not parkinson's dz. Medications on Admission: Triamterene 50-25 mg 1 tab PO QAM Avodart 0.5 mg PO QAM Felbatol 600 mg PO BID Carbidopa-Levodopa 50-200 mg 0.5 tab PO QPM Acetazolamide 250 mg 0.5 tab PO QPM Potassium chloride CR 10 mEq PO QPM Allopurinol 300 mg PO daily Discharge Medications: 1. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. felbamate 400 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 3. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 4. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 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. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily): hold for loose stools. 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hrs on, 12 hrs off, low back. 11. trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as needed for insomnia. 12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 13. ampicillin sodium 2 gram Recon Soln Sig: One (1) Injection every four (4) hours for 4 weeks: last day [**8-10**]. 14. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO at bedtime. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) **] Discharge Diagnosis: Febrile neutropenia Bacteremia, Listeria CLL Subarachnoid and subdural hemorrhages Urinary retention Toxic-metabolic encephalopathy Discharge Condition: Mental Status: Clear and coherent, difficulty communicating because of non-compliance with hearing aide. Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 41671**], You were admitted after a fall in which caused bleeding in and around your brain (subdural and subarachnoid hemorrhage). The size of the bleeding remained stable, and the Neurosurgery service felt that no intervention was needed. You were found to have a bloodstream infection (with the bacteria Listeria) while your white blood cell count was low. You were treated with antibiotics, and should continue antibiotics for a total of 4 weeks. You became confused while you were in the hospital, but this cleared spontaneously prior to discharge. You were seen by a geriatrician. Followup Instructions: Department: Hematology/ Oncology Name: Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 4966**] When: We are working on a follow up appt in the [**Hospital 3894**] Healthcare Hematology/ Oncology department with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 4966**] in [**8-28**] days after your discharge from the hospital. You will be called at home with the appointment. If you have not heard or have questions, please call the office number listed below. Address: [**Street Address(2) 84025**], [**Location (un) **],[**Numeric Identifier **] Phone: [**Telephone/Fax (1) 84026**] Department: RADIOLOGY When: TUESDAY [**2132-8-26**] at 1:15 PM 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 [**2132-8-26**] at 2:15 PM 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 Department: INFECTIOUS DISEASE When: TUESDAY [**2132-7-29**] at 11:00 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 [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**] Completed by:[**2132-7-16**]

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Discharge summary

report

Admission Date: [**2117-8-5**] Discharge Date: [**2117-8-14**] Date of Birth: [**2071-4-1**] Sex: M Service: MEDICINE Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 2387**] Chief Complaint: S/p cardiac arrest Major Surgical or Invasive Procedure: ICD placement Cardiac catheterization History of Present Illness: 46yoM with no cardiac history who was in the outpatient waiting area of [**Hospital6 2910**] on [**2117-8-4**], waiting for his wife who was having a procedure. He collapsed, had reported seizure-like activity and urinary incontinence, then had subsequent cardiac arrest, was intubated with ETT #7, received 1mg Epinephrine via ET tube, shocked once with return of palpable femoral pulses within 15-30 secs after first shock, and then given second 1mg Epinephrine. He began to move afterwards, but pupils were noted to be "midsized and not responsive to light." He was noted to have "spontaneous respiration" and then transferred to ICU. Review of the strips was concerning for VFib but ICU MD thinks maybe PEA. . Through his ICU course: ABG there showed 7.31/37/477/19; normal BMP/Ca/Mg, WBC 14.9, Hct 44, Plts 269. He was given 1gm Mg and started on Propofol gtt. L subclavian CVL was placed. ? infiltrate in RML on CXR for which he is on Clindamycin; there was also concern for ? L clavicle fracture that per discussion may be old (he is a steel worker and was seeing a doctor and PT for L shoulder pain previous to this). He is ventilated with 500 Tv, PEEP 5, FiO2 50%, and has had no issues on the vent. Exam on admission significant for pupils 2mm equal but not responsive to light, no doll's eyes, decerebrate posturing, fine tremor in BUE's, irregular rhythm with systolic murmur, wheezy lungs. Out of concern for the "seizure" they have CT'd his head which was negative, and did an EEG which did not show any seizure activity; per discussion they did not feel that he actually had any seizure. . Per discussion with NEBH ICU physician, [**Name10 (NameIs) **] was Wellens pattern in V3-4 with deep symmetric T waves. Echo significant for PASP 25-30, EF 55%, HK of mid to distal anterior free wall and anteroseptum. Initial Trop on ICU admission was 2.5 but was risen to 5 last night, and 11 this am. He has had no arrthymic issues. . This am, he continues on Heparin gtt 1300 (with prolonged PTT), Amiodarone 0.5mg/min gtt, and has been on 325 ASA, was Plavix loaded 600 and 75 daily, Atorvastatin 80 daily, Lopressor 25 q6, still intubated on Propofol. Just this am he has developed mild hypoTN to the 90's for which he is being bolused with IVF's, no pressors. Plan is to transfer to CCU and have cardiac cath at 11a today with Dr. [**Last Name (STitle) **]. . The pt's wife arrived and confirms he has no cardiac history, no h/o HTN, HL, DM, FHx, but does actively smoke a few cigarettes daily. His cardiac ROS was entirely negative before the event, is very active without complaints of angina, DOE, syncope, dizziness, swelling. . ROS otherwise with some musculoskeletal complaints; he had a herniated disc and subsequent lower extremity radiculopathic pain. She states he was doing PT, who wanted him to do some weight lifting, and then for the past week was having L shoulder pain (? L clavicle fx on CXR?). Also with some depression/anxiety from being on disability and not being able to work, otherwise all negative. . Past Medical History: 1. CARDIAC RISK FACTORS: Former heavy smoker but has no cut down to a few cigs per day, but no h/o HL/HTN/DM/FHx 2. CARDIAC HISTORY: No prior known cardiac disease [**7-/2117**]: cardiac arrest requiring shock, ICU admission, echo showing WMA concering for LAD lesion, transfer to [**Hospital1 18**] for cath 3. OTHER PAST MEDICAL HISTORY: - Herniated vertebral disc and radicular sxs - L clavicle fracture incidentally noted on plain film - EtOH 14 yrs ago - ? depression/anxiety Social History: Born in [**Country 4754**], has a brother in [**Name (NI) 4754**], married with 13 yo son. Wife = [**Name (NI) **]. Disabled sheet metal worker, currently not working due to L shoulder injury. Fairly active, walks his dog daily. Has one brother in [**Name (NI) 4754**]. - Tobacco history: Wife and pt share 3 packs of cigs per week - ETOH: Drank heavily but quit 14 yrs ago - Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: Deceased when pt was 3yo from multiple sclerosis - Father: Alive at 78, healthy Physical Exam: Temp 100 p84 117/79 99% Vent settings AC 500x14, PEEP5, and 100% FiO2 Average, not-obese M in no distress, diaphoretic, intubated, not responding to verbal stimuli. PERRL from 4 -> 3, but no oculovestibular reflex. No scleral icterus. Deferred mouth exam. Internal jugular pulsations noted at 6cm above sternal notch at 30 deg, and prominent external jugulars noted, no Kussmaul's sign. CTAB on the anterolateral chest, looks synchronous with the vent but occasionally coughing, with tan-white thick secretions suctioned RRR with no murmurs, gallops, strong S1/S2, bilateral palpable DP and PT's Abd overweight but not obese, soft, NT ND, benign BLE's without edema, no chronic venous stasis changes. Extremities are all warm, not mottling. Neuro exam deferred Pertinent Results: [**2117-8-5**] 11:58PM GLUCOSE-109* UREA N-9 CREAT-0.8 SODIUM-142 POTASSIUM-3.1* CHLORIDE-107 TOTAL CO2-26 ANION GAP-12 [**2117-8-5**] 11:58PM CALCIUM-7.9* PHOSPHATE-0.8* MAGNESIUM-1.9 [**2117-8-5**] 08:17PM TYPE-ART PO2-113* PCO2-46* PH-7.41 TOTAL CO2-30 BASE XS-4 [**2117-8-5**] 08:17PM LACTATE-0.9 [**2117-8-5**] 05:07PM TIDAL VOL-500 O2-100 PO2-312* PCO2-42 PH-7.42 TOTAL CO2-28 BASE XS-3 AADO2-359 REQ O2-64 -ASSIST/CON INTUBATED-INTUBATED [**2117-8-5**] 05:07PM GLUCOSE-105 LACTATE-0.8 [**2117-8-5**] 05:07PM O2 SAT-98 [**2117-8-5**] 05:07PM O2 SAT-98 [**2117-8-5**] 12:22PM TYPE-ART PO2-268* PCO2-44 PH-7.40 TOTAL CO2-28 BASE XS-2 [**2117-8-5**] 12:22PM LACTATE-0.9 [**2117-8-5**] 12:22PM O2 SAT-98 [**2117-8-5**] 12:22PM freeCa-1.14 [**2117-8-5**] 11:46AM URINE COLOR-AMB APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2117-8-5**] 11:46AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2117-8-5**] 11:35AM GLUCOSE-107* UREA N-8 CREAT-0.8 SODIUM-142 POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-26 ANION GAP-10 [**2117-8-5**] 11:35AM estGFR-Using this [**2117-8-5**] 11:35AM ALT(SGPT)-42* AST(SGOT)-80* CK(CPK)-720* ALK PHOS-51 TOT BILI-0.5 [**2117-8-5**] 11:35AM CK-MB-19* MB INDX-2.6 cTropnT-0.89* [**2117-8-5**] 11:35AM CALCIUM-8.3* PHOSPHATE-1.9* MAGNESIUM-2.1 [**2117-8-5**] 11:35AM WBC-12.6* RBC-4.05* HGB-13.5* HCT-37.1* MCV-92 MCH-33.4* MCHC-36.4* RDW-13.7 [**2117-8-5**] 11:35AM NEUTS-83.2* LYMPHS-12.2* MONOS-3.5 EOS-0.7 BASOS-0.4 [**2117-8-5**] 11:35AM PLT COUNT-240 [**2117-8-5**] 11:35AM PT-13.2 PTT-45.8* INR(PT)-1.1 . . ECG: NEBH #1 = ~100 NSR, normal axis/intervals, elevations in hyperacute TW's in V1-3, STD in V3-4, TWI in V5-6 and I/aVL; possible Q wave in V1-3 NEBH #2 = worsening symmetric TWI in V4-6 and I/aVL and TWF inferior leads NEBH #3 = about the same but with STD inferior leads, improvement in lateral TWI's . At NEBH on [**2117-8-4**]: normal LV size, wall thickness, HK of mid-distal anterior and anteroseptal region. LV systolic fxn low normal at 50-55%, RVSP = 23 + RAP . NEBH head CT non contrast without acute abnormality . Cardiac cath ([**2117-8-5**]) 1. Selective coronary angiography of this left dominant system demonstrated non-obstructive coronary artery disease. The LMCA and LAD had minimal disease. The LCx was a large vessel with mild disease. The RCA was a small, non-dominant vessel. 2. Limited resting hemodynamics revealed elevated right- and left-sided filling pressures, with a mean RA pressure of 15 mmHg, and a LVEDP of 24 mmHg. The systemic arterial pressure was noted to be normal, with a central aortic pressure of 106/65, mean 82 mmHg. No gradient was seen on careful pullback from the left ventricle to the aorta. Cardiac output and cardiac index likely significantly OVERestimated due to FiO2 100%. 3. Left ventriculography revealed an estimated LVEF of 35%, and was notable for anteroapical hypokinesis. FINAL DIAGNOSIS: 1. There appears to have been a probable LAD territory infarct/thrombus that spontaneously resolved with medical therapy. 2. Discussed with CCU Fellow/staff: wean off amiodarone, restart heparin gtt later, and continue ASA and Plavix. 3. IV Lasix for diuresis due to volume overload. 4. The patient will need a B-blocker and ACE-I once he is extubated. 5. Transthoracic echocardiogram in the morning. 6. EP consult will likely be necessary. . Cardiac Cath [**2117-8-10**] COMMENTS: 1) Selective coronary angiography of this left-dominant system demonstrated no significant CAD. The LMCA and LAD had minimal disease throughout. The dominant LCX was a large caliber vessel with minimal disease. The non-dominant RCA was not injected. 2) Limited resting hemodynamics revealed mildly elevated left-sided filling pressures with an LVEDP of 21mmHg. There was normal systemic arterial pressure with a central aortic pressure of 133/84 with a mean of 86mmHg. 3) Left ventriculography revealed reduced systolic function with an estimated EF 40%. There were focal regional wall motion abnormalities with antero-apical and lateral hypokinesis. 4) Successful closure of the LFA with a 6F angioseal device. FINAL DIAGNOSIS: 1. Possible vasospasm. Would continue NTG and calcium-channel blockers if BP tolerates (norvasc). 2. Rule out myocarditis by checking anti-myocardial antibodies and viral titers. 3. Resume heparin latertonight with no bolus. 4. Continue coumadin, ASA, clopidogrel (75mg/day x12mo). 5. Start ACEi (ramipril) if BP tolerates. 6. Successful closure of the LFA with a 6F angioseal device. . Echocardiogram [**2117-8-6**] The left atrium is mildly dilated. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal third of the ventricle.. The remaining segments contract normally (LVEF = 40 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w Takotsubo cardiomyopathy or mid-LAD lesion. . Echocardiogram [**2117-8-10**] The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with mid to distal anterior, distal septal and apical akinesis and distal lateral hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is a small pericardial effusion. No right ventricular diastolic collapse is seen. There is brief right atrial diastolic collapse. Compared with the prior study (images reviewed) of [**2117-8-6**], the LVEF has decreased. . Cardiac MR [**2117-8-9**] Pending at time of discharge Brief Hospital Course: 46yoM with no known cardiac history who had witnessed cardiac arrest, s/p resuscitation, with concern for LAD lesion, now transferred from NEBH ICU to [**Hospital1 18**] CCU for cardiac catheterization. 1. S/p cardiac arrest: It was unclear how long pt was down before compressions started but he was in ventricular fibrillation and after being shocked, he returned to sinus tach within ten minutes. Pt was not cooled because he was responsive and moving around by the time he reached [**Hospital1 18**]. Also, cooling protocol had not been initiated at OSH and by time he reached [**Hospital1 **] he was out of the window to start cooling. On arrival he was tubed and sedated. Pt was loaded with amio. Over the next 24 hours, weaned off vent and pt responded appropriately. He did not have any other dangerous arrhythmias. Etiology of vfib was most likely secondary to ischemia. [**Hospital1 **] and Echo were concerned of mid-LAD lesion. Initially cardiac cath was performed and showed that there appeared to have been a probable LAD territory infarct/thrombus that spontaneously resolved with medical therapy. EP was consulted and performed EP study, placed single chambe ICD with no complications. A CMR was performed and preliminarily suggested some scaring but final read is still pending at time of discharge. It was rec f/u with Dr. [**Last Name (STitle) **] [**Name (STitle) **] from cognitive neurology at time of d/c. He will need repeat echo [**1-22**] wks after d/c. . Cardiomyopathy: Pt was previously healthy and now with depressed LV function with apical hypokinesis. Most likely secondary to ischemia, but concern given coronary arteriogram did not show any direct evidence occlusion. Echo pattern was somewhat consistent with takatsubo's. Pt was started on metoprolol, lisinopril and coumadin (apical akinesis) at time of discharge. He was euvolemic without need for diuresis, so was not started on lasix on discharge. . STE in lateral leads: Post cath, pt had persistent STE in lateral leads and he was asymptomatic. CE were relatively flat with exception of CK (but pt had rhabdo). Concern for coronary vasospasm, so started on diltiazem drip, but this did not resolve to elevations. Pt was re-cathed, but coronaries were clean. Concern that these elevations are secondary to myocarditis. Labs were notable for mildly positive rheumatoid factor, negative varicella and EBV. At time of d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], viral cx and antimyocardial ab were all pending. Pt was discharged on home dose of asa and started on plavix 75. . H. flu PNA: RML consilidation found post extubation. Sputum cx grew out h. flu and pt has not had prior vaccination. He was treated with azithromycin and ctx. At time of d/c he had two additional days of ctx so was started on cefpodoxime to finish the abx course. . # Rhabdomyolysis: Thought to be secondary to amiodarone and Atorvastatin. Pt's CKs rose to >11K but kidney function remained normal throughout. He also had mild transaminitis. With aggressive fluid resuscitation, CK's trended down and were wnl by time of d/c. Kidney fxn remained wnl as well. Pt should avoid atorvastatin and other lipophilic statins in the future. . # Delirium: After pt was extubated, he was persistently delerius with difficulty following commands, signs of anterograde amnesia, and difficulty with word finding. He was also anxious and paranoid, particularly at night. Over course of hospitalization his MS improved but was still mildly impaired at time of d/c. There is concern for hypoxic brain injury secondary to cardiac arrest. This will need to be worked up as an outpatient and pt/family were encourage to follow up with cognitive neurologist as above. . Transitional: - needs f/u in device clinic one week after discharge - [**Location (un) **] virus B AB, HSV 1 and 2 IGG, Myocardial Ab screen, Parvovirus B19 Ab all pending at time of discharge - follow up final read on cardiac MR Medications on Admission: - Trazadone 50 hs occasionally - Neurontin 100 occasionally - Flexeril prn Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 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. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*5 Tablet(s)* Refills:*0* 8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 5 days. Disp:*10 Tablet(s)* Refills:*0* 10. Neurontin 100 mg Capsule Sig: One (1) Capsule PO once a day as needed for pain. 11. Outpatient Lab Work on [**2117-8-16**] please Check a Chem 7, PT, PTT, INR and fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 17382**] Discharge Disposition: Home Discharge Diagnosis: Myocarditis Acute CHF exacerbation pneumonia Rhabdomyolysis Delirium Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 827**]. You were transfered here after experiencing a cardiac arrest at [**Hospital6 2910**]. Further tests have shown that you do not have blockages in your heart arteries. We believe this cardiac event could have been due to a viral infection at the present time. We placed a defibrillator in your heart to help prevent any further cardiac arrests from occuring. We started you on a medication called warfarin which is a blood thinner. You will need to have your blood checked at a lab on Monday [**2117-8-16**] and the results to be sent to Dr.[**Name (NI) 5452**] office. Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Changes to your medications: STARTED: Clopidogrel 75mg daily Metoprolol Succinate 50 mg daily Isosorbide Mononitrate 30 mg daily Lisinopril 5 mg daily Coumadin 5 mg daily Please see below for follow up appointment information. Followup Instructions: We are working on a follow up appointment in Cardiology with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The office will contact you at home with an appointment. If you have not heard within 2 business days or have any questions please call [**Telephone/Fax (1) 7960**]. You also should follow up with the [**Hospital3 **] Cardiac Device clinic in one week. If you do not hear from then in the next several days, please call ([**Telephone/Fax (1) 2037**] to make this appointment. Please call our Cognitive Neurology department at [**Telephone/Fax (1) 1690**] to book a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-22**] weeks.

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