ChanBeDu/relevant_section_length · Datasets at Hugging Face

7,698

176,801

22018

Discharge summary

report

Admission Date: [**2152-10-20**] Discharge Date: [**2152-11-2**] Date of Birth: [**2091-1-16**] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This 61 year old female was admitted to an outside hospital one day prior with the complaints of intermittent exertional chest pain times three to four days. She complained also of diaphoresis and shortness of breath associated with chest pain. She denies worsening paroxysmal nocturnal dyspnea, orthopnea, edema, nausea, vomiting or syncope. Her cardiac enzymes were negative at the outside hospital. A spiral CT was negative for pulmonary embolus. Stress test in [**2152-6-29**] showed normal ejection fraction and no inducible ischemia. She was transferred to the [**Hospital1 69**] for catheterization which showed two vessel coronary disease with an ejection fraction of 60 percent, left main 50 percent lesion, left anterior descending coronary artery 80 percent lesion, circumflex 40 percent, 95 percent lesion of the second obtuse marginal and the right coronary artery was normal. The patient was referred to Dr. [**First Name (STitle) **] [**Name (STitle) **] for coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Carotid artery stenosis. 4. Asthma. 5. Noninsulin dependent diabetes mellitus. 6. Fatty liver. 7. Anxiety. 8. History of nonsustained ventricular tachycardia. 9. Gallstones. PAST SURGICAL HISTORY: Is remarkable only for hysterectomy. ALLERGIES: She was allergic to aspirin which caused gastrointestinal upset and Percocet which has caused her to hallucinate. MEDICATIONS AT HOME: Diovan 80 mg P.O. daily, Klonopin 0.5 mg P.O. twice a day PRN, Celexa 40 mg P.O. daily while at the outside hospital. At home she was taking Lexapro. Plavix 75 mg P.O. daily. Lasix dose was [**10-20**] in the morning. Fosamax 1 tablet P.O. every Sunday. Singulair 10 mg P.O. daily. Multivitamin 1 tablet P.O. daily. Metformin 500 mg P.O. B.I.D, Lescol 80 mg P.O. once daily and calcium 1 tablet P.O. daily. Patient also took vitamin D. SOCIAL HISTORY: Patient lives with her husband. She works at home. Is active. Had no history of tobacco use and used alcohol only rarely. She has a positive family history for coronary artery disease with the mother having a myocardial infarction in her 40s and her bother dying of myocardial infarction at 53. PHYSICAL EXAMINATION: She admitted to a 20 pound weight gain over the past month and was sleeping very poorly at the time. Her height was 5, 1. Her weight was 160 pounds. Blood pressure 133/80, heart rate 82, respiratory rate 22, saturation 95 percent on room air. She was lying flat in bed on examination in no apparent distress. She was alert and oriented times three and appropriate. She had carotid bruits bilaterally. Her lungs were clear bilaterally. Her heart was regular rate and rhythm with S1, S2 tones and no murmur, rub or gallop. Abdomen was soft, obese, nontender, nondistended with positive bowel sounds. Her extremities were warm and well perfused with no edema or varicosities. On the right she had 2 plus radial, 1 plus dorsalis pedis and 1 plus posterior tibial pulses. On the left 1 plus radial, 1 plus dorsalis pedis, and 1 plus posterior tibial pulses. PREOPERATIVE LABORATORY DATA: White count 7.1, hematocrit 37.1, platelet count 185,000. PT 13.9, PTT 23.8, INR 1.2. Sodium 135, potassium 4.4, chloride 99, bicarb 23, BUN 14, creatinine 0.7 with a blood sugar of 260, anion gap 17, total bilirubin 0.5, amylase 57, alkaline phosphatase 100, ALT of 96, AST 89, albumin 4.0. HBA1C 9.7 percent, significantly elevated. Preoperative carotid ultrasound study showed less than 40 percent right internal carotid artery stenosis and no left internal carotid artery stenosis. Preoperative electrocardiogram showed sinus tachycardia at 103 with occasional ventricular ectopy, diffuse nonspecific ST-T wave abnormalities. Please refer to the official report on [**2152-10-21**]. HOSPITAL COURSE: Patient's Plavix was discontinued. Patient was referred to Dr. [**Last Name (STitle) **] and over the course of the next couple of days as the carotid ultrasound was done the patient was followed by cardiology daily in preparation for her surgery on Monday morning. Patient was seen by cardiology daily and was seen also by the case manager and on [**10-23**] the patient underwent coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending coronary artery, a vein graft to the second obtuse marginal and a vein graft to the diagonal which is a Y graft off the saphenous vein graft to the obtuse marginal. Patient was transferred to cardiothoracic Intensive Care Unit in stable condition on a Neo-Synephrine drip at 0.24 mcg per kilograms per minute and a propofol drip at 10 mcg per kilogram per minute. On postoperative day one the patient had been extubated in the early morning hours, was in sinus rhythm at 97 with a blood pressure of 97/61, saturating 97 percent on 3 liters of nasal cannula with a cardiac index of 2.29. She was alert and oriented times three. Heart was regular rate and rhythm. She had decreased breath sounds bilaterally. Otherwise lungs were clear. Abdomen was soft, nontender. Chest tubes were in place. She had 1 plus peripheral edema bilaterally. Lasix intravenous diuresis was begun. Swan-Ganz was discontinued. Neo-Synephrine wean was begun. Postoperative laboratories as follows: White count 17.4, hematocrit 32.4, platelet count 207,000. Potassium 4.7, BUN 8, creatinine 0.6 with an INR o 1.2. Patient needed for Neo- Synephrine for tone on the following morning, postoperative day two remained at 1.0. Beta blockade was held. Neo- Synephrine was continued. The following day the blood pressure was 110/64 with a heart rate of 111. Patient was saturating 94 percent on 5 liters nasal cannula. Patient remained tachycardic. Examination was otherwise unremarkable. The Neo-Synephrine wean continued. Chest tubes were discontinued. Foley was discontinued. Hematocrit rose to 28.3. Creatinine was stable at 0.6. Patient was eligible to go to the floor as soon as the Neo-Synephrine was weaned off but was allowed to be out of bed in the room. On postoperative day three chest tubes were discontinued. Neo- Synephrine was off. Patient was in sinus rhythm in the 90s. Blood pressure 95/68. Examination was unremarkable. Incisions were clean, dry and intact with 1 plus peripheral edema. Creatinine stabilized at 0.5, hematocrit 27.4, potassium 3.8, beta blockade was begun with Lopressor 25 mg P.O. B.I.D Chest x-ray was repeated, Lasix diuresis continued. On postoperative day four the patient had a 10 beat run of supraventricular tachycardia in the morning which was monomorphic. No chest pain. Patient had been transferred out to the floor. Patient continued with perioperative Kefzol and continued to get Combivent and Singulair to help her for her asthma. Her pacing wires were discontinued. She was encouraged to do aggressive pulmonary toilet, cough and deep breath. She was placed on Kefzol for her sternum which had minimal erythema. She continued to work on the floor with physical therapy. Patient had some complaints of palpitations overnight but maintained a good blood pressure of 104/58. On postoperative day five she was in the sinus rhythm in the 90s with blood pressure of 116/65. She had no erythema of her sternal wound. Otherwise her examination was unremarkable with trace peripheral edema. She was stable and afebrile with a maximum temperature of 99.8. On postoperative day seven the patient had no overnight events but was still desaturating with ambulation. Her saturations were 93 percent on 2 liters nasal cannula. Her hematocrit was 27, her potassium 3.7, and magnesium 1.8. Her oral Metformin was started again. She had a few bibasilar crackles, still had 1 plus peripheral edema. Also the patient had an episode of rapid atrial flutter today with a heart rate of 150 and a stable blood pressure. Patient was give 5 mg intravenous of Lopressor twice and magnesium 2 grams and patient converted to sinus rhythm. The plan was the patient would be able to be discharged home if the O2 saturations were greater than 90 percent with ambulation. The patient continued to work with physical therapy and the nursing staff to achieve this. Early in the morning at approximately 4:15 A.M. on [**10-31**] the patient was found on the floor in the bathroom. By report she woke up to go to the bathroom. She was found on the bathroom floor. When asked if she had any pain or complaints of pain she said she slipped on her slipper and onto the floor. She was assisted back to the bed without any complains of headache, hip pain, nausea, vomiting, back pain. Patient was reminded to use the call bell for assistance,. On examination she was resting comfortably. Her neurologic examination was grossly normal. She has no obvious deformities noted. Patient was observed closely for any potential injury but appeared to be doing fine. On postoperative day eight the patient was on day five of a seven day course of Keflex for the sternal erythema. The sternal incision had no erythema at that time. She continued to increase her activity. A repeat chest x-ray was done. Lasix was increased to 20 intravenous B.I.D for 24 hours with plans to discharge her the following morning. She did have a temperature of 101 overnight which was brought to 99 in the morning. Her white count rose slightly to 14.6. Lopressor was increased to 75 B.I.D The patient was encouraged to use her incentive inspirometer. She was alert and oriented. On postoperative day nine she had rapid atrial fibrillation that began the day prior. She was started on Coumadin and amiodarone for her atrial fibrillation. She converted back to sinus rhythm with a blood pressure of 90/56 and a heart rate of 77. Her white count dropped slightly to 12.6. Her creatinine was stable at 0.7. Her examination was otherwise unremarkable and the plan was she would be to be discharged home if she had 24 hours of no arrhythmias. On postoperative day nine her lungs had decreased breaths on the left side [**1-1**] of the way down. Her sternum was stable with no drainage or erythema. She had bowel sounds. She had no peripheral edema. Her leg incisions bilaterally were clean, dry and intact. Patient did level five, was instructed to follow up with Dr. [**Last Name (STitle) **] in the office for postoperative surgical visit in four weeks and to see Dr. [**Last Name (STitle) 284**], her cardiologist, in four to six weeks. Patient was also instructed to get blood drawn for INR checks on [**11-3**] and [**11-6**] and have results called to Dr. [**Last Name (STitle) **], phone number [**Telephone/Fax (1) 11554**] who is responsible for following her Coumadin dosing and INR level management. DISCHARGE MEDICATIONS: Colace 100 mg P.O. B.I.D, 81 mg enteric coated aspirin P.O. daily, Dilaudid 2 mg tablet, 1 tablet P.O. q 4 to 6 hours PRN for pain, Metformin 500 mg P.O. B.I.D, escitalopram oxalate 20 mg P.O. daily, Montelukast sodium 10 mg P.O. daily, albuterol/ipratropium 103-108 mcg actuation aerosol 1 to 2 tabs inhalation every six hours as needed, Lasix 20 mg P.O. B.I.D for one week, then Lasix 20 mg P.O. daily times one week, Lipitor 40 mg P.O. daily, fluticasone/salmeterol 100-50 mcg dose disk with device, 1 disk with device inhalation 2 times a day, potassium chloride 20 mEq P.O. B.I.D times one week, Keflex 500 mg P.O. q.i.d. times five days, metoprolol tartrate 75 mg P.O. B.I.D, amiodarone 400 mg P.O. t.i.d. times one week, then amiodarone 400 mg P.O. B.I.D times one week, then amiodarone 200 mg P.O. daily. Coumadin 3 mg for that single dose on the evening of discharge with a goal INR of 2 to 2.5 and INR checks scheduled with Dr. [**Last Name (STitle) **] on [**11-3**] and [**11-6**]. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting times three. 2. Hypertension. 3. Hyperlipidemia. 4. Carotid artery stenosis. 5. Asthma. 6. Noninsulin dependent diabetes mellitus. 7. Fatty liver. 8. Anxiety. 9. Nonsustained ventricular tachycardia. 10. History of atrial fibrillation. 11. Gallstones. Again the patient was given the previously mentioned discharge instructions and was discharged to home with [**Hospital6 407**] services on [**2152-11-2**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2152-11-24**] 13:32:25 T: [**2152-11-24**] 14:53:10 Job#: [**Job Number 57623**]

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icd9cm

[ [ [] ] ]

[ "88.53", "39.61", "99.04", "37.22", "36.12", "88.72", "88.56", "36.15" ]

icd9pcs

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146,534

53653

Discharge summary

report

Admission Date: [**2108-2-8**] Discharge Date: [**2108-2-20**] Date of Birth: [**2045-7-17**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: headache Major Surgical or Invasive Procedure: [**2108-2-9**] Angiogram with coiling of ACOMM aneurysm History of Present Illness: HPI: 62 y/o female who presents to [**Hospital1 18**] after being seen at [**Hospital1 **] and transferred for a subarachnoid hemorrhage. Patient developed a sudden onset headache and neck pain this morning at 10am, denies nausea and vomiting, changes in vision, loss of bowel or bladder function. Blood pressure at outside hospital was greater than 200. She was placed on a nicardipine drip and also recieved labetalol. She was weaned off Nicardipine in route and had a systolic pressure in the 130s upon arrival. Past Medical History: PMHx:HTN Social History: Social Hx: Pt. moved here from [**Country 11150**] 3 months ago, lives with daughter Family History: Family Hx: Mother died of an aneurysm Physical Exam: PHYSICAL EXAM: Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 2 GCS E: 4 V: 6 Motor:5 Gen: WD/WN, comfortable, NAD. HEENT: NTNC Neck: rigid Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Hindi speaking, few words in english Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**3-31**] throughout. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally Pertinent Results: [**2108-2-8**] CTA IMPRESSION: 1. Subarachnoid hemorrhage in anterior interhemispheric fissure, right sylvian fissure and basal cisterns. 2. Aneurysm arising from anterior communicating artery pointing anteriorly. [**2108-2-10**] CT Head FINDINGS: The previously seen subarachnoid hemorrhage in the right sylvian fissure, anterior interhemispheric fissure and basal cisterns has decreased in size and extent. Coil embolization is seen in the region of the anterior communicating artery. Some residual subarachnoid blood is in the interhemispheric fissure, right sylvian fissure, and right ambient and collicular cistern. Ventricle size has decreased compared to [**2108-2-8**]. No evidence of new hemorrhage. No hydrocephalus. No evidence of infarction. No shift of normally midline structures. There is mucosal thickening in the bilateral maxillary sinuses with aerosolized secretions on the left and mucosal thickening in the ethmoid air cells and sphenoid sinus. The mastoid air cells are well aerated bilaterally. IMPRESSION: Decrease in size and extent of subarachnoid hemorrhage. No hydrocephalus. [**2-11**] Ct head with Angiogram 1. Decrease in the previously noted diffuse subarachnoid hemorrhage with small foci of subarachnoid hemorrhage, persistent as described above and also a few foci of hemorrhage along the tentorial leaflets and the right atrium. 2. Mildly prominent ventricles as before. No increase in the size of the lateral ventricles. 3. Patent major intracranial arteries; however, there is mild decrease in the size of the distal vertebral and the basilar artery and the A1, A2 segments and the M1 segments of the middle cerebral arteries on both sides and also parts of the posterior cerebral arteries, related to a component of vasospasm. The superior cerebellar arteries are not well seen. Limited assessment of the coiled aneurysm. [**2108-2-15**] CTA Head 1. Caliber and overall appearance of the intracranial vessels is now similar to the "baseline" study of [**2108-2-8**], and improved since interval study of [**2108-2-11**]. No definite evidence of vasospasm at this time. 2. Complete interval clearance of subarachnoid hemorrhage. No new blood or edema. [**2-18**] LENIS No DVT Brief Hospital Course: Pt was received as a transfer from [**Hospital1 **] after CT imaging revealed SAH on [**2108-2-8**]. She underwent a CTA which confirmed and ACOMM aneurysm. She was taken to the angiography suite and underwent uneventful coiling of the aneurysm. She was recovered in the ICU. Dilantin and Nimodipine were intiated and baseline TCD's were obtained. On [**2-9**], the patient was extubated. The Transcranial dopplers were found to be grossly Normal TCD evaluation but technically limited due to bone windows. the patient exam: the patient was able to eye open and was found to be sleepy. She was easily arouseable. oriented to person place and time. The patient was able to move all extremities and there was no pronator drift. There was right Nasal Labial flattening noted.EOMs were intact. On [**2-10**], SQH was initiated. transcranial dopplers were inconclusiove. Non Contrast head Ct did not show any hydrocephalas. There was no new hemorhage. The patient was mobilized out of bed to the chair. She was nauseous with headache but otherwise intact. The angio site in the right groin was clean/dry with no hematoma. The dilantin level was 17.3. On [**2-11**], patient remained stable on ecxamination. TCDs were inconclusive so a CTA of the head was ordered to evaluate for vasospasm. She remains in ICU for close vasospam monitoring. On [**2-13**] and [**2-14**] patient had high fevers up to 102.6, a normal WBC and normal LFTs, she was taken off of Dilantin to elevate that as a source of fevers. She remained neurologically stable. On [**2-15**], her CTA showed improved caliber of the vessels and her SAH had resolved. She had quite a bit of nausea and vomitting. She remained in the Neuro ICU. On [**2-16**], patient was transferred to SDU in stable condition. PT/OT was consulted and evaluated the patient on [**2-17**], they recommended DC home when stable. On [**2-18**] she developed a fever and cultures were obtained. Urine cultures were negative. CXR was clear and blood cultures have shown no growth to date. She remained afebrile on [**2-19**]. Pt was DC'd home in stable condition on [**2-20**] and will follow up with Dr. [**First Name (STitle) **] accordingly. Medications on Admission: not known Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for headache. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever/pain. Discharge Disposition: Home Discharge Diagnosis: Ruptured Anterior communicating artery aneurysm Subarachnoid hemorrhage Lethargy Nausea Pyrexia dysphagia Discharge Condition: AOx3. Activity as tolerated. No lifting greater than 10 pounds. Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Please call the office of Dr.[**First Name (STitle) **] to be seen in _4-6_ weeks at [**Telephone/Fax (1) **] You will need an MRI MRA of the brain with Dr [**First Name (STitle) **] protocol at that time Completed by:[**2108-2-20**]

[ "780.60", "401.9", "430", "286.9", "285.9" ]

icd9cm

[ [ [] ] ]

[ "88.41", "39.75" ]

icd9pcs

[ [ [] ] ]

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48,383

183,244

12550

Discharge summary

report

Admission Date: [**2165-11-6**] Discharge Date: [**2165-11-15**] Date of Birth: [**2113-12-16**] Sex: F Service: SURGERY Allergies: Codeine / Paxil / Lisinopril Attending:[**First Name3 (LF) 2777**] Chief Complaint: Left thigh wound infection with exposed vein and hemorrhage from the wound. Major Surgical or Invasive Procedure: Exploration of the left thigh wound History of Present Illness: This is a woman who is status post a left femoropopliteal bypass with vein graft, who was noted to have a superficial wound infection and was treated with packings. On office visit today ([**11-6**]), the infection was noted to extend more proximally, therefore, this area was opened with scissors in the office. There was exposed vein graft noted in the base of the wound and therefore she was admitted for close observation in case of hemorrhage. While still in the office, she was noted to saturate her dressing and pant leg with blood. A rapid exploration in the office at that time did not suggest a active hemorrhage from the vein graft. There was some minor subcutaneous tissue bleeding. It did not appear to be enough to explain the amount of blood and therefore she was taken emergently to the operating room for more careful exploration to rule out graft rupture with possible ligation Past Medical History: PMH: CAD s/p CABG [**2154**], EF 75% LA mild dilated, RVH ([**5-12**]), IDDM, s/p pancreatic tsplnt [**3-/2161**], ESRD s/p cadaveric renal transplant [**1-9**], PVD s/p left fem-[**Doctor Last Name **] bypass [**3-13**], HTN, diabetic neuropathy, depression, dyslipidemia, right arm fistula, hypothyroidism, h/o complex partial and generalized seizures (last [**2163-9-7**]), s/p right arm graft, s/p R BKA Social History: lives on her own in [**Location (un) 38864**],[**State 350**] with home [**State 269**]. Local pharmacy delivers pill boxes weekly. She smokes a pack and a half daily. She denies alcohol use or illicit drugs. Family History: N/C Physical Exam: VS: AFVSS Gen: AOx3 NAD CVS: RRR Pulm: CTAB Abd: S/NT/ND LE: L groin: open wound, packed wet to dry, graft exposed no surrounding erythema, no drainage. s/p R BKA 1+ edema LLE. Pulse: L: [**Doctor Last Name 38865**], [**Name (NI) 38866**], PT-dop Pertinent Results: [**11-7**] Rectal swab cx: positive for VRE [**2165-11-6**] 11:26PM TYPE-ART PO2-191* PCO2-41 PH-7.38 TOTAL CO2-25 BASE XS-0 [**2165-11-6**] 11:26PM GLUCOSE-79 LACTATE-0.9 K+-3.0* [**2165-11-6**] 11:26PM O2 SAT-98 [**2165-11-6**] 11:26PM freeCa-1.02* [**2165-11-6**] 10:40PM TYPE-ART PO2-174* PCO2-18* PH-7.48* TOTAL CO2-14* BASE XS--6 [**2165-11-6**] 10:40PM GLUCOSE-45* LACTATE-0.5 K+-1.6* [**2165-11-6**] 10:40PM O2 SAT-97 [**2165-11-6**] 10:40PM freeCa-0.64* [**2165-11-6**] 06:05PM TYPE-ART PO2-83* PCO2-36 PH-7.42 TOTAL CO2-24 BASE XS-0 [**2165-11-6**] 05:51PM GLUCOSE-82 UREA N-24* CREAT-1.6* SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-24 ANION GAP-12 [**2165-11-6**] 05:51PM estGFR-Using this [**2165-11-6**] 05:51PM CALCIUM-8.6 PHOSPHATE-3.7 MAGNESIUM-1.9 [**2165-11-6**] 05:51PM WBC-5.4# RBC-3.25* HGB-9.8* HCT-31.1* MCV-96 MCH-30.3 MCHC-31.7 RDW-14.3 [**2165-11-6**] 05:51PM NEUTS-78.0* LYMPHS-15.2* MONOS-4.3 EOS-1.8 BASOS-0.7 [**2165-11-6**] 05:51PM PLT COUNT-244 [**2165-11-6**] 05:51PM PT-12.8 PTT-28.1 INR(PT)-1.1 [**2165-11-6**] 03:45PM TYPE-ART PO2-105 PCO2-36 PH-7.41 TOTAL CO2-24 BASE XS-0 INTUBATED-NOT INTUBA [**2165-11-6**] 03:45PM GLUCOSE-134* LACTATE-2.2* NA+-139 K+-4.2 CL--108 [**2165-11-6**] 03:45PM HGB-11.5* calcHCT-35 [**2165-11-6**] 03:45PM freeCa-1.19 Brief Hospital Course: 51F with ESRD s/p DDRT in [**2159**], and s/p L fem-[**Doctor Last Name **] bypass in [**Month (only) 216**], admitted on Wed [**11-6**] for emergent L groin exploration because for concern about a groin hematoma, but no source of bleeding found. She was also started. She was extubated on Friday [**11-8**]. Her open wound was treated with hydragel and adaptik over the graft and a wound vac which was changed every 1-2 days. Patient is s/p pancreatic and renal transplant so has been receiving tacrolimus 2mg [**Hospital1 **] with daily level checks, and renal transplant has been following her daily. On [**11-12**] patient was consented for debridement closure of her wound. Pt kept on IV antibiotics, Leaving on PO Post operatively: Patient did well. Transplant medicine recommended only ciprofloxacin PO for long term antibiotics on discharge, the vancomycin and metronidazole was stopped on [**11-13**]. Medications on Admission: Zetia 10 mg daily, Neurontin 100 mg three times a day, Lamictal 150 mg daily, Keppra 500 mg twice daily, Levoxyl 75 mcg daily, Metoprolol tartrate 50 mg twice daily, Mirtazapine 45 mg daily, Mycophenolate mofetil 500 mg twice daily, Omeprazole 20 mg daily, Prednisone 4 mg daily, Simvastatin 40 mg daily, Tacrolimus 2 mg daily, Travatan eyedrops, keralac lotion, Aspirin 81 mg daily, Colace, Multivitamin, Loprox cream, Plavix 75 mg daily, Timolol eyedrops, Lexapro Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 weeks. Disp:*56 Tablet(s)* Refills:*0* 3. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 4. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 12. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic 1 drop HS (). 13. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*28 Tablet(s)* Refills:*0* 14. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. Insulin Take as directed Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 269**] Discharge Diagnosis: Left thigh wound infection with exposed vein and hemorrhage from the wound. IDDM, s/p pancreatic tsplnt [**3-/2161**], ESRD s/p cadaveric renal transplant [**1-9**], HTN, diabetic neuropathy, depression, dyslipidemia, hypothyroidism Discharge Condition: stable Discharge Instructions: Post Surgery Wound Care Overview Your doctor has placed sutures (stitches) to keep the incision closed for proper wound healing. Sometimes, sutures need to be removed in a few weeks. Sometimes, the sutures are all under the skin and will eventual dissolve on their own and do not need to be removed. In either case, please follow these routine wound care instructions. Leave the original bandage that was applied at the time of your surgery in place for 48 hours. If the bandage should become loose, reinforce the dressing with surgical tape. After approximately 48 hours, you can gently remove the bandage. If you have steri-strips on your incision (little white paper tapes), keep them in place until they begin to fall off on their own. Do not pull the steri-strips off as this could put stress on the incision line. When the steri-strips start to peel off, they can be gently washed off. Please try to keep the incision line clean and dry. You can shower and gently wash the incision line with soap and water. Dry the incision area and keep the incision line open to air. It is not necessary to apply antibiotic ointment, alcohol, hydrogen peroxide, or a new bandage to the incision line. If your sutures get caught on your clothing or there is a small amount of drainage from the incision, you may want to cover it with small gauze for your own comfort. If so, please use as little tape as possible to hold the gauze in place as tape can irritate the skin. A small amount of drainage from the incision in the first few days after surgery is not unusual and it will probably resolve on its own. However, if you should notice bleeding from the surgical site, apply firm direct pressure for ten minutes. If the bleeding persists, reapply firm direct pressure for an additional ten minutes. If the bleeding does not stop after 20 minutes, call our contact phone numbers or go to the nearest emergency room for assistance. What to Avoid Please avoid the following: Do not submerge the incision line under water for a prolonged period of time with activities like taking a bath, swimming, or sitting in a hot tub. Do not participate in any vigorous activities or exercises that may put stress on the incision. Do not take aspirin, ibuprofen, or any other nonsteroidal anti-inflammatory medication that may cause problems with bleeding unless instructed by your doctor. Do not apply perfumes or scented lotions to the sutures as this may cause irritation. When to Call the Doctor Please contact us immediately if you develop: Fevers, chills, or night sweats Increasing redness, pain, or pus at the incision Bleeding that does not stop with firm pressure Followup Care If your sutures need to be removed, this is usually done [**2-9**] weeks after surgery. Even if your sutures will dissolve, the doctor usually likes to examine the incision while it is healing. Therefore, you should have been scheduled for a follow-up appointment in clinic at the time of your discharge from surgery. As this appointment is very important, please contact the clinic if you do not have one scheduled or you need to change the date and/or time. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2165-11-28**] 11:15 Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**] Date/Time:[**2165-11-29**] 10:30 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-1-20**] 1:40 Completed by:[**2165-11-15**]

[ "357.2", "250.60", "401.9", "414.00", "V45.81", "V42.0", "998.11", "V42.83", "311", "998.59", "V49.75", "345.50", "E878.2", "272.4", "244.9" ]

icd9cm

[ [ [] ] ]

[ "86.22", "86.3", "83.82" ]

icd9pcs

[ [ [] ] ]

6452, 6551

3651, 4571

367, 404

6829, 6838

2295, 3628

10036, 10515

2005, 2010

5087, 6429

6572, 6808

4597, 5064

6862, 10013

2025, 2276

251, 329

432, 1331

1353, 1762

1778, 1989

30,410

154,933

47727

Discharge summary

report

Admission Date: [**2114-11-18**] Discharge Date: [**2114-11-20**] Date of Birth: [**2039-9-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2736**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 75 y/o M w/ atrial fibrillation, HTN, dyslipidemia, and DVT (while on coumadin so now on lovenox) who persented with a 1 day history of worsening SOB and cough productive of clear sputum. He has recently been admitted twice within the last 2 months for complaints of uncontrolled atrial fibrillation and SOB thought to be secondary to a CHF flare with his most recent dicharge ~ 6 weeks ago. He was in his USOH until this AM when he awoke feeling fatigued. He walked around and noticed increased dyspnea with exertion. He has had no orthopnea or PND and denies any recent CP, palpatations, fevers, HA, visual changes, diarrhea or chills. His chronic LE edema is stable per the patient since his last admission. Of note, the patient did not take any of his medications today but has otherwise compliant. He denies any sick contacts or recent travel. He says that he has been diet compliant but eats pastrami frequently. . While in the ED, he was noted to have a rapid ventricular rate to the 130s for which he received 25mg of IV diltiazem followed by 60mg of PO verapamil with good response. His symptoms disappeared but he was then noted to have rates in the 150s w/ new STE in I/aVL. He received 10mg of IV metoprolol followed by 25mg PO and slowed into the 90s again. Repeat EKG showed reversion of his EKG changes to his baseline STD. Cardiology was consulted and felt this episode did not represent an acute STEMI but suggested admission to [**Hospital Unit Name 196**]. While in the ED, he also had a negative CTA and received a single dose of azithromycin. Past Medical History: 1. Hypetension 2. Atrial fibrillation 3. Dyslipidemia 4. h/o L popliteal vein DVT (while on coumadin) 5. Anxiety/Depession 6. Peptic ulcer disease 7. Diaphragmatic hernia 8. CKD 9. Prostate CA dx [**5-2**] T2a prostate cancer 10. R hernia repair [**2069**] 11. Tachycardia induced cardiomyopathy Social History: Patient is married and lives with wife. [**Name (NI) **] is retired and walks with a walker. He peviously smoked but 30yrs ago (~ 15 pack years). Denies EtOH or IVDU. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS - 98.0, 157/93, 111, 20, 96%RA, 328lbs Gen: Morbidly obese AAM sitting up in bed in NAD. Oriented x3. Mood, affect appropriate. Speaking in full sentences HEENT: NCAT. Injected R medial sclera. Neck: Supple, no JVD. No appreciable JV elevation. No carotid bruits. CV: Irregular rhythm. Distant heart sounds. No appreciable M/R/G. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bibasilar crackles Abd: Obese but nontender. + BS. Organ exam limited by habitus. Ext: Bilateraly pitting edema to the hips. Chronic venous stasis changes. Pertinent Results: [**11-18**] CTA: IMPRESSION: 1. No evidence of acute pulmonary embolism. Probable chronic PE in the right lower lobe subsegmental bronchus, seen previously. 2. No evidence of pneumonia. 3. Cardiomegaly, mild interstitial edema, small bilateral pleural effusions. 4. Stable bilateral hilar lymphadenopathy and peribronchovascular density most notable on the right side. Etiology unclear and PET CT can be performed to further evaluate. 5. Stable 5-mm right upper lobe pulmonary nodule, again a repeat evaluation in [**5-8**] months could document two-year stability. . [**11-18**] CXR: IMPRESSION: Cardiomegaly with pulmonary vascular congestion. . [**11-19**] Head CT: HEAD CT WITHOUT CONTRAST: There is no comparison. There is no acute intracranial hemorrhage, mass effect, or shift of normally midline structures or [**Doctor Last Name 352**]-white differentiation or cerebral edema. There are bilateral small vessel ischemic changes. No gross acute territorial infarct is identified on this CT scan. There is opacification of ethmoid sinuses. The skeletal structure is unremarkable. IMPRESSION: Chronic small vessel ischemia. No acute intracranial hemorrhage or mass effect. Sinus disease. . [**11-19**] Port Abd: PORTABLE ABDOMEN: Single portable abdominal view is somewhat limited by motion. An endotracheal tube is seen terminating in the mid trachea. No orogastric or nasogastric tube is seen; it is presumably out of the field of view, i.e., in the patient's pharynx. EKG leads are seen draping over the patient. There is probable left-sided retrocardiac atelectasis and/or pleural effusion. IMPRESSION: No orogastric tube seen, likely representing coiling in pharynx. Findings discussed with Dr. [**Last Name (STitle) **] by telephone at 10 a.m., [**2114-11-19**]. . [**11-19**] ECHO: EF > 60% The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is moderately dilated with moderate globa free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. 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. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2114-10-5**], the estimated pulmonary artery systolic pressure is now lower. The other findings are similar. . Labs: [**2114-11-18**] 08:45AM BLOOD WBC-3.6* RBC-4.01* Hgb-11.4* Hct-35.9* MCV-90 MCH-28.4 MCHC-31.6 RDW-17.2* Plt Ct-274 [**2114-11-20**] 03:23AM BLOOD WBC-14.3* RBC-UNABLE TO Hgb-9.0* Hct-34.5* MCV-UNABLE TO MCH-UNABLE TO MCHC-27.4* RDW-UNABLE TO Plt Ct-148* [**2114-11-18**] 08:45AM BLOOD Neuts-62.7 Lymphs-25.1 Monos-7.3 Eos-3.6 Baso-1.2 [**2114-11-18**] 08:45AM BLOOD Plt Ct-274 [**2114-11-18**] 09:30AM BLOOD PT-19.9* PTT-42.8* INR(PT)-1.9* [**2114-11-20**] 03:23AM BLOOD PT-38.0* PTT-98.3* INR(PT)-4.1* [**2114-11-19**] 05:42AM BLOOD Fibrino-357 [**2114-11-18**] 08:45AM BLOOD Glucose-122* UreaN-17 Creat-1.5* Na-143 K-3.6 Cl-105 HCO3-27 AnGap-15 [**2114-11-20**] 03:23AM BLOOD Glucose-156* UreaN-31* Creat-3.8* Na-142 K-5.6* Cl-98 HCO3-6* AnGap-44* [**2114-11-19**] 05:42AM BLOOD ALT-42* AST-92* LD(LDH)-481* CK(CPK)-157 AlkPhos-99 TotBili-1.8* [**2114-11-20**] 03:23AM BLOOD ALT-1545* AST-4828* CK(CPK)-524* AlkPhos-136* Amylase-[**2038**]* TotBili-2.1* [**2114-11-19**] 11:03AM BLOOD Lipase-65* [**2114-11-20**] 03:23AM BLOOD Lipase-274* [**2114-11-18**] 08:45AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-9271* [**2114-11-19**] 11:03AM BLOOD CK-MB-10 MB Indx-3.7 cTropnT-0.12* [**2114-11-19**] 05:43PM BLOOD CK-MB-14* MB Indx-3.8 cTropnT-0.22* [**2114-11-20**] 03:23AM BLOOD CK-MB-16* MB Indx-3.1 cTropnT-0.16* [**2114-11-20**] 03:23AM BLOOD Albumin-2.9* Calcium-8.8 Phos-9.2* Mg-2.5 [**2114-11-19**] 05:42AM BLOOD Cortsol-42.9* [**2114-11-19**] 05:40AM BLOOD pO2-61* pCO2-76* pH-6.72* calTCO2-12* Base XS--31 Intubat-INTUBATED Comment-GREEN TOP [**2114-11-20**] 07:57AM BLOOD Type-ART Temp-35.6 Rates-26/10 Tidal V-600 PEEP-12 FiO2-40 pO2-80* pCO2-18* pH-7.24* calTCO2-8* Base XS--17 -ASSIST/CON Intubat-INTUBATED [**2114-11-20**] 07:57AM BLOOD Glucose-116* Lactate-16.1* Na-136 K-4.9 Cl-103 calHCO3-8* [**2114-11-20**] 07:57AM BLOOD freeCa-0.93* Brief Hospital Course: Mr. [**Known lastname 30207**] is a 75 M w/ pmh of afib, CRI, DVT on coumadin, HTN who was admitted to the hospital for increasing shrotness of breath in the setting of afib w/ RVR. He was admitted for rate-control and the plan was for him to be discharged home the following day as he was feeling much better. The morning of [**11-20**], he was seen in stable clinical condition at approximately 5:24am. At 5:36am, he was found face down on the floor in his room. Chest compressions were initiated and Code Blue was called. Initial electrical rhythm was asystole. He received 2 rounds of epinephrine and Atropine, after which a wide complex rhythm (consistent with baseline RBBB) was obtained at rate in 70s. He then received 3 more rounds of epinephrine, as well as 2 rounds of calcium and bicarbonate, and a liter of bolus IV NS. Spontaneous circulation was restored at 5:50am. . Review of telemetry revealed atrial fibrillation with progressive bradycardia and eventual asystole. ECHO w/o new WMA and CE without significant elevation which does not support cardiogenic cause. Likely a respiratory arrest, ? from hypercarbia/hypoventilation after a fall. ? from massive PE given h/o DVT and chronic PE seen on CTA on admission. Head CT w/o bleed so heparin ggt re-started. After the code, he never regained consciousness and his pupils were eventally fixed and dilated. He continued to requre maximum dose of dopamine, vasopressin and levophed with persistent hypotension. Also w/ shock liver and anuric renal failure and likely significant brain damage was not awakening after sedation turned off. Family was notified immediately after the code and were at his side until the time of his death. Because of his poor prognosis, and with the knowledge that he never wanted to be institutionalized and enjoyed being very independent, they made the decision to make him DNR. He passed away on [**Holiday **] night secondary to cardiac arrest, likely from hyperkalemia. Medications on Admission: 1. Aspirin 325 mg daily 2. Enoxaparin 120 mg [**Hospital1 **] 3. Verapamil 240 mg daily 4. Atorvastatin 10 mg daily 5. Pantoprazole 40 mg daily 6. Paroxetine 10 mg daily 7. Olmesartan 20 mg daily 8. Toprol XL 300 mg daily 9. Ranitidine 150 mg daily 10. Furosemide 60 mg daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

[ "272.0", "278.01", "185", "276.2", "584.9", "425.4", "428.30", "403.90", "272.4", "428.0", "427.5", "427.31", "585.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10236, 10245

7907, 9882

337, 343

10292, 10301

3185, 3851

10353, 10359

2467, 2549

10208, 10213

10266, 10271

9908, 10185

10325, 10330

2564, 3166

278, 299

371, 1946

3860, 7884

1968, 2265

2281, 2451

41,958

182,711

54629

Discharge summary

report

Admission Date: [**2155-8-9**] Discharge Date: [**2155-8-21**] Date of Birth: [**2079-3-1**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4327**] Chief Complaint: VFib Major Surgical or Invasive Procedure: surgical debridement of wound Placement of external pacemaker placement of internal pacemaker PICC line placement History of Present Illness: 76 yo M w/ h/o paraplegia [**12-26**] T9 epidural abscess and osteomyelitis, CAD s/p CABG, AV dissociation, h/o VT, pAF, ischemic CMP (EF 35%), PVD, and COPD on 2L oxygen who presents to [**Hospital1 18**] from [**Hospital **] rehab after VF arrest. He has previously been seen by cardiology during his two most recent admissions in [**Month (only) 205**] and [**Month (only) 216**] for episodes of AV dissociation. During his initial hospitalization, cardiology recommended holding nodal and QT prolonging agents; there was no indication for pacing at that time as the block was transient and thought to be related to extubation. During his second admission in [**Month (only) 216**], the EP service again felt he was not a candidate for a pacer as he was asymptomatic, hemodynamically stable, and on IV abx for prolonged treatment of osteomyelitis, precluding placement of any permanent pacer. The day prior to presentation, patient was complaining of dyspnea and was noted to have dropping sats in his rehab. He subsequently per report had a witnessed VF arrest though there are no EKGs or other records of the event. CPR was initiated w/o delay and he was intubated on the scene in the setting of his arrest. He received 4 rounds of shock w/ ROSC. At that time, patient was responsive so he was not cooled. He was given xanax and morphine and transported on AC 14 x 600, PEEP5, 50% FIO2. A double lumen mid-line was placed prior to transporting him to [**Hospital1 18**]. On arrival to the floor, patient T97.6 HR 62 BP 127/46 RR 25 O2 sat 92% on the vent settings above. He quickly deteriorated dropping his HR's to the 30s, initially keeping his pressures in the 100s, but then subsequently dropped his pressures 60/40s. He was bolused one liter and then started on levophed. Cardiology was contact[**Name (NI) **] and a transvenous pacemaker was placed emergently in the MICU. The patient is now being transferred to the CCU for further management. Past Medical History: CABG [**2147**] (4 vessle) Systolic CHF EF - 35% COPD on Home O2 Obstructive Sleep Apnea Chronic Kidney Diease Stage 3 baseline Cr 1.7 Type 2 Diabetes (IDDM) Hypothyroidism Atrial Fibrillation Heel Ulcers BPH Social History: Lives in [**Hospital1 1501**]. 50 pack year hx of smoking, quit in [**2147**]. no EtOH or drug use Family History: Family history unknown by patient Physical Exam: ADMISSION: GENERAL: overweight, intubated. Paraplegic. Does squeeze hands, and does move head slightly to voice. HEENT: NGT in place, ETT in place. NECK: Very large/pickwikian neck habitus, cannot appreciate JVP CARDIAC:Distant heart sounds given body habitus. Paced S1 and S2 LUNGS: On CMV ventilation. No chest wall deformities, scoliosis or kyphosis. ABDOMEN: Soft, obese. Hypoactive BS EXTREMITIES: Paraplegic from hips down, also sedated, can squeeze hands b/l. PULSES: Right: Dopplerable DP & PT [**Name (NI) 2325**]: Dopplerable DP & PT . DISCHARGE: 98, 102/64, 70, 21, 96% 4L Gen: AOx2, pleasant HEENT: PERRLA, EOMI HEART: RRR, distant heart sounds with no murmurs appreciated, chest wall at pacemaker site is CDI, bandage clean, no erythema LUNGS: CTAB listened anteriorly, mild dullness at bases ABD: soft, obese, NT, +BS BACK: Sacral decub ulcer with bandage in place EXT: No sensation, 0/5 motor strength Pertinent Results: ADMISSION: [**2155-8-9**] 01:59AM BLOOD WBC-19.7*# RBC-3.47* Hgb-10.5* Hct-33.5* MCV-96# MCH-30.3 MCHC-31.4 RDW-15.9* Plt Ct-369 [**2155-8-9**] 01:59AM BLOOD Neuts-75.1* Lymphs-16.1* Monos-7.9 Eos-0.5 Baso-0.4 [**2155-8-9**] 01:59AM BLOOD PT-13.6* PTT-33.5 INR(PT)-1.3* [**2155-8-9**] 01:59AM BLOOD Glucose-196* UreaN-52* Creat-1.9* Na-139 K-4.7 Cl-98 HCO3-31 AnGap-15 [**2155-8-9**] 01:59AM BLOOD ALT-22 AST-39 LD(LDH)-378* CK(CPK)-438* AlkPhos-187* TotBili-0.4 [**2155-8-9**] 01:59AM BLOOD CK-MB-13* MB Indx-3.0 cTropnT-0.96* [**2155-8-9**] 01:59AM BLOOD Calcium-9.0 Phos-5.3*# Mg-2.2 [**2155-8-9**] 02:13AM BLOOD Type-[**Last Name (un) **] Temp-37.6 Rates-[**5-12**] Tidal V-500 PEEP-5 FiO2-100 pO2-37* pCO2-60* pH-7.33* calTCO2-33* Base XS-3 AADO2-616 REQ O2-100 Intubat-INTUBATED [**2155-8-9**] 02:13AM BLOOD Glucose-174* Lactate-2.8* K-4.2 [**2155-8-9**] 02:13AM BLOOD freeCa-1.16 STUDIES: ([**8-9**]) ECHO: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is severe regional left ventricular systolic dysfunction with mid to distal septal and anterior akinesis and hypokinesis of all other walls apart from the basal septum and basal inferolateral segments. The apex is dyskinetic. A left ventricular mass/thrombus cannot be excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Severe focal LV systolic dysfunction consistent with multi-vessel ischemia. There may be an apical thrombus - suboptimal image quality precludes certainty about this finding. No significant valvular abnormality. ([**8-9**]) CXR: The ET tube is 6 cm above the carina. There is an NG tube, but the tip is not adequately visualized to assess for appropriate position. There is increased opacity at both bases, which could be due to volume loss or early infiltrate. Spinal fixation device and sternal wires are visualized. ([**8-13**]) CXR: In comparison with study of [**8-10**], there is continued evidence of vascular congestion with hazy opacification at the bases consistent with bilateral pleural effusions and compressive atelectasis at the bases. The difference in appearance may merely reflect the changes in patient position, with the patient more supine on the current study. Endotracheal tube and nasogastric tube have been removed. There is now a left subclavian catheter that extends to the lower portion of the SVC. Single-channel pacemaker device remains in place. Extensive spinal surgery is again evident. DISCHARGE: [**2155-8-21**] 06:18AM BLOOD WBC-13.0* Hct-32.3* [**2155-8-21**] 06:18AM BLOOD PT-31.6* INR(PT)-3.1* [**2155-8-21**] 06:18AM BLOOD UreaN-20 Creat-1.6* Na-137 K-4.6 Cl-100 EKG [**8-16**]: Indeterminate atrial rhythm. Ventricular pacing intermittently with occasional suppression by ventricular premature complexes. Compared to the previous tracing of [**2155-8-15**] the ventricular premature complexes are new. CXR [**8-20**]: FINDINGS: As compared to the previous radiograph, there has been interval removal of a right-sided pacing hardware, placement of a left side generator with a single lead. Interval decrease in pleural effusions. Moderate cardiomegaly that is unchanged. No evidence of pneumothorax. The vertebral stabilization devices are unchanged. Pre-existing areas of atelectasis at the lung bases have decreased. CXR [**8-21**]: pending Brief Hospital Course: 76M with a PMH significant for CAD (s/p CABG), ischemic CMP (LVEF 35%), COPD (on home oxygen), history of ventricular tachycardia and atrial fibrillation, and paraplegia [**12-26**] T9 epidural abscess and osteomyelitis presenting s/p VF arrest w/ evidence of AV-dissociation and prolonged QTc with hemodynamic instability. . # AV-DISSOCIATION - Patient had complete heart block, and had a transvenous pacer placed. Patient has reported history of VT and paroxysmal atrial fibrillation and a recent admission noted asympatomatic bradycardia to the 30-40s. His EKG on admission demonstrated AV-dissociation with a ventricular rate of 40, and this has been at least intermittently occurring since 6/[**2154**]. Based on the morphology of the ventricular escape rhythm, it appeared to be in the nodal region and appeared to be stable. The source of the nodal dysfunction was thought to likely be due to his prior ischemic cardiomyopathy vs. structural heart disease or fibrosis of the conduction system. He appeared hemodynamically stable on admission and had a semi-permanent pacer placed soon after. On [**2155-8-20**] he had a permament pacemaker placed. Procedure was uncomplicated without PTX. The patient will be discharged on Bactrim DS for infection prophylaxis in the setting of a UTI. HCP was made aware that this PPM has a very high risk of infection given the chronic osteo. . # UTI: The patient had cloudy urine in Foley bag on [**8-20**]. No fever, chills, or leukocytosis to suggest active infection. UA, however, showed 182 WBC, positive leuks, and bacteria. Due to the high risk of systemic infection, we will treat him for a UTI. The patient will be treated with a 7 day course of Bactrim (renally dosed). The patient's Foley was changed out on [**8-21**]. The patient has a urine culture pending at the time of discharge. . # HEALTHCARE ASSOCIATED PNEUMONIA: Pt had evidence of RLL consolidation and small effusion on the right side in the setting of a recent hospital admission. Patient denied cough or respiratory symptoms. The patient was intubated in the context of the semi-permanent pacemaker placement, and he was extubated successfully on [**8-10**]. He was put on vancomycin and Zosyn and completed a course of antibiotics on [**8-15**]. . # PROLONGED QTC - Patient presents with evidence of QTc of 560 msec. Previously has been in the 450-500 msec range per recent EKGs. Home fluoxetine and Seroquel were intially held (it's actually unclear if he was on Seroquel immediately prior to admission). Seroquel was given PRN for agitation in the CCU. On discharge, fluoxetine and Seroquel were not continued. QTc was 479 on discharge. . # EPIDURAL ABSCESS, T9 OSTEOMYELITIS, SACRAL DECUB ULCER - Patient underwent surgical repair on [**2155-5-23**], and was most recently re-admitted from [**Date range (1) **] for delirium and sacral ulcer debridement. Had been maintained on Ceftriaxone 2 gram IV Q24H which was continued through [**2155-7-26**] for confirmed Strep viridans in the T9 vertebrae. Has been continued on calcium and vitamin D for bone metabolism. ID was consulted and recommended no ongoing or PPX antibiotics for the sacral ulcer and prior osteomyelitis. Surgery debrided the ulcer on [**8-13**], and wound care followed the patient as well. The ulcer was difficult to keep clean secondary to fecal contamination from fecal incontinence. The patient will need continued wound care and frequent repositioning at rehab. . # CORONARY ARTERY DISEASE - Known history of CAD s/p CABG in [**2147**]. He presented without chest pain, but he had troponin elevation in the setting of AV-dissociation. Patient has known ischemic cardiomyopathy as well. EKG with inferior and anterior Q waves present, nonspecific TWI V4-6 and in the ED patient had a Troponin of 0.14 (which has been in a similar range given his renal insufficiency). We had no acute concerns for active coronary ischemia. He was initially continued on ASA 325 mg PO daily, clopidogrel 75 mg PO daily, and statin. Prior to discharge, his Plavix was stopped, his aspirin was reduced to 81mg daily, and warfarin was initiated for afib. INR on discharge was 3.1. Warfarin dose on discharge 2mg Qday. The patient will need daily INR monitoring until stable dose can be established. . # ATRIAL FIBRILLATION - Paroxysmal and patient had not been on warfarin prior to presentation. Warfarin was initiated on [**8-17**]. On discharge, INR was 3.1, and rhythm was V-paced. . # CHRONIC RENAL INSUFFICIENCY - Evidence of possible CKD, although creatinine baseline was 0.9-1.1 in 7/[**2154**]. Creatinine peaked at 2.4 on a prior admission presumed to be from pre-renal azotemia and aggressive diuresis for volume overload. His furosemide was recently decreased to 40 mg QHS (from 80 mg QAM and 40 mg PO QHS). This admission, creatinine appears in range with previous values at 1.6-2.2. We avoided nephrotoxins and renally dosed his medications. . # CONGESTIVE HEART FAILURE - Known history of CAD and CABG history in [**2147**] with evidence of ischemic cardiomypathy. Most recent TTE demonstrated moderate regional LV systolic dysfunction with hypokinesis of the distal third of the ventricle. The remaining segments contract normally (LVEF = 35%). Home regimen included no ACEI given renal insufficiency, no AV-nodal blockers, only diuretics. Exam and CXR did not demonstrate significant volume overload. We continued furosemide 40 mg PO daily. Metoprolol 25mg Daily added. ACEI continued to be held due to renal insufficiency. Weights not well documented. . # CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND OSA - Evidence of COPD and stable on inhalers and nebulizers with home oxygen requirement. No evidence of acute exacerbation, stable oxygen requirement and no wheezing on exam. Evidence of RLL consolidation, but no COPD exacerbation. Patient requires CPAP at nighttime and this has been continued on recent admissions with O2 saturations in high 90s. However, patient refused to use CPAP on most nights during this admission. . # HYPOTHYROIDISM - Remains on levothyroxine 175 mcg PO daily. TSH eleavted to 20 with normal T4 and free T4 on recent admission; consistent with sick euthyroid syndrome. Repeat TFTs should be done in several months when acute illness resolves. He was continued on levothyroxine 175 mcg PO daily. . # DIABETES MELLITUS - Stable on recent admission. Maintained on insulin sliding scale at rehab facility and during this admission. . # MENTAL STATUS - Patient appeared delerious, was verbally abusive towards staff, and pulled at lines and tubes. He was treated PRN with Seroquel. On [**8-19**], he was seen by geriatrics consults, who initially recommended haldol, however could not be given secondary to QTc prolongation. Trazadone was then started qhs per their recs. He did not have capacity to make health care decisions, which were deferred to his nephew, [**Name (NI) 449**] [**Name (NI) 976**]. Patient was pleasant and cooperative on discharge. . . Transitional Issues: # CODE STATUS: DNR/DNI, confirmed with official HCP "nephew" - f/u urine culture - will need to monitor INR while at facility as pt was restarted on warfarin on day of discharge - f/u final read on [**8-21**] CXR - Please pull PICC if not needed any more - Pt is to f/u with PCP and [**Name9 (PRE) 3782**] cardiologist after discharge from rehab facility Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from [**Hospital1 **] north. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 2. ALPRAZolam 0.25 mg PO Q6H:PRN anxiety 3. Aspirin 325 mg PO/NG DAILY 4. Calcitriol 0.25 mcg PO DAILY 5. Calcium Carbonate 1000 mg PO/NG DAILY 6. Vitamin D 800 UNIT PO DAILY 7. Clopidogrel 75 mg PO DAILY 8. Collagenase Ointment 1 Appl TP DAILY coccyx 9. Docusate Sodium (Liquid) 100 mg PO BID 10. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 11. Furosemide 40 mg PO/NG DAILY hold for sbp < 100 12. Levothyroxine Sodium 175 mcg PO DAILY 13. Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 14. Senna 1 TAB PO BID 15. Tiotropium Bromide 1 CAP IH DAILY Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 2. Aspirin 81 mg PO DAILY 3. Collagenase Ointment 1 Appl TP DAILY coccyx 4. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 5. Furosemide 40 mg PO DAILY 6. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 7. Levothyroxine Sodium 175 mcg PO DAILY 8. Senna 1 TAB PO BID 9. Tiotropium Bromide 1 CAP IH DAILY 10. Ascorbic Acid 500 mg PO BID Duration: 7 Days 11. Atorvastatin 80 mg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Metoprolol Succinate XL 25 mg PO DAILY Hold SBP < 90 14. Multivitamins 1 TAB PO DAILY 15. traZODONE 50 mg PO HS:PRN insomnia 16. Vitamin A 20,000 UNIT PO DAILY Duration: 7 Days 17. Zinc Sulfate 220 mg PO DAILY Duration: 7 Days 18. Calcitriol 0.25 mcg PO DAILY 19. Calcium Carbonate 1000 mg PO DAILY 20. Vitamin D 800 UNIT PO DAILY 21. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days 22. Warfarin 2 mg PO DAILY16 Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: AV dissociation Delerium Pneumonia Acute renal failure Hyponatremia Acute on Chronic systolic congestive heart failure Chronic sacral decub COPD on O2 Coronary artery disease 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: Dear Mr. [**Known lastname **], You had a cardiac arrest and were brought to the hospital. You were found to have pneumonia that was treated with antibiotics. Your heart rhythm was very slow so a pacemaker was inserted. Your sacral ulcer was also debrided by the surgery service. You have been very confused but this is slowly improving. Weigh yourself every morning, and call Dr. [**Last Name (STitle) 13310**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Your weight on discharge was 228 lbs. Followup Instructions: . Name: [**Last Name (LF) 64403**],[**First Name3 (LF) **] L. Location: [**Hospital 46644**] MEDICAL ASSOCIATES Address: [**Location (un) 32946**], [**Location (un) **],[**Numeric Identifier 32948**] Phone: [**Telephone/Fax (1) 32949**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Department: CARDIAC SERVICES When: WEDNESDAY [**2155-8-27**] at 4:00 PM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *At this appointment you will discuss about when you should next follow up with a Cardiologist. They will help you arrange that appointment.

[ "327.23", "414.8", "730.18", "272.4", "V49.86", "496", "707.07", "403.90", "486", "599.0", "344.1", "707.03", "V46.2", "428.0", "250.00", "426.0", "426.82", "427.31", "276.1", "707.23", "V49.87", "518.81", "585.3", "244.9", "041.09", "428.23", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "37.78", "37.81", "96.71", "86.28", "38.97", "37.71" ]

icd9pcs

[ [ [] ] ]

16623, 16723

7478, 14467

307, 423

16942, 16942

3764, 7455

17658, 18420

2777, 2812

15646, 16600

16744, 16921

14870, 15623

17117, 17635

2827, 3745

14488, 14844

263, 269

451, 2411

16957, 17093

2433, 2643

2659, 2761

1,473

117,038

18742

Discharge summary

report

Admission Date: [**2128-7-19**] Discharge Date: [**2128-7-26**] Service: NEUROLOGY HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 6993**] is an 81-year-old right-handed male with bilateral total knee replacement, hip fractures, diabetes mellitus, atrial fibrillation on Coumadin, congestive heart failure. His family brought patient in for mental status changes of three or four day- duration, mainly "he was slow when speaking, answering their questions". They brought him to an outside hospital where a CT scan revealed bilateral subdural collections, subfalcial herniation, and a parasagittal hemangioma. Patient also had high INR. Coumadin was discontinued and he was given 6 units of fresh-frozen plasma to reverse INR. He was sent here for Neurosurgical evaluation, but they felt these collections were old and did not require intervention. Therefore, Neurology was consulted. The patient had an episode of desreased LOC on the floor. The patient was then admitted to Intensive Care Unit, and given mannitol x1 to decrease edema. He had a repeat CT which showed no significant change. Neurosurgery discussed options with family, and he was deemed not to be a surgical candidate. On examination when seen on the general floor, the patient had a blood pressure of 140/60, heart rate of 60, temperature of 100.8, and respiratory rate of 18. On physical exam, pertinent positives: The patient had an irregular rhythm with a positive S1, S2. There are no carotid bruits. Lungs were clear to auscultation bilaterally. Patient had no clubbing, cyanosis, or edema with 2+ dorsalis pedis. On neurologic examination, the patient had an appropriate affect. Was oriented to name, but did not know the hospital. Thought the date was [**6-22**]. Was unable to identify year and he was mildly inattentive. The patient did have slow fluent speech. Repetition and naming were intact. The patient was able to read and write. Memory was [**3-8**] registration, 0/3 consolidation. The patient had no apraxia, neglect to frontal signs. On cranial nerve examination, visual fields were intact to confrontation. Pupils are round from 2 mm to 1.5 mm bilaterally. Extraocular movements are intact without nystagmus. Patient had normal facial sensation and musculature. Hearing intact to finger rub. Patient had normal tone and bulk. Patient had 4+ iliopsoas and quadriceps, otherwise 5+. Patient had 2+ reflexes aside from triceps 1. On sensory examination, the patient had a negative Romberg with decreased proprioception, vibration, and temperature below shins bilaterally, otherwise intact sensation. The patient had no dysmetria on finger-to-nose. LABORATORIES AND TESTS: The patient had white blood cells [**11-19**] over the past five days with 75% neutrophils. Patient's INR was controlled. Patient had a BUN and creatinine of 37/2.1, which was rechecked daily. Patient also had a repeat head CT and MRI which showed redemonstration of bilateral subdural hematoma with left frontal parasagittal meningioma. He also had an EEG, which did not show seizure activity. CONCISE SUMMARY OF HOSPITAL STAY: Coumadin was discontinued with only aspirin for atrial fibrillation and beta blocker for hypertension with digoxin. Beta blockers were later discontinued because of asymptomatic bradycardia (~ 30s). Patient also had positive MRSA in heel which was treated during admission. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSIS: 1- Subdural hematomas 2- Left frontal meningioma. DISCHARGE MEDICATIONS: 1. Glipizide 10 mg q am/5 mg q hs. 2. Aspirin 325 mg q day. 3. Digoxin 0.25 mg po q day. The patient will be discharged with Occupational Therapy and Physical [**Hospital **] rehab home. DR.[**Last Name (STitle) **],[**First Name3 (LF) 4267**] 13-282 Dictated By:[**Name8 (MD) 15274**] MEDQUIST36 D: [**2128-7-26**] 11:03 T: [**2128-7-26**] 11:20 JOB#: [**Job Number 51359**]

[ "432.1", "427.31", "225.2", "428.0", "V02.59", "V09.0", "593.9", "401.9", "250.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3571, 3985

3497, 3548

122, 3414

3439, 3476

32,448

193,316

31362

Discharge summary

report

Admission Date: [**2109-5-17**] Discharge Date: [**2109-5-22**] Date of Birth: [**2027-8-13**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Angina Major Surgical or Invasive Procedure: [**2109-5-17**] Urgent Coronary Artery Bypass Graft x 5 (LIMA to LAD, SVG to DIAG, SVG to OM to PLB, SVG to Acute Marginal) History of Present Illness: 81 y/o male with known CAD and MI in [**2102**] with PTCA x 2 of LCX who was experiencing increasing angina. Had recent positive ETT and then underwent cardiac cath. Cath revealed left main disease and ostial 95% LAD (and 3vd). Transferred to [**Hospital1 18**] for surgical care. Past Medical History: Coronary Artery Disease w/ Myocardial Infarction [**2102**] (PTCA x 2 LCX), Hypertension, Anemia, Hypercholesterolemia, Chronic Renal Insufficiency, h/o Syncope and tremors, s/p Left hernia repair Social History: Denies Tobacco use. ETOH 1 drink/day. Lives with wife Family History: Sister with MI. Physical Exam: VS: 50 18 154/88 5'8" 77kg Gen: WD/WN male in NAD Skin: Unremarkable HEENT: EOMI, PERRL, NC/AT Neck: Supple, FROM -JVD, -Bruits Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused -c/c/e, -varicosities Neuro: A&O x 3, non-focal Pertinent Results: [**2109-5-17**] Echo: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. There are simple 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 (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: Preserved biventricular systolic fxn. 1+MR, 1+AI. Aorta intact. Other parameters as pre-bypass. [**5-19**] CXR: Various lines and tubes have been removed with a right internal jugular vascular catheter remaining in place, in standard position. There is no pneumothorax. Cardiac and mediastinal contours are stable in the postoperative period. There has been slight improvement in bibasilar atelectasis. Small left pleural effusion has also decreased in size. Finally, pneumomediastinum extending into the cervical region has nearly resolved. [**2109-5-17**] 07:41PM BLOOD WBC-9.5 RBC-3.48* Hgb-11.1* Hct-30.2* MCV-87 MCH-31.9 MCHC-36.7* RDW-14.3 Plt Ct-103* [**2109-5-21**] 07:00AM BLOOD WBC-4.3 RBC-3.47*# Hgb-11.0*# Hct-30.9* MCV-89 MCH-31.6 MCHC-35.5* RDW-14.5 Plt Ct-134* [**2109-5-17**] 07:41PM BLOOD PT-14.5* PTT-33.8 INR(PT)-1.3* [**2109-5-18**] 02:56AM BLOOD Glucose-61* UreaN-18 Creat-1.0 Na-141 K-4.2 Cl-112* HCO3-26 AnGap-7* [**2109-5-21**] 07:00AM BLOOD WBC-4.3 RBC-3.47*# Hgb-11.0*# Hct-30.9* MCV-89 MCH-31.6 MCHC-35.5* RDW-14.5 Plt Ct-134* [**2109-5-22**] 06:50AM BLOOD PT-10.7 INR(PT)-0.9 [**2109-5-22**] 06:50AM BLOOD Glucose-111* UreaN-34* Creat-1.3* Na-142 K-4.1 Cl-102 HCO3-30 AnGap-14 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 73920**] was transferred to [**Hospital1 18**] for urgent CABG. Following admission he was consented for surgery and brought to the operating room where he underwent a coronary artery bypass graft x 5. Please see operative report for details. Following surgery her was transferred to the CSRU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. He was weaned off of Inotropes by post-op day two and started on beta blockers. He was diuresed towards his pre-op weight during his post-op course. Chest tubes and epicardial pacing wires were removed per protocol. Amiodarone was initiated for episodes of atrial fibrillation during initial post-op course. He was eventually transferred to the SDU on post-op day three for further care. He continued to improve quite well and worked with physical therapy for strength and mobility. He was discharged home with Amiodarone and his rhythm was sinus over last 48 hours of hospital course. On post-op day five he was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Aspirin 81mg qd, Atenolol 12.5mg qd, Lipitor 10mg qd, Diovan 80mg qd, Vit B injection Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*1* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days: Take with lasix. 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO As instructed: Take amiodarone 400mg twice daily until [**2109-5-26**]. On [**2109-5-27**], take 400mg once daily for 7 days. On [**2109-6-2**] take amiodarone 200mg once daily until further instructions from Dr. [**First Name (STitle) 1075**].: Take amiodarone 400mg (2 pills) twice daily until [**2109-5-26**]. On [**2109-5-27**], take 400mg (2 pills)once daily for 7 days. On [**2109-6-2**] take amiodarone 200mg (1 pill) once daily until further instructions from Dr. [**First Name (STitle) 1075**]. Disp:*60 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Artery Disease s/p Urgent Coronary Artery Bypass Graft x 5 PMH: Hypertension, Anemia, Hypercholesterolemia, Myocardial Infarction [**2102**], Chronic Renal Insufficiency, h/o Syncope and tremors, s/p Left hernia repair Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Take lasix for 7 days then stop. Take with potassium. Weigh yourself daily. 8) Take amiodarone 400mg twice daily until [**2109-5-26**]. On [**2109-5-27**], take 400mg once daily for 7 days. On [**2109-6-2**] take amiodarone 200mg once daily until further instructions from Dr. [**First Name (STitle) 1075**]. Call with any questions or concerns. Followup Instructions: Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Dr. [**First Name (STitle) 1075**] PCP/Cardiologist in [**11-27**] weeks. ([**Telephone/Fax (1) 20259**] [**Hospital Ward Name 121**] 2 in 2 weeks for Wound check Please call all providers for appointments. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2109-5-22**]

[ "997.1", "427.31", "414.01", "413.9", "585.9", "285.9", "272.0", "403.90" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5948, 5997

3170, 4335

327, 452

6268, 6274

1383, 3147

7297, 7698

1069, 1086

4471, 5925

6018, 6247

4361, 4448

6298, 7274

1101, 1364

281, 289

480, 762

784, 982

998, 1053

2,015

102,479

28062

Discharge summary

report

Unit No: [**Numeric Identifier 68286**] Admission Date: [**2135-4-19**] Discharge Date: [**2135-4-30**] Date of Birth: [**2087-3-21**] Sex: M Service: MED HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old male who was well known to the surgery service having had a malignant pheochromocytoma resected in [**2134-8-20**]. At the time he had multiple small liver metastases and a very large malignant pheochromocytoma. The decision at that time was to observe his liver metastases. Hence, the endocrinologist thought that this would not create a problem. The patient represented to [**Location (un) **] in late [**Month (only) 547**] with distention and difficulty having bowel movements. He was also found to have hypoxia based on shunting. No pulmonary embolism was found. The patient had massive hepatomegaly which may have been the cause of some of his pain. The patient was transferred to [**Hospital6 2018**] and underwent a CT scan which confirmed the finding at [**Hospital3 **]. We made multiple efforts to decompress the colon with enemas and cathartics but this did not work. There was some question as to whether he had a small bowel obstruction. The patient did not progress and the decision was made to take him to the operating room on [**2135-4-21**]. At this point, the patient had been transferred to the ICU because of difficulty breathing. We were hoping to do colonoscopy with the patient intubated but the GI service felt that was probably not an option given his tenuous state. Lysis of adhesions showed a transition point in the mid jejunum with some lysis of adhesions but this did not appear to be the cause for his bowel obstruction. The patient developed acute renal failure requiring dialysis. By [**4-23**] the hope was that he can be weaned from the ventilator. He continued to require labetalol and nicardipine to control his blood pressure. By [**4-24**], the patient had worsening chest x- ray consistent with pneumonia. He was extubated on [**4-25**] but no real progress was made on his ileus. He was started TPN. At this point consideration for colonoscopy was reopened with the GI team. The endocrine team recommended starting doxazosin. The GI service continued to be reluctant to perform colonoscopy. By [**4-26**] the patient was felt to be stable but no progress was made in terms of GI function. The decision was made to try to a Gastrografin enema both for diagnosis and treatment as recommended by the GI service. The patient continued to be somewhat unstable but was unable to maintain his ventilatory status without intubation. By [**4-27**] he had a couple of small bowel movements after the Gastrografin enema and the NG tube was removed because of lack of output and discomfort. Unfortunately by [**4-28**] the patient continued to do poorly and we felt that we had to do a decompressive laparotomy for his pseudoobstruction with high bladder pressures. On the beginning of the operation he desaturated and the feeling was that he probably had an endobronchial on the right and a left chest tube was placed and the endotracheal tube was pulled back. Decompressive laparotomy showed massive dilated loops of bowel without specific obstruction. The cecum was very distended and cecostomy tube was placed with a 26 Foley. The abdomen was left open. After this operation, the patient continued to deteriorate with worsening respiratory status. On [**4-29**] the opened abdomen was removed and bowel was visualized and appeared to be pink and viable. There was some question as to whether it was not viable, but this did not seem to be the case. The patient continued to require high-dose pressors without much response. A family meeting was held with the patient's wife and they decided that given his current status and his underlying condition, that they would proceed with comfort measures only. On [**2135-4-30**], the patient expired at 5:20 p.m. DIAGNOSIS: 1. Metastatic pheochromocytoma. 2. Colonic pseudo-obstruction. 3. Sepsis. 4. Renal failure. 5. Acute respiratory distress syndrome. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16263**] Dictated By:[**Last Name (NamePattern1) 16475**] MEDQUIST36 D: [**2135-11-8**] 12:39:35 T: [**2135-11-10**] 09:49:37 Job#: [**Job Number **] cc:[**Last Name (NamePattern1) 68287**]

[ "556.1", "507.0", "543.9", "197.7", "401.9", "997.4", "584.9", "E878.8", "327.23", "560.81", "194.0", "427.1", "560.1", "276.7", "560.39", "E849.7", "799.02", "486", "197.6", "518.0", "557.9", "274.9" ]

icd9cm

[ [ [] ] ]

[ "96.07", "96.04", "89.64", "33.23", "47.19", "46.11", "96.72", "99.04", "38.93", "54.59", "38.95", "99.15", "45.73" ]

icd9pcs

[ [ [] ] ]

190, 4365

59,056

192,429

42799

Discharge summary

report

Admission Date: [**2136-6-29**] Discharge Date: [**2136-7-4**] Date of Birth: [**2054-5-28**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 3376**] Chief Complaint: transverse colon cancer Major Surgical or Invasive Procedure: [**2136-6-29**] Right hemicolectomy History of Present Illness: Ms. [**Known lastname 25139**] is an 82 F with 6cm ascending colon mass found on c' scope after admission for anemia. Described as "6 cm polyp which may be of malignant appearance was found in the distal ascending colon and hepatic flexure". Mass was tattooed. Pathology demonstrated adenoma with focal high grade dysplasia. She is admitted now for surgical resection. Past Medical History: Prinzmetal's Angina (LHC was reportedly clean 20 years ago) Hemorrhoidectomy >20 years ago HTN HLD Social History: Tobacco- 2 cigarettes for 5 years, greater than 50 years ago Alcohol- Manischewitz rarely Drugs- denies "what do you mean by that?" She is a retired book keeper. She lives in [**Location **] in an apt, by herself (husband in rehab). She is independent in daily living. Family History: No hx of CAD. Mother-colon ca dx at age 58, deceased at age 64 Father-deceased of PUD in his 50s. Had DM. Twin sister-deceased of breast cancer in 60s Sister-deceased in 90s Physical Exam: Admission Physical Exam: Tm 100.2 Tc 98.2 BP 160/73 HR 90 O2: 96% high flow General: Calm, no acute distress, intermittently removing air mask HEENT: Sclera anicteric, MMM, EOMI Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, III/VI SEM at LUSB Lungs: Coarse bibasilar crackles bilaterally [**2-6**] way up the lungs Abdomen: soft, non-distended, vertical incision covered by gauze, no bowel sounds, TTP in the RLQ GU: foley present, draining clear yellow urine Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Physical Exam: Tc 98.0 BP 163/62 HR 60 RR 18 02: 98%RA General: alert and oriented, NAD HEENT: Sclera anicteric, MMM, EOMI Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, III/VI SEM at LUSB Lungs: Soft bibasilar crackles Abdomen: soft, non-distended, vertical incision c/d/i, normoactive bowel sounds, appropriately TTP around incision Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS [**2136-6-30**] 05:50AM BLOOD WBC-23.3*# RBC-3.15* Hgb-7.1* Hct-24.6* MCV-78* MCH-22.6* MCHC-29.0* RDW-19.8* Plt Ct-203 [**2136-7-1**] 05:07AM BLOOD Neuts-93.2* Bands-0 Lymphs-2.6* Monos-3.4 Eos-0.4 Baso-0.1 [**2136-7-1**] 05:07AM BLOOD PT-10.6 PTT-28.1 INR(PT)-1.0 [**2136-6-30**] 05:50AM BLOOD Glucose-122* UreaN-16 Creat-0.8 Na-138 K-4.2 Cl-105 HCO3-22 AnGap-15 [**2136-7-1**] 05:07AM BLOOD CK(CPK)-242* [**2136-6-30**] 09:00PM BLOOD CK(CPK)-178 [**2136-6-30**] 09:00PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-2063* [**2136-7-1**] 05:07AM BLOOD CK-MB-2 cTropnT-<0.01 [**2136-6-30**] 05:50AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.3 [**2136-6-30**] 08:17PM BLOOD Type-ART Temp-37.3 FiO2-85 pO2-81* pCO2-37 pH-7.45 calTCO2-27 Base XS-1 AADO2-497 REQ O2-83 Intubat-NOT INTUBA [**2136-7-1**] 10:20AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.012 [**2136-7-1**] 10:20AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2136-7-1**] 10:20AM URINE RBC-10* WBC-1 Bacteri-FEW Yeast-NONE Epi-0 [**2136-7-1**] 10:20AM URINE CastHy-9* [**2136-7-1**] 10:20AM URINE Mucous-OCC . IMAGING: -[**2136-7-1**] CXR: FINDINGS: Comparison is made to previous study from [**2136-6-30**]. There is unchanged cardiomegaly. There is improvement of the airspace opacities in the right perihilar region and the left retrocardiac area. There is persistent prominence of pulmonary interstitial markings consistent with pulmonary edema. This is slightly improved. Brief Hospital Course: The patient was taken to the operating room for scheduled right hemicolectomy for colon mass. She tolerated this procedure well and was taken to the PACU initially in good condition; for full details please see the dictated operative note. On POD#1 she became hypoxic to the 70's on room air, and was transferred to the [**Hospital Unit Name 153**] for close monitoring of her respiratory status. O2 sats improved with NRB and hypoxia was thought likely [**3-8**] atelectasis, fluid overload, and possibility of brewing infection. Pt was given IV lasix, encouraged to use the incentive spirometer, and was maintained on aggressive pain control to prevent splinting. She was started on vancomycin/cefepime to treat for HCAP given low grade temp to 100.2 upon arrival to the [**Hospital Unit Name 153**], increasing leukocytosis, as well as retrocardiac opacity seen on CXR. Additionally, she was given 2 units of pRBC for HCT 22 on [**Hospital Unit Name 153**] day 2 along with another dose of lasix. Her oxygen saturations improved with deep breathing and adequate pain control was helping with this. She was stable and transferred to the surgical floor on 5/28am. Her floor course was very straight forward and she improved daily. She was stable on 3L NC by the time she was transferred out of the [**Hospital Unit Name 153**]; over the next day this was weaned off to room air. She ambulated with assistance from nursing and physical therapy and increased her activity level daily. Once she had flatus she was advanced to a regular diet, which she tolerated with no difficulties. She had multiple BM's prior to discharge. She was continued on vanc/cefepime for HCAP throughout her stay, and will go to rehab on an additional 5 days of PO levaquin. This has been addressed with her PCP as well who has approved of the antibiotic plan. At time of discharge she is improving steadily. She is ambulating with some assistance, tolerating a regular diet, and pain is well controlled on oral medications. She is discharged to rehab on POD 5 and will follow up in clinic in [**2-6**] weeks. Medications on Admission: Benzapril 40mg daily Amlodipine 5mg daily Metoprolol Succinate 25mg daily Atorvastatin 10mg daily Chlorthalidone 25mg daily Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) treatment Inhalation Q6H (every 6 hours). 7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 9. benzapril Sig: Forty (40) mg once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: colon mass 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 after an open Right Sided Colectomy for surgical management of your colon mass. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you [**Name2 (NI) 19605**] these results they will contact you before this time. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. It is important that you continue to have bowel movements. Some loose stool and passing of small amounts of dark, old appearing blood are explected however, if you notice that you are passing bright red blood with bowel movments or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms does not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonges loose stool, or constipation. You have a long vertical incision on your abdomen that is closed with staples. This incision can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing. The staples will stay in place until your first post-operative visit at which time they can be removed in the clinic, most likely by the office nurse. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may gradually increase your activity as tolerated and directed by the physical therapists at rehab. You will be prescribed a small amount of pain medication. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 4. Take prescription pain medications for pain not relieved by tylenol. 5. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 6. 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. . Followup Instructions: Call the colorectal surgery office to make an appointment for follow-up two weeks after surgery with the colorectal surgery outpatient nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) 1124**], NP. At that appointment you will be set up with an appointment for your second post-operative check. Call [**Telephone/Fax (1) 160**] to make this appointment. Completed by:[**2136-7-4**]

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icd9cm

[ [ [] ] ]

[ "45.73", "99.77" ]

icd9pcs

[ [ [] ] ]

6936, 7006

3928, 6018

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127,378

23071

Discharge summary

report

Admission Date: [**2108-1-19**] Discharge Date: [**2108-1-24**] Service: MEDICINE Allergies: Cough Attending:[**First Name3 (LF) 8487**] Chief Complaint: 88 yo M w/NSCLC xferred from OSH for IP intervention for "airway stent placement". Major Surgical or Invasive Procedure: Bronchoscopy with Y stent placement on [**2108-1-21**], repeat bronchoscopy [**2108-1-23**]. History of Present Illness: 88 yo M w/NSCLC. He presented to [**Hospital 28159**] Hospital for work-up of weight loss (20lbs in a few months), progressive dyspnea x2-3 mos. He had been treated w/antibiotics and MDIs without improvement for presumed recurrent bronchitis. He was found to have mediastinal masses on CXR and was xferred to [**Hospital6 6689**] on [**1-15**] for further workup. [**Hospital **] HOSPITAL: chest CT showed 2cm right upper lobe mass, [**Hospital1 **]-hilar LAD w/major airway compression, pleural effusion. Pleural fluid cytology revealed adenocarcinoma. No bronchoscopy was performed secondary to concern for worsening airway and plan for stent placement via IP at [**Hospital1 18**], with possible return for palliative XRT. Pt currently denies pain, denies SOB - feels that his breathing is significantly improved since OSH. Has a nonproductive cough. Reports intermittent dysphagia, with the feeling of food getting stuck around his mid-chest. Denies [**Location (un) **], PND, orthopnea. Past Medical History: adenocarcinoma of lung with impending airway obstruction - in right upper lobe with extensive mediastinal and perihilar mets benign prostatic hypertrophy osteoporosis compression fractures of T12 bilateral cataract surgery R knee replacement hypertension cholelithiasis seen on CT Social History: cigar smoking no cigarette smoking lives alone Pt worked in the railroad service, then as superintendent of public services in [**Location 45910**]. Denies any known asbestos exposure. Family History: no known lung disorders Physical Exam: VS: 96.0 150/88 60 24 94% 3LNC Gen: cachectic, in mild respiratory distress with mild tachypnea, difficulty hearing HEENT: dry MM, small amount of thrush visible; EOMI, PERRL Neck: no JVD, no cervical LAD CV: RRR, nl S1/S2, no murmurs Pulm: diffuse scattered wheezes and coarse breath sounds, no localized crackles Chest: large mass visible - firm, across sternum Abd: soft, NT/ND, +BS, no masses, well healed appy scar and midline scar Ext: no edema, 2+ pulses Skin: large ecchymosis on L flank, being resorbed Pertinent Results: outside hospital: chest CT: bihilar lymphadenopathy with considerable compression of major airways, RUL mass; pleural effusion thoracentesis - pleural fluid positive for adenocarcinoma [**2108-1-24**] 03:54AM BLOOD WBC-16.5* RBC-4.38* Hgb-13.4* Hct-38.8* MCV-89 MCH-30.5 MCHC-34.5 RDW-14.1 Plt Ct-153 [**2108-1-24**] 03:54AM BLOOD Plt Ct-153 [**2108-1-24**] 03:45PM BLOOD Glucose-158* UreaN-54* Creat-1.6* Na-142 K-4.1 Cl-113* HCO3-18* AnGap-15 [**2108-1-19**] 11:30PM BLOOD Glucose-131* UreaN-34* Creat-0.9 Na-136 K-4.6 Cl-103 HCO3-29 AnGap-9 [**2108-1-24**] 03:45PM BLOOD Calcium-7.0* Phos-3.7 Mg-2.0 [**2108-1-23**] 04:45PM BLOOD Cortsol-54.0* [**2108-1-24**] 03:54AM BLOOD Vanco-25.1* [**2108-1-24**] 02:18PM BLOOD Type-ART Temp-36.8 Tidal V-550 PEEP-5 FiO2-60 pO2-149* pCO2-37 pH-7.28* calHCO3-18* Base XS--8 Intubat-INTUBATED [**2108-1-24**] 02:18PM BLOOD Lactate-2.7* Brief Hospital Course: Mr. [**Known lastname 59454**] was admitted to [**Hospital1 18**] for stent placement by Interventional Pulmonology. On [**2108-1-21**] he had rigid bronchoscopy with Y stent placed in trachea/right/left mainstem. Patient intubated for 6 hours and extubated. 45 minutes following extubation, patient had increased SOB, tachypnea, ABG 7.21/65/181 on non-rebreather. X-ray demonstrated element of volume overload. Patient diuresed with 80 mg lasix, placed on nitro (to which patient's BP dropped to 80s), placed on BIPAP (to which he responded well). Patient transferred to MICU. Repeat ABG was 7.35/44/70. 1. Respiratory compromise - Initially he did well on BIPAP. His repsiratory failure was felt to be secondary to tumor burden/obstruction and post obstructive pneumonia. His bronchial lavage gram stain showed 4+ gram positive cocci in pairs and clusters. He was started on vancomycin, levofloxacin and flagyl for coverage of staphlococcus, gram negatives and anaerobes due to aspiration pneumonia. His repeat bronchoscopy on [**2108-1-23**] showed patent stent. On [**2108-1-23**] his respiratory status decompensated and he was intubated. On [**2108-1-24**], he became hypotensive and was started on zosyn for broad spectrum coverage including pseudomonas. He remained hypotensive, requiring neosynephrine and IVF boluses and acidotic on [**2108-1-24**]. A family meeting with two of his sons was had that evening. Given his poor prognosis, he was made CMO. He was extubated and started on a fentanyl drip. He was comfortable and expired at 11:25 PM on [**2108-1-24**]. 2. Cardiac: On [**2108-1-23**], he developed hypotension and tachycardia (MAT and atrial flutter). He was given fluid boluses to try to slow his rate as his BP was low and could not tolerate beta blockade. Medications on Admission: dexamethasone 8mg IV q8h tylenol albuterol nebs aspirin 81mg po daily atenolol 25mg po daily heparin SC tid atrovent nebs zofran 1mg IV q12h protonix 40mg po daily Discharge Disposition: Expired Discharge Diagnosis: Non small cell lung cancer, hypertension, MAT, BPH, osteoporosis L hemidiaphragm paralysis Discharge Condition: Expired Followup Instructions: None. We will call his primary doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **], Referring pulm: [**First Name8 (NamePattern2) 2491**] [**Last Name (NamePattern1) 59152**], [**0-0-**]

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icd9cm

[ [ [] ] ]

[ "33.23", "96.05", "96.71", "33.24", "96.04" ]

icd9pcs

[ [ [] ] ]

5422, 5431

3422, 5208

296, 390

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2522, 3399

5598, 5804

1940, 1965

5452, 5545

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1980, 2503

174, 258

418, 1417

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1737, 1924

8,803

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4037

Discharge summary

report

Admission Date: [**2171-9-30**] Discharge Date: [**2171-10-4**] Date of Birth: [**2089-4-21**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3021**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: None. History of Present Illness: 82M with history of IgG-lambda multiple myeloma, s/p 1 cycle melphalan/prednisone/bortezomib, presently day 25 cycle 2 melphalan with one dose of bortezomib on day 1, CHF, CAD s/p CABG x 2 with pacemaker, DM presenting with 2 day history of cough, confusion, and increased weakness. Patient has had nonproductive cough since saturday. Patient was seen at [**Hospital1 112**] yesterday because he is followed by cards there. A CXR there reportedly showed evidence of bilateral pleural effusions, his BNP was at baseline of [**Numeric Identifier 961**]. He was diagnosed with PNA and discharged home on PO levaquin. Reported chills last night to daughter, but temperature not taken. Reported increased fatigue with mildly increased SOB to daughter this AM. Had one episode of vomiting after peg-tube feeding for supplements. No current nausea. No diarrhea. Patient feels that his lower extremity swelling is at baseline. . In the ED inital vitals were, 99.1 97 125/53 18 98%. infectious tests were sent and patient was stabilized and transferred to the [**Hospital Unit Name 153**]. Patient was satting well on RA/NC. . Upon arrival, patient was placed on FM to improve saturation. family says that he looks much better and is less confused compared to before. Patient appears sleepy and drifts into sleep often. Otherwsie stable and intermittent dry cough. . Review of systems: as above, otherwise neg. Past Medical History: ONC HISTORY: Multiple myeloma, s/p melphalan, prednisone, and bortezomib. Prednisone stopped due to CHF exacerabation. . CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension CARDIAC HISTORY: - [**10/2157**] cardiac catheterization - LAD diffusley diseased with 30%proximal, 40% mid and 70% apical stenosis. D2 90% ostial lesion. Circ diffusley diseased with a 60% proximal and a complex 70% bifucation lesion involving OM1. RCA had a 90% mid and a 60% distal. The PDA and posterolateral vessels had 90% ostial lesions. EF 59%. New LBBB - [**10/2157**] CABG (SVG-D2, SVG-D1and Circ OM, sequential) - [**3-28**] cardiac catheterization - right ICA 90% treated with 8 x 30mm Precise stent, left ICA 50-60% stenosis was not intervened. - [**3-31**] SVG graft to the obtuse marginal Cyper stenting followed by POBA result of instant restenosis to that Cyper stent . OTHER PAST MEDICAL HISTORY: - History of peripheral vascular disease with carotid stenosis status post right carotid stenting in [**2163**] - GERD - Gastrointerstinal bleeding: [**7-1**] endoscopy - antral gastritis was possible site of bleed, followed by Dr. [**Last Name (STitle) **] - Barrett's and healed antral ulcer - Anemia and monoclonal gammopathy of unknown origin, followed by Dr. [**First Name (STitle) **] in Heme Onc - DM-II on PO meds Social History: -Tobacco history: Remote -ETOH: Denies -Illicit drugs: Denies Family History: - Father died of MI - No other family history of early coronary disease, PVD, HTN Physical Exam: ADMISSION EXAM: Vitals: T: 100.3 BP: 132/52 P: 91 R: 28 O2: 94% on 50%FM General: Alert, oriented, lethargic, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: very rhonchorous throughout, no wheezing CV: Regular rate and rhythm, loud heart sounds, difficult to ascertain murmurs given rhonchorous breaching Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: feet cool but +1 pulses, +1 pitting edema to ankles Pertinent Results: ADMISSION LABS: [**2171-10-1**] 11:42AM BLOOD WBC-4.0 RBC-2.34* Hgb-8.2* Hct-24.8* MCV-106* MCH-34.9* MCHC-33.0 RDW-20.2* Plt Ct-75* [**2171-10-1**] 03:29AM BLOOD WBC-5.5 RBC-2.38* Hgb-8.4* Hct-24.6* MCV-104* MCH-35.3* MCHC-34.1 RDW-20.2* Plt Ct-64* [**2171-9-30**] 05:00PM BLOOD WBC-7.9 RBC-2.50* Hgb-8.8* Hct-25.9* MCV-104* MCH-35.3* MCHC-34.1 RDW-20.2* Plt Ct-77* [**2171-9-30**] 11:00AM BLOOD WBC-10.0# RBC-2.96* Hgb-10.3* Hct-30.7* MCV-104* MCH-34.9* MCHC-33.7 RDW-20.9* Plt Ct-101*# [**2171-9-30**] 05:00PM BLOOD Neuts-91.9* Lymphs-4.4* Monos-3.1 Eos-0.4 Baso-0.2 [**2171-9-30**] 11:00AM BLOOD Neuts-93.6* Lymphs-3.6* Monos-1.7* Eos-0.8 Baso-0.3 [**2171-10-1**] 11:42AM BLOOD Plt Ct-75* [**2171-10-1**] 11:42AM BLOOD PT-23.8* PTT-38.5* INR(PT)-2.2* [**2171-10-1**] 03:29AM BLOOD Plt Ct-64* [**2171-10-1**] 03:29AM BLOOD PT-19.7* PTT-37.0* INR(PT)-1.8* [**2171-9-30**] 05:00PM BLOOD Plt Smr-VERY LOW Plt Ct-77* [**2171-9-30**] 05:00PM BLOOD PT-19.3* PTT-32.4 INR(PT)-1.7* [**2171-9-30**] 11:00AM BLOOD Plt Ct-101*# [**2171-10-1**] 11:42AM BLOOD Fibrino-298 [**2171-10-1**] 03:29AM BLOOD Glucose-92 UreaN-57* Creat-1.4* Na-139 K-4.8 Cl-105 HCO3-26 AnGap-13 [**2171-9-30**] 05:00PM BLOOD Glucose-101* UreaN-65* Creat-1.4* Na-137 K-4.8 Cl-102 HCO3-26 AnGap-14 [**2171-9-30**] 11:00AM BLOOD Glucose-224* UreaN-66* Creat-1.6* Na-135 K-5.6* Cl-100 HCO3-26 AnGap-15 [**2171-10-1**] 11:42AM BLOOD LD(LDH)-326* TotBili-1.1 [**2171-9-30**] 11:00AM BLOOD cTropnT-<0.01 [**2171-9-30**] 11:00AM BLOOD proBNP-[**Numeric Identifier 17788**]* [**2171-10-1**] 03:29AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.4 [**2171-9-30**] 05:00PM BLOOD Calcium-8.8 Phos-3.0 Mg-2.5 [**2171-10-1**] 03:49AM BLOOD Type-[**Last Name (un) **] pH-7.43 [**2171-10-1**] 03:49AM BLOOD Lactate-1.0 [**2171-9-30**] 11:10AM BLOOD Glucose-206* Lactate-3.4* K-5.5* . [**2171-9-30**] CXR: IMPRESSION: Right upper lobe pneumonia with superimposed mild pulmonary edema. . [**2171-10-1**] CXR: FINDINGS: In comparison with study of [**9-30**], there is some decreased opacification in both the right mid zone and in the left lower lung. Continued pleural effusion with compressive atelectasis at the left base. . DISCHARGE LABS: [**2171-10-4**] 06:20AM BLOOD WBC-3.4* RBC-2.88* Hgb-9.7* Hct-29.3* MCV-102* MCH-33.8* MCHC-33.2 RDW-20.4* Plt Ct-107* [**2171-10-2**] 06:40AM BLOOD Neuts-84* Bands-0 Lymphs-4* Monos-10 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2171-10-4**] 06:20AM BLOOD PT-16.3* PTT-31.6 INR(PT)-1.4* [**2171-10-3**] 06:15AM BLOOD Fibrino-434* [**2171-10-3**] 06:15AM BLOOD Thrombn-14.7* [**2171-10-3**] 06:15AM BLOOD Ret Aut-2.8 [**2171-10-4**] 06:20AM BLOOD Glucose-120* UreaN-32* Creat-1.1 Na-138 K-4.6 Cl-106 HCO3-25 AnGap-12 [**2171-10-2**] 06:40AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.4 UricAcd-5.4 [**2171-10-3**] 06:15AM BLOOD Albumin-3.2* Calcium-8.7 Phos-2.8 Mg-2.3 [**2171-10-4**] 06:20AM BLOOD ALT-38 AST-60* AlkPhos-428* TotBili-1.7* DirBili-PND [**2171-10-3**] 06:15AM BLOOD GGT-361* [**2171-9-30**] 11:00AM BLOOD proBNP-[**Numeric Identifier 17788**]* [**2171-9-30**] 11:00AM BLOOD cTropnT-<0.01 [**2171-10-1**] 11:42AM BLOOD calTIBC-234* VitB12-1419* Folate-GREATER TH Hapto-<5* Ferritn-1205* TRF-180* Brief Hospital Course: 82yo man with IgG-lambda multiple myeloma s/p 2nd cycle melphalan/prednisone/bortezomib, CHF, CAD s/p CABG and pacemaker, and DM admitted for cough, weakness, and pneumonia. He has had two recent hospitalizations (at B&W Hospital) since starting chemotherapy: one for dehydration, then soon after for acute CHF. He needed a RBC transfusion ~1wk ago (previously five months ago for chronic AVM GI bleeding). He was started on levofloxacin for pneumonia the day before admission, but the following day he was having difficulty breathing and coughing and weakness had substantially worsened. He was admitted to the ICU due to hypoxia and altered mental status and given cefepime, vancomycin, and levofloxacin. Vancomycin was stopped [**2171-10-2**]. Abx changed to cefpodoxime and levofloxacin upon discharge with home O2 during ambulation. . # Pneumonia: RLL infiltrate on CXR and bilateral pleural effusions (L>R), lactate 3.4, tachypnea to 30s, MAP 60s, good urine output, trop negative, U/A negative. Started cefepime, vancomycin, and levofloxacin. Improved altered mental status. Vancomycin was stopped [**2171-10-2**]. Changed cefepime to cefpodoxime and continued levofloxacin at hospital discharge. Cultures pending. Nebs q6hr. O2 support as needed. Desats with ambulation, so home oxygen arranged. . # Hypotension: Held outpatient anti-hypertensives (metoprolol, lisinopril). BP increasing, so restarting lower dose metoprolol at 25mg [**Hospital1 **] and plan to restart lisinopril in outpatient setting as directed by his primary care physician. . # Multiple myeloma: Held chemo during infection. Continued allopurinol. . # Anemia: Chronic, but worse. Ttransfused 1U pRBC [**2171-10-1**] with furosemide. Unclear etiology. Possibly chemo induced. Haptoglobin <5 and LDH elevated suggesting hemolysis. Retics may be suppressed by chemo. Direct Coombs negative. Occasional schistocytes reported, acute kidney injury, and altered mental status. However, TTP/HUS is not his diagnosis considering he has clinically improved with antibiotics. He may have a mild compensated DIC considering elevated coags and normal fibrinogen. Elevated thrombin time may suggest a dysfibrinogenemia. Mixing study cancelled with minimal PTT elevation. [**Month (only) 116**] consider repeat mixing study for PT. Continued folate. . # Coagulopathy: Unclear etiology: DIC vs. liver dysfunction. Mixing study cancelled (see above). . # Neutropenia: Likely chemo-induced. Stable. . # Acute renal failure: Creatinine 1.1 --> 1.6 --> 1.1. No additional IV fluids considering high risk for fluid overload with RBC transfusion and CHF (furosemide on hold for low BP, restarted [**2171-10-3**]). . # Abnormal LFTs: Unknown etiology. Chemo-induced? GGT elevated. [**Month (only) 116**] benefit from outpatient RUQ U/S. . # CHF: BNP [**Numeric Identifier 17788**] with baseline ~10,000. Slight elevation of JVP and trace ankle edema. Given furosemide 20mg IV x1 with RBC transfusion [**2171-10-3**]. Restarted furosemide [**2171-10-4**] at lower dose 20mg daily. Planned to increase to full outpatient dose 40mg daily [**2171-10-5**]. Restarted metoprolol at lower dose 25mg [**Hospital1 **] prior to discharge. . # CAD: Stable. Aspirin and clopidogrel held for thrombocytopenia. Continued statin. Restarted metoprolol at lower dose 25mg [**Hospital1 **] as BP improved. Continued to hold lisinopril until outpatient appointment with PCP. . # Gastroparesis: Possibly due to diabetes and cause of nausea/vomiting. Started metoclopramide day of discharge. # DM: Decreased insulin glargine from 10 to 8U qHS to avoid recurrent hypoglycemia. Continued insulin sliding scale. . # Depression: Continued outpatient bupropion. . # Pain: None. . # FEN: Regular cardiac/diabetic diet. Restarted tube feeds [**2171-10-2**]. . # GI PPx: PPI and bowel regimen. . # DVT PPx: Heparin SC. . # Precautions: None. . # Lines: Peripheral. . # CODE: FULL. Medications on Admission: Moxifloxicin 400 mg QOD restated on [**9-19**] with 15 tablets Voriconazole 200 [**Hospital1 **] (started [**9-13**]) Acyclovir 400 [**Hospital1 **] Zovirax ointment Folic acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY Lorazepam 1-2 mg Tablet qHS PRN Prednisone 40 mg daily (25 mg until [**9-19**]) Albuterol sulfate INH Dilaudid 2mg q4 prn Oxycodone 5 mg q8 PRN Vitamin D 800 units daily Multivitamin daily TMP-SMX SS tablet daily since [**7-30**] Bupropion HCl ER 150mg PO daily Furosemide 40mg daily Metoprolol succinate (Toprol XL) 50mg [**Hospital1 **] Lisinopril 10mg daily Allopurinol 100mg daily Insulin glargine 10U qAM Insulin lispro (Humalog) sliding scale Fluticasone 50mcg nasal spray daily Ondansetron 4-8mg prn Pantoprazole 20mg [**Hospital1 **] Simvastatin 20mg daily Discharge Medications: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY. 2. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY. 3. bupropion HCl 150 mg Tablet Extended Release PO QAM. 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY. 5. Oxygen Oxygen 2L NC with ambulation. Pulse dose for portability. Ambulatin sat 88%. Dx: Pneumonia. 6. Nebulizer Nebulizer machine. Diagnosis: Pneumonia. 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY. 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID. 9. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY. 10. insulin glargine 100 unit/mL Cartridge Sig: Eight (8) Units SC QHS. 11. insulin lispro 100 unit/mL Sig: Units SC QID: Per sliding scale. 12. fluticasone 50 mcg/Actuation Nasal Spray DAILY. 13. ondansetron HCl 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours. 14. pantoprazole 40 mg Tablet PO Q12H. 15. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID. Disp:*600 mL* Refills:*2* 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN Constipation. 17. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY. 18. guaifenesin 600 mg Tablet Extended Release PO BID PRN Cough. 19. benzonatate 100 mg PO TID PRN Cough. Disp:*20 Capsule(s)* Refills:*0* 20. levofloxacin 750 mg PO Q48H x6 days: Last dose [**2171-10-10**]. Disp:*3 Tablet(s)* Refills:*0* 21. cefpodoxime 200 mg PO BID x6 days: Last day [**2171-10-10**]. Disp:*12 Tablet(s)* Refills:*0* 22. ipratropium bromide 0.02 % Solution Sig: One (1) Neb Inhalation Q6H PRN shortness of breath or wheezing. Disp:*40 Neb* Refills:*1* 23. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation Q6H PRN shortness of breath or wheezing. Disp:*40 Nebs* Refills:*1* 24. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS. Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: 1. Pneumonia. 2. Cough. 3. Shortness of breath. 4. Multiple myeloma. 5. Anemia (low red blood cell count). 6. Hypoxemia (low oxygen levels). 7. Hypotension (low blood pressure). 9. Hypertension (high blood pressure). 10. Acute kidney failure. 11. Abnormal liver function tests. 12. Congestive heart failure (CHF). 13. Gastroparesis (slowing of the intestines). 14. Diabetes. 15. Hypoglycemia (low blood sugar level). Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital for cough, shortness of breath, weakness, and pneumonia. You needed to go to the Intensive Care Unit because of low oxygen levels. However, you quickly improved with IV antibiotics. At home, you will need to complete a course of antibiotics and use oxygen while walking. While you were hospitalized, you needed a red blood cell transfusion for anemia (low red blood cell count). Your blood pressure medications were held because of low blood pressure, but prior to leaving the hospital furosemide (Lasix) and metoprolol were restarted at lower doses. Your kidney function temporarily worsened, but has now returned to baseline. Metoclopramide (Reglan) was started for gastroparesis (slowing of the intestines), which may cause your occasional nausea and vomiting. Lastly, your liver function tests were mildly abnormal while here and these should be followed as an outpatient. If they continue to be abnormal, an ultrasound of the liver may be helpful. Your insulin glargine (Lantus) was decreased because of low blood sugar levels (hypoglycemia). . NEW MEDICATIONS: 1. Cefpodoxime 2x a day. 2. Levofloxacin 2x a day. 3. Increase furosemide (Lasix) to previous dose 40mg daily. 4. Metoprolol dose has been decreased to 25mg 2x a day. This dose can be increased to his previous dose as determined by your other doctors in follow-up. 5. Hold lisinopril. This can be restarted in the future as determined by your other doctors in follow-up. 6. Metoclopramide (Reglan) with meals and at night. 7. Decrease insulin glargine (Lantus) to 8 units each night. 8. Albuterol and ipratropium nebulizers every 6 hours as needed for wheeze or shortness of breath. 9. Oxygen 2L while walking. 10. Currently therapy for your multiple myeloma is on hold. . PLEASE WEIGH YOURSELF DAILY AND CALL A PHYSICIAN IF YOU GAIN MORE THAN 5 LBS. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2171-10-8**] at 4:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . PLEASE CALL YOUR PRIMARY CARE PHYSICIAN TO ENSURE [**Name Initial (PRE) **] FOLLOW-UP APPOINTMENT NEXT WEEK.

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Discharge summary

report

Admission Date: [**2188-4-19**] Discharge Date: [**2188-4-25**] Date of Birth: [**2104-12-31**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Fever, altered mental status Major Surgical or Invasive Procedure: Central line placement PICC line placement Nasogastric intubation Intubation for respiratory compromise History of Present Illness: Ms. [**Known lastname 4027**] is a 83 yo F w/ h/o dementia (non-verbal at baseline), recurrent cholangitis s/p multiple ERCPs, AF, multiple decubitus ulcers, recurrent UTIs with chronic foley, who presents from NH for fever and AMS. Of note, prior to arrival in the ED, the pt's status was reversed from DNR/DNI to full code per ED staff signout. Per NH notes, this am she was found to have tremors (preventing accurate measurement of BP) 1gm daily presumably for UTI. Also gave novolog 12 u for unclear FS. At 1p she was given lunch and juice and tremors started again with temp 99.8 and pt was given acetaminophen. Pt was noted to be alert but confused. On arrival to the ED, the pt had pus coming from her foley catheter which was changed. She also had hypernatremia to 170 which corrected to 179 based on glucose in 600s. SBPs were initially in the 80s and she was thought to be dehydrated with likely urosepsis +/- sepsis from multiple decubs. She was given 4L NS within 1hr with Na to 167 after correction for Glu in 500s, 174. UOP was low at 150cc during first 6 hrs in ED, up to 500cc in total ED course. She was also given vancomycin 1gm, zosyn 4.5 gm and tylenol 1gm PR. . At about 10pm, ED team decided to send pt to Head CT for AMS, labile BPs (ranging from 80s-260s ? related to pt rigoring) and elevated INR which was negative for vein swelling or bleed. Pt was reported to have PERRLA. After this, her SBPs fell and her respiratory status decompensated and, at the request of her DTR who is HCP and was present, she was intubated, CVL was placed in groin (pt with poor IJs after 6 L and INR 7.9). She was started on levophed. Around this time, the pt was noted to have TWI in all anterior leads ? [**1-15**] levophed and volume status. CXR in ED confirmed placement of OGT and ETT. . On arrival to the ICU, the pt is intubated and sedated. Past Medical History: PMH last Updated [**2187-5-31**] - cholilithiais and choledocholithiasis with recurrent admissions for ascending cholangitis s/p [**Month/Day/Year **]/stents, perc chole. last [**Month/Day/Year **] [**4-20**] stent placement, removed on [**5-30**] with more stone extraction and another stent placed. - recurrent C.diff [**3-21**] and [**4-20**] - paroxysmal Afib -on coumadin - DVT on coumadin, dx [**3-21**], L common femoral, still present [**4-20**] - DM2 on insulin - HTN - Recurrent admission for dehydration/hypernatremia - Recurrent UTIs with MDR organisms (ecoli, pseudomonas-?colonizer)-on chronic foley - Dysphagia-dx [**4-20**], on pureed diet with nectar thicks, 1:1 supervision, aspiration precautions - Osteochondroma of L knee as a child - MVP - Alzheimer's disease - severe, baseline speaks to self, doesnt recognize people - Sacral decub (stage IV) and bilateral heel (stage III) pressure and deep tissue wounds - severe knee arthitis-bed bound - Anemia-?ACD, baseline H/H [**9-11**] - s/p right ORIF of hip fracture at age 75 Social History: Not currently smoking, alcohol or illicit drug use. Lives in a High Gate Manor [**Hospital1 1501**]. Fully dependent on all ADLs. Mostly bed bound due to severe knee arthritis and deformity. Family History: Daughter with arthritis, father died of hepatitis C from a blood transfusion. Mother died at age 86 of a myocardial infarction. Son with hypertension. Physical Exam: From [**2188-4-25**]: VS: 97.2, 103/50, 81, 16, 98% RA FS: 389, 284, 241, 245 GENERAL: Elderly woman in NAD. Makes eye contact and generally responds appropriately to questioning, but speech is frequently unintelligible HEENT: NG tube in place. No conjunctival icterus or injection. No JVD or LAD. MMM. EOMI CARDIAC: RRR. + soft ejection murmur over upper sternal borders LUNG: CTAB, but limited inspiratory effort ABDOMEN: Soft, NT, ND. NABSx4. +mildly TTP throughout. No rebound tenderness or guarding. No organomegaly or pulsatile masses. EXT: Thin. WWP. Soft 2 point UE restraints in place. Symmetric 2+ radial/DP/PT pulses bilaterally NEURO: Awake, makes eye contact and tracks across room. Responsive as above. Moving extremities freely, but diffusely weak. Reports normal sensation to light touch over upper and lower extremities. DERM: Dressings over known decubitus ulcers. Stage 4 on L hip, Stage 4 on sacrum, Unstageable on R hip, blisters with underlying tissue damage on heels b/l. Pertinent Results: [**2188-4-25**] 08:36AM BLOOD WBC-7.1 RBC-3.11* Hgb-7.6* Hct-23.7* MCV-76* MCH-24.5* MCHC-32.1 RDW-18.5* Plt Ct-211 [**2188-4-25**] 08:36AM BLOOD PT-23.1* PTT-37.9* INR(PT)-2.2* [**2188-4-25**] 08:36AM BLOOD Glucose-300* UreaN-16 Creat-0.7 Na-142 K-3.8 Cl-113* HCO3-21* AnGap-12 [**2188-4-25**] 08:36AM BLOOD Calcium-7.3* Phos-1.9* Mg-2.0 [**2188-4-23**] 05:17AM BLOOD calTIBC-124* Ferritn-104 TRF-95* MICROBIOLOGY: -[**4-19**] BCx: Negative -[**4-19**] UCx: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . STUDIES: -[**4-19**] ECG: Sinus tachycardia with premature atrial contractions. Diffuse ST-T wave changes in the anterolateral and inferior leads may be due to myocardial ischemia. Compared to the previous tracing of [**2187-6-11**] ST-T wave changes are new. Intervals Axes Rate PR QRS QT/QTc P QRS T 102 152 80 358/431 66 9 -145 . -[**4-19**] CT Head: 1. No acute intracranial pathology. 2. Chronic small vessel ischemic disease and cerebral atrophy. . -[**4-21**] CXR: Since a little over eight hours ago, patient has been extubated. A feeding tube remains in place with side port within the stomach. The cardiomediastinal silhouette and hilar contours are normal. There is persistent retrocardiac density, most likely atelectasis. The lungs are otherwise clear without pneumothorax. There is no evidence of pulmonary edema. A CBD stent is in stable position. Degenerative changes are noted in the right AC joint. . -[**4-23**] UE U/S: 1. No DVT. PICC line within a right brachial vein. The basilic and cephalic veins are not visualized. No deep venous thrombosis in the visualized veins. 2. The internal jugular vein is patent but is of a small caliber and may have previously been thrombosed. . Brief Hospital Course: Ms. [**Known lastname 4027**] is an 83 yo woman with a history of dementia (frequently confused but able to answer many simple questions), recurrent cholangitis s/p multiple ERCPs, afib on coumadin who presented from her nursing home for fever and AMS. . # Respiratory failure- The pt was intubated in the ED for concerns about ability to protect airway and to facilite CT scan/procedures. No overt respiratory failure, CXR without signs of pna or fluid overload. The patient weaned rapidly on the vent and extubated on HD2 after demonstrating a gag and what was postulated to be her baseline mental status given advanced dementia. . # [**Name (NI) 15305**] The pt reportedly had pus from foley on ED arrival and grossly positive U/A so a urinary source though to be most likely. The pt was noted to have approximately 9 decubitus ulcers with several stage IV ulcers that revealed [**Last Name (LF) 500**], [**First Name3 (LF) **] this was also considered a potential nidus of infection. The ulcers, though, did not appear to be infected. The pt was initially on Vanco/zosyn for broad coverage but this was changed to ceftriaxone following urine culture sensitivity results. The pt did not experience any fevers and her WBC remained stable. The pt will complete a 10-day course of ceftriaxone on [**2188-4-30**]. . # [**Name (NI) 300**] The pt's admission sodium was 170, likely due to hyperglycemic, hyperosmolar state causing dehydration. Corrected Na went from 179 on arrival to the ED to 174 within 1 hr after 4L NS. The pt's sodium was followed closely and corrected slowly. On discharge sodium was 142. # EKG changes- New TWI diffusely suggestive of global ischemia likely from systemic illness. The pt's troponin elevation and EKG changes were attributed to demand ischemia. . # AMS- On admission the pt had a CT head that did not show evidence of ICH. Her diminished mental status (per daughter she had recently been able to talk and eat) was attributed to metabolic encephalopathy in the setting of numerous electrolyte derangements. As her electrolytes normalized the pt became more interactive, and on discharge the pt was able to answer simple questions. # [**Name (NI) 20191**] The pt's presentation was consistent with a hyperosmolar hyperglycemic state likely triggered by UTI. The pt's glucose was managed with sliding scale and long-acting insulin. This will need to continue to be titrated at the [**Hospital 100**] Rehab. . # Elevated [**Name (NI) 10954**] The pt's INR was supratherapeutic on admission likely due to poor po intake including poor intake of vitamin K causing longer half life of coumadin. DIC labs did not reveal evidence of DIC physiology. On discharge the pt's INR was at a therapeutic level. . # [**Name (NI) 10271**] The pt wase noted to have a Cr of 2.1 on admission, which was up from a baseline of 0.7. This was likely prerenal kidney injury, given evidence of dehydration on initial labs. On discharge Cr was 0.7. . # Stage III-IV Decubitus ulcers- The pt was seen by wound care, general surgery and plastic surgery during this admission. Debridement of the left trochanteric wound was done by plastic surgery on [**2188-4-25**]. There was no evidence infection of the ulcers. . # FEN: Speech and swallow evaluation: RECOMMENDATIONS: 1. Suggest a PO diet of nectar thick liquids and pureed consistency solids. 2. Strict 1:1 supervision for aspiration precautions including: a) slow rate of intake b) liquids by straw 3. Meds crushed with puree. 4. Additional discussion with primary medical team, geriatrics, nutrition and pt's daughter should occur to determine if pt should continue to receive supplemental nutrition for now to improve healing and nutrition. Pt may benefit from a calorie count. 5. Q6 oral care. 6. We will f/u early next week to f/u if she has not yet been d/c'd. She will benefit from additional speech therapy services in rehab s/p d/c. # Prophylaxis: Coumadin. # Access: PICC line in R arm, please discontinue on [**4-30**] after IV antibiotics course is complete. # Communication: [**Name (NI) 111413**] HCP- [**Name (NI) **] [**Name (NI) 111409**] [**Telephone/Fax (1) 111414**] or [**Telephone/Fax (1) 111415**]. # Code: DNR, per HCP would want intubation temporarily, but not longterm. Medications on Admission: MEDS (at NH): coumadin 4mg daily aminoacids [**Hospital1 **] Novolog ISS lantus 15u QAM tylenol 650 [**Hospital1 **] docusate [**Hospital1 **] Milk of Magnesia daily PRN Bisacodyl PR daily PRN tylenol 650 Q 6 hrs PRN clotrimazole cream fleets enema PRN Discharge Medications: 1. Warfarin 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4 PM. 2. Insulin Lispro 100 unit/mL Cartridge [**Hospital1 **]: see below u Subcutaneous four times a day: See attached sliding scale. 3. Insulin Glargine 100 unit/mL Cartridge [**Hospital1 **]: Fifteen (15) u Subcutaneous at bedtime. 4. Silver Sulfadiazine 1 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Zinc Sulfate 220 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily). 6. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 7. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback [**Hospital1 **]: One (1) gm Intravenous Q24H (every 24 hours): Final day [**2188-4-30**] (ten day course). 8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Sepsis due to urinary tract infection Multiple stage III- IV decubitus ulcers severe malnutrition Dementia Diabetes mellitus type II, uncontrolled Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Ms. [**Known lastname 4027**], You were admitted to the hospital with a urinary tract infection and multiple skin ulcerations that were due to poor nutrition and immobility. You were treated for the former with antibiotics, and your fever and blood pressure abnormalities improved. We tried to improve your nutritional status by giving you tube feedings through a nasogastric tube. Your mental status improved as we improved your electrolytes. You are being discharged to the [**Hospital 100**] Rehab MACU for continued wound care, speech and swallow evaluation and, eventually, physical therapy. Followup Instructions: Department: ENDO SUITES When: THURSDAY [**2188-5-29**] at 10:00 AM Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2188-5-29**] at 10:00 AM With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12452, 12518

6932, 11209

345, 451

12709, 12709

4822, 6052

13468, 14057

3636, 3789

11513, 12429

12539, 12688

11235, 11490

12846, 13445

3804, 4803

276, 307

479, 2340

6061, 6909

12724, 12822

2362, 3410

3426, 3620

56,128

155,213

33875

Discharge summary

report

Admission Date: [**2139-12-22**] Discharge Date: [**2139-12-22**] Date of Birth: [**2094-6-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Zantac / Morphine / Tylenol / Naprosyn / ketorolac / Potassium Attending:[**First Name3 (LF) 594**] Chief Complaint: Hyperkalemia Major Surgical or Invasive Procedure: none History of Present Illness: This is a 45 year old female with a history of schizophrenia, end-stage renal disease on hemodialysis, and poorly-controlled HTN who presented to the ED with warmth and tenderness over the site of her right upper extremity AV fisula. Her last dialysis session was 3 days prior to presentation. 2 days prior to presentation, her fistula was felt to be clotted, and she received a fistulogram - its unclear if this reflected an underlying thrombus. Nevertheless, following the fisutologram, she developed worsening warmth and redness overlying the fistula site at her [**Hospital1 1501**], with temperature max of 101 and severe pain. She presented to the ED, where her pain was improved, although warmth was persistent. Her potassium was noted to be 6.6 on 2 separate lab draws. EKG reflected mild peaking of T waves. A known right bundle was again visualized. Calcium gluconate, insulin, albuterol, and kayexalate was administered. Renal and transplant surgery were consulted; transplant recommended against using the AV fistula - renal team felt dialysis was necessary given elevated potassium. She was transferred to the MICU for urgent dialysis. On arrival to the MICU, she was repeatedly apneic but arousable. Her vital signs were stable; repeat EKG did not show any peaked T waves. Review of systems positive for "whole body pain" but nothing else specific. She was oriented X 3. Past Medical History: 1. Hypotension (likely mineralocorticoid deficient, hypo-renin, hypo-aldosterone, not likely complete adrenal insufficiency vs. autonomic dysfunction on Florinef) 2. ESRD on HD M/W/F (RUE AV-fistula) 3. type 2 diabetes mellitus 4. coronary artery disease (inferior MI, cardiac cath [**2129**], EF 65%, inferior hypokinesis; MIBI [**11/2138**] no perfusion defects, no ischemic ST changes) 5. h/o LLE DVT (no longer on coumadin), popliteal DVT ([**7-/2136**]) s/p IVC filter placement 6. hypertension 7. GERD 8. h/o positive MRSA swab ([**2138**]) 9. hyperlipidemia 10. chronic abdominal pain (no etiology identified, extensive work-up including MRA abdomen, strongyloides serologies, RUQ U/S, multiple KUBs) 11. borderline personality disorder 12. drug-seeking behavior, ? suicidality 13. left eye prosthesis (followed by ophthalmology at [**Hospital1 2177**]) 14. Bilateral IJ and SC DVTs Social History: Born in [**Country 2045**] and moved from [**State 108**]; divorced, has two daughters. Worked as a CNA. Now resides in long term care facility. Denies any recent tobacco, EtOH or illicit drug use. Family History: Extensive family h/o DMII with significant morbidity/mortality from DM complications in her immediate family. Physical Exam: Admission exam VS: Temp 98, RR 12, 100% 2L, BP 120/70, HR 86 Gen: Morbidly obese, black female, repeated apneic episodes noted, drowsy, but otherwise orientable X 3 HEENT: Pupils mid-size, responsive to light, EOMI, oropharynx clear, malanpatti score II-III Cardiac: Nl s1/S2 RRR Pulm: Lungs clear bilaterally Abd: morbidly obese, soft, nontender, no palpable masses Ext: right upper extremity has AV fistula that is nontender and nonerythematous on exam Discharge exam VS: Temp 98.2, RR 16, 99% 2L, BP 118/65, HR 82 Gen: Morbidly obese, black female, more alert, A+O X 3 HEENT: Pupils mid-size, responsive to light, EOMI, oropharynx clear, malanpatti score II-III Cardiac: Nl s1/S2 RRR Pulm: Lungs clear bilaterally Abd: morbidly obese, soft, nontender, no palpable masses Ext: right upper extremity has AV fistula that is nontender and nonerythematous on exam Pertinent Results: Admission labs [**2139-12-22**] 06:30AM BLOOD WBC-5.1 RBC-3.91* Hgb-12.0 Hct-37.5 MCV-96 MCH-30.6 MCHC-32.0 RDW-17.1* Plt Ct-160 [**2139-12-22**] 06:30AM BLOOD Neuts-69.0 Lymphs-14.5* Monos-6.8 Eos-8.7* Baso-0.9 [**2139-12-22**] 12:51PM BLOOD PT-11.4 PTT-36.2 INR(PT)-1.1 [**2139-12-22**] 06:30AM BLOOD Glucose-177* UreaN-47* Creat-10.6*# Na-133 K-6.6* Cl-92* HCO3-28 AnGap-20 [**2139-12-22**] 06:30AM BLOOD ALT-20 AST-29 LD(LDH)-336* AlkPhos-199* TotBili-0.3 [**2139-12-22**] 06:30AM BLOOD Lipase-25 [**2139-12-22**] 06:30AM BLOOD cTropnT-0.06* [**2139-12-22**] 12:51PM BLOOD Calcium-9.3 Phos-4.0 Mg-4.6* Discharge labs [**2139-12-22**] 12:51PM BLOOD WBC-5.0 RBC-3.66* Hgb-11.1* Hct-35.1* MCV-96 MCH-30.4 MCHC-31.7 RDW-17.1* Plt Ct-152 [**2139-12-22**] 12:51PM BLOOD Glucose-146* UreaN-49* Creat-11.7*# Na-133 K-5.4* Cl-95* HCO3-29 AnGap-14 CXR [**2139-12-22**]: Previously visualized right basilar opacity has mostly resolved. The lungs are clear with no evidence of consolidation, effusion, or pneumothorax. Cardiomediastinal silhouette remains at borderline top. Vascular stents are in unchanged position. Osseous structures are grossly normal. IMPRESSION: No acute cardiopulmonary process Brief Hospital Course: This is a 45 year old female with a history of chronic kidney disease secondary to type II DM, a history of chronic abdominal pain, presenting with warmth/tenderness over fistula site and hyperkalemia. . # Hyperkalemia - Given persistent hyperkalemia, it was thought that she needed dialysis. In ED, she did receive calcium gluconate, kayexalate, insulin, and albuterol. Per review by transplant surgery of recent fistulogram, the AV graft is patent and suitable as access for HD. She was transferred to the MICU where she received dialysis through the AV fistula without complication, then was discharged from the MICU back to her [**Hospital1 1501**]. . # Chronic kidney disease - Secondary to type II DM - is on usual HD schedule of Tues/Thurs/Sat. Fistula functional. . # Pain: pt initially reported full body pain. Resolved upon admission to MICU. Unclear precipitant. Borderline personality disorder may explain in part. Her fistual dose not appear to be clotted off. She was started on tramadol PRN for symptomatic relief. . # Apenic episodes - Has known history of obstructive sleep apnea; mallampati score on exam is II-III; is ordered for CPAP at home. . # Type II DM - Continue home insulin regimen. . # CAD - Continued ASA, statin. Not on ACE-I, BBlocker secondary to autonomic dysfunction and hypotension. . # History of hypotension - Currently normotensive. Is usually on florinef and midodrine. . #. Borderline personality disorder/depression - Seroquel at night; not currently on SSRIS. Ativan q8PRN at home as well. Medications on Admission: Medications: (per last discharge summary) 1. [**Hospital1 **] 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO DIALYSIS DAYS (). 4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO HS (at bedtime). 7. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 8. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 9. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. insulin lispro 100 unit/mL Solution Sig: As Directed Subcutaneous With Meals. 12. Lantus 100 unit/mL Solution Sig: Fourteen (14) Units Subcutaneous at bedtime. 13. lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical QID (4 times a day). 14. midodrine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO QID (4 times a day). 16. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 17. gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 18. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 19. quetiapine 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 20. tizanidine 2 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 21. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 22. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for itching. 23. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 24. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 25. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 26. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 27. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 28. Dilaudid 2 mg Tablet Sig: 0.5 Tablet PO every 6-8 hours as needed for pain. 29. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO Dialysis days. 30. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 31. lactulose 10 gram/15 mL Solution Sig: Two (2) PO once a day as needed for constipation. 32. Maalox Advanced 200-200-20 mg/5 mL Suspension Sig: One (1) PO twice a day as needed for constipation. 33. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for Chest Pain. 34. erythromycin 5 mg/gram (0.5 %) Ointment Sig: 0.25 Inch Ophthalmic once a day: Please START Erythromycin eye drops on your glass eye. Continue use until you follow-up with your [**Hospital1 25745**]. Discharge Medications: 1. [**Hospital1 **] 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. lorazepam 1 mg Tablet Sig: One (1) Tablet PO PRN dialysis days. 4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO HS (at bedtime). 7. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 8. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q 8H (Every 8 Hours). 9. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO twice a day. 10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. insulin lispro 100 unit/mL Solution Sig: As directed . Subcutaneous with meals. 12. Lantus 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous at bedtime. 13. lidocaine 5 % Cream Sig: One (1) appl Topical four times a day. 14. midodrine 2.5 mg Tablet Sig: One (1) Tablet PO three times a day. 15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 16. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 17. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q HD. 18. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 19. quetiapine 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 20. tizanidine 2 mg Tablet Sig: 0.5 Tablet PO once a day. 21. latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic at bedtime. 22. hydroxyzine HCl 25 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for itching. 23. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety. 24. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 25. lactulose 10 gram Packet Sig: Two (2) PO once a day as needed for constipation. 26. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual Q5 minute PRN chest pain, up to 3 doses max. 27. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **] Discharge Diagnosis: Renal failure, hyperkalemia 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 78242**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for pain and a high potassium level. It was thought that your dialysis fistula was clotted off, but it was evaluated by our doctors and it was open. Your pain was treated with medications. You received dialysis for your high potassium levels. The following changes were made to your medications: ** START tramadol, take up to every 6 hours only as needed for pain Followup Instructions: Department: [**Hospital3 1935**] CENTER When: FRIDAY [**2140-1-22**] at 3:00 PM With: EYE IMAGING [**Telephone/Fax (1) 253**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 1935**] CENTER When: FRIDAY [**2140-1-22**] at 3:20 PM With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: TRANSPLANT CENTER When: TUESDAY [**2140-2-9**] at 8:40 AM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "403.91", "V12.51", "585.6", "311", "278.01", "412", "301.83", "530.81", "276.7", "583.81", "414.01", "250.40", "272.4" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

12116, 12215

5165, 6705

350, 357

12287, 12287

3942, 5142

12974, 13861

2931, 3043

9820, 12093

12236, 12266

6731, 9797

12470, 12951

3058, 3923

298, 312

385, 1783

12302, 12446

1805, 2699

2715, 2915

25,800

196,594

21733

Discharge summary

report

Admission Date: [**2130-12-12**] Discharge Date: [**2130-12-21**] Date of Birth: [**2052-9-26**] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Penicillins / Iodine / Sulfa (Sulfonamides) / Benadryl Attending:[**First Name3 (LF) 2901**] Chief Complaint: R femoral hematoma Major Surgical or Invasive Procedure: Stent revascularization of right renal artery. History of Present Illness: Ms. [**Known lastname **] is a 78 yo female s/p in-stent restenosis of R renal artery on [**12-12**]. Tolerated procedure and there were no immediate complications. The same evening she was triggered for hypotension with SBP~90 and responded to IV fluids. Baseline SBP 130's. Her Hct post procedure was 34 and slowly dropped to 26.1 by the next afternoon. CT scan was done and showed a large hematoma in the R thigh, but there was no evidence of an RP bleed. Between 7 and 8:30pm this evening there was a signicant increase in pain as well as induration of her thigh. There was some concern that her blood pressures had also decreased and she was hemodynamically unstable. She was mentating well during this time. Pt was seen by [**Month/Day (4) 1106**] surgery. She was then immediately transferred to the CCU for closer monitoring. Past Medical History: 1)CAD s/p OM stenting: Her first OM PCI was on [**2128-1-14**] followed by in-stent restenosis and Cypher stent to OM (2.5x18mm and 3x18mm) on [**2128-10-22**]. She again had in-stent restenosis and had repeat DES placed in OM in [**2129-5-15**]. For surveillance, she underwent pharmacologic nuclear study on [**2130-10-11**] that demonstrated posterolateral ischemia with drop in SBP from 170 to 130. 2)RAS s/p right renal stent, s/p [**2129**] 3)Hypertension 4)Hyperlipidemia 5)Type 2 Diabetes 6)s/p left partial foot amputation 7)s/p right BKA 8)Asthma 9)Sleep apnea Social History: Lives with husband, denies any alcohol or tobacco use Family History: HTN, DM, cardiac disease. Physical Exam: vitals T 96.0 Tm 97.5 AR 60 BP 92/20 RR 20 O2 sat 99% RA Gen: NAD HEENT: PERRLA, MMM Neck: no JVD Heart: nl s1/s2, no s3/s4, no m,r,g Lungs: CTAB, poor air intake Abdomen: obese, soft, NT/ND, +BS Extremities: R groin-increased induration to the level of the mid-thigh, no bruising or ecchymosis. Pertinent Results: Laboratory results: [**2130-12-12**] 03:46PM BLOOD Hct-34.0* [**2130-12-13**] 07:25AM BLOOD Hct-29.0* Plt Ct-301 [**2130-12-13**] 10:20AM BLOOD Hct-28.6* [**2130-12-13**] 04:20PM BLOOD Hct-26.1* [**2130-12-13**] 08:57PM BLOOD WBC-18.6*# RBC-2.83*# Hgb-8.5* Hct-23.8* MCV-84 MCH-29.9 MCHC-35.6* RDW-14.6 Plt Ct-254 [**2130-12-13**] WBC 18.6 [**2130-12-13**] BUN 45 Cr 1.4 [**2130-12-14**] 01:19AM BLOOD WBC-16.1* RBC-3.31* Hgb-10.1* Hct-27.9* MCV-84 MCH-30.4 MCHC-36.1* RDW-14.6 Plt Ct-200 [**2130-12-14**] 08:00AM BLOOD WBC-15.6* RBC-3.36* Hgb-9.9* Hct-28.2* MCV-84 MCH-29.4 MCHC-34.9 RDW-14.7 Plt Ct-205 [**2130-12-14**] 08:30PM BLOOD Hct-27.7* Plt Ct-158 [**2130-12-15**] 12:10AM BLOOD Hct-26.0* [**2130-12-15**] 10:41AM BLOOD WBC-11.3* RBC-3.54* Hgb-10.5* Hct-30.3* MCV-86 MCH-29.7 MCHC-34.7 RDW-15.0 Plt Ct-167 [**2130-12-15**] 10:25PM BLOOD Hct-31.4* [**2130-12-17**] 08:15AM BLOOD WBC-10.3 RBC-3.74* Hgb-11.4* Hct-31.9* MCV-85 MCH-30.4 MCHC-35.6* RDW-14.9 Plt Ct-226 [**2130-12-20**] 03:52AM BLOOD WBC-9.3 RBC-3.57* Hgb-10.9* Hct-31.1* MCV-87 MCH-30.5 MCHC-35.1* RDW-14.8 Plt Ct-313 [**2130-12-21**] 06:00AM BLOOD WBC-8.2 RBC-3.44* Hgb-10.5* Hct-30.4* MCV-88 MCH-30.7 MCHC-34.7 RDW-14.9 Plt Ct-300 [**2130-12-21**] Glu 97 BUN 13 Cr 0.6 Na 141 K 4.0 Cl 102 Relevant Imaging: 1)Cardiac catheterization ([**12-12**]):1. Selective coronary angiography of this right dominant system revealed no angiographically apparent coronary artery disease. The LMCA, LAD, and RCA were all free of disease. The LCX had 20% proximal stenosis prior to the stent. 2. Limited hemodynamics demonstrated severely elevated systemic pressures (SBP 210). 3. Selective renal angiography demonstrated 70% instent restenosis of right renal artery with gradient of 20-30mmHg with pressure wire. 2)CT Abdomen/pelvis ([**12-13**]):There is a hematoma within the right groin and extending along the medial aspect of the right thigh measuring up to 7.9 x 4.6 cm, without evidence of intrapelvic or retroperitoneal extension. 3)CT Head ([**12-13**]):No intracranial hemorrhage or mass effect is identified. 4) R Femoral U/S ([**12-14**]): Complex right common femoral artery pseudoaneurysm consisting of multiple lobes in a wide neck. This was unresponsive to thrombin injection. The wide next and lack of response thrombin suggest a wide [**Month/Day (4) 1106**] defect. 5) CT Abdomen/Pelvis w/o contrast ([**12-15**]): The visualized lung bases and lower thorax are unremarkable. Note is again made of coronary artery calcifications. The liver, spleen, pancreas, adrenal glands, and kidneys are within normal limits. Again seen is a right renal artery stent extending from the ostium of the right kidney into the aorta. There is moderate atherosclerotic calcification throughout the abdominal aorta, without evidence of dilatation. The stomach and intra-abdominal loops of bowel are normal in appearance. Contrast is again seen layering within the gallbladder, consistent with recent administration of intravenous contrast. There is no free air, free fluid, or abnormal lymphadenopathy seen within the abdomen. A Foley catheter is seen within a decompressed bladder. The rectum, sigmoid colon, uterus, and adnexa are normal in appearance. Small focus of calcification in the posterior right gluteal soft tissues is unchanged in appearance from prior study. Again seen in the right groin and extending into the mid right thigh is a hematoma, currently measuring 9.9 x 5.0 cm, increased in size from previously measured 7.9 x 4.6 cm. There is no evidence of intrapelvic or retroperitoneal extension. There remains no evidence of pelvic sidewall or retroperitoneal hematoma. 6)R Femoral U/S ([**12-18**]):Unchanged appearance of complex pseudoaneurysm with overall appearance raising the question of a large underlying vasculature defect as the cause. Brief Hospital Course: Ms. [**Known lastname **] is a 78 yo female s/p R renal artery in-stent restenosis presenting with a rapidly enlarging R groin hematoma, now hemodynamically stable. 1)R groin hematoma: Patient was transferred to the CCU for a rapidly enlarging R femoral hematoma (s/p RA stent) and a dropping Hct. Her Hct decreased from 34 on admission to 23.8 when she came to the CCU. She was transfused a total of 8 units pRBCs during her stay in the ICU and her Hct stabilized at 31. Initally there was increase in the size of the hematoma but stabilized within 1 day of her transfer to the CCU. She otherwise remains hemodynamically stable. Repeat U/S was done which showed a pseudoaneurysm 0.5cm in diameter. Thrombin injection was attempted twice but failed. [**Known lastname **] surgery felt that this was not operable at this time but recommended repeat u/s in 1 week. Appointment has been scheduled. 2)s/p in-stent RA restenosis: Patient was initally admitted on [**12-11**] for renal artery stent placement. Cardiac catheterization showed significant right renal artery restenosis of 70% which was restented. She was started on Plavix 75mg daily, which she will likely need to take lifelong given history of restenosis. On discharge she was placed on Lisinopril 2.5mg daily. 3)CAD: Patient underwent cardiac catheterization. Coronary arteries were normal and OM was patent. No further intervention was done. Medical management was optimized with [**Last Name (LF) **], [**First Name3 (LF) **], Toprol XL, and Plavix. Small dose Ace-inhibitor was started prior to discharge. She remained in sinus rhythm, no evidence of fluid overload. Of note, pt complained of right chest pain discomfort. No EKG changes and in light of nl coronaries on cardiac cath, likely muskuloskeletal. 4)Diabetes: No documentation of oral regimen at home. She was started on an insulin sliding scale with fasting sugars checked QID. 5)Back Pain: Patient has long history of back pain which responds well to Morphine. 6)UTI: Patient complained of dysuria and increased frequency. Her UA was positive. She was started on a 7 day course of Nitrofurantoin 50mg QD to end on [**12-25**] 7)Fungal infection: Predominantly in right groin. Started on Miconazole powder [**Hospital1 **]. Discharge Disposition: Extended Care Facility: [**Location (un) **] Discharge Diagnosis: 1. Coronary arteries are normal. 2. Patent OM stent. 3. Instent restenosis of right renal artery. 4. Successful revascularization of the right renal artery. 5. Complex pseudoaneurysm of proximal right lower limb Discharge Condition: Stable Discharge Instructions: 1)Please take all medications as listed in the discharge instructions 2)Please schedule follow-up with your primary care physician 3)You are scheduled for a repeat ultrasound to monitor the status of your pseudoaneurysm. Please refer to discharge instructions for date and time. 4)If you experience any chest pain, SOB, right thigh pain, back pain, or any other concerning symptoms please return to the emergency department. Followup Instructions: 1)Provider: [**Name10 (NameIs) 6811**] STONE, RVT Date/Time:[**2130-12-27**] 11:45 2)Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2130-12-27**] 12:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "427.89", "401.9", "996.74", "272.4", "V49.73", "E879.0", "V45.82", "110.3", "599.0", "780.57", "440.1", "V49.75", "250.00", "584.9", "998.12", "496", "442.3" ]

icd9cm

[ [ [] ] ]

[ "37.22", "39.50", "99.29", "88.56", "38.93", "00.40", "39.90", "00.45", "99.04", "99.07", "88.45" ]

icd9pcs

[ [ [] ] ]

8438, 8485

6158, 8415

352, 401

8741, 8750

2305, 3569

9227, 9620

1945, 1973

8506, 8720

8774, 9203

1988, 2286

294, 314

3587, 6135

429, 1264

1286, 1858

1874, 1929

4,336

139,963

44581

Discharge summary

report

Admission Date: [**2143-11-24**] Discharge Date: [**2143-12-3**] Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 618**] Chief Complaint: Found down Major Surgical or Invasive Procedure: Intubation. History of Present Illness: The pt is a [**Age over 90 **] year-old woman with a history of DM2, diastolic dysfunction, colon cancer s/p resection who was brought to the ED by EMS after her daughter found her slumped to the left on the toilet. She was last seen well at 10:30pm on the evening prior to presentation. She lives with her daughter and was at her baseline when her daughter heard some moaning. She first thought it to be the television but then went to check on her mother. She found her on the toilet, slumped to the left. EMS was called immendiately. There was no antecedent report of trauma. On arrival to the ED, she was afebrile but hypertensive to 197/79. Head CT showed a large intraventricular hemorrhage, originating from the right thalamus and she received labetalol gtt and was intubated for airway protection, after also receiving propofol gtt and dilantin 1g IV. She was admitted to the NeuroICU. Past Medical History: -DM2 with A1C 7.2 [**3-18**] -restless leg syndrome -colon cancer s/p partial colectomy '[**28**], recurrent adenoma -DJD -chronic LE edema -uterine prolapse, s/p bladder suspension -TAH '[**35**] -s/p L hip ORIF -diastolic dysfunction Social History: She is homebound, progressively less able to care for self over past 6 months per PCP and daughter, lives with her daughter and in [**Name (NI) 3146**]. Family History: Not elicited Physical Exam: Tc 100.0/Tm 101.1 79-115 109-132/32-61 16-24 99% intubated Gen Lying in bed, comfortable CV rrr Pulm ctab Abd soft nt/nd +bs Ext mild extremity edema NEURO MS Opens eyes to voice. Follows simple commands to show 2 fingers on R, squeeze fingers on R, wiggle both toes, opens/closes eyes to command. CN: Pupils 2mm on L, R surgical. Blinks to threat b/l and EOM full no nystagmus. b/l corneal response. No facial asymmetry. Motor: Increased tone in LE's bilaterally. Normal tone in UE's. Normal bulk. R biceps/triceps at least [**4-14**], grip [**6-14**]. L has trace grip. IPs at least [**4-14**] on R and [**3-17**] on L. Sensory: Grimaces to pain throughout. Coordination: unable to assess Gait: deferred Reflexes: toes up b/l, 2+ throughout with 1+ at achilles Pertinent Results: [**2143-11-24**] 06:25AM BLOOD WBC-7.6# RBC-3.67*# Hgb-11.8*# Hct-33.0*# MCV-90# MCH-32.1*# MCHC-35.7*# RDW-14.8 Plt Ct-176 [**2143-11-24**] 06:25AM BLOOD Neuts-72.3* Lymphs-21.0 Monos-4.7 Eos-1.8 Baso-0.2 [**2143-11-24**] 08:12AM BLOOD PT-13.3* PTT-23.8 INR(PT)-1.2* [**2143-11-24**] 06:25AM BLOOD Glucose-250* UreaN-20 Creat-0.9 Na-138 K-4.7 Cl-102 HCO3-24 AnGap-17 [**2143-11-24**] 06:25AM BLOOD CK(CPK)-65 [**2143-11-25**] 03:15AM BLOOD ALT-19 AST-22 LD(LDH)-169 CK(CPK)-128 AlkPhos-88 TotBili-0.7 [**2143-11-24**] 06:25AM BLOOD cTropnT-<0.01 [**2143-11-25**] 03:15AM BLOOD CK-MB-3 cTropnT-<0.01 [**2143-11-24**] 06:25AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.9 [**2143-11-25**] 03:15AM BLOOD calTIBC-295 VitB12-215* Ferritn-28 TRF-227 [**2143-11-25**] 03:15AM BLOOD %HbA1c-6.8* [Hgb]-DONE [A1c]-DONE [**2143-11-25**] 03:15AM BLOOD Triglyc-102 HDL-47 CHOL/HD-2.2 LDLcalc-38 [**2143-11-25**] 03:15AM BLOOD TSH-1.4 CT head on admission: There is a 2.8 x 1.5 cm area of intraparenchymal hemorrhage in the region of the posterior limb of the right internal capsule and right thalamus, with extension into the lateral, third, and fourth ventricles. Given the location of intraparenchymal hemorrhage, this is of likely hypertensive etiology. Brief Hospital Course: The patient was intubated for airway protection in the ED and admitted to the NeuroICU. She was evaluated by neurosurgery, who deemed her not to be a good surgical candidate and the family declined an EVD after extensive discussion. She was found to have a UTI and was treated with ciprofloxacin, with subsequent improvement, but she intermittently spiked fevers and was found to have MRSA in her sputum and was thus placed on vancomycin. Neurologically, she remained arousable by voice, opening her eyes and following commands on her left side; she was able to lift the left arm and move both legs. There was no response on her right arm to noxious stimuli. CT showed an intracerebral hemorrhage, starting just above the right thalamus and extending into both lateral ventricles, the third ventricle, and the fourth, spreading down the cerebral aqueduct, with some blood exiting the foramina of Magendie and Luschka to add a small subarachnoid component. The patient's daughter and son serve as the health care proxys. Discussions regarding trach/PEG and nursing home lead to the conclusion that the family did not want to pursue either of those options, since they were deemed inconsistent with the patient's wishes. She was extubated and made CMO. She passed away at 0318 on [**2143-12-3**]. Post-mortem examination was declined by family. Medications on Admission: Lasix 10-20mg daily Glyburide 1.25mg daily ASA 81 Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Intracranial hemorrhage Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

[ "250.00", "401.9", "428.0", "V66.7", "431", "V10.05", "276.1", "715.90", "V12.72", "599.0", "280.9", "281.1" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

5170, 5179

3693, 5039

231, 244

5247, 5258

2434, 3353

5310, 5408

1615, 1629

5140, 5147

5200, 5226

5065, 5117

5282, 5287

1644, 2415

181, 193

272, 1168

3367, 3670

1190, 1428

1444, 1599

12,708

124,901

51362

Discharge summary

report

Admission Date: [**2197-5-22**] Discharge Date: [**2197-5-26**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old Russian speaking female with past medical history of type 2 diabetes, hypertension, hyperlipidemia, and peripheral vascular disease who presents to [**Hospital1 190**] with change in mental status. Her daughter assisted in taking the history, but the patient does not speak English. On the day of admission, the patient was found to be confused by her home health aide with a low blood sugar. Her primary care physician was called. Her blood sugar was corrected, but the patient's mental status did not improved. She later fell prompting a visit to the [**Hospital1 1444**] Emergency Department. In the Emergency Department, the patient reported chest pain that began the evening prior to admission. She had told a friend about this chest pain, but had not told her daughter or her primary care physician regarding chest pain or the visiting nurse. In the Emergency Department, she had electrocardiogram changes consistent with ST elevations in the anterior leads. In the Emergency Department, she also received aspirin, sublingual nitroglycerin, and 5 mg of IV Lopressor. Integrilin and Heparin drips were ordered, but she was brought to the catheterization laboratory before they were begun. The patient's electrocardiogram showed sinus rhythm at 71 beats per minute, left ventricular hypertrophy, and [**Last Name (LF) **], [**First Name3 (LF) **] elevations in V1 through V4 with biphasic T-wave inversions in V2 through V3, poor R-wave progression. Coronary angiography revealed severe one vessel disease. She had a mid left anterior descending artery total occlusion with distal collaterals. She had PTCA and stented x2, left circumflex was diffusely and moderately diseased throughout its course with a 60% lesion and a large OM-1 branch. Right coronary artery had diffuse mild disease. Left ventriculography was not performed. Hemodynamics showed mildly elevated right sided filling pressures, P.A. mean of 9 mm, reduced cardiac output, cardiac index of 1.8, and a low wedge of 15. PAST MEDICAL HISTORY: 1. Diabetes type 2. 2. Hypothyroidism. 3. Peripheral vascular disease. 4. Hypercholesterolemia. PAST SURGICAL HISTORY: 1. Status post cholecystectomy. 2. Status post appendectomy. 3. Status post spinal decompression. 4. History intracranial surgery for hemangioma in [**2195-1-9**]. ALLERGIES: The patient has no known drug allergies. MEDICATIONS AS AN OUTPATIENT: 1. Lisinopril. 2. Lorazepam. 3. Nitroglycerin prn. 4. Synthroid. 5. Cardizem. 6. Glipizide. 7. Effexor. 8. Serax. 9. Lipitor. SOCIAL HISTORY: She lives alone. Her daughter's name is [**Name (NI) 106511**]. She was contact[**Name (NI) **] many times throughout the hospitalization regarding treatment and disposition. [**Name (NI) 106511**]'s home number [**Telephone/Fax (1) 106512**], work number [**Telephone/Fax (1) 106513**]. EXAMINATION AT PRESENTATION: Blood pressure 140/60, heart rate 70-80, temperature 96 degrees. Breathing 18 per minute, and 99% on 3 liters, and then 99% on room air. She initially came to the CCU status post catheterization on an Integrilin drip and nitrodrip. Both were titrated off. The Integrilin drip was kept for 18 hours status post catheterization. The patient was not in acute distress. Lying in bed, pale, and slightly confused. Extraocular movements are intact. Pupils are equal, round, and reactive to light and accommodation. Anicteric. Pale conjunctivae. Dry mucous membranes. No jugular venous distention. Clear to auscultation anteriorly and laterally. S1, S2 regular, rate, and rhythm with a 2/6 systolic ejection murmur loudest at the right upper sternal border to the ears of the author. She was mildly obese and normoactive bowel sounds, no rebound tenderness. Soft abdomen. She had no clubbing, cyanosis, or edema. Her dorsalis pedis and posterior tibial pulses were [**3-12**] palpable. Cranial nerves II through XII are intact. She had good upper and lower extremity strength. She had a groin pressure dressing in place. When this was removed following catheterization, noted to have ecchymosis and stable hematoma and a bruit. The patient had an echocardiogram on the [**2197-5-23**]. Patient had an ejection fraction estimated to be 40%, left atrium is mildly dilated. Right atrium is mildly dilated, mild symmetric left ventricular hypertrophy with normal cavity size, mild regional left ventricular systolic dysfunction, no resting left ventricular outflow tract obstruction. Resting regional left ventricular motion abnormalities were seen. Mid anteroseptal hypokinetic anterior apex, hypokinetic septal apex, akinetic inferior apex, akinetic apex, dyskinetic RV chamber size and free wall motion were normal, [**2-9**]+ aortic regurgitation, [**2-9**]+ mitral regurgitation, 1+ tricuspid regurgitation, no pericardial effusion was noted. The patient had an ultrasound of the right femoral region to evaluate her bruit. Duplex and carotid Doppler of the right inguinal area demonstrated no evidence of pseudoaneurysm or A-V fistula. There is moderate calcification of underlying vascular indicating peripheral vascular disease. LABORATORY DATA ON ADMISSION: Hematocrit 37.0, hemoglobin 12.2, white count 12.1, platelets 337. Creatinine 1.2, BUN 24, chloride 102, bicarb 22. Sodium 136, potassium 5.6, CK 1654, MB 293, MDI 17.7, troponin greater than 25, the 1654 was the peak CK, #2 was 1182. So the patient is an 81-year-old Russian speaking female who presents to the [**Hospital1 69**] with anterior myocardial infarction status post PTCA and stenting x2 of her left anterior descending artery. HOSPITAL COURSE: Coronary artery disease: She had the anterior myocardial infarction, cardiac catheterization, and intervention. She will receive Plavix x75 mg. She was loaded with 300 mg, but she had 75 mg x9 months, aspirin 325 mg q day. She was continued on Integrilin 18 hours status post catheterization as per protocol, and was stopped. After that, she was initially started on low dose of 12.5 mg of Captopril. She had been on lisinopril as an outpatient. She will be discharged on 40 of lisinopril for cardioprotection given an ejection fraction of 40% as well as for blood pressure control. She is on Lipitor 20 q day, and will be discharged on a beta blocker and Toprol XL 100 q day. The patient was chest pain free through the rest of her stay status post intervention. Her peak CK as stated before was 1600. She will follow up with her cardiologist, Dr. [**Last Name (STitle) 3357**], who is a Russian speaking cardiologist. The importance of taking Plavix and aspirin was reviewed by the house office with the patient and the patient's daughter, and the importance and the consequences including death of not taking the Plavix were reviewed with the patient and the patient's daughter. Rhythm: Patient was placed on Telemetry. Had no real events except for occasional APCs. She had an echocardiogram as above for risk stratification, and ejection fraction of 40%. Thankfully, patient is less likely for risk of sudden death. Should be on the beta blocker, however, to reduce this theoretic possibility. For pump, as stated above, the systolic function was 40%, which given the anterior nature of her myocardial infarction and the large size of the CKs, gives hope that the patient may recover function from this point, and was noted to have apical akinesis. However, given the patient was a considerable fall risk following the day of presentation, actually had a hematocrit drop status post catheterization. It was felt the patient cost-benefit ratio especially given the high ejection fraction, the patient favored towards not anticoagulating the patient for the apical akinesis. Renal: Patient is diabetic. She has received 280 cc dye load. She received IV fluid as well as blood status post catheterization. Her creatinine was 1.2 on admission, it was 1.3 on the day of discharge, and very stable. This is four days out after catheterization. Dye induced nephropathy would have been visualized by this point, and did not present itself. ID: There were no issues. Endocrine: The patient was continued on her Synthroid. Was initially placed on insulin sliding scale until she had sufficient po intake to tolerate oral hypoglycemics and then was placed on her Glipizide. Heme: The patient's hematocrit was 37 prior to catheterization, and it was 26 postprocedure. She received 1 unit of packed red blood cells and had a discharge hematocrit of 35.8. Psych: The patient was continued on her Effexor. At times was slightly disoriented to the situation and her surroundings, possibly an element of sundowning while in the Cardiac Care Unit as well as language barrier. She seemed to improve and do better on the floor. Prophylaxis: The patient received proton-pump inhibitor for GI prophylaxis pneumoboots while she was not ambulating. The patient was seen by Physical Therapy and was ambulating with a rolling walker. Physical Therapy thought the patient would benefit from [**Hospital 3058**] rehabilitation to get up to her baseline strength level before returning home. The topic of long-term disposition was approached with the daughter and again reemphasized the importance of the patient's need to comply with medications especially her aspirin and Plavix for the stents that were placed during the hospitalization. DISCHARGE DIAGNOSES: 1. Anterior myocardial infarction status post cardiac catheterization and left anterior descending artery stent x2. 2. Hypercholesterolemia. 3. Hypertension. 4. Peripheral vascular disease. 5. Diabetes type 2. DISCHARGE CONDITION: Good. DISCHARGE PROCEDURE: Cardiac catheterization, status post left anterior descending artery stent. DISCHARGE MEDICATIONS: 1. Plavix 75 mg po q day x9 months. 2. Aspirin 325 mg po q day. 3. Glipizide 5 mg q day. 4. Lipitor 20 mg po q day. 5. Toprol XL 100 mg po q day. 6. Effexor 75 mg po q day. 7. Levothyroxine sodium 25 mcg po q day. 8. Lisinopril 40 mg po q day. 9. Hydrochlorothiazide 12.5 mg po q day. 10. Lactulose 3 mg prn constipation. FOLLOW-UP INSTRUCTIONS: The patient was given a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3357**] in [**Location (un) 583**] on [**6-19**] at 2 pm, and instructed to followup this appointment and experienced the importance regarding medication compliance and proper followup. [**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**] Dictated By:[**Last Name (NamePattern1) 1659**] MEDQUIST36 D: [**2197-5-26**] 11:10 T: [**2197-5-26**] 12:47 JOB#: [**Job Number 106514**]

[ "244.9", "285.9", "414.01", "272.4", "443.9", "410.11", "250.00", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9767, 9873

9534, 9745

9896, 10219

5753, 9513

2291, 2667

113, 2149

5291, 5735

10244, 10828

2171, 2268

2684, 5276

24,846

191,086

13182

Discharge summary

report

Admission Date: [**2125-5-15**] Discharge Date: [**2125-6-22**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: 84 year old male with multiple medical problems including diabetes, CAD, CHF, CRI who is admitted with cholangitis. Major Surgical or Invasive Procedure: [**5-16**] [**Month/Year (2) **] and stent placement [**5-16**] percutaneous cholecystostomy tube placement [**5-28**] Tracheostomy History of Present Illness: Patient came to the ER with three days of right upper quadrant pain. In ER was found to be afebrile but a CT of the abdomen was suggestive of gall bladder pathology. He was admitted and started on broad spectrum antibiotics with Vancomycin/levo/flagyl administered in the ER. He had a percutaneous cholecystostomy tube placed on [**5-16**] after elective intubation for respiratory distress. He underwent an [**Month/Year (2) **] which revealed a compacted ampullary stone, likely cholangitis and possible CBD stone; a biliary stent was placed. Past Medical History: 1. CAD, cath 5 years ago at NEBH (cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) 2. CHF, TTE [**3-5**] w/depressed EF 3. Hypertension, per daughter pt's bp usually 90s-100s on meds 4. Severe Lumbar Spinal stenosis, mild cervical stenosis 5. Sleep apnea, on 2L home O2 at night 6. Afib, s/p DCCV which failed, now rate controlled 7. Arthritis 8. Gout 9. COPD 10. NIDDM 11. E-coli-Sepsis (admission [**2122-12-23**] - [**2123-1-1**]) 12. BPH 13. Parkinson's disease Social History: Patient uses a cane for assistance at baseline. He lives with his daughter [**Name (NI) 13118**]. Formerly worked at Sears. Widowed. No tobacco or EtOH use. Family History: Notable for CAD, HTN, and stroke. Physical Exam: T: 100.4 P: 64 R: 16-20 BP: 96/62 General: resp distress, acute pain, alert and oriented times three HEENT: Mucous membranes moist Neck: Supple without LAD Cardiovascular: Irregular S1 S2 Respiratory: Diffuse wheezes throughout; decreased breath sounds at right base Gastrointestinal: Soft, NT, ND bowel sounds normal and active Musculoskeletal: Knees swollen and warm bilaterally with effusion L>R,left elbow warm and swollen Skin: Multiple eccymoses Pertinent Results: [**2125-5-15**] Abdominal CT - Thickened gallbladder wall with stranding, without evidence of gallstones, however, concerning for acute cholecystitis. This was posted to the ED dashboard on the afternoon of the study. [**2125-5-15**] Abdominal Ultrasound - There is a small area of increased echogenicity in the gallbladder, which is not shadowing and may represent sludge, polyp, or much less likely gallstone. The gallbladder wall is 4 mm but not striated. There was no tenderness when scanning over the gallbladder. The common bile duct was normal measuring 3.2 mm. There is normal hepatopetal flow in the portal vein. [**2125-5-15**] Labs - [**2125-5-15**] 10:06PM GLUCOSE-132* UREA N-19 CREAT-1.4* SODIUM-134 POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-25 ANION GAP-16 [**2125-5-15**] 10:06PM ALT(SGPT)-204* AST(SGOT)-236* LD(LDH)-360* ALK PHOS-267* AMYLASE-148* TOT BILI-3.4* [**2125-5-15**] 10:06PM WBC-15.0* RBC-3.75* HGB-11.9* HCT-36.3* MCV-97 MCH-31.6 MCHC-32.6 RDW-16.3* [**2125-5-16**] - Successful ultrasound-guided placement of a percutaneous cholecystostomy tube. [**2125-5-22**] Central Line placement - In comparison with the study of [**5-20**], there has been placement of a left subclavian line that extends to the mid portion of the SVC. No evidence of pneumothorax. There appears to be some increasing prominence of the pulmonary markings, suggesting elevated pulmonary venous pressure. [**2125-5-29**] Hemodialysis Catheter placed. [**2125-5-29**] 02:11AM BLOOD Glucose-127* UreaN-85* Creat-2.5* Na-133 K-4.2 Cl-99 HCO3-21* AnGap-17 [**2125-5-28**] 01:30AM BLOOD WBC-35.5* RBC-3.31* Hgb-10.0* Hct-30.7* MCV-93 MCH-30.2 MCHC-32.5 RDW-16.7* Plt Ct-504* [**2125-6-19**] 1. No evidence of colonic wall thickening or megacolon to suggest C. difficile. 2. Bilateral pleural effusions with some adjacent consolidation and atelectasis, right greater than left. 3. Anasarca. 4. Interval removal of cholecystostomy tube. [**2125-6-21**] 05:14AM BLOOD WBC-6.6 RBC-2.93* Hgb-9.0* Hct-27.3* MCV-93 MCH-30.8 MCHC-33.0 RDW-17.5* Plt Ct-373 [**2125-6-21**] 10:18AM BLOOD PTT-61.9* [**2125-6-21**] 05:14AM BLOOD PT-15.5* PTT-52.9* INR(PT)-1.4* [**2125-6-21**] 05:14AM BLOOD Glucose-136* UreaN-56* Creat-1.3* Na-143 K-3.7 Cl-107 HCO3-26 AnGap-14 [**2125-6-19**] 09:07AM BLOOD ALT-10 AST-26 AlkPhos-71 Amylase-35 TotBili-0.2 [**2125-6-19**] 09:07AM BLOOD Lipase-12 Microbiology: 5/16-8:C diff neg x 3 [**6-11**] BAL: staph aureus, coag +; yeast ([**6-3**]) sputum cx: coag MRSA UCx >100k E. Coli ([**5-23**]) BAL: Coag + staph Pleural fluid: MRSA BCx: neg UCx: neg, L elbow fluid: no WBCs, 97 polys, many monosodium urate crystals ([**5-22**]) cath tip: MRSE ([**5-21**]) Pancx: negative except, Sputum: MRSA and yeast, Joint aspirate: WBC 25K Mod amount - monourate sodium crystals ([**5-19**]) Bile Cx: neg; BCx: neg, Sputum Cx: MRSA, UCx: neg; ([**5-18**]) Sputum: MRSA; [**6-18**] Echo: LA, RA dilated. Mild symmetric LV hypertrophy. LVEF>55%. Ao root moderately dilated @sinus level. Mildly thickened Ao & mitral valve leaflets. Mild 1+ MR. [**First Name (Titles) **] [**Last Name (Titles) **] a systolic HTN. Brief Hospital Course: The patient was admitted on [**2125-5-15**] and started on broad spectrum antibiotics with Vancomycin/levo/flagyl administered in the ER. He had a percutaneous cholecystostomy tube placed on [**5-16**] after elective intubation for respiratory distress. He underwent an [**Month/Year (2) **] which revealed a compacted ampullary stone, likely cholangitis and possible CBD stone; a biliary stent was placed. He had post procedure hypotension and SIRS with progressive low grade fever, elevated WBC and a pressor requirement and he remained intubated. He spiked to 101.5 and was pan cultured on [**5-18**]. Sputum from that date ultimately grew MRSA. Neuro: The patient was initially sedated with fentanyl and propofol as needed. [**6-1**]: APS consult, started ketamine infusion for acute gout flare. PO Dilaudid started and fentanyl patch started [**6-7**]. Fentanyl drip stopped [**6-10**]. For pain control, the patient continued on a fentanyl patch, tylenol liquid and PO dilaudid. Cardiovascular: initially started on cardizem on arrival to ICU but this was changed to levophed for hypotension. The levophed was titrated to a goal MAP >60. Throughout his stay in the ICU, his blood pressure and heart rate were treated intermittently with neo, levo, lopressor, and IVF boluses. Midodrine started [**6-12**]. He was eventually weaned off all pressors on [**6-19**]. He continued on metoprolol digoxin 0.125mg PO daily for rate control. A heparin drip was started on [**6-18**] for anticoagulation for atrial fibrillation with a goal PTT of 60-80 until therapeutic on coumadin. Coumadin was started on [**6-19**] at low doses with an INR goal of [**3-4**]. Lovenox was started on day of discharge as a bridge to a therapeutic INR. Pulmonary: The patient was intubated on [**5-16**] for respiratory distress. He underwent a tracheostomy on [**5-28**]. The patient continued on the ventilator and was weaned to a trach collar on [**6-11**]. Pulmonary toilet continued with intermittent ventilator support as needed. GI: [**5-18**] dobbhoff feeding tube placed and enteral nutrition started. Nutren Renal full strength with beneprotein 40gm/day, banana flakes 3 packets per day tube feedings continued at goal rate of 40ml/hr. GU: Foley catheter placed on admission. A sore on the meatus was noted. Urology was consulted and recommended changing position of the foley daily, changing the foley every six weeks and appyling bacitracin ointment daily. [**6-7**]: Foley changed FEN: The patient was initially started on IV lasix for fluid overload and was dosed prn. CVVH started on [**5-29**] for fluid overload. It continued for a goal of 50-100ml/hr and eventually stopped [**6-8**]. Lasix continued as a drip for a goal of keeping the fluid balance even. The lasix drip was stopped on day of discharge and PO lasix was started. Rheumatology : consulted on [**5-23**] for acute, painful flare of gout. Colchicine and indocin were both used for treatment of gout. Endocrine: insulin drip was used prn to control blood sugars followed by an insulin sliding scale. ID: Vanc/zosyn started on [**5-17**] for MRSA PNA and biliary tract coverage. Changed to Linezolid/zosyn on [**5-23**]. [**5-28**] zosyn discontinued and cipro and flagyl added. [**5-30**] flagyl and cipro d/c. Linezolid was discontinued on [**6-12**] [**6-6**]: started Meropenem, urine cx positive for E.Coli. Meropenem was discontinued on [**6-15**]. Flagyl started on [**6-19**] empirically for c diff colitis. Medications on Admission: celebrex 200', coumadin 2.5/5 alternating', wellbutrin ER 100', protonix 40', lasix 160', potassium 20', crestor 5', carbidopa 25/100''', flomax 0.4', glipizide 5'', colchicine 10.6 q2d, trazadone 100', [**Doctor First Name 130**] 180', sotalol 80'', digoxin 0.125 q2d, xalatan 1 drop L eye', lidoderm [**1-31**] patch' Discharge Medications: 1. Metronidazole 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 2. Colchicine 0.6 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Coumadin 3 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day: goal INR [**3-4**] Dose daily. Disp:*30 Tablet(s)* Refills:*2* 4. Carbidopa-Levodopa 25-100 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (3) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (3) **]: Ten (10) ml PO BID (2 times a day). Disp:*600 ml* Refills:*2* 7. Bacitracin Zinc 500 unit/g Ointment [**Month/Day (3) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*2* 8. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 9. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Trazodone 50 mg Tablet [**Hospital1 **]: 1.5 Tablets PO HS (at bedtime) as needed. Disp:*60 Tablet(s)* Refills:*0* 11. Indomethacin 25 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID (3 times a day). Disp:*180 Capsule(s)* Refills:*2* 12. Fentanyl 75 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*2* 13. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day): Use only if patient is on mechanical ventilation. Disp:*400 ML(s)* Refills:*0* 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 15. Latanoprost 0.005 % Drops [**Last Name (STitle) **]: One (1) Drop Ophthalmic HS (at bedtime). Disp:*20 ml* Refills:*2* 16. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff Inhalation QID (4 times a day). Disp:*1 unit* Refills:*2* 17. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours). Disp:*500 ml* Refills:*2* 18. Levothyroxine Sodium 50 mcg IV DAILY 19. Albuterol 90 mcg/Actuation Aerosol [**Age over 90 **]: 1-2 Puffs Inhalation Q6H (every 6 hours). Disp:*1 unit* Refills:*2* 20. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Age over 90 **]: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours) as needed for pain for 7 days. Disp:*7 Adhesive Patch, Medicated(s)* Refills:*0* 21. Lorazepam 0.5 mg Tablet [**Age over 90 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 22. Bupropion 75 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 23. Erythromycin 5 mg/g Ointment [**Age over 90 **]: 0.5 in Ophthalmic QID (4 times a day). Disp:*60 in* Refills:*2* 24. Metoprolol Tartrate 5 mg IV Q6H:PRN AFIB / RVR 25. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 26. Furosemide 40 mg Tablet [**Age over 90 **]: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 27. Enoxaparin 100 mg/mL Syringe [**Age over 90 **]: One Hundred (100) mg Subcutaneous Q 12H (Every 12 Hours): until therapeutic on coumadin (INR [**3-4**]) then may d/c lovenox. Disp:*25 syringes* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 100**] Senior Life Discharge Diagnosis: Acute cholangitis Gall Stone Pancreatitis Respiratory Failure- MRSA Pneumoniae Gout Acute on Chronic Renal Failure Congestive Heart Failure (LVEF > 55%) Atrial Fibrillation Coronary Artery Disease Parkinson's Disease Diverticulosis Discharge Condition: Fair Discharge Instructions: Please call your surgeon or return to the emergency room if you have a fever greater than 101.5, chills, nausea, vomiting, chest pain, shortness of breath, if your skin becomes yellow-tinged or any other symptom that should worry you. Please take all medications as prescribed. Continue to wean off the vent as tolerated. You are being discharged on blood thinners, you must have your PT, PTT checked daily and have your coumadin dosed daily for an INR goal of [**3-4**]. The heparin drip may stop once your INR is at a therapeutic level. Speech and swallow should assess for PMV placement and swallow evaluation. Please change position of Foley catheter qdaily to avoid further erosion; bacitracin to meatus TID for lubrication and topical antibiosis and we would recommend Foley change every 6 weeks. You will need to stop the coumadin 5 days prior to your [**Date Range **] on [**2125-7-19**]. Therefore, do not take your coumadin dose on [**7-29**], [**7-16**], [**7-17**], [**7-18**]. Followup Instructions: Please call the office of Dr. [**Last Name (STitle) **] to make a follow up appointment in [**3-4**] weeks at [**Telephone/Fax (1) 3201**] Please call your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to make a follow up appointment in [**3-4**] weeks. ([**Telephone/Fax (1) 5455**] Please call rheumatology to make a follow-up appointment in [**3-4**] weeks with Dr [**First Name (STitle) **] at [**Telephone/Fax (1) 2226**] Previously Scheduled Appointments: Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2125-7-19**] 10:00 Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2125-7-19**] 10:00

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icd9cm

[ [ [] ] ]

[ "00.14", "51.01", "31.1", "81.91", "96.6", "38.93", "51.87", "96.04", "96.72", "33.24", "38.95", "39.95", "34.91" ]

icd9pcs

[ [ [] ] ]

13110, 13168

5474, 8990

377, 511

13444, 13451

2321, 5451

14497, 15236

1797, 1832

9360, 13087

13189, 13423

9016, 9337

13475, 14474

1847, 2302

222, 339

539, 1085

1107, 1606

1622, 1781

23,108

119,164

19980

Discharge summary

report

Admission Date: [**2137-5-1**] Discharge Date: [**2137-5-4**] Date of Birth: [**2068-7-31**] Sex: M Service: MEDICINE Allergies: Penicillins / Erythromycin Base Attending:[**Doctor First Name 1402**] Chief Complaint: ICD firing Major Surgical or Invasive Procedure: ICD interrogation History of Present Illness: 68 y/o M w/ischemic cardiomyopathy (EF 15%), CAD s/p MI [**56**] yrs ago, and recurrent VT (ICD [**2126**], [**Hospital1 **]-v upgrade [**2131**], [**Last Name (un) 19961**] change-out [**2137-2-15**]), s/p intracoronary stem cell therapy in [**Country 2784**] in [**2135-6-21**], s/p multiple VT ablations most recently in [**1-26**] and again [**4-17**]. He was taken off all antiarrhythmics (high LFT's and prolonged baseline QTc). His BiV pacer was also changed from BiV pacing to AV sequential (RV only) pacing for thought that BiV pacing may be exacerbating his recurrent VT. Since time of last discharge, he has been feeling well until yesterday afternoon when he felt palpitaitons and sharp umbilical pain with firing of his device. He presented to [**Hospital **] clinic today and was found again to be in slow VT and sent to CCU for management. He was then shocked en route to the CCU from [**Hospital Ward Name 23**] cliic. Subjectively he feels sharp belly pain with his VT and denies chest pain, SOB or CNS symptoms. Denies BRBPR, melenic stools or increased orthopnea. Took 20mg valium yesterday [**1-23**] anxiety. Past Medical History: 1. Coronary artery disease status post myocardial infarction 25 years ago. 2. Congestive heart failure with an ejection fraction of 15% by echo [**8-25**]. 3. Peripheral vascular disease with poor vascular access, last EP study [**1-26**] done via R brachial artery approach 4. Ventricular tachycardia status post implantable cardioverter-defibrillator placement s/p VT ablation and BiV ICD upgrade (ICD is [**Company 1543**]). Most recent VT ablation [**1-26**] demonstrated 6 inducible VT's, 2 of which were ablated; this required pressor support during and post-procedure. PAST SURGICAL HISTORY: He has had a cardiac aneurysm resected. Social History: Retired businessman. He lives in [**Location 311**]. He does not smoke and does not drink alcohol. Family History: Non-contributory. Physical Exam: AF 92/57 80 (paced) 14 98%RA Gen: NAD, A&O X 3 Heent: EOMI, PERRL Neck: No JVD or [**Doctor Last Name **] A's Heart: RRR, soft systolic murmur at LUSB, lateral PMI Lungs: Clear Abd: Soft, nt/nd. NABS Ext: Trace edema Brief Hospital Course: A/P: 68 y/o male with ischemic DCM, PVD, and recurrent VT s/p numerous VT ablations. 1. Rhythm: Pt presents with polymorphic VT at rate of 110's. Morphology is inferior and right asix. Appears to be at least 2 foci. He remained hemodynamically stable, although he does experience belly pain (? hypoperfusion in setting mesenteric vascular dz) during the episodes. He also experiences marked anxiety in anticipation of ICD firing. He was given 2mg IV magnesium and 200mg IV amiodorone on arrival to CCU. His pacer was reprogrammed to BiV pacing with rate increase from 70 to 80. He was then started on amiodorone 200mg TID. This appears to have stabilized his VT. Continued coumadin for PAF. Upon discharge, he continues having short ([**10-5**]) beat runs of NSVT, all of which are completely assymptomatic. 2. Pump: EF 15%. Pt had no component of volume overload during this hospitalization. His oupt regimen was continued. We tried switching from aldactone to eplerenone, but the pt did not favor this medication, so he was discharged with aldactone. 3. CAD: Cardiac enzymes were cycled and negative. Anti-ischemic regimen was continued as above. 4. Transaminitis: Pt had elevated LFT's during last hospitalization that was attributed to lidocaine vs anesthesia vs amiodorone. Dr.[**Last Name (STitle) **] felt elevated LFT's may be [**1-23**] CHF. Currently at baseline with normal bili. Likely from hypoperfusion [**1-23**] VT. He should have his LFT's periodically checked now that he is back on amiodorone. 5. Anemia: Microcytic. Never had C-scope. CT scan done in [**2137-1-22**] to evaluate for RP bleed, there were 3 small lesions noted in his liver. It was a noncontrast CT and so these lesions were difficult to characterize. They are most likely to be hepatic cysts, but given the guaiac positive stool, iron def. anemia, and 68 y/o M who's never had a colonoscopy, it is worrisome for malignancy and emphasizes the need for colonoscopy. Because his anemia also has a component of anemia of chronic disease, he was given a dose of epo prior to discharge. Should have a colonoscopy as an outpt if any intervention is planned. 6. Thrombocytopenia: Chronic and stable. No evidence of bleeding now. Felt to be [**1-23**] myelosuppression of unknown etiology. 7. CRI: Stable. Discharged with serum creatinine of 1.6. Normal lytes. Medications on Admission: carvedilol 6.25 [**Hospital1 **] lasix 40 daily imdur 30 daily ramipril 2.5 daily lipitor 10 daily asa 81 dig 0.0625 daily aldactone 50 feso4 325 coumadin 7 dialy mvi Discharge Medications: 1. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Pantoprazole Sodium 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* 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 8. Warfarin Sodium 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): take with 3mg tablet. Disp:*30 Tablet(s)* Refills:*2* 9. Warfarin Sodium 3 mg Tablet Sig: One (1) Tablet PO at bedtime: take with 4mg tablet. Disp:*30 Tablet(s)* Refills:*2* 10. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Imdur 30 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: Ventricular Tachycardia Severe ischemic cardiomyopathy Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 Litres If you have these symptoms, call your physician, [**Name10 (NameIs) **] go to the ED: - ICD firing - belly pain - chest pain - shortness of breath - palpitations - dizziness - fainting Followup Instructions: Please follow up with your physician in [**Name9 (PRE) **]. Also follow up with your next scheduled appointment with Dr.[**Last Name (STitle) **]. Completed by:[**2137-5-4**]

[ "V53.32", "427.1", "287.5", "414.01", "412", "414.8", "443.9", "428.0", "280.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6747, 6753

2586, 4972

302, 321

6852, 6858

7223, 7401

2290, 2309

5190, 6724

6774, 6831

4998, 5167

6882, 7200

2114, 2155

2324, 2563

252, 264

349, 1486

1508, 2090

2171, 2274

55,801

165,940

41969

Discharge summary

report

Admission Date: [**2159-4-28**] Discharge Date: [**2159-5-23**] Date of Birth: [**2117-8-13**] Sex: F Service: MEDICINE Allergies: Keflex / Bactrim / aspirin / Motrin / Toradol / Vistaril / NSAIDS Attending:[**First Name3 (LF) 3918**] Chief Complaint: Neck Pain Major Surgical or Invasive Procedure: Left neck mass biopsy Mechanical Intubation History of Present Illness: Pt is a 41 y.o female with h.o hypothyroidism, Crohns, back pain, seizures, with recent h.o neck pain/thyroid mass s/p thyroid bx [**2159-4-18**] with cytology that returned as "atypical lymphocytes" who has had increase pain (stabbing [**10-3**]-worse with talking radiates to L.neck/face/posterior neck), dysphagia, odynophagia, SOB, inability to tolerate any PO, n/v with leaning forward. Pt reports that her pain was not controlled with PO oxycodone at home. Pt also reports cough, productive of phlegm. She also reports L.ear pain with decreased hearing on the L.side since this am. Symptoms started about 2-3 weeks ago, but then increasingly worsened over the last 1-3 days. Pt reports feeling feverish, heat intolerance, abdominal cramping, and ?palpitations with 10lb weight loss over last month. However, she denies headache, dizziness, blurred vision, CP, abdominal pain, constipation, melena, brbpr, dysuria, hematuria, joint pain, skin rash, paresthesias, or weakness. . In the ED, INitial vitals: T 98.2, BP 118/95, HR 91, RR 22, sat 97% on RA recent 97.4, BP 129/97, HR 84, RR 14, sat 99% on RA PT was given morphine and zofran. ENT evaluated the pt at bedside, L.vocal cord is paramedial, airway not compromised, no airway edema. CT scan revealed large fluid/air space collection with mass effect, ddx includes infection mass. Neighboring enlarged necrotic nodes are present. Past Medical History: thyroid mass HTN Hypothyroid Crohn's Dz Two herniated disc, unoperable Anxiety Seizures- last 1yr ago Endometriosis L IM Nail ([**2158-8-2**]) Laparascopy for endometriosis C-sections x 5 Social History: Pt lives at home with her fiance. Denies smoking, ETOH, drug use Family History: Uncle with lung cancer Aunt with esophageal/throat ca Sister with hyperthyroidism [**Name (NI) **] with lupus Physical Exam: Admission Exam: GEN: appears anxious and tearful vitals: T 99, BP 113/70, HR 82, RR 20, sat 100% on RA HEENT: ncat eomi anicteric MMM, tongue midline neck: +L.sided neck fullness and tenderness to palpation along the anterior and L.side of the neck/posteriorly and up to the L.ear. No ear tenderness. No noticable bruits chest: b/l ae no w/c/r heart: s1s2 no m/r/g abd: +bs, soft, NT, ND, no guarding or rebound ext: no c/c/e 2+pulses skin: no apparent rash neuro: AAOx3, CN2-12 intact, motor [**4-28**] x4, sensation intact to LT, no tremor psych: calm, cooperative . Discharge Exam: Vitals: T 99, BP 113/70, HR 82, RR 20, sat 100% on RA GEN: NAD HEENT: ncat eomi anicteric MMM, tongue midline neck: +L. sided neck fullness and tenderness to palpation along the anterior and L.side of the neck/posteriorly and up to the L.ear. No ear tenderness. No noticable bruits chest: b/l ae no w/c/r heart: s1s2 no m/r/g abd: +bs, soft, NT, ND, no guarding or rebound ext: no c/c/e 2+pulses skin: no apparent rash neuro: AAOx3, CN2-12 intact, motor [**4-28**] x4, sensation intact to LT, no tremor psych: calm, cooperative Pertinent Results: Admission Labs: [**2159-4-28**] 02:07PM LACTATE-1.3 [**2159-4-28**] 02:00PM GLUCOSE-79 UREA N-15 CREAT-0.7 SODIUM-134 POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-26 ANION GAP-15 [**2159-4-28**] 02:00PM estGFR-Using this [**2159-4-28**] 02:00PM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-2.3 [**2159-4-28**] 02:00PM URINE HOURS-RANDOM [**2159-4-28**] 02:00PM URINE HOURS-RANDOM [**2159-4-28**] 02:00PM URINE UCG-NEGATIVE [**2159-4-28**] 02:00PM URINE GR HOLD-HOLD [**2159-4-28**] 02:00PM WBC-8.0 RBC-4.05* HGB-11.8* HCT-37.9 MCV-94 MCH-29.1 MCHC-31.1 RDW-13.4 [**2159-4-28**] 02:00PM NEUTS-70.3* LYMPHS-19.3 MONOS-4.3 EOS-5.7* BASOS-0.3 [**2159-4-28**] 02:00PM PLT COUNT-427 . [**4-25**] CT NECK Small fluid collection just anterior to the left sternocleidomastoid muscle and deep to the platysma muscle now measures 1.1 x 0.9 cm, previously 2.1 x 1.1 cm (2:47). There is continued improvement in the small fluid collection abutting the posterolateral aspect of the cricoarytenoid cartilage, which now only measures 0.4 cm, previously 1.2 x 0.4 cm (2:56). Several locules of gas persist in the surrounding area. Mild soft tissue stranding and thickening surrounds common carotid and internal jugular vessels decreased from initial study; vessels appear patent. Extensive cervical lymphadenopathy seen on [**2159-4-28**] exam has decreased and stable comapred to [**2159-5-10**]. . Airway is patent. Cervical vessels demonstrate normal opacification. No flow-limiting stenosis is noted. Submandibular Salivary glands are normal in appearance; fatty change is noted in parotids. . Near complete opacification of the left maxillary sinus has resolved with only mild mucosal thickening of its posterior wall remaining (2:24). Inspissated secretions of the left sphenoid sinus persists. Otherwise, paranasal sinuses and mastoid air cells are well aerated. Limited views of the brain are unremarkable. Partially imaged lungs are clear. There is no pneumothorax. . C5/6: Disc-osteophyte complex indenting the ventral thecal sac; mild foraminal narrowing. IMPRESSION: Continued improvement of left cervical inflammatory changes when compared to [**2159-5-10**] exam with details as above with some residual abnormalities. . [**5-10**] CT NECK Overall, much improved appearance of the inflammatory and necrotic changes from the prior study. There remain two small fluid collections which still exert some regional mass effect on the esophagus, but no airway compromise at this stage. Continued close surveillance with followup ultrasound and/or CT is recommended. . [**4-29**] CT NECK 1. Although incompletely evaluated, multiple necrotic lymph nodes are again noted in the left neck, better delineated on dedicated neck study from [**2159-4-28**]. Nodularity is also noted at the left thyroid lobe, and a focal lesion cannot be excluded. As a result, a dedicated thyroid ultrasound is recommended in a non-emergent setting. 2. No evidence of malignant disease in the chest, abdomen, or pelvis otherwise. 3. Aerosolized secretions are noted in the distal esophagus and may be representative of reflux in the proper clinical setting. . Discharge Labs: [**2159-5-23**] 12:00AM BLOOD WBC-4.2 RBC-3.23* Hgb-9.6* Hct-29.8* MCV-92 MCH-29.7 MCHC-32.2 RDW-14.9 Plt Ct-269# [**2159-5-23**] 12:00AM BLOOD Neuts-59 Bands-2 Lymphs-30 Monos-4 Eos-1 Baso-0 Atyps-0 Metas-3* Myelos-1* NRBC-1* [**2159-5-23**] 12:00AM BLOOD Plt Smr-NORMAL Plt Ct-269# [**2159-5-23**] 12:00AM BLOOD Glucose-120* UreaN-13 Creat-0.6 Na-137 K-4.1 Cl-95* HCO3-30 AnGap-16 [**2159-5-23**] 12:00AM BLOOD ALT-30 AST-16 LD(LDH)-241 AlkPhos-189* TotBili-0.3 [**2159-5-23**] 12:00AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.2 [**2159-5-1**] 04:32AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE Brief Hospital Course: 41 yo F with newly diagnosed DLBCL in the neck, admitted to the [**Hospital Unit Name 153**] for airway compromise. #Diffuse large B cell lymphoma: Patient was transferred to the [**Hospital Unit Name 153**] for airway protection after a large left sided neck mass was noted on exam and on CT of the neck. She was intubated on [**2159-4-29**] with ENT and anesthesia present for airway protection given the extrinsic compression from this mass as well as concern for laryngeal edema. The biopsy of the neck mass showed diffuse large B cell lymphoma and she was started on R-CHOP therapy by the hematology/oncology team. Her neck mass was markedly reduced in size with this intervention. She was noted to have a cuff leak and was successfully extubated on [**2159-5-7**], again with ENT and anesthesia present. She was called out to the BMT team for ongoing managent of her lymphoma. . She was subsequently transfrred to the [**Hospital Unit Name 153**] a second time for worsening hoarseness and dysphagia after extubation. She had a CT neck on [**2159-5-20**] which showed no airway compromise and markedly improved edema compared to the prior study. She was also seen by ENT who also say no evidence of airway compromise during laryngoscopy. Her symptoms remained stable and she was transferred back to the floor. . She remained stable on the floor and received a second cycle of CHOP. Her pain improved as the mass continued to recede. She was discharged home with close Heme/Onc follow up. . # TMJ: She complained of significant left ear pain. ENT was consulted and felt her pain was most consistent with TMJ dysfunction. She was put on jaw rest with a pureed diet and prescription Oxycodone was provided at the time of discharge. . #Pneumonia: There was an equivocal LLL infiltrate on her CXR and the decision was made to treat her for pneumonia given that she was to be started on chemotherapy and would be immunosuppressed. She was treated with vanc and Zosyn for an 8 day course. Sputum culture was negative during this admission. . # UTI: Pt complained of dysuria and UA revealed UTI. Cultures grew pan sensitive E Coli and she was given a 5d course of Ciprofloxacin. . # Hypothyroidism Continued on levothyroxine. . # Crohns disease Continued asacol (held while intubated) . # Seizure disorder Continued trileptal . # Depression/anxiety Continued seroqual and clonazepam. . # HTN Continued clonidine . TRANSITIONAL ISSUES: Patient has endorsed decreased hearing in her left ear, likely due to compression from the mass. She will need an audiology assessment as an outpatient. She was afebrile and HD stable at the time of discharge. She will follow up with Heme/Onc within 5d of discharge. Medications on Admission: seroquel 300mg, 2 tabs at bedtime seroquel 50mg TID trileptal 600mg [**Hospital1 **] clonidine 0.1mg QID klonapin 1mg QID prazosin 1mg QHS asacol 400mg TID soma 350mg QID synthroid 150mcg daily levsin 0.125mg, 2 tabs prn percocet 2 tabs 4-6hrs prn Discharge Medications: 1. quetiapine 300 mg Tablet Sig: Two (2) Tablet PO at bedtime for 30 days. Disp:*60 Tablet(s)* Refills:*0* 2. quetiapine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 30 days. Disp:*90 Tablet(s)* Refills:*0* 3. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO twice a day for 30 days. Disp:*60 Tablet(s)* Refills:*0* 4. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO three times a day for 30 days. Disp:*90 Tablet(s)* Refills:*0* 5. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) for 30 days. Disp:*120 Tablet(s)* Refills:*0* 6. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day) for 30 days. Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day for 30 days. Disp:*30 Tablet(s)* Refills:*0* 8. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) PO DAILY (Daily). Disp:*300 ml* Refills:*0* 9. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*0* 10. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*0* 11. Ensure Liquid Sig: Four (4) bottles PO once a day. Disp:*120 bottles* Refills:*0* 12. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. Disp:*6 Tablet(s)* Refills:*0* 13. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain for 10 days. Disp:*80 Tablet(s)* Refills:*0* 14. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation for 30 days. Disp:*60 Tablet(s)* Refills:*0* 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 16. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 30 days. Disp:*60 Tablet(s)* Refills:*0* 17. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for N/V for 30 days. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Diffuse Large B Cell Lymphoma Urinary tract infection TMJ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 91115**], You were admitted to the hospital with swelling in your neck, which was biopsied and found to be lymphoma. You went to the ICU to be intubated, and were given chemotherapy to reduce the size of your cancer. You also had a Urinary tract infection for which we started you on Ciprofloxacin - you will need to complete a 5 day course of this. Please note the following changes to your medications: STARTED Ciprofloxacin for 5 days STARTED Oxycodone 5-10mg by mouth every 6 hours as needed for pain Followup Instructions: [**5-24**] with her psychopharm, Dr [**First Name (STitle) 391**] [**Name (STitle) 91116**] at 12:40, and her counselor [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 3:15 Department: BMT/ONCOLOGY UNIT When: MONDAY [**2159-5-28**] at 8:30 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 Garage Department: VOICE,SPEECH & SWALLOWING When: THURSDAY [**2159-5-31**] at 1 PM With: [**Doctor First Name **] BAARS [**Telephone/Fax (1) 3731**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2159-5-28**] at 2:30 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2159-5-28**] at 2:30 PM With: [**First Name8 (NamePattern2) 2747**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3983**], NP [**Telephone/Fax (1) 3237**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]

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icd9cm

[ [ [] ] ]

[ "41.31", "83.21", "99.28", "96.04", "38.97", "31.42", "21.21", "96.6", "29.11", "96.72" ]

icd9pcs

[ [ [] ] ]

12187, 12193

7144, 9566

336, 382

12295, 12295

3374, 3374

13000, 14469

2112, 2223

10153, 12164

12214, 12274

9881, 10130

12446, 12847

6538, 7121

2238, 2808

2824, 3355

9587, 9855

12876, 12977

287, 298

410, 1802

3390, 6522

12310, 12422

1824, 2014

2030, 2096

6,262

168,039

1926

Discharge summary

report

Admission Date: [**2159-12-21**] Discharge Date: [**2159-12-23**] Date of Birth: [**2108-11-3**] Sex: M Service: MEDICINE Allergies: Bactrim / Aspirin Attending:[**First Name3 (LF) 348**] Chief Complaint: fevers/sepsis Major Surgical or Invasive Procedure: None History of Present Illness: 50-year-old male from [**Country 2045**] with a past medical history significant for peptic ulcer disease, chronic renal disease status post renal transplant in [**2155**] for hypertensive nephropathy, HIV diagnosed in [**2141**] (last CD4 [**11/2159**] 308), disseminated TB presenting with fever and tachyacardia. At dialysis today he had fever up to 101.4 and HR up to 140's he had 2 blood cultures drawn and then was administered Vanc. and Gent. at [**Location (un) **] [**Location (un) **]. He endorses productive cough for several days with myalgias. Sputum is yellow and nonbloody. He completed his HD today. . In the ED, initial VS were: 99.4 137 107/67 18 93%. He was given 2L IV NS bolus and SBP remained the 80-90's, he was oriented X 3, though lethargic at times, He was given Levofloxacin for a pneumonia. . On arrival to the MICU, Pulse: 120, RR: 22, BP: 98/57, O2Sat: 98, O2Flow: 3L. . The patient endorses no pain,sick contacts, he denies chest pain, dyspnea, lightheadedness, confusion. He does endorse chills and increased frequency of chronic productive cough of white sputum. He also has chronic brown watery diarrhea, [**10-4**] episodes /day, and denies any change in characteristcs of his bowel movements. He denies abdominal pain, hematochezia, melena.He endorses having 2 episodes of vomiting [**12-17**] teaspoons of clear fluid once yesterday and once this morning in the setting of smoking marijuana. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion.Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, 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: # ESRD - s/p renal transplant in [**2155**]. Delayed graft function and acute rejection, with ultimate failure requiring dialysis. # HIV/AIDS - CD4 340, viral load undetectable # HPV related HSIL of the anus # multiple fistula thromboses - now with leg fistula # chronic diarrhea # HTN # h/o DVT # h/o MTB Social History: Lives alone in an apartment in JP. Married, wife lives in area with 2 sons- aged 10 and 17-who are HIV negative. Denies ETOH, IVDU but smokes marajuana daily. Has a past smoking history but states he quit ~ 2 years ago. Disabled on SSDI since [**2140**]. Came to the US in [**2124**], first having lived in [**State 531**] and since in [**Location (un) 86**]. His wife also has HIV. Family History: Non-contributory. Both parents are deceased. Patient is unable to contibute any information about his FH. Physical Exam: Vitals: T:99.1 BP: 125/64 P:80s R:14 18 O2:94% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes,right insp. rales, no ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2159-12-21**] 02:41PM LACTATE-2.3* [**2159-12-21**] 12:17PM LACTATE-3.8* [**2159-12-21**] 12:00PM GLUCOSE-121* UREA N-12 CREAT-3.3*# SODIUM-137 POTASSIUM-4.4 CHLORIDE-93* TOTAL CO2-29 ANION GAP-19 [**2159-12-21**] 12:00PM estGFR-Using this [**2159-12-21**] 12:00PM ALT(SGPT)-19 AST(SGOT)-36 ALK PHOS-726* TOT BILI-0.7 [**2159-12-21**] 12:00PM LIPASE-31 [**2159-12-21**] 12:00PM ALBUMIN-4.3 CALCIUM-8.6 PHOSPHATE-2.7 MAGNESIUM-1.7 [**2159-12-21**] 12:00PM WBC-11.5* RBC-2.86* HGB-11.2* HCT-34.3* MCV-120* MCH-39.1* MCHC-32.6 RDW-14.5 [**2159-12-21**] 12:00PM NEUTS-92* BANDS-1 LYMPHS-4* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2159-12-21**] 12:17PM BLOOD Lactate-3.8* [**2159-12-21**] 02:41PM BLOOD Lactate-2.3* [**2159-12-22**] 03:23AM BLOOD Lactate-1.2 CXR [**2159-12-21**]: Large area of consolidation in the right lung base is highly worrisome for pneumonia. The left lung is clear. Bilateral brachiocephalic stents are stable in position. No pleural effusion or pneumothorax is seen. Cardiac and mediastinal silhouettes are stable. Innumerable rounded calcifications projecting over the spleen are again seen in this patient with history of prior granulomatous disease. IMPRESSION: Right lower lung consolidation worrisome for infection/pneumonia. Recommend followup to resolution to exclude underlying mass. Brief Hospital Course: 50 yo M with HIV, ESRD s/p failed transplant, disseminated TB, PUD, admitted to the MICU with pneumonia sepsis. ACUTE # Pneumonia Sepsis- Hypotension resolved on arrival to the floor with MAP over 60 without support. Continued Vancomycin, Levofloxacin and Zosyn for HCAP. Blood cx and sputum cx pending. He was transferred to the floor the following day and remained stable. Given his benign clinical course, it's unlikely he needed zosyn for the pseudomonas coverage. He was discharged back home with plans to continue vanco and levaquin dosed after HD. CHRONIC # HIV - continued HAART: Abacavir, efavirenz, lamivudine, zidovudine. Last CD4 308 in [**11/2159**], with below 100 viral load. Continued Dapsone prophylaxis. # Renal transplant - continued prednisone and Tacrolimus. Creatinine at baseline. Continued Nephrocaps, cinacalcet. Medications on Admission: ABACAVIR [ZIAGEN] - (Prescribed by Other Provider) - 300 mg Tablet - 2 Tablet(s) by mouth daily B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - 1 mg Capsule - one Capsule(s) by mouth daily CINACALCET [SENSIPAR] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 60 mg Tablet - 1 Tablet(s) by mouth twice a day CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg Tablet - 1 Tablet(s) by mouth daily DAPSONE - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth HS (at bedtime) EFAVIRENZ [SUSTIVA] - (Prescribed by Other Provider) - 600 mg Tablet - 1 Tablet(s) by mouth q hs IMIQUIMOD [ALDARA] - 5 % Cream in Packet - apply to area three times per week use after showering LAMIVUDINE [EPIVIR HBV] - (Dose adjustment - no new Rx) - 100 mg Tablet - 1 Tablet(s) by mouth daily METHYLPHENIDATE [RITALIN] - (Prescribed by Other Provider) - 5 mg Tablet - [**12-18**] Tablet(s) by mouth takes 1-3 tabs in the AM METOPROLOL SUCCINATE - (Dose adjustment - no new Rx) - 25 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day in AM MIRTAZAPINE [REMERON] - (Prescribed by Other Provider) - 15 mg Tablet - 1 Tablet(s) by mouth q hs OXAZEPAM - (Prescribed by Other Provider) - 30 mg Capsule - 1 Capsule(s) by mouth daily OXYCODONE - (Prescribed by Other Provider: [**First Name4 (NamePattern1) 717**] [**Last Name (NamePattern1) 8389**] NP; Dose adjustment - no new Rx) - 5 mg Capsule - [**12-20**] Capsule(s) by mouth q4-6 hr as needed for pain take colace with oxycodone to prevent constipation PANTOPRAZOLE - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice daily PREDNISONE - (Dose adjustment - no new Rx) - 5 mg Tablet - 1 Tablet(s) by mouth daily ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) (On Hold from [**2159-10-26**] to unknown for muscle weakness and pain) - 5 mg Tablet - 1 Tablet(s) by mouth once a day SEVELAMER CARBONATE [RENVELA] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 800 mg Tablet - 2 Tablet(s) by mouth three times a day with meals TACROLIMUS [PROGRAF] - (Prescribed by Other Provider; update) - 1 mg Capsule - 2 Capsule(s) by mouth twice a day Med list from NP states that pt. only taking 1 mg [**Hospital1 **] TAMSULOSIN - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day ZIDOVUDINE - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 300 mg Tablet - 1 Tablet(s) by mouth qpm Medications - OTC DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a day please take colace to soften stools while taking vicodin Discharge Medications: 1. abacavir 300 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 3. cinacalcet 60 mg Tablet Sig: One (1) Tablet PO once a day. 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. dapsone 100 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. methylphenidate 5 mg Tablet Sig: 1-3 Tablets PO once a day. 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 10. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. oxazepam 30 mg Capsule Sig: One (1) Capsule PO once a day. 12. oxycodone 5 mg Capsule Sig: 1-5 Tablets PO Q4H (every 4 hours) as needed for pain. 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 14. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day. 16. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 17. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 18. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 19. zidovudine 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 20. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO every other day for 1 weeks. Disp:*3 Tablet(s)* Refills:*0* 21. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) injection Intravenous every other day for 1 weeks: after dialysis. Disp:*3 injection* Refills:*0* Discharge Disposition: Home With Service Facility: Community Medical Alliance Discharge Diagnosis: PRIMARY Pneumonia Sepsis SECONDARY ESRD 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: Mr. [**Known lastname 10133**], You were admitted to the hospital for pneumonia which initially required you to be in the ICU. You were treated with antibiotics and your sypmtoms improved. You will be discharged home on antibiotics. Medication changes: # START vancomycin 1000mg after dialysis for 1 week # START levaquin 500mg every other day for 1 week Followup Instructions: Department: [**Hospital1 7975**] INTERNAL MEDICINE When: THURSDAY [**2159-12-27**] at 3:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site

[ "042", "996.81", "V45.11", "V14.8", "787.91", "E878.0", "530.81", "V12.71", "486", "038.9", "V12.51", "995.92", "403.90", "V70.7", "276.52", "V12.01", "276.7", "585.9", "785.52", "V15.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10209, 10266

4909, 5752

293, 299

10350, 10350

3539, 4886

10913, 11261

2891, 2999

8449, 10186

10287, 10329

5778, 8426

10532, 10767

3014, 3520

1778, 2144

10787, 10890

240, 255

327, 1759

10365, 10508

2166, 2474

2490, 2875

20,684

175,661

9826+56122

Discharge summary

report+addendum

Admission Date: [**2120-9-18**] Discharge Date: [**2120-10-10**] Date of Birth: [**2090-12-2**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 29-year-old right handed Chinese speaking female with history of a right cerebellar meningioma that was followed as an outpatient. Patient's initial neurological symptoms began in [**2115**] when she was having difficulty hearing in the right ear while using the telephone. In [**2116**], she started having neck pain. In [**2117**], she was noted as having a right drift while walking and started drooling on the right. MRI in [**Country 651**] done at that time revealed a right cerebellar lesion. She had two surgical resections in [**First Name11 (Name Pattern1) 651**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 15935**] months apart. Pathology slides were not available from [**Country 651**], but her family had her MRIs and the tumor looks consistent with a meningioma. Postoperatively, she was left with a total right facial droop, loss of sensation, and hearing. In [**2118-3-24**], she had an episode of abdominal pain, nausea, and loss of consciousness. The MRI was unchanged, and she has been followed with surveillance MRI by Dr. [**Last Name (STitle) 724**] for surgery in [**Country 651**]. On [**2120-4-4**], she had an increase in the size of her tumor on routine MRI. Repeat MRI done on [**2120-8-14**] showed progression of the tumor as well again of her right cerebellar-pontine angle tumor on [**2120-9-18**]. Right facial weakness and numbness was observed. Patient had VII and VIII cranial nerve palsies on admission. Shrug and strength was [**5-27**] throughout her upper extremities and lower extremities. Sensation was intact. Reflexes are 2+ and Romberg was negative. Patient underwent resection of a right cerebellar-pontine angle tumor on [**9-18**]. Postoperative diagnosis was right cerebellar-pontine angle schwannoma and patient had a right frontal ventricular drain placed intraoperatively. Estimated blood loss was 200 cc. Surgery was unremarkable. Postoperatively, patient was admitted to the Trauma SICU. Postoperatively, the patient was neurologically unchanged from preoperative. Left upper extremity weakness persisted on [**9-20**], believed to be a left upper extremity brachial plexopathy from surgical positioning. Patient was otherwise neuro stable. Patient underwent her first bedside swallow evaluation on [**9-20**], which showed overt aspiration on thin and nectar-thick liquids. A video swallow examination followed, which revealed that the patient had moderate oral and profound pharyngeal paresis characterized by moderately reduced A/P tongue movement and moderately reducible with control as well as right pharyngeal paralysis. It was recommended the patient be kept strictly NPO with a nasogastric tube for nutrition, hydration, and medications at that time. Her left arm numbness and weakness continued to improve until [**9-22**] when she exhibited full strength on neurologic examination. External ventricular drain was decreased to 5 cm of water on [**9-22**]. The patient's drain was repositioned on [**9-22**]. The patient tolerated the procedure well. Decadron was tapered on [**9-23**]. Patient reported no headache or neck stiffness. Strength was again [**5-27**] bilateral upper extremities and lower extremities. Drain was clamped on [**9-24**]. Patient had a repeat swallow examination on [**9-24**] which revealed that patient still had right pharyngeal paresis and was to remain NPO. ENT was consulted on [**9-24**] for vocal cord paralysis. Agreed that patient should be kept NPO and repeated swallow should be done routinely. Ophthalmology was consulted on [**9-24**] as well secondary to right conjunctivitis of her right eye secondary to her right facial palsy. Lacrilube and erythromycin ophthalmic solution was suggested. On [**9-25**], the patient's repeat head CT showed increased ventricular size after drain was clamped. Ventriculoperitoneal shunt placed without complication on [**9-26**]. Patient tolerated procedure well. Neurologically unchanged after V-P shunt placement. Patient with persistent difficulty in closing right eye on [**9-27**]. Patient transferred to the floor on [**9-27**]. Repeat video swallow done revealed that the patient should remain NPO because of severe dysphagia and nonfunctional swallow mechanism. Possible need for PEG tube discussed with family and patient, who refused initially. Reconsult of Ophthalmology on [**9-28**] to placement a [**Doctor Last Name 5749**] shield over eye because of her risk for corneal perforation. Patient's steroids continued to be tapered on the 7th. Eyelid suture of the right eye to prevent progression of her corneal keratopathy. Patient tolerated procedure well with no sequelae. On [**10-4**], her staples were D/C'd. Repeat swallow on [**10-4**] again noted a severe dysphagia, and need for the patient to remain NPO. The patient still continued to refuse PEG placement at this time. Repeat swallow examination done on [**10-7**] again was unchanged. The patient agreed to go for PEG placement on [**10-8**]. Patient underwent PEG placement on [**10-8**], which was without difficulty. Bolus feeds were started on [**10-8**]. Patient was discharged on [**10-10**] to home with instructions on proper tube feed boluses as well as with instructions to followup with Dr. [**First Name (STitle) 7363**] in the Brain [**Hospital 341**] Clinic in two weeks. DISCHARGE MEDICATIONS: 1. Dexamethasone 2 mg p.o. q.12h. 2. Erythromycin 0.5% ophthalmic ointment for right eye b.i.d. 3. Oxycodone acetaminophen elixir [**6-1**] mL p.o. q.4-6h. through PEG tube prn. 4. Lacrilube eye ointment one application O.U. prn. 5. Artificial Tears 1-2 drops O.U. prn. Patient although instructed to followup with Ophthalmology at the [**Hospital 23**] Clinic on Thursday, [**10-17**] at 2 p.m., Dr. [**First Name (STitle) **]. Patient is neurologically stable at time of discharge. [**First Name11 (Name Pattern1) 125**] [**Known lastname 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 27454**] MEDQUIST36 D: [**2120-10-9**] 10:30 T: [**2120-10-11**] 09:40 JOB#: [**Job Number 33058**] Name: [**Known lastname **], [**Known firstname **] LING Unit No: [**Numeric Identifier 5974**] Admission Date: [**2120-9-18**] Discharge Date: [**2093-3-23**] Date of Birth: [**2090-12-2**] Sex: F Service: ADDENDUM: Upon discharge, the patient was also instructed to follow up with Speech and Swallow in four weeks. The patient was provided to Speech and Swallow for a follow-up video esophagram. [**First Name11 (Name Pattern1) 919**] [**Known lastname 920**], M.D. [**MD Number(1) 921**] Dictated By:[**Dictator Info 5975**] MEDQUIST36 D: [**2120-10-9**] 10:34 T: [**2120-10-9**] 12:34 JOB#: [**Job Number 5976**]

[ "372.30", "478.30", "351.0", "225.0", "331.4" ]

icd9cm

[ [ [] ] ]

[ "02.34", "08.52", "45.13", "02.2", "43.11", "96.6", "01.59" ]

icd9pcs

[ [ [] ] ]

5562, 7022

157, 5539

47,266

139,996

39181

Discharge summary

report

Admission Date: [**2143-3-3**] Discharge Date: [**2143-3-6**] Date of Birth: [**2061-5-2**] Sex: M Service: NEUROSURGERY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 1271**] Chief Complaint: Found down Major Surgical or Invasive Procedure: No surgical procedures were done History of Present Illness: This is a 81 year old man on Coumadin for afib who was found down at home today. The last time a family member spoke with the patient was 48 hours ago. The patient was brought to an outside hospital and found to have a large right SDH and an initial INR of 10. The patient was given 1 gram of fosphenytoin, 2 units of FFP, and 10 mg Vitamin K and was transferred here for further care. Cervical spine was cleared at the outside facility per EMS report. Past Medical History: Atrial fibrillation, HTN Social History: Married, wife lives in a nursing facility. Has 3 children. Family History: unknown Physical Exam: Upon Admission: PHYSICAL EXAM: O: T:98.4 BP: 145/71 HR:124 afib R: 20 O2Sats: 100% Gen: comfortable, NAD. HEENT: Pupils:3-2.5 bilaterally EOMs:pt unable to participate Neck: Supple. Lungs: lung sounds coarse throughout. Extrem: Warm and well-perfused. Neuro: Mental status: lethargic, able to state name only, GCS =14 Orientation: Oriented to person only. Recall: unable to perform Language:pt lethargic and hard of hearing and only able to state name at this time. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,3 to 2.5 mm bilaterally. Visual fields-unable to test III, IV, VI: Extraocular movements unable to test V, VII: Facial strength and sensation-pt does not participate in exam VIII: patient is hard of hearing IX, X: Palatal elevation unable to test [**Doctor First Name 81**]: Sternocleidomastoid and trapezius unable to test XII: Tongue midline patient unable to participate Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength- patient spontaneously moving RUE and bilateral lower extremities. Left upper extremity 4-/5, Pronator drift- patient unable to participate Sensation: patient unable to participate Toes mute bilaterally Coordination: pt unable to participate Discharge: xxxxxxxxxxxx Pertinent Results: Head CT [**2143-3-3**]: large right mixed density SDH measuring approx 4.0 cm with concern for active bleeding with shift to the left of 6 mm. Small SAH. Brief Hospital Course: This is a 81 year old man on Coumadin for afib who was found down at home on [**2143-3-3**]. Last known contact was 48 hrs prior. Patient was brought to an outside hospital and found to have a large right SDH and an initial INR of 10. The patient was given 1 gram of fosphenytoin, 2 units of FFP, and 10 mg Vitamin K and was transferred here for further care. At [**Hospital1 18**], his initial INR was 2.6 and Profiline was given. A repeat head CT showed large right mixed density SDH measuring approx 4.0 cm with concern for active bleeding with shift to the left of 6 mm and a small SAH. Initial exam: the patient was very hard of hearing and lethargic. He was unable to fully participate in the exam. Cervical spine was cleared at the outside facility per EMS report. He was loaded with Dilantin in the ER. While in the ER, the patient decompensated and was intubated. Family was reached for consent to go to the OR emergently for evacuation of the SDH, and surgery was put on hold after discussion with family, pre-op lab values, and poor overall health. On [**3-4**] he was made CMO and extubated. He was on Morphine drip and prn for comfort. He was seen by Palliative care. He expired on [**2143-3-6**]. Medications on Admission: Coumadin Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Right subdural hematoma SAH Discharge Condition: Expires Discharge Instructions: N/A Followup Instructions: N/A [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2143-3-6**]

[ "427.31", "E934.2", "790.92", "V66.7", "432.1", "780.09", "401.9", "238.75" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

3786, 3795

2481, 3698

308, 343

3867, 3876

2302, 2458

3928, 4057

969, 978

3757, 3763

3816, 3846

3724, 3734

3900, 3905

1025, 1268

258, 270

371, 829

1492, 2283

1010, 1010

1283, 1476

851, 877

893, 953

6,008

128,051

11855+11879+56297

Discharge summary

report+report+addendum

Admission Date: [**2143-1-5**] Discharge Date: [**2143-1-16**] Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 77 year old male with a past medical history significant for lung adenocarcinoma status post recent right upper lobectomy and right middle lobe wedge resection on [**2142-12-18**]. The [**Hospital 228**] hospital course was complicated by right upper lobe pneumothorax treated with chest tube placement and subsequent right lower lobe collapse, now status post pleurodesis. The patient was discharged on [**12-27**], to home. The patient's other medical history is significant for chronic atrial fibrillation on Coumadin, hypertension, chronic obstructive pulmonary disease, Hepatitis C and prostate cancer. The patient awoke on the morning of [**1-4**], with acute onset of shortness of breath, tachypnea, palpitations and worsening weakness. He also reported right sided pleuritic chest pain and cough with reddish sputum. The patient presented to outside hospital where he was hypoxic, hypotensive and in rapid atrial fibrillation. At the outside hospital the patient was given a Diltiazem drip, intravenous fluids, and then transferred to [**Hospital1 69**]. In the Emergency Department at [**Hospital1 188**], the patient was noted to be anemic and have an elevated INR to 4.8. He was tachycardic to the 140s. Chest x-ray revealed reticular nodule pattern on the left and a CT scan angiogram revealed left-sided pulmonary emboli. The patient was transferred to the Medical Intensive Care Unit. On review of systems, the patient reported dyspnea, bilateral lower extremity edema, weakness and poor appetite. He denied chest pain except for the pleuritic chest pain described above, fevers, chills or melena. There was no nausea or vomiting. PAST MEDICAL HISTORY: 1. Adeno lung cancer status post right upper lobe resection; status post right middle lobe wedge resection; status post pneumothorax and status post right sided collapse and subsequent pleurodesis. 2. Hepatitis C. 3. Atrial fibrillation. 4. Hypertension. 5. Chronic obstructive pulmonary disease. 6. Prostate cancer. 7. Ejection fraction of approximately 40% and history of negative P-thallium in [**2142-6-3**]. HOME MEDICATIONS: 1. Cardizem. 2. Lisinopril 5 mg p.o. q. day. 3. Colace 100 mg p.o. twice a day. 4. Coumadin, unknown dose. 5. Percocet p.r.n. 6. Albuterol MDI. 7. Atrovent MDI. 8. Azmacort. 9. Iron sulfate 325 mg p.o. three times a day. SOCIAL HISTORY: The patient is married. He has a 52 year pack year smoking history and drinks appropriate two drinks a day. The patient is full code. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: On admission, blood pressure 70/58, pulse of 120; oxygen saturation is 85% on two liters. In general, he is a cachectic male, conversive in mild respiratory distress. HEENT: Extraocular muscles are intact. Oropharynx is dry. Mucous membranes were dry. Neck was supple with no jugular venous distention. Cardiovascular: Tachycardic, irregular, with a distant S1, S2. Respiratory: Right side with crackles below the surgery site. Distant breath sounds on the left. Abdomen was soft, nontender, nondistended, with positive bowel sounds. Extremities with bilateral lower extremity edema, left greater than right. Left toes with arterial insufficiency changes. Neurologic: Cranial nerves II through XII intact. Neurologic examination nonfocal. LABORATORY: Data on admission, white blood cell count of 18.6, hematocrit of 27.6 with a baseline of approximately 32, platelets 359. Sodium was 134, potassium 4.8, chloride 98, bicarbonate 25, BUN 34, creatinine 1.5, glucose 102. An arterial blood gas done on 40% FIO2 was 7.42/33/70, the lactate was 1.7. Coagulation studies were significant for an INR of 4.4. Chest x-ray showed moderate cardiomegaly, right upper pneumothorax unchanged, and some fluid within the resection cavity. Increased opacity was also seen throughout the right hemithorax. CT angiogram showed multiple filling defects in the left main and smaller arteries. It also demonstrated emphysema in the left upper and left lower lobe as well as reticular opacities in the right lower lobe consistent with infection of lymphangitic spread. MEDICAL INTENSIVE CARE UNIT HOSPITAL COURSE: 1. Pulmonary embolus: The patient was heparinized. He had an IVC filter placed on [**1-5**]. He had lower extremity non-invasive studies done on [**1-10**], which showed deep venous thrombosis in the popliteal vein and in the calf veins on the left. The patient was restarted on Coumadin and his INR was therapeutic by the time of transfer to the Medical Floor. The patient continued to have oxygen requirement of 40 to 50% by face mask. 2. Rapid atrial fibrillation: This was initially caused by his Diltiazem drip plus/minus an Esmolol drip. Eventually, the patient was transitioned to Cardizem and Lopressor. Digoxin was used transiently but was subsequently discontinued. The patient was anti-coagulated as above. 3. Chronic obstructive pulmonary disease: The patient was treated with a steroid taper as well as his Serevent, Flovent, Atrovent and Albuterol inhalers. 4. Pneumonia: The patient was treated with Vancomycin for Methicillin resistant Staphylococcus aureus in his sputum and Levofloxacin for Klebsiella in his sputum. The patient was called out to the Medical Floor on [**2143-1-14**]. Management of his multiple medical problems as initiated in the Intensive Care Unit was continued. The patient continued to have a stable but elevated oxygen requirement. Heparin was discontinued on [**1-15**], after three days of therapeutic INR. CONDITION AT DISCHARGE: The patient is medically stable for discharge to Rehabilitation. DISCHARGE STATUS: To Rehabilitation. DISCHARGE MEDICATIONS: 1. Multivitamin one tablet p.o. q. day. 2. Iron sulfate 325 mg p.o. q. day. 3. Colace 100 mg p.o. three times a day. 4. Senna one tablet p.o. twice a day. 5. Protonix 40 mg p.o. q. day. 6. Cardizem CR 360 mg p.o. twice a day. 7. Prednisone taper currently at 20 mg p.o. q. day. 8. Flovent two puffs p.o. twice a day. 9. Lopressor 15 mg p.o. four times a day. 10. Levofloxacin, 500 mg p.o. q. day until [**1-19**]. 11. Serevent two puffs twice a day. 12. Atrovent two puffs q. four to six hours p.r.n. 13. Coumadin 5 mg p.o. q. h.s. 14. Dulcolax 10 mg p.o. twice a day p.r.n. 15. Captopril 12.5 mg p.o. twice a day. 16. Lasix 20 mg p.o. q. day. 17. Percocet 1 to 2 tablets p.o. q. four to six p.r.n. 18. Ambien 5 mg p.o. q. h.s. p.r.n. 19. Vancomycin 1 gram intravenous q. 12 hours until [**1-21**]. DISCHARGE DIAGNOSES: 1. Deep venous thrombosis and pulmonary emboli status post IVC Filter placement. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 15468**] MEDQUIST36 D: [**2143-1-15**] 16:05 T: [**2143-1-15**] 16:32 JOB#: [**Job Number 37423**] Admission Date: [**2143-1-5**] Discharge Date: [**2143-1-16**] Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 77 year old male with a past medical history significant for lung adenocarcinoma status post recent right upper lobectomy and right middle lobe wedge resection on [**2142-12-18**]. The [**Hospital 228**] hospital course was complicated by right upper lobe pneumothorax treated with chest tube placement and subsequent right lower lobe collapse, now status post pleurodesis. The patient was discharged on [**12-27**], to home. The patient's other medical history is significant for chronic atrial fibrillation on Coumadin, hypertension, chronic obstructive pulmonary disease, Hepatitis C and prostate cancer. The patient awoke on the morning of [**1-4**], with acute onset of shortness of breath, tachypnea, palpitations and worsening weakness. He also reported right sided pleuritic chest pain and cough with reddish sputum. The patient presented to outside hospital where he was hypoxic, hypotensive and in rapid atrial fibrillation. At the outside hospital the patient was given a Diltiazem drip, intravenous fluids, and then transferred to [**Hospital1 69**]. In the Emergency Department at [**Hospital1 188**], the patient was noted to be anemic and have an elevated INR to 4.8. He was tachycardic to the 140s. Chest x-ray revealed reticular nodule pattern on the left and a CT scan angiogram revealed left-sided pulmonary emboli. The patient was transferred to the Medical Intensive Care Unit. On review of systems, the patient reported dyspnea, bilateral lower extremity edema, weakness and poor appetite. He denied chest pain except for the pleuritic chest pain described above, fevers, chills or melena. There was no nausea or vomiting. PAST MEDICAL HISTORY: 1. Adeno lung cancer status post right upper lobe resection; status post right middle lobe wedge resection; status post pneumothorax and status post right sided collapse and subsequent pleurodesis. 2. Hepatitis C. 3. Atrial fibrillation. 4. Hypertension. 5. Chronic obstructive pulmonary disease. 6. Prostate cancer. 7. Ejection fraction of approximately 40% and history of negative P-thallium in [**2142-6-3**]. HOME MEDICATIONS: 1. Cardizem. 2. Lisinopril 5 mg p.o. q. day. 3. Colace 100 mg p.o. twice a day. 4. Coumadin, unknown dose. 5. Percocet p.r.n. 6. Albuterol MDI. 7. Atrovent MDI. 8. Azmacort. 9. Iron sulfate 325 mg p.o. three times a day. SOCIAL HISTORY: The patient is married. He has a 52 year pack year smoking history and drinks appropriate two drinks a day. The patient is full code. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: On admission, blood pressure 70/58, pulse of 120; oxygen saturation is 85% on two liters. In general, he is a cachectic male, conversive in mild respiratory distress. HEENT: Extraocular muscles are intact. Oropharynx is dry. Mucous membranes were dry. Neck was supple with no jugular venous distention. Cardiovascular: Tachycardic, irregular, with a distant S1, S2. Respiratory: Right side with crackles below the surgery site. Distant breath sounds on the left. Abdomen was soft, nontender, nondistended, with positive bowel sounds. Extremities with bilateral lower extremity edema, left greater than right. Left toes with arterial insufficiency changes. Neurologic: Cranial nerves II through XII intact. Neurologic examination nonfocal. LABORATORY: Data on admission, white blood cell count of 18.6, hematocrit of 27.6 with a baseline of approximately 32, platelets 359. Sodium was 134, potassium 4.8, chloride 98, bicarbonate 25, BUN 34, creatinine 1.5, glucose 102. An arterial blood gas done on 40% FIO2 was 7.42/33/70, the lactate was 1.7. Coagulation studies were significant for an INR of 4.4. Chest x-ray showed moderate cardiomegaly, right upper pneumothorax unchanged, and some fluid within the resection cavity. Increased opacity was also seen throughout the right hemithorax. CT angiogram showed multiple filling defects in the left main and smaller arteries. It also demonstrated emphysema in the left upper and left lower lobe as well as reticular opacities in the right lower lobe consistent with infection of lymphangitic spread. MEDICAL INTENSIVE CARE UNIT HOSPITAL COURSE: 1. Pulmonary embolus: The patient was heparinized. He had an IVC filter placed on [**1-5**]. He had lower extremity non-invasive studies done on [**1-10**], which showed deep venous thrombosis in the popliteal vein and in the calf veins on the left. The patient was restarted on Coumadin and his INR was therapeutic by the time of transfer to the Medical Floor. The patient continued to have oxygen requirement of 40 to 50% by face mask. 2. Rapid atrial fibrillation: This was initially caused by his Diltiazem drip plus/minus an Esmolol drip. Eventually, the patient was transitioned to Cardizem and Lopressor. Digoxin was used transiently but was subsequently discontinued. The patient was anti-coagulated as above. 3. Chronic obstructive pulmonary disease: The patient was treated with a steroid taper as well as his Serevent, Flovent, Atrovent and Albuterol inhalers. 4. Pneumonia: The patient was treated with Vancomycin for Methicillin resistant Staphylococcus aureus in his sputum and Levofloxacin for Klebsiella in his sputum. The patient was called out to the Medical Floor on [**2143-1-14**]. Management of his multiple medical problems as initiated in the Intensive Care Unit was continued. The patient continued to have a stable but elevated oxygen requirement. Heparin was discontinued on [**1-15**], after three days of therapeutic INR. CONDITION AT DISCHARGE: The patient is medically stable for discharge to Rehabilitation. DISCHARGE STATUS: To Rehabilitation. DISCHARGE MEDICATIONS: 1. Multivitamin one tablet p.o. q. day. 2. Iron sulfate 325 mg p.o. q. day. 3. Colace 100 mg p.o. three times a day. 4. Senna one tablet p.o. twice a day. 5. Protonix 40 mg p.o. q. day. 6. Cardizem CR 360 mg p.o. twice a day. 7. Prednisone taper currently at 20 mg p.o. q. day. 8. Flovent two puffs p.o. twice a day. 9. Lopressor 15 mg p.o. four times a day. 10. Levofloxacin, 500 mg p.o. q. day until [**1-19**]. 11. Serevent two puffs twice a day. 12. Atrovent two puffs q. four to six hours p.r.n. 13. Coumadin 5 mg p.o. q. h.s. 14. Dulcolax 10 mg p.o. twice a day p.r.n. 15. Captopril 12.5 mg p.o. twice a day. 16. Lasix 20 mg p.o. q. day. 17. Percocet 1 to 2 tablets p.o. q. four to six p.r.n. 18. Ambien 5 mg p.o. q. h.s. p.r.n. 19. Vancomycin 1 gram intravenous q. 12 hours until [**1-21**]. DISCHARGE DIAGNOSES: 1. Deep venous thrombosis and pulmonary emboli status post IVC Filter placement. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Last Name (NamePattern1) 15468**] MEDQUIST36 D: [**2143-1-15**] 16:05 T: [**2143-1-15**] 16:32 JOB#: [**Job Number 37458**] Name: [**Known lastname 6729**], [**Known firstname 6730**] Unit No: [**Numeric Identifier 6731**] Admission Date: [**2143-1-5**] Discharge Date: [**2143-1-18**] Date of Birth: [**2065-7-31**] Sex: M Service: Medicine DISCHARGE SUMMARY ADDENDUM: This is an addendum to the discharge summary dictated on [**2143-1-15**]. On [**2143-1-16**] the patient's surgical team determined that he should undergo a bronchoscopy. This was done to evaluate for a possible bronchopleural fistula. During the procedure, large amounts of secretions right greater than left were suctioned out. The stump from his prior lobectomy was intact and there was no fistula. The only other events during this hospitalization were decreasing of Diltiazem from 360 a day to 240 a day due to episodes of bradycardia. Also the patient's Lasix was discontinued due to a climb in bicarbonate. CORRECTED DISCHARGE MEDICATIONS: 1. Multi vitamin one tablet po q day. 2. Iron Sulfate 325 milligrams po q day. 3. Colace 100 milligrams po tid. 4. Senna one tablet po bid. 5. Protonix 40 milligrams po q day. 6. Cardizem CR 240 milligrams po bid. 7. Prednisone taper currently at 20 milligrams po q day. 8. Flovent two puffs po bid. 9. Lopressor 15 milligrams po qid. 10. Levofloxacin 500 milligrams po q day until [**2143-1-19**]. 11. Serevent two puffs twice a day. 12. Atrovent two puffs q four to six hours prn. 13. Coumadin 5 milligrams po q HS. 14. Dulcolax 10 milligrams po bid prn. 15. Captopril 12.5 milligrams po tid. 16. Percocet one to two tablets po q four to six hours prn. 17. Ambien 5 milligrams po q HS prn. 18. Vancomycin 1 gram IV q 12 hours until [**2143-1-21**]. [**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 3609**] MEDQUIST36 D: [**2143-1-18**] 14:40 T: [**2143-1-21**] 09:53 JOB#: [**Job Number 6732**]

[ "427.31", "415.19", "799.4", "428.0", "276.5", "707.0", "482.41", "496", "453.8" ]

icd9cm

[ [ [] ] ]

[ "96.56", "33.22", "38.7" ]

icd9pcs

[ [ [] ] ]

13738, 15019

15042, 16075

11381, 12764

9302, 9533

9765, 11364

12780, 12885

7171, 8841

8863, 9284

9550, 9742

8,502

191,893

27112

Discharge summary

report

Admission Date: [**2108-3-24**] Discharge Date: [**2108-4-26**] Date of Birth: [**2057-1-21**] Sex: M Service: SURGERY Allergies: Shellfish / Ativan Attending:[**First Name3 (LF) 148**] Chief Complaint: Abdominal pain, increasing shortness of breath. Pancreatic Abcess Major Surgical or Invasive Procedure: PICC line Placement [**2108-4-17**] Thoracentesis, Right VATS, Right Chest Tubes [**2108-4-3**] Bedside Tongue Biopsy [**2108-4-24**] Multiple CT scans Multiple daubhoff placements History of Present Illness: 51 yo male with a history of HTN, and ETOH use, was admitted to an OSH for a pancreatic abcess, nausea and vomitting for 1 week. He was an inpatient for 2 weeks at an OSH and developed worsening of abdominal pain and increasing shortenss of breath and a rising amylase, lipase and WBC count. Over the past few months he unintentially lost about 30 pounds. Past Medical History: HTN, back pain, ETOH use, smoker restless leg syndrome, jaundice, gallstone Social History: Wife [**Name (NI) **], former 100pack-year smoker Family History: NK Physical Exam: VS: 100.6, 115, 114/55, 16, 96% RA MS: A+O x 3 HEENT: PERRLA, EOMI CVS: RRR, tachy Resp: coarse bilat. increase WOB with wheeze ABD: BS distant, diffuse tenderness Ext: + 2 Edema Pertinent Results: [**2108-3-25**] 01:22AM BLOOD WBC-32.7* RBC-3.26* Hgb-9.9* Hct-29.2* MCV-90 MCH-30.3 MCHC-33.8 RDW-15.2 Plt Ct-661* [**2108-3-26**] 02:12AM BLOOD WBC-33.5* RBC-2.80* Hgb-8.7* Hct-25.6* MCV-92 MCH-31.2 MCHC-34.0 RDW-15.0 Plt Ct-601* [**2108-3-31**] 04:36AM BLOOD WBC-19.3* RBC-3.02* Hgb-8.8* Hct-27.1* MCV-90 MCH-29.2 MCHC-32.6 RDW-14.4 Plt Ct-559* [**2108-4-1**] 08:03PM BLOOD WBC-38.6*# RBC-3.45* Hgb-10.1* Hct-31.0* MCV-90 MCH-29.1 MCHC-32.5 RDW-14.4 Plt Ct-740* [**2108-4-6**] 02:21AM BLOOD WBC-18.3* RBC-2.33* Hgb-6.8* Hct-20.8* MCV-89 MCH-29.1 MCHC-32.6 RDW-15.8* Plt Ct-519* [**2108-4-17**] 03:25PM BLOOD WBC-24.7* RBC-2.20* Hgb-6.4* Hct-20.0* MCV-91 MCH-29.2 MCHC-32.2 RDW-16.6* Plt Ct-466* [**2108-4-19**] 03:40AM BLOOD WBC-24.6* RBC-3.41*# Hgb-10.0*# Hct-29.9* MCV-88 MCH-29.3 MCHC-33.4 RDW-17.1* Plt Ct-399 [**2108-4-23**] 05:02AM BLOOD WBC-20.5* RBC-3.27* Hgb-9.7* Hct-29.4* MCV-90 MCH-29.8 MCHC-33.1 RDW-15.9* Plt Ct-300 [**2108-4-23**] 05:34AM BLOOD WBC-19.6* RBC-3.42* Hgb-9.8* Hct-30.6* MCV-90 MCH-28.7 MCHC-32.0 RDW-15.8* Plt Ct-298 [**2108-4-24**] 04:33AM BLOOD WBC-17.0* RBC-3.14* Hgb-9.3* Hct-28.1* MCV-89 MCH-29.6 MCHC-33.1 RDW-15.6* Plt Ct-292 . [**2108-3-25**] 01:22AM BLOOD Glucose-123* UreaN-15 Creat-0.4* Na-133 K-4.1 Cl-103 HCO3-20* AnGap-14 [**2108-4-20**] 03:56AM BLOOD Glucose-103 UreaN-23* Creat-0.9 Na-138 K-3.4 Cl-102 HCO3-28 AnGap-11 [**2108-4-25**] 05:30AM BLOOD Glucose-104 UreaN-40* Creat-1.0 Na-138 K-3.6 Cl-101 HCO3-27 AnGap-14 . [**2108-3-25**] 01:22AM BLOOD ALT-11 AST-16 AlkPhos-266* Amylase-740* TotBili-1.5 [**2108-3-26**] 02:12AM BLOOD ALT-8 AST-14 AlkPhos-199* Amylase-542* TotBili-0.7 DirBili-0.6* IndBili-0.1 [**2108-3-30**] 03:14AM BLOOD Amylase-190* [**2108-4-14**] 08:37AM BLOOD ALT-13 AST-25 AlkPhos-557* Amylase-1727* TotBili-0.4 [**2108-4-15**] 08:27AM BLOOD Amylase-2820* [**2108-4-23**] 05:34AM BLOOD Amylase-2523* [**2108-4-24**] 04:33AM BLOOD Amylase-2831* [**2108-4-25**] 05:30AM BLOOD ALT-47* AST-34 AlkPhos-827* Amylase-1562* TotBili-0.5 . Approved: WED [**2108-4-25**] 11:28 AM [**2108-3-25**] 01:22AM BLOOD Lipase-187* [**2108-3-26**] 02:12AM BLOOD Lipase-122* [**2108-3-30**] 03:14AM BLOOD Lipase-71* [**2108-4-14**] 08:37AM BLOOD Lipase-1179* [**2108-4-15**] 08:27AM BLOOD Lipase-2764* [**2108-4-23**] 05:34AM BLOOD Lipase-2546* [**2108-4-24**] 04:33AM BLOOD Lipase-1549* [**2108-4-25**] 05:30AM BLOOD Lipase-449* . RADIOLOGY Final Report CHEST (PORTABLE AP) [**2108-4-25**] 9:34 AM PORTABLE CHEST OF [**2108-4-25**] COMPARISON: [**2108-4-23**]. Right PICC line and right chest tube are unchanged in position. Cardiac and mediastinal contours show interval decrease in width, likely due to improving volume status of the patient. There is also improvement in bilateral asymmetric perihilar and basilar alveolar process, particularly in the left perihilar region. Although these opacities may in part be due to improving pulmonary edema, underlying pneumonia is suspected, particularly in the lower lobes. Moderate right pleural effusion is unchanged. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] . . RADIOLOGY Final Report CTA CHEST W&W/O C &RECONS [**2108-4-23**] 10:39 AM CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Contrast: OPTIRAY INDICATION: 51-year-old with head and neck cancer, recent pancreatitis, presenting with acute shortness of breath, rule out PE and reassess abdominal collections. COMPARISONS: CT torso of [**2108-4-17**]. TECHNIQUE: Axial MDCT images of the chest, abdomen, and pelvis with oral and 100 cc of nonionic Optiray contrast. CT CHEST WITH IV CONTRAST: Right-sided chest tube remains in place. There are bilateral pleural effusions, with persisting consolidation in the right lower lobe. The mid and upper lung zones are clear. The airway is patent to the segmental level. The pulmonary arteries enhance normally without filling defect. There are diffuse enlarged lymph nodes throughout the mediastinum, suspicious for metastatic nodes. The thoracic aorta is normal in caliber and enhances normally. Multiple small subcentimeter axillary nodes. CT ABDOMEN WITH IV CONTRAST: Again demonstrated are multiple small thin- walled fluid collections throughout the abdomen, not significantly changed in size and appearance compared to the prior study. None of these are large enough for safe percutaneous drainage. The pancreatic parenchyma enhances homogeneously without evidence of significant necrosis or intraparenchymal abscess. There are coarse calcifications along the duct near the pancreatic head, likely the sequela of chronic pancreatitis. Moderate amount of ascites surrounding the liver and throughout the pelvis. Small ill-defined hepatic hypodense lesion within segment VI, too small to characterize. Additional tiny hypodense lesion in segment V anteriorly, too small to characterize as well. Cholelithiasis without evidence of cholecystitis. The kidneys, adrenal glands, stomach, and proximal small bowel are normal. The spleen contains an ill-defined lesion posteriorly, not well characterized on this study. CT PELVIS WITH IV CONTRAST: Large amount of ascites and free fluid in the pelvis. Subcentimeter inguinal lymph nodes. No pathologically enlarged lymph nodes are seen. BONE WINDOWS: 2.5-cm ill-defined lytic lesion in the right iliac bone lateral to the SI joint, suspicious for metastasis. Old right lateral rib fracture, demonstrating some callus formation. No other suspicious lytic or blastic lesions. MULTIPLANAR REFORMATS: Coronal and sagittal reformatted images confirm the above findings. IMPRESSION: 1) No pulmonary embolism. 2) Stable size and appearance of multiple small fluid collections throughout the abdomen, likely pancreatic pseudocysts; too small to be amenable to percutaneous drainage. 3) Bilateral pleural effusions with right lower lobe consolidation which may relate to persisting pneumonia versus less likely lymphangitic carcinomatosis. 4) Enlarged mediastinal lymphadenopathy, suspicious for metastatic nodes. 5) Stable moderate abdominal and pelvic ascites. 6) 2.5cm lytic lesion in the right iliac bone lateral to the SI joint, suspicious for metastasis. 7) Small hypodense lesions in the liver and spleen, too small to characterize. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Approved: TUE [**2108-4-24**] 7:11 AM . Brief Hospital Course: #Pancreatitis: Upon admission to [**Hospital1 18**] on [**2108-3-24**] he was started on Morphine PCA and Neurontin for [**7-26**] pain, he was placed on IV fluids, made NPO, and continued on TPN. An abdominal CT at this time showed pancreatic pseudocyst given history of pancreatitis, ascites, bilateral pleural effusions - right greater than left. A abdominal CT on [**2108-4-17**] showed multiple dynamic fluid collections again seen within the abdomen, some smaller and some larger when compared to prior study. Relatively stable fluid collection seen in the area of the head of the pancreas.` [**2108-3-31**] tube feedings were started for nutritional support. The feedins were discontinued several days later when his prancreatic enzymes [**Hospital Ward Name **] rocketed to the 2700 range. The patient was, however, asymptomatic in terms of abdominal pain/N/V. He was subsequently maintained on TPN with complete bowel bowel rest. His pancreatic enzymes were monitored regularly and remained elevated. . # Respiratory/Bilateral pleural effusions/pneumonia: [**2107-3-26**] he was intubated for respiratory distress, on [**2108-3-26**] he was re intubated after self-extubation. Blood cultures revealed GPC [**1-21**]. a sputum sample revealed 2+ yeast. A chest x-ray revealed worsening of his bilateral pleural effusions with associated basilar atelectasis. He was being suctioned for copious thick rusty/blood tinged secretions and respiratory support was continued. An NGT was draining small quantities of bilious fluid. Antibiotics Imipenem-Cilastatin was given for pneumonia empirically. [**2108-3-28**] he was extubated and placed on a 50% face tent. A Heimlich valve/chest tube was placed to the right medial chest. [**2108-3-31**] Thoracic surgery was consulted. A chest tube was placed on the right side. On [**2108-4-1**] he was transfered back to the ICU for O2 sats to 80% and tachycardia with his heart rate in the 130's. He was started on Vancomycin, Flagyl, and Levofloxacin for a rising WBC count. He went to the OR on [**2108-4-3**] for a right VATS, decortication and bronchoscopy with chest tubes x 3. Pleural tissue was Staphylcoccus coagulase negative. The patient continued to having respiratory difficulty and the bilateral effusions were very slow to improve. He completed a 2-week course of vanocymycin. [**2108-4-9**] Interventional pulmonolgy performed a therapeutic throacentesis of the left side, draining 1000cc. [**2108-4-17**] the patient had acute onset of shortness of breath and an O2 saturation of 75% and was transfered to the ICU. He responded well to Lasix and nebulizers and continued respiratory care. He was transfered back to the floor on [**2108-4-19**]. Chest tubes were sequentially discontinued per the thoracic surgery service over the next 2 weeks. The last tube was removed on [**2108-4-25**], a follow-up chest x-ray was negative for pneumothorax. . #Hemetology: The patient was transfused on multiple occasions from [**Date range (1) 66583**] for anemia of chronic disease. Mr. [**Known lastname 66584**] white count continued to be slightly elevated throughout his hospital stay, though is currently trending down. . # Aspiration/failed swallowing: Speech and Swallow was consulted on [**2108-4-6**] for aspiration and continued to recommend he stay NPO. They again saw the patient on [**2108-4-10**] for reevaluation of his swallowing. Mr. [**Known lastname **] was noted to have symptoms of aspiration of any liquids/thickened liquids/solids taken PO. He was also noted at this time to have a left tongue mass. He was kept NPO. A doubhoff was placed the next day in order to administer medications enterally. Over the next 5-7 days the patient removed the doubhoff on multiple occassions. It was ultimately not replaced and his medications converted again to IV form. . #Large tongue mass: ENT/ORL consult was obtained on [**2108-4-10**] for a left, posterior tongue lesion. The patient had slurring of speach and difficulty with clearing of oropharyngeal secretions. The mass is 2 cm firm lesion and highly concerning for malignancy especially given the patient's history of alcohol and tobacco abuse. A biopsy was done on at the bedside on [**2108-4-24**] by ENT. Oncology was also consulted regarding his tongue mass. They had no specific course of treatment without a confrimed tissue diagnosis. . #Decub ulcer: a Wound Care consult was obtained for evaluation of a coccyx skin breakdown and Duoderm was placed on the site, and other skin care measures were continued. . #Disposition: Continued hospitalization in [**Location (un) 86**], at such a distance from home, continued to put added strain on Mr. [**Known lastname 66584**] family. Per the patient's request arrangements were made to transfer him back to Southern New [**Hospital 66585**] Medical Center where he was originally hospitalized. Dr. [**Last Name (STitle) 66586**] accepted the patient's return. He was transfered on [**2108-4-26**]. Medications on Admission: neurontin, oxycontin, cardizem Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Injection TID (3 times a day). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 5. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED): insulin sliding scale. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 7. Acetaminophen 650 mg Suppository Sig: [**12-19**] Suppositorys Rectal Q4-6H (every 4 to 6 hours) as needed. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day). 9. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 10. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 11. Pantoprazole 40 mg IV Q24H 12. Furosemide 40 mg IV BID 13. Hydromorphone 2-4 mg IV Q6H:PRN 14. Dolasetron Mesylate 12.5 mg IV ONCE Duration: 1 Doses 15. Metoprolol 7.5 mg IV Q6H Hold for SBP <100 16. Cefazolin 1 g Piggyback Sig: One (1) Piggyback Intravenous Q8H (every 8 hours). Discharge Disposition: Extended Care Discharge Diagnosis: Pancreatitis/Pancreatic Abscess Bilateral Pleural Effusions Tongue Mass Pneumonia Anemia of chronic disease Discharge Condition: Stable Discharge Instructions: Please come to the emergency room if you have fever >101.4F, nausea or vomiting, shortness of breath, abdominal pain, inability to take liquids or any other concerning symptoms. Followup Instructions: 1. Follow-up with Dr. [**Last Name (STitle) **] as needed. Call to schedule an appointment. ([**Telephone/Fax (1) 2363**] 2. Follow-up with Hematology-oncology for your tongue mass.

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icd9cm

[ [ [] ] ]

[ "34.51", "33.23", "99.07", "96.07", "38.93", "99.10", "99.15", "25.02", "34.04", "34.09", "99.04", "34.91", "96.6", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

14314, 14329

7912, 12891

343, 526

14481, 14490

1313, 7889

14717, 14903

1094, 1098

12972, 14291

14350, 14460

12917, 12949

14514, 14694

1113, 1294

238, 305

554, 912

934, 1011

1027, 1078

781

189,928

21865+57266

Discharge summary

report+addendum

Admission Date: [**2117-9-10**] Discharge Date: [**2117-9-16**] Date of Birth: [**2041-8-18**] Sex: F Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: This is a 76-year-old woman with past medical history significant for aortic stenosis and patent foramen ovale status post atrial septal defect repair and aortic valve replacement in [**2117-8-6**], that presents to the emergency room with complaint of abdominal pain and report of free intraperitoneal air on x-ray at her rehabilitation facility, [**Hospital2 57361**] [**Hospital3 **]. Briefly, this is a 76-year-old female who has multiple medical problems as described above, including hypercholesterolemia, peripheral vascular disease, chronic obstructive pulmonary disease, and known lung cancer, that was recently discharged 2 days prior to [**Hospital1 57361**] Rehabilitation facility after a lengthy hospital course in which she underwent an aortic valve replacement and an atrial septal defect closure. She was taken after this point to the surgical intensive care unit for monitoring, however, had developed respiratory distress that required intubation. She required tracheostomy, as well, during this prior stay and was noted to be doing well at the rehabilitation facility in terms of her respiratory status up to this point. Also of note, she also received before her prior discharge a percutaneous endoscopic gastrostomy tube placed by the general surgery service. This was done on [**2117-9-1**], seven days before discharge to the rehabilitation facility. Of note, the patient continued to have free intra-abdominal air during her stay in the intensive care unit before her discharge. However, her abdominal pain resolved, and she was able to resume her tube feeds per recommendation of the general surgery service. Upon discharge she was sent to the [**Hospital1 57361**] rehabilitation facility, where she was noted to be progressing well until her 3rd day when she noted abdominal pain. At this time a kidney/ureter/bladder x-ray was performed that revealed significant right- and left-sided intraperitoneal free air. The patient was then sent back to the [**Hospital1 190**] for further evaluation and treatment. PAST MEDICAL HISTORY: Hypercholesterolemia, peripheral vascular disease, chronic obstructive pulmonary disease, right iliac artery disease, lung cancer, malignant pericardial and pleural effusions, pacemaker in situ, left carotid endarterectomy, hysterectomy, pericardial window, tonsillectomy, mitral regurgitation, aortic stenosis, patent foramen ovale, and coronary artery disease. MEDICATIONS: Amiodarone, Lipitor, Warfarin, furosemide, lansoprazole, digoxin, aspirin, fluconazole, and vancomycin. Vancomycin was for a methicillin-resistant Staphylococcus aureus that was growing out of her sputum prior to her previous discharge. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.8 F, heart rate 81 in sinus rhythm, blood pressure 148/71, respiratory rate 18, 100 % on room air. She is generally comfortably appearing and is sitting up in bed at this time. Her tracheostomy is noted to be in place without drainage or erythema around the site. Her lungs are clear to auscultation bilaterally with some coarse breath sounds reported. Her incision is noted to be well healed with Steri-Strips beginning to slough off. There is no drainage or erythema around the sternal wound. Her heart is in regular rate and rhythm. Without murmurs, rubs, or gallops at this time. Her abdomen is noted to be slightly distended with slightly hypoactive bowel sounds. Soft. Minimally tender throughout. No signs of rebound or guarding at this time. Her extremities are warm and well perfused. Distal pulses are 2+ with no clubbing, cyanosis, or edema. HOSPITAL COURSE: Thus, at this time the patient was admitted to the [**Hospital1 69**] for further evaluation and treatment. This 75-year-old female recently discharged with an aortic valve replacement and atrial septal defect repair was brought back into the hospital for further evaluation of persistent intraperitoneal free air status post percutaneous endoscopic gastrostomy tube placement on [**2117-9-1**], nine days prior to this at readmission. The question at this point was whether there was an active leak from the percutaneous endoscopic gastrostomy tube. A CAT scan was performed at this time that revealed no extravasation, though this did not satisfy our curiosity in regard to the possibility of anterior leak of the percutaneous endoscopic gastrostomy tube. The patient was noted to be stable, was afebrile, with a leukocyte count that was within normal limits and unchanged from 5 days previously. The plan at this time was to do a water-soluble contrast study through this PEG tube and to assess the patient in the prone position for possible anterior leak. On hospital day #3 the patient began to feel better, with less abdominal pain and less distention at this time. Patient continued to remain afebrile and to remain hemodynamically stable. There were no sudden rises in the leukocyte count, as well. The rest of her laboratories was within normal limits. We placed her PEG tube to gravity at this time with the plan to have a prone study performed the following day, and to continue to hold tube feeds at this time. In addition, Clostridium difficile toxin was sent off which came back negative. It was also notable that the patient was passing gas and having bowel movements at this time. On hospital day #4 the patient continued to progress well and was noted to be comfortable and did receive 1 unit of packed red blood cells at this time for a hematocrit of 25.6, noted to be down from 28 the previous day. The patient then had a follow up portable abdominal x-ray on Tuesday, [**9-14**], hospital day #5, that continued to show persistent large amount of free intraperitoneal air. There was retained contrast present in the colon, but there was, again, no sign of any sort of leak at this time. Thus, throughout the hospital course there was, at no point, that we could locate a definitive leak of contrast due to the percutaneous endoscopic gastrostomy tube. It was determined that the patient could have her tube feeds resumed. On hospital day #5 these tube feeds were resumed, indeed, and the patient tolerated them well and was slowly increased to her goal rate of 50 mL per hour of ProBalance with fiber. Also at this time, the patient received a PICC line on the right side that was placed under interventional radiology due to her presence of a permanent pacemaker on the left side. The patient also had a study of the venous system in the left upper extremity that revealed thrombosis of the left subclavian vein. This venous catheter was removed after the procedure and the port remained in place in the left antebrachial area. Then, on hospital day #6, the patient was evaluated again and had been continued on her tube feeds at this time. She was noted to be tolerating these well and was noticeably less distended on examination. She was spending significant amounts of time in her chair and was tolerating a tracheostomy mask at this time with continued plan for her to rest at night on the ventilator. On hospital day #6, it was determined the patient was fit for discharge to rehabilitation facility on continued tube feeds. The patient was to receive 1 more week of vancomycin for positive blood culture and yeast in sputum. The patient was to continue on tracheostomy mask during the day as needed and to be placed on the ventilator as needed at night so that she could rest. Fluconazole was not given necessary upon discharge. ER[**Last Name (STitle) 57362**]ving any increasing pains, fevers, chills, nausea, vomiting, shortness of breath, chest pain, redness or drainage about the wounds, or if there are any questions or concerns or signs of any events there untoward. Patient to continue on continuous positive airway pressure and pressure support for 12-14 hours a day goal and to receive assist control at night for rest. Patient to have International Normalized Ratio checked daily with goal of 2.0-2.5. Patient to receive tube feedings of ProBalance full strength at 50 mL per hour with checks every 4 hours for residuals, and tube feeds to be held for any residual greater than 100 mL. Patient to have an appointment with Dr. [**Last Name (Prefixes) **] scheduled upon discharge from rehabilitation facility. DISCHARGE DIAGNOSES: 1. Intraperitoneal free air in abdomen. 2. Status post aortic valve replacement. 3. Status post atrial septal defect repair. 4. Status post tracheostomy. 5. Status post percutaneous endoscopic gastrostomy. 6. Status post stage 3 lung cancer treatment. 7. Methicillin-resistant Staphylococcus aureus of the sputum. 8. Aortic stenosis. 9. Patent foramen ovale. 10. Chronic obstructive pulmonary disease. 11. Respiratory failure. 12. Cerebrovascular accident. 13. Hyperlipidemia. 14. Hypertension. 15. Peripheral vascular disease. 16. Status post permanent pacemaker in situ. 17. Status post left port placement [**2110**]. DISCHARGE MEDICATIONS: 1. Fluticasone 110 mcg 2. Actuation aerosol 2 puffs inhalation b.i.d. 3. Digoxin 125 mcg tablets 1 tablet p.o. once daily 4. Furosemide 20 mg p.o. once daily 5. Amiodarone 200 mg 0.5 tablets p.o. once daily for a total of 100 mg per day. 6. Lansoprazole 30 mg suspension delayed release 1 p.o. once daily. 7. Atorvastatin calcium 20 mg p.o. once daily. 8. Azintamide 10 mg p.o. once daily. 9. Albuterol ipratropium. 10. Actuation 103/18 mcg 6-8 puffs inhalation q.4 hours. 11. Aspirin 81 mg chewable p.o. once daily. 12. Vancomycin 1 g q.24 hours for 7 days intravenously. 13. Potassium chloride 20 mEq as needed for potassium less than 4.0. 14. Acetaminophen 325 mg 1-2 tablets p.o. q.4-6 hours as needed for pain. DISPOSITION: Stable and to be discharged to rehabilitation facility, [**Hospital2 57361**] [**Hospital3 **], on [**2117-9-16**]. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) 15912**] MEDQUIST36 D: [**2117-9-15**] 17:25:52 T: [**2117-9-15**] 20:43:05 Job#: [**Job Number 57363**] Name: [**Known lastname 5160**],[**Known firstname 2219**] Unit No: [**Numeric Identifier 10616**] Admission Date: [**2117-9-10**] Discharge Date: [**2117-9-16**] Date of Birth: [**2041-8-18**] Sex: F Service: CARDIOTHORACIC Allergies: Augmentin Attending:[**First Name3 (LF) 674**] Addendum: Pt. is on goal TF and tolerating it well. She has been on coumadin for afib and a clot in her L subclavian vein. Her INR was 1.5 today and she was restarted on heparin. Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**7-14**] Puffs Inhalation Q4H (every 4 hours). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 7 days. 11. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1) Intravenous PRN (as needed) as needed for K < 4.0. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 13. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day. 14. Heparin (Porcine) in NS 2 unit/mL Parenteral Solution Sig: Four Hundred (400) units Intravenous per hour: PTT goal 40-60. 15. Coumadin 1 mg Tablet Sig: One (1) Tablet PO tonight: INR goal 2-2.5. Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] [**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**] Completed by:[**2117-9-16**]

[ "V44.0", "272.4", "285.9", "V44.1", "V45.01", "V42.2", "793.6", "V12.59", "443.9", "162.5", "453.8", "496", "568.89" ]

icd9cm

[ [ [] ] ]

[ "96.72", "99.04", "96.6", "38.93", "88.67" ]

icd9pcs

[ [ [] ] ]

12155, 12372

8465, 9128

10841, 12132

3786, 8444

183, 2224

2899, 3768

2247, 2884

60,977

170,510

38791

Discharge summary

report

Admission Date: [**2142-4-2**] Discharge Date: [**2142-4-7**] Service: MEDICINE Allergies: Penicillins / Fosamax / Codeine / Zestril / Norvasc / Hydrochlorothiazide Attending:[**First Name3 (LF) 7651**] Chief Complaint: Dizziness Major Surgical or Invasive Procedure: AVNRT ablation - [**2142-4-3**] History of Present Illness: Ms [**Known lastname 5448**] is an 86 year old woman with history of HTN, vasovagal syncope, AVNRT, diastolic heart failure who presents with dizziness and shortness of breath. Per her NH notes, she complained of acute dizziness, weakness and SOB starting today. She was found to have a heart rate in 150's and SBP 100. She was BIBA to the ED. There she was found to be in AVNRT with HR 140's. She was given adenosine 6mg x6, each with temporary return to sinus but also fall in SBP to 60-70's. She was also given metoprolol 2.5mg x2, and dropped her BP as well. She was seen by the EP cardiology fellow who recomended admission to the CCU and amiodarone. She received amiodarone 150mg IV. On transfer to the CCU, her BP was 79/39. On the floor the patient states she currently feels "bad", breathing is "sore", no CP, no dizziness. Of note, she was admitted to [**Hospital1 18**] in [**2142-1-15**] for AVNRT as well. At that time, she presented with LOC while having a BM. She was cardioverted successfully with adenosine. She remained in sinus and was discharged on her previous dose of Metoprolol 12.5mg [**Hospital1 **]. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: (incomplete, as could not read last line of record from [**Hospital 4382**] facility) - chronic dCHF (echo '[**40**]: ef 65% LVF wnl, mod MR, TR) - h/o vasovagal stimulation - PVD - Dementia - Basal cell carcinoma - Anxiety - Condyloma - OA - Anemia of chronic disease Social History: -Tobacco history: Denies -ETOH: Denies -Illicit drugs: Denies Lives at [**Doctor Last Name **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] Estates [**Hospital3 400**] ([**Telephone/Fax (1) 86120**]) has paid help at home for ADL's. Walks with a [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is Dr. [**Known lastname 5448**] cell: [**Telephone/Fax (1) 86121**] Family History: NC; unable to be obtained from pt. Physical Exam: GEN: elderly female, Oriented x1. appears slightly anxious HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10 cm. CV: PMI located in 5th intercostal space, midclavicular line. tachycardic, No m/r/g. No thrills, lifts. No S3 or S4. LUNG: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: CXR: UPRIGHT AP VIEW OF THE CHEST: Heart size remains mildly enlarged, with rightward shift of the mediastinal structures secondary to volume loss within the right hemithorax, unchanged. The mediastinal and hilar contours are otherwise stable. A moderate-sized hiatal hernia is redemonstrated. The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: 1. No acute cardiopulmonary process. 2. Moderate-sized hiatal hernia. . CBC [**2142-4-3**] 05:45AM BLOOD WBC-8.8 RBC-3.45* Hgb-9.3* Hct-28.0* MCV-81* MCH-27.1 MCHC-33.4 RDW-20.1* Plt Ct-207 [**2142-4-2**] 11:30AM BLOOD WBC-13.7* RBC-4.12* Hgb-11.0* Hct-33.1* MCV-80* MCH-26.7*# MCHC-33.3 RDW-20.2* Plt Ct-281 . Coags [**2142-4-3**] 05:45AM BLOOD PT-11.9 PTT-26.2 INR(PT)-1.0 [**2142-4-2**] 11:30AM BLOOD PT-11.4 PTT-24.1 INR(PT)-0.9 . Chemistry [**2142-4-3**] 05:45AM BLOOD Glucose-98 UreaN-19 Creat-1.2* Na-139 K-5.0 Cl-106 HCO3-27 AnGap-11 [**2142-4-2**] 09:57PM BLOOD Glucose-119* UreaN-23* Creat-1.4* Na-139 K-4.4 Cl-104 HCO3-25 AnGap-14 [**2142-4-2**] 02:13PM BLOOD Glucose-188* UreaN-24* Creat-1.4* Na-135 K-3.8 Cl-98 HCO3-26 AnGap-15 [**2142-4-3**] 05:45AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.1 [**2142-4-2**] 09:57PM BLOOD Calcium-8.2* Phos-3.8 Mg-1.9 . labs at discharge: [**2142-4-6**] 06:15AM BLOOD WBC-9.2 RBC-4.66 Hgb-12.1 Hct-37.2 MCV-80* MCH-25.8* MCHC-32.4 RDW-19.4* Plt Ct-226 [**2142-4-6**] 06:15AM BLOOD Glucose-103* UreaN-43* Creat-1.9* Na-137 K-2.9* Cl-88* HCO3-32 AnGap-20 [**2142-4-4**] 06:44AM BLOOD calTIBC-404 Ferritn-21 TRF-311 Brief Hospital Course: Ms [**Known lastname 5448**] is an 86 year old female with h/o atrial fibrillation and AVNRT who presents with AVNRT and hypotension. #. AVNRT - patient has history of past episodes of AVRNT. On this admission, she was again noted to have AVNRT, rhythm was broken with adenosine x6 times on this admission, but recurred following the first 5 tries. On the last administration of adenosine, patient stayed in NSR. Given history of recurrent AVNRT, patient underwent successful EP ablation. Patient will continue on full dose aspirin for at least 1 month. # Hypotension: patient presented with SBP in the high 80s. Following conversion from AVNRT to NSR, blood pressure improved. Patient had no sign of sepsis on clinical exam, and no growth from blood cultures. Diuretics were initially held on admission given hypotension, but were restarted on discharge. . # Renal insufficiency: unknown baseline creatinine. On her last admission, she had a creatinine of 1.4-1.5, however improved to 1.1 on discharge. Her creatinine increased suddenly to 2.1 on [**4-5**] in the setting of mild dehydration. Her creatinine is now improving and is 1.7 today. Her diuretics were held and restarted at discharge. She has no signs of infection or evidence of ATN. No medication changes to cause nephritis. Chem 7 should be checked again on Monday [**4-9**]. K was initially high, then has required repletion. She is discharged on 20 meq daily. # Chronic Diastolic CHF: Pt was without symptoms on admission and appeared euvolemic on exam. Diuretics were initially help for hypotension, but with reversion to normal sinus rhythm following adenosine and ablation, patient's hemodynamics stablized. Patient will resume diuretics on discharge. She appears to have mild fluid overload with 1+ peripheral edema but has clear lung fields and no O2 requirement. # CAD: Patient was noted to have troponin of 0.02 on admission in the setting of tachyarrhythmia. Cardiac enzymes trended down to 0.01 following reversion to normal sinus rhythm. Patient was continued on ASA, metoprolol, and simvastatin. # Depression/Dementia: patient was continued on citalopram, effexor, and risperidone. Her mental status has waxed and waned but she has always been responsive with no signs of agitation. # Chronic constipation: patient was continued on senna and colace. Last BM on [**4-5**]. Medications on Admission: - Citalopram 40 mg daily - ASA 325 mg daily - Effexor 37.5 mg daily - Lasix 120 mg in AM and 80 mg in PM - Toprol 25 mg daily - Potassium 10 MEQ [**Hospital1 **] - Risperidone 0.5 mg daily - Simvastatin 40 mg daily - Spironolactone 25 mg daily - Metolazone 2.5 mg prn volume q Monday and Thursday Discharge Medications: 1. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 4. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO QAM (once a day (in the morning)). 5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 7. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day. 8. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 11. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for volume overload. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Discharge Diagnosis: Primary Diagnosis: - AVNRT Secondary Diagnosis: - Dyslipidemia - Hypertension - h/o AVNRT - chronic dCHF (echo '[**40**]: ef 65% LVF wnl, mod MR, TR) - h/o vasovagal syncope - Dementia - Basal cell carcinoma - Anxiety - Condyloma - OA of hip - Anemia of chronic disease - h/o basal cell carcinoma - osteopenia - depression - parkinsons disease - constipation Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to [**Hospital1 69**] because of dizziness and shortness of breath. You were found to be in an abnormally fast heart rhythm, which we treated with medication. Because you have been in this abnormal rhythm in the past, likelihood or this abnormal rhythm returning is high. During your stay here, you got an ablation in order to insure that this abnormal rhythm does not return. You will need to take aspirin for a month following this procedure. Your medications have changed. Please make note of the following changes: - new: aspirin 325 mg daily for 1 month The rest of your medications have not changed. Please continue to take them as originally prescribed. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow up with your primary care doctor, Dr. [**Last Name (STitle) **], in [**12-21**] weeks following discharge from the hospital. His office number is [**Telephone/Fax (1) 1579**].

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icd9cm

[ [ [] ] ]

[ "37.26", "37.34" ]

icd9pcs

[ [ [] ] ]

8401, 8531

4731, 7100

289, 323

8934, 8934

3113, 4413

9911, 10105

2377, 2413

7449, 8378

8552, 8552

7126, 7426

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351, 1481

8600, 8913

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8949, 9087

1665, 1935

1503, 1556

1951, 2361

8,107

103,661

53139

Discharge summary

report

Admission Date: [**2139-8-31**] Discharge Date: [**2139-9-9**] Date of Birth: [**2088-8-6**] Sex: M Service: PLASTIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 51-year-old male with a complex past medical history, significant for recent diagnosis of osteomyelitis of the right tibia, who presented to [**Hospital1 69**] on [**2139-8-31**], for a scheduled debridement of the right tibia with concomitant rectus free flap reconstruction and split thickness skin graft. The patient was most recently an inpatient at [**Hospital1 69**] from [**2139-7-12**], to [**2139-8-7**], at which point the diagnosis of right tibial osteomyelitis was confirmed via core biopsy conducted by the Plastic Surgery service of a right tibial lesion. At this time, the patient's biopsy was positive for pseudomonas, and the patient was started on a six week course of ceftazidime 2 grams intravenously every eight hours to be administered via PICC line, with plans for subsequent scheduled debridement and reconstruction. The patient was instructed to present to the [**Hospital1 188**] on [**2139-8-31**], in preparation for debridement and reconstructions scheduled for [**2139-9-1**]. PAST MEDICAL HISTORY: Post-traumatic stress disorder secondary to death of wife, hepatitis C, panic attack disorder, gastroesophageal reflux disease, previous right tibial skin graft secondary to motor vehicle accident, right total hip replacement secondary to motor vehicle accident, multiple fractures in [**2107**] secondary to motor vehicle accident. MEDICATIONS ON ADMISSION: Ceftazidime intravenously 2 grams via PICC line every eight hours, Protonix 40 mg by mouth once daily, Celexa 30 mg by mouth every morning, Norvasc 5 mg once daily by mouth, multivitamin one caplet by mouth once daily, vitamin C 1 gram by mouth once daily, Neurontin 800 mg by mouth three times a day, Klonopin 1 mg by mouth every 12 hours administered at 9 A.M. and 9 P.M., Klonopin 0.5 mg by mouth every 12 hours, methadone 30 mg by mouth three times a day, dilaudid 8 mg by mouth every three hours as needed, Ativan 1 mg by mouth every six hours as needed, Benadryl 25 mg by mouth twice a day as needed, Ambien 10 mg by mouth daily at bedtime as needed, Maalox 30 cc by mouth every four hours as needed, Compazine 5 mg by mouth every six hours as needed. ALLERGIES: Penicillin and codeine reportedly promote a rash in the patient. Trazodone causes headache. HOSPITAL COURSE: The patient was admitted to the Plastic Surgery service on [**2139-8-31**], under the direction of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Preoperative laboratory studies demonstrated a white blood cell count of 6.2, a hematocrit of 41.1. Chemistries: Sodium 137, potassium 4.4, chloride 102, bicarbonate 26, BUN 16, creatinine 0.9, glucose 109. PT 13.5, INR 1.5, PTT 35.8. The patient was made nothing by mouth at midnight, and prepared adequately for surgery the next day. On [**2139-9-1**], the patient underwent a right tibial debridement with a left rectus abdominis muscle free flap and split thickness skin graft from the left thigh to the right tibia reconstruction. The patient tolerated the procedure well, and received 6600 cc of fluid intraoperatively, with a urine output of 3225 and an estimated blood loss of 350 cc. No complications were noted, and a Dopplerable pulse was obtained intraoperatively and at the end of the procedure. Postoperatively, the patient was admitted to the Surgical Intensive Care Unit for close monitoring of his free flap. On postoperative day number one, the patient was noted to have stable vital signs and be afebrile. His flap demonstrated a Dopplerable pulse, and his left lower extremity donor site dressing was noted to be intact, with minor serosanguinous drainage. The patient's pain, however, was poorly controlled via a fentanyl patient-controlled analgesia, necessitating institution of basal rate infusion in tandem with on-demand pain medication administration. On postoperative day number two, the patient was noted to be stable enough for transfer to the regular inpatient floor, where he remained for the duration of his admission. On postoperative day number three, the patient was fitted with an Orthoplast posterior splint for his right lower extremity, to prevent equinus deformity. At this point, his flap was noted to continue to demonstrate Dopplerable pulses. All incision lines were noted to be clean, dry and intact, with minimal drainage, and no evidence of erythema or purulence. Due to continued breakthrough pain, however, the patient was evaluated by the Chronic Pain service, who recommended an increase in the patient's methadone dosage to 40 mg three times a day, with an oral dilaudid schedule of 8 to 12 mg by mouth every three to six hours as needed. On postoperative day number three, the patient's Foley was also discontinued, and the patient was subsequently noted to be independently productive of adequate amounts of urine. The patient continued to remain stable and progressed well clinically through [**2139-9-7**], at which point his intraoperative tissue cultures returned demonstrating Klebsiella species, sensitive to imipenem and Zosyn, and enterococcus species sensitive to ampicillin, levofloxacin, penicillin and vancomycin. An Infectious Disease consult was obtained, and the patient was subsequently recommended for continuance of vancomycin for a six week course via his PICC line, discontinuance of his ceftazidime dosage, and institution of imipenem 500 intravenously every six hours for six weeks. Electrolyte studies obtained at this point demonstrated adequate renal clearance, with a BUN of 11 and a serum creatinine of 0.6. On [**2139-9-9**], the patient was again noted to be afebrile, with stable vital signs, and was subsequently cleared for discharge to a rehabilitation facility, with instructions for long course intravenous antibiotic therapy and follow up with Plastic Surgery clinic. At the time of his discharge, the patient demonstrated a white blood cell count of 9.6, hematocrit 31.3, platelet count 307, sodium 139, potassium 4.3, chloride 102, bicarbonate 28, BUN 11, creatinine 0.7, glucose 92. Total protein was 6.7, albumin 3.4, total bilirubin 0.2, direct bilirubin 0.1. AST 35, ALT 30, alkaline phosphatase 134, C-reactive protein 1.05. CONDITION AT DISCHARGE: The patient is to be discharged to a rehabilitation facility, with instructions for follow up. DISCHARGE STATUS: Stable. DISCHARGE MEDICATIONS: 1. Pantoprazole 40 mg by mouth every 24 hours 2. Citalopram 30 mg by mouth every morning 3. Amlodipine besylate 5 mg by mouth once daily 4. Multivitamin one capsule by mouth once daily 5. Prochlorperazine 5 mg by mouth every six hours as needed 6. Ascorbic acid 1000 mg by mouth once daily 7. Gabapentin 800 mg by mouth three times a day 8. Clonazepam 1 mg by mouth every 12 hours at 9 A.M. and 9 P.M. 9. Clonazepam 0.5 mg by mouth once daily at 12 noon 10. Diphenhydramine 25 mg by mouth twice a day as needed 11. Zolpidem 10 mg by mouth daily at bedtime as needed 12. Aluminum magnesium 30 ml by mouth every four hours as needed 13. Docusate sodium 100 mg by mouth twice a day 14. Bisacodyl 10 mg by mouth/per rectum once daily as needed 15. Enteric-coated aspirin 16. Heparin 5000 units subcutaneously every 12 hours 17. Nicotine 14 mg transdermally once daily 18. Clonidine TTS one patch transdermally every Monday 19. Methadone 40 mg by mouth three times a day 20. Dilaudid 8 mg by mouth every three to four hours as needed for pain 21. Celecoxib 200 mg by mouth twice a day 22. Vancomycin 1000 mg intravenously every 12 hours through PICC line until [**2139-10-17**] 23. Imipenem 500 mg intravenously every six hours through PICC line until [**2139-10-19**] FOLLOW UP INSTRUCTIONS: The patient is to keep his right lower extremity flap clean and dry with Xeroform and dry sterile dressing changes twice per day. The patient may sponge bath until follow-up appointment, but should pat dry his right lower extremity wound afterwards. No bathing until further notice. The patient's abdominal Steri-Strips will fall off on their own. The right lower extremity is strictly non-weight bearing. Vancomycin and imipenem should be administered for a six week course via the PICC line. The patient is to follow up in the Plastic Surgery Clinic in one week following discharge. The patient is to call [**Telephone/Fax (1) 274**] to schedule an appointment. ACTIVITY INSTRUCTIONS: The patient is to remain non-weight bearing on his right lower extremity. Activity for the right lower extremity is limited to five minutes of dangling over the bed edge per hour per day. The patient may advance by five minutes per hour per week. The patient is to keep the right lower extremity elevated at all times while in bed or seated and when not dangling. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2647**], M.D. [**MD Number(1) 2648**] Dictated By:[**Last Name (NamePattern1) 1053**] MEDQUIST36 D: [**2139-9-8**] 21:36 T: [**2139-9-9**] 00:31 JOB#: [**Job Number **]

[ "730.16", "707.19", "300.01", "304.90", "309.81", "530.81" ]

icd9cm

[ [ [] ] ]

[ "86.69", "77.67", "83.82" ]

icd9pcs

[ [ [] ] ]

6551, 9217

1580, 2445

2463, 6389

6404, 6528

175, 1196

1219, 1553

68,860

127,116

8944

Discharge summary

report

Admission Date: [**2125-9-29**] Discharge Date: [**2125-10-9**] Date of Birth: [**2039-3-17**] Sex: F Service: MEDICINE Allergies: Cipro Cystitis / Bactrim DS Attending:[**First Name3 (LF) 2297**] Chief Complaint: cough Major Surgical or Invasive Procedure: Bronchoscopy ([**2125-10-8**]) History of Present Illness: This is an 86 year old woman with a history of rheumatoid arthritis on Humira and dementia who is presenting from her [**Hospital1 1501**] with three weeks of cough and new O2 requirement. Her son explains that her cough started 3 weeks ago and was junky and productive. Her LTC facility gave her a a [**Name (NI) 31069**] (unclear date given) but she did not improve. According to the son she has been intermittently on O2 at her [**Hospital1 1501**] for the past month. No fevers, chills, shortness of breath or other symptoms. On the day of admission she started complaining of increased fatigue and developed a low grade fever. Her O2 sats at the LTC facility were 92% on 2L. She also mentioned some abdominal pain to her son this morning which he thinks was consistent with her ongoing constipation. . On arrival to the ED her initial vital signs were temp 98.4 and heart rate of 79 blood pressure of 89/33 respiratory rate of 22 and O2 sats of 74% on room air (and then 92% on 4L O2). A chest x-ray showed an ill-defined retrocardiac opacity which could reflect aspiration or infection with a small left pleural effusion. She did not improve on a trial of nebs. She was started on vanc/zosyn for health care associated pneumonia and received a total of 500cc of IVF. She denied any abdominal pain and had a benign abdominal exam. Her vital signs at the time of transfer were HR 66 RR 27 BP 109/43 with O2 sats of 96% on a non-rebreather. . On arrival to the MICU she is in visible discomfort and breathing through a non-rebreather. She endorsed some shortness of breath and cough but denied any chest pain. . Her son also mentions that he noticed bilateral conjunctivitis this morning, L>R, and he thinks that she got this from one of the other residents in her LTC facility. She does not wear contacts and has no history of glaucoma. . Review of systems: (+) Per HPI + eye discharge starting today, L>R + low grade fevers day of admission (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure or palpitations. Denies nausea, vomiting, diarrhea, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Seronegative RA and PMR, on Humira Hypertension Urinary incontinence History of TIAs h/o Diverticulitis s/p L colectomy Osteopenia h/o MRSA HSV meningitis - on acyclovir through [**2119-8-26**] Status post cholecystectomy Status post total abdominal hysterectomy Social History: Lives in [**Hospital1 1501**]. Former smoker. No alcohol or illicits. Family History: Mother with [**Name2 (NI) **] Physical Exam: Admission exam: General: Alert, oriented x2, moderate distress HEENT: eyes with prurulent discharge bilaterally, L>R, unable to open left eye, dry MMM Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, III/VI SEM throughout precordium Lungs: rhonchi, L>R, poor exam Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: trace edema bilaterally, warm, well perfused with palpable pulses, no clubbing or cyanosis Neuro: grossly intact Discharge exam: expired with patient unarousable, absent pupillary dilation, absent corneal reflexes, absent heart sounds, breath sounds on auscultation or air movement, absent pulse. Pertinent Results: Labs on Admission: [**2125-9-29**] 05:59PM COMMENTS-GREEN TOP [**2125-9-29**] 05:59PM LACTATE-1.3 [**2125-9-29**] 05:59PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.024 [**2125-9-29**] 05:59PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-TR [**2125-9-29**] 05:59PM URINE RBC-10* WBC-6* BACTERIA-MANY YEAST-NONE EPI-6 [**2125-9-29**] 05:59PM URINE HYALINE-13* [**2125-9-29**] 05:59PM URINE WBCCLUMP-FEW MUCOUS-FEW [**2125-9-29**] 05:35PM GLUCOSE-151* UREA N-19 CREAT-0.9 SODIUM-136 POTASSIUM-5.6* CHLORIDE-98 TOTAL CO2-29 ANION GAP-15 [**2125-9-29**] 05:35PM estGFR-Using this [**2125-9-29**] 05:35PM ALT(SGPT)-8 AST(SGOT)-30 CK(CPK)-40 ALK PHOS-81 TOT BILI-0.3 [**2125-9-29**] 05:35PM LIPASE-18 [**2125-9-29**] 05:35PM cTropnT-0.02* [**2125-9-29**] 05:35PM CK-MB-1 [**2125-9-29**] 05:35PM CALCIUM-8.8 PHOSPHATE-3.6 MAGNESIUM-1.8 [**2125-9-29**] 05:35PM WBC-11.1*# RBC-4.13* HGB-10.8* HCT-36.3 MCV-88 MCH-26.2* MCHC-29.8* RDW-14.8 [**2125-9-29**] 05:35PM NEUTS-86.8* LYMPHS-7.2* MONOS-5.4 EOS-0.4 BASOS-0.2 [**2125-9-29**] 05:35PM PLT COUNT-399 [**2125-9-29**] 05:35PM PT-12.4 PTT-32.6 INR(PT)-1.1 [**2125-10-9**] 04:18AM BLOOD WBC-12.0* RBC-4.08* Hgb-10.8* Hct-37.4 MCV-92 MCH-26.4* MCHC-28.8* RDW-15.0 Plt Ct-333 [**2125-10-9**] 04:18AM BLOOD Plt Ct-333 [**2125-10-9**] 04:18AM BLOOD [**2125-10-9**] 04:18AM BLOOD Glucose-127* UreaN-52* Creat-4.7* Na-135 K-5.4* Cl-95* HCO3-25 AnGap-20 [**2125-10-9**] 04:18AM BLOOD Calcium-8.6 Phos-6.5* Mg-2.3 Micro:URINE CULTURE (Final [**2125-10-1**]): GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. Blood Cx: [**9-29**]- negative, final Cdiff toxin [**2125-10-1**] -negative, final Urine Cx [**2125-10-4**]- yeast, final Brief Hospital Course: 86F a history of RA on Humira and dementia who presents from her [**Hospital1 1501**] with pneumosepsis. She was presented with a CXR showing a left pleural/parapneumonic effusion that quickly worsened to complete white-out of this lung, likely secondary to a post-obstructive pneumonic process. She was febrile and hypotensive, sent to the MICU for management. She was covered for HCAP with Vancomycin and Zosyn, extended past the typical 8-day coverage due to the severity of her pneumonia and extremely high O2 requirement of 6L NC and high-flow O2 through the mask. She then developed RML collapse and she was unable to wean off any of this oxygen. Her code status was confirmed DNR/DNI with her family. Her severe conjunctivitis was treated with erythromycin ointment on admission and improved markedly over her hospital course. She then developed progressive acute kidney injury, with urine sediment confirming acute tubular necrosis. She continued to become more somnolent with hypercarbia. BiPAP was initiated without benefit, though orotracheal suctioning seemed to stimulate her cough and wake her up. Given the refractoriness of her disease, an awake bronchoscopy was performed to look for any acute, reversible conditions (i.e. mucus plugging). Follow-up CXRs showed progression of her disease bilaterally and her O2 saturations dropped into the 70s. Given the irreversibility of her condition, the family decided to transition the patient to comfort measures only and morphine boluses were given for comfort. Ms. [**Known lastname 3549**] passed away the following morning, on [**2125-10-9**]. An autopsy was declined by the family. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from webOMR LTC records. 1. Citalopram 20 mg PO DAILY 2. Memantine 10 mg PO DAILY 3. Lisinopril 30 mg PO DAILY Hold for SBP < 100 4. traZODONE 25 mg PO HS:PRN insomnia 5. Amlodipine 5 mg PO DAILY hold for SBP < 100 6. Donepezil 10 mg PO DAILY Do not crush. Give whole in apple sauce. 7. FoLIC Acid 1 mg PO DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY Start: In am Hold for SBP < 100 or HR < 60 9. Guaifenesin [**6-7**] mL PO Q6H:PRN cough 10. Bisacodyl 10 mg PR HS:PRN constipation 11. Milk of Magnesia 15-30 mL PO Q6H:PRN constipation If ineffective see dulcolax suppository order 12. Multivitamins 1 TAB PO DAILY Start: In am Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A

[ "V49.86", "995.92", "733.90", "331.0", "714.0", "285.9", "519.19", "311", "V12.72", "788.30", "518.81", "038.9", "294.10", "511.9", "745.5", "V88.01", "E944.4", "482.9", "V12.04", "530.81", "372.30", "V12.54", "584.5", "725", "787.91" ]

icd9cm

[ [ [] ] ]

[ "33.23" ]

icd9pcs

[ [ [] ] ]

8164, 8173

5685, 7345

294, 326

8220, 8225

3782, 3787

8277, 8283

3030, 3061

8136, 8141

8194, 8199

7371, 8113

8249, 8254

3076, 3578

3594, 3763

2216, 2640

249, 256

354, 2197

3802, 5662

2662, 2927

2943, 3014

16,579

135,932

1223

Discharge summary

report

Admission Date: [**2146-11-23**] Discharge Date: [**2146-11-29**] Date of Birth: [**2079-5-7**] Sex: F Service: CARDIOTHOR CHIEF COMPLAINT: Ms. [**Known lastname 7716**] is a 67-year-old female with a past history of non-Q wave MI and PTCA to the RCA in [**2139**] referred to [**Hospital1 69**] for an outpatient cardiac catheterization due to recurrent positional angina and a positive stress test. HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 7716**] is status post non-Q wave MI in [**2139**]. At that time, she had an angioplasty to the RCA. Post intervention she had an episode of PSVT. Since then she has done well until the last few months when she started to experience recurrent symptoms. She reports chest tightness and dyspnea with exertion such as going up a flight of stairs. Also she has been complaining of periods of lightheadedness and feeling very fatigue. She reports her symptoms having become progressively worse over the past few months and having felt palpitations on a daily basis lasting less than a minute at a time. She had an episode of discomfort two nights prior to admission that lasting 20 minutes then resolved on its own. She presented to the [**Hospital1 **] Emergency room which she reported had two sets of negative CPKs and two EKGs that were negative for any acute changes. A stress test done on [**10-26**] during which the patient achieved 73% of her predicted age heart rate and did not have any chest pain throughout the procedure. T segments were uninterpretable because the patient had PSVT beginning one minute after exercise which resolved spontaneously two minutes following the end of the stress test. Nuclear imaging revealed mild completely reversible inferior wall defect. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Coronary artery disease. 4. Mild aortic regurgitation. PAST SURGICAL HISTORY: 1. Left hemiarthroplasty. 2. Cholecystectomy. SOCIAL HISTORY: Patient is married with adult children. She lives at home with her husband. She has a father who died of acute MI at age 42 and two nephews who died suddenly at ages 39 and 40. ALLERGIES: Patient has allergies to aspirin which causes hives and Niacin which causes a rash. MEDICATIONS PRIOR TO ADMISSION: 1. Atenolol 75 q.d. 2. Lipitor 20 q.d. 3. Plavix 75 mg q.d. 4. Somantadine 300 mg q.d. 5. Prempro 0.625 mg q.d. LABORATORY: White count 7.5, hematocrit 38.3, platelets 255. Sodium 140, potassium 4.5, chloride 104, CO2 27, BUN 17, creatinine 0.6, INR 1.1. PHYSICAL EXAMINATION: Neuro grossly intact. No carotid bruits appreciated. Pulmonary: Lungs are clear to auscultation bilaterally. Heart sounds S1, S2 with a IV/VI systolic ejection murmur. Abdomen: Obese, benign. Extremities are warm with 1+ peripheral edema, no varicosities. As stated previously, the patient was admitted to the [**Hospital1 1444**] for cardiac catheterization. Please see the cath report for full details. Summary of cath showed elevated right and left heart filling pressures with preserved cardiac output 40 mm gradient across the aortic valve area 0.8 cm square. No mitral regurgitation. Ejection fraction of 67%. Mild left main disease, 50% LAD, 50% left circumflex and total occlusion of RCA with right to left and left to left collaterals. Cardiac surgery was consulted. The patient was seen by the Cardiothoracic Service and accepted for aortic valve replacement and coronary artery bypass grafting. On [**11-23**], the patient was brought to the Operating Room. Please see the OR report for full details. In summary, the patient had a coronary artery bypass graft times two with a LIMA to the LAD and saphenous vein graft to the RCA. AV section of the subendocardial membrane root enlargement with bovine pericardium and AVR with a #22 [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. She tolerated the surgery well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. The patient did well immediately postoperatively. She was hemodynamically stable with both Nipride and Amiodarone infusion on postoperative day #1. Anesthesia was reversed upon arrival to the cardiothoracic Intensive Care Unit. She was successfully weaned from the ventilator and extubated on the day of surgery. On postoperative day #2, the patient was weaned from her Nipride and her Amiodarone drips. She remained hemodynamically stable. On postoperative day #3, the patient's chest tubes were removed and she was transferred from the Cardiothoracic Intensive Care Unit to [**Hospital Ward Name 7717**] for continuing postoperative care and cardiac rehabilitation. Over the next several days with the assistance of the nursing staff and Physical Therapy, the patient's activity level was increased. On postoperative day #6, it was deemed that the patient was stable and ready for discharge to home. At the time of discharge, the patient's physical exam is as follows: Vital signs with a temperature of 98.0 F, heart rate 74, sinus rhythm, blood pressure 115/74, respiratory rate 18, O2 saturation 94% on room air. Weight preoperatively is 106 kilograms and at discharge is 110.8 kilograms. Labs with a white count of 13, hematocrit 32.9, platelets 236. Sodium 136, potassium 4.1, chloride 98, CO2 28, BUN 15, creatinine 0.6. Glucose 104. Physical exam is alert and oriented times three. Moves all extremities and conversant. Pulmonary: Clear to auscultation bilaterally. Heart: Regular rate and rhythm, S1, S2. Sternum is stable. Incision with staples open to air, clean and dry. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well-perfused. Right thigh wound with Steri-Strips open to air, clean and dry. Large ecchymotic surrounding the right side incision. DISCHARGE MEDICATIONS: 1. Amiodarone 400 mg t.i.d. times five days then b.i.d. times one week then q.d. 2. Lopressor 25 mg b.i.d. 3. Lipitor 20 mg q.d. 4. Plavix 75 mg q.d. 5. Captopril 6.5 mg t.i.d. 6. Furosemide 20 mg b.i.d. times two weeks. 7. Potassium Chloride 20 mEq b.i.d. times two weeks. 8. Keflex 500 mg q.i.d. times 10 days. 9. Percocet 5/325 one to two tabs q. four hours p.r.n. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass graft times two. 2. Aortic regurgitation status post aortic valve replacement. 3. Hypertension. 4. Hypercholesterolemia. 5. Status post hemiarthroplasty. 6. Status post cholecystectomy. Th[**Last Name (STitle) 1050**] is to be discharged home with visiting nurse visits to assess wound care. She is to follow up with Dr. [**Last Name (Prefixes) 2545**] in four weeks. Follow up with Dr. [**Last Name (STitle) **] also in four weeks and follow up with Dr. [**Last Name (STitle) 931**] in three to four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2146-11-29**] 15:39 T: [**2146-11-29**] 15:36 JOB#: [**Job Number 7718**]

[ "413.9", "458.2", "401.9", "414.01", "412", "794.31", "427.31", "424.1", "427.1" ]

icd9cm

[ [ [] ] ]

[ "36.11", "89.68", "39.61", "35.21", "36.15" ]

icd9pcs

[ [ [] ] ]

6289, 7119

5890, 6268

1916, 1965

2291, 2554

2577, 5867

162, 424

453, 1766

1788, 1893

1982, 2259

30,208

143,396

51836

Discharge summary

report

Admission Date: [**2183-11-14**] Discharge Date: [**2183-11-14**] Date of Birth: [**2111-12-2**] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Compazine / Benadryl / Sulfa (Sulfonamide Antibiotics) / Zinc / Phenothiazines / Oxycodone / aspirin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: s/p PEA cardiac arrest Major Surgical or Invasive Procedure: Endotracheal intubation Right subclavian line placement Femoral line placement Therapeutic hypothermia protocol Needle decompression for pneumothorax Bilateral chest tube placement History of Present Illness: 70 y/o with DM2, HTN, HLD, asthma, who presented from her [**Hospital1 1501**] with cardiac arrest. She was reported to be in respiratory distress, and when receiving a nebulizer, went into PEA arrest. EMS was called, CPR was initiated and epinephrine was given x2. The pt was intubated in the field and an I/O line was placed. She arrived to [**Hospital1 18**] with CPR in progress, however shortly upon arrival had confirmed return of spontaneous circulation with SBP was low ~60s. She was started on norepinephrine and phenylephrine and dopamine were added sequentially. Initial labratory tests showed a lactate of 10 and a venous pH of 6.95. She received one ampule of sodium bicarb and 3L NS. Bedside cardiac ultrasound showed global hypokinesis, but no pericardial effusion or right heart strain. ECG showed sinus rhythm. ET tube placement was confirmed by laryngoscopy (was pulled back out of right main stem bronchus). She had a sterile right subclavian line placed and an unsterile femoral arterial line placed. She was started on the artic sun cooling protocol. . She then became increasingly more difficult to ventilate, with high peak pressures. Manual bagging was attempted, but was also difficult. Needle decompression was then preformed on the right with positive release of air. Right chest tube then placed, however, bagging was persistently difficult. Needle decompression on left was negative, but chest tube was placed on the left anyway, with improvement in bagging. . Family is here and attending spoke with family. Requested aggressive care including pressor support, but no CPR/DNR. . Most recent set of vitals prior to transfer: afebrile, 110, 87/56 18 100% on AC 300/24/8/100% with peak pressures 31. Plan was to get CT-A on way up to MICU to r/o PE. Past Medical History: - Type 2 diabetes mellitus - Hypertension - Dyslipidemia - Obesity - s/p GI bleed - Peptic ulcer disease/GERD/hiatus hernia - Diverticulosis - Osteoarthritis - OSA on CPAP at home, Epworth Sleepiness score is a [**8-8**] - Sinusitis - recurrent (4 severe episodes) of Group B strep cellulitis/bacteremia - TIA in [**12-24**] presented with facial droop and weakness for 2 hours; had her aspirin increased to 325mg. - Panic disorder/Depression (3 prior suicide attempts by drug overdose) - Personality disorder, NOS - Borderline personality . PSxH: - Total abdominal hysterectomy-for Ovarian CA in [**2158**] - She mentioned that she had a recent lung biopsy which was suggestive of sarcoidosis according to the patient, in her CTA chest carried out in [**2182-3-18**], there is a mention of possible BAL lung ca. - Bilateral Breast reduction complicated by Left breast cellulitis/abscess - s/p R knee replacement [**2176**] - cholecystectomy Social History: Currently lives at [**Hospital3 **]. She is able to ambulate with assistance of a walker but is basically wheelchair dependant. She does not smoke, or drink alcohol. Tried marijuana for a year in the [**2142**]. Family History: Mother died of renal failure. Father died of an MI at age 58. She has a brother with skin cancer. She has another sister w HTN. Physical Exam: ADMISSION EXAM: Intubated, sedated, not responsive to voice, pupils fixed and dilated. Right subclavian CVL and femoral line in place. RRR. Bilateral chest tubes in place. Coarse breath sounds bilaterally. Abdomen soft but increasingly distended with minimal bowel sounds. Extremities cool with palpable pulses. DISCHARGE EXAM: No pulse detected. Patient not responsive to voice or sternal rub. Pupils fixed and dilated. No spontaneous respirations. No cardiac sounds auscultated. No respirations auscultated. Pertinent Results: [**2183-11-14**] 02:50AM BLOOD WBC-9.6 RBC-3.55* Hgb-10.2* Hct-34.4* MCV-97 MCH-28.8 MCHC-29.7* RDW-14.8 Plt Ct-194 [**2183-11-14**] 02:50AM BLOOD PT-12.9 PTT-35.1* INR(PT)-1.1 [**2183-11-14**] 02:50AM BLOOD PT-12.9 PTT-35.1* INR(PT)-1.1 [**2183-11-14**] 02:50AM BLOOD Fibrino-311 [**2183-11-14**] 02:50AM BLOOD UreaN-18 Creat-1.1 [**2183-11-14**] 02:50AM BLOOD Lipase-18 [**2183-11-14**] 02:50AM BLOOD Cortsol-8.5 [**2183-11-14**] 02:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-10 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2183-11-14**] 02:54AM BLOOD pH-6.95* Comment-GREEN TOP [**2183-11-14**] 02:54AM BLOOD Glucose-340* Lactate-10.3* Na-139 K-4.8 Cl-99 calHCO3-24 [**2183-11-14**] 02:54AM BLOOD freeCa-1.17 [**2183-11-14**] 07:17AM BLOOD WBC-21.7*# RBC-3.73* Hgb-10.9* Hct-33.3* MCV-89# MCH-29.1 MCHC-32.6 RDW-14.8 Plt Ct-242 [**2183-11-14**] 07:17AM BLOOD Neuts-91.2* Lymphs-6.3* Monos-0.8* Eos-1.5 Baso-0.3 [**2183-11-14**] 07:17AM BLOOD Glucose-326* UreaN-23* Creat-1.3* Na-150* K-4.5 Cl-101 HCO3-37* AnGap-17 [**2183-11-14**] 03:15PM BLOOD Glucose-425* UreaN-28* Creat-1.6* Na-136 K-3.6 Cl-93* HCO3-23 AnGap-24* [**2183-11-14**] 07:17AM BLOOD ALT-63* AST-138* LD(LDH)-477* AlkPhos-124* TotBili-0.2 [**2183-11-14**] 11:44AM BLOOD CK(CPK)-596* [**2183-11-14**] 07:17AM BLOOD CK-MB-10 cTropnT-<0.01 [**2183-11-14**] 11:44AM BLOOD cTropnT-0.03* [**2183-11-14**] 07:17AM BLOOD Calcium-7.3* Phos-7.9*# Mg-1.9 [**2183-11-14**] 03:15PM BLOOD Calcium-8.3* Phos-5.3* Mg-1.9 [**2183-11-14**] 04:03PM BLOOD Type-ART pO2-123* pCO2-71* pH-7.14* calTCO2-26 Base XS--6 [**2183-11-14**] 04:03PM BLOOD Lactate-4.6* [**2183-11-14**] 04:03PM BLOOD freeCa-1.09* Blood culture [**11-14**]: Pending Urine culture [**11-14**]: ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. TTE: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Symmetric LVH with normal global and regional biventricular systolic function. CTA Chest: 1. No pulmonary embolism or acute aortic pathology. 2. Bilateral chest tubes terminating in the medial lung bases. No large pneumothorax. 3. Nonspecific patchy opacity in the right upper lobe, could represent pulmonary contusion from chest compression and/or insertion of chest tube, pneumonia or aspiration. CT Head: Limited study. No acute intracranial pathologic process. No intracranial hemorrhage. Brief Hospital Course: 70F with DM2, HTN, HLD, and asthma, who presented from her [**Hospital1 1501**] s/p PEA arrest. Suspected that acute hypoxia, possibly secondary to asthma exacerbation, had led to cardiac arrest. The patient was intubated in the field, arrived to the [**Hospital1 18**] ED with CPR in progress, and shortly upon arrival was found to have return of spontaneous circulation with SBP in the 60s. Admission labs notable for lactate 10 and venous pH of 6.95. She had a sterile right subclavian line placed and an unsterile femoral arterial line placed. She was bolused 3L NS, treated with sodium bicarb, and started on norepinephrine, phenylephrine, and dopamine for blood pressure support. She was started on the therapeutic hypothermic cooling protocol. In setting of patient becoming difficult to ventilate with high peak pressures, she had right-sided needle compression with positive release of air; right chest tube then placed. Needle decompression on left was negative for release of air; left chest tube also placed. Bedside cardiac ultrasound showed global hypokinesis, but no pericardial effusion or right heart strain. ECG showed sinus rhythm. CTA chest did not show e/o PE or acute aortic pathology. CT head was negative for acute intracranial pathologic process and intracranial hemorrhage. Per discussion between attending and patient's family, decision was made to pursue aggressive care including pressor support, but no CPR/DNR. Patient was admitted to the MICU for further management. In the ICU, she continued to require maximum doses of three pressors to maintain adequate blood pressure in the setting of post-arrest distributive and cardiogenic shock. She was continued on the cooling protocol, and bedside EEG was set-up. Over the course of the day, she was noted to have an increasing amount of ectopy on telemetry. Another family meeting was held between the ICU attending and the patient's sister/HCP. [**Name (NI) 227**] poor prognosis, decision was made to withdraw aggressive care and focus on patient's comfort. The patient expired at 21:20 on [**2183-11-14**] with her family at the bedside. The family declined an autopsy. Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA - 2 puffs inhaled q4-6h ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tab QD AZELASTINE - 137 mcg (0.1 %) Aerosol, - 2 spray [**Hospital1 **], post nasal drip CITALOPRAM - 20 mg Tablet - 3 Tabs QD ***CLINDAMYCIN HCL - 300 mg Cap - 2 Capsule(s) by mouth today and tonight as needed FLUTICASONE - 50 mcg Spray, Suspension - 2 squirts(s) nasally QD FUROSEMIDE - 20 mg Tab, every other day GLIPIZIDE - 10 mg Tablet - 1 Tab QD HYDROCODONE-ACETAMINOPHEN [VICODIN] - Dosage uncertain LAMOTRIGINE [LAMICTAL] - 200 mg Tab - 1 Tab QD LIPITOR - 40MG Tablet - 40MG QD LISINOPRIL - 10MG Tablet - 10MG QD METFORMIN - 500 mg Tablet Extended Release 24 hr - one tablet QD METOCLOPRAMIDE - 5 mg Tablet - 1 Tablet [**Hospital1 **] METOPROLOL TARTRATE - 25 mg Tab - t1/2 tablet [**Hospital1 **] MIRTAZAPINE - 15 mg Tablet - 3 Tab QHS MUPIROCIN - 2 % Ointment - apply to ulcers QD under xeroform gauze MUPIROCIN - 2 % Ointment - [**Hospital1 **] to ulcerated areas around umbilicus PROPOXYPHENE - Dosage uncertain QUETIAPINE [SEROQUEL] - 400 mg Tab, 1 Tab QHS SIMVASTATIN [ZOCOR] - 80 mg Tab - 1 Tab QD TEMAZEPAM - 15 mg Capsule - 1 QHS VALSARTAN [DIOVAN] - 40 mg QD Medications - OTC CALCIUM CARBONATE - 500 mg (1,250 mg) 1 Tab TID CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - 400 u Tab QD OMEPRAZOLE MAGNESIUM - 20 mg Tablet, Delayed Release (E.C.) - QD SENNOSIDES [SENNA] - Dosage uncertain ZEASORB-AF - 2% Powder - [**Hospital1 **] for fungal infection Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: s/p PEA arrest Distributive and cardiogenic shock s/p cardiac arrest Hypoxic respiratory failure Metabolic acidosis Pneumothorax with chest tube placement Discharge Condition: Patient expired. Discharge Instructions: Not applicable. Followup Instructions: Not applicable. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "493.90", "250.00", "V49.86", "530.81", "401.9", "311", "300.01", "276.2", "785.51", "512.8", "272.4", "427.5", "715.90", "301.83", "518.5", "327.23" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.91", "38.93", "34.04", "34.91", "96.71" ]

icd9pcs

[ [ [] ] ]

10790, 10799

7068, 9240

427, 609

10997, 11015

4321, 6950

11079, 11233

3639, 3768

10761, 10767

10820, 10976

9266, 10738

11039, 11056

3783, 4100

4116, 4302

365, 389

637, 2429

6959, 7045

2451, 3394

3410, 3623

8,414

191,366

4263

Discharge summary

report

Admission Date: [**2196-11-16**] Discharge Date: [**2196-11-22**] Date of Birth: [**2124-6-9**] Sex: F Service: CICU HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old female with a past medical history significant for coronary artery disease (status post coronary artery bypass graft in [**2184**] with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the first obtuse marginal, saphenous vein graft to the posterior descending artery), status post cardiac catheterization in [**2196-6-27**] with stenting of the left main, left circumflex, and second obtuse marginal, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, and recent upper gastrointestinal bleed who was admitted for elective cardiac catheterization. The patient is status post a recent cardiac catheterization in [**2196-6-27**] with a hospital course complicated by post catheterization anemia and esophagogastroduodenoscopy demonstrating gastritis and three nonbleeding ulcers. At that time, the patient was treated with 5 units of packed red blood cells, epinephrine injection, and high-dose proton pump inhibitor. The patient is now referred for a repeat cardiac catheterization on [**11-16**] following a positive nuclear stress test on preoperative workup for knee surgery. The patient underwent a nuclear stress test demonstrating a reversible lateral defect with an ejection fraction of 45%. The patient denies recent or current chest pain, orthopnea, paroxysmal nocturnal dyspnea, dyspnea on exertion, as well as angina. The patient also denies recent or current melena and bright red blood per rectum. PAST MEDICAL HISTORY: 1. Coronary artery disease; status post 3-vessel coronary artery bypass graft in [**2184**]; status post cardiac catheterization in [**2190**] with evidence of 3-vessel disease with an ejection fraction of 67%, and patent grafts, status post cardiac catheterization in [**2196-5-28**] demonstrating 70% to 80% occlusion of the left anterior descending artery, 60% of the left main artery, 80% of the left circumflex artery, 60% of the second obtuse marginal, 60% occlusion of the ostial second diagonal, diffusely diseased right coronary artery with a mid total occlusion and 60% proximal occlusion, a total occlusion of the saphenous vein graft to second obtuse marginal, a 20% to 30% occlusion of the saphenous vein graft to posterior descending artery, and patent graft of the left internal mammary artery to left anterior descending artery. The cardiac catheterization was aborted prior to stent placement secondary to acute hypotension and left groin hematoma during the catheterization. A subsequent abdominal CAT scan was without evidence of retroperitoneal bleed. The patient is status post cardiac catheterization in [**2196-5-28**] demonstrating 80% occlusion of the left main artery, total occlusion of the left anterior descending artery, 80% occlusion of the mid left circumflex artery, and 90% occlusion of the second obtuse marginal branch. The patient underwent stent placement in the left main artery, mid left circumflex, as well as second obtuse marginal branch. 2. Upper gastrointestinal bleed in [**2196-6-27**]; status post cardiac catheterization (details above). 3. Chronic obstructive pulmonary disease (on home oxygen). 4. Hypertension. 5. Paroxysmal atrial fibrillation. 6. History of small cell lung cancer; status post chemotherapy and radiation therapy approximately eight years ago. 7. Hypothyroidism. 8. Type 2 diabetes mellitus. 9. Parkinson disease. 10. Alzheimer's dementia. 11. History of colon cancer; status post resection approximately two years ago. 12. Morbid obesity. 13. Gastroparesis. 14. Status post total abdominal hysterectomy. 15. Status post appendectomy. 16. Chronic anemia (with a baseline hematocrit of 34 to 35). ALLERGIES: Allergies include CODEINE and AMBIEN. MEDICATIONS ON ADMISSION: 1. Synthroid 125 mcg p.o. q.d. 2. Lasix 40 mg p.o. q.d. 3. Amiodarone 100 mg p.o. q.d. 4. Prednisone 7.5 mg p.o. q.d. 5. Glyburide 5 mg p.o. q.d. 6. Reglan 10 mg p.o. t.i.d. 7. Cogentin 1 mg p.o. b.i.d. 8. K-Dur 20 mEq p.o. q.d. 9. Naprosyn 500 mg p.o. q.d. 10. Zestril 5 mg p.o. q.d. 11. OxyContin 2 mg p.o. b.i.d. 12. Nexium 40 mg p.o. q.d. SOCIAL HISTORY: The patient is married and lives with her husband. The patient reports a remote tobacco history of approximately a 20-year duration. The patient denies alcohol as well as intravenous drug use. FAMILY HISTORY: Family history was noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed temperature was 97.7, heart rate was 87, blood pressure was 117/48, respiratory rate was 11, oxygen saturation was 96% on room air. In general, the patient was an obese elderly female in no acute distress. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Sclerae were anicteric. Pupils were equal, round, and reactive to light and accommodation. Extraocular movements were intact bilaterally. Mucous membranes were moist. Edentulous. The oropharynx was clear. Neck examination revealed supple, with no jugular venous distention, and no lymphadenopathy. Cardiovascular examination revealed a regular rate and rhythm with a 2/6 systolic ejection murmur at the left upper sternal border with no third heart sound or fourth heart sound appreciated. Pulmonary examination was clear to auscultation bilaterally with no wheezes, rhonchi, or rales. Abdominal examination revealed soft, obese, normal active bowel sounds nontender, and nondistended. No hepatosplenomegaly was appreciated. Extremity examination revealed 2+ nonpitting edema with 2+ dorsalis pedis and posterior tibialis pulses bilaterally. No clubbing or cyanosis. PERTINENT LABORATORY DATA ON PRESENTATION: Pertinent laboratories and studies during the hospitalization revealed the patient's admission hematocrit was 31.1. On transfer to the Cardiothoracic Intensive Care Unit on hospital day three, the patient had a complete blood count with a white blood cell count of 7.4, hematocrit was 22.3, mean cell volume was 84, and platelets were 190. The patient's Chemistry-7 revealed sodium was 138, potassium was 4, chloride was 103, bicarbonate was 23, blood urea nitrogen was 29, creatinine was 0.8, and blood glucose was 83. Calcium was 8, magnesium was 1.6, and phosphate was 2.6. HOSPITAL COURSE: The patient underwent a two-step cardiac catheterization on hospital day one. The patient's cardiac catheterization revealed 20% left main artery in-stent restenosis, total occlusion of the stented left circumflex, serial 60% and 80% stenoses of the saphenous vein graft to the posterior descending artery with a patent left internal mammary artery graft to the left anterior descending artery. The cardiac catheterization also demonstrated normal filling pressures. The patient underwent percutaneous transluminal coronary angioplasty of the left circumflex followed by left circumflex brachy therapy. The patient underwent a second stage cardiac catheterization on hospital day two with stenting of the saphenous vein graft to the right coronary artery with good results. The second stage cardiac catheterization also revealed 70% elastic recoil of the left circumflex without intervention. The [**Hospital 228**] hospital course was uneventful until the morning on hospital day three when the patient complained of nausea, orthostatic symptoms, and mild shortness of breath. The patient was found with a systolic blood pressure in the 80s, heart rate was in the 90s, with a hematocrit of 21.3 (down from 30.3 the night prior). There was no evidence of melena, bright red blood per rectum, groin hematoma, or signs of external bleeding. The patient was transferred to the Cardiothoracic Intensive Care Unit for evaluation and management. The patient's Integrilin was discontinued at this time, and the patient was continued on aspirin and Plavix for recent stenting of the coronary arteries. The patient was bolused with intravenous fluids with sustained blood pressures in the range of 110 to 120. A right internal jugular triple lumen was placed for intravenous access. The patient underwent a STAT abdominal and pelvic CAT scan with evidence of large retroperitoneal bleed (right iliopsoas hematoma with right common femoral artery soft tissue stranding). The patient was typed and crossed and transfused a total of 4 units of packed red blood cells with an inappropriate bump in her hematocrit of 8 points; from 21.3 to 29.8. The patient automatically diuresed without evidence of volume overload during transfusion. The patient remained without angina or chest pain and in a normal sinus rhythm on amiodarone throughout the extent of the hospitalization. The patient's hematocrit stabilized at 29 to 30 without evidence of groin hematoma. However, later on hospital day three, the patient had one episode of large melanotic stool with a subsequent drop in her hematocrit from 32 to 27 (hemodynamically stable without abdominal pain). The patient was placed on high-dose proton pump inhibitor and underwent an upper endoscopy on hospital day five with evidence of a clean-based, acute, nonbleeding gastric antral ulcer; presumably the source of the gastrointestinal bleed. There was no further evidence of melena, and the patient was transfused 2 units of packed red blood cells with an appropriate increase in her hematocrit from 27 to 34. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE DIAGNOSES: 1. Coronary artery disease; status post coronary artery bypass graft in [**2184**] and multiple cardiac catheterizations including cardiac catheterization in [**2196-10-28**] with left circumflex angioplasty and brachy therapy and stenting of the saphenous vein graft to the posterior descending artery. 2. Retroperitoneal hemorrhage. 3. Status post upper gastrointestinal bleed in [**2196-6-27**] and in [**2196-10-28**] with gastric ulcers. 4. Anemia. 5. Paroxysmal atrial fibrillation. 6. Chronic obstructive pulmonary disease (on home oxygen). 7. Hypertension. 8. Alzheimer's dementia. 9. Parkinson disease. 10. Type 2 diabetes mellitus. 11. Status post colon cancer. 12. Status post small cell lung carcinoma. 13. Hypothyroidism. MEDICATIONS ON DISCHARGE: 1. Plavix 75 mg p.o. q.d. (for a 30-day course). 2. Amiodarone 100 mg p.o. q.d. 3. Zestril 5 mg p.o. q.d. 4. Synthroid 125 mcg p.o. q.d. 5. Prednisone 5 mg p.o. q.d. 6. Glyburide 5 mg p.o. q.d. 7. Reglan 10 mg p.o. t.i.d. 8. Cogentin 1 mg p.o. b.i.d. 9. OxyContin 2 mg p.o. b.i.d. 10. Nexium 30 mg p.o. q.d. 11. Naprosyn 500 mg p.o. q.d. 12. Aspirin 325 mg p.o. q.d. 13. Lasix 40 mg p.o. q.d. 14. K-Dur 20 mEq p.o. q.d. DISCHARGE STATUS: The patient was discharged to home with home [**Hospital6 407**] and Physical Therapy services. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with her primary care physician/cardiologist in one to two weeks status post discharge. 2. The patient was also instructed to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the [**Hospital **] Clinic for a follow-up upper endoscopy and ulcer biopsy in four to six weeks status post discharge (at the completion of Plavix therapy). [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**] Dictated By:[**Last Name (NamePattern1) 18503**] MEDQUIST36 D: [**2196-11-24**] 16:15 T: [**2196-11-29**] 07:59 JOB#: [**Job Number 18504**]

[ "401.9", "496", "294.10", "531.40", "414.00", "427.31", "332.0", "331.0", "458.2" ]

icd9cm

[ [ [] ] ]

[ "88.53", "88.56", "45.13", "37.22", "36.06", "36.01", "92.27", "38.93" ]

icd9pcs

[ [ [] ] ]

4564, 6480

9647, 10404

10431, 10990

3969, 4333

6499, 9576

11023, 11716

9591, 9625

163, 1673

1696, 3942

4350, 4546

52,260

110,896

52235+59406

Discharge summary

report+addendum

Admission Date: [**2166-2-15**] Discharge Date: [**2166-2-24**] Date of Birth: [**2100-10-22**] Sex: M Service: MEDICINE Allergies: Darvocet-N 50 Attending:[**First Name3 (LF) 2751**] Chief Complaint: Epistaxis, nausea, hypotension Major Surgical or Invasive Procedure: EGD History of Present Illness: The patient is a 65 yo M with Hx of multiple CVAs, CAD with stents (DES to RCA [**2164**], off plavix), HTN, pacemaker, Mechanical Aortic valve who has had several recent admissions to [**Hospital1 18**] for anemia (thought secondary to epistaxis and hematuria). Most recently admission was([**Date range (1) 80819**]), where he initially presented with SOB, dizziness and Hct of 22, and guaiac pos stools. He was transfused, and did not bump appropriately to transfusions; labs were suggestive of hemolysis although coombs and antibody testing were normal. His Hct stabilized and was 23.6 on discharge; he was sent home with a plan to f/u with hematology and undergo outpatient egd/[**Last Name (un) **]. Overnight, he experienced an episode of copious epistaxis and returned to the ED today complaining of HA, nausea and mild SOB. In the ED, initial vs were: 98.8 86 93/48 18 100% on RA. BP declined to 70s/40s and Hct was down approx 3 pts to 20.8 with INR 3.1. Rectal exam showed black, guaiac pos stool and nasal examination showed slight oozing of the septum. The patient was given approximately 800 cc NS, protonix 80 mg IV, zofran IV, and given 3 units prbcs. During his transfusion, reportedly passed a large amount of melena, and was cross-matched for another 4 units prbcs. Vitals on transfer were: BP 86/50, HR 74, RR 25, 100% on RA. He was admitted to the ICU for ongoing hypotension in the setting of anemia. On the floor, patient reports dizziness, nausea and abdominal tenderness. Has some SOB, which he describes as chronic. No epistaxis today. Review of systems: (+) Per HPI, also reports recent constipation the past week (relieved with today's melena, as well as intermittent black stools for the past several months. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - CVA x 4 (most recent [**7-9**] while on warfarin, ASA and plavix) - HTN - CAD - single vessel distal LAD - MI - in [**2164**], 3 stents unknown type unknown date - s/p ICD implantation [**2163-12-8**] Parciology PC [**Telephone/Fax (1) 107924**] - CHF - preserved EF, diastolic - AVR - Mechanical valve [**2159-3-31**] - DM-II - COPD - Low Back Pain - Nephrolithiasis - Duodenal ulcer on EGD [**2161-9-28**] Social History: -Smoking/Tobacco: 60 pack years, quit 2 years ago -EtOH: seldom -Illicits: IV drugs once in his life when young, never again -Lives at/with: daughter and her family. She assists with his medications. Independent with ADLs and ambulates with cane. From [**2162**]-[**2164**] he lived in [**State 9512**] and so we have no records of his care at that time. He states that he has never been in the military, never been incarcerated although he has been around individuals who have. He is not currently sexually active and has had female partners in the past. Family History: (from OMR) There is diabetes mellitus, hypertension and dyslipidemia in several immediate family members. His sister had CHF/?MI begining in her late 40s. His mother had breast cancer and CHF. Physical Exam: Vitals: T: 96.6 BP: 83/46 P: 70 R: 18 O2: 99% on RA General: elderly AA man, appearing in mild discomfort HEENT: NCAT, Sclera anicteric, MMM, oropharynx clear, nasal mucosae with dried blood visible on nasal septum b/l Lungs: mild bibasilar rales, otherwise CTAB CV: Regular rate and rhythm, normal S1 + S2, II-III/VI systolic murmur loudest RUSB Abdomen: soft, non-distended, bowel sounds present, TTP in upper quadrants b/l, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, 2+ pitting edema b/l (per family, slightly improved from baseline) Discharge: Pertinent Results: Admission Labs [**2166-2-14**] WBC-6.8 RBC-2.49* Hgb-8.1* Hct-23.6* MCV-95 MCH-32.6* MCHC-34.4 RDW-18.2* Plt Ct-184 PT-38.0* PTT-47.9* INR(PT)-3.9* Glucose-105* UreaN-22* Creat-0.7 Na-133 K-4.1 Cl-105 HCO3-21* AnGap-11 HCT nadir 20.8 CXR ([**2166-2-20**]): Small bilateral pleural effusions, larger on the left side associated with adjacent atelectasis worse in the left side are new. Cardiomegaly is stable. Left transvenous pacemaker leads terminate in standard position in the right atrium and right ventricle. Mild vascular congestion is new. Sternal wires are aligned. Degenerative changes are in the thoracic spine. Patient is status post AVR. EGD: Erythema and contact bleeding in the antrum compatible with diffuse gastritis [**2166-2-23**] 07:00AM BLOOD PT-28.8* PTT-106.5* INR(PT)-2.8* [**2166-2-22**] 06:35AM BLOOD PT-23.8* PTT-83.0* INR(PT)-2.3* [**2166-2-21**] 07:25AM BLOOD PT-22.4* PTT-65.5* INR(PT)-2.1* [**2166-2-20**] 09:54AM BLOOD PT-20.9* PTT-47.5* INR(PT)-1.9* [**2166-2-19**] 06:18PM BLOOD PT-20.8* PTT-39.7* INR(PT)-1.9* Brief Hospital Course: 1. Acute blood loss anemia: Multifactorial with (a) epistaxis; (b) gastritis; (c) anticoagulation. A total of 8 units of pRBC were transfused and aspirin/warfarin were held. No reversal of anticoagulation was done given mechanical valve and prior stroke. After EGD showed gastritis, pantoprazole dose was increased. ENT follow-up was arranged to help manage epistaxis which stopped spontaneously. 2. Hypotension: Per family and the patient, he has had chronically low BPs for at least the past month. Likely secondary to hypovolemia in the setting of acute bleed. SBP remained in 90s after stabilization of bleeding. Given CHF/CAD, Low dose beta blocker and daily morning lasix was resumed on discharge since BP was at its baseline. 3. Epistaxis: Patient with multiple episodes of epistaxis in the past several months. Last ENT evaluation showed evidence of anterior bleeding. Afrin was given for 3 days was given as well as nasal saline, humidified air and vaseline to nasal mucosa. ENT follow-up was arranged. 4. Gastritis: Given guaiac positive stool, EGD was done and showed gastritis. Pantoprazole dose was increased. 5. Mechanical AVR: Anticoagulated with goal INR 2.5-3.5. Managed with a heparin gtt with warfarin resumed after stabilization of HCT. He was instructed to take 2mg Warfarin on discharge ([**2166-2-23**]), repeat level will be drawn by VNA on [**2166-2-24**] and [**Company 191**] will be in touch with patient. Pt's PCP [**Name Initial (PRE) 21150**] (Dr. [**Last Name (STitle) **] was paged and this issue discussed. Date - INR value:Warfarin Dose [**2166-2-19**] - 1.9:3mg [**2166-2-20**] - 1.9:3mg [**2166-2-21**] - 2.1:3mg [**2166-2-22**] - 2.3:3mg [**2166-2-23**] - 2.8:2mg 6. Congestive heart failure, diastolic, acute on chronic: Initially dry to euvolemic but after administration of pRBC, experienced orthopnea with CXR showing mild vascular congestion. Improved with one day of IV furosemide diuresis. As above, resumption of beta-blocker and lisinopril was initially limited by SBP, though BP normalized to his baseline of low 90s. Once daily lasix and low dose betablockade was resumed. Medications on Admission: (list confirmed with patient on arrival to the floor) - Flovent HFA 110 1 puff twice daily - folic acid 1 mg daily - furosemide 20 mg daily - glyburide 10 mg daily - Combivent 18-103 mcg 1 puff twice daily as needed for shortness of breath - lisinopril 2.5 mg daily - metoprolol succinate (Toprol) 12.5 mg daily - nitroglycerrin SL 0.4 mg as needed chest pain - oxycodone 10 mg daily as needed for back pain - polyethylene glycol 3350 17 gram daily as needed for constipation - aspirin 81 mg daily - colace 100 mg twice daily - warfarin with goal INR 2.5-3.5 - recently prescribed but not yet taken: ferrous sulfate 300 mg daily and omeprazole 20 mg daily Discharge Medications: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 3. glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day. 4. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) puff Inhalation twice a day as needed for shortness of breath or wheezing. 5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain. 7. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for back pain. 8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) packet PO once a day as needed for constipation. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. ferrous sulfate 324 mg (65 mg Iron) Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: take night of [**2166-2-23**] (Sunday). Discuss Monday night's dose with [**Hospital 191**] [**Hospital3 **] nurse. [**Last Name (Titles) **]:*10 Tablet(s)* Refills:*0* 14. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 15. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: 1. Acute blood loss anemia 2. Gastritis, diffuse with active bleeding 3. Epistaxis 4. Mechanical heart valve 5. Prior stroke 6. Coronary artery disease, native [**Last Name (un) 108044**] 7. CHF, diastolic, chronic 8. Diabetes, type II, controlled Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with a low blood count (anemia). This is most likely from both a nose bleed (epistaxis) but may also be from some bleeding in your stomach (gastritis). You received a total of 8 units of blood transfused. To help promote healing of the stomach, we have increased your dose of pantoprazole to twice daily. You had some fluid overload (heart failure) from the transfusions and required a higher lasix dose, but this has been readjusted back to your baseline. You were treated with IV heparin bridge until your INR was at normal levels again. You will need to have your INR and BLood count checked tomorrow and faxed to your doctor's office. Followup Instructions: Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] When: WEDNESDAY [**2166-2-26**] at 10:50 AM With: Dr [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] 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: OTOLARYNGOLOGY (ENT) When: WEDNESDAY [**2166-2-26**] at 1:45 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**] Building: LM [**Hospital Unit Name **] [**Location (un) 895**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE Department: CARDIAC SERVICES When: MONDAY [**2166-3-3**] at 3:30 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: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2166-3-5**] at 4:30 PM With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Known lastname 17639**],[**Known firstname 17640**] E. Unit No: [**Numeric Identifier 17641**] Admission Date: [**2166-2-15**] Discharge Date: [**2166-2-24**] Date of Birth: [**2100-10-22**] Sex: M Service: MEDICINE Allergies: Darvocet-N 50 Attending:[**First Name3 (LF) 310**] Addendum: Patient's discharge was delayed 18 hours because he had mild repeat epistaxis when being given discharge papers after he blew his nose. He was give Afrin nasal spray and manual compression x 45 min with good hemostasis after discussion with ENT consult team over phone. His HCT remained stable. He was given 2mg coumadin on evening [**2166-2-23**]. INR was 2.7 on [**2166-2-24**]. He remained stable overnight. He is discharged with instructions to repeat nasal compression in forward leaning position x 45 min in case of epistaxis, and to not pick or blow nose. He will continue Afrin nasal spray 3 sp q 8 hr for another two and a half days. A hand-written prescription was given to him for this prior to discharge from the medical floor since his DC orders had already been signed. [**Hospital 112**] [**Hospital **] clinic was contact[**Name (NI) **] by me and they are aware of his INR. He will go home on Warfarin 3mg nightly per their instructions, and should have repeat INR and CBC checked on [**2166-2-26**]. Discharge Disposition: Home With Service Facility: [**Hospital 197**] [**Name (NI) 198**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 314**] MD [**MD Number(2) 315**] Completed by:[**2166-2-24**]

[ "250.00", "285.1", "428.32", "V45.01", "784.7", "V43.3", "401.9", "428.0", "496", "V15.82", "V58.61", "724.2", "V12.54", "414.01", "535.41", "458.9" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

14016, 14240

5339, 7470

307, 313

10227, 10227

4266, 5316

11061, 13993

3446, 3641

8176, 9842

9957, 10206

7496, 8153

10377, 11038

3656, 4247

1935, 2424

236, 269

341, 1916

10242, 10353

2446, 2857

2873, 3430

10,954

109,166

6265

Discharge summary

report

Admission Date: [**2177-1-16**] Discharge Date: [**2177-2-6**] Date of Birth: [**2125-1-14**] Sex: F Service: MEDICINE Allergies: Darvon Attending:[**First Name3 (LF) 17865**] Chief Complaint: bilateral lower extremities arterial ulcers Major Surgical or Invasive Procedure: left femoral-popliteal bypass graft angioplasty History of Present Illness: 52 yof with extensive [**First Name3 (LF) 1106**] history presents to clinic with concern for infected bilateral lower extremity ulcers. Ms. [**Known lastname 13257**] is well known to our team and presented today for eval of her LE ulcers. She recently saw her pcp who put her on oral steroids. She reports the uclers worsened and are draining. Past Medical History: Type I Diabetes Mellitus Peripoheral neuropathy Diabetic Nephropathy (failed transplant) - pt was scheduled for repeat transplant on [**2174-8-23**] but was cancelled because of her PVD historybilateral retinopathy s/p retinal detachment. Benign Hypertension significant PVD history with multiple prior LE bypass surgeries Prior GI bleeding on ASA and plavix CAD s/p MIx2, s/p LAD stents s/p CABG [**8-19**] Meningitis chronic anemia - likely multifactorial due to renal failure, hx of antral erosions and mild esophagitis on EGD CVA x 2 hyperlipidemia Social History: Two children in their 20s. She lives with her boyfriend and has 24-hour support at home from him and from her daughter. She formerly worked at the post-office. She has a 30-pack-year history of smoking and quit in [**2165**]. She does not drink alcohol. Family History: Her mother is alive at age 77 without significant medical problems. [**Name (NI) **] father died at age 76 of sepsis. He also had type 2 diabetes and prostate cancer. She has a sister age 51 and another sister age 41 who has type 1 diabetes. There is no family history of blood disorders or colon cancer. Physical Exam: On admission: Vitals: T 94.5-97.2, BP 119-152/40-46, P 58-70, RR 14, O2sat 94% 2L NC General: lying in bed, no acute distress, appears stated age HEENT: NCAT, PERLL, anicteric, OP clear Neck: supple, no LAD Pulm: poor inspiratory effort, mildly reduced BS at bases, occasional rhonchi at left base CV: irreg, appears to have PVCs on A-line [**Location (un) 1131**], nl S1 S2, no m/r/g Abd: ecchymoses, soft, overweight, non-tender, +BS Extrem: both lower extremities wrapped, poor and faint DP/PT pulses bilaterally, right extremity prior digit amputation Neuro: CN 2-12 intact, non-focal Pertinent Results: admission labs: [**2177-1-16**] 10:00PM GLUCOSE-219* UREA N-86* CREAT-6.3*# SODIUM-139 POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-23 ANION GAP-25* [**2177-1-16**] 10:00PM WBC-17.4* RBC-5.51*# HGB-13.8 HCT-48.5* MCV-88# MCH-25.1*# MCHC-28.5* RDW-20.0* [**2177-1-16**] 10:00PM PLT COUNT-424 Brief Hospital Course: The patient was admitted to the [**Year/Month/Day **] Surgical Service for evaluation and treatment of the ulceration of bilateral lower extremities. Patient was hemodynamically stable at the time of admission. Neuro: The patient received oral and intravenous pain control with good effect. During the periods when she was mildly confused or lethargic, the pain medications were used with care. Patient was alert and oriented until the HD 11 when she was found to be confused and obtunded in respiratory distress and subsequently transferred to the ICU. Her mental status has been fluctuating since. Psych: Patient has been depressed throughout the entire stay. She experienced hoplessness and helplessness with her current situation. She was also voiced wishes to die. Patient has been seen on by a social work services. CV: At the time of admission patient was stable from a cardiovascular standpoint. Few days after the admission she experienced episodes of nausea. She was rulled out for myocardial ischemia. Her troponin was elevated in 0.4 range and in the days to follow, it rose as high as 1.2. Cardiology was consulted and felt that the etiology was the stress ischemia. They recommended trending troponins, serial EKGs were done. No intervention was recommended. There was no acute ischemia. Recommendation was to stop lisinopril as patient was in worsening renal failure, beta blocker was recommended, but currently held, as patient blood pressure has been quite low. Further follow up was not necessary, perhaps catheterization in the future. Patient was cleared for the angiogram by cardiology. Patient had an echocardiogram which showed right ventricular strain. Patient had an angiogram done which showed stenosis in the left femoral to popliteal bypass graft, which was angioplastied. Patient tolearted the procedure well and was stable post-procedure. Her signals dopelarable monophasic - posterior tibialis and dorsalis pedis bilaterally. Pulmonary: Patient has an underlying COPD. She was initially stable from the respiratory standpoint. Her oxygen requirement increased over the course of the week of hodpitalization from one liter to three liters on nasal canula. As her renal function worsened she developed bilateral pleural effusion, worse on the right. She was found with altered mental status on HD 11. Her ph at that time was 7. She was emergently intubated and transferred to the ICU. She remained intubated for a day and extubated easily. She underwent diagnostic/therapeutic thoracocentesis on HD 12 while in ICU. She also recieved more agressive hemodialysis to optimaize her respiratory status. After transfer from the ICU to floor her repiratory status remained stable, sating over 92% on 3L NC. GI/GU/FEN: Patient's intake and output were closely monitored. She is on hemodialysis and continued to be hemodialysed on MWF per her schedule. However, she was also hemodilaysed on three consecutive days following the respiratory distress which was most likely attributable to right heart failure and fluid overload. Electrolytes were routinely followed, and were not replaced as patient is on hemodialysis. Patient was on regular diet, however has had a poor intake. No supplemental nutrition was provided. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Her WBC remoned high despite the treatment with levofloxacin and unasyn. Levofloxacin was stopped on HD 12, the dose of unasyn was decreased on HD14. Patient has remained afebrile. Patient has blood cultures pending. Wound care was provided twice daily to lower extremitied bilaterally. The wounds are significantly improved bilaterally. The culture grew beta streptococcus. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Patient was followed by [**Last Name (un) **]. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin, aspirin and plavix. She was unable to umbulate secondary to her painful feet. She ambulated to chair. At the time of transfer, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, yet had poor intake. She was stable from respiratory and cardiovascular standpoint. Her code status was not addressed, she is full code at the time of transfer. . . ICU course: The patient was transferred to the MICU for GI bleed. This stabilized shortly after ICU admission, with no further signs of bleeding per rectum. However, she developed a supraventricular arrhythma with HR 130-140, similar to episodes of junctional tachycardia documented during prior admissions. EKG while tachycardic also demonstrated ischemic ST elevations in the inferior leads with reciprocal depressions in the precordium. Goals of care were clarified with the patient and her family, and the decision was made not to pursue aggressive cardiac interventions including cathetherization, CPR, shocks, or intubation. Shortly thereafter, the patient's blood pressure became unstable, requiring >8L of fluid as well as neosynephrine. She then spontaneously converted to NSR and her BP stabilized, although pressors continued to be required. Goals of care were again addressed with the patient and her family. The decision was made to move toward making the patient comfortable. Appropriate medication changes were made, and the patient died the following day. Medications on Admission: lipitor 40mg once daily, nephrocaps 1 tab daily, calcium acetate 667 2tabs [**Hospital1 **], plavix 75mg daily, tricor 145mg daily, lantus 12u am , humalog ss, lisinopril 20 mg daily, lorazepam 1mg qhs, metop succinate 100mg daily, faroxetine 10mg daily, tylenol prn, vit c 500mg daily, asa, zinc 50 mg daily Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased Completed by:[**2177-2-6**]

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icd9cm

[ [ [] ] ]

[ "96.04", "34.91", "38.93", "99.60", "88.48", "00.41", "39.50", "39.95", "96.71" ]

icd9pcs

[ [ [] ] ]

8733, 8742

2852, 8374

311, 360

8794, 8804

2538, 2538

8861, 8899

1603, 1913

8763, 8773

8400, 8710

8828, 8838

1928, 1928

228, 273

388, 735

2554, 2829

1942, 2519

757, 1311

1327, 1587

32,703

147,061

33653

Discharge summary

report

Admission Date: [**2159-2-26**] Discharge Date: [**2159-3-2**] Date of Birth: [**2115-5-15**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [**2159-2-26**] - CABGx4 (Left internal mammary->Left anterior descending artery, Vein->Diagonal artery, Vein->Obtuse marginal artery, Vein->Right coronary artery). History of Present Illness: 43 y/o female with positive ETT performed for cardiac clearance for hysterectomy. A cardiac catheterization was performed which showed severe left main disease. She is now admitted for surgical revascularization. Past Medical History: HTN, DM2, lipids, PVD, obesity, L SFA atherectomy, R SFA stent with ISR, known lung nodule Social History: Quit smoking 3 months ago. Denies alchol use. Lives with husband and daughter. She is employed as a crossing guard. Family History: + For strokes. Physical Exam: 91 18 144/72 GEN: WDWN in NAD SKIN: Warm, dry, no clubbing or cyanosis. HEENT: PERRL, Anicteric sclera, OP Benign. Poor dentition. NECK: Supple, no JVD, FROM. LUNGS: CTA bilaterally, mild kyphosis. HEART: RRR,Nl S1-S2 No M/R/G ABD: Soft, ND/NT/NABS EXT:warm, well perfused, no bruits, no varicosities, No peripheral edema NEURO: No focal deficits. Pertinent Results: [**2159-2-26**] ECHO PRE-CPB:1. The left atrium is normal in size. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). 7. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusion of phenylephrine. Preserved biventricular systolic function post bypass. LVEF now 65%. Trace MR. Aortic contour is normal post decannulation. [**2159-2-28**] CXR The right internal jugular line was removed in the meantime interval as well as mediastinal drains and left chest tube. The bibasal atelectasis are moderate, unchanged. There is no increase in pleural effusion. There is no evidence of frank pneumothorax although minimal amount of left apical air cannot be excluded. [**2159-3-2**] 06:00AM BLOOD WBC-6.8 RBC-3.71* Hgb-9.9* Hct-30.2* MCV-81* MCH-26.7* MCHC-32.8 RDW-15.0 Plt Ct-415# [**2159-3-2**] 06:00AM BLOOD Plt Ct-415# [**2159-3-2**] 06:00AM BLOOD Glucose-129* UreaN-16 Creat-0.7 Na-138 K-4.3 Cl-105 HCO3-24 AnGap-13 Brief Hospital Course: Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2159-2-26**] for surgical management of her coronary artery disease. She was taken to the operating room where she underwent coronary artery bypass grafting to four vessels. Postoperatively she was taken to the intensive care unit for monitoring. By postoperative day one, she had awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. She was transfused 2 units of packed red blood cells for postoperative anemia. Plavix was resumed given her recent superficial femoral artery atherectomy. On postoperative day two, she was transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. Chest tubes and pacing wires removed without incident.She continued to make steady progress and was discharged home on postoperative day 4.Pt. is to make all followup appts. as per discharge instructions. Medications on Admission: Lipitor 40mg QD Lisinopril 10mg QD Aspirin 325mg QD Glipizide 10mg [**Hospital1 **] Metformin 500mg [**Hospital1 **] Lopressor 50mg [**Hospital1 **] Plavix 75mg QD Discharge Medications: 1. Atorvastatin 40 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 DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1 weeks. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: CAD s/p CABGx4 HTN Diabetes Mellitus Type 2 Hyperlipidemia Uterine adenocarcinoma PVD Obesity Lung Nodule Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. Shower daily and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with Dr. [**Last Name (STitle) 8579**] in 2 weeks. Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Please call all providers to schedule appointments. Completed by:[**2159-3-2**]

[ "443.9", "414.01", "250.00", "180.9", "401.9", "278.00" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.13", "99.04", "39.63" ]

icd9pcs

[ [ [] ] ]

5731, 5780

3176, 4238

333, 500

5930, 5939

1406, 3153

6635, 6929

1005, 1021

4452, 5708

5801, 5909

4264, 4429

5963, 6612

1036, 1387

281, 295

528, 742

764, 856

872, 989

50,782

177,873

3504

Discharge summary

report

Admission Date: [**2120-4-4**] Discharge Date: [**2120-4-30**] Date of Birth: [**2048-5-25**] Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Shellfish Derived Attending:[**First Name3 (LF) 10323**] Chief Complaint: SOB/weakness Major Surgical or Invasive Procedure: Thoracentesis (left side) Thoracentesis with pigtail drains (left and right) Pleurex catheter placement (left) History of Present Illness: 71 F with h/o Stage II pancreatic cancer diagnosed in [**2118-6-7**] s/p pancreatoduodemectomy and adjuvant radiation and Gemcitabine in [**2118-10-7**] p/w SOB and generalized weakness for several days, worse with exertion. pt is s/p IR thoracentesis on [**3-29**] w/ 2.5L of transudative effusion removed from the right side. After procedure went home and almost immediately began experiencing some SOB particularly with exertion and standing which worsened to the point where her oncologist referred her to the ED today. Pt noted lightheadedness and extreme weakness and palpitations when attempting to stand up with severe DOE of just several steps. States these symptoms are similar to what she experienced prior to pleurocentesis [**3-29**] but worse. Pt states she has been able to keep up with PO intake despite. Denies n/v but has had diarrhea for the last 3 weeks s/p antibiotic course w/ CTX for E.coli bacteremia, course ending [**3-9**]. Stool is now loose for the last week but no longer watery and never with blood. Denies abd pain/headaches. . OF note, during her recent hospitalization she had a thoracentesis. Fluid analysis showed transudate and path showed ?reactive. mesothelial cells (from ascitic tap). PT also with known portal vein thrombosis and at home on treatment dose lovenox. . ED course: Initial vitals: 97.8 106 88/43 20 97%. Triggered for hypotension but BP in the room was then 118/72. Did not receive IVF at that time. EKG: sinus rhythm at 94 bpm, no STE, low voltage diffusely CXR: bilateral pleural effusions. Labs pertinent for: Na 123, K 5.3 ?hemolyzed, BUN/CR 17/0.8, glucose 283. Hct 42 (up from 29 recent b/l) WBC 6 with PMNs 80%, LFTs with AST/ALT at 54/74 and alk phos stable but elevated at 362. IP was paged and will evaluate pt in the AM. . PT was admitted to the [**Hospital Unit Name 153**]. On arrival appeared comfortable on 3L NC with BP 110/84, 96, 98% 3LNC. Pt stated she felt fine with breathing improved. Denied pain of any kind. Drank some [**Location (un) 2452**] juice. Repeat labs in [**Hospital Unit Name 153**] showed Na of 128. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or wheezing. Denies chest pain, chest pressure. Denies 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: - T2, N1, stage IIB pancreatic adenocarcinoma diagnosed in [**1-/2118**] on ERCP. s/p pylorus-preserving pancreaticoduodenectomy. s/p gemcitabine c/b thrombocytopenia and neutropenia. [**3-17**] CT showed bilateral lung nodules. [**11-17**] with development of ascites and CT with hypodensity in liver c/f mets vs perfusion abnormality. - Infectious IBS - Diabetes mellitus II - on oral hypoglycemics and insulin - Pancreatic insufficiency - on pancreatic enzyme replacement - Portal vein thrombosis - on lovenox at home Social History: Lives in [**Location 686**] alone. Her sister lives next door. She has a history of smoking many years ago and does not currently smoke. no ETOH or IVDU. Family History: Family history of DM in her mother and sister. Father died of cancer (unknown type) Physical Exam: ON ADMISSION: Vitals: T: AF BP:111/60 P:90 R:22 95% O2:2L NC General: Alert, oriented, no acute distress, cachectic female HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, without discernable JVD Lungs: diffuse crackles throughout inicreasing at the bases. Left lower lung field with decreased air movement. NO wheezing CV: Regular rate and rhythm, normal S1 + S2, ?splitting of S1 vs ?S4 no murmurs, rubs, gallops Abdomen: scaphoid soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. midline hernia adjacent to umbilicus easily reducible and nontender to palpation GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . ON DISCHARGE: Vitals: T: 98.4 BP:110/60 P:89 R:16 93% O2:RA General: Alert, oriented, no acute distress, cachectic female HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, without discernable JVD Lungs: Left lower lung field with decreased air movement. NO wheezing CV: Regular rate and rhythm, normal S1 + S2 Abdomen: scaphoid soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. midline hernia adjacent to umbilicus easily reducible and nontender to palpation GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: CXR [**2120-4-4**] FINDINGS: Single portable view of the chest is compared to previous exam from [**2120-3-29**]. When compared to prior, there has been significant interval enlargement of bilateral pleural effusions which are now moderate in size. Underlying airspace disease is also possible. Superiorly, however, the lungs are grossly clear. Cardiac silhouette is difficult to assess given the size of effusions. Osseous and soft tissue structures are unchanged. IMPRESSION: Significant interval increase in the bilateral pleural effusions since prior exam with possible underlying airspace disease not excluded. . EKG [**2120-4-4**] low voltage, SR at 90bpm no ST changes prior ECG without such low voltage in lateral precordial leads . [**2120-4-15**] CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST CT OF THE ABDOMEN: The visualized heart is normal. The pericardium demonstrates no evidence of effusion. Small left pleural effusion is decreased in size compared to the most recent prior examination. There has been interval resolution of right-sided pleural effusion. Bilateral pigtail drains are noted in appropriate position. A 6 mm nodule in the right lung base is present (series 2, image 1). Additional nodularity within the right lung base measuring approximately 10 mm (series 2, image 10) and 6 mm linear density within the right lung base (series 2, 8) represent atelectasis versus infectious process. Pleural-based nodularity at the left lung base measures approximately 6 mm. There is moderate intrahepatic bile duct dilation predominantly involving left lobe of the liver with new pneumobilia compared to [**2120-3-6**], which may be secondary to hepaticojejunostomy. A 12-mm enhancing focus in the right lobe of the liver demonstrates arterial enhancement and is isodense on the venous phase and may represent enhancing metastasis versus perfusion abnormality. Hypodense area involving the right and left lobes of the liver extending from the porta hepatis to the periphery is new since most recent prior examination and may represent infiltrative tumor or metastases versus perfusion abnormality. The patient is status post pylorus-preserving Whipple with hepaticojejunostomy. The gallbladder is surgically absent. The remaining pancreatic tail appears unremarkable. The spleen and bilateral adrenal glands appear unremarkable. Both kidneys enhance and excrete contrast symmetrically. The upper poles of bilateral kidneys demonstrate thinned cortex similar to [**2120-3-6**] and may represent prior ischemic injury. Persistent thrombus of the main portal vein, right and left portal veins, the upper portion of the superior mesenteric vein and the splenic vein is again noted. There is mild calcification at the origin of the celiac artery. There is minimal irregularity of the common hepatic artery. The SMA, [**Female First Name (un) 899**] and bilateral renal vessels appear unremarkable. There is stranding of the mesentery which may represent edema versus tumor involvement. There is no evidence of pneumoperitoneum. Retroperitoneal and mesenteric lymph nodes do not meet CT size criteria for pathology. CT OF THE PELVIS: The bladder, uterus is unremarkable. Pelvic lymph nodes do not meet CT size criteria for pathology. There is mild anasarca. OSSEOUS STRUCTURES: No focal lytic or sclerotic lesions suspicious for malignancy are identified. IMPRESSION: 1. Bilateral pigtail catheters in appropriate position with resolution of right and improved small left pleural effusion. 2. 6 mm nodule at the right lung base. Additional nodular densities within the right lung base may represent atelectasis or infections. 3. Moderate intrahepatic bile duct dilatation especially in the left lobe, not significantly changed from [**2120-3-6**]. New pneumobilia within the left lobe of the liver may be secondary to hepatojejunostomy. 4. Persistent occlusion of main portal vein, right and left main portal veins, upper portion of the SMV and the splenic vein. 5. Large area of low density involving the right and left lobes of the liver extending from the porta hepatis to the periphery may represent infiltrative tumor or metastases versus perfusion abnormality. MRI is suggested for further evaluation. 6. Small enhancing focus in segment VI of the right lobe of the liver measuring 12 mm may represent enhancing metastases versus perfusion abnormality. 7. Stranding of the mesentery may represent edema versus tumor infiltration. 8. Mild anasarca. MRI ABDOMEN W/O & W/CON MRI Abdomen FINDINGS: The previously noted bilateral pleural effusions have resolved. There is small volume ascites. The patient is status post Whipple resection and reconstruction. There is persistent portal vein occlusion with nonenhancing thrombus seen extending into the right anterior, right posterior,left and main portal vein. The thrombus is also seen extending into the proximal portion of the SMV. The thrombus in the SMV is well demonstrated as a hyperintense structure on the T1-weighted imaging (8:74). No evidence of thrombus enhancement to suggest tumor thrombus. There is persistent biliary dilatation, more pronounced in the left hepatic lobe. This biliary dilatation has progressively increased over interval studies over the last 12 months. There are significant peribiliary varices, secondary to the portal vein occlusion, which may be contributing to some stenosis at the level of the hepaticojejunostomy (1002:62). There is pneumobilia (6:11), which suggests patency of the hepaticojejunostomy, however. On the post-contrast images, there is perfusional abnormality involving the left hepatic lobe. These areas are non-mass-like and likely reflect altered perfusion following the longstanding portal vein thrombosis. No evidence of a concerning mass-like hepatic lesion to suggest a metastasis. There is abnormal soft tissue, however, encasing the celiac axis and involving the SMA. This soft tissue extends along the proximal SMA as an abnormal soft tissue cuff (1002:65). The abnormal soft tissue is difficult to accurately measure, but abuts the left adrenal gland, abuts the IVC and extends into the porta hepatis. An approximate measurement is best estimated on the delayed post-contrast sequences ([**Numeric Identifier 16105**]:54) measuring 4.7 x 2 cm in maximal axial dimension. Narrowing and encasement of the celiac trunk is best appreciated on image (1001:50). The spleen is normal in size measuring 10 cm in long axis. Normal appearance of both kidneys, which enhance symmetrically. Incidental note is made of small Tarlov cysts in the lower sacrum (4:22). No concerning marrow abnormality identified in the thoracic or lumbar spine. IMPRESSION: 1. Thrombosis of the intra- and extra-hepatic portal vein and SMV. 2. Signal change in the liver following contrast likely reflects perfusion changes secondary to chronic portal vein thrombosis. 3. No evidence of metastatic tumor to the hepatic parenchyma. 4. Abnormal soft tissue encasing the celiac axis extending inferiorly to involve the SMA resulting in vessel narrowing. These features are highly concerning for local tumor recurrence. 4. Progressive, predominantly left-sided intrahepatic biliary dilatation with prominent peribiliary varices . Admission: [**2120-4-4**] 06:20PM BLOOD WBC-6.0# RBC-5.02# Hgb-12.7 Hct-42.9# MCV-85 MCH-25.3* MCHC-29.6*# RDW-17.8* Plt Ct-367# [**2120-4-5**] 03:05AM BLOOD WBC-4.7 RBC-4.57 Hgb-12.0 Hct-37.8 MCV-83 MCH-26.3* MCHC-31.9 RDW-17.9* Plt Ct-237 [**2120-4-4**] 06:20PM BLOOD Neuts-80.6* Lymphs-8.5* Monos-8.1 Eos-1.5 Baso-1.2 [**2120-4-4**] 06:20PM BLOOD PT-13.3* PTT-40.8* INR(PT)-1.2* [**2120-4-4**] 06:20PM BLOOD Plt Ct-367# [**2120-4-4**] 06:20PM BLOOD Glucose-283* UreaN-17 Creat-0.8 Na-123* K-5.3* Cl-89* HCO3-24 AnGap-15 [**2120-4-4**] 06:20PM BLOOD ALT-54* AST-74* AlkPhos-362* TotBili-0.8 [**2120-4-7**] 07:49AM BLOOD ALT-42* AST-34 LD(LDH)-157 AlkPhos-314* TotBili-0.5 [**2120-4-4**] 06:20PM BLOOD Lipase-9 [**2120-4-4**] 06:20PM BLOOD Albumin-3.0* Calcium-8.5 Phos-3.1 Mg-2.0 [**2120-4-11**] 06:55AM BLOOD Ferritn-51 [**2120-4-18**] 07:10AM BLOOD Triglyc-82 [**2120-4-8**] 06:45AM BLOOD Cortsol-32.4* [**2120-4-29**] 05:55AM BLOOD Cortsol-21.2* [**2120-4-11**] 06:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2120-4-11**] 06:55AM BLOOD [**Doctor First Name **]-NEGATIVE [**2120-4-11**] 06:55AM BLOOD IgG-794 [**2120-4-11**] 06:55AM BLOOD HCV Ab-NEGATIVE [**2120-4-5**] 05:06PM BLOOD pH-7.52* Comment-PLEURAL FL [**2120-4-5**] 03:20AM BLOOD Lactate-1.4 CA [**27**]-9 Test Result Reference Range/Units CA [**27**]-9 337 H <37 U/mL ON discharge: [**2120-4-30**] 06:55AM BLOOD WBC-3.3* RBC-3.56* Hgb-9.3* Hct-29.8* MCV-84 MCH-26.2* MCHC-31.3 RDW-18.5* Plt Ct-76* [**2120-4-30**] 06:55AM BLOOD Neuts-71.5* Lymphs-16.9* Monos-8.9 Eos-2.5 Baso-0.2 [**2120-4-28**] 07:05AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-OCCASIONAL [**2120-4-18**] 01:10PM BLOOD LMWH-0.62 [**2120-4-30**] 06:55AM BLOOD Glucose-195* UreaN-17 Creat-0.7 Na-132* K-4.5 Cl-102 HCO3-22 AnGap-13 [**2120-4-30**] 06:55AM BLOOD ALT-50* AST-30 AlkPhos-315* TotBili-0.7 [**2120-4-30**] 06:55AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0 Brief Hospital Course: REASON FOR ICU ADMISSION Patient is a 71 y/o F h/o pancreatic cancer s/p Whipple, recent pleurocentesis with large volume fluid removal from R lung now presents with several days worsening SOB and generalized weakness found to have bilateral pleural effusions on CXR. HOSPITAL COURSE #pleural effusions/dyspnea - reaccumulation of pleural fluid in setting of known portal vein thrombosis with recurrent transudative ascites and pleural effusions. Left pleural effusion is new this admission. She was maintained on her home dose of diuretics after last discharge however she has reaccumulated fluid quickly. IP was consulted who originally placed bilateral pigtails with a massive amount of drainage on a daily basis from both. She would match out in her lungs whatever fluid was given through the IV or PO. She was tried on steroids empirically without resolution of drainage. As her lengthy hospital course continued, the output from her right drain decreased and this was pulled. However, her left drain continued with output, so a pleurex catheter was placed by IP. The etiology of her pleural effusions is unknown. Due to her portal hypertension, it was presumed secondary to hepatic hydrothorax, but throughout her admission we noted that she had minimal to no ascites and yet would put out 4-5 liters daily from the pleural space. We attempted to do an intraabdominal tracer study to prove hepatic hydrothorax, however the tracer was unintentionally injected into the bowel without any clinical consequences. Renal, cardiac and liver disease were ruled out. The pleural and ascitic fluid from previous taps over the last few months have all consistently been extremely transudative without any evidence of malignancy. When her pancreatic cancer was found to have reoccurred via MRI (done to better evaluate her portal vein thrombosis ?bland thrombus vs tumor thrombus), we felt that her effusions might have been related to a capillary leak paraneoplastic process, because after starting chemotherapy her effusions slowed. She will follow up with pulmonary as an outpatient to determine the ongoing need for a pleurex catheter. # stage IIB pancreatic adenocarcinoma ?????? CA [**27**]-9 had been rising as an outpatient for the past few months, without clear evidence of a recurrence. Finally MRI of the abdomen was done which showed a suspicious soft tissue mass in the resection bed. She started chemotherapy with gemcitabine on [**2120-4-18**]. Next chemotherapy is due on [**2120-5-3**]. # hypotension/volume status - A major issue and the main driver of her lengthy hospitalization. We were unable, through any intervention (colloid or crystalloid), to improve her volume status without causing significant pleural output into both lungs. She was placed on an octreotide drip for possible hepatorenal syndrome (noted due to orthodeoxia when standing, however after further analysis we noted that her orthodeoxia was more likely due to hypoperfusion because of extreme orthostasis (sbp in the 40s while standing)). Octreotide provided no benefit and so it was stopped. Cardiology, interventional pulmonary and liver were all consulted, who all agreed that her orthostasis was due to severe hypovolemia, so she was uptitrated to max dose florinef, salt tabs and midodrine. After taking these medications, she was able to stand without symptomatic hypotension and walk with minimal assistance. She will be discharged on florinef, salt tabs and midodrine and the patient was encourage to stand up slowly. She was also chronically hyponatremic throughout her hospital course, typically 128-132, despite the salt tabs. # [**Last Name (un) **] - C/w likely somewhat pre-renal etiology although unusual that FeUrea is 45%. Still pt appears dry on exam and history c/w volume depletion (recent diarrhea and limited mobility/access to PO intake). She was volume resuscitated in the [**Hospital Unit Name 153**] with resultant worsening of her pleural effusions. Her creatinine stabilized. #pancreatic insufficiency - diabetes and enzyme deficiency. Issues with hyperglycemia when on steroids requiring aggressive uptitration of her insulin regimen. When off of steroids and after starting octreotide (an inhibitor of pancreatic function) she developed severe symptomatic hypoglycemia requiring discontinuation of her insulin. After stopping octreotide, she was restarted on an humalog insulin sliding scale. She also had large volumes of diarrhea due to her pancreatic enzyme deficiency s/p whipple. Her home zenpep was continued. #portal vein thrombosis - likely [**2-8**] hypercoagulability from malignancy. Has had asictes requiring taps over the last several months but no ascites on presentation. Liver was consulted who felt that she should not have portal hypertension without cirrhosis, however her cirrhosis workup was negative and she has known Grade II esophageal varices. Her factor Xa level was barely therapeutic after once daily dosing of lovenox, so she was switched to [**Hospital1 **] dosing. We attempted to find an intervention to remove/lyse this clot, however in discussion with many different services found no options (the clot was present for too long to be lysed with TPA via IR, and would require an open abdominal surgery with reconstruction via vascular/transplant). Transitional Issues - Please continue to drain 500-1500cc of fluid from the pleurex catheter as needed for comfort. - She will need to return for follow up appointments with Hem-Onc (see appointment within this discharge summary) Medications on Admission: - enoxaparin 70 mg Subcutaneous DAILY - furosemide 40 mg PO DAILY - glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day. - insulin aspart Four (4) units SC three times a day: please use before meals . - insulin glargine 12 units Subcutaneous once a day - spironolactone 100 mg PO DAILY - lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: Three (3) Cap PO QID (4 times a day). Discharge Medications: 1. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO four times a day. 2. Zenpep 20,000-68,000 -109,000 unit Capsule, Delayed Release(E.C.) Sig: Capsule, Delayed Release(E.C.) PO ASDIR (AS DIRECTED): 3 caps with meals 2 caps with snacks. 3. sodium chloride 1 gram Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). 7. loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day) as needed for diarrhea. 8. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 9. opium tincture 10 mg/mL Tincture Sig: Four (4) drop PO every four (4) hours as needed for constipation. 10. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 11. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a day. 12. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for diarrhea. 13. insulin Please see attached Insulin Sliding Scale Discharge Disposition: Extended Care Facility: [**Hospital1 **] at the [**Doctor Last Name 1263**] Discharge Diagnosis: Pleural effusions s/p pleurex catheter placement Portal vein thrombosis Pancreatic cancer (recurred) Orthostatic hypotension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for shortness of breath and found to have a reaccumulation of the fluid around your right lung as well as a new fluid collection around your left lung. As you know, we had extreme difficulty preventing water from accumulating around your lungs; eventually we had to place a pleurex catheter in your left lung due to the speed of reaccumulation of fluid. You will need the pleurex catheter drained between 500-1500cc of fluid periodically for comfort. Extra vacuum bottles have been sent with you at discharge. Complicating this was your low blood pressure when standing. We gave you new medications to raise your blood pressure. Please note the following changes to your medications: STOP lasix spironolactone enoxaparin 70mcg START salt tabs 2g twice per day enoxaparin 40mg twice per day florinef 0.2mg daily midodrine 10mg three times per day, please take the last dose at least 4 hours before bed, and the first dose as soon as you wake up prior to standing Please see discharge summary for more details regarding your new medications. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2120-5-3**] at 10:00 AM With: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2120-5-10**] at 10:00 AM With: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY (please obtain a chest xray on the same day just prior to this appointment) When: THURSDAY [**2120-5-16**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "34.91", "33.23", "99.25", "34.04" ]

icd9pcs

[ [ [] ] ]

21773, 21851

14464, 20027

318, 431

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23323, 24319

3698, 3784

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172,508

36909

Discharge summary

report

Admission Date: [**2153-6-30**] Discharge Date: [**2153-7-4**] Date of Birth: [**2089-6-23**] Sex: M Service: MEDICINE Allergies: Gluten / Wheat Flour / Lactose Attending:[**First Name3 (LF) 358**] Chief Complaint: pancreatitis, cholangitis Major Surgical or Invasive Procedure: [**First Name3 (LF) **] History of Present Illness: This is a 64 yo M with h/o Down's syndrome, hypothyroidism, s/p R THR on coumadin who presents with jaundice. Pt is unable to provide a history as nonverbal at baseline. Per OSH records and ED report, pt presented to [**Hospital3 7571**]Med Center for jaundice. Reportedly did not have any fevers, chills, abdominal pain, nausea, vomiting. where labs revealed WBC 25.4 with 25% bandemia, Tbili 8.3, DBili 6.5. CT abd/pelvis reportedly revealed CBD dilation. Given concern for pancreatitis and possible cholangitis, the pt was transferred to [**Hospital1 18**]. . In the ED, T 98, HR 71, BP 100/60, RR 16, O2 sat 97% RA. Labs signficant for WBC 24.1, AST 270, ALT 309, AlkPhos 800, TBili 8.7, DBili 7.7, lipase 766, lactate 3.3, and INR 6.2. OSH CT was reviewed with radiology who confirmed CBD dilation. RUQ U/S revealed intra and extrahepatic biliary ductal dilation without a clear obstructing stone, possible cholecystitis, and distended GB with sludge and stones. He was given 6L IVFs for drop in SBPs to 70s -80s and eventually started on levophed gtt after placement of L groin TLC, vancomycin 1 gm IV X 1, zosyn 4.5 gm IV X 1, vitqamin K 10 mg IV X 1, and planned for 2 units FFP. [**Hospital1 **] and surgery consulted who recommended an urgent [**Hospital1 **] in the morning. . Upon arrival to the [**Name (NI) 153**], pt is not clearly following commands but is alert and looking around the room. Non-verbal. Does not appear to be in acute distress. Past Medical History: Down's syndrome - non-verbal at baseline Hypothyroidism Celiac disease s/p R total hip replacement on [**6-20**] on coumadin Gout Hearing loss Osteoarthritis of hip Gastritis Social History: Currently living in NH s/p hip replacement surgery. Previously at group home. Unknown EtOH, illicits, tobacco history. Family History: non-contributory Physical Exam: Gen - NAD, sitting up in bed, occasional lip smaking HEENT - adentulous, very dry MM, sclerae icteric, no LAD, JVD unable to be fully assessed due to pt movement but does not appear to be grossly distended CV - RRR, nl s1/s2, no m/r/g Lungs - limited by pt not taking deep breaths but appears to be CTA b/l Abd - Soft, mild-mod distention, + BS, no HSM appreciated, no clear TTP throughout including no RUQ tenderness, epigastric tenderness. Negative [**Doctor Last Name 515**]. Ext - nonpitting LE edema with RLE > LLE. Legs in brace. R heel wrapped. dressing over R hip c/d/i. WWP, 2+ distal pulses Neuro - alert, unable to assess orientation. Spontaneous mvmt of upper extremities, lower extremities in brace. Skin - no rash appreciated Discharge exam: VSS, afebrile, up in chair and interactive, nonverbal except single words at times, uses hand signals. HEENT -- anicteric, op clear, scale on tongue Heart -- regular Lungs -- clear Abd -- soft, nontender, +BS Ext -- right hip staples in place with edema and mild erythema, no drainage, participates in ROM exercises. Pertinent Results: Admission labs- [**2153-6-29**] 11:18PM BLOOD WBC-24.1* RBC-3.73* Hgb-11.6* Hct-36.4* MCV-98 MCH-31.1 MCHC-31.9 RDW-16.2* Plt Ct-593* [**2153-7-1**] 04:13AM BLOOD WBC-23.7* RBC-3.01* Hgb-9.7* Hct-28.7* MCV-96 MCH-32.3* MCHC-33.9 RDW-16.9* Plt Ct-441* [**2153-6-29**] 11:18PM BLOOD Neuts-92.6* Lymphs-5.2* Monos-1.3* Eos-0.6 Baso-0.4 [**2153-6-30**] 09:47AM BLOOD Neuts-94.2* Lymphs-2.5* Monos-2.6 Eos-0.6 Baso-0.1 [**2153-6-29**] 11:18PM BLOOD PT-53.2* PTT-33.5 INR(PT)-6.2* [**2153-7-1**] 04:13AM BLOOD PT-16.2* PTT-25.2 INR(PT)-1.4* [**2153-6-29**] 11:18PM BLOOD Fibrino-931* [**2153-6-29**] 11:18PM BLOOD Glucose-99 UreaN-21* Creat-1.0 Na-135 K-4.4 Cl-98 HCO3-26 AnGap-15 [**2153-7-1**] 04:13AM BLOOD Glucose-89 UreaN-15 Creat-0.7 Na-142 K-4.0 Cl-112* HCO3-20* AnGap-14 [**2153-6-29**] 11:18PM BLOOD ALT-309* AST-270* AlkPhos-800* TotBili-8.7* DirBili-7.7* IndBili-1.0 [**2153-7-1**] 04:13AM BLOOD ALT-143* AST-89* LD(LDH)-194 AlkPhos-491* Amylase-57 TotBili-3.0* [**2153-6-29**] 11:18PM BLOOD Lipase-766* [**2153-7-1**] 04:13AM BLOOD Lipase-46 [**2153-6-30**] 09:47AM BLOOD Calcium-7.2* Phos-2.1* Mg-2.3 [**2153-7-1**] 04:13AM BLOOD Calcium-6.7* Phos-2.4* Mg-2.4 [**2153-6-29**] 11:18PM BLOOD D-Dimer-8999* [**2153-6-30**] 09:47AM BLOOD Hapto-240* [**2153-6-30**] 09:46AM BLOOD Cortsol-75.0* [**2153-6-30**] 11:00AM BLOOD Cortsol-69.4* [**2153-6-30**] 12:28AM BLOOD Lactate-3.3* [**2153-6-30**] 06:06PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.024 [**2153-6-30**] 06:06PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.5 Leuks-NEG [**2153-6-30**] 06:06PM URINE RBC-15* WBC-2 Bacteri-NONE Yeast-NONE Epi-0 REPORTS- Gallbladder US- 1. Moderate-to-severe intra- and extra-hepatic biliary ductal dilatation. While no stone or obstructing mass is identified, there is limited evaluation of the CBD near the pancreas and further investigation is warrented. 2. Distended gallbladder containing stones. While there is no wall edema, early cholecystitis cannot be excluded. CXR- IMPRESSION: Bilateral lower lobe infiltrates. [**Month/Day/Year **] [**2153-7-2**] Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Normal major papilla Cannulation: Cannulation of the biliary and pancreatic ducts was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. Biliary Tree: There was a filling defect that appeared like sludge in the middle third of the common bile duct and lower third of the common bile duct. There was evidence of a long common channel. Pancreas: A mild diffuse dilation was seen at the pancreas. Two regular nonobstructive stones ranging in size from 3mm to 4mm were seen at the head of the pancreas. Procedures: A 7cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed successfully in the lower third of the common bile duct using a Microvasive 10FR stent introducer kit. Impression: Normal major papilla There was a filling defect that appeared like sludge in the middle third of the common bile duct and lower third of the common bile duct. There was evidence of a long common channel. A mild diffuse dilation was seen at the pancreas. Two regular nonobstructive stones ranging in size from 3mm to 4mm were seen at the head of the pancreas. A 7cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed successfully in the lower third of the common bile duct using a Microvasive 10FR stent introducer kit. Sphincterotomy was not performed considering patient's elevated INR and PTT levels. Recommendations: Repeat [**Doctor Last Name **] in 4 weeks with stent pull,sphincterotomy and stone/sludge extraction Please call if develops jaundice, black stools, fever, or abdominal pain Follow-up with Dr. [**Last Name (STitle) **] [**Name (STitle) **] with Dr. [**Last Name (STitle) **] Continue broad spectrum antibiotics History: The procedure was performed by Dr. [**Last Name (STitle) **] and the GI fellow. The patient's reconciled home medication list is appended to the hospital report Other Labs: [**2153-6-30**] 04:05PM BLOOD WBC-26.5* RBC-3.17*# Hgb-10.1* Hct-30.3*# MCV-96 MCH-32.0 MCHC-33.4 RDW-16.4* Plt Ct-465* [**2153-7-1**] 04:13AM BLOOD WBC-23.7* RBC-3.01* Hgb-9.7* Hct-28.7* MCV-96 MCH-32.3* MCHC-33.9 RDW-16.9* Plt Ct-441* [**2153-7-2**] 03:53AM BLOOD WBC-20.5* RBC-3.29* Hgb-10.5* Hct-31.5* MCV-96 MCH-32.0 MCHC-33.4 RDW-16.7* Plt Ct-542* [**2153-7-3**] 06:10AM BLOOD WBC-16.8* RBC-3.65* Hgb-11.4* Hct-34.4* MCV-94 MCH-31.4 MCHC-33.2 RDW-16.4* Plt Ct-600* [**2153-7-4**] 07:55AM BLOOD WBC-14.0* RBC-3.86* Hgb-12.2* Hct-37.0* MCV-96 MCH-31.5 MCHC-32.9 RDW-17.1* Plt Ct-593* [**2153-7-4**] 07:55AM BLOOD PT-16.5* INR(PT)-1.5* [**2153-7-1**] 04:13AM BLOOD Glucose-89 UreaN-15 Creat-0.7 Na-142 K-4.0 Cl-112* HCO3-20* AnGap-14 [**2153-7-2**] 03:53AM BLOOD Glucose-72 UreaN-15 Creat-0.8 Na-138 K-3.3 Cl-108 HCO3-23 AnGap-10 [**2153-7-3**] 06:10AM BLOOD Glucose-79 UreaN-16 Creat-0.8 Na-134 K-3.6 Cl-100 HCO3-23 AnGap-15 [**2153-7-4**] 07:55AM BLOOD Glucose-100 UreaN-13 Creat-0.9 Na-136 K-3.4 Cl-100 HCO3-25 AnGap-14 [**2153-6-30**] 09:47AM BLOOD ALT-183* AST-181* LD(LDH)-263* AlkPhos-582* Amylase-326* TotBili-7.3* [**2153-7-1**] 04:13AM BLOOD ALT-143* AST-89* LD(LDH)-194 AlkPhos-491* Amylase-57 TotBili-3.0* [**2153-7-2**] 03:53AM BLOOD ALT-122* AST-57* LD(LDH)-216 AlkPhos-439* Amylase-34 TotBili-2.3* [**2153-7-3**] 06:10AM BLOOD ALT-89* AST-39 AlkPhos-389* TotBili-2.3* [**2153-7-4**] 07:55AM BLOOD ALT-77* AST-39 AlkPhos-355* TotBili-2.1* [**2153-7-2**] 03:53AM BLOOD Lipase-54 [**2153-7-3**] 06:10AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.2 [**2153-6-30**] 12:28AM BLOOD Lactate-3.3* Brief Hospital Course: 64 yo M with h/o Down's syndrome, hypothyroidism, s/p recent R THR on coumadin who p/w elevated LFTs in obstructive pattern with likely cholangitis and pancreatitis in setting of coagulopathy and leukocytosis. . #) Sepsis/cholangitis - In setting of likely biliary source with cholangitis, possible cholecystitis, and pancreatitis all contributing etiologies. WBC very elevated with significant bandemia upon presentation to OSH. Patient was continued on IV vancomycin and zosyn for broad spectrum antibiotics upon admission to the ICU and briefly required levophed for BP support, which was able to be weaned off post-[**Month/Day/Year **]. A left femoral CVL was placed on presentation for access. Urgent [**Month/Day/Year **] demonstrated sludge in the lower third of the CBD, 2 non-obstructing stones in the pancreatic head, and a biliary stent was placed in the distal CBD. Sphincterotomy was deferred in the setting of the patient's coagulopathy. He was initially started on stress dose steroids for hypotension, which was quickly weaned down to his home dose of prednisone after receiving further IVF boluses. At the time of transfer to general medical floor, the patient was afebrile, HD stable with downtrending Tbili and WBC, and continued on broad spectrum antibiotics. Surgery recommends CCY in the future and an appointment was arranged. He self discontinued his femoral CVL without complications. His antibiotics were transitioned to oral ciprofloxacin and flagyl. . #) Coagulopathy - In setting of receiving coumadin after recent hip replacement. Possible that coagulopathy was exacerbated in setting of infection. No signs of thrombocytopenia that would suggest DIC. Received vitamin K 10 mg IV and 4 units FFP in preparation for [**Month/Day/Year **] and type and screened. Post [**Month/Day/Year **], the patient was started back on coumadin for DVT prophylaxis in setting of recent right THR. . #) Mental Retardation - Secondary to Down's syndrome. Per sister and group home manager, at baseline, pt is non-verbal but may be able to follow simple commands. he also becomes agitated easily and is known to throw objects at others, stomp his feet, and bang his head against objects. Occasionally redirectable in ICU but also required intermittent doses of haldol 5 mg prn with good effect. No haldol was required after transfer to the general medical floor. . #) Hypothyroidism - Continued levothyroxine. . #) s/p THR - Initially held coumadin for anticipated [**Month/Day/Year **] and post-[**Month/Day/Year **] coumadin was restarted for DVT prophylaxis. It is unclear why the pt was chosen to be anti-coagulated with coumadin as opposed to lovenox. He will need follow up with his orthopedic surgeon regarding staple removal and post-operative evaluation. . #) Communication - with pt and sister/guardian [**Name (NI) **] [**Name (NI) 83315**] [**Telephone/Fax (1) 83316**] ([**Country 29586**])/ [**Telephone/Fax (1) 83317**] and Denene Hurtean (Resident Program Director at [**Location (un) 25576**] NH) [**Telephone/Fax (1) 83318**]. Mieke Monen [**Telephone/Fax (1) 83319**] if cannot get ahold of Denene. Mr. [**Known lastname 83320**] was discharged back to [**Hospital6 46972**]. Medications on Admission: Coumadin 2.5 mg daily (planned to be on hold on [**5-14**] then restarted at 2 mg daily on [**7-1**]) Prednisone 10 mg daily Centrum MVI Colace 100 mg [**Hospital1 **] Viokase 8 1 tab daily Indocin prn for gout Calcium carbonate 1 tab tid Fosamax 75 mg weekly Vitamin D [**Numeric Identifier 1871**] units qweek Robitussin prn Tylenol 650 mg q4h prn Percocet 1 tab q4h prn Omeprazole 20 mg daily Levothyroxine 75 mcg daily Kaopectate prn Iron 325 mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week: on Sunday. 13. Viokase 8 468 mg (30,[**Telephone/Fax (1) 83321**]-30K unit) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: Cholangitis Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital with an infection in your biliary tree. You will need to finish the antibiotics prescribed. You will also need to continue your physical therapy for the hip replacement, and have your surgeons take out the staples that remain in place. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Followup Instructions: Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2153-7-31**] 11:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2153-7-31**] 11:30 Dr. [**Last Name (STitle) **] - [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building - Appointment Friday [**Month (only) 205**] 10that 1:30pm call with questions ([**Telephone/Fax (1) 9000**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2153-8-3**] 1:30 Please arrange transport for [**Known firstname **] for the above appointments.

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icd9cm

[ [ [] ] ]

[ "38.93", "51.87" ]

icd9pcs

[ [ [] ] ]

13986, 14072

9144, 12362

315, 340

14147, 14156

3310, 7512

15263, 15944

2182, 2200

12869, 13963

14093, 14093

12388, 12846

14180, 15240

2215, 2956

2972, 3291

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368, 1831

14112, 14126

1853, 2030

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27,897

176,292

8135

Discharge summary

report

Admission Date: [**2106-6-20**] Discharge Date: [**2106-6-23**] Date of Birth: [**2059-10-11**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 19193**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: EGD on [**2103-6-22**] History of Present Illness: Ms. [**Known lastname 2643**] is a 46 yo woman with a PMH significant for obesity s/p gastric bypass surgery ~10 years and chronic anemia who presented to [**Hospital3 **] on [**2106-6-20**] after passing out. She reports that she was at work on the day of admission when she began to feel lightheaded, put her head down and then when she got up lost consciousness. . She awoke in an ambulance, and she was taken to [**Hospital3 **], where her Hct was noted to be 15.7. She was not tachycardic, but her BP was 98/54. She was given pantoprazole, and a unit of blood was hung, and she was transferred to [**Hospital1 18**] for further management. . She reports worsening fatigue and dyspnea on exertion over the past few weeks, and had to stay home from work 2 days prior to admission [**1-22**]. . She has noted dark stools, but reports that this has been because of iron supplements. She reports blood on the toilet paper and sometimes scant amounts in the toilet bowl after bowel movements, but ascribes this to hemorrhoids. She denies hemoptysis, hematemesis, coffee-ground emesis, tarry, sticky stool or frank hematochezia. She denies abdominal pain. She denies darkening of her urine, yellowing of her eyes or skin. Of note, the patient did describe taking significant quantities of ibuprofen (up to 3 pills 3 times a day) for refractory headaches, in addition to aspirin and fioricet. . In the ED, her VSs were 99.1, 94, 96/55, 16, 100%RA. NG lavage was negative. A rectal exam revealed guaiac positive brown stool. She received pantoprazole and 1 unit pRBCs. . The patient spent the night in the ICU. She received an additional 2 U PRBC's. Her Hct climbed to 30. She remained hemodynamically stable. Immediately prior to transfer to the medicine floor, the patient underwent endoscopy revealing 2 clean based, non-bleeding ulcers at the site of her gastric bypass anastomosis. . Review of symptoms was positive only for headache. The pt denied recent unintended weight loss, fevers, night sweats, constipation, steatorrhea, melena, hematochezia, cough, hemoptysis, wheezing, shortness of breath, chest pain, palpitations, dyspnea on exertion, increasing lower extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while walking, joint pain. Past Medical History: - TAH for fibroids - H/o obesity s/p gastric bypass surgery ~ 10 years ago at [**Hospital1 336**] - Anxiety - Depression - Tension headaches - Hypercholesterolemia Social History: Patient smokes 3 cigarettes per day, occasional alcohol, denies any illicit drugs Family History: Father died of "bone marrow cancer" at 66 yo. Physical Exam: Vitals: 98.5 76 108/70 18 100% RA Gen: Nervous, well-appearing. NAD. CV: RRR. Normal S1 and S2. No M/R/G. Pulm: CTA bilaterally. Abd: Soft, nontender, nondistended. Ext: No edema Pertinent Results: Admission Labs: [**2106-6-20**] 07:27PM BLOOD WBC-5.4 RBC-1.89*# Hgb-6.2*# Hct-17.7*# MCV-94# MCH-32.9*# MCHC-35.1*# RDW-16.7* Plt Ct-191 [**2106-6-20**] 07:27PM BLOOD Neuts-69.5 Lymphs-26.1 Monos-3.3 Eos-1.1 Baso-0.1 [**2106-6-20**] 07:27PM BLOOD Glucose-103 UreaN-19 Creat-0.5 Na-141 K-3.8 Cl-113* HCO3-21* AnGap-11 . Imaging/Studies: . ECG [**2106-6-20**]: Sinus rhythm, Borderline prolonged/upper limits of normal Q-Tc interval - is nonspecific and may be within normal limits, but clinical correlation is suggested, rate 88 . [**2106-6-21**] EGD: Normal mucosa in the esophagus 1. A small pouch of stomach leading into proximal jejenum was noted.This is from her gastric bypass surgery.There were two ulcers noted at the anastomotic area.The ulcers were not actively bleeding. Ulcers had clean base. Otherwise normal EGD to second part of the duodenum . Discharge Labs: [**2106-6-23**] 08:15AM BLOOD WBC-5.2 RBC-3.40* Hgb-10.9* Hct-31.5* MCV-93 MCH-32.0 MCHC-34.5 RDW-16.5* Plt Ct-217 [**2106-6-23**] 08:15AM BLOOD Glucose-95 UreaN-11 Creat-0.6 Na-143 K-4.2 Cl-110* HCO3-24 AnGap-13 [**2106-6-23**] 08:15AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.3 Brief Hospital Course: # Anemia/Syncope. Likely secondary to GI bleed from ulcers at anastomotic site which was likely complication by extensive ibuprofen and aspirin use for headaches. After transfusion, the patient's hematocrit continued to remain stable. There was no active bleeding on EGD as above. In addition, GI recommended no colonoscopy at this time as the bleed was likely explained by the findings on EGD. Patient was placed on a proton pump inhibitor, and was discharged on carafate as well. . # Headache. Patient with complaints of severe headaches exacerbation by tension and stress. Patient was continued on topiramate and acetaminophen prn and was told to avoid ibuprofen. Would recommend outpatient follow up for progression of headaches (MRI/CT) . # Anxiety/depression. Continued clonazepam, sertraline. Medications on Admission: Sertraline 100 mg PO daily Ezetemibe/simvastatin [**10-9**] Vitamin B12 1000 Clonazepam 1 mg PO tid prn Topiramate 50 [**Hospital1 **] Iron 64 mg PO bid MVI Discharge Medications: 1. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Vytorin [**10-9**] 10-20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day: Take 30 minutes before breakfast and dinner. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. Carafate 100 mg/mL Suspension Sig: Two (2) gram PO twice a day. Disp:*30 days* Refills:*0* 8. Iron (Ferrous Sulfate) 325 (65) mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed Discharge Condition: Stable Discharge Instructions: You were admitted with an extensive gastrointestinal bleed that was likely from ulcers in your stomach. Your blood count was very decreased when you arrived, and you were given blood which improved your count considerably. While you were admitted, you had an upper GI scope (EGD) which showed that you had two ulcers in your stomach at the site of your gastric bypass surgery. As a result, we have put you on a medication (protonix) to decrease your chances of having another bleeding ulcer. You should take this twice daily, 30 minutes before breakfast and dinner until you see your gastroenterologist. In addition, we are sending you home on Carafate, which is another medication to protect your stomach lining. You should take this twice daily. You should avoid taking any non-steroidal anti-inflammatory medications (NSAIDS) which include advil, aleve, motrin, ibuprofen, as well as aspirin and many others. Please speak with your primary care doctor before starting new medications that may contain NSAIDS. If you develop any dizziness, lightheadedness, shortness of breath, chest pain, increasing black or tarry stools, increased bright red blood in your stools, or any other symptom that concerns you, please proceed to the nearest Emergency Department or contact your primary care doctor as soon as possible. Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16258**], within one week of discharge from the hospital. Please follow up with your gastroenterologist, Dr. [**First Name (STitle) 679**], within 2 weeks.

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icd9pcs

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231, 240

331, 2595

3180, 4027

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2800, 2886

46,984

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42621

Discharge summary

report

Admission Date: [**2104-12-29**] Discharge Date: [**2104-12-31**] Date of Birth: [**2038-10-7**] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 2569**] Chief Complaint: R-sided weakness and R facial droop Major Surgical or Invasive Procedure: None History of Present Illness: 66 year-old right-handed man with PMH significant for HTN, a.fib (on Coumadin), s/p defibrillator/pacemaker (he says for bradycardia) CAD s/p 2 stents, prior stroke(initially with left sided weakness but he reports no residual weakness) presented to [**Hospital6 50929**] this morning with right sided weakness. He says he woke up at 4AM to go to the bathroom, but upon awakening, noticed that his right hand and arm was weak. He tried getting out of bed, but fell to the ground because of right sided weakness. He says he stayed on the ground for a few minutes, but was able to get himself up. He noticed that the right side of his face was drooping and that his speech was slurred. He was initially brought to OSH, where a NCHCT showed a left basal ganglia hemorrhage. He was given 10 mg of Vitamin K for an INR of 2.6 (no FFP was given) and Labetalol 20 mg IV for a SBP in the 170s. He was then transferred to [**Hospital1 18**] for further management. He says that he believes his right arm is most affected (weakest, no sensory changes reported), followed by his face and then his leg. He says there has not been any progression of his symptoms since onset this morning upon awakening. No other symptoms aside from right sided weakness and slurred speech, inlcuding no sensory changes, visual changes, headache, vertigo, nausea/vomiting. In the [**Hospital1 18**] ED, he received Profilinine, was ordered for 2 units FFP (did not receive while in ED, but was due to receive in ICU) and started on a Nicardipine gtt. Neuro ROS: Positive for right sided weakness and dysarthria as per HPI. He does note neck pain beginning yetserday evening, but no headache, loss of vision, blurred vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. No difficulties producing or comprehending speech. No focal numbness, parasthesiae. He does report episode of urinary incontinence with standing this morning, but no prior episode of urinary incontinence. General ROS: No fever or chills. No cough, shortness of breath, chest pain or tightness, palpitations, nausea, vomiting, diarrhea, constipation or abdominal pain. No dysuria. No rash. Past Medical History: -HTN -a. fib (on Coumadin) -pacemaker/defibrillator (he reports for slow heart rate) -CAD s/p 2 stents -2 prior strokes (one resulted in left sided weakness at presentation but no residual deficits) -left wrist surgery -depression Social History: He lives with his son. [**Name (NI) **] is retired; he previously worked for a construction company. He has a distant smoking history, quit over 40 years ago. No alcohol or illicit drug use. Family History: Mother deceased at age 77 with history of diabetes and CAD. Father deceased at age 56 from a stroke. Sister with [**Name2 (NI) **]. Physical Exam: Admission Physical Exam: Vitals: T: 98.6 P: 50 R: 16 BP: 178/95 (up to 200s systolic) SaO2: 98% on 2L NC General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, dry mucus membranes Neck: Supple Chest: lcta b/l. there is well-healed scar on anterior left chest with underlying device (pacemaker/defib). Cardiac: bradycardic, S1S2 Abdomen: soft, nondistended, +BS Extremities: warm, well perfused Skin: no rashes or lesions noted. Neurologic: Mental Status: Awake, alert, oriented to person, "hospital," month and year, but not to date. Able to relate history without difficulty. Able to name POTUS. Inattentive, unable to name [**Doctor Last Name 1841**] forwards or backwards; able to name DOW backwards. Able to follow both midline and appendicular commands. No right-left confusion. Able to register 3 objects and recall [**12-19**] at 5 minutes ([**1-17**] with prompting). No evidence of apraxia or neglect Language: speech is dysarthric, but is otherwise fluent with intact naming, repetition and comprehension. Normal prosody. Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact to light touch. VII: right lower facial droop VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. Motor: Normal bulk. Slightly increased tone in RLE. Right pronator drift. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc L 5 5 5 5 5 5 5 5 5 5 5 R 4+ 5 5- 5- 5 5- 5- 5 5 5 5 Sensory: No deficits to light touch, pinprick, proprioception throughout. Vibratory sense 3 seconds at right great toe and 5 seconds at left great toe. No extinction to DSS. DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 3 2 3 3 0 R 1 1 1 2 0 Plantar response was extensor bilaterally. Coordination: no dysmetria or intention tremor on F-N or F-N-F on left. There is dysmetria on F-N-F on right (did not appear out of proportion to weakness. RAMs are slow and slightly clumsy b/l, but more impaired on right. Gait: deferred . . DISCHARGE PHYSICAL EXAM: A+Ox3 Spanish speaking but speaks good English and follows commands well. Speech is dysarhtric but fluent and no evidence of mental status abnormalities with no neglect. Right facial droop and otherwise CN exam unremarkable. Right pronator drift with mild right hemiparesis (delt [**2-19**], tri/WE/FE/IP 4+/5). Plantars extensor bilaterally. Pertinent Results: Laboratory investigations: ADMISSION LABS: [**2104-12-29**] 02:00PM BLOOD WBC-5.6 RBC-4.68 Hgb-14.8 Hct-41.4 MCV-88 MCH-31.7 MCHC-35.8* RDW-13.6 Plt Ct-188 [**2104-12-29**] 02:00PM BLOOD Neuts-79.6* Lymphs-11.2* Monos-5.9 Eos-2.6 Baso-0.6 [**2104-12-29**] 02:00PM BLOOD PT-24.2* PTT-35.4 INR(PT)-2.3* [**2104-12-29**] 02:00PM BLOOD Glucose-105* UreaN-23* Creat-1.3* Na-141 K-3.2* Cl-105 HCO3-27 AnGap-12 [**2104-12-30**] 02:49AM BLOOD ALT-49* AST-30 AlkPhos-99 TotBili-1.9* . Other pertinent labs: [**2104-12-29**] 02:00PM BLOOD cTropnT-<0.01 [**2104-12-30**] 12:09AM BLOOD cTropnT-<0.01 [**2104-12-30**] 02:49AM BLOOD ALT-49* AST-30 AlkPhos-99 TotBili-1.9* [**2104-12-30**] 02:49AM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.4 Mg-2.0 Cholest-240* [**2104-12-30**] 02:49AM BLOOD Triglyc-111 HDL-41 CHOL/HD-5.9 LDLcalc-177* [**2104-12-30**] 02:49AM BLOOD %HbA1c-5.4 eAG-108 [**2104-12-29**] 02:00PM BLOOD PT-24.2* PTT-35.4 INR(PT)-2.3* [**2104-12-29**] 06:03PM BLOOD PT-14.9* PTT-29.1 INR(PT)-1.4* [**2104-12-30**] 02:49AM BLOOD PT-12.8* PTT-29.6 INR(PT)-1.2* [**2104-12-31**] 04:45AM BLOOD PT-11.2 PTT-26.7 INR(PT)-1.0 . Discharge labs: [**2104-12-31**] 04:45AM BLOOD WBC-5.5 RBC-4.51* Hgb-13.3* Hct-40.1 MCV-89 MCH-29.5 MCHC-33.2 RDW-13.7 Plt Ct-185 [**2104-12-31**] 04:45AM BLOOD PT-11.2 PTT-26.7 INR(PT)-1.0 [**2104-12-31**] 04:45AM BLOOD Glucose-116* UreaN-32* Creat-1.6* Na-142 K-3.6 Cl-107 HCO3-28 AnGap-11 [**2104-12-31**] 04:45AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.1 . . Urine: [**2104-12-30**] 03:26AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012 [**2104-12-30**] 03:26AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG . . Mictobiology: [**2104-12-29**] 5:45 pm MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Pending): . . Radiology: CT HEAD W/O CONTRAST Study Date of [**2104-12-29**] 4:58 PM Preliminary report FINDINGS: A 17 x 14 mm intraparenchymal bleed in the left lentiform nucleus is unchanged from the prior CT approximately six hours prior. There is mild mass effect due to surrounding edema with compression of the adjacent sulci, but no shift of the normal midline structures or evidence of herniation. No new foci of hemorrhage are present. A hypodense region just anterior to the hemorrhage is likely an old lacunar infarct. The ventricles and sulci are normal in size and configuration. The basal cisterns are patent. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No change in the left lentiform nucleus intraparenchymal hemorrhage. This is likely secondary to hypertension. Further workup to exclude vascular or neoplastic etiologies can be pursued based on clinical correlation. . CTA HEAD W&W/O C & RECONS Study Date of [**2104-12-30**] 3:18 AM FINDINGS: As seen on the previous CT, there is a 1.7 cm x 1.4 cm x 2.4 cm sized acute intracranial hematoma in the left basal ganglia with surrounding edema. There is no appreciable mass effect on the lateral ventricle. There is no midline shift. An old infarct is seen in the left anterior basal ganglia extending into the corona radiata with ex vacuo dilatation of the left lateral ventricle. Also seen are multiple chronic lacunar infarcts in the right caudate and lentiform nuclei. Visualized orbits, paranasal sinuses, and mastoid air cells are unremarkable. No fracture is seen. CTA HEAD: Bilateral intracranial internal carotid arteries, vertebral arteries, basilar artery and their major branches are patent with no evidence of stenosis, occlusion, or dissection. A small less than 2-mm sized aneurysm is seen arising from the left ICA bifurcation. The anterior communicating artery appears bulbous without any definite saccular aneurysm. IMPRESSION: 1. Unchanged left basal ganglia hemorrhage. 2. Chronic infarct in the left anterior basal ganglia with ex vacuo dilatation of the left lateral ventricle as described above. 3. Less than 2-mm sized outpouching from the left ICA bifurcation may represent a tiny aneurysm. The anterior communicating artery appears bulbous without any definite saccular aneurysm. . Cardiology: ECG Study Date of [**2104-12-29**] 2:45:18 PM Sinus bradycardia. A-V conduction delay. Prolonged Q-T interval. Marked anterior and anterolateral T wave inversion consistent with metabolic abnormality or myocardial ischemia. No previous tracing available for comparison. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] E. Intervals Axes Rate PR QRS QT/QTc P QRS T 50 238 96 540/522 31 -1 -87 Brief Hospital Course: 66 RHM with PMH significant for HTN, AF (on warfarin), s/p defibrillator/pacemaker (for ? bradycardia) CAD s/p 2 stents, prior stroke (initially with left sided weakness but no residual deficit) presented to [**Hospital6 3105**] with right sided weakness (arm>face>leg) and dysarthria. CT revealed a left basal ganglia IPH and he was transferred to [**Hospital1 18**] on [**2104-12-29**]. Given the presence of the IPH, his warfarin was reversed and stopped. Patient was initially admitted to the ICU given significant hypertension requirinng an IV nicardipine infusion. He was transferred to the floor on [**2104-12-30**]. CTA was stable and no significant aneurysm was identified. Although the most likely cause for his IPH is hypertension, it was not possible to do an MRI to look for an underlying lesion given pacemaker. Aspirin should be started in 1 week and he will not be continued on warfarin. He was transferred to rehab on [**2104-12-31**] and has neurology follow-up. He should have a repeat CT head with and without contrast prior to his follow-up to assess for the presence of an underlying mass lesion. . . # Neuro: Patient had a previous stroke as above with no residual deficits and presented with right face, arm and leg weakness in the setting of some mild neck pain but no clear headache on [**2104-12-29**]. At OSH he was found to have a left basal ganglia hemorrhage. He was given 10 mg of Vitamin K for an INR of 2.6 (no FFP was given) and Labetalol 20 mg IV for a SBP in the 170s. He was then transferred to [**Hospital1 18**] for further management. At [**Hospital1 18**] ED, he received Profilinine (activated factor IX) and received 2 units FFP later for INR 2.3. Examination revealed right hemiparesis and right facial droop with dysarthria but no aphasia, neglect or visual field defect. He was started on a Nicardipine infusion for SBP up to 200s and was admitted to the neuro ICU. His head CTs remained stable showing no extension of the bleed. CTA showed an old infarct in the left anterior basal ganglia extending into the corona radiata with ex vacuo dilatation of the left lateral ventricle in addition to multiple chronic lacunar infarcts in the right caudate and lentiform nuclei and angiography demonstrated a less than 2-mm sized aneurysm arising from the left ICA bifurcation. Stroke risk factors were assessed with HbA1c 5.4% and FLP revealed Cholesterol 240 TGCs 111 HDL 41 LDL 177. CEs were negative. He was initially monitored with glucose fingersticks and this was stopped after several normal readings. He was therefore started on atorvastatin 40mg daily and his fasting lipids should be repeated in 3 months. He continued to receive daily vitamin K until [**2104-12-30**] and INR on [**2104-12-31**] was 1.0. He passed bedside swallow evaluation and was placed on a regular diet. He slowly improved and was transferred to the neurology floor on [**2104-12-30**]. We held all antiplatelets and aspirin 325mg should be started in 1 week. We stopped warfarin due to his hemorrhage. We were unable to obtain an MRI given the patient's pacemaker and he will therefore need a repeat CT scan with contrast to evaluate any possible malignancy underlying the hemorrhage before his neurology appointment. The most likely cause of his hemorrhage is a hypertensive bleed although his hypertension was controlled previously. As above we will evaluate with interval scan to look for an underlying lesion which may have bled. His weakness was slowly improving at the time of discharge. He was stable and BP was controlled on his home medications. He was assessed by PT and deemed to benefit from rehab. He was therefore transferred to rehab on [**2104-12-31**]. . # CVS: BP was initially uncontrolled and was markely hypertensive requiring IV meds and ICU admission. This was latterly controlled and BP on discharge was SBP 120s-130s. He was briefly hypotensive in the setting IV nicardipine and home anti-hypertensives and this resolved before transfer to the flor. We continued patient's home lisinopril and carvedilol. We monitored his INR daily and was 1.0 on discharge. Warfarin was stopped and he should be restarted on aspirin 325mg daily in 1 week. Patient was started on atorvastatin 40mg daily as above and should have repeat FLP in 3 months. . # Renal: Patient was admitted with Cr 1.3. He was not known to have CRF. His Cr rose to 1.6 post-CT contrast on [**2104-12-31**]. This should be repeated in 2 days time and then at least weekly. . # Code: Full Code . . TRANSITIONAL CARE ISSUES: Patient will need a repeat CT head scan with contrast as an outpatient in [**4-24**] weeks from discharge. This has been requested. Restart aspirin at 325mg daily in 1 week. Please monitor Chem 7 as Cr rose from 1.3 to 1.6 following CT contrast. Repeat fasting lipids in 3 months. Medications on Admission: -Nitroglycerin 0.4 mg SL prn chest pain -Lisinopril 20 mg daily -Sertraline 100 mg daily -Pantropazole 40 mg daily -Coumadin 5 mg daily -ASA 81 mg daily -Carvedilol 25 mg [**Hospital1 **] Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 5. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: Primary diagnosis: Left basal ganglia intraparenchymal hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid ([**Hospital6 **] or cane). Neurologic: A+Ox3 Spanish speaking but speaks good English and follows commands well. Speech is dysarhtric but fluent and no evidence of mental status abnormalities with no neglect. Right facial droop and otherwise CN exam unremarkable. Right pronator drift with mild right hemiparesis (delt [**2-19**], tri/WE/FE/IP 4+/5). Plantars extensor bilaterally. Discharge Instructions: It was a pleasure taking care of you during your stay at the [**Known firstname 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented with right-sided weakness and facial droop. You had a CT scan and were found to have a bleed in your brain in the area of the left basal ganglia. As you were on warfarin (Coumadin) which is a blood thinner and worsens bleeding, this was reversed with medications and Coumadin was stopped. Your blood pressure was initially high and you had to be treated with IV medications to lower your blood pressure in the ICU. Your blood pressure normalised and you were transferred to the neurology floor. You did well and your strength on the right side was slowly improving. Your warfarin was stopped and should not be continued due to further risk of bleeding. You should stop aspirin currently and restrat at 325mg daily in 1 week. We also started atorvastatin for high cholesterol as your cholesterol was found to be high. This should be repeated in 3 months time. Your kidney function tests were also slightly abnormal following the CT contrast and this will be followed at rehab. You were continued on your other home medications. The most likely cause of this brain hemorrhage was high blood pressure although given your pacemaker we were unable to do an MRI. As a result you will need to have a repeat CT scan in 6 weeks as at this point the blood should have reabsorbed and we will be able to look to see if there is any lesion underlying your hemorrhage. You were deemed appropriate for rehab and transferred to rehab on [**2104-12-31**]. . Medication changes: We STOPPED aspirin and this should be restarted at 325mg daily in 1 week We STOPPED warfarin (Coumadin) We STARTED atorvastatin 40mg daily for high cholesterol Please continue your other medications as previously prescribed Followup Instructions: Please see your PCP Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4886**] [**Telephone/Fax (1) 92176**] following discharge from rehab. . We have arranged the following neurology follow-up: Department: NEUROLOGY When: FRIDAY [**2105-2-27**] at 10:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You are due to have a CT scan before this appointment. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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311, 317

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16308, 16357

6400, 7017

16393, 16902

2535, 2768

2784, 2977

5539, 5883

26,230

114,942

11808

Discharge summary

report

Admission Date: [**2148-11-27**] Discharge Date: [**2148-12-5**] Date of Birth: [**2092-1-16**] Sex: F Service: OMED CHIEF COMPLAINT: Pain. HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 56 year-old female with no past medical history who presented for an initial visit with outpatient oncologist on [**2148-11-27**]. Her pertinent oncologic history began eight months ago when she noticed a lump in her right breast. She did not seek medical attention until [**Month (only) 1096**] due to desire to spare her family pain of dealing with cancer. The patient's family recently lost a son to [**Name (NI) **] sarcoma six years ago. The patient finally sought medical attention when her back pain became too severe to ignore. The patient's back pain had begun in [**Month (only) 216**] and waxed and waned over the fall. The patient saw her primary care nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7749**] at the [**Hospital 14840**] Health Center and was referred to a surgeon. The patient underwent excisional breast biopsy on [**2148-11-18**] revealing an infiltrating carcinoma grade 3 out of 3 with a lobular component, ER positive, HER-2/neu negative. Bone scan done one week ago shows uptake in multiple ribs and vertebral bodies as well as lighter areas of uptake in the right femur and right hip. Formal report of this study is not available. The patient's family reports that her pain control had been very inadequate and they had been up with her q one hour giving her breakthrough liquid Oxycodone in addition to a Fentanyl patch, which has been up from 25 to 75 over the last two weeks. They also report that her breathing has become labored and she has not eaten anything and taking only liquids for two weeks as well. The patient has had sweats, but no fevers, headache, no bowel movements for one week. The patient has been essentially bedridden since last Thursday. PAST MEDICAL HISTORY: Benign breast biopsy twenty years ago. MEDICATIONS: Fentanyl patch 75 micrograms, Oxycodone for breakthrough pain, Zantac liquid b.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Married with three living children. Son died six years ago from [**Doctor First Name **] sarcoma. The patient has a 100 pack year history of tobacco. Previously drank three to four beers per day, but none since [**2148-11-2**]. The patient worked as a teacher and then stayed home with the kids. Recently was working as a retail store manager. PHYSICAL EXAMINATION: Temperature 99.2. Pulse 100. Blood pressure 112/84. Respiratory rate 24. O2 sat 94% on 4 liters. Cachectic, ill appearing female in mild respiratory distress. HEENT temple wasting, anicteric sclera. Oropharynx dry with no thrush. No cervical adenopathy. Lungs decreased breath sounds bilaterally. Cardiac regular. Normal S1 S2. No murmurs, rubs or gallops. Breast examination fresh surgical biopsy on the right with extensive ecchymosis. Left breast unremarkable. Abdomen flat with hypoactive bowel sounds. Nontender, nondistended. No organomegaly. Extremities no clubbing, cyanosis or edema. Neurological lethargic with poor recalls. Cranial nerves II through XII are intact. Strength 4 out of 5 throughout. Decreased sensation to light touch in right arm and left leg. Reflexes 2+ throughout. Down going Babinski. LABORATORY: White blood cell count 8.4, hematocrit 39.3, platelets 328, PT 13.9, INR 1.3, PTT 27.7, sodium 126, potassium 4.4, chloride 83, bicarb 32, BUN 13, creatinine 0.3, ALT 15, AST 31, LDH 479, alkaline phosphatase 132, total bilirubin 0.6, albumin 2.9, calcium 9.3, CEA 24, CA27-29 pending. IMAGING: Head CT from [**2148-11-29**] showed no intracranial metastases with possible cystic lung lesions. Chest CT from [**2148-11-29**] showed bolus emphysema, small bilateral pleural effusions. No metastasis. Spinal MR from [**2148-12-1**] showed multiple areas of metastatic disease in the cervical, thoracic and lumbar spine. No evidence of cord compression. Mild pathologic compression fracture of T3 and T6, bilateral small pleural effusions. HOSPITAL COURSE: 1. Pulmonary: The patient was in moderate respiratory distress on arrival with an O2 sat of 80% on room air that increased to 94% on 4 liters. The patient was also given significant amount of narcotics as well as benzodiazepines for pain and anxiety. The patient became more lethargic and arterial blood gases showed hypercarbic respiratory failure. The patient was intubated on the floor and taken to the _________ Intensive Care Unit. The patient initially got a single dose of Azithromycin in the Intensive Care Unit and remained on the ventilator until she self extubated on [**2148-12-1**]. The patient did well with multiple Atrovent and Albuterol nebulizers. Flovent was added to her pulmonary regimen. The patient remained extubated and did well and was transferred to the floor. Pulmonary function tests will be obtained on [**2148-12-5**] to assess her emphysema. A chest CT showed large bolus emphysema. The patient has a long significant history of smoking. Will schedule Ms. [**Known lastname **] with outpatient follow up with Dr. [**Last Name (STitle) 575**] in the Pulmonary Department. Tolerated O2 sat at 92% given patient's tendency to retain CO2. Also need to avoid increasing her narcotics or giving her any benzodiazepines given her propensity to retain CO2. 2. Oncologic: The patient has significant skeletal metastases of her breast cancer. The patient was started on Arimidex and given pamidronate in the Intensive Care Unit. The patient will continue on Rumidex for hormonal treatment of her breast cancer and will receive monthly doses of pamidronate. The patient will follow up with her Dr. [**Last Name (STitle) 26065**] her oncologist in one month for dose of Pamidronate and to assess the effectiveness of the Arimidex. 3. Pain: The patient's pain was better controlled after her Intensive Care Unit stay when her Fentanyl patch was increased to 100. She was on low dose NSIR for breakthrough. In addition, will add NSAIDS for breakthrough pain Ibuprofen 600 mg t.i.d. Any changes in her narcotics should be discussed with Dr. [**Last Name (STitle) 26065**] her primary oncologist. Should avoid increasing her narcotics due to her demonstrated ability to retain CO2 and develop hypercarbic respiratory failure. If the patient's pain again becomes difficult to manage will consider palliative radiation therapy, but at this time there is no acute indication for radiation therapy given no evidence of sinal cord compression. DISCHARGE MEDICATIONS: Multiple vitamin one tab po q.d., Atrovent MDI two puffs meter dose inhaler q 6 hours, Albuterol MDI two puffs q 2 hours prn, Albuterol Atrovent nebulizers q 4 hours prn, heparin subQ 500 units b.i.d., Arimidex 1 mg po q day, Fentanyl patch 100 micrograms po q 72 hours, Colace 100 mg po b.i.d., Boost one po b.i.d., Flovent 110 micrograms per puff four puffs b.i.d., Ibuprofen 600 mg po q 8 hours prn should be used initially prior to using narcotics for breakthrough. NSIR 10 mg po q 4 hours prn if NSAIDS do not relieve pain. Dulcolax 10 mg po pr q day prn. Senna one tab po q.h.s. DISCHARGE STATUS: To rehab. DISCHARGE CONDITION: Fair. DISCHARGE DIAGNOSES: 1. Breast cancer with skeletal metastasis. 2. Bolus emphysema. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 26066**], M.D. [**MD Number(1) 26067**] Dictated By:[**Last Name (NamePattern1) 16516**] MEDQUIST36 D: [**2148-12-4**] 12:02 T: [**2148-12-4**] 13:05 JOB#: [**Job Number 37309**]

[ "174.9", "492.8", "293.0", "518.81", "198.5", "276.5" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7372, 7379

7400, 7751

6732, 7350

4226, 6708

2615, 4208

156, 163

192, 2026

2049, 2226

2243, 2592

32,054

106,034

1895

Discharge summary

report

Admission Date: [**2106-1-23**] Discharge Date: [**2106-1-27**] Date of Birth: [**2055-3-1**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5272**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: central venous line placement History of Present Illness: Mr. [**Known lastname **] is a 50 y/o male with depression who presents with dysuria and fever after a prostate biopsy for an elevated PSA. Patient had an elective prostate biopsy performed by urology on [**1-21**]. Of note he had been taking prophylactic cipro beginning 1 day prior to the biopsy, as prescribed by urology. Despite this, beginning overnight on Friday, he noted fevers and chills to 102 at home as well as dysuria. He had also been having some hematuria and perineal pain. Vitals upon presentation to the ED: T 98.5 HR 100 BP 91-63 RR 14 100%RA In the ED, he received ceftriaxone, vancomycin, and levofloxacin. Despite this he quickly became hypotensive to 81/43 with HR 100 and T 100.0. Code sepsis was called and he received 5.3L NS and had a RIJ central venous line placed. He had an intial SvO2 of 73. He did not receive pressors as MAPs recovered with IVF resuscitation. He had over 2L UOP in ED. An EKG was performed with showed a RBBB/question Brugada syndrome. Cardiology was consulted. Urology examined pt and recommended admission to ICU for possible urosepsis. Past Medical History: Depression BPH/elevated PSA Hypertriglyceridemia Hepatic steatosis Hx pulmonary tuberculosis Social History: Works in the [**Location (un) 86**] Public Library. Originally from [**Country 651**], moved here 20 years ago. Married with two children. Lifetime nonsmoker, does not drink. Speaks a good amount of English Family History: Two children with asthma. Diabetes and CAD run in family, but no hx of sudden cardiac death or early MI. Physical Exam: Gen: diaphoretic and slightly anxious but otherwise NAD HEENT: NC/AT, MMM, R IJ TLC in place Hrt: RRR, borderline tachycardia Lungs: CTAB Abd: S/NT/ND, + BS Ext: WWP, no c/c/e Neuro: non-focal Pertinent Results: Admission Labs: [**2106-1-23**] WBC-16.8*# RBC-4.58* Hgb-14.0 Hct-40.3 MCV-88 MCH-30.5 MCHC-34.7 RDW-12.5 Plt Ct-242 Neuts-94.5* Bands-0 Lymphs-2.7* Monos-2.3 Eos-0.3 Baso-0.2 . PT-13.4 PTT-32.7 INR(PT)-1.2* . Glucose-204* UreaN-16 Creat-1.0 Na-135 K-3.6 Cl-101 HCO3-23 AnGap-15 Calcium-9.2 Phos-1.5* Mg-1.8 . ALT-26 AST-29 AlkPhos-45 TotBili-0.9 . CK(CPK)-91 cTropnT-<0.01 CK(CPK)-155 CK-MB-2 cTropnT-<0.01 . Cortsol-6.8 . CRP-19.0* . Lactate-2.7* . URINE RBC-[**2-3**]* WBC-[**5-11**]* Bacteri-FEW Yeast-NONE Epi-0-2 URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM ********************MICRO************** [**2106-1-23**] 7:00 am BLOOD CULTURE Blood Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ GRAM NEGATIVE ROD(S) | CEFTAZIDIME----------- I CEFTRIAXONE----------- R CIPROFLOXACIN--------- R GENTAMICIN------------ R LEVOFLOXACIN---------- R MEROPENEM------------- S TRIMETHOPRIM/SULFA---- R . [**2106-1-23**] 5:05 pm URINE Source: Catheter. URINE CULTURE (Preliminary): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. . [**1-23**] CXR UPRIGHT CHEST: Cardiomediastinal silhouette is unchanged allowing for differences in technique. Pulmonary vascularity is unremarkable. Lungs are clear and there is no evidence of pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process. . [**1-24**] CXR Since earlier on [**1-23**], pulmonary vasculature has become engorged and there is new perihilar opacification in both lower lungs as well as a new small right pleural effusion. Overall, findings suggest cardiac decompensation, but I cannot exclude a contribution from either infection or aspiration, inducing atelectasis. The heart is normal size and mediastinal vasculature is not engorged. Tip of the right jugular line projects over the low SVC. No nasogastric or endotracheal tube is seen. No pneumothorax. Brief Hospital Course: Mr. [**Known lastname **] is a 50 yo M w/PMHx sx for recent prostate biopsy for elevated PSA who now presents with fevers, hypotension, and leukocytosis suggestive of urosepsis. . #. Urosepsis. Pt underwent CVL placement in ED. He was aggressively volume resuscitated receiving over 5L NS, with SVO2 after 5L >70%. He was dosed withh broad spectrum antibiotics including vanc, ceftriaxone, and levofloxacin. Upon arrival to the ICU he was hemodynamically stable and not requiring pressors. He quickly spiked a fever up to 104 with myalgias and rigors. He was changed to double gram negative coverage with zosyn and gentamycin. In total he received over ( liters of IVF but still began to drop his MAPs and SvO2 sats. As a result he was started on levophed, with successful maintenance of MAPs > 65. A cortisol was sent and returned at 6.8. No stress steroids were begun. Tight glycemic control was maintained with RISS to keep FSG <150. Shortly thereafter, his blood cultures returned with GNRs. His fever curve was trending downwards and he was able to be weaned off pressors on the morning of Sunday [**1-24**]. Pt afebrile, switched to ertepenum for 2wks abx course. . #. Depression. Continued wellbutrin. . #. FEN - ate a regular diet. Put on RISS for tight glycemic control. . #. PPx - sQ heparin . #. Code. Full. . #. Access. CVL and peripheral . #. Dispo. ICU care Medications on Admission: Wellbutrin 100 mg daily Ciprofloxacin 500 mg [**Hospital1 **] (started [**1-20**]) Discharge Medications: 1. Bupropion 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Ertapenem 1 gram Recon Soln Sig: One (1) Intravenous qd () for 2 weeks. Disp:*12 grams* Refills:*0* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Sepsis Discharge Condition: Stable. Discharge Instructions: -You may shower. -Do not lift anything heavier than a phone book. -Do not drive or drink alcohol while taking narcotic pain medication. -Resume all of your home medications. -If you have fevers > 101.5 F, vomiting, or increased pain, call your doctor or the nearest emergency room. -cont abx for 2wks. Followup Instructions: Please call Dr. [**Last Name (STitle) 770**], [**Telephone/Fax (1) 10566**] for f/u appt.

[ "600.00", "311", "746.89", "275.3", "038.40", "285.1", "571.8", "E878.8", "599.0", "995.91", "426.4", "998.11" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

6208, 6260

4402, 5776

320, 351

6311, 6321

2164, 2164

6671, 6764

1829, 1935

5909, 6185

6281, 6290

5802, 5886

6345, 6648

1950, 2145

2911, 3447

274, 282

3482, 4379

379, 1471

2180, 2867

1493, 1588

1604, 1813

16,860

165,303

45141

Discharge summary

report

Admission Date: [**2121-12-26**] Discharge Date: [**2122-1-11**] Date of Birth: [**2064-12-26**] Sex: M Service: CARDIOTHORACIC Allergies: Motrin / Glyburide / Glucophage Attending:[**First Name3 (LF) 5790**] Chief Complaint: L. empyema Major Surgical or Invasive Procedure: Left thoracotomy with rib resection, total pulmonary decortication, parietal pleurectomy, flexible bronchoscopy. History of Present Illness: 56M p/w 3 wk h/o worsenig SOB. CT/CXR with lg loculated L pleural effusion. On admission pt also complained of N/V, decreased appetite, and increased BS despite poor po intake. Past Medical History: IDDM anemia Mechanical valve, AVR for MRSA endocarditis BKA Toe amp appy Social History: Cig 1ppd -> quit Pipe 3-4 qd Currently on disability. Lives at home with his partner, Ms. [**Name13 (STitle) **]. Denies alcohol, drugs, or tobacco. No pets. Family History: Family ALW. No hx of MI, CAD, or DM. Physical Exam: AF VSS NAD RRR CTA-B decreased BS L base. +BS S/NT/ND no edema. L BKA stump well healed. R great toe amputation incision well healed wound: Incision c/d/i no surrounding erythema, cellulitis or fluctuance. No drainage. Basalar CT in place with pneumostat in place. surrounding area without eerythema or cellulitis. Pertinent Results: Admission PA AND LATERAL CHEST [**2121-12-26**]: A moderate-to-large, laterally and posteriorly loculated left pleural effusion has increased in size relative to [**2121-9-1**], though there has been no progressive rightward mediastinal shift. Right lung is clear. Heart size is normal. The patient has had median sternotomy and aortic valve replacement. . repeat CXR [**2121-12-26**]: COMPARISON: Study from 9:07 a.m. the same day. FRONTAL AND LATERAL CHEST: The size of the large left-sided partially loculated pleural effusion is stable. The patient is status post median sternotomy. The right lung remains clear. There is no cardiomegaly. There is no new mediastinal shift. IMPRESSION: Stable large loculated left pleural effusion, unchanged. . CT chest/abdomen [**12-28**]:IMPRESSION: 1. Long-standing large loculated left pleural effusion surrounded by thickened pleura may be due to infectious process, although the long-standing nature of this finding could be the cause of pleural thickening. 2. Slightly enlarged mediastinal and left mammarian lymph nodes could be reactive to infectious process. 3. Smaller but still large hypodense splenic lesion. Given the decrease in size over the last four months of this lesion, it is most likely due to a previous traumatic insult, although the intrasplenic infection cannot be excluded. Further followup with abdominal CT or ultrasound is recommended. . AP/Lat pre-op [**2122-1-2**]:Large left pleural effusion, without evidence of mediastinal shift. Status post right internal jugular central venous catheter placement without pneumothorax. [**2122-1-2**] 02:20AM BLOOD WBC-17.0* RBC-3.56* Hgb-8.5* Hct-26.6* MCV-75* MCH-23.9* MCHC-32.1 RDW-17.5* Plt Ct-698* [**2122-1-1**] 04:26AM BLOOD ESR-134* [**2122-1-1**] 04:26AM BLOOD CRP-226.1* [**2122-1-1**] 10:31AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG [**2122-1-1**] 01:39PM PLEURAL WBC-[**Numeric Identifier 96489**]* RBC-[**Numeric Identifier 961**]* Polys-0 Lymphs-0 Monos-0 [**2122-1-1**] 01:39PM PLEURAL TotProt-4.3 Glucose-1 Creat-1.0 LD(LDH)-[**Numeric Identifier 74920**] Albumin-LESS THAN [**2121-12-26**] 01:20PM GLUCOSE-205* UREA N-20 CREAT-1.2 SODIUM-134 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-25 ANION GAP-14 [**2121-12-26**] 01:20PM WBC-17.6* RBC-3.47* HGB-8.0* HCT-24.5* MCV-71* MCH-23.1* MCHC-32.7 RDW-15.3 [**2121-12-26**] 01:20PM CK-MB-NotDone [**2121-12-26**] 01:20PM cTropnT-<0.01 [**2121-12-26**] 01:20PM CK(CPK)-56 [**2121-12-26**] 01:20PM PT-58.7* PTT-64.3* INR(PT)-7.2* Brief Hospital Course: The pt was admitted to the Medicine service on [**2121-12-26**] with an INR of 7.2. A L IJ TLC was placed for access. Thorasic surgery was consulted on admission and recomended that interventional pulmonology preform a pleural tap. The patients INR was supratherapeutic on admission and he was observed as an inpatient until his INR drifted down to normal levels. During this time the pt was afebrile but had continuing symptoms of dyspnea. An Echo was done which showed no vegatations but higher than nl gradient across the aortic valve. On [**2122-1-2**] The INR was 1.7 and a L pleural tap was done. Purulent fluid was obtained and gram stain showed GPC. That evening the pt was placed on ceftriaxone and vancomycin. The pt was taken to the operating room the following day where he [**Date Range 1834**] Left thoracotomy with rib resection, total pulmonary decortication, parietal pleurectomy, flexible bronchoscopy. The pleural fluid culture grew MRSA. Post operativly the patient was taken to the ICU intubated but was extubated the following day. His postoperative [**Last Name (un) **] was uneventful. Intra operativly 3 chest tubes were placed. One was removed on POD#3 and the second was removed on POD#4. He was transfered to the floor on POD#2 and a PICC line was placed on POD 3. At the time mof discharge his pain was well controlled on PO pain medication. His symptom of dyspnea had resolved and his O2 sats were greater then 92 % on room air. He has one chest tube in place that is connected to a pneumoSTAT that he will be discharged with. He is tolerating a regular diet and has had return of bowel and bladder function. He is ambulating on his own and has been cleared by physical therapy. He has been afebrile with no signs or symptoms of infection. He will be continued on vancomycin on discharge. He was restarted on coumadin. Medications on Admission: ACUCKECK STRIPS --To check fingersticks ASPIRIN 81MG--One by mouth every day Accu-Chek Comfort Curve Test --use as directed up to tid COUMADIN 5 mg--as directed tablet(s) by mouth daily per [**Hospital **] clinic to achieve inr 2.0-3.0 FERROUS SULFATE 325 mg (65 mg)--1 tablet(s) by mouth up to 3 times a day for anemia FOLIC ACID 1MG--Take one tablet once per day GLUCOSE TEST STRIP --Use as directed HOME GLUCOSE MONITORING KIT --Use as directed for diabetes LANCETS --Use as directed to measure blood glucose up to 4 times a day for diabetes NPH INSULIN --16 unites sq qam, 10 untis sq qpm OXYCODONE 5 mg--1 tablet(s) by mouth twice a day as needed for pain Power Wheelchair --Use as directed every day for mobility WARFARIN 5 mg--2 tablet(s) by mouth every day; modify dose as directed by anticoagulation service stump sox multiple ply --apply to stump as directed stump sox single ply --apply to stump as directed Discharge Medications: ACUCKECK STRIPS --To check fingersticks ASPIRIN 81MG--One by mouth every day Accu-Chek Comfort Curve Test --use as directed up to tid COUMADIN 5 mg--as directed tablet(s) by mouth daily per [**Hospital **] clinic to achieve inr 2.0-3.0 FERROUS SULFATE 325 mg (65 mg)--1 tablet(s) by mouth up to 3 times a day for anemia FOLIC ACID 1MG--Take one tablet once per day GLUCOSE TEST STRIP --Use as directed HOME GLUCOSE MONITORING KIT --Use as directed for diabetes LANCETS --Use as directed to measure blood glucose up to 4 times a day for diabetes NPH INSULIN --16 unites sq qam, 10 untis sq qpm OXYCODONE 5 mg--1 tablet(s) by mouth twice a day as needed for pain Power Wheelchair --Use as directed every day for mobility stump sox multiple ply --apply to stump as directed stump sox single ply --apply to stump as directed Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Left empyema and fibrothorax. Discharge Condition: Good Discharge Instructions: Call clinic or return to ED for Temp > 101.5, SOB, CP, purulent or bloody drainage from the wound. Pain not controlled by oral medications. Or anything else that is of concern to you. Ok to shower. Pat wound dry after showering. Leave steri strips on. Completed by:[**2122-1-11**]

[ "790.92", "V43.3", "041.11", "250.00", "V58.67", "510.9", "511.0", "V49.71", "289.50", "285.9", "V49.75" ]

icd9cm

[ [ [] ] ]

[ "96.05", "34.91", "99.04", "38.93", "34.51", "99.07" ]

icd9pcs

[ [ [] ] ]

7597, 7654

3905, 5773

311, 426

7728, 7734

1310, 3882

921, 959

6747, 7574

7675, 7707

5799, 6724

7758, 8043

974, 1291

261, 273

454, 632

654, 729

745, 905

31,756

192,411

32744

Discharge summary

report

Admission Date: [**2185-2-24**] Discharge Date: [**2185-3-5**] Date of Birth: [**2161-3-2**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: none History of Present Illness: 23 yo M unrestrained driver s/p rollover MVC, ejected, unknown LOC. Transfered from Cape Code with bilateral pulmonary contusions, retroperitoneal hematoma, multiple rib fractures, L2 burst fracture, mediatsinal hematoma. Past Medical History: 1. bipolar disorder 2. anxiety Social History: +EtOH, +tob, neg for illicits. Pt lives at home, is oldest of 4 children all of whom still at home (sibs are 21, 17, 11). [**Name (NI) 1094**] mother is RN. Family History: non-contributory Physical Exam: on admission: P: 109 BP: 139/P R: 18 99% FM General: NAD HEENT: wnl Respiratory: bs equal bilaterally CV: nl rate, regular rhythm GI: soft, non-tender GU: rectal tone nl, +hematuria MSK: 5/5 strength. L-spine TTP. . on discharge: Gen: NAD Resp: bs equal bilat CV: nl rate, reg rhythm chest/abdomen: brace in place MSK: MAEW Pertinent Results: on admission: [**2185-2-24**] 05:59AM ASA-NEG ETHANOL-93* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2185-2-24**] 05:59AM WBC-20.7* RBC-4.08* HGB-13.6* HCT-39.1* MCV-96 MCH-33.3* MCHC-34.7 RDW-13.0 [**2185-2-24**] 05:59AM PLT COUNT-209 [**2185-2-24**] 05:59AM PT-13.4 PTT-23.0 INR(PT)-1.1 [**2185-2-24**] 05:59AM UREA N-10 CREAT-1.4* [**2185-2-24**] 06:00AM URINE RBC->50 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 TRANS EPI-[**4-6**] [**2185-2-24**] 06:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG pertinent imaging: OSH imaging CT A/P [**2-24**]: avascular L kidney, retroperitoneal hematoma, L2 burst, multiple posterior R rib fx Trauma x-ray chest/pelvis [**2-24**]: No evidence of acute traumatic injury within the thorax or pelvis. Reported rib fractures are poorly visualized. CT spine [**2-24**]: L2 burst fx, L1-L5 displaced R TP fx, T8 spinous fx T9 R TP, spinous fx, T10 R TP, spinous fx; R T11 rib fx, no bony intrusion, patchy enhancement of right kidney, no enhancement of L kidney MRI T/L [**2-24**]: 1. Posterior epidural hematoma starting at approximately the T1 level extending throughout the thoracic spine and into the upper lumbar spine to the L2 level. Anterior epidural hematoma at the L4-L5 levels. No signal abnormality within the thoracic cord, conus or cauda equina, and there is no significant cord compression. CXR [**2-26**]: No focal opacity. CXR [**2-27**]: No focal infiltrate. . Brief Hospital Course: A trauma basic was initiated in the Emergency Department and the patient was admitted to the Trauma Intensive Care Unit, Dr. [**Last Name (STitle) **].J. [**Doctor Last Name **], Attending Physician. [**Name10 (NameIs) **] patient's injuries are as described above. The orthopedic spine surgery team was consulted regarding his spinal fractures. It was decided to treat his fractures conservatively and a TLSO brace was ordered. The patient had 2 hour neuro checks and was kept in bed on logroll precautions with a dilaudid PCA for pain control. On HD 2, the patient was seen by psychiatry due to concerns raised by the patien's parents, and additionally due to concerns about the patient's agitation in the ICU. On HD 3, the patient received his TLSO brace, and was OOB to chair. He tolerated clears without difficulty. On HD 4, the patient was transferred to the floor with a sitter. The patient continued to be seen by psychiatry. On HD 5, the patient's PCA was discontinued and he was given oral pain medications. He worked with physical therapy, and occupational therapy on ADLs wearing his brace, and spine safety. Psychiatry continued to see the patient and his psychiatric medications were changed. The patient was cleared for home with outpatient PT on hospital day 7. The patient will need to wear his brace at all times when out of bed, and he will need to follow up with Dr. [**Last Name (STitle) 1007**] in 1 month. He will need to follow up with outpatient psychiatry. Medications on Admission: ativan Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA Discharge Diagnosis: 1. s/p MVC 2. R retroperitoneal hematoma 3. Avascular L kidney 4. L2 burst fracture 5. Multiple posterior R rib fractures Discharge Condition: stable Followup Instructions: Please follow up in trauma clinic in 1 week. Please call [**Telephone/Fax (1) 6429**] to make an appointment. . Please follow up with Dr. [**Last Name (STitle) 1352**] in 1 month. Please call ([**Telephone/Fax (1) 15940**] to make an appointment.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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2734, 4230

320, 327

4504, 4513

1202, 1202

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650, 808

75,469

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8502

Discharge summary

report

Admission Date: [**2178-1-7**] Discharge Date: [**2178-1-13**] Date of Birth: [**2144-5-12**] Sex: F Service: MEDICINE Allergies: Penicillins / Acetaminophen / Oxycodone Attending:[**First Name3 (LF) 30**] Chief Complaint: acute on chronic renal failure, pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 29940**] is a 33 year old female with h/o ESRD [**1-26**] reflux and recurrent infections of a congenital single kidney, s/p cadaveric renal transplant in [**2165**] with chronic allograft nephropathy (b/l Cr [**2-25**]), who presented to her nephrologist on [**1-6**] with generalized malaise and myalgias developing over the 2 days. She also reports high blood sugars and feeling generally unwell. No fevers, but some chills. No new cough, no abdominal pain, no N/V. she does endorse some dysuria beginning yesterday. She also endorses some progressive chest tightness/heaviness a/w some SOB, but no radiation or associated N/V/diaphoresis. Has had a normal appetite with good po and fluid intake, no abdominal pain. Her nephrologist sent routine outpt labs, which revealed severe uremia with BUN 140, Cr 9, and bicarb less than assay. WBC count was elevated at 20. Dr. [**First Name (STitle) 805**] tried unsuccessfully to contact pt last night but was able to reach her this AM and she was referred to the ED. . In the ED, VS 98.8 88 105/61 18 96% 3L. Exam revealed no signs of volume overload (no edema, no crackles), and no belly pain. EKG was WNL and CXR showed basilar atelectasis but no focal infiltrate. U/A was dirty. Labs confirmed severe uremia with BUN 164 and AG acidosis with bicarb less than assay. Lactate was normal at 0.6. ABG returned at 7.03/25/81/7. CBC revealed WBC of 20.0 with 4% bands. A renal graft U/S showed appropriate flow, waveforms and RIs in the tx kidney, but there was also new ascites, which prompted LFTs and a CT abd/pelvis. Lipase returned at 595. CT revealed pancreatitis. Blood and urine cultures were sent and she received levofloxacin 750mg x 1 to cover possible UTI. Renal was consulted and recommended 40 mEq KCl, 2 amps NAbicarb, and fluid D5 with normal bicarb @ 100cc/hr, but saw no need for emergent dialysis. She was admitted to the MICU for acute renal failure and pancreatitis. Past Medical History: - native renal failure: thought to be due to secondary to chronic UTIs and Reflux from augmented bladder (age 12) in a single kidney - Cadaveric Kidney Transplant - [**2165**]: Dr. [**Last Name (STitle) 15473**]: [**Hospital **] Hospital -- No bx of native kidney. Tx from mother. initially on cya, imuran, in [**Last Name (un) **] study but had thrombotic reaction to cya at 6 months, converted to prograf and out of study. First BX: thrombotic microangiopathy. Also changed from imuran to cellcept. creat 3.2 in 5/[**2168**]. Best recent value was 2.6 in [**2-25**]. BX [**4-/2169**]: no cellular rejection, [**6-8**] sclerotic glomeruli, moderate interstitial fibrosis. Moderate proteinuria with pcr 1.6. did not tolerate [**Last Name (un) **]. - chronic transplant nephropathy- bx [**2168**], with impending graft failure - recent proteinuria - hypertension - DM2 on insulin - diagnosed [**2174**] - Anemia of Chronic Illness - Transfusion [**2176-5-24**] - Hyperparathyroidism- secondary - squamous epithelial neoplasia involving multiple areas - vulva, anal areas [**2173**] - agressively managed with vulvectomy, some urinary incontinence . past surgical hx: - cataract - renal transplant - multiple pelvic surgeries for bicornuate uterus, imperforate anus, and end colostomy with a colostomy takedown, multiple surgeries for augmentation of the bladder, and other abnormalities. Social History: She lives in [**Doctor Last Name 792**]with her boyfriend. She denies tobacco. Very infrequent EtOH (1 glass of wine q 2 weeks) Family History: noncontributory Physical Exam: VS: 96.8 94 114/61 22 97%RA GEN: cushingoid young female in NAD HEENT: NC/AT, anicteric sclerae. Very dry uremic MM. O/P clear. NECK: obese, JVP not grossly elevated COR: RRR no m/r/g PULM: CTAB no w/r/r ABD: surgically scarred. obese, soft, non-distended, slightly tender to deep palpation in epigastrium and LLQ. + BS EXT: WWP, trace b/l pitting edema. Old left antecubital graft. Pertinent Results: [**2178-1-7**] 01:10PM BLOOD WBC-20.0*# RBC-4.08* Hgb-9.1* Hct-28.6* MCV-70* MCH-22.3* MCHC-31.8 RDW-21.5* Plt Ct-203 [**2178-1-8**] 05:21AM BLOOD WBC-11.7* RBC-3.42* Hgb-7.8* Hct-22.7* MCV-66* MCH-22.7* MCHC-34.2 RDW-21.8* Plt Ct-172 [**2178-1-8**] 05:21AM BLOOD PT-13.5* PTT-25.4 INR(PT)-1.2* [**2178-1-7**] 01:10PM BLOOD Glucose-62* UreaN-163* Creat-10.0*# Na-136 K-3.1* Cl-106 HCO3-LESS THAN [**2178-1-7**] 11:07PM BLOOD Glucose-88 UreaN-148* Creat-8.2*# Na-136 K-2.9* Cl-105 HCO3-9* AnGap-25* [**2178-1-8**] 05:21AM BLOOD Glucose-57* UreaN-146* Creat-8.0* Na-143 K-2.9* Cl-107 HCO3-16* AnGap-23* [**2178-1-7**] 01:10PM BLOOD ALT-22 AST-17 CK(CPK)-47 AlkPhos-135* TotBili-0.1 [**2178-1-7**] 01:10PM BLOOD Lipase-595* [**2178-1-8**] 05:21AM BLOOD Lipase-209* [**2178-1-8**] 05:21AM BLOOD Amylase-207* [**2178-1-7**] 01:10PM BLOOD Triglyc-310* [**2178-1-7**] 04:49PM BLOOD tacroFK-PND [**2178-1-7**] 06:28PM BLOOD Type-ART pO2-81* pCO2-25* pH-7.03* calTCO2-7* Base XS--23 [**2178-1-7**] 03:30PM BLOOD Lactate-0.6 AP and lateral CXR [**2178-1-7**]: TECHNIQUE: AP and lateral radiographs of the chest were performed. There is no relevant prior imaging for comparison. The right hemidiaphragm is raised. There is atelectasis at the right lung base. There is no focal pulmonary consolidation. The heart size is at the upper limits of normal. CONCLUSION: Raised right hemidiaphragm with atelectasis at the right lung base. No focal pulmonary consolidation. Renal Transplant U/S [**2178-1-7**]: FINDINGS: Comparison is made to [**2169-5-23**]. Renal transplant is identified in the right lower quadrant, measuring 11.4 cm. There is minimal fullness of the collecting system, but no frank hydronephrosis. There is a 2.0 cm simple cyst in the mid pole of the transplant kidney. There is no perinephric fluid collection. There is however, evidence of moderate ascites throughout the right lower quadrant. Color Doppler evaluation of the transplant renal vasculature shows normal flow, and waveforms in the main renal artery and vein. Normal flow, waveforms, and resistive indices are seen in segmental branches of the transplant renal arterial vasculature, with resistive indices ranging between 0.71 and 0.76. The bladder is partially collapsed, with a Foley catheter in place. IMPRESSION: 1. Patent renal transplant vasculature, with appropriate flow, waveforms, and resistive indices. 2. Moderate ascites. CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST [**2178-1-7**] IMPRESSION: 1. Stranding around the pancreas may represent mild pancreatitis, though correlation with clinical exam and laboratory values is needed. Small perihepatic free fluid. A small amount of fluid also appears to track along the ascending colon. 2. Small bilateral pleural effusion. 3. 4.5 cm right posterior pelvic cyst is slightly larger than in [**2172**] and may be postoperative (ie seroma, lymphocele, pelvic inclusion cyst) in nature. Brief Hospital Course: Ms. [**Known lastname 29940**] is a pleasant 29-year-old woman with ESRD s/p cadaveric renal transplant in [**2165**] with slowly progressive renal failure who now presents with acute on chronic renal failure, severe uremia, and evidence of pancreatits. # Pancreatitis - unclear etiology, there was evidence of stranding on CT abdomen. There was no evidence of gallstones on CT, triglycerides were elevated at 310. Unlikely due to medications. She had mild abdominal pain and nausea/emesis on HD 1 and 2, resolved HD 3. Diet was advanced as tolerated and she was tolerating POs HD 3. She was given IVF, amylase and lipase were trended. # Acute on chronic Renal Failure - Peak creatinine was 10.0 in pt with prior baseline ~3.7. Renal was consulted and after review of urinary sediment, felt that the pt had ATN due to her recent poor PO intake in the setting of pancreatitis. Other intrinsic renal causes including graft rejection, infection (esp BK virus, CMV), and medications were considered but were unlikely. Renal did not feel that there was acute indication for hemodialysis as her creatinine was trending down since admission. Urine lytes revealed intrarenal pattern. There was no evidence of hydronephrosis or acute rejection on ultrasound of her graft. She continued to make urine initially with UOP of 30-50cc/hour which increased to up to 100cc/hour on HD [**1-27**]. CMV and BK serologies were negative. Tacrolimus and prednisone were continued. Tacrolimus levels were followed. Medications were renally dosed. # AG acidosis - due to uremia. Lactate WNL. Glucose had been low since admission and DKA in a type 2 diabetic was felt to be very unlikely. She received 2 amps of sodium Bicarbonate in the ED. She was administered bicarbonate via IVF with resolution of her acidosis. HD 2, bicarbonate was discontinued with improvement in acidosis. # s/p renal transplant- continued outpatient prednisone and tacrolimus doses. Levels were monitored. No evidence of graft rejection. BK virus and CMV PCR were negative. # Leukocytosis - No focal infiltrate on CXR and no obvious infectious source on CT scan. Blood and . She initially received levofloxacin for a possible UTI, but antibiotics were discontinued when urine cultures returned negative. Her leukocytosis resolved. # Anemia- epoietin was started per renal recs. She was transfused 2 units [**2178-1-8**]. She was guaiac negative. Iron studies were consistent w/anemia of chronic disease. # DM- continued lantus and insulin SS # HTN-antihypertensives were initially held, restarted HD 3. Medications on Admission: prograf 1mg [**Hospital1 **] prednisone 5 mg daily lasix 20mg daily amlodipine 10mg daily calcitriol unknown dose insulin: lantus 24 units qHS, Novolog SS Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Lantus 100 unit/mL Cartridge Sig: One (1) 24 units Subcutaneous at bedtime. 7. Novolog 100 unit/mL Cartridge Sig: One (1) Subcutaneous QACHS: per outpatient sliding scale. 8. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection once a week. Disp:*4 doses* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: primary: uremia acute renal failure Acute tubular necrosis pancreatitis hypocalcemia hypokalemia secondary: chronic renal failure history of renal transplant type 2 diabetes mellitus hypertension anemia Discharge Condition: stable Discharge Instructions: You were admitted with acute on chronic renal failure and uremia. It improved with IV fluid hydration. You also had pancreatitis on admission. This improved with bowel rest and IV fluid hydration. It is very important that you take all of your medications as directed and follow up with your appointments. If you should have fever/chills, abdominal pain, nausea/vomiting, headache/dizzyness, please present to the emergency department. Followup Instructions: Please follow up with your nephrologist, Dr. [**First Name (STitle) 805**] or Dr.[**Name (NI) **] within the next 1-2 weeks.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10724, 10730

7284, 9849

342, 349

10978, 10987

4340, 7261

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45109

Discharge summary

report

Admission Date: [**2109-3-16**] Discharge Date: [**2109-3-21**] Date of Birth: [**2042-6-25**] Sex: F Service: MEDICINE Allergies: Mevacor / Bactrim / Dilantin Kapseal / Naprosyn / Clindamycin / Percocet / Quinine / Levofloxacin / Penicillins / Vicodin / latex gloves / Morphine / optiflux / Warfarin / Phenytoin Attending:[**First Name3 (LF) 30**] Chief Complaint: Diarrhea, Tachypnea Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 1968**] is a 66y/o lady with Afib on Lovenox, ESRD on HD, dCHF, HTN, DMII, restricitve lung disease on home O2, necrotizing breast infections from Warfarin skin necrosis s/p bilateral mastectomies [**2109-1-17**], with two subsequent admissions in the past six weeks, one for hypoglycemia and pneumonia and another for mental status changes and hypotension who was admitted to the MICU [**3-16**] for HD because she had missed her outpatient HD due to diarrhea, and is now called out to the floor. . Per MICU admission H+P: "Her last admission, [**Date range (3) 96410**] her AMS was attributed to Oxycontin, Oxycodone, and Neurontin, which was not appropriately dosed for an HD patient and was actually initiated 5 days prior to admission. She realized it had been discontinued during a recent hospitalization, but was not sure why, and she wanted to restart it. She also reported taking increased amounts of oxycodone and oxycontin prior to admission. She also had a presumed R IJ HD line infection [**2-28**] [**Female First Name (un) **] PARAPSILOSIS. She was discharged on fluc (for 9 more days) and oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H. They STOPPED gabapentin, CHANGED metoprolol to 12.5 mg [**Hospital1 **], STOPPED digoxin, STOPPED oxycontin, STOPPED PhosLo. . Since discharge, 66 year old female who presents for 2 days of diarrhea. She reports 25 episodes of diarrhea for each of the past 2 days. She reports nausea but [**Hospital1 **] vomiting. She was sent from [**Hospital1 2286**] and she did not complete [**Hospital1 2286**] today. She [**Hospital1 **] abdominal pain. [**Hospital1 4273**] black or bloody stools, reports watery diarrhea. Reports cough and fatigue." . During this brief (few hour) MICU stay, her mental status has been clear, except that she has been crying out that she is very cold and wants more blankets. She is at her baseline O2 requirement. No loose stools since being here. . Currently, she feels very well and is without complaints. Past Medical History: - CAD s/p Taxus stent to mid RCA in [**2101**], 2 Cypher stents to mid LAD and proximal RCA in [**2102**]; 2 Taxus stents to mid and distal LAD (99% in-stent restenosis of mid LAD stent); NSTEMI in [**8-1**] - CHF, LVEF >55% on echo in [**2107**]. 1+ MR - Atrial fibrillation - Hypertension - Dyslipidemia: Chol: 171, LDL 92 in [**1-/2108**] on Pravastatin - Multiple prior Syncope/Presyncopal episodes - Type 2 DM on insulin, last A1c 8% in [**2107**] - ESRD on HD since [**2107-2-28**] - [**Year (4 digits) 2286**] on MWF, and UF on Thursday - She had a left upper arm brachiocephalic AV fistula created which did show some maturation, but the vein was found to be too deep and too tortuous for use. - PVD s/p bilateral fem-[**Doctor Last Name **] in [**2093**] (right), [**2100**] (left) - restricitve lung disease last [**Year (4 digits) 1570**]'s of [**10-6**] consistent with restrictive pattern. FEV1 = 71%, FVC = 68% FEV1/FVC = 105, on home O2 3L - title of COPD but most recent [**Date Range 1570**]'s showed reastrictive pattern - OSA- CPAP at home 14 cm of water and 4 liters of oxygen - Morbid obesity (BMI 54) - Crohn's disease - not currently treated, not active dx [**2093**] - Depression - Gout - Hypothyroidism - GERD - Chronic Anemia - Restless Leg Syndrome - Back pain/leg pain from degenerative disk disease of lower L spine, trochanteric bursitis, sciatica - calciphylaxis - warfarin skin necrosis - invasive ductal breast cancer Social History: -Home: Lives at a Nursing Home ([**Location (un) 1036**] in [**Location (un) 620**]). Very close with her sister [**Name (NI) **], HCP) and [**Initials (NamePattern4) 96407**] [**Last Name (NamePattern4) 96408**] [**Last Name (un) **]. -Tobacco: Quit smoking in [**2102**], smoked 2.5ppd x 40 years (100py history). -EtOH: [**Year (4 digits) **] -Illicits: [**Year (4 digits) **] Family History: Sister: CAD s/p cath with 4 stents MI, DM Brother: CAD s/p CABG x 4, MI, DM Mother: died at age 79 of an MI, multiple prior, DM Father: [**Name (NI) 96395**] MI at 60 She also has several family members with PVD Physical Exam: ON ADMISSION 140/54, 94, 20, 95% on 3L. General: Obese lady, no respiratory distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: Bradycardic, irregular, S1 and S2, no murmur Lungs: End-expiratory wheezes bilaterally Chest: b/l mastectomy sites with no erythema, no fluctuance Abdomen: obese, soft, non-tender, non-distended, bowel sounds present Ext: very edematous legs (2+) up to thighs bilaterally with chronic venous stasis; non-healing 2cm ulcers on left posterior calf and left medial calf with serous drainage Neuro: drowsy, localizes and withdraws to sternal rub or peripheral noxious stimuli; 2+ brachial and patellar reflexes; normal bulk and tone; intermittent myoclonic jerks On Discharge: 97.8 145/84 94 22 96% on 2L General: Obese lady, no respiratory distress while on NC (baseline of 2L) HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: irregularly irregular, S1 and S2, no murmur Lungs: End-expiratory wheezes bilaterally, mild crackles at base Chest: b/l mastectomy sites with no erythema, no fluctuance Abdomen: obese, soft, non-tender, non-distended, bowel sounds present Ext: edematous legs (2+) up to thighs bilaterally with chronic venous stasis; non-healing 2cm ulcers on left posterior calf and left medial calf with serous drainage Neuro: awake and alert,non-focal Pertinent Results: On Admission: [**2109-3-16**] 07:40PM BLOOD WBC-3.4*# RBC-2.80* Hgb-8.5* Hct-26.0* MCV-93 MCH-30.2 MCHC-32.6 RDW-15.9* Plt Ct-309 [**2109-3-16**] 07:40PM BLOOD Neuts-85.7* Lymphs-9.1* Monos-4.2 Eos-0.8 Baso-0.2 [**2109-3-16**] 07:40PM BLOOD PT-11.2 PTT-29.1 INR(PT)-1.0 [**2109-3-16**] 07:40PM BLOOD Glucose-93 UreaN-11 Creat-2.3* Na-141 K-3.5 Cl-99 HCO3-27 AnGap-19 [**2109-3-16**] 07:40PM BLOOD ALT-14 AST-17 AlkPhos-181* TotBili-0.2 [**2109-3-17**] 03:00AM BLOOD CK(CPK)-53 [**2109-3-16**] 07:40PM BLOOD proBNP-[**Numeric Identifier 96411**]* [**2109-3-17**] 03:00AM BLOOD CK-MB-2 cTropnT-0.14* [**2109-3-16**] 07:40PM BLOOD Albumin-3.2* Calcium-7.7* Phos-2.1* Mg-1.5* Vitamin D and PTH-pending at discharge On Discharge: [**2109-3-20**] 06:10AM BLOOD WBC-8.0 RBC-3.07* Hgb-9.4* Hct-28.2* MCV-92 MCH-30.7 MCHC-33.3 RDW-16.4* Plt Ct-309 [**2109-3-20**] 06:10AM BLOOD Glucose-127* UreaN-15 Creat-2.8*# Na-138 K-4.3 Cl-94* HCO3-28 AnGap-20 Stools Studies: FECAL CULTURE (Final [**2109-3-19**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2109-3-19**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2109-3-19**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2109-3-17**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Blood Cultures from [**2109-3-16**]-pending at the time of discharge CXR [**2108-3-16**] FINDINGS: Single AP semi-erect portable view of the chest was obtained. Moderate-to-severe pulmonary edema is again seen. Difficult to exclude underlying pleural effusions. The cardiac and mediastinal silhouettes are stable. There has been interval placement of a large-bore left-sided catheter, distal tip not optimally seen, but likely terminates in the cavoatrial junction/right atrium. Brief Hospital Course: qaMs. [**Known lastname 1968**] is a 66y/o lady with ESRD on HD, dCHF, Afib on Lovenox, HTN, DMII, restricitve lung disease on home O2, necrotizing breast infections from Warfarin skin necrosis as well as calciphylaxis s/p bilateral mastectomies who presents with diarrhea and tachypnea. . #. Tachypnea, Acute on Chronic CHF - The patient reports multiple dietary indiscretions prior and during this admission. She had consumed extra fluid and salt, in particular she was found eating french fries given to her by her sister on the second day of admission. Since the patient is anuric, she underwent 2 rounds of UF on the first day of admission removing 7 litters of fluids. Her dysnpea and tachypnea resolved subsquent to her second round of ultrafiltration. She was also received 1 dose of solumedrol 125mg and standing nebs for inital concerns of a COPD exacerbation. Given drastic improvement after UF, solumedrol was not contined. She under went sceduled HD on [**2109-3-19**] and [**2109-3-21**], and additional UF on [**2108-3-17**], again on [**2108-3-17**] and 2/2/22/12. The patient's discharge weight was 97 kg (down from 114kg at her peak), although the patient continued to have 2+ pitting edema in her legs bilaterally. She was instructed to restrict her fluid intake to 1500cc or less per day and to restrict her sodium intake to 2000mg daily or less. She should resume her HD on t/th/sat. . #. Diarrhea - The patient presented with >20 episodes of diarrhea 1 day prior to admission. Stool studies were negative and the diarrhea resolved on HD#1. Stood studies were negative. She was acutally very volume overloaded despite the reported amounts of diarrhea. The diarrhea resolved and the patient was discharge back on her bowel regime prn. . # Leg wounds: The patient was started on pain control and wound care was consulted. Wound care recommended to the right anterior tibia, Left posterior thigh , and left medial posterior calf: Please apply commerical cleanser with DuoDerm gel and mepilex foam change q3 days. To the right medial knee, commercial cleanser with hydrofiber silver (aquacel AG) daily, cover with dry gauze or abd pad, and secure with medipore tape. . #. AFib on Lovenox: The patient was slightly uptitrated to metoprolol 37.5 TID with rate typically in the 90's. Lovenox was continued at QMo/We/Fr. . #. ESRD: on HD T/Th/Sa. She will be continued on her T/Th/Sa schedule. She was continued on nephrocaps. She was found to be hypophosphatemic at the time of discharge with a PO4 or 1.0. She was given 4 patchets of neutraphos and rose to 1.8 prior to discharge. She was discharged on 3 additional days of 2 pkt of neutra-phos daily. Also cincalset was discontinued and she was started on calitriol 0.5mcg daily . #. Restrictive lung disease: stable. She was continued on her baseline home O2 requirements of 2L via NC. She was also continued on nebs. -continue home O2 -continue home nebs PRN . #. Type 2 DM: stable; She was started on a humalog ISS. . #. Depression: stable. She was continued on paroxetine. . #. Chronic anemia: Hct was at baseline. She will need epo per HD. . #. Hypothyroidism: stable. She was continued on her home levothyroxine dose. Medications on Admission: Aspirin 81 mg daily Metoprolol tartrate 12.5 mg [**Hospital1 **] Enoxaparin 100 mg/mL Syringe subcutaneous Q M/W/F Pravastatin 80 mg daily Oxycodone 5-10mg Q4H PRN Levothyroxine 175 mcg daily Aspart SS with breakfast, lunch, dinner Omeprazole 40 mg daily Allopurinol 100mg daily Paroxetine HCl 40 mg daily Albuterol sulfate 2.5 mg /3 mL (0.083 %) neb Q6H PRN Ipratropium bromide 0.02 % neb Q6H Cinacalcet 30 mg daily B complex-vitamin C-folic acid 1 mg daily Ascorbic acid 500 mg daily Senna 8.6 mg QHS Polyethylene glycol 3350 17 gram/dose daily PRN constipation Bisacodyl 10mg PR PRN Lactulose 10 gram/15 mL: 30mL PO daily PRN constipation Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO once a day. 3. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous QMWF (). 4. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. insulin aspart 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous four times a day: please see attached sliding scale; please give prior to meals. 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO once a day as needed for constipation. 16. bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. 17. lactulose 10 gram/15 mL (15 mL) Solution Sig: [**1-28**] PO once a day as needed for constipation. 18. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 19. potassium & sodium phosphates 280-160-250 mg Powder in Packet Sig: Two (2) Powder in Packet PO once a day for 3 days. 20. Outpatient Lab Work PLEASE have your serum sodium, potassium, chloride, bicarbonate, calcium, magnesium, and phosphate check 2 days after discharge. 21. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: acute exacerbation of diastolic congestive heart failure Chronic Kidney Disease Hypophosphatemia 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 1968**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted because of difficulty breathing. We found that you were in congestive heart failure due to consuming too much fluid and salty foods. Please restrict your fluid intake to no more than 1.5 litters of fluid a day or less. Also please restrict your sodium intake to no more than 2000mg of sodium or less. Your discharge weight is 97kg. If you gain more than 4 kilograms, please let your [**Hospital1 2286**] center know so they may adjust the amount of fluid they remove from your body. We also found found that you had low phosphate, which will need to be replete and monitor after discharge. Please continue to undergo hemodialysis per your rountine schedule. Please follow up with your Dr. [**First Name (STitle) 437**], your cardiologist on [**2109-3-25**] at 1pm. Medication Changes: STOP taking Cinacalcet INCREASE to metoprolol succinate 50mg daily START taking NeutraPhos 2 pkt daily for the next 3 days START taking Fluconazole 200mg daily START taking Calcitriol 0.5mcg daily Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2109-3-25**] at 1 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

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14095, 14172

8125, 11337

461, 467

14312, 14312

6025, 6025

15613, 15917

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310

Discharge summary

report

Admission Date: [**2148-4-2**] Discharge Date: [**2148-4-16**] Date of Birth: [**2069-6-14**] Sex: M Service: NEUROLOGY Allergies: Phenobarbital Attending:[**First Name3 (LF) 2927**] Chief Complaint: transferred for seizure management Major Surgical or Invasive Procedure: Intubation Long Term EEG monitoring History of Present Illness: 78yo RH M h/o brain tumor s/p R frontal resection in [**2132**], CAD, hyperlipidemia, prostate cancer s/p XRT and seizure disorder who is transferred for increasing seizures. . He initially presented to OSH on [**3-29**] with "symptoms of left-sided hand weakness and clumsiness of 3 days duration", worse from a baseline weakness on the left subsequent to tumor resection. He also complained of slowly progressive deterioration in his gait over several months, leaning to the left. . He was admitted with seizures and found to have UTI and hypoxia due to poor mucous clearance, all per his discharge summary. Head CT was negative for acute stroke. MRI showed a "cystic/encephalomalacic change in the right superior frontal gyrus and left medial cerebellar hemisphere without evidence of enhancement." MRA showed patent ant/post circulation. EEG seems to have had right frontal seizure focus/slowing. . On [**3-31**], he was "noted to have seizure activity" though this is not further specified; depakote was found to be subtherapeutic and the dose was increased. He was transferred to the OSH ICU for further management. . He "continued to have intermittent episodes of seizure activity with hypoxia". He was started empirically on zosyn for aspiration pneumonia; UA was positive for UTI with pseudomonas. The patient was tranferred here [**4-1**] for further care and intubated on arrival for respiratory distress. He has been off of propofol since 2am. . On morning rounds at 9:25am, he was observed to have 30sec of left hand shaking then his left face, with right gaze deviation and eye opening/closure and no responsiveness. He was given ativan 2mg IV x 1. Past Medical History: - Brain tumor (path unknown) dx'd [**2132**] s/p resection - Angina s/p PTCA @ [**Hospital1 1774**] - Hyperlipid - Prostate Ca s/p XRT Social History: Lives with wife, needs help with ambulating and dressing. h/o smoking, quit 40yrs ago. Family History: unknown Physical Exam: VS 98.3/100.0 64-95 106-148/47-75 [**8-27**] 1266/272 100% Gen Lying in bed in NAD Neck supple CV rrr no bruits Pulm ctab Abd soft benign Ext no edema . NEURO (prior to seizure this morning) MS Intubated, off sedation. Awakens to gentle sternal rub. Opens his eyes. Follows commands to raise his right arm or squeeze its fingers, or lift either leg. No preference in visuospatial attention. . CN CN I: not tested CN II: Blinks to threat b/l. Pupils 3->2 b/l. CN III, IV, VI: EOMI no nystagmus CN V: b/l corneal reflex; symmetrical grimace to nasal tickle CN VII: full facial symmetry and strength CN VIII: hearing intact to FR b/l . Motor Normal bulk and tone. Right arm/leg [**4-6**]. Left is at least [**2-5**] but with less spontaneous movement. Legs are antigravity for at least 5 seconds, though the left is raised less than the right. . Sensory withdraws to pain in all extremities. . Reflexes 2+ symmetric, toes down b/l . Coordination deferred . Gait deferred Pertinent Results: Admission Labs [**2148-4-2**] 07:48AM ALT(SGPT)-5 AST(SGOT)-14 CK(CPK)-126 ALK PHOS-46 AMYLASE-85 TOT BILI-1.2 LIPASE-20 [**2148-4-2**] 07:48AM ALBUMIN-3.5 MAGNESIUM-2.2 CHOLEST-114 [**2148-4-2**] 07:48AM VIT B12-730 FOLATE-15.1 [**2148-4-2**] 07:48AM %HbA1c-5.7 [**2148-4-2**] 07:48AM TRIGLYCER-77 HDL CHOL-58 CHOL/HDL-2.0 LDL(CALC)-41 [**2148-4-2**] 07:48AM VALPROATE-83 [**2148-4-2**] 03:00AM TYPE-ART PO2-71* PCO2-37 PH-7.45 TOTAL CO2-27 BASE XS-1 [**2148-4-2**] 03:00AM LACTATE-1.8 [**2148-4-2**] 03:00AM freeCa-1.11* [**2148-4-2**] 01:13AM GLUCOSE-113* UREA N-15 CREAT-1.0 SODIUM-142 POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-27 ANION GAP-15 [**2148-4-2**] 01:13AM CK(CPK)-145 CK-MB-3 cTropnT-<0.01 [**2148-4-2**] 01:13AM CALCIUM-9.1 PHOSPHATE-3.8 MAGNESIUM-2.2 [**2148-4-2**] 01:13AM WBC-13.2* RBC-4.15* HGB-14.7 HCT-41.8 MCV-101* MCH-35.3* MCHC-35.0 RDW-13.5 PLT COUNT-178 [**2148-4-2**] 01:13AM NEUTS-77* BANDS-2 LYMPHS-6* MONOS-8 EOS-0 BASOS-1 ATYPS-6* METAS-0 MYELOS-0 [**2148-4-2**] 01:13AM PT-14.0* PTT-26.8 INR(PT)-1.2* . Admission CXR [**4-2**]: There is no focal abnormality in the lungs to indicate aspiration but elevation of the left hemidiaphragm may reflect acute volume loss from aspirated material in the left lower lobe bronchus. Followup is recommended. ET tube is in standard placement and a nasogastric tube ends in the stomach. No pneumothorax or pleural effusion. Normal cardiomediastinal silhouette . Most recent CXR [**2148-4-15**]: Ill-defined right infrahilar opacity persists with no new focal infiltrates or evidence of pulmonary edema. Cardiomediastinal silhouette, hilar contours, and pleural surfaces are within normal limits. No evidence of pneumothorax. Nasogastric tube terminates in the stomach and linear opacity projecting over the right neck is likely external to the patient. . IMPRESSION: Unchanged right infrahilar opacity, likely representing aspiration pneumonia. No evidence of new infiltrates or pulmonary edema . MRI Head: FINDINGS: The patient is status post remote craniotomy and resection of a small portion of the right frontal lobe with surrounding gliosis. Periventricular FLAIR hyperintensity likely represents a combination of small vessel ischemic changes and chronic changes from radiation. No intracranial mass, hemorrhage, shift of normally midline structures, or evidence of abnormal enhancement is identified. Prominence of the ventricles and sulci is slightly pronounced for patient's age. There is no evidence of acute minor or major vascular territorial infarct. Opacification of multiple mastoid air cells is noted. . IMPRESSION: Status post remote resection of a small portion of the right frontal lobe with no evidence of new mass or abnormal enhancement . Admission EEG [**4-2**]: ABNORMALITY #1: The right hemisphere revealed a [**1-7**] Hz low voltage slowing throughout the record. ABNORMALITY #2: Over the left hemisphere, a [**5-9**] Hz slow posterior background rhythm was noted throughout the tracing. BACKGROUND: As above. HYPERVENTILATION: Contraindicated due to patient's mental status. INTERMITTENT PHOTIC STIMULATION: Portable study precluded photic stimulation. 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 72 beats per minute. IMPRESSION: This is an abnormal EEG due to the low voltage right hemisphere delta slowing and the left hemisphere background slowing. This suggests right hemisphere subcortical dysfunction. The left hemisphere background slowing suggests a mild encephalopathy, which may be seen with infections, medication effect, or toxic metabolic abnormalities . EEG telemetry [**4-4**]: This 24-hour video EEG telemetry captured five electrographic seizures. Two appeared to have onset in the right temporal region with subsequent spread to the left hemisphere and then involvement of both hemispheres quite prominently and were characterized by a gagging or coughing sound at onset followed by left arm elevation and shaking. Three seizures appear to have exclusively left temporal onset with subsequent spread to the remainder of the left hemisphere and the right temporal region prominently and were not characterized by any visible clinical change on video. No interictal epileptiform discharges were seen. The background was slow and disorganized throughout the recording suggestive of a mild to moderate encephalopathy . EEG telemetry [**4-5**]: This 24-hour EEG telemetry captured six electrographic seizures by automated detection. These all began with rhythmic sharp changes in the right frontal region typically spreading to rapid sharp alpha frequency activity of high amplitude in the left temporal region and then rapid sharp high amplitude alpha activity throughout much of the brain. Clinically, the patient had gagging or coughing noises occasionally with additional mouth movements or with elevation and clonic shaking of the left arm. No interictal epileptiform discharges were seen. The background was slow and disorganized throughout the recording suggestive of a moderate encephalopathy . Most recent EEG, [**4-10**]: This 24-hour video EEG telemetry captured no pushbutton activations. There were no electrographic seizures or interictal epilepiform discharges. The background was mostly slow and disorganized in the theta frequency range throughout the day's recording although some periods of alpha frequency activity were seen on occasion. These findings suggest the presence of a mild to moderate encephalopathy. Compared to the prior day's recording, the encephalopathy appeared slightly improved. Brief Hospital Course: ICU Course: The patient was transferred from an OSH to the neuro-ICU. His valproate level was found to be therapeutic initially and he was seen to have left-sided focal seizures of his arm/face (thought to be due to R frontal tumor resection). He was therefore started on keppra 1000mg IV q12 in addition to Depakote 750 [**Hospital1 **]. Valproate dose was subsequently increased up to 1000 mg Q8 as it was found to be low and the patient had continued seizures (~1/day). Continuous EEG monitoring showed electrographic seizures with R temporal onset (see full EEG report above). After initiation of Keppra and up-titration of Depakote seizures slowed and then stopped on telemetry. He was extubated without incident. He finished a course of Zosyn -> Ceftazadime for aspiration PNA. Pt. was transferred to the floor for further care. Floor Course: MRI Head was performed (see results above) and showed the remote resection of a small portion of the right frontal lobe with no evidence of new mass or abnormal enhancement or infarct. This was felt to be the focus for his seizures. He had no further seizures on the floor. ASA 325 and Zocor were continued and we resumed atenolol 50 mg QD. A1c and lipid panel were checked (see results above) and were at goal. Blood, urine, and blood cultures were negative throughout his course. Pt. was afebrile throughout his floor course. He had some episodes of desaturation, but given that he was afebrile and CXR findings were stable, these were felt to be due to mucous plugging. He should continue to receive chest PT and frequent suctioning at rehab. Depakote level was checked and was subtherapeutic at 48, so Depakote was increased to 1250 TID. It should be rechecked on [**4-22**] and titrated as needed for goal 80-100. Nutrition was maintained with tube feeds throughout his course. Pt. initially was encephalopathic and inattentive on the floor, which was felt to be contributing to his inability to swallow on swallow evaluations. Given that he did not have any further seizures, we therefore decided to wean off his Keppra. His inattention improved with this intervention. A decision was made not to proceed with PEG for long term nutrition given that there was some chance that his swallowing would continue to improve as Keppra came out of his system. He should be followed by speech therapy at rehab, and if he continues to fail swallow evals PEG may need to be considered. Medications on Admission: - Atenolol 50mg QD - Lipitor 10mg QD - Flomax 0.4mg QD - ASA 325 - Imodium PRN - SL NTG PRN - Depakote 250mg QID Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) Injection TID (3 times a day). 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 3. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 4. Atenolol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 6. Valproate Sodium 100 mg/mL Solution [**Last Name (STitle) **]: 1250 (1250) mg Intravenous Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: Left focal motor seizures Discharge Condition: Stable Discharge Instructions: Please notify your doctor if you develop any further left arm shaking or seizures, fevers, chills, nausea, vomiting, diarrea, chest pain, shortness of breath, or any other symptoms that concern you. Please attend all follow up appointments. Followup Instructions: Neurology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], Friday [**6-7**] at 9:00. [**Hospital Ward Name 23**] building, [**Location (un) **]. Phone:[**Telephone/Fax (1) 2928**] for any questions. Completed by:[**2148-4-16**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "96.6" ]

icd9pcs

[ [ [] ] ]

12324, 12407

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310, 348

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2320, 2329

11670, 12301

12428, 12456

11532, 11647

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376, 2040

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82,933

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38046

Discharge summary

report

Admission Date: [**2150-11-19**] Discharge Date: [**2150-12-7**] Date of Birth: [**2070-6-28**] Sex: F Service: NEUROSURGERY Allergies: Phenergan / Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 78**] Chief Complaint: Mental status changes new IPH Major Surgical or Invasive Procedure: None History of Present Illness: 80 yo F with history of HLD, on ASA 81 mg daily, transferred from St. [**Hospital 11042**] hospital for ICH. The patient was found by her son on the floor in her home this AM. She lives alone and prior events are unknown. She was arousable to voice and said "yes" and "no" and recognized her son. She appeared less interactive than usual and was weak on her left side as per her son. She was taken to St. [**First Name4 (NamePattern1) 11042**] [**Last Name (NamePattern1) **] . There she was noted to respond to pain, was incontinent of urine, and unaware of what happened. She vomited once while in ED. As per patient's daughter, she had been acting abnormal the prior night, eating food with her hands and appeared drowsy. At baseline she lives alone and is independent with ADLs. She was intubated for airway protection and transferred to [**Hospital1 18**] for further management. Past Medical History: HLD GERD overactive bladder Social History: Lives alone independently has 4 adult children Family History: Unable to obtain Physical [**Hospital1 **]: T- 98.3 (Tm = 101.4 last night) BP- 125/46 HR- 67 RR- 18 O2Sat 99% intubated Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: In C-collar CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender; prominent abdominal pulse ext: no c/c/e; equal radial and pedal pulses B/L. Neurologic examination: Mental status: Off propofol, eyes remain closed without spontaneous opening. No response to verbal stim. Some mvmt to sternal rub. Cranial Nerves: Pupils 2 mm and min reactive bilaterally. Weak VOR B/L (though [**Hospital1 **] limited by C-collar). No gross facial asymmetry, (+) corneals B/L. Motor: Normal bulk bilaterally. Increased tone in all 4 ext. LE seem tonically extended. No observed myoclonus or tremor Moves RUE and RLE spont. and withdraws both to noxious stim. No spont mvmt on L. To noxious, there is mild flexion of the LUE, while the LLE mainly inverts with some trace flexion, but not against gravity. Sensation: responds to noxious in all 4 ext. Reflexes: +3, brisk and symmetric throughout the UE. 2+ at the knees. 0 at the Achilles B/L. Toes mute bilaterally Labs: pH 7.44 pCO2 37 pO2 194 HCO3 26 BaseXS 1 Type:Art [**Hospital1 **] on discharge: Opens eyes, MAE, non verbal, intermittent commands. Pertinent Results: [**11-19**] IMPRESSION: 1. Stable right frontal 4.4 cm intraparenchymal hemorrhage with extension into the lateral ventricles and a small amount of adjacent subarachnoid hemorrhage. No significant midline shift. 2. 9 mm focus of high density in the right inferior temporal lobe, which is new compared to the prior study and may represent artifact (favored) and less likely contusion. [**11-23**] Impression: 1. Stable intraparenchymal hemorrhage within the right frontal lobe, with slight interval improvement of the intraventricular extension. 2. No evidence of new hemorrhage or mass effect. 3. Ventricles are stable in size with no evidence of hydrocephalus. [**2150-12-7**] 05:46AM BLOOD WBC-8.7 RBC-3.31* Hgb-10.4* Hct-30.8* MCV-93 MCH-31.5 MCHC-33.8 RDW-14.8 Plt Ct-506* [**2150-11-27**] 02:25AM BLOOD Neuts-78.6* Bands-0 Lymphs-15.0* Monos-4.1 Eos-1.7 Baso-0.7 [**2150-12-7**] 05:46AM BLOOD PT-12.6 PTT-26.6 INR(PT)-1.1 [**2150-12-7**] 05:46AM BLOOD Glucose-131* UreaN-14 Creat-0.4 Na-139 K-3.9 Cl-105 HCO3-27 AnGap-11 Brief Hospital Course: 80 F w/ hx HLD, GERD, overactive bladder, on ASA admitted to the neurosurgery service in the ICU for close neurological observation due to new right IPH. She underwent a CTA which was negative for a vascular cause of her bleed and MRI to rule out an underlying lesion. Neurology was involved due to her [**Month/Day/Year **] being inconsistent with bleed(minimally reponsive to small right IPH). She was placed on Dilantin due to questionable seizure by son at home. Off all sedation, she remained with eyes closed, unresponsive to voice. The IPH alone likely did not explain this. The patient was found to have a UTI, VAP and possible bacteremia for which she was placed on triple antibiotics. A family meeting was held on [**11-23**] and it was explained that the patients infectious processes may be causing her poor neurologic [**Month/Year (2) **], the family decided to continue with full medical care. A routine EEG on [**11-24**] showed:mild diffuse encephalopathy, brief left anterior temporal epileptiform discharges and suppression of right hemispheric activity. A LP puncture was performed to rule out meningitis which was negative. Ms [**Known lastname **] [**Last Name (Titles) **] slowly improved she opens eyes, tracks examiner and moves right side purposely. She withdraws her legs and left arm. Her antibiotics were tailored to treat her pneumonia to Levaquin for a total of 14 days. On [**11-30**] she was transferred to the neuro floor, she was not able to participate in speech and swallow trial thus a PEG was placed on [**12-4**] and she tolerated TF at goal. She then had continuous EEG monitoring for about 48 hours which showed most likely encephalopathy from quinolones. She was then stable to go to re-hab. Medications on Admission: Aspirin 81 mg daily Crestor 10 mg daily KCl 10 meq daily Nexium 40 mg daily Vit C Vit D Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 4. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours: Please hold for SBP <90 and HR <55. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Right IPH Discharge Condition: Neurologicaly Stable Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? 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. ?????? We have restarted your Aspirin while you were in the hospital You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy 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. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.[**First Name (STitle) **] to be seen in 6 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[**2150-12-7**]

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icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "03.31", "38.91", "38.93", "43.11" ]

icd9pcs

[ [ [] ] ]

6481, 6528

3814, 5550

342, 349

6582, 6605

2759, 3791

7609, 7969

1400, 1785

5690, 6458

6549, 6561

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273, 304

377, 1268

1957, 2672

1824, 1941

1809, 1809

1290, 1320

1336, 1384

27,392

172,901

34691

Discharge summary

report

Admission Date: [**2112-9-22**] [**Month/Day/Year **] Date: [**2112-10-5**] Date of Birth: [**2031-6-15**] Sex: F Service: SURGERY Allergies: Nsaids / Ibuprofen / Altace Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: [**2112-9-22**] ORIF left tibial plateau fracture [**2112-9-29**] IVC filter placment History of Present Illness: 81 yr-old female driver; not restrained, s/p motor vehcile crash vs. pole. Per EMS report extenisive front end damage with both air bags deployed. She was taken to an area hospital and was then transported to [**Hospital1 18**] for further care. Past Medical History: CAD s/p MI with stent placed in [**2107**], Hypertension LVH, mild-moderate mitral rugurgitation, mild-moderate Secondary hyperparathyroidism, GERD, CKD, left atrophic kidney [**3-5**] renal artery occlusion. R sided renal artery stenosis 60% ( essentially 1 func kidney), hx esophageal stricture s/p dilation, CHF, diastolic hyperlipidemia, peripheral neuropathy, Spinal stenosis, urinary stress incontinence, osteoporosis, diverticulosis. Family History: Noncontributory Physical Exam: Upon admission: Vitals: T 101.0 P 91 BP 128/78 RR 14 SaO2 93% on RA GEN: awake and alert HEENT: NCAT, PERRL, EOMI, no icterus, MMM, OP clear NECK: supple, no bruits, trachea midline CHEST: sternum TTP PULM: CTAB CARD: II/VI systolic murmur over apex ABD: +BS, soft NT/ND, no peritoneal signs EXT: R hematoma over forearm, L knee deformity with TTP, L hip TTP SKIN: multiple ecchymoses over upper extremities NEURO: II-XII intact, normal rectal tone, motor/sensation intact throughout Pertinent Results: [**2112-9-22**] 09:06PM GLUCOSE-171* LACTATE-1.5 NA+-141 K+-3.6 CL--102 TCO2-26 [**2112-9-22**] 08:55PM estGFR-Using this [**2112-9-22**] 08:55PM CK(CPK)-262* [**2112-9-22**] 08:55PM CK(CPK)-276* AMYLASE-22 [**2112-9-22**] 08:55PM CK-MB-8 [**2112-9-22**] 08:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2112-9-22**] 08:55PM WBC-15.3* RBC-4.02* HGB-10.4* HCT-31.6* MCV-79* MCH-25.9* MCHC-32.9 RDW-17.0* [**2112-9-22**] 08:55PM PLT COUNT-343 [**2112-9-22**] 08:55PM PT-14.2* PTT-21.9* INR(PT)-1.2* [**2112-9-22**] CT OF THE CHEST: The heart size is normal and there is no pericardial effusion. There are tiny bilateral pleural effusions with associated atelectasis. Calcification within the LAD is severe. The pulmonary arteries are enlarged, suggesting underlying pulmonary artery hypertension. The aorta is of normal caliber, however, there is extensive calcified and soft plaque throughout the descending aorta and particularly in the upper abdominal aorta. There is no mediastinal hematoma. No mediastinal, hilar, or axillary lymphadenopathy. Aside from mild bibasilar atelectasis, the lungs are clear. A 4 mm nodular opacity along the right major fissure and 2-mm nodule in the right upper lobe (2:17) are noted. There is no pneumothorax or pulmonary contusion. CT OF THE ABDOMEN: The liver, spleen, and adrenal glands are normal. Multiple gallstones are seen within a moderately distended gallbladder, however, there is no pericholecystic stranding. The left kidney is atrophied. The right kidney enhances and excretes contrast normally. The pancreas is moderately atrophied. There is a duodenal diverticulum containing fecalized material abutting the head of the pancreas. There are extensive splenic artery calcifications, and the spleen is small. Extensive ulcerated plaque is seen throughout the ectatic abdominal aorta, which measures up to 2.7 cm. The intra-abdominal small and large bowel loops are normal. There is no free air or free fluid. CT OF THE PELVIS: There is extensive sigmoid diverticulosis without diverticulitis. Foley catheter and air is seen within the bladder. There is no free fluid or lymphadenopathy. There is a nondisplaced transverse fracture through the left acetabular roof in a transverse configuration. There are also bilateral rib fractures involving ribs five through seven on the right and four through seven on the left, all located anterolaterally. The chronicity of these rib fractures is indeterminate, as there does seem to be some amount of remodeling associated with the left-sided rib fractures. There is a sternal fracture, also age indeterminate, though likely old given the lack of soft tissue abnormality in this area. Compression deformities in the thoracic and lumbar spine are likely chronic. There is a mild compression deformity at T6 with subtle sclerosis and impaction of the bone at the superior endplate, but no loss of vertebral body height. More severe fractures are seen at T8 and T11 with approximately 50% loss of vertebral body height at these levels and focal kyphosis at T11. A slight step-off at the left lateral aspect of L3 is likely due to a Schmorl's node. There are severe degenerative changes at L5-S1. No retropulsed bony fragments are seen abutting the thecal sac. There is no paravertebral hematoma. IMPRESSION: 1. Acute transverse posterior acetabular fracture. 2. Multiple bilateral rib fractures and sternal fracture, age indeterminate. The lack of soft tissue swelling associated with these fractures suggests a subacute/chronic nature. There is no pneumothorax or pulmonary contusion. 3. Multiple chronic appearing vertebral body compression fractures involving T6, T8, and T11. 4. Severe atherosclerotic disease throughout the descending and abdominal aorta. 5. Incidentally noted diverticulosis, gallstones, and an atrophic left kidney. Probable pulmonary arterial hypertension. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Test Information Date/Time: [**2112-9-27**] at 09:55 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], RDCS Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2008W052-0:08 Machine: Vivid [**8-9**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.2 cm <= 4.0 cm Left Atrium - Peak Pulm Vein S: 0.5 m/s Left Atrium - Peak Pulm Vein D: 0.7 m/s Left Atrium - Peak Pulm Vein A: *0.4 m/s < 0.4 m/s Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.7 cm Left Ventricle - Fractional Shortening: 0.36 >= 0.29 Left Ventricle - Ejection Fraction: >= 60% >= 55% Left Ventricle - Peak Resting LVOT gradient: *15 mm Hg <= 10 mm Hg Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 13 < 15 Aorta - Sinus Level: *3.8 cm <= 3.6 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 1.5 m/sec Mitral Valve - E/A ratio: 0.73 TR Gradient (+ RA = PASP): *34 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Normal LA size. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). Mild resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened. 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 mild pulmonary artery systolic hypertension. There is no pericardial effusion. URINE CULTURE (Final [**2112-9-26**]): GRAM NEGATIVE ROD(S). ~[**2104**]/ML. MRSA SCREEN (Final [**2112-9-29**]): No MRSA isolated. UGI series: [**2112-10-4**] FINDINGS: This study was technically limited secondary to patient's reduced mobility secondary to multiple fractures and pain. A barium swallowing study was performed using a lateral and AP views only. Barium passes freely through the esophagus. There is no aspiration at the airway, and there is mild retention in the valleculae. There are no structural abnormalities detected in the region of the pharynx and cervical esophagus. The thoracic esophagus is unremarkable with no esophageal strictures or webs noted. A motility study could not be performed secondary to patient's inability to tolerate the [**Doctor Last Name **] position. Free reflux and hiatal hernia were also unable to be assessed. IMPRESSION: Limited study secondary to reduced mobility of the patient. No evidence of esophageal stricture or webs. [**2112-10-4**] 12:14 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2112-10-5**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2112-10-5**]): REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 79541**] @ 3:36A [**2112-10-5**]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). Brief Hospital Course: [**9-22**]: She was admitted to the Trauma Service s/p motor vehicle crash where she was the unrestrained driver of car vs pole. She was found to have multiple right and left rib fractures (right [**5-9**], left [**3-9**]), a sternal fracture, fracture of left posterior acetabulum, left comminuted impacted tibial plateau fracture, left patella fracture, left distal radius fracture, and extensive ulcerated plaque of abdominal aorta, concerning for abdominal aortic aneurysm. Orthopedics and vascular were consulted given her injuries. [**9-23**]: She was taken to the operating room for repair of her left tibia plateau fracture. There were no intraoperative complications. She was also placed in a splint for her left distal radius fracture. She was evaluated by Physical and Occupational therapy and is being recommended for rehab after her acute hospital stay. [**9-25**]: Urine culture grew gram negative rods and she was treated appropriately. Follow-up urine culture on [**9-30**] showed no growth. [**9-27**]: A Medical consult and work-up for syncope were done to determine the cause of her motor vehicle crash. Both carotid series and ECHO were negative. Syncopal episode most likely from poor cerebral perfusion from splanchnic pooling of blood after eating lunch. [**9-29**]: Due to her multiple fractures and lack of mobility, she was taken to the OR for IVC filter placement. There were no intraoperative complications. Vascular surgery recommending repeat CT scan in 3 months to follow progression of AAA. [**9-30**]: She underwent an oral and pharyngeal swallowing medial fluoroscopy and speech evaluation due to her reported trouble swallowing and history of multiple esophageal dilation. There was no evidence of a stricture. She is able to take ground solids and thin liquids. [**10-2**]: She was noted to have multiple mouth sores which were consistent with thrush. ID was eventually consulted and agreed with starting Nystatin. She also continued to have leukocytosis without fever. All wounds and surgical sites were checked, urine culture, blood culture and stool cultures were obtained. Of not e she was not having any stool at the time. Most of her cultures came back and were negative, with exception of the stool, this was still pending. She was empirically started on Flagyl. The final report did come back positive and she is currently being treated with a 2 week course of Flagyl. [**10-4**]: She underwent an UGI which did not show any show any esophageal stricture or webs. She failed a voiding trial and the Foley was replaced. Once at rehab another voiding trial should be initiated. [**Month/Day (2) **] planning, which had been initiated 1 week prior to [**Month/Day (2) **] were finalized. Medications on Admission: Meclizine 12.5mg PO daily, Plavix 75mg PO daily, ASA 81mg PO daily, Lipitor 80mg PO daily, Gemfibrozil 600mg PO daily, Zetia 10mg PO daily, Toprol XL 50mg PO daily, Norvasc 5mg PO daily, Lasix 40mg Po daily, KCl SR 10mg three times daily, Actonel 35 Qwk, Glucosamine 2g Po daily, Omeprazole EC 20mg PO daily, Colace 100mg PO twice daily, Iron sulfate 325mg Po twice daily, Renal caps 1mg PO daily Caltrate [**Month/Day (2) **] Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 5. Enoxaparin 40 mg/0.4 mL Syringe Sig: 0.4 ML's Subcutaneous DAILY (Daily) for 4 weeks. 6. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime): hold for loose stools. 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 14 days. 17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML's PO QID (4 times a day) for 7 days: Swish and spit. 18. Florastor 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 5 days. [**Month/Day (2) **] Disposition: Extended Care Facility: [**Hospital3 7665**] [**Hospital3 **] Diagnosis: s/p Motor vehicle crash Injuries: Multiple right and left rib fractures (right [**5-9**], left [**3-9**]) Sternal Fracture Left Posterior Acetabulum Left Comminuted impacted tibial plateau fracture Left Patella fracture Left Wrist fracture Secondary diagnosis: Abdominal Aortic Aneurysm Urinary tract infection C. diff colitis [**Month/Day (3) **] Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled [**Month/Day (3) **] Instructions: Continue with the Lovenox for 4 weeks per Orthopedics recommendation. Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Orthopedics. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery, call [**Telephone/Fax (1) 6429**] for an appointment. It is being recommended that you follow up with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD, Vascular Surgery for your abdominal aortic aneurysm. Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2113-1-4**] 1:15 It is being recommeded that you follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab as you will need a repeat abdominal CT scan to follow the progression of your abdominal aortic aneurysm within the next 3 months. Completed by:[**2112-10-13**]

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icd9cm

[ [ [] ] ]

[ "96.6", "79.36", "38.7" ]

icd9pcs

[ [ [] ] ]

10388, 13135

323, 411

1704, 10365

15854, 16659

1168, 1185

13162, 15524

1200, 1202

260, 285

439, 687

15545, 15831

1216, 1685

709, 1152

32,438

178,763

32994

Discharge summary

report

Admission Date: [**2156-3-12**] Discharge Date: [**2156-4-5**] Date of Birth: [**2104-9-3**] Sex: M Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[**First Name3 (LF) 922**] Chief Complaint: mental status changes secondary to acute hemmorrhagic cva. Major Surgical or Invasive Procedure: none History of Present Illness: 51 yo M s/p mechanical redo-AVR for endocarditis in [**1-23**] c/b take back for tamponade. He completed his antibiotic course at home but then was hospitalized on [**2-23**] for PICC line sepsis with serratia sensitive to Cipro. He was started on Cipro, the PICC was dc'd and he was discharged. He was readmitted on [**3-6**] with altered mental status and found to have an acute hemoorhage in the left parietal lobe iwht breakthrough hemorrhage in the left lateral ventricle and third ventricle with subfalcine shift up to 7mm. Craneictomy was performed, he was stabilized and transferred to [**Hospital1 18**] for further management of his ID issues. Past Medical History: PMH thrombocytopenia, COPD, HepC, endocarditis/diskitis, depression, anxiety, AVR '[**45**] Social History: + tobacco 20 pack years denies etoh unemployed Family History: NC Physical Exam: NAD, A&O x 3 RRR, no M/R/G Lungs CTAB Abdomen benign Extrem no edema Skin MSI well healed, Left craniotomy c/d/i with staples. Left UE & LE strenth [**3-19**], Right UE & LE strength 3/4 Pertinent Results: [**2156-4-5**] 07:45AM BLOOD WBC-3.2* RBC-3.59* Hgb-10.7* Hct-32.2* MCV-90 MCH-29.9 MCHC-33.3 RDW-15.6* Plt Ct-93* [**2156-4-5**] 10:00AM BLOOD PT-24.7* PTT-37.2* INR(PT)-2.4* [**2156-4-5**] 07:45AM BLOOD Glucose-94 UreaN-24* Creat-0.7 Na-135 K-5.2* Cl-98 HCO3-30 AnGap-12 [**2156-3-12**] 05:25PM BLOOD ALT-20 AST-26 LD(LDH)-265* AlkPhos-90 Amylase-94 TotBili-0.6 RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2156-4-4**] 3:53 PM CT HEAD W/O CONTRAST Reason: please assess ICH [**Hospital 93**] MEDICAL CONDITION: 51 year old man with s/p ICH x 2 / now on anticoagulation REASON FOR THIS EXAMINATION: please assess ICH CONTRAINDICATIONS for IV CONTRAST: None. CLINICAL HISTORY: 51-year-old male status post intracranial hemorrhage, now on anticoagulation. Heterogeneous focus of high-attenuation is seen within the left frontoparietal with surrounding vasogenic edema, slightly improved compared to prior exam from [**2156-3-28**]. Mixed density extra-axial collection persists along the left cerebral convexity subjacent to the craniotomy site. A new 4-mm focus of high- attenuation is seen within the right occipital lobe (series 2, image 14), likely representing a hemorrhage. Compared to the prior exam, the degree of sulcal effacement in the left cerebral hemisphere and mass effect exerted upon the left lateral ventricle is unchanged. There is no hydrocephalus or shift of normally midline structures. The visualized sinuses and mastoid air cells remain normally aerated. IMPRESSION: 1. Evolving intraparenchymal hemorrhage within the left parietal lobe, with minimal improvement in the surrounding vasogenic edema since [**2156-3-28**]. [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76735**]Portable TTE (Complete) Done [**2156-3-29**] at 12:21:04 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: [**2104-9-3**] Age (years): 51 M Hgt (in): 71 BP (mm Hg): 110/70 Wgt (lb): 130 HR (bpm): 95 BSA (m2): 1.76 m2 Indication: Left ventricular function. Endocarditis. ICD-9 Codes: V42.2, 424.1, 424.2, 424.0, 424.90 Test Information Date/Time: [**2156-3-29**] at 12:21 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) **], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 16812**] [**Last Name (un) 16813**], RDCS Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6 Contrast: None Tech Quality: Adequate Tape #: 2008W000-0:00 Machine: Vivid i-3 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.3 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.1 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.0 cm Left Ventricle - Fractional Shortening: 0.30 >= 0.29 Left Ventricle - Ejection Fraction: >= 55% >= 55% Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 10 < 15 Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Ascending: 3.3 cm <= 3.4 cm Aorta - Arch: *3.2 cm <= 3.0 cm Aortic Valve - Peak Velocity: *3.3 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *44 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 26 mm Hg Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 1.14 Mitral Valve - E Wave deceleration time: *348 ms 140-250 ms TR Gradient (+ RA = PASP): 13 to 19 mm Hg <= 25 mm Hg Findings This study was compared to the prior study of [**2156-3-13**]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic function (LVEF>55%). Mild regional LV systolic dysfunction. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Mildly dilated aortic arch. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). Increased AVR gradient. Small vegetation on aortic valve. Trace AR. [The amount of AR is normal for this AVR.] MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Trivial MR. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets. Physiologic (normal) PR. Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). There is very mild regional left ventricular systolic dysfunction with septal hypokinsis. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. A bileaflet aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. There is a small vegetation/?thrombus (0.5cm x 0.4cm) on the aortic valve (clip [**Clip Number (Radiology) **]). Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. The pulmonic valve leaflets are thickened. Compared with the prior study (images reviewed) of [**2156-3-13**], the small mass on the prosthetic aortic valve is new with increased transvalvular gradient. The left ventricular systolic function may be better. RADIOLOGY Preliminary Report CAROT/CEREB [**Hospital1 **] [**2156-3-23**] 11:16 AM CAROT/CEREB [**Hospital1 **] Reason: Was recurrent left parietal bleed caused by a mycotic aneury Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 51 year old man with history of endocarditis and AVR who had a recurrent left parietal bleed. REASON FOR THIS EXAMINATION: Was recurrent left parietal bleed caused by a mycotic aneurysm or AVM? HISTORY: 51-year-old male patient with history of endocarditis and aortic valve replacement had recurrent left parietal bleed. Evaluate for mycotic aneurysm or arteriovenous malformation. PROCEDURE PERFORMED: Right common carotid arteriogram, right internal carotid arteriogram, left internal carotid arteriogram, left external carotid arteriogram and right vertebral artery arteriogram. 2. New 4-mm punctate focus of high-attenuation in the right occipital lobe, consistent with hemorrhage. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**] Brief Hospital Course: He was admitted to cardiac surgery. He was started on vanco, cipro and gent. He was seen by neurosurgery and restarted on coumadin and heparin secondary to the risk of embolic stroke from his mechanical valve. TEE showed no evidence of recurrent endocarditis. Vanco and gentamycin were dc'd. MRA showed no evidence of mycotic aneurysm. Prostate u/s was negative as well, and his cipro was dc'd. Repeat head CT on [**3-21**] showed worsening intracranial hemorrhage, and he was transferred to the ICU for closer monitoring. His anticoagulation was held and he received 4 units of FFP. Angiography on [**3-23**] which demonstrates no aneurysm, vascular malformation or arteriovenous fistula. He was transferred back to the floor. Anticoagulation continued to be held. Prior to restarting anticoagulation, repeat head CT on [**3-27**] showed Slight improvement in trapping of left temporal [**Doctor Last Name 534**]. Otherwise minimal change compared to prior study. [**3-30**] HIT [**Doctor First Name **] was found to be positive, argatroban and coumadin were started. A serotonin assay was sent.Infectious Diseases was consulted for recommendations if deemed necessary. He awaited therapeutic INR for discharge to home with VNA. [**2156-4-4**] Head CT showed an evolving intraparenchymal hemorrhage within the left parietal lobe, with minimal improvement in the surrounding vasogenic edema since [**2156-3-28**].And new 4-mm punctate focus of high-attenuation in the right occipital lobe, consistent with hemorrhage. Neurosurgery was reconsulted and a repeat head CT was performed prior to discharge which showed no short-term interval change compared to CT from [**2156-4-4**] at 15:57. Neurosurgery recommended anticoagulation with Coumadin.Mr.[**Known lastname **] was discharged to home with VNA services on [**2156-4-5**]. Medications on Admission: naficillin 2gm q4h (staph), ASA, Lasix 40', KCL, Methadone 15"', Roxicodone 15 prn, rifampin Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(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) for 1 months. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Methadone 10 mg Tablet Sig: One (1) Tablet PO three times a day. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 10. Outpatient [**Name (NI) **] Work PT/INR mon-wed-fri with goal INR 2.5-3.0 for mechanical AVR results to Dr [**Last Name (STitle) 39975**] office # [**Telephone/Fax (1) 66607**] fax # [**Telephone/Fax (1) 76739**]. 11. Coumadin 5 mg Tablet Sig: 1.5 Tablets PO once a day for 2 days: please take 7.5mg on mon [**4-5**] and tues [**4-6**] - have inr checked [**4-7**] for further coumadin dosing . Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] vna Discharge Diagnosis: ICH Heparin induced thrombocytopenia PMH Chronic diastolic heart failure Endocarditis bacteremia bentall w/ homograft '[**45**] Hepatitis C Chronic pain depression Anxiety Discharge Condition: Good Discharge Instructions: PT/INR mon-wed-fri with goal INR 2.5-3.0 for mechanical AVR results to Dr [**Last Name (STitle) 39975**] office # [**Telephone/Fax (1) 66607**] fax # [**Telephone/Fax (1) 76739**]. No lifting greater than 10 pounds for 10 weeks from date of surgery Call for fevers greater 100.5 redness or drainage from wounds No driving until cleared by neurology Shower daily, wash and pat incisions dry Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Dr [**Last Name (STitle) 914**] in 2 weeks [**Telephone/Fax (1) 170**] Dr [**Last Name (STitle) 656**] (neurology) 2 weeks [**Telephone/Fax (1) 1694**] Dr [**Last Name (STitle) 39975**] in 3 weeks Dr [**Last Name (STitle) **] in 3 weeks PT/INR mon-wed-fri with goal INR 2.5-3.0 for mechanical AVR results to Dr [**Last Name (STitle) 39975**] office # [**Telephone/Fax (1) 66607**] fax # [**Telephone/Fax (1) 76739**]. Completed by:[**2156-4-6**]

[ "070.70", "305.1", "V62.0", "428.32", "431", "428.0", "287.4", "496", "300.4", "V45.81", "414.01", "V58.61", "V15.81", "E934.2", "V43.3", "432.1" ]

icd9cm

[ [ [] ] ]

[ "88.72", "87.03", "99.07", "88.41" ]

icd9pcs

[ [ [] ] ]

12281, 12336

8800, 10633

339, 346

12552, 12559

1453, 1937

13072, 13560

1227, 1231

10776, 12258

7885, 7979

12357, 12531

10659, 10753

12583, 13049

1246, 1434

239, 299

8008, 8777

374, 1030

1052, 1146

1162, 1211

60,955

118,101

28564+57601

Discharge summary

report+addendum

Admission Date: [**2134-3-31**] Discharge Date: [**2134-4-6**] Date of Birth: [**2050-1-29**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Abnormal stress test Major Surgical or Invasive Procedure: [**2134-3-31**] Cardiac Catheterization [**2134-4-1**] Urgent Coronary Artery Bypass Grafting x 4 utilizing the left internal mammary artery to left anterior descending, saphenous vein grafts to the diagonal, obtuse marginal and posterior lateral ventricular branch. History of Present Illness: Mr. [**Known lastname **] is a 84 year old gentleman who was referred to the [**Hospital1 18**] for cardiac catheterization secondary to abnormal stress test. His past medical history is notable for hypertension, dyslipidemia, cerebrovascular disease and prior tobacco use. On admission, he denies chest pain, shortness of breath, nausea, dizziness/syncope, palpitations and back pain. Past Medical History: Hypertension Dyslipidemia History of Transient Ischemic Attack Carotid Disease, s/p Left Carotid Endarterectomy [**2130**] Polymyalgia Rheumatica Glaucoma Appendectomy Prostatism, s/p TURP Bilateral Cataract Surgery Compression Fracture of Lumbar Spine Social History: Retired. Quit tobacco over 40 years ago. Social ETOH. Lives with wife. Family History: Brother had CABG in his 70's. Physical Exam: Vitals: 172/63, 61, 17, 99% room air General: elderly gentleman in no acute distress HEENT: oropharynx benign Neck: supple, no JVD, full ROM Chest: clear bilaterally Heart: regular rate and rhythm, normal s1s2, no murmur or rub Abdomen: benign Ext: warm, no edema Neuro: alert and oriented, cranial nerves grossly intact, full range of motion, no focal deficits noted Pulses: 2+ distally, no carotid bruits noted Pertinent Results: [**2134-3-31**] Cardiac Cath: Selective coronary angiography of this right dominant system demonstrated 3 vessel coronary artery disease. The LMCA had an eccentric calcified 80% stenosis. The LAD was heavily calcified with a proximal 60% stenosis. The D1 had a mid vessel stenosis of 60%. The LCX had a proximal 50% and proximal 50% OM1 stenosis. The RCA had a ostial 60% with a PL of 60% and a proximal 60% PDA stenosis. [**2134-3-31**] 01:10PM BLOOD WBC-8.3 RBC-2.96* Hgb-9.6* Hct-27.6* MCV-93 MCH-32.4* MCHC-34.7 RDW-13.8 Plt Ct-254 [**2134-3-31**] 01:10PM BLOOD PT-14.5* PTT-28.7 INR(PT)-1.3* [**2134-3-31**] 01:10PM BLOOD Glucose-164* UreaN-26* Creat-1.1 Na-140 K-4.9 Cl-106 HCO3-26 AnGap-13 [**2134-3-31**] 01:10PM BLOOD ALT-11 AST-17 AlkPhos-40 TotBili-0.3 [**2134-3-31**] 01:10PM BLOOD Albumin-3.7 [**2134-3-31**] 01:10PM BLOOD %HbA1c-6.0* [**2134-4-1**] 06:05AM BLOOD Triglyc-142 HDL-47 CHOL/HD-3.9 LDLcalc-107 [**2134-4-1**] Echocardiogram: The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). 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 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 estimated pulmonary artery systolic pressure is normal. The pulmonic valve leaflets are thickened. Significant pulmonic regurgitation is seen. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent cardiac catheterization which revealed severe three vessel coronary artery disease including an 80% left main lesion. Cardiac surgery was consulted and preoperative evaluation was performed - see result section. Workup was unremarkable and he was cleared for surgery. Given inpatient stay was greater than 24 hours prior to surgery, Vancomycin was given for perioperative antibiotic coverage. The following day, urgent coronary artery bypass grafting surgery was performed. Please see operative note for details. After the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. Stress dose steroids were administered for polymyalgia rheumatica. He maintained good hemodynamics and transferred from the ICU on postoperative day one. Chest tubes and pacing wires were removed without complication. On postoperative day three, he experienced a brief episode of paroxysmal atrial fibrillation which responded to intravenous beta blockade. Over several days, beta blockade was advanced. He remained in a normal sinus rhythm and no further atrial arrhythmias were noted. He developed audible upper airway wheezes which repsonded to nebs and steroid MDI, aggressive diuresis and po prednisone (which was resumed for polymyalgia rheumatica).His respiratory status improved. He developed transient increase in BUN and creat likely from lasix administration required for diuresis. His lasix dose was decreased and creat remained elevated but stabilized at the time of discharge. He was evaluated by physical therapy and rehab was recommended. he was discharged to rehab on [**2134-4-6**]. Medications on Admission: Lopressor 12.5 [**Hospital1 **], Lisinopril 10 qd, Amlodipine 5 qd, Aggrenox [**Hospital1 **], Prednisone, Multivitamin Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Coronary Artery Disease - s/p Coronary Artery Bypass Grafting Hypertension Dyslipidemia History of Transient Ischemic Attack Carotid Disease, s/p Left Carotid Endarterectomy [**2130**] Polymyalgia Rheumatica Discharge Condition: Good Discharge Instructions: 1)No lifting more than 10 lbs for at least 10 weeks. 2)No driving for one month. 3)Shower daily. Wash incisions with soap and water only. Pat dry, do not rub incision. Do not apply ointments or lotions to surgical incisions. 4)Please call cardiac surgeon immediately if there is concern for wound infection, call [**Telephone/Fax (1) 170**]. Followup Instructions: call and schedule the following appointments: Dr. [**Last Name (STitle) 914**] in [**4-4**] weeks [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) 11493**] in [**2-2**] weeks [**Telephone/Fax (1) 11767**] Dr. [**Last Name (STitle) 12982**] in [**2-2**] weeks [**Telephone/Fax (1) 62842**] Completed by:[**2134-4-6**] Name: [**Known lastname 779**],[**Known firstname **] J Unit No: [**Numeric Identifier 11815**] Admission Date: [**2134-3-31**] Discharge Date: [**2134-4-6**] Date of Birth: [**2050-1-29**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1543**] Addendum: Mr [**Known lastname **] developed acute renal failure with a transient rise in BUN/CREAT to 51/2.1 from a baseline of 17/1.0 respectively. Pt's lasix was d/c'd and at the time of discharge the BUN/CREAT were decreasing. Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2134-4-30**]

[ "427.31", "725", "V58.65", "411.1", "E878.2", "997.1", "518.82", "414.01", "V12.54", "584.9", "365.9", "272.4", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.22", "36.15", "99.20", "29.11", "36.13", "39.64", "88.56" ]

icd9pcs

[ [ [] ] ]

7317, 7544

3736, 5465

340, 609

5955, 5962

1884, 3713

6352, 7294

1405, 1436

5724, 5934

5491, 5612

5986, 6329

1451, 1865

280, 302

637, 1024

1046, 1301

1317, 1389

32,515

145,754

29693

Discharge summary

report

Admission Date: [**2129-8-10**] Discharge Date: [**2129-8-27**] Date of Birth: [**2065-10-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: DOE Major Surgical or Invasive Procedure: [**8-12**] CABG x 3 (LIMA->LAD, SVG->OM, SVG->PDA) History of Present Illness: 63 yo with DOE, +ETT for elective cath. Past Medical History: PMH: CAD, PVD, htn, hyperlipidemia, gout, metabolic syndrome, homocysteinemia, morbid obesity, dm, GERD, TIA, L carotid disease, sleep apnea PSH: permanent pacemaker for symptomatic bradycardia, tonsillectomy, LLE bypass Social History: retired 1-1.5 ppd x 12 years lives alone in [**Doctor First Name **] 4-5 drinks/day Family History: NC Physical Exam: 71" 150 kg NAD Lungs CTAB Distant heart sounds Abdomen benign, obese Extrem warm with stasis changes bilaterally, 2+LLE edema, 1+RLE edema Pertinent Results: [**2129-8-23**] 10:00AM BLOOD WBC-12.4* RBC-3.18* Hgb-10.3* Hct-32.2* MCV-101* MCH-32.5* MCHC-32.1 RDW-17.3* Plt Ct-341 [**2129-8-23**] 10:00AM BLOOD Plt Ct-341 [**2129-8-21**] 02:51AM BLOOD PT-14.5* PTT-28.3 INR(PT)-1.3* [**2129-8-23**] 10:00AM BLOOD Glucose-143* UreaN-28* Creat-1.1 Na-139 K-3.9 HCO3-26 [**2129-8-22**] 03:12AM BLOOD UreaN-29* Creat-1.3* Na-143 Cl-103 HCO3-31 [**2129-8-20**] 02:45AM BLOOD ALT-250* AST-35 LD(LDH)-454* AlkPhos-152* Amylase-19 TotBili-1.9* Cardiology Report ECHO Study Date of [**2129-8-12**] PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for off pump CABG Status: Inpatient Date/Time: [**2129-8-12**] at 15:00 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW3-: Test Location: Anesthesia West OR cardiac Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *6.0 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *6.0 cm (nl <= 5.2 cm) Left Ventricle - Inferolateral Thickness: *1.6 cm (nl 0.6 - 1.1 cm) Left Ventricle - Ejection Fraction: 55% (nl >=55%) Aorta - Ascending: 3.4 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: *2.6 cm (nl <= 2.5 cm) Aortic Valve - LVOT Diam: 1.9 cm INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement. Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Lipomatous hypertrophy of the interatrial septum. LEFT VENTRICLE: Moderate symmetric LVH. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV systolic function. AORTA: Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Complex (mobile) atheroma in the aortic arch. Focal calcifications in aortic arch. Mildly dilated descending aorta. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Physiologic MR (within normal limits). TRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. Suboptimal image quality. The patient appears to be in sinus the patient. Conclusions: Limited study due to poor acoustic windows. The left atrium is markedly dilated. The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function appears normal (LVEF>55%). Right ventricular systolic function is normal. There are complex (mobile) atheroma in the aortic arch. There are focal calcifications in the aortic arch. 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 but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is a trivial/physiologic pericardial effusion. The interatrial septum is poorly seen and an ASD/PFO can not be completely ruled out. After completion of bypass grafting, the echo windows were even more limited. The right ventricle appeared somewhat underfilled but with normal free wall function. Only limited left ventricular segments could be seen but there appeared to be mild global hypokinesis with somewhat more septal hypokinesis. Overall function is probably mildly decreased. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD on [**2129-8-13**] 10:11. [**Location (un) **] PHYSICIAN: ([**Numeric Identifier 71128**]) Brief Hospital Course: Mr. [**Known lastname 71129**] [**Last Name (Titles) 1834**] cardiac catheterization which showed LM and RCA disease. Carotid u/s showed Left ICA stenosis of 60-69%. He was taken to the operating room on [**8-12**] where he [**Month/Year (2) 1834**] an off pump CABG x 3. He was transferred to the ICU in critical but stable condition on epinephrine, neosynephrine and propofol. He continued to require pressors and volume, and remained intubated until POD #4. He was found to have subcutaneous air on chest xray and an air leak in his chest tube, and he was seen by thoracic surgery who followed with serial clamping trials. His chest tubes were subsequently pulled (one by the patient) without pneumothorax. He was confused, and was placed on haldol. Bedside swallow allowed regular solids and thin liquids. He was transferred to the floor on POD # 10. Over the next several days, medical therapy was optimized and he continued to make clinical improvements. He was eventually cleared for discharge to home with services on POD #15. Pt. to make all follow-up appts. as directed. Medications on Admission: asa, darvocet, indomethacin, lipitor, prevacid 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): until [**8-29**], then 200 mg daily ongoing. Disp:*40 Tablet(s)* Refills:*2* 10. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl Topical DAILY (Daily): to left arm wound and cover with dry dressing . Disp:*qs qs* Refills:*2* 11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*qs qs* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: CAD PVD HTN hyperlipidemia gout metabolic syndrome homocysteinemia morbid obesity DM GERD TIA Left carotid disease sleep apnea PPM for symptomatic bradycardia Tonsillectomy LLE bypass postop A fib Discharge Condition: GOod. Discharge Instructions: Call with fever, rednes 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 or driving until follow up with surgeon. Followup Instructions: Please call to schedule all appointments Dr. [**First Name (STitle) 13014**] when you return home [**Telephone/Fax (1) 71130**] Dr. [**First Name (STitle) **] 2-3 weeks [**Telephone/Fax (1) 4022**] Dr. [**First Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**] Wound check [**Hospital Ward Name 121**] 2 Wednesday [**8-31**] at 11am with nurse practitioner [**Telephone/Fax (1) 170**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2129-8-29**]

[ "414.01", "277.7", "998.0", "433.10", "V45.01", "401.9", "443.9", "274.9", "327.23", "278.01", "707.09", "530.81", "285.1" ]

icd9cm

[ [ [] ] ]

[ "36.15", "88.53", "36.12", "37.22", "93.90", "88.56", "96.72", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

7853, 7911

5297, 6379

324, 377

8153, 8161

989, 1521

8460, 8973

808, 812

6476, 7830

7932, 8132

6405, 6453

8185, 8437

1547, 5201

827, 970

281, 286

405, 446

5236, 5274

468, 691

707, 792

41,733

104,218

24809

Discharge summary

report

Admission Date: [**2123-6-6**] Discharge Date: [**2123-6-18**] Date of Birth: [**2039-8-14**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Heparin Agents / argatroban / Lepirudin Attending:[**First Name3 (LF) 618**] Chief Complaint: R arm numbness/weakness Major Surgical or Invasive Procedure: upper endoscopy Colonoscopy with polyp removal History of Present Illness: The pt is a 83 y/o RHF with history of multiple TIA's and bilateral CEA's mos most recent 2 weeks ago for a left CEA after "TIA's". She comes in today as an OSH transfer for two episodes concerning for TIA. She states that yesterday she had a sudden onset inability to get her words out. She states that this lasted hours, was not all words, and had no slurred speech, no inability to understand speech and she knew which words she wanted to say. This resolved and then today had another event where she was suddenly unable to use her right hand. She states she was trying to use a fork for dinner and was unable to do so. This lasted about 3 hours and then resolved. During this time those around her stated that she had a left sided droop and possibly slurred speech. At this point she feels back to baseline. She is unable to give me any useful information regarding her previous "TIA's". On ROS she denies current HA, language difficulty, vertigo, CP, SOB, fever or chills, weakness or chances to sensation. She does however support pain in her low back and hips with walking and uses support for ambulation. Past Medical History: 1. HTN 2. asthma 3. emphysema 4. Hx of GI bleed 5. GERD 6. right subclavian stenosis 7. hypothyroid 8. anemia Social History: Former smoker. Drinks wine daily Family History: N/C Physical Exam: Physical Exam on Admission: Vitals: T: 98 P:56 R: 16 BP:178/78 SaO2:99% General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM Neck: left side post surgical scar clean and intact. No nuchal rigidity Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2, no M/R/G appreciated Abdomen: soft. Extremities: 1+ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Unable to provide details to history. Able to name DOW backward without difficulty. Language is fluent with intact repetition and comprehension. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [**12-14**] at 5 minutes [**1-14**] with prompts. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1mm. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: right side slight facial droop. VIII: Hearing not intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Right side pronator drift Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: decreased vibratory sensation at the feet. No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 0 R 2 2 2 2 0 Plantar response was extensor on the left mute on the right. -Coordination: No rebounding. No dysmetria on FNF bilaterally. -Gait: deferred. Pertinent Results: Labs on admission: [**2123-6-6**] 08:21PM PT-12.9 PTT-23.9 INR(PT)-1.1 [**2123-6-6**] 08:21PM PLT COUNT-174# [**2123-6-6**] 08:21PM NEUTS-67.1 LYMPHS-21.2 MONOS-7.6 EOS-3.6 BASOS-0.5 [**2123-6-6**] 08:21PM WBC-5.2 RBC-2.86* HGB-10.0* HCT-29.3* MCV-103* MCH-35.1* MCHC-34.2 RDW-13.0 [**2123-6-6**] 08:21PM estGFR-Using this [**2123-6-6**] 08:21PM GLUCOSE-103* UREA N-30* CREAT-1.6* SODIUM-139 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14 [**2123-6-6**] 08:30PM URINE MUCOUS-RARE [**2123-6-6**] 08:30PM URINE HYALINE-3* [**2123-6-6**] 08:30PM URINE RBC-1 WBC-46* BACTERIA-NONE YEAST-NONE EPI-3 TRANS EPI-1 [**2123-6-6**] 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG [**2123-6-6**] 08:30PM URINE GR HOLD-HOLD [**2123-6-6**] 08:30PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.010 [**2123-6-6**] 08:30PM URINE HOURS-RANDOM Imaging: CT-A [**6-6**] IMPRESSION: 1. Small low attenuation in the left caudate head consistent with an infarct of indeterminate age, likely chronic. 2. Small area of low density in the left subinsular white matter, infarct of indeterminate age. 3. No evidence of intracranial hemorrhage. 4. Status post left carotid endarterectomy with soft tissue changes and without evidence of a flow-limiting stenosis in the major neck vessels. 5. Thrombus in the right proximal subclavian artery. 6. Calcifications of the vertebral artery origin, limit evaluation for stenosis. MRI-HEAD [**6-7**] IMPRESSION: Two small foci of bright diffusion signal abnormalities in the left frontal cortex and left centrum semiovale associated with FLAIR signal changes likely to suggest recent infarcts without convincing ADC abnormality. Old lacunar infarct in the left head of caudate nucleus. . . EEG [**6-9**] IMPRESSION: This is an abnormal video EEG despite the normal posterior dominant rhythm during the waking state due to the presence of bursts of generalized delta frequency slowing which represents deep midline and subcortical dysfunction. There were no epileptiform discharges or electrographic seizures seen . . ECHO [**6-9**] IMPRESSION: Suboptimal image quality. No obvious cardiac source of embolism in a technically limited study. Normal global left ventricular systolic function. Technically suboptimal to exclude focal wall motion abnormality. Right ventricle not well-visualized. Borderline pulmonary hypertension. . . MR HEAD W/O CONTRAST [**6-9**] IMPRESSION: Acute watershed infarction involving the left cerebral hemisphere, new since the prior MRI of the brain dated [**2123-6-7**], also seen on the prior CT perfusion from [**2123-6-9**]. No hemorrhagic transformation is seen. . CT- HEAD [**6-11**] IMPRESSION: Evolving left hemispheric watershed infarcts, with no evidence of hemorrhagic conversion. No new acute process is seen. . KUB IMPRESSION: 1. No obstruction or free air. 2. Bibasilar atelectasis and pleural effusions. 3. Gallstones. . . Labs at discharge: Brief Hospital Course: NEURO: STROKE 83 yo RHW with h/o L CEA [**2123-5-25**] presented with transient episodes of R hand and arm numbness and speech difficulties. She was initially transferred to the [**Month/Day/Year 1106**] service from [**Hospital3 17921**] Center in NH. She had a transient episode of right hand numbness that spread over the right arm and face over seconds to minutes, followed by difficulty using the right hand, disorientation and difficulties speaking. This occured on [**6-5**] and again on [**6-6**]. Neurology was consulted on [**6-7**]. Neuro exam was significant for right pronator drift and slowness with finger tapping. CTA showed bilateral carotids had no significant stenosis. The patient had been started on heparin drip empirically by [**Month/Year (2) 1106**] service. At that concern, neuro team was concerned for hyper- or reperfusion syndrome s/p L CEA. It was therefore recommended to keep her blood pressure well controlled (SBP<160) and stop the heparin drip given risk of edema and hemorrhage. EEG was performed to rule out seizure. On [**6-8**] overnight, the patient's neuro exam worsened. On evening rounds, she had some slowness in right hand fast finger movements. At 2am, her right arm was flaccid and could not lift it antigravity. Neurology nightfloat saw the patient, however at that point it was still unclear whether this episode was due to developing stroke or seizure secondary to hyperperfusion syndrome. The patient's blood pressure was being kept controlled between sBP 100-120 for concern of hyperperfusion syndrome. At 4am, patient was R hemiplegic and aphasic. CT with perfusion done at that time showed ischemia in the L anterior and posterior watershed borderzones. CTA showed small plaque in the proximal L common carotid artery. There was no hemorrhage. The patient was transferred to the Neuro ICU. She was started on heparin drip again for concern of L CCA plaque. She was immediately bolused with 2L IVF and then started on neosynephrine to keep MAP >90-100. She improved with these interventions. Her language improved significantly, her right leg was antigravity, though her right arm remained densely plegic. MRI showed watershed infarct in the L MCA-PCA borderzone and internal borderzone superiorly. Her neuro exam continued to improve over the next 24 hours. Both expressive and receptive language was intact, RLE strength was nearly full, and she was able to shrug her RUE proximally. She was transferred to the neuro step down unit on [**6-10**]. She was continued on heparin drip, with plan to transition to coumadin, but this plan was aborted due to falling hematocrit on [**6-11**]. The pathophysiology of the stroke remains unclear. The most likely cause is a mechanical event at the L carotid post-operatively, that transiently blocked the vessel and made the brain suspectible to watershed stroke. Repeat CT of the Head did not show hemorrhagic conversion and the patient was started on heparin, however transient thrombocytopenia and dropping HCT (likely from GI bleed), led to discontinuation of anticoagulation. The patient also had a RUE ultrasound that did not show any DVT. Over the next days, her clinical motor exam improved daily and her strength in her R upper extremity increased significantly. She was seen by PT who recommended inpatient rehabilitation. HEME: The patient's HCT at admission was 29. It declined gradually to 25 and then to 23.5 on [**6-10**]. She received 1 U PRBCs on [**6-10**]. HCT repeated after transfusion was unchanged, and HCT continued to drop over the next 12 hours. CT abdomen and pelvisd was negative. Medicine and GI were consulted. Hemolysis labs were negative. Given the thrombocytopenia, there was a concern for HIT. Heparin was transitioned to Argotroban. However, she developed a rash and this medication was stopped. She was also briefly started on lepirudin, but another rash led to discontinuing these medications as well. Repeat falling HCT and concern for GI bleed led to discontinuation of all anticoagulation other than aspirin. HIT antibodies were positive, however the optical density of this test was low and suggestive of a false positive result. Currently, we do not feel this patinet has HIT. At the time of discharge, the SEROTONIN RELEASE ASSAY RESULTS ARE PENDING. GI: Rectal guiaic was positive without [**Month/Year (2) **] blood, however NG lavage was negative. Patient was started on Protonix drip empirically which was transitioned to IV push [**Hospital1 **]. She then underwent upper and lower endoscopy which revealed "A few small angioectasias with stigmata of recent bleeding seen in the second part of the duodenum. A gold probe was applied for hemostasis successfully." "A single sessile 1.8 cm polyp of benign appearance was found in the transverse colon and this was resected. There was melena found in the ascending colon during this colonoscopy. After colonoscopy, she remained on aspirin (despite recommendations from GI post-procedure), although she was not started on other anticoagulants. On the night after the procedure, she developed abdominal pain (worse in the RLQ) that was concerning for possible post-procedure complications. KUB did not show free air and the pain decreased over the next 2 days without interventions. Her diet was advanced without complication prior to her discharge. Her HCT remained stable in the low-mid 20s over last 2 days of this admission. GI was reconsulted but did not recommend other acute interventions at this time. She will be followed by GI services as an outpatient in [**2-12**] weeks at which time further investigation (repeat colonoscopy or capsule endoscopy) might be undertaken. CKD: Patient had baseline Cr 1.4-1.6 which was stable. Medications on Admission: ASA 325 Plavix Levothyroixine 25mcg daily Rosuvastatin 20mg Daily Doxazosin 8mg daily Synthroid 25mcg clonidine 0.1 PO TID Colace Percocet 5/125 1PO q6 Lasix 40mg Daily Potassium B12 Senna Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-13**] Drops Ophthalmic PRN (as needed) as needed for dry eyes/ blurriness. 7. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 12. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 17921**] Center - [**Location (un) 5450**], NH Discharge Diagnosis: Primary L hemispheric stroke GI bleeding Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). NEUROLOGIC EXAM: Residual right arm weakness, with distal weakness predominant ([**12-16**] FE, [**2-13**] WE) Discharge Instructions: You were admitted to the [**Hospital3 **] Medical center for numbness and weakness in your arm. Upon further investigation and imaging studies it became clear that you had suffered a stroke. This was likely a complication from a previous surgery -endarterectomy- on your left carotid. Your weakness improved during your stay and we believe you will benefit from rehabilitation. Your hospitalization was complicated by an intestinal bleed. Because of this, you underwent an endoscopy and a colonoscopy to investigate the source of bleeding. You had a polyp removed from you colon and small bleeding vessel was intervened on in your stomach. After this you had some abdominal pain that appeared to resolve without intervention. However, given your ongoing bleeding, you were given blood products. We also held blood thinning agents other than aspirin given your ongoing bleeding. We believe your bleeding then slowed down and you were restarted on blood thining agents. During your hospitalization, some of your medications changed, you should note the following: START: - Pantoprazole PO BID - Artificial tears STOP: -Plavix -Clonidine Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2123-7-14**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9864**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage . Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD (Neurologist) Phone:[**Telephone/Fax (1) 2574**] Date/Time: [**2123-8-6**] at 2:00 pm Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2123-7-14**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9864**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage . Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD (Neurologist) Phone:[**Telephone/Fax (1) 2574**] Date/Time: [**2123-8-6**] at 2:00 pm [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

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Discharge summary

report

Admission Date: [**2177-11-6**] Discharge Date: [**2177-11-12**] Date of Birth: [**2105-12-9**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: right ij cordis a-line Temporary pacemaker placed and removed History of Present Illness: 71 year old female with h/o morbid obesity, COPD/asthma, DM, HTN, CAD s/p PTCA distal LAD ([**2177-7-31**]) with 2 episodes of chest pain resolved by sublingual NTG x 1 and complaining of SOB/wheezing. By the time the patient arrived in the ED she had no complaints of chest pain. Her EKG showed HR in the 40's and junctional rhythm. She was given aspirin. CXR done and without pneumonia/pulm edema. She was also in acute renal failure with K 6.4, Cr 4.0. A Right IJ cordis was placed in the ED and she was started on dopamine. . Patient had a similar presentation in [**9-14**] when she presented in a junctional rhythm and acute renal failure. It was felt that she was pre-renal and once fluids were given her renal funtion improved. The junctional rhythm was felt to be due to beta-blocker toxicity and also resolved. . ROS: difficult to obtain as patient lethargic, but oriented. Past Medical History: 1. DM- last HgA1c 6.8 in [**4-14**]. 2. HTN 3. OSA- uses BiPAP at home 21/17 4. Restrictive/obstructive lung disease; asthma- on home O2-2 L 5. [**Name (NI) **] pt unable to ambulate, uses wheelchair 6. Hyperlipidemia 7. s/p cholecystectomy 8. s/p hysterectomy 9. Chronic back pain 10. CHF with diastolic dysfunction 11. CAD- s/p PTCA to distal LAD [**7-15**] 12. CRI- baseline ~1.4 Social History: Lives alone in an appartment in [**Location (un) **], divorced. Currently unemployed, Mass Health/Medicaid. Has an aide that comes every day to help her with cleaning, dishes, etc. Denies ever smoking, using Alcohol, or IV drugs. Family History: Mother died at age 80yo - had CAD, DM Father passed away at age 89yo - had CAD Physical Exam: Vitals: 96.4F HR 55 112/60 RR 15 97% Bipap: 40%/[**11-13**] Gen: sleeping, but arousable with bipap on, oriented x 3, morbidly obese, NAD HEENT: Pupils large, reactive to light bilaterally, OP clear, MM sl dry with dentures. Neck: supple, RIJ cordis CV: distant S1, S2, regular rate Pulm: diffuse exp wheezes b/l - Anteriorly Abd: (+) BS, soft, obese, nontender, no rebound or guarding Ext: somewhat cool, well-perfused, 1+ pretibial edema b/l Pertinent Results: EKG: Junctional bradycardia, HR 46, Nl axis, RBBB . [**2177-11-5**] 08:42PM BLOOD WBC-7.8 RBC-3.78* Hgb-9.3* Hct-29.0* MCV-77* MCH-24.6* MCHC-32.1 RDW-15.3 Plt Ct-203 [**2177-11-5**] 08:42PM BLOOD Neuts-79.3* Lymphs-14.7* Monos-3.7 Eos-2.1 Baso-0.2 [**2177-11-5**] 08:42PM BLOOD PT-12.8 PTT-26.8 INR(PT)-1.1 [**2177-11-5**] 08:42PM BLOOD Glucose-171* UreaN-66* Creat-4.5*# Na-131* K-6.3* Cl-94* HCO3-23 AnGap-20 [**2177-11-5**] 08:42PM BLOOD ALT-23 AST-22 CK(CPK)-162* AlkPhos-109 Amylase-48 TotBili-0.2 [**2177-11-5**] 08:42PM BLOOD cTropnT-0.07* [**2177-11-5**] 08:42PM BLOOD CK-MB-PND proBNP-3563* [**2177-11-6**] 01:30AM BLOOD Type-ART pO2-352* pCO2-51* pH-7.28* calTCO2-25 Base XS--2 Intubat-NOT INTUBA [**2177-11-6**] 03:07AM BLOOD Lactate-1.4 [**2177-11-6**] 03:07AM BLOOD freeCa-1.19 . [**2177-11-5**] CXR: Cardiomegaly is stable given differences in projection. Perihilar haze is not significantly changed from previous radiographs and may represent patient's baseline. No interstitial lines or pulmonary engorgement is identified. No airspace opacities are present. . [**11-8**] Echo: Conclusions: 1. There is moderate 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%). 2. The right ventricular cavity is markedly dilated. There is severe global right ventricular free wall hypokinesis. 3. The ascending aorta is mildly dilated. 4. The mitral valve leaflets are mildly thickened. 5. There is moderate pulmonary artery systolic hypertension. 6. Compared with the prior study (images reviewed) of [**2177-8-1**], there is probably no significant change. . [**11-7**] Renal US: IMPRESSION: No hydronephrosis. . Brief Hospital Course: Ms. [**Known lastname **] is a 71 year old female with h/o morbid obesity, COPD/asthma, diabetes mellitus, HTN, CAD s/p PTCA to distal LAD ([**2177-7-31**]) who presents to the ED with chest pain, SOB. . Cardiac: Ms. [**Known lastname **] presented with junctional escape and hypotension. She has a known history of LAD disease, s/p PTCA in [**7-15**], EF 60%. In the ED, her BP was 86/51 and HR in the 40s so she was given glucagon (pt was on metoprolol and CCB), kayexelate 30 g, dopamine gtt, 2 liters NS, insulin and Ca gluconate in ED. Beta blockers were held and cardiac enzymes were cycled. Her troponins were slightly elevated with peak at 0.07, peak CK at 160. Both trended down over the course of the hospitalization. BNP on admission was elevated at 3563. She had an elevated CVP which was felt to be secondary to OSA. CXR was clear without evidence of pulmonary edema and no clinical signs of CHF. In MICU, SBP 150s and HR 60s. She developed pulmonary edema which responded to lasix. A temporary pacer with screw-in lead was put in place by the EP service on [**11-6**] and the patient was transferred to the CCU. She was put back on an aspirin and statin. Her lasix was held. The patient was temporarily pacer dependent. A permanent pacemaker was considered, however, the patient began pacing on her own and a permanent pacemaker became unnecessary and the temporary screw lead was removed on [**11-10**]. The etiology of the patient's sick sinus and stunned atria was felt to be due to her hyperkalemia and acute renal failure. A low dose beta blocker was restarted, however her ACE inhibitor was held and renal artery stenosis was ruled out with a normal renal US. An MRI was not performed as the patient is unable to fit in MR machine. She was started on coumadin for atrial fibrillation and INR will be checked as an outpatient. Plavix was discontinued. She was followed in the CCU by her primary cardiologist Dr. [**Last Name (STitle) **]. ACE inhibitor should be restarted at her first PCP [**Name Initial (PRE) **]. . ARF: Ms. [**Known lastname **] presented with acute renal failure with a creatinine of 4.5 (baseline 1.3). A FeNa was calculated and found to be <1% and FeUrea 12.5%, both indicative of pre-renal renal failure, however possibly in setting of low cardiac output from bradycardia. The renal service was consulted in the ED and felt there was no urgent indication for HD. K was 6.2 on presentation and 5.5 on recheck. Electrolytes were checked frequently while the patient was in renal failure and fluids were given. Potassium normalized and was 3.5 on d/c. A renal ultrasound was performed which showed no hydronephrosis. The patient's creatinine normalized prior to discharge. Her ace inhibitor was held, but will be restarted at first outpatient f/u visit as above. . Pulm: Ms. [**Known lastname **] presented with shortness of breath and wheezing which could was felt to be secondary to a COPD flare. She was treated with fluticasone/salmeterol inh, fluticasone nasal spray and ipratroprium inh. A CXR was clear. She was put on BiPap per her home regimen. . Hypertension: Ms. [**Known lastname **] blood pressure stabilized after admission and became difficult to control. She was treated with Isosorbide Dinitrate 10 mg PO TID, Hydralazine HCl 20 mg IV Q6H, Clonidine HCl 0.2 mg PO BID, and Amlodipine 10 mg PO daily. . Diabetes: The patient was on insulin sliding scale with finger sticks. Glyburide was held. . Full Code Medications on Admission: Albuterol Sulfate 0.083 % one Neb q4h Aspirin 325 mg Tablet po qday Atorvastatin 80 mg po qday Clopidogrel 75 mg po qday Metoprolol Tartrate 12.5mg po bid Lisinopril 20 mg po qday Glyburide 5 mg po bid Amitriptyline 50 mg po qhs Ferrous Sulfate 325mg po qday Gabapentin 600 mg po tid Ipratropium Bromide 17 mcg inh qid Fluticasone-Salmeterol 250-50 [**Hospital1 **] Fluticasone 50 mcg one spray each nostril qday Furosemide 40 mg po qday verapamil SR 240mg po qday Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day): One spray in each nostril. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Imdur 30 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* 10. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 12. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime. Disp:*60 Tablet(s)* Refills:*2* 13. Outpatient Lab Work INR monitoring twice a week by VNA, goal INR 2.0-3.0, results to be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office (fax # [**Telephone/Fax (1) 14632**], phone # [**Telephone/Fax (1) 2394**]). Discharge Disposition: Home With Service Facility: Family Services Association of Greater [**Location (un) 8973**] Discharge Diagnosis: Primary: Bradycardia Acute renal failure Right heart failure with pulmonary htn DM HTN OSA- uses BiPAP at home Asthma- uses O2 at home CAD s/p LAD PTCA on [**7-15**] Secondary: Restrictive lung disease on [**Name (NI) 96801**] [**Name (NI) **] pt unable to ambulate, uses wheelchair Hyperlipidemia Discharge Condition: Stable. The patient is chest pain free and taking PO. A rehab facility was recommended by physical therapy, however the patient refused. She will be discharged home with VNA. Discharge Instructions: You were admitted with a slow heart rate and renal failure. You have been started on a new medication called coumadin for a heart rhythm called atrial fibrillation. This medication needs to be taken daily and must be followed in [**Hospital 263**] clinic. The VNA will be drawing your blood and faxing the results to Dr.[**Name (NI) 5452**] office until the coumadin clinic takes over monitoring of your INR. You had been taking Lisinopril at home. This medication was held while you were in the hospital because your kidneys weren't functioning appropriately. You should restart this medication after seeing your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. You are no longer taking Plavix. Please keep all outpatient appointments. If you begin to experience any chest pain, shortness of breath, immediately. Followup Instructions: You have the following appointments: 1. [**Doctor Last Name 9894**],NON-FLUORO(B) PAIN MANAGEMENT CENTER Date/Time:[**2177-11-26**] 1:40 2. [**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2177-12-4**] 1:45 3. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7059**], M.D. Date/Time:[**2177-12-24**] 4:30 4. Dr. [**Last Name (STitle) **] on [**12-10**], at 12:30 in [**Location (un) **]. [**Telephone/Fax (1) 2394**] You also need to follow up with the coumadin clinic to have the level of coumadin in your blood tested. The VNA will draw your blood twice a week and fax the results to Dr.[**Name (NI) 5452**] office (fax # [**Telephone/Fax (1) 14632**]) in the meantime.

[ "493.20", "250.51", "428.0", "362.01", "E885.9", "276.52", "584.9", "281.9", "427.31", "272.0", "276.1", "585.9", "403.90", "V45.82", "276.2", "427.89", "278.01", "583.81", "327.23", "250.41", "276.7", "414.01", "458.9" ]

icd9cm

[ [ [] ] ]

[ "37.78", "99.04" ]

icd9pcs

[ [ [] ] ]

9888, 9982

4407, 7906

348, 412

10325, 10505

2570, 4384

11391, 12144

2006, 2086

8421, 9865

10003, 10304

7932, 8398

10529, 11368

2101, 2551

277, 310

440, 1333

1355, 1740

1756, 1990

50,494

196,067

3887

Discharge summary

report

Admission Date: [**2192-4-29**] Discharge Date: [**2192-5-11**] Date of Birth: [**2135-9-22**] Sex: M Service: SURGERY Allergies: Bactrim Attending:[**First Name3 (LF) 6088**] Chief Complaint: Necrotic toe, hyperglycemia. Major Surgical or Invasive Procedure: Amputation of second toe and debridement of necrotic tissue. Right below-knee amputation. History of Present Illness: 56 y/o M with PMHx of DMII, HIV off HAART and Depression who presented with fevers, hyperglycemia and an infected/necrotic toe. Per report, he had not been taking his medications or checking his BS. Pt reports feeling achey and weak at home but denies any fevers, chills, nausea or vomiting. During his last admission in [**3-7**], he was scheduled to follow up with podiatry but has not been seen since discharge. . In the ED, initial VS were: T 101 P 102 BP 161/66 R 18 O2 sat 98% Patient was given Vancomycin, Zosyn, 2L IVF, 6 units Regular Insulin followed by an insulin gtt on 8u/hr and his BS came down to the 300s. Plain films of the left foot revealed subcutaneous gas concerning for necrotizing fascitis. Pt was taken to the OR for emergent debridement prior to transfer to the MICU. . On arrival, pt was comfortable and sleepy from anesthesia. He was denying chest pain, shortnesss of breath, abd pain, nausea, vomiting, joint pain, fevers, chills, [**Month (only) **] appetite, diarrhea or constipation. He has not been taking his DM meds or HAART medications regularly since discharge. On further questionning, he reports that his PCP is frustrated with him because "i am a bad patient" and "I can't take care of myself". He was emotional and unable to identify specific barriers preventing him from caring for himself. Past Medical History: HIV x 8 years, CD4 count >400 in 08, VL undetectable Type 2 diabetes mellitus Hypercholesterolemia Attention deficit disorder Retinopathy, status post laser surgery Depression Tonsillitis, status post tonsillectomy. Social History: The patient denies intravenous drug use. He has had a history of binge drinking in the past, but currently does not drink more than once a month. Denies tobacco use. Family History: The patient's father had lymphoma and pancreatic cancer as well as diabetes mellitus. His grandfather had hypertension. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses femoral BL/, no clubbing, cyanosis or edema. Amp site c/d/i, staples in place Pertinent Results: On Admission: [**2192-4-29**] 02:55PM WBC-17.3*# RBC-4.13* HGB-12.3* HCT-35.1* MCV-85 MCH-29.8 MCHC-35.1* RDW-13.5 [**2192-4-29**] 02:55PM NEUTS-88.4* LYMPHS-8.0* MONOS-3.3 EOS-0.2 BASOS-0.2 [**2192-4-29**] 02:55PM PLT COUNT-517* [**2192-4-29**] 02:55PM PT-13.6* PTT-33.1 INR(PT)-1.2* [**2192-4-29**] 02:55PM GLUCOSE-504* UREA N-34* CREAT-1.3* SODIUM-126* POTASSIUM-4.8 CHLORIDE-85* TOTAL CO2-23 ANION GAP-23 [**2192-4-29**] 04:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.027 [**2192-4-29**] 04:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-150 GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [**2192-4-29**] 04:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-<1 [**2192-4-29**] 04:30PM URINE AMORPH-FEW Brief Hospital Course: 56 y/o M with PMHx of HIV (off HAART) and DMII who presents with fevers and necrotizing fascitis of 2nd digit of right foot. . Pt with necrotic toe, elevated WBC of 17.3 with 88% PMNs, fever, hypovolemic hyponatremia of 126, tachycardia and plain films showing subcutaneous gas concerning for nec fascitis. Had debridement and amputation of toe in OR by podiatry. Pain significantly improved. Started on vancomycin, zosyn, clindamycin, and morphine on [**2192-4-29**]. Clindamycin was added to supress toxin production until cultures were back. Vascular surgery was consulted, and after examining the tissue cultures, patient was advised to have amputation BKA Operation occured on [**2192-5-3**]. . ARF: Pt developed ARF with anuria post operative period from low BP in the OR. A renal Consult was obtained. Pt was given multiple fluid boluses. On DC he is making good urine. His high creatinine was 7.6. On DC his creatinine is. 6.1. His [**Last Name (un) **] and ACE inhibitor are currently being held. LaMIVudine is now renal dosed at 25 mg. This will have to be adjusted with improving creatinine. Diagnosis of ATN. . Hyperglycemia/Ketosis: Pt p/w acute necrotizing infection and BS 504 which was trending down to 300s with insulin gtt at 8units/hr. UA was +ketones though he is a type II DM. Pt improved with IVF and insulin gtt and his BS dropped to 151 in ICU. Pseudohyponatremia (126) resolved with improvement of blood sugars. On the floor, he was switched to 45 units of 80/20 of NPH/Humalog with breakfast and dinner and his sugars remained in the range of 200-300s. Insulin dose increased to 55 units of 75/25 of NPH/Humalog with breakfast and dinner, and sliding scale starting at 5 units and increasing by increments of 2. Sugars then dropped to 150-160s in the day before surgery for BKA. His BS where stable post operative period. . HIV (off HAART): Pt unable to reliably take medications at home and thrush was seen on exam, so a CD4 was checked (CD4 243). In consultation with PCP, [**Name10 (NameIs) **] was restarted on HAART. Thrush was treated with nystatin swish and swallow, then switched to fluconazole 200 mg PO daily for 14 days (starting [**2192-5-2**]). . Fevers: Pt spiked temperatures as high as 102.9 each night before surgery, which was believed due to infection in right foot. Preliminary blood cultures found Gram-positive cocci in clusters. In one bottle. No additional antibiotics were prescribed beyond the vancomycin, clindamycin, and zosyn. Urine cultures (prelim) had no growth. His antibiotics where stopped, He is currently afebrile and with out a white count. . Psychiatric issues: Pt has been under treatment for major depression and attention deficit disorder by outpatient psychiatrist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 16471**] of the [**Hospital3 17370**], although he has not seen her since Fall [**2190**]. These disorders were considered central to why pt was unable to manage home meds, and why he returned to [**Hospital1 18**] after six weeks with worsened infection of foot requiring amputation. Per Dr.[**Name (NI) 17371**] recs, pt was restarted on fluoxetine starting at 20mg daily for two days, then 40mg daily. In addition, she recommended restarting him on Ritalin SR pt was started and is doing well. . Dyslipidemia: Pt was continued on lisinopril 20mg and pravastatin 40mg. when switched from nystatin to fluconazole x 14 days, pravastatin was discontinued due to drug interactions. On [**2192-5-16**], he will be done with fluconazole and should be restarted on pravastatin. . Anemia: Pt has chronic normocytic anemia at baseline. He was guaiac negative. He will need to be trended as an outpatient. Medications on Admission: Per last d/c summary, but not taking: Humalog Insulin 75/25 65 units [**Hospital1 **] (taking less than 50% of time) Omega-3 Fatty Acids [**Hospital1 **] Multivitamin daily Aspirin 81 mg daily Valsartan 80 mg daily Ritonavir 100 mg daily Pravastatin 40mg daily Pioglitazone 45 mg daily Methylphenidate 30mg daily Lisinopril 40mg daily Gemfibrozil 600 mg daily Fluoxetine 40mg daily Efavirenz 600 mg daily Atazanavir 300mg daily Lamivudine 300mg daily Abacavir 600 mg tablet daily Bisacodyl 10mg daily Docusate Sodium 100 mg [**Hospital1 **] Senna 8.6 mg [**Hospital1 **] prn Oxycodone-Acetaminophen Insulin SS Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 2. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 9. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 10. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)). 11. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). 12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 14. Lamivudine 10 mg/mL Solution Sig: 2.5 25 mg PO QHS (once a day (at bedtime)). 15. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 17. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 19. insulin Insulin SC Sliding Scale & Fixed Dose Fingerstick QACHS Insulin SC Fixed Dose Orders Breakfast Dinner Humalog 75/25 55 Units Humalog 75/25 55 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 5 Units 5 Units 5 Units 5 Units 201-250 mg/dL 7 Units 7 Units 7 Units 7 Units 251-300 mg/dL 9 Units 9 Units 9 Units 9 Units 301-350 mg/dL 11 Units 11 Units 11 Units 11 Units 351-400 mg/dL 13 Units 13 Units 13 Units 13 Units > 400 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Right lower extremity ischemia with gangrene. ARF secondary to low BP in operating Room, reolving Mild hypoactive delirium, ADD Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Mental Status: Clear and coherent. Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING ABOVE KNEE OR BELOW KNEE AMPUTATION This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are restrictions on activity. On the side of your transmetatarsal amputation you are non weight bearing for [**4-3**] weeks. You should keep this amputation site elevated when ever possible. You may use the heel of your amputation site for transfer and pivots. But try not to exert to much pressure on the site when transferring and or pivoting. If possible avoid using the heel of your amputation site when transferring and pivoting. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. Do not drive a car unless cleared by your Surgeon. No heavy lifting greater than 20 pounds for the next 14 days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. WOUND CARE: Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. Avoid pressure to your amputation site. No strenuous activity for 6 weeks after surgery. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. If you have diabetes and would like additional guidance, you may request a referral from your doctor. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE Followup Instructions: Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2192-6-6**] 9:45 Dr. [**Last Name (STitle) 17372**] 2-3 weeks , please call for appt Completed by:[**2192-5-11**]

[ "362.01", "V15.81", "293.0", "443.81", "440.24", "403.90", "285.9", "250.42", "314.01", "275.3", "272.4", "250.62", "296.30", "112.0", "584.5", "V58.67", "728.86", "314.00", "585.3", "042", "357.2", "707.19", "276.1", "038.9", "995.92", "250.12", "250.72", "682.7", "250.52" ]

icd9cm

[ [ [] ] ]

[ "84.11", "84.15" ]

icd9pcs

[ [ [] ] ]

10242, 10285

3647, 7351

296, 388

10457, 10579

2862, 2862

16100, 16341

2194, 2315

8012, 10219

10306, 10436

7377, 7989

10640, 12497

2330, 2843

228, 258

12510, 15404

15428, 16077

416, 1755

2876, 3624

10594, 10616

1777, 1994

2010, 2178

49,224

165,261

52470

Discharge summary

report

Admission Date: [**2103-6-15**] Discharge Date: [**2103-6-22**] Date of Birth: [**2020-10-25**] Sex: F Service: MEDICINE Allergies: Lovastatin / Sulfa (Sulfonamide Antibiotics) Attending:[**Doctor Last Name 1857**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 82 year-old woman with CAD s/p NSTEMI [**5-19**] managed medically, hypertension, diabetes mellitus type 2, dyslipidemia, [**Hospital 15134**] transferred from [**Hospital3 **] [**2103-6-15**] after presenting there with progressive exertional dyspnea, 5-lb weight gain, orthopnea, leg swelling, and cough productive of white sputum. Her ECG showed lateral ST depressions, CXR showed mild CHF, and labs showed hyponatremia (Na 130), acute renal failure (Cr 3.9, baseline 2.2), TropI 1.04, and Hct 25. She was transfused 1 unit PRBC for anemia. Guaiac negative, so she was given ASA, Plavix load, Lasix 120 mg, Heparin gtt, nitropaste, and Mucomyst and was transferred for possible cardiac catheterization. She had a 5 L/min O2 requirement upon transfer. Serial CK were flat and troponin levels remained stable ~0.4 (Cr ~4.0). Nonetheless, she was treated with heparin gtt x 48 hours for possible acute coronary syndrome leading to decompensated heart failure. She was started on Lasix gtt and metolazone upon arrival here but did not display adequate urine output. TTE showed EF 45% with inferior and inferolateral hypokinesis, mildly dilated RV with borderline normal free wall function, 1+ AI, 2+ MR, and moderate pulmonary HTN. Nephrology was consulted for management of volume status in the setting of acute on chronic renal failure - they felt that hypoxemia did not correlate to volume status and recommended discontinuing diuresis. She was started on vancomycin+ceftazidime for right lower lobe hospital-acquire pneumonia and UTI. She received an extra dose of Klonopin on the evening of HD #2. The morning of HD #3, she was more delirious and hypoxemic, with O2 sat 85% on 5 L/min (ABG 7.34/34/96/23) and was transferred to the CCU. CXR showed progression of pulmonary edema. Oxygenation requirement improved to 3 L/min NC without diuresis, and CXR [**6-17**] showed improvement in pulmonary edema. Urine output 600 cc since midnight, negative 700 cc since arrival in CCU. Metoprolol was changed to carvedilol 12.5 mg [**Hospital1 **], increased hydralazine to 30 mg q8h. Patient was then transferred back to the [**Hospital1 1516**] Cardiology Service. Past Medical History: 1. CAD Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Diabetes mellitus, type II PAD, s/p bilat fem-tib bypass, Left toe amputation Hypertension Chronic renal failure with baseline Cr ~2.2 Anemia of chronic (renal) disease & iron-deficiency Gout Hypothyroidism Acoustic neuritis Generalized anxiety disorder Social History: Lives alone in [**Location (un) 22287**]. Son lives nearby. Has never smoked. Uses EtOH rarely. Family History: No known family history of early MI, arrhythmia, cardiomyopathy, or sudden cardiac death. Physical Exam: DISCHARGE PHYSICAL EXAM: GENERAL: Well-appearing elderly Caucsian woman in NAD, breathing non-labored VITAL SIGNS: T 97.6 HR 66 BP 125/58 RR 20 O2 sat 99% on RA HEENT: Anicteric, conjunctiva pale, OP clear MMM NECK: No JVD CARDIAC: regular rate, normal S1 and S2, II/VI holosystolic murmur at apex LUNGS: CTAB ABDOMEN: soft NTND normoactive BS EXTREMITIES: warm, dry; trace pedal edema; no calf tenderness; L toe dressing clean, dry and intact NEURO: awake, alert, oriented x person, place, month, year PULSES: Right: Carotid 2+ Femoral dopplerable distal pulses Left: Carotid 2+ Femoral dopplerable distal pulses Pertinent Results: [**2103-6-15**] 10:12PM WBC-9.4 RBC-2.96* HGB-9.3* HCT-27.0* MCV-91# MCH-31.6 MCHC-34.6 RDW-15.4 [**2103-6-15**] 10:12PM PLT COUNT-414 [**2103-6-15**] 10:12PM PT-15.3* PTT-40.0* INR(PT)-1.4* Glucose UreaN Creat Na K Cl HCO3 AnGap [**2103-6-15**] 10:12PM 177 63* 4.0 132 4.7 96 20 21 [**2103-6-16**] 06:10AM 131 66* 4.2* 134 4.9 97 22 20 [**2103-6-16**] 01:10PM 155 70* 4.3* 130* 4.5 93 22 20 [**2103-6-17**] 05:40AM 142 71* 4.1* 132* 3.9 94 23 19 [**2103-6-17**] 05:30PM 95 69 3.9* 134 3.6 96 24 18 [**2103-6-18**] 05:38AM 125 68* 3.6* 131* 4.0 95 24 16 [**2103-6-18**] 05:12PM 193 66* 3.3* 130* 3.6 93 23 18 [**2103-6-19**] 06:20AM 157 62* 2.8* 134 3.7 97 24 17 [**2103-6-20**] 06:30AM 103 54 2.5 133 3.3 94 28 14 [**2103-6-21**] 06:57AM 122 47 2.3 138 3.3 97 31 13 CK(CPK) TropnT [**2103-6-15**] 10:12PM 39 0.35 [**2103-6-16**] 06:10AM 34 0.39 [**2103-6-16**] 01:10PM 87 0.34 [**2103-6-17**] 05:30PM 44 0.45 [**2103-6-18**] 05:38AM 38 0.44 HEMATOLOGIC calTIBC VitB12 Folate Ferritn TRF [**2103-6-16**] 06:10AM 229* 1060* 8.4 897* 176* DIABETES MONITORING %HbA1c [**2103-6-16**] 06:10AM 6.4% LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc [**2103-6-16**] 06:10AM 233* 851 61 3.8 155* PITUITARY TSH [**2103-6-16**] 06:10AM 1.1 [**2103-6-16**] 5:02 am URINE Site: CATHETER ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- =>16 R ECG [**2103-6-15**] 6:58:18 PM Sinus rhythm with sinus arrhythmia. Q-T interval is prolonged for rate. Extensive ST-T wave abnormalities. Cannot rule out myocardial ischemia. Clinical correlation and repeat tracing are suggested. No previous tracing available for comparison. CXR [**2103-6-15**] There are no old films available for comparison. The heart is upper limits of normal in size. There is bilateral lower lobe volume loss with probable infiltrate as well on the right. There is some mild pulmonary vascular redistribution. IMPRESSION: Bilateral lower lobe volume loss with right lower lobe infiltrate. The overall appearance is worrisome for an infectious process rather than pulmonary edema. CXR [**2103-6-19**] PA and lateral upright chest radiograph was compared to [**2103-6-17**]. There is interval increase in bilateral pleural effusions. The patient is in mild-to-moderate pulmonary edema that appears to be unchanged since the prior study. Bibasilar retrocardiac opacities are most likely consistent with areas of atelectasis. Echocardiogram [**2103-6-16**] Suboptimal image quality. 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 mildly depressed (LVEF= 45 %) with inferior and infero-lateral hypokinesis suggested. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with borderline normal free wall function. 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. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Renal ultrasound [**2103-6-18**] There is cortical thinning involving the kidneys bilaterally. No hydronephrosis or nephrolithiasis is seen. The right kidney measures 10.0 cm in size, and the left kidney measures 7.3 cm in size. A Foley catheter is in place, which limits evaluation of the urinary bladder. IMPRESSION: Renal cortical thinning bilaterally, consistent with chronic medical renal disease. No hydronephrosis. LEFT TOE 2VIEWS [**2103-6-18**] Two radiographs of the left forefoot demonstrate amputation of the distal second ray. Dense atherosclerotic calcifications are noted. No joint space abnormalities appreciated. Assessment is slightly limited by overlying dressing material. No tracking subcutaneous emphysema is seen. No previous studies are available for comparison. LOWER EXTREMITY ARTERIAL DUPLEX U/S [**2103-6-19**] Bilateral outflow arterial disease in the lower extremities. On the right disease is likely located at the distal popliteal/tibial arteries. On the left disease is likely located at the superficial femoral artery. Brief Hospital Course: # Non-ST-elevation myocardial infarction - Given acute on chronic renal failure and rapid improvement in symptoms, cardiac catheterization was deferred and the patient was treated with optimal medical therapy. Heparin gtt was continued for 48 hours after admission. Atorvastatin was started given that the documented allergy to lovastatin was likely a history according to the patient's son (baseline [**Name (NI) 53324**] were WNL). Continued aspirin, Plavix, carvedilol, Imdur, lisinopril, and atorvastatin on discharge. Omeprazole was changed to ranitidine given initiation of Plavix therapy and concern about inhibition of the anti-platelet effects of Plavix in the setting of concomitant PPI use. # Acute on chronic diastolic (with mild systolic) left ventricular heart failure - CXR evidence of pulmonary edema consistent with acute diastolic heart failure. TTE showed mild regional LV systolic dysfunction with mild hypokinesis of the inferior and inferolateral segments (LVEF 40-45%), mild aortic and moderate mitral regurgitation, borderline pulmonary artery systolic hypertension. Diuresed initially with Lasix gtt followed by Lasix IV boluses. Transitioned to an increased maintenance dose (compared with admission dose) of 80 mg PO daily. Metoprolol was changed to carvedilol, started lisinopril, uptitrated hydralazine to 50 mg q8h. Continued Imdur. Demonstrated normal room air oxygenation prior to discharge. # Acute on chronic renal failure - Improved even with diuresis. Renal ultrasound showed evidence of medical renal disease but no hydronephrosis. Lisinopril started, as above. # Hospital acquired pneumonia - Started empirically on vancomycin and ceftazidime. Vancomycin was dosed according to trough level given acute on chronic renal insufficiency, and ultimately discontinued after 72 hours. Completed 7 day course of ceftazidime. One set of blood cultures were negative. # Acute uncomplicated urinary tract infection - Urine culture grew cephalosporin-sensitive, fluoroquinolone-resistant E. Coli. Treated with ceftazidime, as above. # Peripheral arterial disease, S/P left toe amputation - Evaluated by podiatry and wound care nurses who made recommendations regarding dressing changes. The wound did not probe to bone on examination and there was no evidence of osteomyelitis on plain film (MRI was deferred given low clinical suspicion and renal insufficiency). Lower extremity Doppler ultrasound showed bilateral outflow arterial disease in the lower extremities with disease located at the distal popliteal/tibial arteries on the right and likely located at the superficial femoral artery on the left. Angiography and further definitive therapy was deferred in the setting of acute illness and impaired renal function, but it was strongly recommended that the patient follow up with her vascular surgeon and wound clinic as an outpatient. # Diabetes mellitus type II - Glargine reduced to 12 units QAM in the setting of acute on chronic renal failure. Blood sugar was well-controlled on this dose of basal as well as sliding scale insulin. HgbA1c 6.4% at goal. # Anemia of iron-deficiency and chronic kidney disease - Hematocrit remained stable obviating the need for transfusion. Started iron sulfate and erythropoeitin at the recommendation of the consulting nephrology team. # Hypertension - Well-controlled on carvedilol, amlodipine, Imdur, and hydralazine. # Hyperlipidemia - Lipid panel was suboptimal, with a total cholesterol of 233 and calculated LDL 155. Continued atorvastatin 80 mg, as above. # Generalized anxiety disorder - Reduced Klonopin to 0.5 mg qhs. Continued Celexa. # Hypothyroidism - Continued levothyroxine. TSH was within normal limits. # Gout - Allopurinol reduced to 100 mg every other day given renal insufficiency. Medications on Admission: ASA 81 mg daily Toprol XL 50 mg daily Hydralazine 10 mg TID Lasix 60 mg daily Norvasc 10 mg daily Klonopin 0.5 mg [**Hospital1 **] Synthroid 100 mcg daily Celexa 10 mg daily Plavix 75 mg daily Allopurinol 100 mg daily Lantus 24 Unit at dinner SS insulin Prilosec 40 mg [**Hospital1 **] Imdur 240 mg daily Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) INH Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day): Please continue while nonambulatory. 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) INH Inhalation every 4-6 hours as needed for SOB / wheezing. 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily): please administer at different time than levothyroxine. 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Imdur 120 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO once a day: hold for sbp<100. 9. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Aspirin 162 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): hold for sbp<100. 14. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day: hold for sbp<100. 15. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday). 16. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)): hold for rr<12, oversedation. 17. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for sbp<95, hr<55. 18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 19. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 20. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sbp<100. 21. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous QAM. 22. Humalog 100 unit/mL Solution Sig: ASDIR injection Subcutaneous QACHS: per attached sliding scale. 23. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sbp<100. 24. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day: please give 30-60 minute prior to eating. 25. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day: please administer at different time than ferrous sulfate. Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay - [**Hospital1 392**] Discharge Diagnosis: Primary 1) Non-ST-elevation myocardial infarction 2) Coronary artery disease 3) Acute on chronic diastolic (with mild) systolic left ventricular heart failure 3) Acute on chronic renal failure 4) Hospital acquired pneumonia 5) Acute uncomplicated urinary tract infection Secondary 1) Peripheral arterial disease status post left toe amputation 2) Diabetes mellitus type II 3) Anemia of iron-deficiency and chronic kidney disease 4) Hypertension 5) Hyperlipidemia 6) Generalized anxiety disorder 7) Hypothyroidism 8) Gout Discharge Condition: Clinically improved with stable vital signs and normal room air oxygenation. Discharge Instructions: You were admitted to the hospital after a heart attack with worsening congestive heart failure leading to worsening kidney function. Your heart and kidneys improved with diuretic medications. You were diagnosed with pneumonia and a urinary tract infection which were treated with antibiotics. The following medication changes were recommended: 1) Furosemide (lasix) was increased to 80 mg daily. 2) Aspirin was increased to 162 mg (two "baby" aspirin) daily. 3) Allopurinol was decreased to 100 mg EVERY OTHER DAY. 4) Atorvastatin (Lipitor) 80 mg was started. 5) Erythropoeitin 4000 units on monday/wednesday/friday was started. 6) Hydralazine was increased to 50 mg three times daily. 7) Prilosec (Omeprazole) was changed to a similar acid-blocking medication called ranitidine (Zantac). 8) Clonazepam (Klonopin) was decreased to 0.5 mg once nightly. 9) Metoprolol (Toprol) was changed to a similar medication called carvedilol (Coreg). 10) Glargine insulin was decreased to 12 units with dinner. 11) Lisinopril (Zestril) was started. Please discuss replacing hydralazine with an increased dose of lisinopril with your outpatient physicians. Please weigh yourself daily and contact your physician if your weight increases by greater than 3 pounds. Please adhere to a diet containing less than 2 grams of sodium daily. Please attend all of your follow-up appointments. Please call your physician or return to the Emergency Department if you experience fever, chills, sweats, dizziness, lightheadedness, chest pain, palpitations, cough, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, urinary symptoms, leg swelling, or other worrisome symptoms. Followup Instructions: Please call the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 14328**] to schedule a follow-up appointment within 1-2 weeks. Please follow up with your cardiologist within 1-2 weeks. Please schedule a follow-up appointment with your vascular surgeon for further evaluation of your left toe wound. You may also call the [**Hospital1 18**] Department of Vascular Surgery at [**Telephone/Fax (1) 1237**] to schedule an appointment at your earliest convenience. Please also ensure that you follow up with your local wound care clinic. [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, MSC 12-339 Completed by:[**2103-6-22**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15715, 15795

9012, 12800

314, 320

16360, 16438

3844, 8989

18154, 18915

3103, 3194

13155, 15692

15816, 16339

12826, 13132

16462, 18131

3209, 3209

2615, 2688

267, 276

348, 2512

2719, 2974

2534, 2595

2990, 3087

3234, 3825

17,341

151,110

46297

Discharge summary

report

Admission Date: [**2132-6-9**] Discharge Date: [**2132-7-19**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2297**] Chief Complaint: status-post fall Major Surgical or Invasive Procedure: LEFT CRANIOTOMY TRACHEOTOMY ([**2132-7-11**]) PERCUTANEOUS ENDOGASTRIC TUBE ([**2132-7-11**]) History of Present Illness: HPI: This is an 89 year old woman with a history of atrial fibrillation not on coumadin, CHF (EF 50-55%), moderate AS who was initially admitted to neurosurgery on [**2132-6-9**] for L subdural hemorrhage after a fall. CT showed subfalcine herniation and developing uncal herniation. She underwent evacuation of SDH on [**2132-6-9**]. [**Name (NI) **], pt was noted to be lethargic but MRI brain was negative for stroke. Hospital course was remarkable for hypernatremia to 147 managed with free water boluses and slow recovery. Post-operatively, the patient was transferred to neurosurg step down where she has remained on 50% VM. The patient has had persistent leukocytosis since admission. Geriatrics consulted and started Levaquin on [**6-17**]. UA negative. CXR c/w CHF. She was noted to be grossly positive with weight of 128 (up from baseline of 111 on [**2132-5-22**] in the clinic) and was started on Lasix boluses for diuresis. . On [**2132-6-18**], patient developed new seizure which resolved with Ativan 2 mg IV once. She then was noted to be tachypneic with altered mental status (less responsive) and MICU team was called. CT head w/o change. When seen on the floor, the patient was minimally responsive breathing at rates 38-45. HR 80, BP 100-110/50s, O2 sat 92-93% on 50% face mask. Upper airway rhoncor and diffuse rales on exam. CXR with pleural effusions and worsening CHF. ABG with pH 7.48 pCO2 34 pO2 79 HCO3 26; WBC 18; Lactate: 1.7. . Past Medical History: PMHx: Atrial Fibrillation, not on coumadin since [**2130**] Congestive Heart Failure, LVEF 50-55% Aortic stenosis duodenal ulcer Depression Hyperlipidemia Appendectomy C-Section Bilateral Cataract Surgery Arthritis Social History: She is a widow with one adult child. She lives alone. She is retired. Prior to retiring she was a piano teacher. Her daughter, [**Name (NI) 17**] [**Known lastname 2455**], lives in [**Name (NI) 3844**]. [**Telephone/Fax (1) 98456**]. Family History: Mother died at the age of 70 from lung cancer . Physical Exam: PHYSICAL EXAM: O: T:100.0 BP:90/54 HR: 72 R 18 O2Sats 96RA Gen: patient laying with eyes closed HEENT: large hematoma left scalp Pupils: R s/p cataract surgery, 2.5 to 2; L [**4-1**] EOMs full Neck: hard collar in place Lungs: CTA bilaterally. Cardiac: prominent systolic murmur at 2nd LICS and L mid axillary line Abd: Soft, NT/ND Extrem: Warm. Neuro: Mental status: Somnolent but arousable to voice (per report from the [**Last Name (un) 4068**], patient was fully awake and interactive on initial exam). Cooperative with exam, but need to repeat commands several times. Orientation: Oriented to person, place, and date. Recall: 0/3 objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils asymmetric. R 2.5-2; L 4-3 mm bilaterally (per report from the [**Last Name (un) 4068**], patient had symmetric pupils on initial exam). Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength 3/5 R deltoid, 4 R bicep, 4 R tricep. [**5-3**] in all other muscle groups. No pronator drift. Sensation: Intact to light touch Reflexes: B T Br Pa Ac Right 2 1 2 1 0 Left 1 1 1 1 0 Toes downgoing bilaterally Coordination: on finger-nose-finger patient unable to follow command correctly - would grab my finger instead of touching it Pertinent Results: RADIOLOGY Preliminary Report ([**2132-6-9**]) CT HEAD W/O CONTRAST 10:15 AM FINDINGS: There has been a left frontoparietal craniotomy. There has been evacuation of majority of the large subdural hematoma. A tiny amount of residual remains. New from the prior examination, there is hypoattenuation in the left frontal lobe with a 1.5-cm area of intraparenchymal frontal lobe hemorrhage. There is 8 mm of rightward midline shift/subfalcine herniation on this study. There is an unchanged lacune within the posterior limb of the left internal capsule. The right frontal subgaleal hematoma remains present. IMPRESSION: Evacuation of majority of the blood contained within left subdural hematoma. Slight improvement in the rightward midline shift. New intraparenchymal left frontal lobe hemorrhage and hypodensity. This could relate to underlying hemorrhage into an anterior cerebral artery infarct or other less likely etiologies such as contusions. These findings were telephoned to Dr. [**Last Name (STitle) **] at the time of dictation. ([**2132-6-9**]) CT C-SPINE W/O CONTRAST CT OF THE CERVICAL SPINE: There is no evidence of fracture or dislocation. No prevertebral soft tissue swelling. Multilevel degenerative changes are seen including posterior disc protrusions at C3-4 and C4-5 as well as calcification of the ligamentum flavum at C5-6 and C6-7 causing mild canal stenosis at these levels. No significant cord compression or neural foraminal narrowing. Vertebral body heights are maintained. A well corticated osteophyte is noted off the superior aspect of the anterior arch of C1. Ground glass opacities and septal thickening in the lung apices suggest pulmonary edema. Dystrophic calcifications as well as a large concentric calcification with hypodense center are seen within the thyroid gland. Large nuchal ligament calcifications are present. IMPRESSION: 1. No evidence of fracture or dislocation. 2. Moderate degenerative changes of the cervical spine as noted above. 3. Pulmonary edema at the lung apices. Clinical evaluation is recommended as well as chest radiographs if clinically indicated. 4. Dystrophic calcifications in the thyroid gland. The gland could be further evaluated by ultrasound on a nonemergent basis. ([**2132-6-9**]) CT HEAD W/O CONTRAST FINDINGS: The left convexity acute subdural hemorrhage has increased significantly in size, from a maximal dimension of 7 mm to now measuring 19 mm. There is significant sulcal effacement and mass effect. Rightward subfalcine herniation has increased from 4 mm to 10 mm. The right ventricle is compressed. Uncal herniation is developing. Large right frontal subgaleal hematoma is unchanged. No fractures are identified. IMPRESSION: 1. Increasing acute left subdural hematoma with significant mass effect and subfalcine herniation. Uncal herniation is developing and urgent neurosurgical consult is recommended. 2. Right frontal subgaleal hematoma is redemonstrated. ([**2132-6-11**]) MRI with DWI = IMPRESSION: 1. No evidence of acute infarction. Areas of hypoattenuation noted on recent CT examination correspond to edema likely from evolving contusions within the left frontal lobe. Mild amount of surrounding mass effect with no significant shift of midline structures. 2. Large amount of motion artifact degrading the MRA makes it virtually uninterpretable for evaluation of aneurysms or definite atherosclerotic disease. Brief Hospital Course: Summary: 89 yo female with AF, CHF, MR, TR, moderate AS, s/p SDH evacuation on [**2132-6-9**] who was transferred to the MICU for respiratory distress, with leukocytosis, hypotension, s/p seizure. At the time of discharge, she was actively being treated for known MSSA ventilator-associated pneumonia. . Sub-dural hemorrhage/mental status: The patient was admitted through the emergency department after CT scan revealed a left SDH. The patient was taken to the OR emergently after the SDH increased in size. Pt underwent left craniotomy for evacuation of hematoma and evacuation of SDH on [**2132-6-9**]. Post-operatively, the patient was noted to be lethargic but MRI brain was negative for stroke. Subsequently, the patient was transferred to the neurosurgery step down unit. She remained on the surgical service until transfer to the ICU. On her transfer to the MICU on [**6-18**] the patient's mental status was poor, as she was non-interactive and not following commands. However, over her stay in the MICU, as described below, the patient's mental status recovered the point that she was much more interactive responding appropriately to questions and following commands. . Respiratory distress: On [**6-18**] the patient was noted to be tachypneic with altered mental status and MICU team was called. The patient was minimally responsive breathing at rates 38-45. She was diffusely rhonchorous on exam. A stat CXR at the time demonstrated pleural effusions and worsening CHF. ABG at the time was: pH 7.48 pCO2 34 pO2 79 HCO3 26 on 50% face mask; WBC 18; Lactate: 1.7. The patient was transfered to the MICU with hypoxic respiratoy distress, felt to be secondary to pulmonary edema in the setting of critical aortic stenosis. The patient was initially managed on high flow oxygen with diuresis. Diuresis was a chanllenge given the patient's pre-load dependence, as she would often drop her pressures with aggressive diuresis. Gentle diuresis with a lasix drip was attempted. Her sats remained stable on high amounts of oxygen. Ultimately, on the morning of [**6-25**] the patient desatted significantly and was intubated on for acute hypoxic respiratory distress, again, felt to be seconadry to volume overload. For the remainder of her hospitalization, the patient remained a challenge to extubate. The patient failed her one attempt at extubation on [**7-5**] due to tachypnea. Subsequently, a tracheotomy and percutaneuos gastric tube were placed on [**2132-7-11**] which she tolerated well. Since that time she has intermittently been on pressure support with occasional trach mask trials. . Fevers/pneumonia: During her course the patient had fevers of unclear etiology. Initally culture data was unremarkable. Early on she was covered empirically with cefepime and vancomycin with no clear source. The antibiotics were discontinued on [**6-30**] followed by the keppra and dilantin on [**7-1**] and proceeded to be afebrile from [**7-2**] until [**7-15**]. It was postulated that these initial fevers might have been drug related. However, on [**7-15**] the patient again developed fevers to 100.1. Sputum and blood culturea at the time grew out MSSA. She was started on a course of vancomycin on [**7-15**]. . Seizure: The patient had an episode of seizure on [**6-18**], despite being on dilantin, that was responsive to ativan IV. She was subsequently placed on keppra seizure prophylaxis with no further evident events. Her dilantin was discontinued as she had a suspected drug rash to the medication. . Aortic stenosis: Cardiology was actively involved in management of aortic stenosis and evaluated patient for possible interventions. However, because of her overall medical condition, no interventions were felt to be indicated at this time and medical management will be continued. . FEN: The patient is presently receiving tube feeds through her PEG. Of note the patient's early course was remarkable for hypernatremia to 148 managed with free water boluses and slow recovery. . ppx: The patient is on famotidine, heparin sc, and pneumoboots . Access: At the time of discharge, the patient had an appropriately positioned PICC line. . Code status: Ms [**Known lastname 2455**] remained full code throughout hospital admission, per discussions with her and her daughter [**Name (NI) 2127**]. . Medications on Admission: Lasix 80 mg once per day, aldactone 12.5 mg daily, aspirin 81 mg daily, Protonix 40 mg daily Discharge Medications: 1. Vancomycin 1000 mg IV Q 12H Please alternate doses among both ports of PICC line 2. Lorazepam 0.5-1 mg IV PRN pls give prn for seizure > 5min 3. Morphine Sulfate 1-2 mg IV Q4H:PRN pain 4. Ondansetron 4 mg IV Q8H:PRN 5. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 6. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever/pain. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 11. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours). 12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours). 13. Famotidine 20 mg Tablet Sig: One (1) Tablet 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) as needed. 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 17. Insulin NPH Human Recomb Subcutaneous Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Dx: s/p Left craniotomy for Acute subdural hematoma evacuation Secondary Dx: Ventilator Associated Pneumonia Discharge Condition: Pt has been hemodynamically stable and has remained off pressors. She has improving strengh and is tolerating out of bed to chair, responsive to commands and engaged. Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY Take your pain medicine as prescribed Exercise should be limited to walking; no lifting, straining, excessive bending Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered 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, drainage Fever greater than or equal to 101.5 F Otherwise: Continue to take your tube feeds at goal Continue to take your prescribed medications If you develop any problems please return to [**Hospital1 771**] Followup Instructions: Please schedule a follow-up appointment with your primary care doctor, [**First Name8 (NamePattern2) 30642**] [**Doctor Last Name **] at ([**Telephone/Fax (1) 26277**]. Also Follow up with your PCP regarding incidental finding of calcifications in your thyroid gland on CT scan of your neck.

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icd9cm

[ [ [] ] ]

[ "43.11", "96.6", "38.93", "38.91", "31.1", "34.91", "01.31", "99.04" ]

icd9pcs

[ [ [] ] ]

13581, 13647

7623, 7948

236, 332

13809, 13979

4193, 7600

15014, 15309

2340, 2395

12089, 13558

13668, 13788

11971, 12066

14003, 14991

2425, 2763

179, 198

360, 1820

3200, 4174

7963, 11945

1842, 2064

2080, 2323

69,483

177,233

52003

Discharge summary

report

Admission Date: [**2169-10-20**] Discharge Date: [**2169-10-30**] Service: MEDICINE Allergies: Codeine / Vasotec / Cortisporin / Ciloxan / Atenolol / Lisinopril / Diovan / Percocet / Ciprofloxacin Attending:[**First Name3 (LF) 2880**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Temporary dialysis line placement Tunneled dialysis line placement History of Present Illness: 88F with hx sCHF (EF 40%), CAD, dyslipidemia, HTN, DM, HL who presents with sudden onset shortness of breath today. She was at an appointment for an EMG of her hand; when she was laid flat she experienced sudden onset shortness of breath that has continued. also c/o mild b/l leg edema. Denies chest pain, fevers, nausea, vomiting, diarrhea, abdominal pain. She is not on home O2. She endorses increased fatigue for the last 2 days, as well as dry cough at night and occasional wheezing. She notes mild leg swelling. She is on torsemide 100mg PO daily and metolazone twice a week. Dry weight from last CHF exacerbation in [**Month (only) 958**] is 164lb. In the ED EKG: SR 68, QRS 104, NA, Q III (old), STD 1, avl, V5/6 Labs - crit drop from prior 28 (pt says she has been having bleeding from hemorrhoids); Cr bumped from prior 2.8 guiaic - neg BNP [**Numeric Identifier 389**] (chronically elevated) UA- dirty CXR - diminished lung volumes, diffuse edema, cardiac silhouette enlarged but stable Patient given lasix 80mg IV and [**Numeric Identifier 9847**], developed [**Last Name (LF) **], [**First Name3 (LF) **] given Benadryl On arrival to the floor, patient still has some SOB, no CP, UOP 500ml. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, DOE, palpitations, syncope or presyncope. Past Medical History: - Dyslipidemia - Hypertension, difficult to control on multiple agents - Diabetes Mellitus since [**95**] years, on insulin - Frequent exacerbations of CHF in the past (most recent [**4-21**]) - CAD with multiple cardiac interventions in the past, including balloon angioplasty of the RCA in [**2157**], stenting of the ostial RCA with two overlapping BMS in [**3-/2167**], stenting of the proximal LAD with BMS in 05/[**2168**]. - Peripheral arterial disease a.) Left common iliac and external iliac artery stenting in 4/[**2164**]. b.) left superior femoral artery angioplasty complicated by dissection, requiring stent placement in 5/[**2166**]. - Renal Insufficiency - Appendicitis treated sx - Bladder suspension by sx - GERD - Hyperparathyroidism ([**2162**]) - Colonic Polyps in [**2157**] - Catarct sx in both eyes - BL Hearing impaired, uses hearing aids Social History: The patient currently lives [**Location 107650**] [**Location (un) **] with her [**Age over 90 **] year old husband whom she has been married to for 63 years. She has 1 son. At baseline she walks with a walker, she is otherwise independent in all ADLs. Tobacco: None EtOH: None Illicits: None Family History: -Father: heart problems, DM -Mother: heart problems -4 brothers: CAD, one with stroke Physical Exam: ADMISSION EXAM: VS: T=96.6 BP=152/63 HR=73 RR=20 O2 sat= 92%2LNC weight 79.1kg GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of [**9-20**] cm. CARDIAC: RR, normal S1, S2. +S3 No m/r. No thrills, lifts. No S4. LUNGS: bilateral wheezes in upper lung fields. Crackles 1/2 up lung. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 1+ edema b/l to ankles. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 1+ PT 1+ Left: Carotid 2+ DP 1+ PT 1+ DISCHARGE EXAM: VS: 98.9; 130-148/49-83; 58-76; 16; 93%RA I/O: 670/525 Weight: 75.1kg GENERAL: NAD. AAOx3 HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with no JVP elevation CARDIAC: RR, normal S1, S2. +S3 No m/r. No thrills, lifts. No S4. LUNGS: Minimal crackles at lung bases, R>L. No wheezes, no rhonchi. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: trace edema b/l to ankles. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 1+ PT 1+ Left: Carotid 2+ DP 1+ PT 1+ Pertinent Results: [**2169-10-20**] 03:10PM BLOOD WBC-6.0 RBC-2.26* Hgb-7.8* Hct-22.4* MCV-99*# MCH-34.3* MCHC-34.5 RDW-14.9 Plt Ct-148* [**2169-10-20**] 03:10PM BLOOD Neuts-85.5* Lymphs-7.8* Monos-5.8 Eos-0.9 Baso-0.1 [**2169-10-20**] 03:10PM BLOOD PT-12.3 PTT-26.7 INR(PT)-1.0 [**2169-10-20**] 03:10PM BLOOD Plt Ct-148* [**2169-10-21**] 08:56AM BLOOD Ret Aut-2.0 [**2169-10-20**] 03:10PM BLOOD Glucose-306* UreaN-137* Creat-3.2* Na-137 K-4.1 Cl-96 HCO3-26 AnGap-19 [**2169-10-21**] 08:56AM BLOOD LD(LDH)-326* CK(CPK)-80 TotBili-0.6 DirBili-0.4* IndBili-0.2 [**2169-10-20**] 03:10PM BLOOD proBNP-[**Numeric Identifier 42619**]* [**2169-10-20**] 03:10PM BLOOD cTropnT-0.47* [**2169-10-21**] 08:56AM BLOOD CK-MB-6 [**2169-10-21**] 05:17AM BLOOD Albumin-3.6 Calcium-9.0 Phos-5.4*# Mg-3.1* [**2169-10-21**] 08:56AM BLOOD Hapto-137 [**2169-10-23**] 05:50AM BLOOD calTIBC-246* Ferritn-849* TRF-189* [**2169-10-20**] 03:25PM BLOOD Lactate-1.1 [**2169-10-21**] 08:21AM BLOOD Type-ART pO2-261* pCO2-45 pH-7.43 calTCO2-31* Base XS-5 [**2169-10-23**] 10:05AM BLOOD Type-ART pO2-124* pCO2-42 pH-7.46* calTCO2-31* Base XS-6 Urine Culture URINE CULTURE (Final [**2169-10-23**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I 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---- <=1 S CXR [**2169-10-20**]: FINDINGS: Lung volumes are diminished. There is diffuse interstitial and alveolar edema and engorgement of the [**Year (4 digits) 1106**] pedicle. Calcified plaque is seen at the aortic arch. The cardiac silhouette is enlarged but stable accounting for patient and technical factors. No definite large effusion is noted. Limited evaluation of the left costophrenic angle due to the enlarged cardiac silhouette. There is no pneumothorax. IMPRESSION: Heart failure. Recommend repeat radiography after appropriate diuresis to assess for underlying infection CT head [**2169-10-21**]: IMPRESSION: No acute intracranial process. CXR [**2169-10-22**]: FINDINGS: As compared to the previous radiograph, there is no relevant change. The distribution of the pre-existing parenchymal opacities, likely caused by pulmonary edema, is changed but its overall severity has not decreased. Unchanged appearance of the cardiac silhouette. Unchanged mild retrocardiac atelectasis. ECHO [**2169-10-23**]: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the distal half of the septum and anterior wall, distal inferior wall and apex. The apex is not aneurysmal. 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) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate ([**2-12**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction c/w CAD (mid-LAD distribution). Mild-moderate mitral regurgitation. Pulmonary artery hypertension. Compared with the prior study (images reviewed) of [**2168-9-16**], regional dysfunction is similar, though global LVEF is now more depressed. Aortic stenosis is no longer suggested. DISCHARGE LABS: [**2169-10-30**] 07:00AM BLOOD WBC-7.6 RBC-3.26* Hgb-10.6* Hct-31.0* MCV-95 MCH-32.4* MCHC-34.1 RDW-15.9* Plt Ct-289 [**2169-10-30**] 07:00AM BLOOD Glucose-138* UreaN-74* Creat-2.3* Na-137 K-3.9 Cl-97 HCO3-28 AnGap-16 [**2169-10-30**] 07:00AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.3 Brief Hospital Course: 88F with hx sCHF (EF 40%), CAD, HTN, DM, HL, CKD presents with sudden onset shortness of breath on the day of admission while laying flat for a study, found to have acute on chronic heart failure. # Acute on chronic systolic heart failure: Patient presents with symptoms consistent with heart failure exacerbation. CXR shows pulm edema. Likely [**3-15**] to progressive renal failure and increasing resistance to diuresis. Has low salt diet at her [**Hospital3 **]. Cognizent of fluid intake restrictions. Recent increase of metolazone 2.5mg weekly to biweekly as outpatient. On the first night on the floor, she was -700cc from 80mg IV Lasix + 100mg IV torsemide + 2.5mg metolazone. On the morning of [**10-21**], patient O2 saturation decreased to 85% on 2LNC. Improved with additional torsemide, neb treatment, NRB, eventually sats in mid 90s on facemask. In the setting of progressive end-stage renal failure, resistance to diuresis, and altered mental status (see below), patient was transferred to CCU for urgent dialysis. She underwent dialysis daily from [**10-21**] to [**10-24**] with improvement in fluid status (-1.5L each session), satting mid 90s on 3LNC. Attempted to diurese with torsemide on [**10-25**] and [**10-26**] while off dialysis with limited urine output (only 100-200cc to 100mg IV torsemide). Patient received additional dialysis on [**10-27**] and [**10-30**], with plans for permanent dialysis (see below). All diuretics were stopped due to ineffectiveness. Patient discharge weight was 75.1kg and appears clinically euvolemic. # Hypoxia: On [**10-21**], patient developed increasing O2 requirement responsive to increased FiO2. Desat into 85% on 2LNC, improving to 95% on facemask. ABG showed normal pCO2. Most likely from V/Q mismatch from pulmonary edema. Other considerations include PE given immobilized state for many days. However, patient was not tachycardic with no significant LE edema or pain. Aspiration pneumonia also possible, but patient afebrile, no leukocytosis. TRALI was another consideration, but patient not tachycardic, no acute increase in O2 requirement within hours of pRBC transfusion. Hypoxia improved with dialysis and improvement in fluid status. O2 sats in mid 90s on room air on discharge. # Altered mental status- Per patient's family, she has had progressively worsening intermittent solmnolence for past [**2-12**] weeks, being difficult to arouse from sleep for hours during the day on several occasions. On [**10-21**] around noon time, patient developed worsening solmnolence. CT head negative (has h/o recent falls). Uremia was likely cause of altered mental status given progressive CKD, and history of intermittent solmnolence. Anemia and heart failure could be contributing to solmnolence. Infectious process may also be contributing- has UTI. Gabapentin toxicity in the setting of worsening CKD also a [**Last Name (LF) **], [**First Name3 (LF) **] Gabapentin was DCed. Decision was made to transfer patient to the CCU for dialysis. Mental status improved after multiple days of dialysis and 3 units of pRBC (see below). Patient AAOx3 on discharge. # Anemia: Baseline in high 20s in [**2169-9-11**]. Hct 22.8 on admission. Guaiac negative in the ED. Has history of recent hemorrhoid bleed. When blood bank attempted to type/screen blood, found to have new autoantibodies concerning for warm agglutinins. However, hemolysis labs were negative. Blood sent to Red Cross in an attempt to find good match. Patient transfused total 3units pRBC and Hct stable at 28-20. EPO given at dialysis on [**10-27**] and [**10-30**]. # CORONARIES: Stable CAD. No chest pain. Chronically elevated troponins in the setting of CKD. # CKD: elevated Cr. to 3.2 (baseline high 2.7-2.9). Urgent dialysis started on [**10-21**] (see per above) for uremia and fluid overload. Last dialysis session PM of [**10-30**]. # UTI: UA dirty in the ED. Asx. H/o multiple UTI, E. coli resistent to [**Date Range **]. Started ceftriaxone treatment on [**10-20**]. Culture and sensitivity showed E. coli only resistant to Ampicillin. Patient treated with 5-day course of ceftriaxone. # HL: Simvastatin decreased to 20mg daily [**3-15**] interactions with amlodipine. LDL 54 in 03/[**2169**]. # Transitional issues: Patient had Quantiferon-TB Gold result pending at time of discharge. Result needed once patient moving to community dialysis center. Medications on Admission: allopurinol 200 mg daily amlodipine 10 mg daily budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/Actuation HFA Aerosol Inhaler 2 puffs po twice a day Calcitriol 0.25 mcg Capsule Monday, Wednesday and Friday Carvedilol 12.5 mg twice a day Clopidogrel [Plavix] 75 mg daily fluticasone 50 mcg Spray gabapentin 300 mg at bedtime; 100mg twice during the day Hydralazine 75 mg TID Isosorbide dinitrate 20 mg TID lidocaine [Lidoderm] 5 % (700 mg/patch) Adhesive Patch Metolazone 2.5 mg twice once a week Nitroglycerin [Nitrolingual] 0.4 mg/dose Spray, Non-Aerosol As directed Every 5 minutes X 3 as needed for Chest painnr polyethylene glycol 3350 17 gram/dose Powder Prednisone 5 mg 1 Tablet(s) by mouth once a day Take 3 tabs x 5days 2 x 5, 1 x 5days then discontinue. [**2169-7-13**] simvastatin 40 mg daily torsemide 100 mg daily tramadol 50 mg [**Hospital1 **] ASA 81mg daily cholecalciferol (vitamin D3) 2,000 unit Tablet Docusate sodium [Colace] 100 mg Capsule twice a day ferrous sulfate 134 mg (27 mg) Tablet daily miconazole nitrate [Athlete's Foot] 2 % Powder to buttocks and groin three times a day (started in rehab) NPH insulin human recomb [Humulin N Pen] 100 unit/mL (3 mL) Insulin Pen 16 units daily nr sennosides [Senna Herbal Laxative] 12 mg 1 Capsule Discharge Medications: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 4. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. hydralazine 100 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 7. isosorbide dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 9. nitroglycerin 0.4 mg/dose Spray, Non-Aerosol Sig: One (1) spray Translingual as directed as needed for chest pain: may repeat every 5 minutes up to 3 times. 10. Miralax 17 gram/dose Powder Sig: One (1) PO once a day as needed for constipation. 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 13. Vitamin D-3 2,000 unit Tablet Sig: One (1) Tablet PO once a day. 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 15. ferrous sulfate 134 mg (27 mg iron) Tablet Sig: One (1) Tablet PO once a day. 16. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for constipation. 17. miconazole Powder Sig: One (1) Miscellaneous three times a day: to affected buttock or groin area. 18. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig: Sixteen (16) unit Subcutaneous once a day. 19. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet(s)* Refills:*2* 20. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 21. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 22. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: PRIMARY: Acute on chronic CHF CKD on dialysis Uremia Anemia 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: Ms. [**Known lastname **], It was a pleasure taking care of you during your hospitalization. You were admitted to us because you had shortness of breath and heart failure exacerbation. Your kidneys were failing and you became very drowsy because of toxin buildup in your system that your kidneys were not able to filter. You started hemodialysis, which helped take off fluids from your lungs and toxins from your blood. You will continue having dialysis at the dialysis center after you leave the hospital. We made the following changes to your medications: STARTED Sevelamer STARTED Nephrocaps INCREASED Hydralazine to 100mg three times a day INCREASED Carvedilol to 25mg twice a day DECREASED Allopurinol DECREASED Simvastatin STOPPED Torsemide STOPPED Metolazone STOPPED Gabapentin STOPPED Tramadol Followup Instructions: Department: RHEUMATOLOGY When: THURSDAY [**2169-11-2**] at 11:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: MONDAY [**2169-11-13**] at 1 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: WEST [**Hospital 2002**] CLINIC When: THURSDAY [**2169-11-16**] at 2:30 PM With: DR. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**] Completed by:[**2169-10-30**]

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Discharge summary

report

Admission Date: [**2106-12-27**] Discharge Date: [**2107-1-3**] Date of Birth: [**2058-7-14**] Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 8747**] Chief Complaint: Right eye blindness Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 48 year old woman with very complex PMH including [**Last Name (un) 24206**] [**Last Name (un) 24206**] disease, multiple strokes, IDDM, CAD with multiple stents, ECA/ICA bypass and right sided CEA, seizures, and HTN who presents with partial right eye visual loss. Her vision was normal until ~11 am this morning when she had the acute disruption of her vision. She is a poor historian, and it is unclear if the loss occured as a shade coming down over her eye or not. She did not totally lose her vision, but it became acutely poor/blurred. She also developed eye pain at some point afterwards(not initially) that has remained stable in the ED. She was not doing any activity when this occured. She had a similar event ~1 year ago and was seen at [**Hospital1 112**]. No intervention was performed and she said the vision normalized over a period of several months. This was assumed to be a retinal artery blockage at that time. She has an extensive history of vascular disease, with [**Last Name (un) 24206**] [**Last Name (un) 24206**] disease. She had a 4 vessel CABG in [**2104**], a right carotid endarterectomy in [**2101**], a carotid bypass procedure in [**2102**]. Prior to all of this, she had 2 strokes. The first in [**2093**] caused left hemiparesis and dysathria. The second in [**2094**] resulted in right hemiparesis. An MRI from [**2104**] shows an old right frontal infarct, chronic small vessel disease. An MRA from that time shows the EC-IC bypass and a very small right vertebral artery. She also has a seizure disorder which started in [**2104**] and sounds like focal left sided seizures from review of prior descriptions. She has not had a seizure for "many years". Today, she denies any headache, dysphagia, fever, nausea, vomiting, neck pain, dizziness,hearing changes, chest pain, shortness of breath. No dysarthria, vertigo. She does have eye pain as above. Past Medical History: [**Last Name (un) 24206**]-[**Last Name (un) **] as above s/p EC-IC bypass [**2102**] as above s/p right CEA in [**2101**] multiple strokes in [**2093**], [**2094**] as above insulin dependent DM HTN CAD as above, s/p MI and 4V CABG. Also had MI during stress with acute cath and stenting seizure disorder as above OSA Social History: Smokes tobacco. EtOH/drugs. Married. Has financial issues with obtaining medication. She is on disability. Family History: Members with CAD and DM Physical Exam: Discharge Exam Vitals: 98.4, 142/60, 90, 18, 96% on RA Gen: NAD Neck: Large. Supple. No pain. No bruits appreciated. CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd:Obese. NT/ND Ext: Swollen feet. No cyanosis. Warm throughout. Skin: No rashes noted Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect Orientation: oriented to person, place, and date, Attentive throughout, Language fluent with good comprehension and repetition; naming intact. No dysarthria or paraphasic errors. No apraxia, no neglect. [**Location (un) **] intact(limited by vision, but possible with good eye) Cranial Nerves: I: not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. The previously observed RAPD in OD is now resolved. Visual fields are full to confrontation in the left eye. OD: There is a visual field deficit in affecting mostly the nasal and central field with relative preservation of the periphery although there is patchy involvement of the superior peripheral field as well. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and movement symmetric. She has decreased LT over right V1-V3 and [**Month (only) **] PP over her entire face bilat. There is no ptosis. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations, intact movements Motor: Normal bulk and tone bilaterally No tremor D T B WE FiF [**Last Name (un) **] IP Q H AF AE TE Right 5 5 5 5 5 4 5 5 5 5 5 5 Sensation: Decreaed to LT over both feet and anterior calf on L. Decreased to PP to ~thighs bilaterally and to mid arm bilaterally(stocking/glove pattern), [**Month (only) **] prop in toes and nL prop in hands. [**Month (only) **] vib to knees. nL vibration in hands. Reflexes: B T Br Pa Pl Right 2 2 tr tr 0 Left 3 2 tr tr 0 Toes were mute bilaterally Coordination: Normal on finger-nose-finger bilaterally. Gait: Slightly wide-based however without ataxia. Pertinent Results: [**2106-12-30**] 05:05AM BLOOD WBC-9.4 RBC-4.45 Hgb-12.0 Hct-36.1 MCV-81* MCH-27.1 MCHC-33.4 RDW-15.6* Plt Ct-254 [**2106-12-30**] 05:05AM BLOOD Plt Ct-254 [**2106-12-29**] 06:15AM BLOOD PT-13.0 PTT-23.1 INR(PT)-1.1 [**2107-1-3**] 05:25AM BLOOD Glucose-106* UreaN-7 Creat-0.6 Na-145 K-4.0 Cl-108 HCO3-26 AnGap-15 [**2107-1-2**] 06:55AM BLOOD Glucose-62* UreaN-6 Creat-0.6 Na-144 K-4.2 Cl-109* HCO3-25 AnGap-14 [**2106-12-28**] 01:48PM BLOOD CK(CPK)-85 [**2106-12-28**] 02:25AM BLOOD CK(CPK)-116 [**2106-12-27**] 02:40PM BLOOD CK(CPK)-120 [**2106-12-28**] 01:48PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2106-12-28**] 02:25AM BLOOD CK-MB-4 cTropnT-<0.01 [**2106-12-27**] 02:40PM BLOOD cTropnT-0.0 [**2107-1-3**] 05:25AM BLOOD Calcium-8.6 Phos-4.1 Mg-1.7 [**2106-12-28**] 03:12PM BLOOD %HbA1c-7.2* [Hgb]-DONE [A1c]-DONE [**2106-12-28**] 01:48PM BLOOD Triglyc-492* HDL-34 CHOL/HD-4.1 LDLmeas-55 [**2106-12-30**] 05:05AM BLOOD TSH-1.9 [**2106-12-30**] 05:05AM BLOOD T4-6.7 T3-127 [**12-27**] Head CT: Large, chronic right frontal infarct, unchanged from prior MR study. MRI is a more sensitive test for acute brain ischemia. Carotid U/S: Occluded right internal carotid artery. Mild plaques are noted in the right common and left internal iliac arteries. The estimated stenosis is 40% for the left ICA. MRI/MRA of Brain: 1. MRI demonstrates stable changes in the brain without evidence of recent infarction. 2. MRA of the circle of [**Location (un) 431**] suggests that there is occlusion of the right internal carotid artery. The most superior intracranial portion of this vessel may have some preserved flow, but this is difficult to assess and appears decreased since the previous study. There is a right extracranial to intracranial vascular anastomosis to the middle cerebral arterial branches, and flow is observed within this vessel. Otherwise, there are no changes in the appearance of the MR angiogram. CT-A of Chest: No evidence for pulmonary embolus or infiltrate. TTE - 1. The left atrium is moderately dilated. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is difficult to assess but is probably normal (LVEF>55%). 3. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is moderate thickening of the mitral valve chordae. There is mild to moderate mitral stenosis. Mild (1+) mitral regurgitation is seen. 5. Compared with the prior report of [**2104-8-28**], mitral stenosis has progressed, and LV function may have improved. EKG [**2106-12-30**] Limb lead reversal. Sinus tachycardia. Non-specific ST-T wave changes. Compared to the previous tracing of [**2106-12-27**] the rate has increased. Brief Hospital Course: Ms. [**Known lastname **] was admitted to the Neurology/Stroke ICU for BP monitoring. Clinically, her sudden-onset partial right monocular field deficit was consistent with occlusion of a branch of the right retinal artery. Ophthalmology was consulted and recommended no acute intervention. The initial goal was to keep her blood pressure relatively high in order to optimize her cerebral perfusion. She was tranferred to the Neuro-ICU where she was kept on a Pheylephrine drip. Within two days, the patient remained hemodynamically and neurologically stable and she was transferred to the floor for the remainder of her stroke work-up. Her lipids were tested and she was found to have very high triglycerides and normal LDL; she was continued on Crestor and Niacin (she apprently has failed treatment with high dose lipitor secondary to intolerable side effects). Her HbA1C was 7.2 indicating poor glycemic control. She was placed on nightly Lantus, and sliding scale. The [**Hospital **] Clinic was consulted. Her FSGs have remained under excellent control thoughout most of her hospitalization. She underwent Carotid U/S which confirmed absence of flow in the RIght ICA. She had a MRA which also showed this as well as her ECA-ICA bypass. An Echocardiogram showed a normal EF and mitral valve disease (calcification). She was found to be orthostatic in the setting of intermittent tachycardia and some loose stools. Her bowel regimen was discontinued. We learned that she has had runs of unexplained tachycardia in the past and had been placed on a beta blocker. As her neurological exam had stabilized, the feeling was that it would be safe to re-start a beta blocker and she was placed on metoprolo 12.5 [**Hospital1 **]. Cardiology was consulted for the tachycardia and they related that the patient is at risk for developing paroxysmal atrial fibrillation which would certianly place at her at even greater risk of future strokes. A discussion about starting warfarin was initiated between the Stroke attending Dr. [**Last Name (STitle) **] and the patient and her sister. They do not want to start warfarin as of now. The patient was placed on Plavix and full-dose aspirin. This will be continued as an outpatient. She received about 3 days of IV NS and her orthostasis resolved. She is eating a normal diet and tolerating it well. She was evaluated by Podiatry for her right [**Last Name (un) 5355**] lesion. They will follow her as an outpatient. The likely cause of monocular visual field deficit in this patinet is occlusion of a branch of the right opthalamic/retinal artery probably secondary to her severe carotid artery disease. Discharge condition: Stable. Medications on Admission: Lantus 100 units q.a.m. and q.p.m. with a Humalog sliding scale, Roxicet 5/325 tablets, [**2-7**] q.4-6 hours p.r.n. for pain, Crestor 20 mg q.d., Metoprolol 50 mg b.i.d., Diovan 160 mg daily, aspirin 325 mg daily, Zantac 300 mg b.i.d., Niaspan 1000 mg extended release tablets, Metformin 850 mg b.i.d. and 100 mg at bed time, Elavil 25 mg q.d., Plavix 75 mg q.d., Atarax 25 mg t.i.d., Tylenol #3 one q.6 hours p.r.n. Discharge Medications: 1. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO qd:prn as needed. Disp:*30 Capsule(s)* Refills:*1* 6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 days. Disp:*2 Tablet(s)* Refills:*0* 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Niacin 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO qhs (). Disp:*60 Capsule, Sustained Release(s)* Refills:*2* 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 11. Lantus 100 unit/mL Solution Sig: 0.9 mL Subcutaneous at bedtime: 0.9 cc= 90 Units. Disp:*30 units* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Right monocular visual field partial deficit possibly secondary to retinal artery infarct Discharge Condition: Stable Discharge Instructions: Please DO NOT DRIVE Take all your medicines Keep you follow-up appointments Drink plenty of fluids Check your blood sugar at least 2-4 times a day. If you develop new weakness, difficulty seeing, chest pain, SOB, or numbness, please see a physician [**Name Initial (PRE) 2227**] Followup Instructions: Neurology Stroke Service [**Telephone/Fax (1) 3767**] [**1-18**] 6:30PM, [**Hospital Ward Name 23**] [**Location (un) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Podiatry Date/Time:[**2107-1-18**] 1:30 Cardiology [**Telephone/Fax (1) 2037**], Wed [**2107-3-2**] 11am, [**Hospital Ward Name 23**] [**Location (un) 436**], Dr. [**First Name (STitle) 437**] Ophthalmology [**Telephone/Fax (1) 253**] [**1-13**] 9:30am [**Hospital Ward Name 23**] [**Location (un) 442**] Eye Clinic, Dr. [**Last Name (STitle) **] Please make an appointment with your Diabetes physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 34488**] at [**Location (un) 41361**]Medical Center PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 33330**]

[ "437.5", "401.9", "362.30", "250.50", "V45.81", "433.10", "362.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12270, 12276

7890, 10540

302, 309

12410, 12419

4927, 5913

12747, 13590

2727, 2752

11040, 12247

12297, 12389

10596, 11017

12443, 12724

2767, 3060

243, 264

337, 2243

3448, 4908

5922, 7867

3099, 3432

3084, 3084

2265, 2586

2602, 2711

25,225

169,468

3958

Discharge summary

report

Admission Date: [**2178-7-31**] Discharge Date: [**2178-8-11**] Date of Birth: [**2147-8-13**] Sex: F Service: SURGERY Allergies: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Morphine / Cyclosporine Attending:[**First Name3 (LF) 1384**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 30 y/o female with complaint of abdominal pain the last few days at [**Hospital1 **]. During her routine dialysis session her SBP was in the 70's and she is now lethargic. Narcotic regimen significant but unchanged recently. HD was terminated after 30 minutes, received albumin and NS bolus, with current SBP in the 80's. Patient alert and oriented on admission Past Medical History: - SLE diagnosed [**2166**] complicated by lupus nephritis, anemia, serositis and ascites - End stage renal disease secondary to lupus, HD T/Th/Sat - History of VSD s/p corrective surgery, age 13 - Hypertension - ITP - h/o MSSA endocarditis - Sickle cell trait - S/p left oophorectomy related to IUD associated infection - Restrictive lung disease noted on PFTs [**2166**]. In [**2173**], chest CT with diffuse ground glass opacities. - GERD - S/p cadaveric renal transplant on [**8-/2175**] complicated by rejection and capsule rupture 11/[**2174**]. - Right pelvic abscess s/p TAH/RSO - B/L renal solid masses s/p resection pathology was negative for carcinoma - R tib/fib fx with ORIF [**2177-6-24**]. Complicated by wound./Hardware infection requiring BKA [**2177-11-21**] -[**2178-4-2**] RUE AVG excision Social History: No smoking, occasional alcohol, no drug use. Originally from [**Country **], currently at [**Hospital1 **]. Used to work at [**Hospital1 18**]. Family History: Noncontributory Physical Exam: VS: 99.1, 111, 115/50, 17, 97% 3L Gen: appears very uncomfortable HEENT: NCAT, no JVD Resp: CTA Card: RRR normal S1S2 GI diffusely tender to palpation, no rebound or guarding Extr: 1+ LE edema, s/p R BKA last year Skin: warm and dry, no rash Neuro: A+Ox3, sleepy but arousable Pertinent Results: On Admission: [**2178-7-31**] WBC-5.0 RBC-3.08* Hgb-8.4* Hct-27.8* MCV-90 MCH-27.3 MCHC-30.3* RDW-20.9* Plt Ct-102* PT-23.9* PTT-35.9* INR(PT)-2.3* Glucose-75 UreaN-28* Creat-5.9*# Na-139 K-5.1 Cl-100 HCO3-25 AnGap-19 ALT-1 AST-24 CK(CPK)-29 AlkPhos-154* TotBili-0.3 Lipase-20 Albumin-3.9 Calcium-9.2 Phos-3.4 Mg-2.1 Brief Hospital Course: 30 y/o female with extensive PMH including failed kidney transplant and native kidney nephrectomy now with abdominal pain, nausea, vomiting. Concern for SBO was very high. She was treated with NGT, NPO status. Vanco, Flagyl and Aztreonam were started. Serial abdominal exams revealed decreased bowel sounds with tenderness. CT exam done on admission showed: 1. High-grade small bowel obstruction, with a definite transition point within the right lower abdomen, as well as a second possible transition point within the lower pelvis. No free intraperitoneal air identified. 2. Bibasilar airspace consolidations. [**Hospital 17552**] medical management was continued, patient monitored in the ICU where she received her routine hemodialysis. She was transferred to [**Hospital Ward Name 121**] 10 on [**8-3**], with NGT still in place, however she had started to stool after receiving soap [**Last Name (un) **] enemas and lactulose [**Hospital1 **]. NG output was decreased. Diet was slowly resumed and tolerated starting on [**8-7**]. Abdomen was soft, non-distended and without pain. She received HD via the tunnelled line on a Monday-Wednesday-Friday schedule. Last HD was [**8-10**]. 1 kg was removed. She received epogen while in HD. PT worked with her and recommended return to acute rehab. Please see PT notes. She will return to [**Hospital **] Rehab. Aggressive bowel regemin should continue consisting of colace, senna, and prn lactulose/SSE. Medications on Admission: PREDNISONE 5' amitriptyline 100hs, phoslo 1334"', kefzol, colace, fentanyl 125q72, neurontin 300"', lactulose, keppra 500", lodocaine patch, ativan 1", protonix 40', senna, albumin, dilaudid, zofran Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution [**Hospital **]: follow sliding scale Injection four times a day. 2. Fentanyl 100 mcg/hr Patch 72 hr [**Hospital **]: One (1) patch Transdermal Q72H (every 72 hours). 3. Fentanyl 25 mcg/hr Patch 72 hr [**Hospital **]: One (1) patch Transdermal every seventy-two (72) hours. 4. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital **]: One (1) ml Injection [**Hospital1 **] (2 times a day). 5. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Levetiracetam 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 8. Prednisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 9. Hydromorphone 2 mg Tablet [**Hospital1 **]: 2-3 Tablets PO Q4H (every 4 hours) as needed for pain. 10. Colace 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day. 11. Amitriptyline 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime. 12. Calcium Acetate 667 mg Tablet [**Hospital1 **]: Two (2) Tablet PO three times a day: with meals. Tablet(s) 13. Neurontin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO at bedtime. 14. Lactulose 10 gram/15 mL Solution [**Hospital1 **]: Thirty (30) ml PO prn: [**Hospital1 **] if no bm x1 day. 15. Ativan 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 16. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 17. SSE prn: if no BM x2 days Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: SBO ESRD Lupus mitral valve vegetation Discharge Condition: fair Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Please call Dr. [**Last Name (STitle) 816**] [**Telephone/Fax (1) 673**] if abdominal pain, nausea, vomiting or malfunction of dialysis access Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2178-8-12**] 2:00 (infectious disease) Provider: [**Name10 (NameIs) 306**] [**Name Initial (MD) 307**] [**Name8 (MD) 308**], M.D. Date/Time:[**2178-8-28**] 11:20 Completed by:[**2178-8-11**]

[ "285.9", "530.81", "V45.1", "V42.0", "038.9", "V43.65", "582.81", "403.91", "710.0", "518.89", "560.9", "287.31", "585.6", "V45.89" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "39.95", "96.07" ]

icd9pcs

[ [ [] ] ]

5740, 5819

2437, 3893

357, 363

5902, 5909

2096, 2096

6219, 6514

1766, 1783

4143, 5717

5840, 5881

3919, 4120

5933, 6196

1798, 2077

303, 319

391, 754

2110, 2414

776, 1588

1604, 1750

12,856

164,115

48058

Discharge summary

report

Admission Date: [**2122-2-27**] Discharge Date: [**2122-3-10**] Date of Birth: [**2076-1-19**] Sex: F Service: CCU CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: A 46-year-old female postpartum dilated cardiomyopathy who presented with shortness of breath and chest pain in the context of not taking Bumex for several days. The patient apparently had branch of brandname of Bumex, and was unwilling to take generic Bumex. Therefore, did not take the medication for at least five days. She complains of some malaise, fatigue. On further questioning, it appears that she has not been taking her ACE inhibitor because she is also worried that generic ACE inhibitor is bad for her heart. At baseline, she has Class II Heart congestive heart failure, able to do activities of daily living and climb one flight of stairs. Over the last few days, however, she noticed a worsening dyspnea on exertion, inability to walk more than 10 feet, and this morning, she had chest pain, diaphoresis, and shortness of breath. She has no lower extremity edema. In the Emergency Department, she had a systolic blood pressure of 90 and was attempted diuresis, which actually worsened the blood pressure to 70. She was started on dobutamine drip, pulse IV fluids, and transferred to CCU. PAST MEDICAL HISTORY: 1. Postpartum dilated cardiomyopathy, ejection fraction of 15% with pulmonary capillary wedge pressure of 40. Catheterization in [**2115**] reveals normal coronary arteries. 2. Diabetes mellitus. 3. Chronic renal failure with creatinine at baseline of about 2. 4. Hepatitis B. 5. Hepatitis C. 6. Increased cholesterol. 7. Chest pain cholecystectomy. 8. Gout. 9. Asthma. ALLERGIES: The patient claims to be allergic to all sorts of generic medications. MEDICATIONS: 1. Enalapril 10 q day. 2. Digoxin 0.125 q day. 3. Avandia 4 q day. 4. Bumex 4 tid. 5. Albuterol inhaler. 6. Flovent inhaler. SOCIAL HISTORY: She lives in a two-level home. Former cocaine user. Has not used any cocaine for the last 10 years. No tobacco, alcohol. PHYSICAL EXAMINATION: Blood pressure 90/40, pulse 100, respiratory rate 30, and sating 96 on nasal cannula. General: Anxious female in no acute distress. HEENT: Anicteric. Equal and reactive pupils. Neck is supple, jugular venous distention about 10 cm. Lungs are clear to auscultation bilaterally. Abdomen is soft, obese, nondistended, and nontender. Cardiovascular: Distant heart sounds, no murmurs. Extremities: No pitting edema. Neurologic examination is generally unremarkable. LABORATORIES ON ADMISSION: White count is 3.9, hematocrit is 32.3, platelets 166. Chem-7 is significant for a creatinine of 2.2. Initial subsequent CKs were normal. BRIEF HOSPITAL COURSE: 1. Cardiovascular: Presentation is most consistent with recent noncompliance with medication, volume overload, and now worsening of the congestive heart failure. A Swan-Ganz catheter was placed which revealed markedly elevated pulmonary artery and wedge pressures consistent with volume overload. She was started on aggressive diuresis with IV Bumex with significant results. A question of a pulmonary embolus was raised given continuing sinus tachycardia. Unfortunately, we were not able to obtain examination given patient's chronic renal failure in addition to her apparent reaction to shellfish. We plan to obtain a MRA of the pulmonary artery to confirm pulmonary embolus, but after significant delay following malfunctioning of the magnet, the patient was unable to fit into the machine secondary to body habitus. At that point, she has already been experiencing significant improvement and had no further episodes of shortness of breath or chest pain. It should be noted that after the first several days, and after she had diuresed a significant amount of fluid, her chest pain and shortness of breath in particular resolved. She was able to breathe comfortably on room air with no significant distress. In the context of her acute management, all of her outpatient medications such as ACE inhibitor and beta blocker are being withheld, she is continued on her digoxin. After about seven days of close monitoring, the patient achieved an euvolemic state and was slowly started on her ACE inhibitor and beta blocker, which are currently at a much lower dose in the past. 2. Pulmonary. Patient continued on her inhalers for a history of asthma. It is highly unlikely that she had a pulmonary embolus as her condition clinically improved with improvement of her volume overload. 3. Renal. Baseline creatinine is 2.0-2.3 range. With improvement of her forward flow and improved kidney perfusion, the creatinine improved to about 1.6-1.7, which is low at time of discharge. This can be expected to come up a little bit with reinstitution of ACE inhibitor. DISCHARGE STATUS: Home. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Lipitor 10 q day. 2. Digoxin 0.125 q day. 3. Flovent 110 mcg two puffs [**Hospital1 **]. 4. Lisinopril 2.5 q day. 5. Bumex 2 mg po bid. 6. Avandia 4 mg po q day. 7. Lopressor 12.5 po bid. [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**] Dictated By:[**Name8 (MD) 5094**] MEDQUIST36 D: [**2122-3-9**] 18:43 T: [**2122-3-11**] 10:50 JOB#: [**Job Number 26510**]

[ "428.0", "425.4", "272.0", "493.90", "412", "274.9", "250.00", "585" ]

icd9cm

[ [ [] ] ]

[ "89.64", "00.13" ]

icd9pcs

[ [ [] ] ]

2759, 4862

4884, 4893

4916, 5369

2095, 2580

150, 172

201, 1314

2595, 2736

1336, 1930

1947, 2072

5,561

191,387

49351

Discharge summary

report

Admission Date: [**2143-11-28**] Discharge Date: [**2143-11-28**] Date of Birth: [**2097-5-26**] Sex: M Service: ADMISSION DIAGNOSIS: End-stage liver disease. TIME OF DEATH: 12:11 p.m. on [**2143-11-28**] HISTORY OF THE PRESENT ILLNESS: The patient is a 46-year-old male with end-stage liver disease secondary to alcoholic and hepatitis C cirrhosis. The patient presented in the morning of [**2143-11-28**] for a liver transplant. The patient had a long history of cirrhosis with multiple variceal bleeding including esophageal banding. The patient had a TIPS procedure done in [**2141-10-30**]. The patient was admitted to [**Hospital6 256**] on [**2143-11-28**] once he had been notified of a cadaveric liver donor. HOSPITAL COURSE: The patient was brought to the Operating Room and had preoperative laboratories drawn. Of note, the patient was coagulopathic. The patient was brought to the OR with a PTT of 40 and an INR of 2.2. The patient was brought to the preoperative holding area and was brought to the Operating Room where multiple invasive lines were placed including venous lines in his right groin and his left subclavian for possible [**Last Name (un) **]-[**Last Name (un) **] bypass. The patient also had a rapid infusion line placed in his right IJ. While the patient was being prepped and draped, the donor liver was being benched and prepared for the operation. At the time of the operation, the patient was prepped and draped in the standard fashion. During the operation, the skin was incised and the abdomen was opened in the standard fashion through a Chevron incision. During the donor hepatectomy, the operation proceeded in a normal fashion without undue blood loss. After the hepatic artery was identified and divided just beyond its bifurcation and the common bile duct was divided, attention was turned towards the portal vein. The portal vein was identified and isolated. Attention was then turned towards mobilizing the liver. Once were mobilized the liver, we noticed that the patient began to become hypotensive. The blood pressure dropped from the one-teens down to the 80s and 60s. We initially thought that this may be due to positioning of the liver and impaired venous return. The liver was turned to its normal fashion; however, the patient became more hypotensive to a blood pressure of 40 while maintaining a sinus pressure. CPR was begun. The patient was also given multiple rounds of epinephrine and Atropine. Intraoperative echocardiogram esophageally demonstrated diffuse clot on both sides of his heart as well as in his aorta. Clinically, the patient had diffuse intravascular clot with thrombosed IVC and thrombosis of his mesenteric veins. The patient was diffusely hypoperfused. The patient developed PEA and the patient was pronounced dead at 12:11 p.m. The patient received a total of 12 units of FFP, 5 units of platelets, 6 of cryoprecipitate, 9 units of packed red blood cells, and 3.6 liters of crystalloid. The patient's family were notified intraoperatively of the proceedings and his grave nature and after the operation of his death. The patient's family declined a postmortem. The medical examiner, Dr. [**Last Name (STitle) 4476**], was notified of the case and also declined postmortem examination as swell. [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**] Dictated By:[**Last Name (NamePattern1) 14369**] MEDQUIST36 D: [**2143-11-28**] 01:16 T: [**2143-11-28**] 19:02 JOB#: [**Job Number 103379**]

[ "458.29", "070.54", "286.6", "789.5", "571.2", "410.91", "572.3" ]

icd9cm

[ [ [] ] ]

[ "54.11", "99.60", "88.72" ]

icd9pcs

[ [ [] ] ]

762, 3576

151, 744

31,911

159,387

4137

Discharge summary

report

Admission Date: [**2120-12-31**] Discharge Date: [**2121-1-6**] Date of Birth: [**2050-7-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 663**] Chief Complaint: fever Major Surgical or Invasive Procedure: ERCP History of Present Illness: Mr. [**Known lastname 18093**] is a 70 year-old-male with DM2, HTN, Crohns s/p ileostomy, who was scheduled for total knee replacement at NEBH but was discovered to have a UTI (at NEBH) on routine pre-operative clearance. He reported fevers, chills, decreased PO intake (especially fluid intake), nausea, and increased urinary frequency. In the ED, he had elevated serum bilirubins and RUQ tenderness concerning for colangitis. He reported intermittent fevers at home with a Tmax 103 on admission. Ultrasound showed evidence of cholecystitis, thickened GB, moderate GB thickening with son[**Name (NI) 493**] [**Name2 (NI) 515**] sign; he also had [**Doctor Last Name 515**] sign on examination. . In the ED, his SBP was 86 and responded to fluids to SBP 110 after transfer to the SICU. Antibiotics (vancomycin and zosyn) were begun. After his BP stablized, he was transferred to the surgical floor. He subsequently became febrile, rigored and was diaphoretic, tachycardia (130s), and hypertensive (SBP 200s). He was given metoprolol 5 mg IV X1 for both hypertension and tachycardia. His blood pressure dropped to SBP 70 and a STAT lactate increased to 2.5-->2.7, sepsis protocol was instituted and he was transferred back to the ICU. While in the unit, he was aggressively volume resuscitated, but he did not require pressors as his BP was fluid responsive; he was positive 10L/first 24 hours in unit. His blood pressure stabilized. . The rest of his hospital course is significant for ERCP that did not show any evidence of clear obstruction; however a stent was placed in an area of stenosis with adequate biliary drainage. Post ERCP T bili continued to rise (3.6 peak) but was decreasing upon transfer to medicine. CT abdomen was unremarkable. In SICU, he was given Zosyn and Vanco intially both, then Vanco was d/c'ed when the patient stabilized. Per report, urine culture from [**Hospital1 **] shows pansensitive E. coli. All cultures at [**Hospital1 18**] are negative to date. Amylase and lipase were negative currently, though the patient was thought to have evidence of mild post-ERCP pancreatitis. . REVIEW OF SYSTEMS: 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. There is no exertional buttock or calf pain. All of the other review of systems were negative. Denied SOB, chest pain, abdominal pain, nausea or vomit. No fevers. . Past Medical History: 1. Crohn's disease. S/P procto-colectomy with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 18094**]. He also received prednisone for long periods of time in the past. 2. Melanoma left forearm, [**2099**] 3. S/P right elbow surgery 4. BPH 5. DJD 6. Right knee replacement. 7. HTN. 8. Erectile dysfunction. Social History: + smoking history in the past. quit almost 40 years ago. Family History: nc Physical Exam: PE upon admission to surgery: VS T 99.4 , Bp 139/66, HR 92, Sats 97% RR 15 Gen: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. moist oral mucosea Neck: Supple, no JVP CV: RRR, holosystolic murmur radiated apex, s1-s2 normal Chest: Resp were unlabored, no accessory muscle use. Lungs: + crackles in the bases Abd: Obese, distented, no tenderness to palpation. + ileostomy Ext: 1+ edema. . PE upon transfer to medicine VS T 99.1, BP 138/86, HR 85, RR 20, Sats 97 3L% RR Gen: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. moist oral mucosea Neck: Supple, no JVP CV: RRR, holosystolic murmur radiates to apex, s1-s2 normal Chest: Respirations unlabored, no accessory muscle use. Lungs: + crackles in the bases Abd: Obese, distented, no tenderness to palpation. Ileostomy bag in place Ext: 1+ edema. Pertinent Results: ============ LABORATORIES ============ ADMISSION LABORATORIES [**2120-12-30**] HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [**2120-12-30**] WBC-10.1 (NEUTS-87 BANDS-5 LYMPHS-2 MONOS-3 EOS-0 BASOS-1 ATYPS-2 METAS-0 MYELOS-0) HGB-13.4 HCT-39.7 MCV-94 PLT COUNT-90 [**2120-12-30**] ALT(SGPT)-34 AST(SGOT)-41 LD(LDH)-152 ALK PHOS-89 TOT BILI-1.6 ALBUMIN-4.1 AMYLASE-43 LIPASE-31 [**2120-12-30**] SODIUM-138 POTASSIUM-3.8 UREA N-16 CREAT-1.5 CHLORIDE-101 TOTAL CO2-24 GLUCOSE-109 [**2120-12-30**] LACTATE-2.4 [**2120-12-30**] URINE MUCOUS-FEW HYALINE-[**5-13**] RBC-[**2-5**] WBC-[**2-5**] BACTERIA-FEW YEAST-NONE EPI-3-5 BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG COLOR-Amber APPEAR-SlHazy SP [**Last Name (un) 155**]-1.025 MUCOUS-FEW HYALINE-[**2-5**] RBC-0-2 WBC-[**2-5**] BACTERIA-FEW YEAST-NONE EPI-0-2M BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2120-12-31**] 03:48AM PT-14.9 PTT-26.2 INR(PT)-1.3 [**2120-12-31**] 03:58AM freeCa-1.20 . OTHER LABORATORIES ABG [**2120-12-31**] TEMP-40.8 O2-3 PO2-88 PCO2-37 PH-7.41 TOTAL CO2-24 BASE XS-0 INTUBATED-NOT INTUBA VENT-SPONTANEOU COMMENTS-NASAL [**Last Name (un) 154**] . ============ MICROBIOLOGY ============ [**2121-1-4**] BILE CULTURE GRAM STAIN (Final [**2121-1-4**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). FLUID CULTURE (Final [**2121-1-7**]): KLEBSIELLA PNEUMONIAE. HEAVY GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- R CEFUROXIME------------ R CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . URINE CULTURES: [**2120-12-30**] URINE CULTURE-FINAL NO GROWTH [**2120-12-31**] URINE CULTURE-FINAL NO GROWTH [**2121-1-3**] URINE CULTURE-FINAL NO GROWTH . BLOOD CULTURES: [**2120-12-30**] BLOOD CULTURE x 4 BOTTLES; -FINAL NO GROWTH [**2120-12-31**] BLOOD CULTURE x 8 BOTTLES; -FINAL NO GROWTH [**2121-1-3**] BLOOD CULTURE x 4 BOTTLES; -FINAL NO GROWTH [**2121-1-4**] BLOOD CULTURE x 4 BOTTLES; -FINAL NO GROWTH . ======= IMAGING ======= [**2119-12-30**]: RUQ u/s 1. Cholelithiasis, moderately distended gallbladder and moderate gallbladder wall thickening, but no pericholecystic fluid. Son[**Name (NI) 930**] reports focal tenderness while scanning over the gallbladder. In concert, these findings are suspicious for acute cholecystitis. 2. Enlarged, coarsely echogenic liver; while this may represent generalized fatty infiltration, [**Name (NI) 13416**] cannot exclude other forms of severe or diffuse hepatic disease, such as cirrhosis and/or fibrosis. . CT Abdomen/Pelvis: [**2120-12-31**] IMPRESSION: 1. Mild peripancreatic inflammatory change corresponding by imaging with mild acute pancreatitis. 2. Moderately distended gallbladder with wall edema and pericholecystic fluid in addition to multiple small stones present within the neck relatively unchanged in appearance compared to the ultrasound from one day prior. Status post common bile duct stenting. 3. Status post total colectomy with right lower quadrant ileostomy. No intra-abdominal abscesses or fistulae noted. 4. Small amount of air noted within the bladder likely relates to introduction of Foley catheter. However, studies cannot be completely excluded and clinical correlation is advised. . ERCP [**2120-12-31**] IMPRESSION: Gallstones, with no filling defect, stricture, or dilation of the cystic duct, common bile duct, or intrahepatic biliary system. A biliary stent was placed. 1. Normal major papilla 2. Successful cannulation of the biliary duct was performed with a sphincterotomey using a free-hand technique. 3. Stones in gallbladder 4. Normal Cholangiogram 5. Normal Pancreatogram 6. Successful placement of a 7cm by 10Fr Cotton [**Doctor Last Name **] biliary stent for drainage 7. Excellent drainage of clear bile. No evidence of cholangitis . CHEST RADIOGRAPH [**2120-12-31**] The heart size is top normal with extensive amount of left fat pad. The mediastinal contours are stable. The lungs are clear except for right lower lung linear atelectasis most likely related to suboptimal inspiratory efforts and relatively low lung volumes. There is no pleural effusion or pneumothorax. IMPRESSION: Low lung volumes with right lower lobe linear atelectasis. Healed left rib fracture. . ECG Study Date of [**2120-12-31**] Sinus tachycardia. Marked left axis deviation. Old inferior infarct Early R wave progression - consider posterior myocardial infarct. Since previous tracing of [**2120-1-16**], heart rate increased Rate 128, PR 152, QRS 96, QT/QTc 282/401, P 58, QRS -49, T 68 . CHEST (PA & LAT) [**2121-1-3**] Cardiac silhouette is upper limits of normal in size allowing for enlarged pericardial fat pads as shown on recent CT abdomen study of [**2120-12-31**]. Minor bibasilar atelectasis and small bilateral pleural effusions were present. IMPRESSION: Small bilateral pleural effusions and adjacent minor basilar atelectasis. . TTE (Complete) [**2121-1-3**] The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (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 ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: Preserved global biventricular systolic function. Dilated thoracic aorta. Brief Hospital Course: #. CHOLECYSTITIS/SEPSIS Rigors and hypotension were likely due to cholecystitis as there was no evidence of other source of infection to explain her fevers/rigors/hypotension. He was admitted for presumed urosepsis versus cholangitis; he was given IV antibiotics (vanc/zosyn, then just zosyn) and aggressively fluid resuscitated (+10 liters) in the SICU. OSH urine cultures had shown pan-sensitive E. Coli one week prior to admission. The patient had been treated with antibiotics prior to admission; this had likely cleared prior to presentation as (1) E. Coli was pan-sensitive, (2) UTI was uncomplicated and easily treated with more than 3 days of a quinolone and (3)all urinalysis and urine cultures were negative on this admission. There was no evidence of cholangitis on ERCP; however, a diagnosis of cholangitis unclear as patient's total bilirubin decreased with biliary stent placement. . He was transfered to medicine when he was felt to be afebrile and hemodynamically stable; the presumed diagnosis at the time of transfer was urosepsis. Though he was +10 L in unit, he had no signs or symptoms of overload (i.e., minimal change from chronic peripheral edema). The patient was switched from IV zosyn to ciprofloxacin PO/flagyl PO but began spiking fevers again with continued RUQ pain, and zosyn was restarted. Cholecystitis was diagnosed by review of prior RUQ ultrasound showing gallbladder wall thickening, prior CT scan showing pericholecystic fluid, and positive son[**Name (NI) 493**] and physical examination [**Doctor Last Name 515**] sign. Percutaneous cholecystostomy was placed by interventional radiology on [**2121-1-3**] with 200 cc of bile immediately drained; bile cultures grew Klebsiella sensitive to ciprofloxacin. The patient was discharged on ciprofloxacin and also scheduled for outpatient surgery followup for interval cholecystectomy. Percutaneous cholecystostomy drainage was to be monitored by the patient daily. Interval removal of the percutaneous cholecystostomy drain is deferred to surgeon, Dr. [**Last Name (STitle) **], at his outpatient surgery followup appointment. . #. ERCP + stent: Per ERCP patient did not appear to have cholangitis; bilirubins trended down post-procedure. The patient also had subclinical pancreatitis after the ERCP per labs but minimal epigastric abdominal/back pain; he complained of more RUQ pain consistent with cholecystitis. Stent should be removed in [**3-9**] weeks as per GI recomendations. . # Thrombocytopenia: Platelets decreased to 50% less than on admission in a time course of less than 4 days from admission. He had no signs of active thrombosis. All heparin products were discontinued. The time course was not typical for HIT; he was HIT antibody negative [**2121-1-1**]. Thrombocytopenia was most likely related to infection or medications, e.g. antibiotics. . # HTN: Continued atenolol. . # BPH: Contined Doxazosin . # ARF: Creatinine was elevated on admission, likely due to dehydration. ARF resolved with aggressive fluid resuscitation for sepsis in ED. . # Hyperlipidemia: Continued simvastatin. . # Prophylaxis: Pneumoboots/ambulation. Held heparin in setting of thrombocytopenia. . Medications on Admission: Tylenol PRN Albuterol PRN Atenolol 50 daily Calcium sliding scale Calcium gluconate sliding scale Doxazosin 4 mg qhs Famotidine 20 [**Hospital1 **] Glyburide 2.5 [**Hospital1 **] Heparin sq TID Ibuprofen PRN INsulin sliding scale Magnesium sliding scale Morphine PRN Zosyn 4.5 q8h D3 Vancomycin 750 q8h Simvastatin 40 mg daily Discharge Medications: 1. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Glyburide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:*28 Tablet(s)* Refills:*0* 6. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO once a day. 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: Do not exceed more than 4 grams (4,000 milligrams) of tylenol (acetaminophen per day). Note: each tablet of percocet contains 325 mg of tylenol (acetaminophen). Disp:*56 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Primary Acute Cholecystitis Sepsis . Secondary Crohn's disease Benign Prostatic Hypertrophy Degenerative Joint Disease Hypertension Erectile dysfunction Discharge Condition: Hemodynamically stable, afebrile Discharge Instructions: You were admitted to the hospital with acute cholecystitis (gall bladder infection). You became septic in the surgical ICU and were treated with fluids and antibiotics. A percutaneous cholecystostomy drain was placed to drain the infected fluid in your gallbladder, and you improved. The gallbladder fluid (bile) grew a bacteria called Klebsiella pneumoniae, which was sensitive to an antibiotic called ciprofloxacin. . Please followup with Dr. [**Last Name (STitle) **] as below in 2 weeks for further instructions regarding your drain care. In the meantime, a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] you with drain care. Dr. [**Last Name (STitle) **] will also discuss scheduling a cholecystectomy (surgery to remove your gallbladder), which will likely be in [**3-9**] weeks. . Please keep all followup appointments. . Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You 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. . =============== NEW MEDICATIONS =============== Please complete a 2 week course of ciprofloxacin as prescribed. Followup Instructions: 1. PCP: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 250**], within the next [**2-4**] weeks. Please call his office to schedule an appointment as needed before this time. . 2. An outpatient surgery appointment has been scheduled for you with surgeon, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2300**] on [**2121-1-17**] at 11:00 AM. [**Hospital Unit Name **] [**Location (un) 470**], [**Hospital3 **] Deaconness [**Hospital Ward Name 517**]. ============================================= REMINDER OF PREVIOUSLY SCHEDULED APPOINTMENTS ============================================= Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2121-2-4**] 4:00 Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2121-2-4**] 4:00

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icd9cm

[ [ [] ] ]

[ "51.85", "88.72", "51.87", "38.93", "51.01" ]

icd9pcs

[ [ [] ] ]

14930, 14989

10590, 13784

319, 325

15186, 15221

4184, 10567

16933, 17811

3293, 3297

14161, 14907

15010, 15165

13810, 14138

15245, 16910

3312, 4165

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274, 281

353, 2476

2872, 3202

3219, 3277

28,806

128,855

43578

Discharge summary

report

Admission Date: [**2158-4-19**] Discharge Date: [**2158-4-22**] Date of Birth: [**2124-1-18**] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Motrin / Tylenol Attending:[**First Name3 (LF) 783**] Chief Complaint: paradoxical vocal cord paralysis, inspiratory stridor Major Surgical or Invasive Procedure: none History of Present Illness: 34 y.o. W with history of questionably steroid-dependent asthma presenting with chest tightness and dyspnea. The patient reports worsening shortness of breath X 2 days. She was admitted to [**Hospital1 18**] with asthma flare in [**4-26**] and treated with an 18-day prednisone taper. The patient says this episode began as back pain about two days ago, which then migrated to her chest and abdomen. She began to feel SOB and tried to take nebs without improvement. The chest pain is typical of her usual episodes of SOB, and she describes it as a tight squeezing around her rib cage. She has it chronically, off and on. This time the pain persisted and so she came to the ED. . In the ED, patient has a CXR which was normal. Per report, she had an ECG which may have had some new diffuse T-wave changes. She refused ASA. She had a upper airway scope and per report had paradoxical vocal cord movement. She was treated with 10 mg of IV Valium with some relief. Given her history of multiple intubations, and persistence of inspiratory stridor, she was admitted to the MICU for close monitoring. . On arrival to the unit patient says that she is breathing comfortably but complains of persistent chest and R back pain. Denies any recent symptoms of illness - no cough, congestion, urinary or bowel symptoms. Past Medical History: Asthma--intubated X 15 times, reports steroid dependence on 20 mg daily although no outpatient notes suggest this dose. Follows with pulmonary at [**Hospital1 18**]. Seizure disorder IDDM--since age 19 HTN-since age 16 Schizophrenia Anxiety/Panic Attacks DVT CVA Diverticulosis Obstructive sleep apnea-10 cm H2O pancreatitis Social History: Lives alone, 3ppd X 15 years, quit 3 yrs ago), no etoh, no drugs, works in "pathology". Family History: CAD, HTN Physical Exam: VS: T: 97 BP: 134/93 P: 85 RR: 19 O2 sat: 100% on RA Gen: obese, no distress, speaking in complete sentences and relates history without distress. No accessory muscle use. HEENT: EOMI, no icterus, no injection, MMM, OP clear, neck supple Car: Tachycardic, no murmur Resp: breath sounds distant, no abnormal sounds Abd: soft, obese, diffusely tender to palpation, moves easily in bed, + R CVA tenderness Ext: no LE edema Pertinent Results: Admission labs: [**Age over 90 **]|105|11 -----------<103 5.0|26 |0.9 Comments: K: Hemolysis Falsely Elevates K estGFR: 72 / >75 CK: 176 MB: 3 Trop-T: <0.01 Ca: 9.2 Mg: 2.3 P: 3.2 ALT: 13 AP: 60 AST: 33 LDH: 448 [**Doctor First Name **]: 59 Lip: 71 Phenytoin: <0.6 Valproate: <3.0 13.2 6.5>-<178 39.6 N:49.4 L:44.1 M:4.3 E:0.7 Bas:1.4 . CXR: SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: Technically limited study due to underpenetration and soft tissue scatter. Low lung volumes are noted. Within these limitations, no focal pulmonary opacities. There is no pleural effusion. Linear subsegmental atelectasis at the left lung base is noted. Cardiomediastinal silhouette is normal. Pulmonary vasculature is within normal limits. There is no pneumothorax. Brief Hospital Course: A/P: 34 y.o. W with history of questionably steroid-dependent asthma presenting with chest tightness and dyspnea. . # Paradoxical vocal cord dysfunction: The patient was initially admitted to the intensive care unit due to feelings of acute shortness of breath and stridor. A chest X-ray showed no acute abnormalities and EKG was within normal limites without evidence of ischemia. By report, visualization of the vocal cords displayed evidence of abnormal vocal cord movement. She was treated convervatively. She was not intubated, she was given frequent albuterol nebulizer treatments and continued on her maintanence asthma medications. She had no evidence of airway compromise or O2 desaturations. She was seen by speech and swallow and felt that she would benefit from speech therapy (note in chart). She should also have ENT follow-up for further management. . # Epigastric pain: This resolved upon admission without intervention and she was continued on a diabetic diet. . # Chest pain: She intermittently had discomfort, but pt reported that this was baseline for her. Her pain improved with nebulizer treatments and as above had normal EKG and cardiac enzymes were normal. . # Right flank pain: She was started on a lidocaine patch for her chronic R flank pain. She had no evidence of UTI. . # DMII: She was continued on NPH, though pm dose transiently lowered due to relative am hypoglycemia. She was discharged on usual dose. . # HTN: Stable, continued on home medications of lisinopril and HCTZ . # Schizophrenia/mood: The patient was seen by psychiatry and felt to have a personality disorder vs cyclothymia vs bipolar disorder, needing further evaluation given short stay and prior history of polysubstance abuse. She was seen previously at [**Hospital1 112**] but wants to transfer her care here. She recently learned that her brother died suddenly and did express the urge to cut herself when she is sad. She endorsed that she would not do this and would be safe at her mother's house. Please see Dr. [**Name (NI) 93743**] note for details. All outpatient depression and mood stabilizing medications were held. . # Seizure disorder: Held depakote or dilantin given no documentation of seizure disorder and levels of these meds zero on admission suggesting that she was not taking them. Medications on Admission: per OMR: Advair 500/50 [**Hospital1 **] abilify 20 mg daily Calcium 600 + D Depakote 1000 daily Colace 100 daily Duoneb qid flovent 2 [**Hospital1 **] fluoxetine 60 mg daily HCTZ 25 mg daily NPH 26 u [**Hospital1 **] lisinopril 30 mg dialy montelukast 10 mg daily dilantin 300 mg qam Prilosec 40 mg daily senna Ziprasidone Discharge Medications: 1. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1) nebulizer treatment Inhalation every six (6) hours. 2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. CALCIUM 500+D Oral 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 6. Flovent Diskus 50 mcg/Actuation Disk with Device Sig: One (1) puff Inhalation twice a day. 7. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Six (26) units Subcutaneous twice a day: at breakfast and dinner. 9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. 11. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane every six (6) hours as needed. Disp:*30 Lozenge(s)* Refills:*0* 12. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): place patch on for 12 hours, then off for 12 hours. Disp:*7 Adhesive Patch, Medicated(s)* Refills:*4* 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: 1) Paroxysmal vocal cord dysfunction 2) Asthma exacerbation 3) Chronic chest and right flank pain Discharge Condition: afebrile, displaying normal vital signs, and tolerating a regular diet Discharge Instructions: You were admitted to the hospital with wheezing, shortness of breath and chest tightness. This improved with nebulizer treatments and continued inhalers for your asthma. You were also started on a lidocaine patch to help with the pain in your hip. You were evaluated by the psychiatry service while you were in the hospital and several of your depression medications were discontinued including Prozac, Abilify and Ziprasidone. It is very important that you follow-up with psychiatry soon after discharge. You will need to see your primary care provider to get [**Name Initial (PRE) **] psychiatry appointment set-up at [**Hospital3 **], since you will be a new patient. . Also, your seizure medications were discontinued including depakote and dilantin since you had no history of recent seizures. You should talk to your doctor [**First Name (Titles) 5001**] [**Last Name (Titles) 9533**] these medications. . You were started on a lidocaine patch to help with the pain in your right side. You should talk to your primary care provider about this pain regimen. . If you feel unsafe in any way, feel that you would hurt yourself or others, call 911 or seek immediate medical attention. . If you feel throat tightening, trouble breathing, new or worsening chest pain, abdominal pain, nausea, vomiting, confusion, worsening mood, or new uncontrolled movement of any body part concerning for a seizure seek immediate medical attention. Followup Instructions: You have a follow-up appointment at [**Hospital3 **] ([**Hospital Ward Name 5074**] of [**Hospital1 **]) on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building on [**4-26**] at 2pm with Dr. [**First Name (STitle) **]. . Provider: [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2158-4-26**] 2:00 . It is important that you arrange follow-up with the psychiatry department at that time. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7589, 7595

3418, 5722

354, 361

7737, 7810

2635, 2635

9292, 9900

2169, 2179

6096, 7566

7616, 7716

5748, 6073

7834, 9269

2194, 2616

261, 316

389, 1698

2651, 3395

1720, 2047

2064, 2153

16,792

129,117

29267

Discharge summary

report

Admission Date: [**2176-5-7**] Discharge Date: [**2176-5-13**] Date of Birth: [**2107-3-28**] Sex: M Service: SURGERY Allergies: Codeine / Iodine Attending:[**First Name3 (LF) 3376**] Chief Complaint: LLQ pain Major Surgical or Invasive Procedure: placement of IVC filter History of Present Illness: 69M c h/o perforated diverticulitis s/p repair p/w LLQ pain x 1 day. Patient states that he developed severe pain last night that had worsened during the day. Patient went to the ED at OSH where he was found to have WBC of 31 and CT that showed diverticulitis. +nausea. No vomiting. No fevers or chills. +loose stool output from ostomy Past Medical History: 1. CAD - MI, PTCA in [**2170**], deccreased EF 2. CVA - left monocular blindness 3. COPD on home O2 4. Chronic renal insufficiency 5. Renal cell carcinoma s/p nephrectomy 6. sleep apnea 7. diverticulitis 8. iliac stent Social History: Patient smokes a pack per day of cigarettes. Family History: Non-contributory Physical Exam: T 99.7 HR 99 a fib BP 73/55 RR 26 Sat 99% A&O IRIR decreased BS bilaterally Soft, ND, + ostomy on RUQ - pink, stool and air in bag, + tender at LLQ, no rebound, no guarding + stage I decubitus ulcers Pertinent Results: [**2176-5-7**] 09:25PM PT-14.3* PTT-24.9 INR(PT)-1.3* [**2176-5-7**] 09:25PM PLT SMR-NORMAL PLT COUNT-152 [**2176-5-7**] 09:25PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [**2176-5-7**] 09:25PM NEUTS-76* BANDS-0 LYMPHS-11* MONOS-9 EOS-1 BASOS-0 ATYPS-0 METAS-2* MYELOS-1* [**2176-5-7**] 09:25PM WBC-31.1*# RBC-4.93# HGB-14.6# HCT-43.7# MCV-89 MCH-29.7 MCHC-33.5 RDW-16.1* [**2176-5-7**] 09:25PM GLUCOSE-114* UREA N-87* CREAT-1.9* SODIUM-133 POTASSIUM-6.1* CHLORIDE-100 TOTAL CO2-21* ANION GAP-18 [**2176-5-7**] 09:36PM LACTATE-1.4 [**5-7**] ECG: Irregular supraventricular rhythm with baseline artifact possibly atrial fibrillation, but cannot rule exclude sinus mechanism with supraventricular premature depolarizations. [**5-8**] LE u/s: IMPRESSION: Acute DVT involving entire right lower extremity. Left lower extremity veins patent. [**5-8**] CT ABD/PELVIS: CT ABDOMEN WITHOUT IV CONTRAST: Limited imaging of the lung bases demonstrate left basilar stable bronchiectasis. There is bibasilar atelectasis. Imaging of the intra-abdominal organs is limited due to lack of IV contrast. There is a stable low-density lesion within the left hepatic lobe, too small to characterize. Calcified gallstones are demonstrated within the gallbladder. The spleen, pancreas, right adrenal gland, and right kidney are unremarkable. The patient is status post left nephrectomy. Again seen is a small left abdominal wall hernia containing small bowel without evidence of bowel obstruction, unchanged. Bowel is normal in caliber. The patient is status post transverse loop colostomy. Scattered colonic diverticula are demonstrated without evidence of acute diverticulitis. There is thickening of the cecum focally, differential diagnosis includes infectious or inflammatory causes, and less likely ischemic. Specifically, there is thickening of the haustra of the cecum in this region, which can be seen in C. diff. colitis. There is stranding of the mesenteric fat, which is unchanged. No focal fluid collections are demonstrated to suggest abscess. CT OF THE PELVIS: A Foley catheter is demonstrated within the bladder, which is relatively decompressed. There are prosthetic calcifications. There is no ascites, lymphadenopathy or free intraperitoneal gas. There is stranding of the presacral fat, which is of uncertain significance. There is stable retroperitoneal fat stranding, which may be post-surgical. No focal fluid collections are demonstrated to suggest abscess. There is a stable infrarenal abdominal aortic aneurysm measuring 4 cm in maximum dimension. The patient is status post sigmoid colectomy. IMPRESSION: 1. Status post sigmoid colectomy and transverse loop colostomy. Scattered colonic diverticula without evidence of diverticulitis. 2. Stranding of the retroperitoneal fat, unchanged, may reflect post-surgical changes. 3. Stable 4-cm infrarenal abdominal aortic aneurysm. 4. Status post left nephrectomy. 5. Cholelithiasis without evidence of cholecystitis. 6. Left lateral abdominal wall hernia containing small bowel without evidence of bowel obstruction. 7. Thickening of the haustra of the cecum. [**5-8**] Stool: C. Diff positive [**5-8**] PICC tip: negative growth Brief Hospital Course: The patient presented to the ED with a WBC=31 and diverticulitis on CT Scan. The patient was admitted to the ICU, the PICC line was removed and tip sent for culture, the foley catheter was changed, blood cultures were taken, coumadin, plavix, and aspirin were held, urine cultures was taken, a CXR was done, was made NPO, and IV Zosyn and Linezolid were started. A CVL was placed on HD2. Serial abdominal exams continued and improved. On HD2, it was noted that the patient's RLE was more edematous compared to the LLE. A LE u/s showed complete DVT of the RLE. A heparin drip was started. On HD3, an IVC filter was placed. On HD4, there was gas in the ostomy and the patient's diet was advanced. The patient was restarted on his PO cardiac meds to allow for proper rate control. WBC was drifting back toward normal. The patient was transferred to the floor in stable condition and was placed on a telemetry bed. On the floor, the patient tolerated a regular diet. The heparin drip was discontinued. The patient was started on SC Lovenox and restarted on coumadin. On HD7, the patient remained afebrile, was receiving Lovenox [**Hospital1 **], and continuing to tolerate a regular diet. The INR was subtherapeutic at 1.5, so will continue with coumadin (3mg given [**5-12**] PM) and SC Lovenox (60mg [**Hospital1 **]). In addition, the patient was on a prednisone taper on admission (initially given IV hydrocortisone due to NPO status). On HD7, the patient's prednisone was decreased from 10mg to 5mg, and the taper will continue at the rehab facility. The patient was discharged to rehab on HD7, PPD4. Medications on Admission: Prednisone taper (currently on 10 qd) Coumadin 1.5 daily, Advair 250/50 [**Hospital1 **] Procrit 40,000 qmon ASA 81 daily Claritin 10 daily Nystatin S&S Metoprolol 25 [**Hospital1 **] Prozac 40 daily Plavix 75 daily Prilosec OTC 20 [**Hospital1 **] Zocor 80 daily Amiodarone 200 daily Tricor 48 daily Lisinopril 2.5 daily Lasix 40 daily Spiriva 1 daily Albuterol IH Prostat 20 mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection ASDIR (AS DIRECTED). 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 18 days: continue Flagyl for 3 weeks (started [**5-10**]. Disp:*54 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 12. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). 13. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier **] ([**Numeric Identifier **]) units Injection QMOWEFR (Monday -Wednesday-Friday). units 15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime): adjust for INR 2.0-3.0. Discharge Disposition: Extended Care Facility: [**Location (un) **] Manor - [**Location (un) **] Discharge Diagnosis: Diverticulitis ?PICC infection RLE DVT CAD - MI, s/p PTCA decreased EF CVA - left monocular blindness COPD on home O2 Chronic renal insufficiency Renal cell carcinoma s/p nephrectomy sleep apnea diverticulitis iliac stent a fib DM HTN hx MRSA, hx VRE, hx c. dif. Discharge Condition: Stable Discharge Instructions: Please call doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101, nausea/vomiting, inability to eat, wound redness/warmth/swelling/foul smelling drainage, pain not controlled by pain medications or any other concerns. Please resume taking all medications as taken prior to this admission. Continue taking Lovenox 60mg [**Hospital1 **] until INR is therapeutic. Continue taking Flagyl 500mg TID for a total of 3 weeks (your treatment started on [**5-10**]). Please follow-up as directed. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 1120**] in [**12-30**] weeks. Please call ([**Telephone/Fax (1) 6316**] for an appointment

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43717

Discharge summary

report

Admission Date: [**2161-8-6**] Discharge Date: [**2161-8-13**] Date of Birth: [**2077-7-15**] Sex: M Service: MEDICINE Allergies: Aspirin / Hydrochlorothiazide Attending:[**First Name3 (LF) 689**] Chief Complaint: hyponatremia, fatigue Major Surgical or Invasive Procedure: None. History of Present Illness: 84 year old male with history recent kidney stone, recent travel to [**Country 14635**], presents with increased lethargy, constipation, back pain, and decreased appetite. He was admitted in [**Month (only) 205**] with kidney stone and pyelonephritis. He was treated with antibiotics, he passed the stone and he felt much improved. He went on a trip to [**Country 14635**] and was very active and feeling well. He had been told to hold his Hyzaar until he returned from his trip and to drink plenty of fluids (2L daily). He noted that he had new peripheral edema, for which he reduced his sodium intake. He has a oral intake of about 2L of fluid daily, he is certain it is not more than than, and tried to meet that goal daily. He returned from his trip on [**7-14**] feeling well. He resumed his Hyzaar on [**7-16**] and noted that his low back pain had started once again. He thought it was another kidney stone. Around [**7-24**] he noticed that he was lethargic. He was less active, tired, and moving more slowly. He became progressively more lethargic. He was unable to do chores, driving due to sleepiness, or extensive walking, but maintaining ADLs. He noted a new tremor in his right hand over the last week and half prior to admission. He was urinating 4-5 times daily due to increased fluid intake. He urinated small to moderate quantities. He was unsure if he voided completely. He denies urgency. He also complained of low back pain at the level of the CVA, and felt the pain is similar to when he had kidney stones. He also complained of abdominal pain, band like. He had been constipated for 1 week. No flatus but burping. He had no nausea vomiting. He complained of reduced appetite. Wt loss 20 lbs over 5 years intentionally. He noticed worsening vision, d/x of glaucoma in right eye, however, he noticed this prior to symptoms of weakness. He went to see his PCP on the day of admission who checked his sodium which was 126 and he was sent to the ED. CXR unremarkable, lots of bowel loops. He received 1000 cc NS, morphine. In the ED, initial VS: 97.7 80 158/73 18 100. Normal mental status. Vitals prior to medicine admit: 76 182/72 20 98/RA. ROS: Denied fever, chills, night sweats, headache, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1.) Diabetes Type II: on Metformin, HgbA1c in [**2-9**]: 6.1 2.) Coronary artery disease status post CABG 20yrs ago Normal stress test [**6-10**]; Echo [**9-10**]: EF 50% 3.) Hypertension-stable, well-controlled 4.) Hyperlipidemia: [**12-12**]: Tchol 126, TG 76, HDL 52, LDL 59 5.) Abdominal aortic aneurysm; infrarenal, 3.6 cm, stable by abd u/s [**8-11**] 6.) Right Common Iliac aneurysm, 2.3 cm, stable by u/s [**8-11**] 7.) Bilateral internal carotid artery stenosis, <40% by doppler [**8-11**] 8.) Stroke, h/o TIA - in [**2156-2-2**] 9.) Mitral regurgitation- mild-moderate, stable 10.) Transaminitis with normal synthetic function, stable, followed in GI 11.) TURP 20 years ago for obstruction [**1-5**] BPH after CABG [**63**].) Nephrolithiasis, 1st episode [**6-11**], 4mm distal uric acid stone passed w conservative tx; currently on flomax per urology recs. Social History: The patient lives in [**Location 3320**] with his wife. [**Name (NI) **] has four healthy children. He does not drink alcohol, smoke, or use drugs with no history of the above. He is currently not working, having retired from accounting 25 years ago. He was injured in his left leg by an explosive during WWII. He was the first person in his division to be awarded a Purple Heart. He has been an active man previous to this most recent state. Family History: elder son with DM. no history of cancer. Physical Exam: ADMISSION: Vitals - T:97 BP:150/82 HR:87 RR:22 02 sat:97RA GENERAL: elderly gentleman, appears stated age, appears fatigued HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNG: Poor inspiratory effort. No rales, wheezes, rhonchi. ABDOMEN: soft, non distended, non tender. EXT: no clubbing or cyanosis. has 1+ pitting edema up to mid calf.2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&OX3. Appropriate. CN2-12 intact. Preserved sensation throughout. [**4-7**] strenth in upper extremities and lower extremties, but has difficulty pushing without falling backwards. Sensation is generally intact. Rectal exam - good tone, no blood. DERM: Small scattered bruises noted on upper extremities. PSYCH: Listens and responds to questions appropriately, pleasant DISCHARGE: Vitals: T: 97.6 HR: 78 BP: 102/89 RR: 18 O2sat: 97%RA Orthostatic BP measurements wnl. GENERAL: elderly gentleman, appears stated age, A+Ox3, NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. Some redness and watery exudate from L eye. MMM. OP clear. Left TM without erythema or edema, no vesicles or evidence of infection. NECK: Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNG: CTAB. No rales, wheezes, rhonchi. ABDOMEN: soft, non distended, slightly ttp in LLQ. EXT: no clubbing or cyanosis. has 1+ pitting edema up to mid calf.2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&OX3. Appropriate. CN2-12 intact except baseline R lid lag, and new L sided facial droop, inability to fully close L eye, L sided nasolabial flattening, decreased ability to raise L eyebrow, and asymetric smile. Preserved sensation throughout-patient has baseline loss of sensation in LLE from trauma. 5/5 strength in upper extremities and lower extremties. PSYCH: Listens and responds to questions appropriately, pleasant, alert and oriented * [**1-6**] ( sometimes misses date) Pertinent Results: ADMISSION LABS: [**2161-8-6**] 09:40AM BLOOD WBC-12.2* RBC-4.18* Hgb-13.1* Hct-37.8* MCV-90 MCH-31.4 MCHC-34.7 RDW-13.1 Plt Ct-176 [**2161-8-6**] 09:40AM BLOOD Neuts-74.0* Lymphs-19.4 Monos-5.5 Eos-0.7 Baso-0.3 [**2161-8-6**] 09:40AM BLOOD Plt Ct-176 [**2161-8-6**] 09:40AM BLOOD Glucose-148* UreaN-24* Creat-1.0 Na-122* K-3.4 Cl-83* HCO3-27 AnGap-15 [**2161-8-6**] 09:40AM BLOOD ALT-28 AST-28 CK(CPK)-181* AlkPhos-107 TotBili-1.1 [**2161-8-6**] 09:40AM BLOOD CK-MB-9 [**2161-8-6**] 09:40AM BLOOD cTropnT-<0.01 [**2161-8-6**] 09:40AM BLOOD Calcium-9.7 Phos-2.6* Mg-1.6 NADIR SODIUM: [**2161-8-7**] 03:00PM BLOOD Na-120* UOsms: [**2161-8-7**] 02:58AM URINE Osmolal-527 [**2161-8-7**] 02:15PM URINE Osmolal-572 [**2161-8-8**] 01:46AM URINE Osmolal-481 [**2161-8-8**] 06:34PM URINE Osmolal-653 [**2161-8-10**] 02:50PM URINE Osmolal-702 [**2161-8-11**] 07:34PM URINE Osmolal-697 DISCHARGE LABS: [**2161-8-11**] 06:35AM BLOOD WBC-9.2 RBC-4.11* Hgb-12.9* Hct-38.3* MCV-93 MCH-31.3 MCHC-33.5 RDW-13.5 Plt Ct-175 [**2161-8-12**] 07:10AM BLOOD Glucose-153* UreaN-23* Creat-0.8 Na-136 K-4.0 Cl-98 HCO3-26 AnGap-16 [**2161-8-10**] 03:44AM BLOOD cTropnT-<0.01 [**2161-8-9**] 10:55PM BLOOD cTropnT-<0.01 [**2161-8-9**] 07:50PM BLOOD cTropnT-<0.01 [**2161-8-12**] 07:10AM BLOOD Calcium-9.4 Phos-2.4* Mg-1.7 [**2161-8-6**] 07:35PM BLOOD TSH-0.59 [**2161-8-7**] 07:20AM BLOOD Cortsol-20.4* Lyme and HSV serologies PENDING. IMAGING: CT/CTA Head [**2161-8-9**]: IMPRESSION: 1. Similar multifocal lucencies within the bihemispheric supratentorial white matter, much of which likely relates to chronic microvascular disease, though the presence of an acute infarct cannot be excluded and could be further evaluated with dedicated MRI as indicated clinically. 2. Intracranial vascular variant as detailed above, with multifocal ectasia with a 2 mm aneurysm at the left A3 origin as detailed. 3. Multifocal atherosclerotic disease with a focal irregularity within the high cervical segment of the right internal carotid artery which may be artifactual, though it is concerning for the possibility of a focal dissection versus ulcerative plaque. Further imaging with dedicated MRA with the T1 fat saturated sequence is recommended in further evaluation of this finding. 4. Extensive atherosclerotic disease of the right vertebral artery with near complete occlusion proximally. 5. Extensive multilevel degenerative changes of the cervical spine, which could be further evaluated with dedicated cervical spine MRI as indicated clinically. 6. Heterogeneous thyroid gland, which may represent an underlying multinodular goiter and should be correlated with patient's clinical course and son[**Name (NI) 493**] findings. CAROTID U/S [**2161-8-11**]: IMPRESSION: Less than 40% stenosis of the bilateral internal carotid arteries. No flow detected in the right vertebral artery (likely occlusion). CARDIAC ECHO [**2161-8-11**]: LVEF: 60% No cardiac source of embolus identified (cannot definitively exclude). Compared with the prior study (images reviewed) of [**2160-9-9**], left ventricular systolic function is probably similar although images are technically suboptimal for comparison. Mitral regurgitation is now less prominent and estimated pulmonary artery systolic pressure is now lower. MRI/MRA Head and Neck with T1 dissection protocol [**2161-8-12**] Wet Read: No evidence of R ICA dissection. No evidence of acute ischemia or bleed. Extensive white matter changes consistent with chronic microvascular infarcts. Brief Hospital Course: MICU COURSE. Patient was admitted to MICU for hypertonic saline for sodiumd of 120 on [**2161-8-6**] (his nadir). He was started on hypertonic saline at 30ml/hr. Goal was to correct by 10 mEq/L over first 24 hours, and with correction not to exceed 0.5 mEq/L per hour. He was also placed on fluid restriction 750 ml per day and HCTZ-Losartan was held. Upon transfer to the floors, sodium had increased to 129. The patient also had a transient hypokalemia of 3.2 on [**2161-8-7**]. His potassium was repleted and was found to be normal throughout the remainder of this admission. FLOOR COURSE: On [**2161-8-9**], the patient was transferred to medicine. On the floor, the patient appeared in NAD with improved lethargy, and was alert and oriented to person, place, and time. A serum cortisol was slightly elevated at 20.4 and a TSH was normal. The etiology of his hyponatremia was deemed to be due to his high fluid intake over the past few months and his decreased sodium intake, in addition to his HCTZ use. He was continued on a 750 mL fluid restriction, high sodium diet, and was kept off of HCTZ. His serum sodium trended towards normal and was 133 by [**2161-8-11**]; on this date he was increased to a 1L daily fluid allowance, per nephrology recommendations. His serum creatinine remained normal throughout admission. On the day prior to discharge, he had a serum sodium of 136. Urine osmolarities showed upward trend on fluid restriction. Patient was discharged on 1- 1.5L fluid restriction. On [**2161-8-10**], the patient was noted to have a new left sided facial droop. He was triggered for stroke and neurology evaluated the patient. CT/CTA of head/brain showed no acute infarct or bleed but there was a question of artifact vs. focal dissection in the right ICA. An MRI/MRA of brain/neck on [**2161-8-11**] confirmed no acute infarct or bleed and showed no evidence of focal R ICA dissection. The patient was ruled out for stroke, and 3 sets of troponins were done and found to be normal. Carotid u/s on [**2161-8-11**] showed stable 40% ICA stenosis bilaterally and cardiac echo showed no evidence of thrombus formation and LVEF of 60%. His neuro exam over the next 48 hours progressed to include the upper part of the left face, and the patient was diagnosed with Bell's Palsy. Ear and skin examination showed no evidence of herpes zoster or other infection. HSV and Lyme titers were drawn and pending at the time of discharge per neurology recommendations. The patient was started on a one week course of 60 mg po prednisone daily for his Bells Palsy on [**2161-8-12**] with no taper. He was also started on a nightly eye patch and artificial tear lubricant to prevent corneal dryness. In addition, since Lyme serologies are pending, we are empirically treating patient with po doxycycline x 21 days and recommend follow-up of labs by patient's PCP and rehab facility (results should be back by Tuesday, [**2161-8-18**]). During this hospitalization, the patient also had complained of upper back pain (initially [**9-12**], radiating down arms bilaterally). Xrays of the total spine were completed and showed only degenerative changes. The patient's pain improved on Tylenol and was deemed to be musculoskeletal in origin. The patient was continued on his home medications for CAD and HTN during admission, with the exception of HCTZ which was discontinued. His blood pressures were noted to trend up during his hospital course to systolic BPs in the 150s-160s. Once acute cerebral infarct/ischemia was ruled out by imaging, the patient's atenolol was increased from 37.5 mg daily to 50 mg daily for better blood pressure control ([**2161-8-12**]). He continued on Losartan 100 mg po daily. His vital signs were stable throughout admission. The patient was deemed medically stable for discharge on [**2161-8-12**]. He was evaluated by physical therapy who determined that the patient would benefit from discharge to a rehabilitation facility. He has been informed to have close follow-up with his primary care physician within two weeks of discharge from rehab. A follow-up appointment has been made for the patient with urology, as he will likely require a different prevention approach regarding his nephrolithiasis. The patient was FULL CODE during this admission Medications on Admission: Atenolol 25 mg once a day Tamsulosin 0.4 mg capsule SR, once a day Clopidogrel [Plavix] 75 mg Tablet once a day Dorzolamide-Timolol [Cosopt] 0.5 %-2 % Drops twice a day Lumigan 1 drop nightly right eye Losartan-Hydrochlorothiazide [Hyzaar] 100 mg-25 mg by mouth twice a day Metformin 500 mg Sust Rel by mouth once a day Simvastatin 40 mg by mouth once a day Multivitamin by mouth daily Omega-3 Fatty Acids-Vitamin E by mouth once a day Vitamin D Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 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. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for back pain. 9. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) ML Rectal PRN (as needed) as needed for constipation. 13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO twice a day as needed for constipation: hold for diarrhea. 15. Erythromycin 5 mg/g Ointment Sig: One (1) thin ribbon Ophthalmic twice a day as needed for eye redness for 5 days: apply to bottom inner eyelid of left eye. 16. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) as needed for Bells Palsy for 6 days. 17. Lumigan 0.03 % Drops Sig: One (1) drop Ophthalmic at bedtime: one drop nightly in right eye. 18. Metformin 500 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 19. Doxycycline Monohydrate 100 mg Capsule Sig: One (1) Capsule PO twice a day for 21 days: PLEASE FOLLOW-UP LYME SEROLOGIES AT [**Hospital1 18**] on [**2161-8-18**], IF LYME NEGATIVE, DISCONTINUE THIS MEDICATION. Thank you. 20. Polyvinyl Alcohol 1.4 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day) as needed for eye dryness, Bells Palsy. 21. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 23. Insulin Lispro 100 unit/mL Solution Sig: as directed units Subcutaneous QIDAC: per sliding scale attached. 24. Tears Again Ointment Sig: One (1) thin ribbon Ophthalmic at bedtime: hold while on erythromycin, apply to help prevent eye dryness at night with bell's palsy. Discharge Disposition: Extended Care Facility: [**Hospital1 11057**] Nursing & Rehabilitation Center - [**Location (un) 3320**] Discharge Diagnosis: Hyponatremia Bells Palsy Musculoskeletal Back Pain Discharge Condition: Stable, Na 136. Discharge Instructions: Mr. [**Known lastname 93960**], you were admitted to the hospital because of hyponatremia, or low blood sodium level. This caused you to have confusion and lethargy prior to presenting to the hospital. You were originally treated with intravenous hypertonic saline in the medical intensive care unit. You were shortly after transferred to the medicine floor for further management. We initially restricted your daily fluid intake, and closely monitored your serum sodium levels. Your sodium levels improved to normal during your stay. We think that you had low sodium levels because you were drinking large amounts of water (2 liters/day) to prevent kidney stones, and because your medication, Hyzaar, contained hydrochlorothiazide, which is known to potentially cause low blood sodium. At home please watch what you drink and only drink 1 liter per day. A follow up appointment has been made for you with urology so that they can determine the appropriate kidney stone prevention plan. While you are in rehab, your sodium level should be checked once daily for the first week to ensure that your sodium level remains normal. You were also found to have a new left lower facial droop while in the hospital, which began on [**2161-8-9**] and progressed to involve the upper part of your left face as well. You were evaluated by neurology, and CT and MRI scans of your brain and neck showed no evidence of stroke. Carotid artery ultrasound and cardiac echocardiogram were normal and without change. Given your symptoms and the negative head imaging, you were diagnosed with Bells Palsy. Bells Palsy is a self-limited condition that is often due to an unclear reason but can be due to viral or bacterial infection. It is estimated that 85% of people show signs of recovery within three weeks and 71% of people have complete recovery. We tested your blood for herpes simplex virus and Lyme disease to see if perhaps these infections caused your symptoms. These tests were pending at the time of discharge, and may be followed-up by your primary care provider as an outpatient. As we await the results of these tests, we will empirically treat you with Doxycycline antibiotic for presumed Lyme infection. If the Lyme test returns negative, you may stop this medication. This lab result should be resulted by Tuesday [**2161-8-18**], and your physician at the rehabilitation facility or your primary care provider should follow this up for you. You were started on a one week course of prednisone for the Bells Palsy. Once you are out of rehab, you should see your primary care provider within two weeks so that he may assess you and manage your condition further if needed. In addition, you had complained of back pain during this admission. X-rays done of your complete spine showed only bony arthritic changes that are expected findings as people age. Your pain was likely related to a musculoskeletal strain, and improved over the time you were admitted in the hospital on Tylenol and a Lidocaine patch as needed. As you also complained of constipation, we placed you on a bowel medication regimen as outlined below in the medication section. Lastly, you were found to have elevated blood pressure once we stopped your Hyzaar. We continued you on Losartan, and increased your atenolol from 37.5 mg daily to 50 mg daily. You were deemed medically stable for discharge to a rehabilitation facility on [**2161-8-12**]. Physical therapy evaluated you and felt that a rehab facility would help you increase your strength prior to going home. Should you have any worsening or new lethargy, neurological symptoms, pain, or any other concerning symptom you should be seen by a medical provider [**Name Initial (PRE) 2227**]. The following changes have been made to your medications: STOPPED: HYZAAR CHANGED MEDICATIONS: Atenolol 25 mg po once daily --->to Atenolol 50 mg po once daily NEW MEDICATIONS: *Losartan 100 mg po once daily for high blood pressure *Prednisone 60 mg po once daily for 7 days then stop (no taper needed) for Bells Palsy *Docusate Sodium 100 mg capsule take one twice per day for constipation. *Senna 8.6 mg tablet, take one twice per day for constipation. *Bisacodyl 5 mg tablet, 2 tabs once daily for constipation, hold for diarrhea. *Lactulose syrup 30 mL, take once every 6 hours as needed for constipation. *Fleet enema, as needed for constipation *Acetaminophen 500 mg tablet, take 1-2 tabs every 6 hours as needed for pain. *Lidocaine 5% patch one patch daily as needed for back pain. *Erythromycin 5mg/g ointment, apply one thin ribbon to bottom L inner eyelid twice daily for eye redness. *Tears Again 1.4% drops, 1-2 drops into the left eye three times per day for left eye dryness until Bells Palsy resolves. *Doxycycline 100 mg twice daily x 21 days for infection. Followup Instructions: You have the following appointments: Vascular Surgery Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Location: [**Location (un) **], [**Hospital **] Medical Building, [**Location (un) 442**] Phone: [**Telephone/Fax (1) 1237**] Date: [**2161-8-31**] Time: 10:30 AM Urology Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Location: [**Location (un) **], [**Location (un) 86**], [**Last Name (LF) **], [**First Name3 (LF) **] 440 Phone:[**Telephone/Fax (1) 5727**] Date: [**2161-8-31**] Time: 3:00 PM You should also make an appointment with your primary care provider within two weeks of discharge from rehab: Name: [**First Name8 (NamePattern2) 2946**] [**Last Name (NamePattern1) **], MD Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 2205**] Completed by:[**2161-8-16**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

17244, 17351

9877, 14187

310, 317

17446, 17463

6348, 6348

22327, 23274

4106, 4149

14684, 17221

17372, 17425

14213, 14661

17487, 22304

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4164, 6329

249, 272

345, 2734

6364, 7226

2756, 3629

3645, 4090

10,999

191,619

22912

Discharge summary

report

Admission Date: [**2188-3-4**] Discharge Date: [**2188-3-13**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: Transfer from OSH for acute MI. Major Surgical or Invasive Procedure: Cardiac catheterization [**2188-3-4**] Percutaneous coronary angioplasty History of Present Illness: Ms. [**Known lastname 37217**] is a [**Age over 90 **] year-old female with CV risk factor of age and hypertension, with a past medical history also significant for lung cancer status post resection, remote colon cancer status post resection, and hypothyroidism, who presented to [**Hospital3 **] on [**2188-3-4**] with acute left-sided chest pain. She notes that she developed a tooth ache 1 day prior to admission. Then at 1100 AM on the day of presentation, she developed acute left-sided chest pain, severe, with radiation to the back. She denies associated SOB, no N/V. No prior similar episode. At the OSH, initial vitals were T 95, BP 124/75, HR 78, RR 18, Sat 98% on room air. EKG revealed ST elevations in V1-4. She was given 4 baby aspirins, [**Name (NI) **] 150 mg PO X 1, Lopressor 2.5 mg IV X 3, then Heparin bolus 1400 units then drip 400 cc/ hour. She was also started on a NTG drip at 70 mcg/min. She was never chest pain free at the OSH and was emergently transferred to the [**Hospital1 18**] for cardiac catheterization. Past Medical History: 1. Lung cancer (adenocarcinoma, stage 1) diagnosed in [**2182**], status post resection. 2. History of colon cancer 10 years ago, status post resection 3. Hypothyroidism 4. History of compression fracture Social History: She is widowed, and lives alone. She has no children. She has a visiting nurse who comes three times a week, and helps her with house chores and groceries. She ambulates without assistance, but has a history of prior falls. She never smoked, no EtOH. Family History: Mother with CAD at advanced age. Physical Exam: Physical examination on admission to CCU: VITALS: T 97.0, HR 93, regular, BP 130/77, RR 25, Sat 99% on 100% NRB Hemodynamics: PA 48/25 (34) GEN: Tachypneic, but still able to speak with full sentences. HEENT: Anicteric. NECK: JVP not seen, patient laying flat. No carotid bruit. RESP: Fair air entry bilaterally. Fairly clear on inspiration, but diffuse expiratory crackles. No wheezing. No bronchial breathing appreciated. CVS: Somewhat distant heart sounds. S1, S2. No murmur appreciated. GI: BS normoactive. Abdomen soft and non-tender. EXT: Right groin (cath site): Sheath still in place. No hematoma, no bruit. Strong pedal pulses bilaterally. Neuro: Alert and oriented X3. Pertinent Results: Laboratory data from OSH [**2188-3-4**]: CBC: WBC 9.3, Hb 10.1, Hct 30.6, Plt 197. Chemistry: Na 140, K 5.1, Cl 104, HCO3 23, BUN 24, Creat 1.0, Glucose 275, Ca 10.0, Mg 2.0. ALP 57, AST 31, ALT 23, T bili 0.4 Cardiac enzymes: Trop I 0.27 EKG at OSH on arrival: NSR, rate 77, normal intervals, LAD. No Qs. ST elevation in V1-4. No clear reciprocal changes. EKG at OSH: NSR, rate 71 bpm. ST elevation (3-5mm) in V1,2,3,4, aVL. ST depression 1-2 mm in II, III. No Qs. [**Hospital1 18**], relevant data on admission: [**2188-3-4**]: PLT COUNT-193 HCT-30.7* POTASSIUM-5.0 Cardiac enzymes: [**2188-3-4**] 10:45PM CK(CPK)-5905* [**2188-3-4**] 10:45PM CK-MB and cTropnT greater than assay [**2188-3-4**] CARDIAC CATHETERIZATION: HEMODYNAMICS RESULTS **PRESSURES RIGHT ATRIUM {a/v/m} 12/10/9 RIGHT VENTRICLE {s/ed} 44/12 PULMONARY ARTERY {s/d/m} 44/24 PULMONARY WEDGE {a/v/m} 28/34/27 AORTA {s/d/m} 119/67/90 HEART RATE {beats/min} 65 RHYTHM SINUS O2 CONS. IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 62 CARD. OP/IND FICK {l/mn/m2} 2.6/2.0 **RESISTANCES SYSTEMIC VASC. RESISTANCE 2492 **% SATURATION DATA (NL) SVC LOW 44 PA MAIN 39 AO 84 COMMENTS: 1. Coronary angiography of this right dominant system revealed single vessel coronary artery disease. The left main coronary artery had a 40% ostial stenosis. The LAD had a total occlusion of the proximal vessel. The LCX had minimal disease. The RCA had serial stenoses in the mid and distal vessel. 2. Resting hemodynamics were performed. Right sided pressures were mildly elevated (mean RA pressure was 9 mm Hg and RVEDP was 12 mm Hg). Pulmonary artery pressures were moderately elevated (PA pressure was 44/24 mm Hg). Left sided pressures were severely elevated (mean PCWP was 27 mm Hg). Cardiac index was low (at 2 L/min/m2). 3. Successful PCI of the LAD-D1 with a 2.5 x 23 mm Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5177**] from the proximal LAD into D1 with rescue of the LAD ostium with a 2.5 mm balloon. 4. Successful closure of right femoral arteriotomy with a 6 French AngioSeal device. FINAL DIAGNOSIS: 1. Severe single vessel coronary artery disease. 2. Severely elevated left sided pressures. 3. Successful PCI of LAD with DES. ************** [**2188-3-4**] CXR: AP single view of the chest has been obtained with the patient in supine position. The heart is enlarged with a prominence of the left ventricular contour to the left. The thoracic aorta is widened and elongated and shows calcium deposits in the wall mostly at the level of the arch. A catheter approached from below passes through the right heart and terminates in the central portion of the left main PA. There is no pneumothorax or any other placement related complication. The accessible lung fields demonstrate a pulmonary vasculature, which is irregular in distribution consistent with COPD. There is no conclusive evidence for pulmonary edema on the left side; however, on the right side a perivascular haze is present and the right lateral pleural sinus is blunted. Diffuse density over the entire lower portion of the right hemithorax is indicative of pleural effusion layering posteriorly. Some pleural effusion is also present on the left side but to a lesser degree. In the hilar region one can identify multiple centrally located surgical clips indicative of previous surgery, nature is unknown. There is no evidence of any external wiring. Diffuse skeletal demineralization is noted, and there is at least one vertebral body with significant compression in the lower thoracic spine. There exists no prior chest examination or records available for comparison. IMPRESSION: Left ventricular enlargement, bilateral pleural effusion more marked on the right, pulmonary emphysema pattern probably interferes with assessment of pulmonary vasculature on the radiograph. Suggest correlation with findings on Swan-Ganz catheter to determine degree of left-sided fitting pressure elevation. ******************** [**2188-3-5**] ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is severe regional left ventricular systolic dysfunction. Overall left ventricular systolic function is severely depressed (20%). Resting regional wall motion abnormalities include mid to distal anteroseptal and apical akinesis with hypokinesis elsewhere. No apical thrombus identified but cannot exclude. Right ventricular chamber size and free wall motion are normal (although apex not fully visualized). The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is no pericardial effusion. [**2188-3-13**] ECHO (preliminary report): No pericardial effusion. No LV thrombus. Brief Hospital Course: [**Age over 90 **] year-old female with CV risk factors of HTN and age, with a PMHx also significant for lung cancer and colon cancer both status post resection, now admitted with AMI, found to have TO of LAD, status post stent/PTCA on [**2188-3-4**]. 1) Anterior MI: As mentioned above, Ms. [**Known lastname 37217**] was taken directly to the cath lab. Coronary angiography revealed total occlusion of the LAD, and stenting of the LAD into OM1 was performed, with rescue PTCA to the LAD. Hemodynamics in the cath lab were remarkable for elevated left-sided pressures with PCWP 27, low CO/CI 2.6/2.0 and elevated SVR 2492, consistent with cardiogenic shock. She was transferred to the CCU for further management. Of note, peak cardiac enzymes were CK 5905, ad CK-MB/TropT greater than assay. In the CCU, she was started on ASA, [**Known lastname **], high-dose Lipitor and continued on low-dose Captopril, later held in the setting of worsening renal failure. She was also started on Dobutamine for inotropic support. Integrilin was not given post-procedure given her age and high bleeding risk. Beta-blockade therapy was held. Dobutamine was later changed to Dopamine on [**2188-3-5**] secondary to hypotension. Her picture was further complicated by a clinical and radiographic picture of CHF, worsening renal failure and poor urine output. Natrecor was added on [**2188-3-6**] to provide afterload reduction, improve forward flow and favor diuresis, with good response. Both medications were eventually stopped on [**2188-3-8**], and she remained hemodynamically stable. Beta-blockade therapy was subsequently reinitiated, along with ACE, and both were titrated up in hospital. An echo was performed on [**2188-3-5**], which revealed EF of 20% with mid to distal anteroseptal and apical akinesis with hypokinesis elsewhere, 2+ AR, 1+ MR, 3+ TR. Given her low EF with concomitant apical akinesis, she was started on Heparin IV. The latter was stopped in the setting of dropping hematocrit and guaiac positive stools. She was also deemed a poor candidate for long-term anticoagulation given a prior history of falls, and anticoagulation was not resumed in hospital. On [**2188-3-12**], she was noted to have a pericardial rub, and a repeat echo was performed on [**2188-3-13**], which revealed no pericardial effusion. There was also no LV thrombus. She was discharged on ASA, [**Date Range **], Lisinopril 10, Toprol 50, and Lipitor 80. She will need follow-up LFTs given high-dose statin therapy. Follow-up will be arranged with Dr. [**Last Name (STitle) **] in cardiology. Consideration could be given to titrating beta-blockade therpay as an out-patient. 2) CHF: As mentioned above, an echo on [**2188-3-5**] revealed an EF of 20%. Clinically, she had elevated oxygen requirements, with a radiographic picture consistent with CHF. Her picture was further complicated by worsening renal failure and poor urine output. She initially responded poorly to Lasix boluses for diuresis and was started on Natrecor in addition to Dopamine. She did well on the latter 2 medications. Lasix diuresis was resumed on [**2188-3-8**] with doses of 20-40mg IV per day and good diuresis. Her oxygen requirement decreased with continued diuresis. ACE inhibitor therapy was temporarily held in the setting of renal failure and reintroduced for afterload reduction. She was also placed on standing Lasix 20 mg PO qd prior to discharge. Weight at discharge is 36.3 kg. She will need close weight monitoring. Consider higher Lasix dose if weight increases >3lbs. She will also need follow-up lytes with repletion as needed. 3) Acute renal failure: Creatinine on admission was 1.4 and rose to 2.1 on [**2188-3-5**]. Urine lytes were suggestive of prerenal physiology with FeNA 0.2%, and her renal failure was ultimately felt likely secondary to poor forward flow and contrast nephropathy. Captopril was held. Her kidney function steadily improved after [**2188-3-6**], and is 1.0 at discharge. ACE was reintroduced and well tolerated. 4) Heme: Ms. [**Known lastname 37217**] had low hematocrits in hospital, with normocytic indices, and was transfused a total of 2 units of PRBCs. Stools were guaiac positive while on Heparin, which was held. Further work-up was not pursued. 5) Hypothyroidism: She was continued on her out-patient dose of Levoxyl 75 mcg PO QD. 6) Code: Ms. [**Known lastname 37217**] expressed her desire to be DNR/DNI after admission. Medications on Admission: Levoxyl 75 mcg PO QD Atenolol 50 mg PO QD Captopril 25 mg PO TID Darvocet 100 mg PO Q8 hours prn for pain Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 90 days: Stent placement [**2188-3-4**]. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Lifecare of [**Location (un) **] Discharge Diagnosis: Myocardial infarction status post coronary stent Congestive heart failure Hypertension Secondary diagnoses: Hypothyroidism Osteoporosis Discharge Condition: Patient discharged to rehab in stable condition. Weight at discharge is 36.3 kg. Discharge Instructions: We have started new medications in the hospital. Please take all medications as prescribed. Most importantly, YOU HAVE TO TAKE [**Location (un) **] AND ASPIRIN DAILY to prevent blockage of your stent. You have a scheduled appointment with Dr. [**Last Name (STitle) **] on Thursday [**3-20**] at 11:30 AM. It is important that you go to this appointment. We will also schedule an appointment with Dr. [**Last Name (STitle) **] in the Department of Cardiology. We will call you with the date, time and location of the appointment. Please call your PCP or return to the hospital if you experience chest pain, worsening shortness of breath, or if your legs start to swell. Followup Instructions: You have a scheduled appointment with Dr. [**Last Name (STitle) **] on Thursday [**3-20**] at 11:30 AM. It is important that you go to this appointment. We will also schedule an appointment with Dr. [**Last Name (STitle) **] in the Department of Cardiology. We will call you with the date, time and location of the appointment. Completed by:[**2188-3-13**]

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icd9cm

[ [ [] ] ]

[ "00.13", "99.04", "36.07", "88.56", "37.23", "36.01" ]

icd9pcs

[ [ [] ] ]

13567, 13626

7720, 12167

293, 367

13807, 13889

2699, 2911

14609, 14969

1950, 1984

12323, 13544

13647, 13735

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13913, 14586

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3218, 3273

1460, 1666

1682, 1934

7,088

178,239

28452

Discharge summary

report

Admission Date: [**2116-12-14**] Discharge Date: [**2117-1-16**] Date of Birth: [**2042-4-17**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3376**] Chief Complaint: Bleeding small bowel mass, presents for elective surgical resection Major Surgical or Invasive Procedure: [**12-14**] Small bowel enteroscopy, small bowel resection, lysis of adhesions History of Present Illness: Mr. [**Known lastname 69005**] is a 74 year old male who who had a probable transient ischemic attack earlier in the year and underwent extensive cardiovascular work-up and was placed on aspirin and Plavix. He became persistently anemic despite iron therapy and GI evaluation was undertaken. Upper GI and colonoscopy were both negative. The small bowel was evaluated with capsule endoscopy, which identified a lesion in the small bowel that was ulcerated and bleeding. Push enteroscopy was not successful. Preoperative CT scan was done which showed no evidence of intraabdominal neoplasia. No small bowel lesion was seen. The preoperative CEA level was normal. Resection was recommended as no other source of bleeding had been found. After preoperative clearance, the patient was taken to the operating room for scheduled surgery on [**12-14**]. Past Medical History: Past Medical History; Lower gastrointestinal bleeding Hypertension ?TIA Osteoarthritis Grade 2 esophagitis Past Surgical History; Removal of bullet in Korean war Social History: Married, former smoker x 20 yrs, 1 pack per day, quit 25 yrs ago; Occasional alcohol use Family History: Non-contributory Physical Exam: T 99 P 78 BP 147/52 R 20 SaO2 95% Gen - no acute distress Heent - no scleral icterus, no cervical lymphadenopathy Lungs - clear heart - regular rate and rhythm Abd - soft, nontender, nondistended, bowel sounds audible Extrem - warm, well perfused, no lower extremity edema Pertinent Results: Post-operative: [**2116-12-14**] 09:55PM BLOOD Hct-30.9* [**2116-12-15**] 04:12AM BLOOD Plt Ct-330 [**2116-12-14**] 09:55PM BLOOD Glucose-190* UreaN-11 Creat-1.0 Na-141 K-3.4 Cl-104 HCO3-21* AnGap-19 [**2116-12-14**] 09:55PM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0 Discharge: OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Small bowel lesion identified by capsule endoscopy, source of anemia. POSTOPERATIVE DIAGNOSIS: Small bowel and pelvic adhesions with acute angulation. PROCEDURE PERFORMED: Exploratory laparotomy, lysis of adhesions, intraoperative enteroscopy of the entire small bowel through jejunal enterotomy and small bowel resection x1. Pathology Examination SPECIMEN SUBMITTED: JEJUNUM. DIAGNOSIS: Segment of jejunum: 1. Peritoneal fibrous adhesions with focal foreign body reaction. 2. Inflammatory polyp with marked granulation tissue. 3. There is a transmural tear without hemorrhage or inflammation which is probably post-surgical. 4. The rest of the mucosa is within normal limits. Clinical: Small bowel ulcerated lesion, source of anemia. RADIOLOGY Final Report CHEST (PORTABLE AP) [**2116-12-15**] 1:07 AM CHEST (PORTABLE AP) Reason: please eval placement of NGT. COMPARISON: No prior studies are available for comparison. CT of the abdomen and pelvis [**2116-11-19**] was reviewed. IMPRESSION: Nasogastric tube tip overlying the stomach. No acute cardiopulmonary process identified. RADIOLOGY Final Report CTA CHEST W&W/O C &RECONS [**2116-12-16**] 5:50 PM Reason: evL FOR PE PT IS S/P sb RESECTION W/ HYPOXIA AND MENTAL STAT CTA OF THE CHEST. COMPARISON: None. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Small right-sided pleural effusion, and minor atelectatic changes bilaterally. CHEST (PORTABLE AP) [**2116-12-16**] 2:00 PM IMPRESSION: Possible left lower lobe infiltrate. Cardiology Report ECG Study Date of [**2116-12-16**] 2:10:24 PM Normal sinus rhythm. Non-specific ST-T wave abnormalities. No change compared to the previous tracing of [**2116-12-8**]. Intervals Axes Rate PR QRS QT/QTc P QRS T 79 134 100 390/424.42 9 -9 86 Operative Report [**12-26**]: PREOPERATIVE DIAGNOSIS: Bile drainage from abdominal wound. POSTOPERATIVE DIAGNOSIS: Enterocutaneous fistula with wound abscess due to suture erosion. PROCEDURE PERFORMED: Exploratory laparotomy, repair of enterotomy, abdominal wash-out and wound closure. CT scan [**1-1**] IMPRESSION: 1. New enterocutaneous fistula, most likely arising from the small bowel anastomosis. Extraluminal contrast within small amount of intraperitoneal fluid. 2. Bibasilar pulmonary opacities probably representing a combination of atelectasis, aspiration, and pneumonia, grossly unchanged since [**2116-12-23**]. 3. New small bilateral pleural effusions. Microbiology: [**2116-12-26**] 10:58 am SWAB Source: wound. **FINAL REPORT [**2116-12-30**]** GRAM STAIN (Final [**2116-12-26**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2116-12-28**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). RARE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES) CONSISTENT WITH SKIN FLORA. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. OF THREE COLONIAL MORPHOLOGIES. ANAEROBIC CULTURE (Final [**2116-12-30**]): NO ANAEROBES ISOLATED. [**2117-1-4**] 10:00 am SWAB Source: Rectal swab. **FINAL REPORT [**2117-1-6**]** R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2117-1-6**]): No VRE isolated. [**2117-1-4**] 10:00 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2117-1-6**]** MRSA SCREEN (Final [**2117-1-6**]): No MRSA isolated. [**2117-1-3**] 2:01 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2117-1-3**]** CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2117-1-3**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. Brief Hospital Course: Mr. [**Known lastname 69005**] had no intra-operative complications, post-operatively he was NPO with a Dilaudid PCA, a subcutaneous pain pump, intravenous hydration, telemetry monitoring, foley catheter, and nasogastric tube. He experienced confusion and agitation post-operatively which was treated with restraints and Haldol, an EKG was negative for ischemia, he was afebrile, and hemodynamically stable with a hematocrit of 29.8, the confusion had resolved by POD 1. On POD 2 he had hypovolemia with decreased urine output which responded well to intravenous bolussing. On POD 2 he had intermittent confusion with desaturation which improved on nasal cannula; chest x-ray and chest CT scan were negative for an embolus, he had a small right pleural effusion without evidence of aspiration. A geriatrics consult was placed and the narcotics were discontinued. On POD 4 he had +flatus and a bowel movement, his diet was advanced which he tolerated well, he had improvement in his mental status with orientation to person, time, and place. On POD 8, he had an episode of emesis with desaturation, was transferred to the ICU for furher management of aspiration pneumonia confirmed by CT and X-ray, broad spectrum antibiotics were started, he was maintained on oxygen therapy, a nasogastric tube was placed, and he was NPO with initiation of TPN. On POD 11, he required mechanical ventilation with intubation, was febrile with leukocytosis of 20k, received a transfusion for a hematocrit of 23; all microbiology cultures had been negative to date. His incision was noted to have bilious drainage, he was taken back to the operating room for an exploratory laparotomy, repair of enterotomy, abdominal wash-out and wound closure, with findings of an enterocutaneous fistula with wound abscess due to suture erosion. The skin was not closed, and the wound was packed with gauze. Post-operatively he required additional transfusions for a hematocrit of 24, with a good response. On POD 16/4, he was sucessfully extubated. The following day, he became hypertensive with SBP up to 200, ekg showed inverted T waves, and cardiac enzymes were cycled which were negative for myocardial infarction. He had a swallow evaluation which showed aspiration of thin liquids. We continued the TPN and advanced his PO diet slowly. Tube feeds were started via a Dobhoff tube, but was stopped because the patient had increased drainage from his wound. On [**2117-1-1**], a CT scan was obtained for leukocytosis and abnormal drainage from the abdominal wound, which revealed an enterocutaneous fistula, most likely arising from the small bowel anastomosis. There was also extraluminal contrast with a small amount of intraperitoneal fluid. A VAC dressing was placed over the wound for drainage purposes. The patient developed hypernatremia and a Renal consult was obtained. It was determined that the patient likely was having post-acute tubular necrosis diuresis with an element of nephrogenic diabetes insipidus. TPN without sodium as well as D5W were infused to keep his sodium level less than 147. Sodium levels were followed closely throughout the day and it remained stable at 143 at discharge with the D5W infusions. On [**2117-1-6**], the patient was transferred to the floor. Throughout the [**Hospital 228**] hospital course, he had been delirious, confused, and agitated at times requiring haldol for sedation. We encouraged the patient to use the incentive spirometer, use of neuroleptics were held, and we continued to reorient the patient. One to one sitter was obtained to monitor the patient. His agitation improved, but he continued to remain confused. Physical therapy was consulted to assist the patient with mobility and rehab was recommended for him. We expect his mental status to improve in rehab. When the patient's bowel function returned, he was started on a diet of nectar thickened liquids, pureed solids with PO meds crushed in puree. Supervision with meals by nursing staff were done to maintain aspiration precautions. The patient continued to have poor PO intake. His TPN was discontinued in order to see if this would increase his appetite and we continued to encourage PO intake. Before discharge, the patient had another swallow evaluation and demonstrated signs of aspiration of thin liquids by straw sips and his diet was changed to a thin liquid, soft solid diet without the use of a straw. The patient continued to have poor PO intake despite the new diet. A PICC line was placed should the patient require TPN. On the day of discharge, the patient had cloudy urine in his foley bag and was having liquidy stools. A cdiff test was pending. A UA was positive for UTI and the patient was started on a 7 day course of Cipro. The patient was discharged in stable condition. Medications on Admission: Plavix ASA Prilosec Iron MVI Glucosamine Triamterene Tylenol Ibuprofen Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebule Inhalation Q6H (every 6 hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebule Inhalation Q6H (every 6 hours) as needed. 5. Levothyroxine 25 mcg 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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Bleeding from small bowel polyp Enterocutaneous fistula Discharge Condition: Stable Discharge Instructions: Call your doctor if you experience fever, chills, lightheadedness, dizziness, chest pain, shortness of breath, palpitations, severe abdominal pain, or nausea/vomiting. No driving while taking pain medications. Activity as tolerated. No tub baths. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 17489**] Follow-up appointment should be in 2 weeks

[ "682.2", "599.0", "568.0", "211.2", "518.81", "280.0", "584.5", "569.81", "560.1", "507.0", "008.45", "401.9", "293.0", "588.1", "276.52", "719.47", "578.9", "997.4", "276.0", "789.5" ]

icd9cm

[ [ [] ] ]

[ "45.11", "38.91", "96.72", "93.59", "38.93", "45.62", "86.22", "99.04", "96.04", "96.07", "54.59", "45.91", "96.6", "33.24", "46.73", "99.15" ]

icd9pcs

[ [ [] ] ]

12163, 12263

6279, 11089

383, 464

12363, 12372

1980, 6256

12668, 12802

1650, 1668

11210, 12140

12284, 12342

11115, 11187

12396, 12645

1683, 1961

276, 345

492, 1340

1362, 1528

1544, 1634

20,639

174,056

27248

Discharge summary

report

Admission Date: [**2178-5-17**] Discharge Date: [**2178-6-4**] Date of Birth: [**2148-9-1**] Sex: M Service: MEDICINE Allergies: Levofloxacin / Nsaids Attending:[**First Name3 (LF) 2181**] Chief Complaint: Shock Major Surgical or Invasive Procedure: Patient had a tunnelled HD line placed on [**2178-6-3**]. . Patient was intubated at OSH, extubated [**5-28**] - total of 11 days. History of Present Illness: 29 year-old male patient with a history of DM2, obesity, OSA and pericarditis (6 months ago) who presented to [**Hospital1 14360**] on [**2178-5-16**] with chest pain, back pain, fevers, chills and shortness of breath for one day. His pain was described as sharp, worse with inspiration and on laying supine and relieved by sitting and leaning forward. He also reported diaphoresis and cough productive of green sputum. He had a similar episode 6 months prior to admission and was diagnosed with pna and "fluid accumulation around the heart". He was treated with NSAIDS at a hospital in [**State 3914**]. . His vital signs on presentation to the OSH were: Temp 103, BP 89/30, HR 116-138, RR 28, 97% on 2 L. His WBC was 15 (73 N, 11 L), CPK 253, (MB 21.5, Index 8.5), trop I 2.88. Glucose was 310. Bili 4.2, alk phos 91, ast 416, alt 325, LDH 1130. CXR was negative for infiltrates, ECG with STE 1mm in I and AVL, PR depression in I and AVL. He received 2L IVF boluses, 1gm of CTX and 500mg of Azithromycin. He was given a diagnosis of percarditis, treated with Motrin 800mg tid, and admitted to teh ICU. . An Echo showed an EF 25%, global HK, dilated LV. There was no pericardial effusion and RV appeared normal size. Dopamine was used for BP support and the patient was subsequently intubated for respiratory distress. He was found to be in DKA with blood glucose in the 600's and ketones in the urine. 100mg of lovenox was given empirically and was transferred to [**Hospital1 18**] for further management. . In the [**Hospital1 18**] CCU, the patient was thought to be in either cardiogenic shock or septic shock from a pneumonia. He was continued on Vancomycin, ceftriaxone, and azithromycin. Renal, GI and ID were consulted for renal failure, transaminitis (to AST 11,916) and septic shock of somewhat unclear etiology. Renal did not feel that there is an acute need for HD at this point and agreed with IVF and pressors. Infectious disease got a history of the patient recently removing dead rodents from an automobile fan and felt that atypical organisms were highly likely. They recommended changing azithromycin to doxycycline. Hepatology felt the clinical picture was most consistent with shock liver. The patient is being transferred to MICU per the request of ID and given evolving septic shock. Past Medical History: 1. Obesity 2. DM2 3. OSA on BiPAP 4. h/o Pericarditis 6 months ago Social History: Patient is married and has a 12 year-old daughter. [**Name (NI) **] works as a restaurant manager at [**Company **] Fridays (contact with food). Denies tobacco and reports rare ETOH use. No hx of IVDU. Recently moved to this area from [**State 3914**] (wooded area). No recent tick, bug or animal bites. No sick contacts. [**Name (NI) **] travel. His car recently had two large rodents removed from car fan. His wife previously worked in a Nursing Home, but hasn't in several months. Family History: Unknown Physical Exam: VS: Tm 103.7 Tc 101.4, BP 112/68 (88-122/62-88), HR 123 (125-150), RR 24 97% on Vent: AC: Tv: 700 x 24, FIO2 0.4, PEEP 10 -> PIP 35, Plateau 29, ABG 7.34/30/99, 7.32/28/130 CVP 23, CO 8.5, CI 2.63, SVR 687, MVO2 76 GEN: morbidly obese young man intubated and sedated HEENT: ETT in place, mmm Neck: large neck but no JVD appreciated CV: tachycardic, regular rhythm, no m/r/g PULM: mechanical breath sounds appreciated, crackles at the bases bilaterally ABD: obese, NABS, NT/ND Ext: cool extremities, no c/c/e, 1+ DP and PT b/l Neuro: intubated, sedated Derm: no rashes noted. Pertinent Results: CXR ([**5-17**]): Ill-defined opacities are present in the left mid and lower zones consistent with pulmonary consolidation. CXR ([**5-18**]): Air bronchogram present in the left lower lobe suggesting LLL pneumonia. Increased opacification in the right lower zone c/w atelectasis rather than pneumonia Abd US ([**5-18**]): Limited examination. Echogenic liver consistent with fatty infiltration. Other forms of liver disease, including more significant hepatic fibrosis or cirrhosis, cannot be excluded on the basis of this examination. Patent left and middle hepatic veins and left portal vein. Otherwise, extremely limited Doppler examination of the liver. Chest/Abd CT ([**5-18**]): Moderate-sized bilateral pleural effusions. No acute abdominal pathology Sinus CT ([**5-18**]): No sinusitis. Echo ([**5-18**]): Mild symmetric LVH. LV cavity moderately dilated. Severe global left ventricular hypokinesis with EF 15-20%. No masses or thrombi are seen in LV. RV systolic function appears depressed. LV inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure ECHO [**2178-5-25**]: Conclusions: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis. EF 45%. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2178-5-18**], the LVEF has improved and the LV cavity size has normalized. B/L LE US: CONCLUSION: Study is limited by body habitus, but there is no evidence of DVT in the left or right lower extremity. CT CHEST/ABDOMEN [**5-27**]: IMPRESSION: 1. Overall stable appearance of the chest, abdomen and pelvis. No CT evidence of pancreatitis. 2. Stable bilateral lower lobe consolidations which could represent aspiration or atelectasis. 3. Stable splenomegaly. Brief Hospital Course: *Shock: There was an initial concern for cardiogenic shock in the setting of possible pericarditis/myocarditis, EKG changes, elevated cardiac enzymes and Echo showing EF 25%. However, fevers, elevated WBC count and low SVR suggested more of a septic picture. Additionally, his cardiac output was elevated (though difficult to use those numbers which were from CVP and not swan). Shock was complicated by acute renal and hepatic failure, respiratory failure, relative adrenal insufficiency, cardiac depression and DKA. Source of septic shock was initially unclear and included multifocal pneumonia, pericarditis/myocarditis, atypical organism in setting of exposure to rodents. ?Hanta virus vs. [**Location (un) **] vs. Mycoplasma? Chest/Abd CT without pathology. No sinusitis on Sinus CT. In terms of BP, pt was appropriately switched from Dopamine to Levophed which was quickly titrated down, and discontinued more than a week before discharge. He remained hemodynamically stable throughout the remainder of his hospital course. He was treated with Zosyn and Vancomycin for a total of 13 days, and Azithromycin for a total of 5 days. All blood and urine cultures showed no growth, he had negative serologies for Chlamydia pneumoniae, [**Location (un) **] B, Leptospira, Mycoplasma pneumoniae, HCV, HBV, Influenza and Parainfluenza,ANCA and [**Doctor First Name **]. He was IgG positive, but IgM negative for EBV and CMV. He also tested positive for Legionella Antibodies and hepatitis. He was further tested positive for IgM Hantavirus, however the confirmatory [**Doctor First Name **] for Sin Nombre virus was negative. A repeat serology was sent to the state lab and the results were still pending on discharge. He was afebrile, with stable blood pressures at discharge. . *Fever: As above, the etiology of his septic shock was unclear. There was a suggestion of multifocal infiltrates on CXR suggesting possible pneumonia with bacterial pathogen. ID was consulted and considered atypical organisms such as mycoplasma, chlamydia, legionella, Leptospirosis and viral pathogens such as hepatitis, influenza, adeno, CMV, EBV, HIV, [**Location (un) **] and Hanta virus. Legionella IgG antibody returned with high titers of 256. This should be repeated at the end of [**Month (only) 116**] (around 30th); a fourfold rise in titer confirms acute infection. He completed a 5 day course of doxycycline, followed by a 5 day course of azithromycin as it was thought the doxycycline may have contributed to his pancreatitis. He continued to run low grade fevers until [**5-28**]. US of LE were done bilaterally without evidence of DVT. His fevers were likely related to atelectasis, with possible contribution of pancreatitis (see below). They resolved on their own by [**5-29**]. By the time of discharge he had completed a 13 day course of vancomycin and zosyn, as well as a 5 day course of azithromycin and was afebrile. He has scheduled follow-up with ID and his hantavirus serologies will be followed at that visit. . *Cardiomyopathy: Echocardiogram on [**5-18**] showed EF 15-20% in the setting of tachycardia (25% at the OSH on [**5-17**]), although windows suboptimal. Likely viral myocarditis (possible induced by [**Location (un) **] B vs. adenovirus vs. Hep C vs. CMV vs. Echovirus vs. EBV) vs. sepsis-induced cardiomyopathy vs. restrictive pericarditis given recent episode of pericarditis and filling defect on Echo. MVO2 73 and CO normal, with good oxygenation, making primary cardiogenic shock somewhat less likely. His BP was stable and heart failure and fluid retention was treated with CVVH. Original primary still unknown at this point, as all blood cultures remained negative and he tested negative for all above mentioned possible viruses. Unclear if possible Hantavirus infection could have been contributory and final results were still pending at discharge. Repeat echo about a week into his hospital course demonstrated recovery of EF to 45% (on [**5-25**]), normal LV cavity size, and no pericardial effusion. He should follow-up with cardiology to deal with this issue as an outpatient and was given their number. . *Acute renal failure: The patient's creatinine rose to 11.3 from a normal baseline. FENa was less than 1% and his renal failure was felt to be a complication of his shock. His potassium gradually increased and his volume status worsened and he was started on CVVH on [**5-21**]. He had improvement in his K, Cr and acidosis. Large volumes of fluid were removed with ultrafiltration. On [**5-26**] he was changed over to HD. He remains HD dependent, and had a HD tunneled line placed on [**6-3**]. Initial anuria resolved and pt puts out small amounts of urine now. He will receive HD as an outpatient and will follow-up with nephrology for further treatment adjusments. . *Acute hepatitis: The patient was admitted with markedly elevated LFTs to an AST of 11,916. The height of his LDL ([**Numeric Identifier **]) and the speed of the rise in LFTs is suggestive of shock liver and not congestion. Hepatology was consulted during his stay and agreed with this as the likely cause. His INR and LFTs improved dramatically, confirming this diagnosis, steadily trending down over the course of his hospital stay. . *Respiratory distress: The patient was intubated at the outside hospital in setting of respiratory distress and DKA. There was no evidence of ARDS on imaging exams and he did well on the ventilator. He underwent a bronchoscopy on [**5-19**] which showed scant secretions that were negative for organisms. He had bilateral lower lobe infiltrates on CT scan, and was started on vancomycin/zosyn, as well as doxycycline for atypical coverage, as above. He was eventually weaned to PSV and then extubated on [**5-28**] without complication after almost 2 weeks of intubation.His O2 Saturation remained stable after extubation, 96-98% on RA, no drop in O2Sat on ambulation. Patient's respiratory status was stable on discharge. . *DKA: The patient was admitted with elevated blood sugars, anion gap and trace ketones in urine. He was treated effectively with an insulin drip. He had a persistent anion gap which was felt to be secondary to his renal failure, as repeat ketone/beta hydroxybutyrate assays were negative. His sugars were well controlled on an insulin sliding scale. . *Pancreatitis: He had low grade fevers even after about 9 days of antibiotics, and in search of a cause, his pancreatic enzymes were found to be elevated. An abdominal CT scan did not reveal radiographic evidence of pancreatitis. It was noted that the enzymes trended up shortly after restarting propofol for sedation, and that this had happened once previously. His amylase and lipase both began to trend down after propofol was discontinued again. There was a thought that doxycycline could also have contributed, and this was changed to azithromycin. Once extubated, he denied abdominal pain, and his fevers resolved. After transfer to the floor his lipase and amylase steadily came down, pt was non-tender in epigastric area on exam and denied abdominal pain. . *Splenomegaly: He was noted to have splenomegaly on both of his abdominal CT scans here. It is unclear if this has been present previously. EBV IgG was positive but not IgM. He had no hilar or mediastinal adenopathy making sarcoidosis less likely. He does not drink alcohol excessively. It's possible that he developed portal hypertension acutely in the setting of shock liver. He should likely have a repeat CT scan at some point in the future to re-evaluate the spleen. His CBC should be monitored periodically as well. On the floor he complained of transient LUQ pain on two occassions for which he did not require any treatment or further work-up. He should follow-up with his PCP for repeat CT and CBC monitoring. He has been set-up with a PCP, [**Name10 (NameIs) 14169**] he did not have one previously, and is scheduled to see him on [**2178-6-11**] in [**Hospital 191**] clinic. . *Hypertension/tachycardia/bigeminy: The patient had persistent tachycardia during the hospitalization, probably related to his fevers, as well as his body habitus/deconditioning. He was treated with beta blockers (labetalol drip peri-extubation, with transition to PO metoprolol). He was noted to have ventricular bigeminy just after starting HD on [**5-27**]. His bigeminy resolved with calcium supplementation (his free calcium was noted to be low). Pt's blood pressures were well controlled on metoprolol. . *Leg pain: Pt developed leg swelling, discolorisation (red to purple), blisters (bloody and non-bloody), necrotic changes on toes and pain in both feet. These changes were most likely due to malperfusion, secondary to cardiogenic shock. His legs improved during his stay, though he still reported dull pain, 'pins and needles' in his feet. He did not require pain medication for that during the days prior to discharge. He will follow up with plastic surgery, and an appointment was scheduled for [**6-12**], for further evaluation and treatment. . *Nausea: Pt had waxing and waining episodes of nausea during the course of his hospital stay which were well controlled with Prochlorperazine. On the day of discharge pt has some nausea and was treated with prochloperazine. Medications on Admission: 1. Metformin CR 2gm daily 2. Afrin 3. Blood pressure medication, which he isn't taking . On transfer to MICU 1. Zosyn 2.25g IV q8h 2. Doxycycline 50mg IV q12 (after 100mg loading dose) 3. Vancomycin 1G IV daily 4. Aspirin 325mg daily 5. Lansoprazole 30mg NG daily 6. CaCO3 1g TID 7. Acetaminophen 325mg-650mg q4-6h prn, do not exceed 2g/day 8. Colace 100mg [**Hospital1 **] 9. Fludrocort 0.05mg daily 10. Hydrocort 50mg IV q6h 11. Hep SQ 12. Senna 1 tab [**Hospital1 **], prn Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) SC injection Injection TID (3 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Insulin sliding scale Please place the patient on an insulin sliding scale per the protocol of your institution 5. Metoprolol Tartrate 25 mg Tablet Sig: [**1-12**] Tablet PO three times a day. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 10. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 11. Prochlorperazine 10 mg IV Q6H:PRN 12. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea 13. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [**4-16**] hours as needed for pain. 14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: no more than 2 gm per day. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Primary Diagnosis: Septic Shock Acute Respiratory Distress Shock Liver Pancreatitis Acute Renal Failure Cardiomyopathy Diabetic Ketoacidosis . Secondary Diagnosis: Diabetes Hypertension Discharge Condition: Stable condition with low UOP and dialysis dependent Discharge Instructions: You are being discharged to a rehabilitation facility. . Please take all your medications as prescribed. . Please call your doctor or return to the ER if you have nausea, vomiting, chest pain, shortness of breath, abdominal pain, fevers, increased difficulty with urination, blood in your urine or other concerning symptoms. Followup Instructions: Please follow up in plastic surgery clinic as below. Please call 2-3 days prior to your appointment to give them your information. Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2178-6-12**] 2:30 . Please follow-up with Infectious Disease. We have scheduled an apppointment for you with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2178-7-1**] at 10 am, Phone:[**Telephone/Fax (1) 457**]. Please call in prior to your appointment at the above mentioned number to check directions. . For your information: Dr. [**Last Name (LF) 9138**], [**First Name3 (LF) **], primary care physician, [**Name10 (NameIs) 66825**] in obesity, working at the [**Hospital 18**] clinic. If you are interested in seeing her please scheduled an appointment with her. Her phone number is [**Telephone/Fax (1) 250**].

[ "577.0", "425.4", "785.4", "518.0", "327.23", "785.52", "584.5", "518.81", "278.01", "250.30", "995.92", "038.9", "486", "789.2", "570", "427.89" ]

icd9cm

[ [ [] ] ]

[ "88.73", "33.24", "39.95", "96.6", "38.93", "00.17", "38.95", "96.72" ]

icd9pcs

[ [ [] ] ]

16993, 17067

5892, 15191

286, 419

17297, 17352

3985, 5869

17725, 18602

3366, 3375

15717, 16970

17088, 17088

15217, 15694

17376, 17702

3390, 3966

241, 248

447, 2758

17252, 17276

17107, 17231

2780, 2848

2864, 3350

1,493

140,633

7077

Discharge summary

report

Admission Date: [**2169-2-27**] Discharge Date: [**2169-3-10**] Date of Birth: [**2110-7-17**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Shellfish Attending:[**First Name3 (LF) 1505**] Chief Complaint: Coronary artery disease Major Surgical or Invasive Procedure: [**2-27**] Cardiac catheterization [**3-2**] CABG x 4 History of Present Illness: Patient is a 58 year old male with a history of IDDM (x 48 years), HTN, hypercholesterolemia, CKD, PVD s/p bypass surgery x2 (right BK/[**Doctor Last Name **] to dital peroneal with SVG; left fem-[**Doctor Last Name **] bypass) and right transmetatarsal amputation who presented to [**Hospital3 2737**] on evening of [**2169-2-26**] with symptoms of [**10-24**] chest pain radiating to left arm that evolved in the setting of shoveling snow. Pain started around 20:00 with associated diaphoresis, nausea, and shortness of breath. EMS evaluation was significant for bradycardia in 40s with SBP of 80 for which the patient received atropine. Initial ECG on arrival to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] revealed ST depresssion with TWI in V3 and small ST seg elevation in V6. Repeat ECG revealed significant ST segment elevation in leads V5,V6 as well as I and aVL as well with reciprocal depression in leads V1 and V2. The patient was treated with heparin, ASA, SLNTG, and Plavix (300mg) and immediately transferred to [**Hospital1 18**] for emergent catheterization. Past Medical History: IDDM (x 48 years) HTN Hypercholesterolemia CKD (baseline creatinine 0.9-1.0, last [**2167-3-16**]) PVD s/p right toe amputation and bypass surgery x2 Social History: Patient lives in [**Location 13360**] with his wife and son. [**Name (NI) **] works currently as an outdoor manager at a golfcourse. He primarily uses a cart and does not walk to much at work. He denies any smoking history and reports previous heavy alcohol use but has been abstinent now x 25 years. Denies any illicit drug use ever. Family History: Patient with strong family history of DM-I with his father and siblings affected at age < 15, most with chronic sequelae of disease. Father passed away from MI. Physical Exam: Vitals: BP: 108/58 (69) HR: 76 RR: 16 O2 Sat 100% 2L NC Gen: Patient is a middle aged male, lying in bed in NAD HEENT: NCAT, ruddy skin. OP: MMM Neck: Soft bruit right neck, none Left. No JVD Chest: CTA anterior and lateral Cor: RRR, no M/R/G Abd: Obese, soft, NT, ND Ext: Right groin: dressing intact, C/D. No hematoma or ecchymosis. No audible bruit Skin over [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 26409**] paper thin and shiny, hairless. Trace pedal edema. DP 1+ bilaterally. Right foot: s/p transmetatarsal amputation Pertinent Results: [**2169-2-27**] 12:35AM BLOOD WBC-9.8 RBC-3.72* Hgb-11.6* Hct-32.5* MCV-87 MCH-31.3 MCHC-35.8* RDW-13.0 Plt Ct-286 [**2169-3-8**] 06:45AM BLOOD WBC-4.7 RBC-3.04* Hgb-9.4* Hct-27.1* MCV-89 MCH-30.9 MCHC-34.7 RDW-14.1 Plt Ct-324 [**2169-2-27**] 12:35AM BLOOD PT-13.5* PTT-145.4* INR(PT)-1.2* [**2169-2-27**] 12:35AM BLOOD Plt Ct-286 [**2169-2-27**] 12:35AM BLOOD Glucose-192* UreaN-28* Creat-1.4* Na-137 K-4.1 Cl-107 HCO3-21* AnGap-13 [**2169-2-27**] 12:35AM BLOOD ALT-33 AST-63* CK(CPK)-893* AlkPhos-144* Amylase-3 TotBili-0.1 [**2169-2-27**] 03:06AM BLOOD Albumin-4.1 Calcium-8.8 Phos-2.5* Mg-1.5* Brief Hospital Course: Mr. [**Known lastname 174**] is a 58-year-old male, with severe peripheral vascular disease status post bilateral lower extremity bypasses, who also had carotid disease with an occluded carotid on the left side, and presented with myocardial infarction. Cardiac catheterization showed an occluded first marginal branch that was opened with balloon angioplasty without stenting. He had left main disease and severe 3-vessel disease presenting for revascularization urgently. He was taken to the operating room on [**2169-3-2**] where he underwent a CABG x3. Please see separate operative note for details. The patient tolerated this procedure well. He was extubated the night after surgery and did well from a cardiac standpoint. On postoperative day 1, the patiet was started on lasix and lopressor. His chest tubes were removed, and he was ambulated. The patient required an ongoing insulin drip for persistent hyperglycemia. The patient had been seen by [**Last Name (un) **] consult prior to surgery, and their input was sought for longterm management. By postoperative day #4, the patient was again off all drips. His foley, cetral line, and pacing wires were removed, and he was transferred to the floor. However, he was transferred back to the ICU the same day for an insulin drip for persistent hyperglycemia. He was seen by physical therapy, and was able to ambulate well by postoperative day 5. He was again transferred back to the floor. The patient's insulin therapy was adjusted and discharge planning was initiated. On postoperative day 7, the patient's fixed dose of lantus insulin was increased, as was his beta blockade for a brief episode of atrial fibrillation that was self-limited. The patient was discharged on postoperative day 8 with adequate glycemic control and plans for follow-up with both cardiac surgery and with his endocrinologist at [**Last Name (un) **] Diabetes Center. Medications on Admission: Lipitor 20mg po qd Diovan 160mg po qd Dilt-XR 240mg po qd HCTZ 12.5mg po qd Piroxicam 20mg po qd Temazepam 15mg po qhs Gabapentin 300mg po qid Humulin N 24Units qam with Humalog sliding scale Humalog U-100 Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily) for 10 days. Disp:*20 Capsule, Sustained Release(s)* Refills:*0* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*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. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Piroxicam 10 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 11. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28) Units Subcutaneous at bedtime. Disp:*1 Month* Refills:*0* 14. Medication Please note new Humalog Sliding Scale Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: sleep apnea L carotid occlusion CRI(1.4) MI IDDM PVD w R [**Doctor Last Name **] tib bypass graft, L fem [**Doctor Last Name **] bypass HTN cataracts right toe amputation Discharge Condition: Good Discharge Instructions: Call with fever, redness or draiange from incision or weight gain more than 2 pounds in one day or five in one week Shower, wash incision with soap and water and pat dry. No lotions creams or powders to incision. No heavy lifting or driving. Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) 26410**] 2 weeks [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**] will call you within 1 week for a follow-up appointment

[ "584.9", "250.01", "427.89", "401.9", "585.9", "V58.67", "433.10", "410.11", "V49.73", "443.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.23", "36.15", "88.56", "99.04", "00.40", "00.66", "99.10", "36.13" ]

icd9pcs

[ [ [] ] ]

7141, 7196

3395, 5300

314, 370

7411, 7418

2773, 3372

7708, 7918

2038, 2200

5556, 7118

7217, 7390

5326, 5533

7442, 7685

2215, 2754

251, 276

398, 1497

1519, 1670

1686, 2022

68,861

182,997

35467

Discharge summary

report

Admission Date: [**2145-1-9**] Discharge Date: [**2145-1-16**] Date of Birth: [**2116-3-14**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: CC:[**CC Contact Info 80821**] Major Surgical or Invasive Procedure: Closure and washout of a open depressed skull fracture History of Present Illness: HPI: This is a 28 year old male who presents to the ED with open skull fracture following snow mobile accident. Pt had LOC at the scene of accident. Currently complains of headache, back pain and decreased sensation over right leg and numbness over back. Past Medical History: PMHx:unknown Social History: Social Hx:wife ? 5 months pregnant Family History: Family Hx:unknown Physical Exam: PHYSICAL EXAM: Gen: pt anxious, in acute distress. HEENT: large right parietal head laceration, bleeding on to stretcher which has been sutured by trauma surgery. Pupils: [**1-18**] PERRL EOMs intact Neuro: Mental status: Awake and alert, anxiety making it difficult to cooperative with exam. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension. No dysarthria. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength exam is limited secondary to pain. Left upper extremity weakness most evident greater than right upper extremity weakness. Pronator drift- unable to assess due to pt limited movement of upper extremities Sensation: Intact to light touch, proprioception left lower extremity impaired Toes downgoing bilaterally No clonus On exam: He was Alert&Orient x3 he was neurologically intact. He was full strength throughout. Pertinent Results: CT Neck: negative CT torso: Transverse Process fx of L1-4 CT Head 2.21:1. Bilateral skull fractures with a depressed right skull fracture and 4.8 mm displacement of one of the medial fracture fragments. 2. Subtle subarachnoid hemorrhage and contusion in the posterior parietal cortex, adjacent to the fractures and pockets of air in the cranial cavity bilaterally. 3. Subtle loss of [**Doctor Last Name 352**]-white matter differentiation which could represent raised intracranial pressure. CT [**1-10**]: Interval increase in the degree of predominantly subarachnoid hemorrhage within the high right parietal lobe compared to pre-operative exam. Slight redistribution of subgaleal hematoma. Mild residual pockets of pneumocephalus and subcutaneous emphysema, not unexpected. CT [**1-14**]:Increased edema surrounding the right parietal blood products since the previous study of [**2145-1-10**]. These result are consistent with resolution of hematoma. [**2145-1-15**] 06:30AM BLOOD WBC-7.3 RBC-2.77* Hgb-8.3* Hct-23.8* MCV-86 MCH-30.1 MCHC-35.1* RDW-14.5 Plt Ct-358 [**2145-1-15**] 06:30AM BLOOD Glucose-80 UreaN-13 Creat-0.8 Na-139 K-3.8 Cl-103 HCO3-28 AnGap-12 [**2145-1-15**] 06:30AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.0 Brief Hospital Course: This Patient is a 28 year old male who presented to the ED as an acitvated trauma. He was an unhelmeted driver of a snow mobile, he lost control of the snow mobile, hit a [**Doctor Last Name **] and was thrown hitting his head and losing conciousness. Upon evaluation in the ED he was found to have an open depressed skull fracture in the right parietal region and multiple lumbar transverse processes fractures. After initial evaluation, he was taken directly to the operating room for elevation of his skull fracture and washout of the open scalp wound. His ICU stay was uncomplicated and he was subsequently transferred to the SDU and then to the floor. He then had subsequent Head CTs and expected increased edema on [**1-14**] was seen however consistent with resolution of blood products. He has been evaluated by physical and occupational Therapy who believe that he would benefit from inpatient rehab. He was ready for rehab on [**1-16**]. Medications on Admission: Medications prior to admission:unknown Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for muscle pain/body ache. 8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for body ache. 9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for breakthrough pain. 10. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**11-20**] Tablets PO Q4H (every 4 hours) as needed for headache. 11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Open head injury Open depressed skull fracture Left upper extremity dysfunction/weakness L [**11-22**] transverse process fractures Discharge Condition: stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after your staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be monitored at re-hab ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????You have an appointment on [**1-21**] with Dr. [**First Name (STitle) **] at 3:15 in the [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name 12193**]. However you have a Head CT WITH contrast prior at 2:45 on the [**Location (un) 470**] of the [**Location (un) 16228**]. If you have have any questions Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.[**First Name (STitle) **] next Thurs. You will have your staples removed when you follow-up with Dr. [**First Name (STitle) **] on the 5th.

[ "805.4", "803.62", "729.89", "401.9", "E820.0" ]

icd9cm

[ [ [] ] ]

[ "01.59", "02.02", "02.11", "86.74" ]

icd9pcs

[ [ [] ] ]

5527, 5597

3444, 4395

346, 403

5773, 5782

2192, 3421

7459, 8051

792, 811

4485, 5504

5618, 5752

4421, 4421

5806, 7436

841, 1040

4452, 4462

277, 308

431, 688

1257, 2173

1055, 1241

710, 724

740, 776

62,672

124,109

35124

Discharge summary

report

Admission Date: [**2155-12-1**] Discharge Date: [**2155-12-13**] Date of Birth: [**2098-12-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Myocardial infarction/Chest pain Major Surgical or Invasive Procedure: [**2155-12-9**] - CABGx4(Left internal mammary->Left anterior descending artery, Saphenous vein graft->Diagonal artery, Saphenous vein graft->Obtuse marginal artery, Spahenous vein graft->posterior descendong artery). [**2155-12-2**] - Cardiac Catheterization History of Present Illness: 56 year old gentleman who while exercising began to feel dizzy, lightheaded and weak. He did not have any chest pain at that time. He stopped working out and showered and went to work. After a few hours, he developed chest pain and took aspirin and began driving home. The pain worsened so he instead went to the emergency room. He was found to be hypertensive 200/119 and given beta blockade. He ruled in for a myocardial infarction by enzymes and was transferred to the [**Hospital1 18**] for cardiac catheterization and further management. Past Medical History: No significant medical or surgical history Social History: Does not smoke. uses alcohol only socially. He lives with wife and daughter. Family History: Father with MI at age 68. Mother with thoracic aneurysm. Physical Exam: VS - T 97.0; BP 169/98; HR 72; RR 16; O2sat 100% on room air Gen: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. CV: regular, normal S1, S2. S4 is present. No murmurs, rubs, or gallops. No thrills, lifts. Chest: No chest wall deformities. Respirations were unlabored, no accessory muscle use. Clear to auscultation bilaterally, no crackles, wheezes or rhonchi. Abd: Soft, non-tender, non-distended. Ext: No clubbing, cyanosis or edema. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Radial 2+ DP palpable Left: Radial 2+ DP palpable Pertinent Results: [**2155-12-1**] 09:45PM WBC-9.5 RBC-4.88 HGB-14.9 HCT-41.1 MCV-84 MCH-30.5 MCHC-36.2* RDW-13.5 [**2155-12-1**] 09:45PM ALT(SGPT)-31 AST(SGOT)-33 LD(LDH)-194 ALK PHOS-81 TOT BILI-0.6 [**2155-12-1**] 09:45PM GLUCOSE-116* UREA N-13 CREAT-1.1 SODIUM-141 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-28 ANION GAP-12 [**2155-12-2**] Cardiac Catheterization 1. Selective coronary angiography of this right-dominant system demonstrated three-vessel coronary artery disese. The LMCA had no significant stenoses. The LAD had a long complex severe stenosis from the proximal- to mid-vessel, crossing a large D1. OM2 had a 80% stenosis. The Ramus had a 70% stenosis. The RCA had a 60% proximal stenosis. 2. Left ventriculography demonstrated normal wall motion, no mitral regurgitation, and an estimated LVEF of 60%. 3. Limited resting hemodynamics demonstrated left ventricular diastolic dysfunction with an LVEDP of 25 mmHg. Mild systemic arterial hypertension was observed with a central aortic pressure of 158/93 mmHg. [**2155-12-9**] ECHO PREBYPASS 1. The left atrium and right atrium are normal in cavity size. No atrial septal defect or PFO is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. 3. Overall left ventricular systolic function is normal (LVEF>55%). 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic arch and descending aorta. 6. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. 7. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 8. There is no pericardial effusion. 9. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2155-2-7**] at 1230. POSTBYPASS 1. Patient is on phenylephrine infusion 2. LV wall motion is normal. 3. There has been no interval change of any of MR, TR, PR. 4. Aortic contour is smooth after decannulation [**2155-12-12**] 05:50AM BLOOD WBC-12.7* RBC-3.06* Hgb-9.4* Hct-26.3* MCV-86 MCH-30.7 MCHC-35.7* RDW-13.5 Plt Ct-224 [**2155-12-1**] 09:45PM BLOOD WBC-9.5 RBC-4.88 Hgb-14.9 Hct-41.1 MCV-84 MCH-30.5 MCHC-36.2* RDW-13.5 Plt Ct-240 [**2155-12-10**] 02:13AM BLOOD PT-14.4* PTT-31.8 INR(PT)-1.3* [**2155-12-1**] 09:45PM BLOOD PT-13.8* PTT-30.5 INR(PT)-1.2* [**2155-12-12**] 05:50AM BLOOD Glucose-105 UreaN-14 Creat-0.8 Na-137 K-4.2 Cl-99 HCO3-30 AnGap-12 [**2155-12-1**] 09:45PM BLOOD Glucose-116* UreaN-13 Creat-1.1 Na-141 K-4.1 Cl-105 HCO3-28 AnGap-12 Brief Hospital Course: Mr. [**Known lastname 80199**] was admitted to the [**Hospital1 18**] on [**2155-12-1**] for further management of his coronary artery disease and myocardial infarction. A cardiac catheterization was performed which revealed severe three vessel disease. Heparin was continued for anticoagulation. Given the severity of his disease, the cardiac surgical service was consulted. Mr. [**Known lastname 80199**] was worked-up in the usual preoperative manner and deemed suitable for surgery. Plavix was allowed to clear from his system. On [**2155-12-9**], Mr. [**Known lastname 80199**] was taken to the operating room where he underwent coronary artery bypas grafting to four vessels. Please see operative note for details. Postoperatively he was taken to the cardiac surgical intensive care unit for invasive hemodynamic monitoring. Within 24 hours, he awoke neurologically intact and extubated. On postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He had one episode of atrial fibrillation on [**12-10**]. He was given IV amiodarone and started on PO. He had no further episodes and remained in NSR. ON pOD 4 he was noted to have some mild erythema of his sternal wound as well as his endovascular vein harvest site. He was started on Keflex 500MG po four times daily for days with instructions to call if things worsened. He was discharged on POD 4 to home. Medications on Admission: [**Last Name (un) 1724**]: none Meds transfer: Metoprolol 50", Plavix 75', ASA 325', Lisinopril 10', Lipitor 80' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): As long as you take narcotics for pain. Disp:*60 Capsule(s)* Refills:*0* 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take 2 pills twice daily for one week, then one pill twice daily for one week, then one pill once daily for one week, then stop. Disp:*120 Tablet(s)* Refills:*0* 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day for 10 days: Take 2 pills twice daily for 5 days, then two pills once daily for 5 days, then stop. Disp:*40 Tablet(s)* Refills:*0* 8. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: CAD s/p CABG NSTEMI Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) 11493**] in 2 weeks. ([**Telephone/Fax (1) 76272**] Please follow-up with Dr. [**Last Name (STitle) 7933**] in [**2-23**] weeks. ([**Telephone/Fax (1) 80200**] Completed by:[**2155-12-13**]

[ "427.31", "998.59", "E878.2", "427.32", "414.01", "410.71", "682.2" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.13", "88.53", "37.22", "39.61", "88.56" ]

icd9pcs

[ [ [] ] ]

7598, 7666

4651, 6209

355, 617

7730, 7739

2125, 4628

8516, 8850

1365, 1423

6372, 7575

7687, 7709

6235, 6349

7763, 8493

1438, 2106

283, 317

645, 1189

1211, 1255

1271, 1349

65,080

148,368

39890

Discharge summary

report

Admission Date: [**2150-12-10**] Discharge Date: [**2150-12-28**] Date of Birth: [**2084-12-6**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 11839**] Chief Complaint: Cord compression, esophageal cancer. Major Surgical or Invasive Procedure: [**2150-12-11**]: Neurosurgery of the spine with T5, T6 and T7 bilateral laminectomy, Anterior decompression with removal of disk material and soft tissue, Posterior instrumented fusion T4, T5, T6, T7 and T8 using pedicle screws, rods and cross-link (EBI spine array), with Autologous graft and Allograft. [**2150-12-17**]: IVC filter placement. History of Present Illness: This is a 66 year old male with PMH significant for squamous cell esophageal cancer diagnosed in [**2149**], s/p 3 cycles of cisplatin and 5FU and XRT, history of radiation pneumonitis, history of SVT s/p ablation, who is transferred from [**Hospital **] Hospital due to concern for cord compression and urgent neurosurgical evaluation. . Patient was admitted to OSH on [**2150-12-7**] due to acute abdominal pain and found to have a partial bowel obstruction. He improved with conservative therapy. However, on the morning of [**2150-12-9**], patient found to have inability to move his legs or feet. CT scan was performed at 7:30PM on [**2150-12-9**] demonstrating severe compression of the T6 vertebral body, resulting in a kyphotic angulation of the spine, with significant retropulsion of bone fragments into the spinal canal at this level, which reduces the diameter of the spinal canal by approximately 50%. . Prior to his transfer, Dr. [**Last Name (STitle) **] of neurosurgery was consulted, who believed that the chance for a neurologic recovery was very low given the period between onset of symptoms and transfer for evaluation. His prior workup is notable for history of persistent tachycardia with heart rates in the 150s, with two prior CTAs (one on [**2150-11-24**] and one on [**2150-12-4**]) both of which were negative for PE. . Patient was directly admitted to the floor, but triggered upon arrival due to HR in the 150s, which initially was sinus tachycardia, but which quickly escalated to 210s with stable blood pressures and oxygen saturations, with telemetry findings consistent with SVT. Broke with 5mg IV lopressor X 1. Patient was asymptomatic through his tachycardia. . On the floor, patient reports that he is anxious. He is able to wiggle his toes but cannot move his thighs and his sensation is gone from the mid thighs downward. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. Past Medical History: - squamous cell esophageal cancer: diagnosed in [**2149**] by EGD with presence of bulky mediastinal adenopathy involving the upper mediastinum; s/p 3 cycles of cisplatin and 5FU and XRT then two more cycles of chemo - history of radiation pneumonitis - intermittent dysphagia - history of supraventricular tachycardia s/p ablation - compression of spinal cord level T6 secondary to fracture of his T6 vertebral body - history of radiation pneumonitis treated with solumedrol - subacute T6 compression fracture - s/p right nephrectomy - cholelithiasis Social History: Married, lives with wife and son. Family History: No history of esophageal or renal cancer. Physical Exam: ADMISSION EXAM: Vitals: T: 97.8, BP: 141/107, P: 153, R: 22, O2 sat: 97%RA. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased breath sounds in the bases, no wheezes or rales. CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A+O X 3. CN 2-12 intact. Decreased rectal tone. No spinal anesthesia. Decreased sensation starting at the mid thighs progressing down to the feet. Unable to lift thighs bilaterally. Unable to dorsiflex/plantarflex foot. Able to move toes bilaterally. Absent patellar reflexes bilaterally. Pertinent Results: OSH CT abdomen/pelvis [**2150-12-6**]: Findings raise concern for a mid small bowel early or partial obstruction, exact site uncertain. No specific signs of closed loop obstruction are identified. No fre air. Distal esophageal changes, consistent with previous clinical diagnosis of esophageal carcinoma. Post right nephrectomy. Gallstones. Pleural effusions. . OSH CT head [**2150-12-7**]: There is a 1cm enhancing mass at the grey-white matter junction of the posterior left frontal lobe, with some associated edema but no significant mass effect. Given history, likely metastasis. . OSH CT thoracic spine [**2150-12-9**]: severe compression of the T6 vertebral body, resulting in a kyphotic angulation of the spine at this level. There is significant retropulsion of bone fragments into the spinal canal at this level which reduces the diameter of the spinal canal by approximately 50%. Although soft tissue resolution in the spinal canal is limited, suspect that soft tissue material is suspicious for tumor extending from the compressed vertebra into the spinal canal. Moderate sized bilateral pleural effusions. . OSH CT lumbar spine [**2150-12-9**]: Moderate compression of L2, L4, L5, appearance of osteoporotic compression fractures. Moderate acquired spinal stenosis at the L3-L4 and L4-L5 levels. . [**2150-12-10**] T & L spine MRI: IMPRESSION: 1. T6: Severe compression fracture, with areas of increased signal intensity on the STIR sequence, likely related to edema. Retropulsion of the posterior aspect of the vertebral body into the spinal canal resulting in severe spinal canal stenosis and moderate degree of compression on the spinal cord at this level. Pre- and paravertebral and epidural component noted. Pathologic compression fracture likely, with involvement by tumor. However, assessment can be better performed with post-contrast images. 2. L2: Moderate degree of loss of height of the L2 with areas of marrow edema. Pathologic compression fracture cannot be completely excluded. Possible prevertebral soft tissue swelling. Post-contrast images can be helpful to assess for tumor at this level. Correlation with bone sca/PET can be considered to assess for neoplastic etiology. 3. Multilevel degenerative changes, multifactorial in the lumbar spine with moderate-to-severe canal stenosis at L4-5 level, crowding of the roots of the cauda equina. Edema in the cord in the thoracic spine from T4-T8 levels. Increased signal intensity in the posterior spinous soft tissues in the mid thoracic spine, question trauma/dependent edema. To correlate clinically. Bilateral pleural effusions, left more than right. Please see other details in the CT chest report. . [**2150-12-10**] Chest CTA: IMPRESSION: 1. No pulmonary embolism or aortic dissection. 2. Moderate bilateral pleural effusions, increased from the comparison study. 3. Collapse of the T6 vertebral body with resultant severe narrowing of the central spinal canal. 4. Thickening of esophagus and para-esophageal lymphadenopathy concordant with history of esophageal cancer. . [**2150-12-11**] Brain MRI: IMPRESSION: 1. Mass with intrinsic susceptibility artifact within the left insular subcortical white matter with adjacent edema. This could represent an aneurysm or pseudoaneurysm, as an M2 branch extends into it. However, a hemorrhagic metastasis (especially given history of renal cell carcinoma) is also possible, as is a small parenchymal hgematoma. Comparison with prior images, particularly the CTA from [**Hospital1 2025**] referred to in Dr.[**Name (NI) 87744**] note, would be helpful. 2. Moderate to severe intracranial atherosclerosis. . [**2150-12-11**] C Spine MRI IMPRESSION: No evidence of cervical metastases on this examination on this limited, incompete examination. If clinical suspicion warrants, the patient could return for sagittal STIR and post-contrast images when he is able. Brief Hospital Course: 66 year old man with metastatic squamous cell esophageal cancer diagnosed in [**2149**] s/p 3 cycles of cisplatin and 5FU and XRT, history of radiation pneumonitis, history of SVT s/p ablation admitted for cord compression and urgent neurosurgical evaluation with bilateral pleural effusions; his hospital course was complicated by MICU admission for bilateral widespread pulmonary emboli, pressor requirement, and intubation. . # Cord compression: The patient was transferred from an outside hospital (OSH) for urgent neurosurgical evaluation of new cord compression beginning on [**12-9**] from a known subacute compression fracture at T6 resulting in a dense, complete paraplegia and sensory loss of bilateral lower extremeties. He was continued on Dexamethasone and evaluated by both radiation oncology and neurosurgical services. He was taken to the operating room on [**2150-12-11**] and underwent T5, T6 and T7 bilateral laminectomy, anterior decompression with removal of disk material and soft tissue, posterior instrumented fusion T4, T5, T6, T7 and T8 using pedicle screws, rods and cross-link (EBI spine array), autologous graft, and allograft. Overnight he was cared for in the PACU and returned to the medical service on [**12-12**]. He had been noted to regain minimal motor and sensory function of bilateral lower extremities. . # Pulmonary emboli/admission to MICU for hemodynamic instability & Persistent left lower extremity DVT: The pt was transferred to the MICU on [**2150-12-16**] for hypotension, tachycardia, and multiple bilateral pulmonary emboli seen on CTA with extensive clot burden seen in the deep veins of his L leg. He was treated initially with a Heparin gtt and transitioned to likely lifelong anticoagulation with Lovenox. He received an IVC filter [**2150-12-17**] for persistent extensive occlusive deep venous thrombosis of the left lower extremity involving the common femoral vein throughout the calf veins documented on [**2150-12-16**] bilateral lower extremity ultrasounds. Of note, the pt had made an informed decision regarding anticoagulation in the face of having had recent nuerosurgery (had been discussed with NSurg attending as well) and also from this unclear lesion noted in his brain. . # Through his course in the MICU, the pt required pressors and intubation. He was successfully extubated after 5 days of intubation. His pressors were also weaned successfully. The etiology of his hypotension was thought to be sepsis (however, all BCx's this admission were negative) vs cardiogenic shock due to the pulmonary emboli. He briefly received steroids for a random am cortisol of 13 but this was stopped by time of discharge from MICU without significant consequence. . Regarding volume status: through his course in MICU was being diuresed with 10-20 mg IV Lasix boluses at a time. By the time of call out from MICU, the pt was recorded as still being net positive approximately 4L. . By time of call out, pt's hemodynamics were stable with pulses in the low 100's and sbp's in the 110-120's. . # Respiratory failure: The pt was intubated for 5 days for respiratory failure after failing non-invasive ventilation. He was extubated successfully and remained stable thereafter. The pt was satting 97-100% on 2-4L NC by discharge from MICU and on d/c from the hospital as well. . # Cognitive dysfuntion: on [**2150-12-24**] the patient was seen in consulation by occupational therapy. Formal testing revealed significant cognitive deficits that call into question the patient's ability to make complex medical decisions. For this reason, all further medical decisions were made in conjuction with the patient's wife who is his health care proxy. . # Code status and disposition: The patient and his wife confirmed on [**2150-12-25**] that the patient is DNR/DNI.After lengthy discussions with the patient and his wife, they do not want the patient to be placed in rehabilitation but prefer to go home with the support of hospice care. Their initial interest in rehabilitation was predicated on the belief that the patient would regain his ability to walk in a rehabilitation program. After further discussion, they understood that rehabilitation would not restore the patient's ability to walk. Rather, the goal of rehabilitation would be to maximize the patient's ability to safely carry out activities of daily living with his permanent paraplegia, including transfer from bed to commode and wheelchair but that he would likely not be able to walk again. . # Dysphagia and aspiration risk: On [**2150-12-24**] formal speech and swallowing study showed the patient to be at risk to aspirate all food consistencies, but particularly thin liquids. The service recommended either 1) nectar/thick liquids/ ground solids diet if a palliative approach was chosen for the patient's care (with knowledge that he would be at ongoing risk to aspirate) PEG or 2) a feeding tube if there was a nonpalliative appraoch to the patient's care. These findings and recommendations were reviewed with the patient and his wife (as health care proxy) on [**2150-12-25**], they chose to accept the risks of aspiration and chose the nectar/thick liquids/ ground solids diet. The patient had a feeding tube during concurrent chemo/xrt for his esophageal cancer and adamantly does not want another feeding tube. He is DNR/DNI and takes considerable pleasure in eating so does not want to give this up. . # Ground glass opacities seen on CTA: Could not rule out infectious process/aspiration PNA, so pt was started on Vanc/Cefepime, was eventually switched to Merrem, and by time of call out from MICU had completed an approximately 7 day course of antibiotics. Sputum culture was negative. He was not noted to have any fevers for at least 3-4 days by time of call out of MICU. He does however have a persistent leukocytosis that was present since admission, peaked to 30, and was downtrending to 17 by time of MICU call out. . # Cardiac rhythm: While on the floor, pt noted to have narrow complex SVT's to the 200's which were intermittently treated with beta blockade. This was also seen in the MICU, in addition to some runs of atrial fibrillation; this was also treated with intermittent beta blockade but pt was not kept on this by time of discharge from MICU. . # Unclear lesion in his brain: Per OMR notes and other reports, this is unclear but DDx was metastatic malignancy or aneurysm vs pseudoaneurysm. This was considered in the face of the necessity of anticoagulation, but was not further evaluated in the MICU. . # Superficial thrombophlebitis: Was noted to have asymmetric L > R UE swelling and had u/s showing LUE superficial clot, not extending to his deep venous system. . # Bilateral pleural effusions: The etiology of these are unclear (malignant vs parapneumonic vs transudative) but these were not tapped in the MICU. . # Metastatic esophageal cancer: The patient has been treated with 3 cycles of cisplatin and 5FU and XRT for esophageal cancer diagnosed in [**2149**] that is now metastatic to spine. There has been a question of brain metastasis versus aneurysm, versus renal cell carcinoma recurrence and metastasis (from his prior nephrectomy). Given pt's poor performance status and multiple co-morbidities pt not a candidate for palliative chemotherapy treatment and after discussions with wife and pt they decided to pursue hospice care. . # UTI: The patient had a urine culture positive for pansensitive klebsiella during his prior admission at the OSH. He was treated with levofloxicin and continued on this after his admission to [**Hospital1 18**]. Repeat urine cultures were negative and the patient completed a full course of levofloxicin. . # Small bowel obstruction: The patient initially presented to the OSH with symptoms c/w bowel obstruction. He was treated conservatively and improved. Following his neurosurgery his diet was advanced and this was no longer an issue through his MICU course. . # Anxiety and depression: The patient was continued on lorazepam and citalopram. . #Disposition: After multiple discussions with patient and family in which concerns of pt's safety were discussed pt and family decided that they did want pt t o go to rehab. Pt d/c home with hospice services. Medications on Admission: HOME medications: - mucinex PO BID - prednisone 10mg PO daily - MVI - megestrol 2 tsp PO daily - metoprolol 50mg PO BID - oxycontin 40mg PO daily - oxycodone 10mg PO q6h - ativan 0.5mg PO TID - omeprazole 20mg PO BID - citalopram 40mg PO daily Discharge Medications: 1. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) 0.8mL syringe Subcutaneous Q12H (every 12 hours). Disp:*60 0.8mL syringe* Refills:*2* 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): This can be purchased over the counter. 4. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 7. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:*20 Tablet(s)* Refills:*0* 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for Anxiety. Disp:*30 Tablet(s)* Refills:*0* 9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day: hold for systolic blood pressure below 100 or diastolic blood pressure below 60. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Hospice of the [**Location (un) 1121**] Discharge Diagnosis: Cord compression with paraplegia. Pulmonary emboli (clot in lungs) requiring admission to ICU. Respiratory failure. Esophageal cancer. Persistent left lower extremity DVT. Cognitive dysfuntion precluding complicated medical decision making. Dysphagia and aspiration risk. Ground glass opacities on CTA consistent with aspiration pneumonia. Narrow complex SVT's. Brain lesion consistent with aneurysm or pseudoaneurysm. Superficial thrombophlebitis. Bilateral pleural effusions. Urinary tract infection. Small bowel obstruction. Anxiety. Depression. h/o resected renal cell cancer. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were transferred from an outside hospital with a cord compression of your thoracic spine. You had surgery for your cord compression and steroids that improved your pain, but these only minimally improved the strength in your legs. You then developed blood clots in your legs, which traveled to your lungs. Because of these problems, you needed to be transferred to the intensive care unit and put on a ventilator (breathing machine) for several days. Because you still had clot in your leg, you had an filter placed in the inferior vena cava (large vein to the heart/lungs) to prevent more clots from breaking off and traveling to your lungs. The speech and swallowing service did testing that shows you aspirate thin liquids into your lungs and are at risk to aspirate all liquids and foods into your lungs. Although, it was recommended that you have a feeding tube, you and your wife decided against this. You agreed to a diet of thickened liquids and ground food even though you may aspirate and develop pneumonia. While in the hospital you were seen by the occupational health service on [**2150-12-24**], they have documented that you have severe cognitive deficits. Since that time, your medical decision making has been carried out with your wife (your health care proxy). Although you and your wife were offered the option to go to a rehab hospital, when you understood that a rehab hospital would not restore your ability to walk, you and your wife have chosen to try to go home with hospice services despite the difficulties of caring for you at home. Followup Instructions: F/U with Neurosurgery, Dr [**Last Name (STitle) **], on [**2150-1-26**]: CT scan of thoracic spine at 8:30 am, [**Hospital Ward Name **] clinical building, [**Location (un) 9158**]. [**Hospital 4695**] clinic [**Hospital Ward Name **] clinical building, 3B,at 9 am. Appointments can be changed by calling [**Telephone/Fax (1) 1669**].

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icd9cm

[ [ [] ] ]

[ "84.52", "80.51", "38.7", "81.05", "81.63", "96.72" ]

icd9pcs

[ [ [] ] ]

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344, 691

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268, 306

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125,169

52261

Discharge summary

report

Admission Date: [**2131-8-29**] Discharge Date: [**2131-9-9**] Date of Birth: [**2086-6-23**] Sex: F Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 3326**] Chief Complaint: Neutropenic fever Major Surgical or Invasive Procedure: Endotracheal intubation Central venous cannulation History of Present Illness: 45yo female with PMH significant for metastatic breast ca (dx in [**6-/2124**], mets to bones, liver, lungs) and GERD, s/p recent chemo (Gemcitabine) with severe mucositis p/w neutropenic fever up to 103.5. Patient has been on multiple chemo/hormonal therapy in the past (see below). However, her breast cancer continued to metastasize. She was recently ([**Date range (1) 66670**]) admitted for N/V/fever, found to have CBD compression secondary to liver mets. She underwent ERCP with stent placement and was discharged after therapeutic paracentesis and abx course. . More recently, she has been started on gemcitabine and was last seen by her oncologist on [**8-27**] in clinic for administration of the next dose of her 1st cycle. However, she was found to have severe mucositis with an ANC of 740 (WBC 1.1) and it was decided to hold off further chemo for now and reassess next week. She also reported intermittent, mild nosebleeds and vaginal bleeds. She is also on IM lupron to suppress her ovaries. . After this clinic visit, she found her temperature to be elevated to 101, then rising to 103 the next when she decided to go to the ED. In the ED her VS were T103.5, BP 102/54, HR 124, 96% on 4L. Her WBC was 2.5 (diff pending). A lactate was 2.9. Her LFTs and TBili are chronically elevated. A CXR showed mild, interstitial edema, UA showed [**7-15**] WBC and few bacteria. She received 2L IVF through her PICC and a PIV. No CVL was placed. She was given one dose of Cefepime 2gm IV, 500mg of Levoflox and Tylenol and was admitted to the ICU. . ROS: chronic productive cough (greenish sputum) since last admission; no SOB, CP, HA, urinary sx,, dizziness; nausea, vomiting x1 yesterday (greenish); loss of appetite; difficulty eating due to mucositis (last PO intake 3days ago); chronic diarrhea (increased recently); transient bleeding from vagina, nose, mouth; bloody stools occasionally. . Past Medical History: . Past Medical History: 1)Metastatic breast cancer (see below for further details) 2)GERD . Oncologic History: - Diagnosed with R breast ca in 5/[**2124**]. She had a 7 x 6 x 2.5 cm infiltrating ductal carcinoma with LVI that was excised at the time but had positive margins as well as DCIS. It was ER positive and HER 2/neu negative. - The patient had metastatic disease to the ribs, vertebrae, liver, and lungs from the start. She was treated with Zoladex and tamoxifen initially and then switched to Femara with Zoladex secondary to progression of her disease. - In [**5-11**] she noticed a large lump in her R breast and her tumor markers had increased so treatment was again changed to Aromasin. She transferred her care to us in [**2130-8-5**] at which time she was noted to have further progression of her disease. - She was started on single [**Doctor Last Name 360**] Taxol qweekly on [**2130-8-28**]. She received a total of 5 cycles of single [**Doctor Last Name 360**] Taxol and then on [**2131-1-9**] was started on weekly Taxol and D1,D15 Avastin IV as her umor markers were increasing - [**8-10**], she was also started on Zometa, which has not been repeated since then due to severe side effects. - Her CA27.29 continued to rise despite Taxol/Avastin x3 cycles so she was switched to Xeloda/Avastin on [**2131-4-9**]. - Admitted on [**7-4**] for CBD compression due to liver mets, s/p biliary stent and therapeutic paracentesis; received also adriamycin during this admission - [**8-11**], she was started on gemcitabine, was on d#8 of first cycle on [**8-27**] when severe mucositis was noted. . Social History: . Lives in [**Location 669**] with her mother and brother. Married but in the process of separating. Denies tobacco, alcohol, or IVDA. . Family History: . non-contributory . Physical Exam: . vitals T 103.2 BP 99/82 HR 126 RR 32 O2 sat 90% 4L Gen: Pleasant female lying in bed covered up, NAD HEENT: multiple large shallow oral ulcers, severe icterus of both sclerae Neck: No cervical LAD, supple Heart: nl s1/s2, no s3/s4, no m,r,g Lungs: CTAB, no crackles Abdomen: soft, mild distension, no tenderness, no hepatosplenomegaly Extremities: 3+ LE edema, 2+ DP pulses bilaterally Skin: no open skin between toes or perirectally, no rash . Brief Hospital Course: Brief hospital course by problem: . # Respiratory distress: She was orally intubated due to increased O2 requirements as well as increased work of breathing on [**8-30**]. Her clinical picture was consistent with ARDS, with bilateral pulmonary infiltrates and no history of CHF. She remained ventilator-dependent despite multiple attempts to wean. Over the last 2-3 days of her hospitalization, her PEEP and O2 requirements increased. Difficulty to wean was thought most likely secondary to multiple etiologies including ARDS, pulmonary edema, and total body volume overload resulting in pressure-dependent atelectasis. . # Hypotension/sepsis: She initially met all the criteria for SIRS, but there was no definite site of infection. She was febrile and neutropenic on admission. Multiple potential etiologies including lung, skin, oropharynx with severe mucositis, perirectal, lines, UTI & possible GI process were considered. She was treated with vancomycin, cefepime, and flagyl for broad-spectrum coverage, fever quickly resolved, and continued to have negative cultures. She also received a course of stress-dose steroids. Yet she remained hypotensive and pressor-dependent. On [**9-4**], she developed a new leukocytosis with bandemia. Blood cultures from [**9-5**] grew [**2-8**] yeast. She was started on ambisome, then switched to caspofungin, which is less renally toxic. Out of concern for line infection, her central line was removed and a new one placed. Blood cx from [**9-8**] grew gram positive cocci and gram positive rods. She remained pressor dependent despite frequent crystalloid and colloid boluses. She became significantly total body fluid overloaded secondary to this aggressive fluid resuscitation yet remained significantly intravascularly depleted. . # Hematocrit drop: Pt had a normal baseline hematocrit, but dropped to 26.6 during this admission. Stools were guiac positive. Near the end of her hospitalization she had evidence of UGI bleed with blood-tinged fluid noted in OGT. PTT and INR were elevated, likely secondary to liver failure [**3-9**] liver mets and shock liver. Bleed from OGT likely secondary to stress induced gastritis. . # Coagulopathy: PTT and INR increased near the end of her hospitalization. Etiology of the coagulopathy was thought to be multifactorial including liver failure and hemodilution [**3-9**] fluid overload. Serial coags were followed and FFP administered as needed. . # Renal failure: She developed acute renal failure during her hospitalization. It was thought most likely pre-renal, secondary to hypovolemia, and initially her renal fuction improved s/p volume repletion. However, later in the course of her hospitalization, creatinine increased again. Likely secondary to hypotension and pressor use. Cr was increased to 2.8 on the day that she expired. . # Metastatic breast CA: Mets to multiple sites including lungs, liver & bone, also with breast mass as well as lymphadenopathy. Liver failure attributed to liver mets & compression of biliary tract. s/p biliary stent placement. Was on Gemcitabine to treat her liver mets, however recently stopped for severe mucositis. Her primary oncologist was aware of pt's presence in the ICU and did not feel that she was a candidate for any further therapy. . # Her family advanced her code status to comfort measures only when it was felt that further medical treatment was futile. She expired [**3-9**] cardiac arrest at 5:27pm on [**2131-9-9**]. Medications on Admission: . Aldactone 100mg [**Hospital1 **] Prilosec 40mg daily Ursodiol (does not know dose) Viscous lidocaine as needed . Discharge Medications: not applicable Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: not applicable Followup Instructions: not applicable

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8253, 8262

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285, 337

8313, 8322

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4073, 4095

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228, 247

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365, 2267

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3919, 4057

5,021

163,436

23197

Discharge summary

report

Admission Date: [**2188-12-7**] Discharge Date: [**2188-12-11**] Date of Birth: [**2111-3-2**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: Epigastric and right upper quadrant pain Major Surgical or Invasive Procedure: Endoscopic retrograde cholangiopancreatography: common bile duct stone removal and sphincterotomy History of Present Illness: 77 year old male presents with 4 day history of right upper quadrant pain with constipation times 2 days. Constipation has resolved with over-the-counter laxitives. Past Medical History: Hypertension Hypercholesterolemia CABG x4 [**2184**] Prostate CA x1year Social History: Patient denies ETOH or drugs. 60 pack-year history of smoking. Family History: Father died of brain tumor. Brother has had MI. Physical Exam: A+Ox3, NAD sclera icteric RRR CTA b/l ABD obese, soft, distended. Tender to palpation over RUQ. Negative [**Doctor Last Name 515**] sign. EXT 2+ pitting LE edema b/l Pertinent Results: [**2188-12-6**] 08:39PM BLOOD WBC-11.2* RBC-3.68* Hgb-12.0* Hct-33.1* MCV-90 MCH-32.6* MCHC-36.3* RDW-12.5 Plt Ct-154 [**2188-12-6**] 08:39PM BLOOD Neuts-85.9* Bands-0 Lymphs-6.9* Monos-2.2 Eos-5.0* Baso-0.1 [**2188-12-6**] 08:39PM BLOOD Plt Smr-NORMAL Plt Ct-154 [**2188-12-6**] 08:39PM BLOOD Glucose-165* UreaN-38* Creat-1.7* Na-134 K-3.7 Cl-93* HCO3-27 AnGap-18 [**2188-12-6**] 08:39PM BLOOD ALT-152* AST-110* AlkPhos-124* Amylase-51 TotBili-3.8* DirBili-2.0* IndBili-1.8 [**2188-12-6**] 08:39PM BLOOD Lipase-18 [**2188-12-7**] 01:19AM BLOOD CK-MB-3.5 cTropnT-<0.01 [**2188-12-7**] 05:20AM BLOOD Albumin-3.1* Calcium-8.3* Phos-3.6 Brief Hospital Course: The patient presented to the hospital with elevated LFT's and hypotension (90/40's) requiring fluid boluses to maintain BP. RUQ US showed intrahepatic dilation in the right lobe of the liver with focal wall edema and a CBD measuring 2-3mm. He was admitted to the SICU for monitoring and was placed on ampicillin, levofloxacin and flagyl. Cardiac enzymes were negative throughout admission. The patient underwent an ERCP on HD#1, which showed a single obstructive stone in the biliary tree. A sphincterotomy was perfored, and the stone was removed. Following this, the patient devoped mild post-ERCP pancreatitis, which quickly resolved. The patient improved post-procedure and was transferred to the floor on HD#3 in stable condition. The patient was scheduled to undergo a laprascopic cholecystectomy on HD#4. This, however, was aborted because he had mild pulmonary atelectatis and toilet concerns. The decision was made at that time to postpone surgery until a later date. The patient was discharged home in stable condition the following morning with the plan for an interval cholecystectomy at a later date. Medications on Admission: ASA Lipitor HCTZ Tegretol Lisinopril Flomax Ultram Discharge Medications: 1. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 2. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days. Disp:*21 Tablet(s)* Refills:*0* 3. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Cholecystitis choledocolithiasis hypertension coronary artery disease history of myocardial infarction hypercholesterolemia history of prostate cancer status post appendectomy status post CABG ('[**84**]) status post hemorrhoidectomy Discharge Condition: Stable Discharge Instructions: Please return if you experience chills or fever greater than 101.5 degrees F. Please return if your abdominal pain worsens. Please resume taking all pre-hospitalization medications. Followup Instructions: Please follow up with Dr. [**First Name (STitle) 2819**] in 2 weeks. Please call ([**Telephone/Fax (1) 35203**] for an appointment. Follow up with Dr. [**Last Name (STitle) **] as needed: [**Telephone/Fax (1) 5179**]

[ "V45.81", "401.9", "574.41", "577.0", "V64.1", "V10.46", "412", "576.1", "272.0", "997.4" ]

icd9cm

[ [ [] ] ]

[ "51.85", "51.88" ]

icd9pcs

[ [ [] ] ]

3477, 3483

1748, 2862

355, 455

3760, 3768

1090, 1725

3999, 4220

840, 889

2963, 3454

3504, 3739

2888, 2940

3792, 3976

904, 1071

275, 317

483, 649

671, 744

760, 824

22,624

110,384

43873

Discharge summary

report

Admission Date: [**2118-10-10**] Discharge Date: [**2118-10-25**] Date of Birth: [**2070-8-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: Altered mental status requiring intubation Major Surgical or Invasive Procedure: Intubation w/ mechanical ventilation History of Present Illness: The pt is a 48y/o M with PMH of Hepatitis C, inoperable HCC and alcoholic cirrhosis admitted with encephalopathy after being found unresponsive with an empty bottle of oxycontin nearby. Pt has a longstanding history of alcohol-induced cirrhosis and Hepatitis C with associated portal hypertension, varices, ascites and encephalopathy, and hepatocellular carcinoma. His most recent scans are notable for recurrence of his hepatocellular carcinoma following his radiofrequency ablation (5/[**2118**]). At his most recent oncology visit on [**2118-10-5**], he was found to have a rapid deterioration in his liver function and was felt not to be a candidate for further cancer-directed therapies. Per report, on the day of this admission, he was found to be unresponsive by his family and was taken to [**Hospital3 **]. There he was intubated for airway protection in the setting of a GCS of 8. CT A&P demonstrated an advanced tumor of the left lobe of the liver and abdominal varices. RLL consolidation consistent with PNA was also seen. CT Head negative for acute process. He was sent to [**Hospital1 18**] for further managemnt. He was given zosyn and clindamycin as treatment for his pneumonia. OG tube showed brown aspirate and he was given zantac for GI protection. On arrival to [**Hospital1 18**], T 95.9, HR 91, BP 136/96, RR 18. He was given 1 L NS and transferred to MICU. Past Medical History: 1. Cirrhosis Child's class C, complicated by varices, encephalopathy, and ascites. 2. Hepatitis C secondary to IV drug use. 3. Hepatocellular carcinoma status post RFA in [**2118-5-5**]. 4. Alcohol abuse, hx of DTs. 5. Polysubstance abuse with cocaine & heroin. 6. Nephrolithiasis. 7. Chronic back pain status post motor vehicle accident with multiple rib fractures. 8. Depression. Social History: The patient is currently living in a trailer on his mother's property in [**Location 23962**]. Social stressor is that his mother is going to kick him out and he needs to find a new location for his trailer. The patient is currently smoking 2 packs per week, has significant tobacco history of 1 to 2 packs per day x 30 years. Alcohol use per HPI. No current IV, illicit or herbal drug use. He is not currently sexually active. He is on disability. Recently broke up with his girlfried, which is an additoinal stressor and contributed to his increased drug and alchohol use. Family History: He does not know of any liver disease or colon cancer. Father with a history of alcoholism Physical Exam: VS - Temp 97.5, BP 140/85, HR 83, R 18, O2-sat 100% RA GENERAL - Chronically ill appearing man, Comfortable HEENT - Mild scleral icterus, No JVD, MMM, OP clear LUNGS - CTA bilat HEART - RRR, III/VI Systolic murmur at apex ABDOMEN - Moderately distended, + shifting dullness, no HSM, NT, no rebound/guarding EXTREMITIES - WWP, 3+ pitting edema of LE's, 2+ peripheral pulses (radials, DPs) SKIN - multiple spider angiomas on chest NEURO - No asterixis, A/OX3 Pertinent Results: [**2118-10-10**] 06:15PM BLOOD WBC-10.7 RBC-3.00* Hgb-10.4* Hct-29.3* MCV-98 MCH-34.6* MCHC-35.4* RDW-18.6* Plt Ct-223# [**2118-10-11**] 05:05AM BLOOD WBC-10.3 RBC-2.48* Hgb-8.6* Hct-24.5* MCV-99* MCH-34.7* MCHC-35.2* RDW-18.9* Plt Ct-192 [**2118-10-11**] 01:49AM BLOOD PT-26.8* PTT-39.1* INR(PT)-2.7* [**2118-10-10**] 06:15PM BLOOD Glucose-128* UreaN-39* Creat-1.1 Na-126* K-3.3 Cl-92* HCO3-26 AnGap-11 [**2118-10-11**] 05:05AM BLOOD Glucose-79 UreaN-41* Creat-1.3* Na-131* K-3.3 Cl-100 HCO3-23 AnGap-11 [**2118-10-10**] 06:15PM BLOOD ALT-39 AST-154* AlkPhos-119* TotBili-11.2* [**2118-10-11**] 01:49AM BLOOD Ammonia-140* [**2118-10-10**] 06:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2118-10-10**] 06:24PM BLOOD Lactate-1.9 [**2118-10-10**] 11:53PM BLOOD Lactate-1.7 [**2118-10-10**] CXR The ET tube is seen in situ with its tip approximately 13 mm from the carina. The NG tube is seen traversing the gastroesophageal junction and following a course towards the stomach. There are bibasal effusions along with atelectasis/probable consolidation at the lung bases. Follow up with AP and lateral chest radiographs would be helpful to assess for atelectasis vs. consolidation. There is apparent deformity of the left humeral head which is not well visualized and if there is suspicion of trauma to the left shoulder joint, dedicated views of the left shoulder would be helpful. [**2118-10-12**] Abd U/S 1. Cirrhosis and large infiltrative mass in the left lobe of the liver consistent with patient's known hepatocellular carcinoma. There is probable new tumor ingrowth into the left portal vein which is non-occlusive. 2. Moderate ascites [**2118-10-22**] 06:32AM BLOOD WBC-9.8 RBC-2.23* Hgb-8.3* Hct-24.4* MCV-110* MCH-37.4* MCHC-34.1 RDW-21.3* Plt Ct-106* [**2118-10-17**] 05:30AM BLOOD Neuts-76.6* Lymphs-15.4* Monos-6.1 Eos-1.6 Baso-0.4 [**2118-10-22**] 06:32AM BLOOD PT-24.8* PTT-42.4* INR(PT)-2.4* [**2118-10-10**] 09:45PM BLOOD Fibrino-257 [**2118-10-24**] 05:20AM BLOOD Glucose-104 UreaN-8 Creat-0.7 Na-132* K-2.7* Cl-103 HCO3-22 AnGap-10 [**2118-10-22**] 06:32AM BLOOD ALT-39 AST-102* LD(LDH)-402* AlkPhos-94 TotBili-7.8* [**2118-10-24**] 05:20AM BLOOD Calcium-7.3* Phos-2.6* Mg-1.3* [**2118-10-17**] 05:30AM BLOOD %HbA1c-4.5* [**2118-10-12**] 05:09AM BLOOD Ammonia-38 [**2118-10-10**] 06:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2118-10-10**] 11:53PM BLOOD Type-ART pO2-263* pCO2-39 pH-7.51* calTCO2-32* Base XS-7 Brief Hospital Course: The pt is a 48y/o M with PMH of Hepatitis C, HCC and alcoholic cirrhosis admitted with altered mental status requiring intubation for airway protection in the setting of suspected opioid overdose. Encephalopathy - The etiology of the patient's AMS was likely multifactorial involving end stage liver disease,?anoxic-insult given unknown down time, and opiate toxicity. Head CT negative at OSH. Upon admission, the patient was sedated and intubated. Pt began regimen of lactulose with >4BMs per day; with a decrease in NH4 from 140-->38 during his MICU stay. The patient's mentation improved during his admission, sedating medications were weaned down before extubation, and upon transfer out of MICU he was A&O to person and place and following commands. Pt. was on CIWA on transfer to floor and gradually cleared w/ less and less lorazepam. AT time of D/C he was A/Ox3 for several days. Respiratory failure/PNA ?????? Pt was intubated for unresponsiveness and a GCS of 8 at an OSH. CT of chest demonstrated RLL consolidation c/w possible aspiration PNA. Upon admission to the MICU, the patient was still intubated and sedated with propofol. Empiric zosyn was started for coverage of aspiration PNA which was changed to Unasyn on [**10-11**]. Repeat CXR on [**10-12**] showed improving lung fields with no signs of consolidation. Sputum GS grew GPCs in pairs, chains, and clusters on [**10-12**]. The pateitn was weaned off sedation on [**10-11**], extubated, and placed on 2LNC O2 with adequate oxygen saturation. Upon transfer, the patient was stable from a pulmonary standpoint. On the floor he did not have any pulmonary distress, but did spike a fever to 102.5 while on unasyn, so he was switched to vanc/levo/zosyn. His CXR was negative and he quickly defervesced so Abx were stopped after a short course. EtOH Cirrhosis/HepC/HCC ?????? Per recent history, the patient has a h/o EtOH abuse, his HCC is rapidly progressing and his liver function is rapidly declining. Upon admission, he had many stigmata of liver disease, both on exam (encephalopathic, scleral icterus, palpable mass in epigastric area c/w HCC mass in left lobe, mild ascites, spider angioma, extensive ecchymosis) and laboratory testing (elevated INR and abnormal liver enzymes). Pt was given vit Kx1 without change in his INR. The liver team was consulted and followed the patient during his stay. An U/S of RUQ on [**10-12**] showed no signs of portal vein thrombosis, cirrhosis and large infiltrative mass in the left lobe of the liver c/w patient's known hepatocellular carcinoma; there is probable new tumor ingrowth into the left portal vein which is non-occlusive. Pt. was offered hospice house but could not wait until this was available, he decided to leave AMA. Hx of heavy EtOH abuse - The patient was maintained on CIWA scale with 1mg of ativan per protocol in the MICU. The ativan was weaned to 0.5mg on [**10-12**] and completely off two days later. Pt. stated that he would continue to drink on d/c. Hypotension: On [**10-11**], the patient developed hypotension to 80/40's. Likely secondary to physiology of hepatic failure and possibly opioid toxicity. Given IVF boluses and bolus of albumin with good response. Home BP medications were held. Pt remained hemodynamically stable afterwards. Guaiac + NGT aspirate - pt with history varices and significant variceal bleeding, also EtOH abuse. Hct stable in mid-20's during admission and hemodynamics not c/w acute bleed. The patient was Type and Screened, adequate peripheral access was achieved and he was placed on a PPI and Hct remained stable for the duration of admission. Medications on Admission: CLONIDINE - 0.1 mg Tablet - 1 tablet twice a day FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 1 spray inhaled apply to each nostril twice daily FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth once a day LACTULOSE - 10 gram/15 mL Solutio- 30mls four times a day LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1 patch daily wear 12 hours on then take off MIRTAZAPINE - 15 mg Tablet - 1 Tablet(s) by mouth at bedtime NADOLOL - 40 mg Tablet - 1 Tablet(s) by mouth daily NICOTINE - 14 mg/24 hour Patch 24hr - 1 patch daily PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 tablet PO twice a day SPIRONOLACTONE [ALDACTONE] - 100 mg Tablet - 1.5 Tablet(s) by mouth once a day Medications - OTC FERROUS SULFATE - 325 mg (65 mg) Tablet - 1 Tablet(s) by mouth daily HEXAVITAMIN - Tablet - 1 tablet daily THIAMINE HCL - 100 mg Tablet - 1 (One) Tablet(s) by mouth once a day Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 2. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 3. Folic Acid 1 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 Q12H (every 12 hours). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) Nasal twice a day. 8. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 9. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 11. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ML PO every six (6) hours. Disp:*3600 ML(s)* Refills:*2* 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 13. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Hepatic encephalopathy Hepatocellular carcinoma Secondary alcohol abuse Hepatitis C Discharge Condition: Against medical advice Discharge Instructions: YOU ARE LEAVING AGAINST MEDICAL ADVICE. You have been diagnosed with hepatic encephalopathy and hepatocellular carcinoma. You will need to take your lactulose and Rifaximin exactly as prescribed so that you do not become confused again. We stopped your clonidine and nadolol because your blood pressure was low. We started you on a calcium supplement because your nutrition was poor. We increased your spironolactone to 200mg daily and your lasix (furosemide) to 80mg daily because your legs were swelling with fluid. We did not change any of your other medications. We started you on rifaximin to help stop you from getting confused. Please take all of your medications exactly as prescribed. If you have any confusion, fevers, chills, nightsweats, chest pain, shortness of breath, abdominal pain, bleeding, black tarry stools, vomiting blood or any other concerning symptoms call your doctor immediately or go to the emergency department. Followup Instructions: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7676**] Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2118-10-26**] 4:10 [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2118-11-2**] 3:00 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2118-11-7**] 11:30 Completed by:[**2118-10-29**]

[ "965.09", "348.31", "070.44", "E932.3", "155.0", "789.59", "276.52", "572.3", "E850.2", "276.0", "507.0", "198.89", "251.1", "518.81", "571.2", "285.29" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

12070, 12076

5950, 9577

359, 397

12213, 12238

3420, 5927

13229, 13648

2836, 2928

10585, 12047

12097, 12192

9603, 10562

12262, 13206

2943, 3401

277, 321

425, 1808

1830, 2221

2237, 2820

15,697

111,822

28317+57586

Discharge summary

report+addendum

Admission Date: [**2178-3-9**] Discharge Date: [**2178-3-13**] Date of Birth: [**2110-6-6**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Admitted for IL-2 treatment Major Surgical or Invasive Procedure: [**2178-3-10**] Pericardial window via mini L thoractomy History of Present Illness: Mr. [**Known lastname 68742**] is a 67 yo with metastatic RCCA admitted to begin IL-2 therapy. CSR to confirm central line placement showed enlarged cardiac silhouette, echocardiogram was done and confirmed moderate pericardial effusion and RV diastolic collapse consistent with tamponade physiology. Past Medical History: RCC to lungs on IL-2 cycle 2, HTN, Stress with reversible inf hypokinesis, S/p L adrenalectomy and splenectomy for L adrenal mass, OA Social History: retired professor 3 etoh/day remote pipe smoking Family History: NC Physical Exam: 97.6 81 144/62 28 NAD crackles L base Preop exam otherwise unremarkable. Pertinent Results: [**2178-3-12**] 01:58AM BLOOD WBC-13.7* RBC-4.11* Hgb-12.6* Hct-38.5* MCV-94 MCH-30.6 MCHC-32.6 RDW-14.0 Plt Ct-695* [**2178-3-12**] 01:58AM BLOOD Plt Ct-695* [**2178-3-11**] 03:00AM BLOOD PT-13.4* PTT-24.1 INR(PT)-1.2* [**2178-3-12**] 01:58AM BLOOD Glucose-114* UreaN-12 Creat-1.1 Na-136 K-4.4 Cl-104 HCO3-24 AnGap-12 Brief Hospital Course: He was taken emergently to teh operating room on [**2178-3-10**] where he underwent a pericardial window via a left mini thoracotomy. He was transferred to the SICU in critical buit stable condition. He was extubated on POD #1. His neo was weaned to off and he was transferred to the floor on POD #2. He was ready for d/c to home on POD #3 with cardiology and oncology follow up locally. Medications on Admission: lipitor, toprol, asa, glucosamine, chondroitin Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 6. 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:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 5 days. Disp:*10 Packet(s)* Refills:*0* 9. Motrin 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 2 weeks. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Tamponade RCC to lungs on IL-2 cycle 2, HTN, Stress with reversible inf hypokinesis, S/p L adrenalectomy and splenectomy for L adrenal mass, OA Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower,no baths, no lotions, creams or powders to incisions. No driving for 2 weeks of while taking narcotic pain medicine. Followup Instructions: Dr. [**First Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) 68744**] 2 weeks Dr. [**Last Name (STitle) 665**](Oncologist) @ [**Hospital 1727**] Medical after discharge Dr. [**Last Name (STitle) 11907**](cardiologist) @ [**State 1727**] Cardiology after discharge for [**State 113**] within one month Already scheduled appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2178-4-21**] 2:00 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2178-4-13**] 3:00 Provider: [**Name10 (NameIs) **] LAB TESTING Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2178-3-16**] 10:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2178-3-13**] Name: [**Known lastname 11765**],[**Known firstname **] Unit No: [**Numeric Identifier 11766**] Admission Date: [**2178-3-9**] Discharge Date: [**2178-3-13**] Date of Birth: [**2110-6-6**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 265**] Addendum: Spoke with Oncology here - taper Toprol stopping Sunday, stop lasix sunday as well as Mr. [**Known lastname **] will be receiving IL-2 on Monday. They would also prefer that he not take any Motrin despite his thoractomy given the nephrotoxic effects of IL-2. D/c instructions changed and info faxed to local cardiologist and oncologist. Discharge Disposition: Home [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2178-3-13**]

[ "189.0", "197.0", "401.9", "428.0", "V58.11", "423.8" ]

icd9cm

[ [ [] ] ]

[ "38.93", "37.12" ]

icd9pcs

[ [ [] ] ]

5159, 5285

1431, 1820

346, 405

3288, 3296

1088, 1408

3585, 5136

976, 980

1917, 3071

3121, 3267

1846, 1894

3320, 3562

995, 1069

279, 308

433, 736

759, 894

910, 960

2,387

177,843

24564

Discharge summary

report

Admission Date: [**2105-1-14**] Discharge Date: [**2105-1-21**] Date of Birth: [**2051-4-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3276**] Chief Complaint: UGI bleeding Major Surgical or Invasive Procedure: Transfusions x 8 History of Present Illness: 53 y/o male with esophageal cancer and h/o PE's on Lovenox who presented to the ED after melena and an episode of coffee ground emesis at home. States that he had one episode of formed black stool approximately 3-4 days ago. No associated dizziness, CP/SOB. Two days ago he had 3 epidoses of dark stool, with the final one begin more diarrheal in nature. He never saw any BRB in or coating the stool. He admits to beginning to feel more fatigued and short of breath with minimal exertion, but denies orthostatic or presyncopal symptoms. Was still tolerated normal po intake without nausea, vomiting or abdominal pain. However, on the evening prior to admission he vomited approximately 200cc of "coffee ground" emesis at home. In total he vomited approximately 4-5 times per his wife. [**Name (NI) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 62047**] or clots. Endorses pleuritic CP that was associated only with vomiting and coughing. Denied any radition of CP or associated nausea or diaphoresis. This AM, when his visiting nurse came, she stated that he looked pale, and upon hearing his story, placed a phone call to pt's oncologist Dr. [**Last Name (STitle) 3274**], who advised going to the ED. Of note, pt had a recent admission from [**2104-12-31**] to [**2105-1-3**] for UGIB, including an EGD on [**1-1**] without obvious upper etiology for bleeding. In the ED, vitals on presention were T 98.1 HR 124 BP 98/62 RR 20 99%RA. He was given 2 units of PRBCs and 2 liters of NS. Had rpt episode of coffee ground emesis. EKG was without any acute ST changes. 18G was placed in right hand and left chest port was accessed. He received 1mg Dilaudid for chest pain related to cough and vomiting. GI was consulted and he was admitted to the [**Hospital Unit Name 153**] for further care. Past Medical History: PMH: 1. Metastatic adenocarcinoma of esophagus. Five cycles of cisplatin and 5-FU completed [**9-/2102**], some with concurrent radiation therapy, followed by consolidation chemotherapy alone and also CyberKnife radiation therapy to left pelvic metastasis in [**10-30**]. Course c/b RUE DVT related to his line. In [**7-/2103**], Mr. [**Known lastname 13144**] began to experience difficulty swallowing, evaluation revealed local recurrence. He was referred to Dr. [**Last Name (STitle) **] who removed as much of the mass as possible. Started irinotecan 65 mg/m2 day one and day eight and cisplatin 30 mg/m2 days one and day eight of three-week cycle [**2103-10-23**]. Developed PE [**2103-11-18**], since then is on Lovenox. Changed to Taxotere [**1-1**] due to insufficient palliative response in esophagus despite apparent systemic control; An esophageal stent was placed in [**2104-1-24**], however, he soon returned to the hospital with increased esophageal area pain and was found to have an abscess. During this hospitalization, he was diagnosed with atrial fibrillation and found to have a pericardial effusion which required drainage, balloon pericardiotomy and pericardial window. He was hospitalized from [**2104-7-5**] - [**2104-7-15**] for fever, shortness of breath, and enlarging pleural effusion. During this hospitalization he underwent talc pleurodesis of the right effusion. Cytology was negative. His primary oncologist is Dr. [**Last Name (STitle) 3274**]. 2. Hyperlipidemia 3. PE as above 4. h/o afib w/ rvr in setting of pericard effusion and window Social History: Married and lives w/ wife, 17 and 13-yo sons, works in IT, never smoked. occasional EtOH. Independent w/ ADLs at home. Family History: Mother had ovarian cancer at age 54, father MI age 48. Multiple family members on mother's side with 'cancers' 3 brothers/sisters in good health. Physical Exam: PE: T 98.3 BP 99/60 HR 97 RR 18 O2sat 97% 2L NC Gen: Pale, chronically ill appearing man in NAD HEENT: MM slighly dry, pale conjunctivae Neck: JVP 7cm, veins not distended, No cervical LAD appreciated CV: borderline Sinus tachy, no m/r/g appreciated Resp: No increased WOB noted. fine rales left lung base, no wheezes nor rhonchi Abd: +BS, soft, NT, ND Rectal: black stool guaiac positive Ext: WWP, 2+ DP/PT pulses b/l, no c/c/e Neuro: CN 2-12, strength, sensation grossly intact Pertinent Results: [**2105-1-14**] 11:51AM PT-13.9* PTT-31.3 INR(PT)-1.2* [**2105-1-14**] 11:51AM PLT SMR-NORMAL PLT COUNT-294 [**2105-1-14**] 11:51AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL SCHISTOCY-1+ [**2105-1-14**] 11:51AM NEUTS-88.7* BANDS-0 LYMPHS-7.4* MONOS-3.5 EOS-0.2 BASOS-0.1 [**2105-1-14**] 11:51AM WBC-8.9 RBC-2.26*# HGB-6.7*# HCT-20.0*# MCV-88 MCH-29.6 MCHC-33.5 RDW-15.5 [**2105-1-14**] 11:51AM PHOSPHATE-3.6 MAGNESIUM-1.5* [**2105-1-14**] 11:51AM CK-MB-NotDone [**2105-1-14**] 11:51AM cTropnT-<0.01 [**2105-1-14**] 11:51AM ALT(SGPT)-20 AST(SGOT)-24 CK(CPK)-9* [**2105-1-14**] 11:51AM estGFR-Using this [**2105-1-14**] 11:51AM GLUCOSE-115* UREA N-20 CREAT-0.6 SODIUM-133 POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-30 ANION GAP-10 [**2105-1-14**] 08:38PM PT-13.8* PTT-26.4 INR(PT)-1.2* [**2105-1-14**] 08:38PM PLT COUNT-292 [**2105-1-14**] 08:38PM WBC-9.8 RBC-2.76* HGB-8.2* HCT-25.2*# MCV-91 MCH-29.8 MCHC-32.6 RDW-15.0 [**2105-1-14**] 08:38PM CK-MB-1 cTropnT-<0.01 [**2105-1-14**] 08:38PM CK(CPK)-10* [**2105-1-14**] 08:38PM GLUCOSE-99 UREA N-16 CREAT-0.6 SODIUM-136 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-13 . CXR [**1-14**]: 1. Dense left retrocardiac opacification possibly secondary to a combination of atelectasis and effusion, less likely pneumonia. 2. Persistent right mid lung opacity which may reflect sequela of chronic aspiration. Brief Hospital Course: A/P: 53 yo M with metastatic esophageal cancer and h/o GIB, h/o PE anticoagulated with lovenox on admission, presenting with 4 day h/o fatigue in association with melena and coffee ground emesis, admitted to ICU for management of GIB, then transferred to OMED, then back to the ICU and then back to OMED. Hospital Course by Problem: Upper GI Bleed: This is secondary to known fungating esophageal CA with gastric fundal extension of mass. GI consult team followed patient. He had EGD [**1-1**] without obvious source of bleeding. No intervention possible to stop bleeding from this mass. Has recieved total of 8U PBRC since admission, with hct dropping despite transfusions. He had continued episode of hematemesis and was taken to endoscopy again. He had substantial tumor burden in the esophagus and GE junction. The tumor is friable and was oozing blood at several sites. There is no endoscopic intervention which is effective in reducing the chance of bleeding. Per GI, it is likely his bleeding and occasional hematemesis will continue. They recommend against further endoscopies as they are unlikely to impact his management. Argon plasma coagulation was considered, but given the vascularity of tumor and location of stent, it is not a feasible option for him at this time. He was maintained on an IV PPI while in the hospital, PO on dischage. For the nausea, he was given compazine and zofran. His Hct was checked 2-3times/day, and he was transfused for Hct >25. The Lovenox for his hx of PE was discontinued given the persistent bleeding. Esophageal Cancer: Patient is s/p multiple rounds of chemotherapy, radiation and cyberknife. Per patient is not a candidate for further therapy given poor health status. No further intervention for tumor. For pain he had been on fentanyl patch 200mcg/hr q72h, and morphine IV prn, PO on discharge. H/o PE: He has a history of upper extremity DVT the embolized. He had been on Lovenox, but this is been discontinued in the setting of continued bleeding from esophageal mass. SVT: The patient has h/o atrial flutter to HR > 160. Patient's heart rate stable in metoprolol, but increases to 160 when even on dose of metoprolol is held. He had several episodes of SVT while on service tha twere trated with 5mg IV metoprolol pushes. they were generally controlled on this. He was continued on metoprolol TID, with a high threshold to hold completely. Patient also had tendency to become hypotensive with metoprolol IV pushes, so gets 500cc NS boluses with metoprolol. Gastroparesis: Patient on erythromycin which was initially held on admission. on [**1-18**] patient complained of early satiety and cramping in abdomen which resolved [**1-19**]. He was restarted on erythromycin. Hyperlipidemia: Initially held, continued on discharge Insomnia: Initially held po trazodone and remeron, but then readded with the addition of ativan PRN Medications on Admission: 1. Prochlorperazine 10 mg PO Q6H as needed. 2. Fentanyl 200 mcg/hr Patch q72 hr 3. Erythromycin 250 mg Tablet, Delayed Release PO TID. Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Mirtazapine 22.5 mg PO HS (at bedtime) as needed for insomnia. 5. Atorvastatin 10 mg Tablet PO DAILY 6. Lorazepam 1 mg Tablet PO HS 7. Lovenox 80 mg Subcutaneous twice a day. 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. 9. Pantoprazole 40 mg PO BID 10. Methylphenidate 5 mg Tablet PO twice a day. 11. Benzonatate 200 mg Capsule PO TID 12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr PO once a day. 13. Trazodone 50 mg PO QHS PRN insomnia 14. Maalox 225-200 mg/5 mL Suspension 15-30 MLs PO QID as needed. 15. Docusate Sodium 100 mg PO BID 16. Bisacodyl 10 mg Tablet PO BID 17. Liquid morphine 10-20 mg QID PRN pain 18. Zofran 4 mg PO TID PRN Discharge Medications: 1. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*10 Tablet(s)* Refills:*1* 2. Remeron 15 mg Tablet Sig: One (1) Tablet PO once a day. 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*30 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. Ritalin 5 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Benzonatate 200 mg Capsule Sig: Two (2) Capsule PO three times a day. 9. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO once a day. 11. Maalox 200-200-20 mg/5 mL Suspension Sig: [**11-26**] PO once a day as needed for nausea. 12. Morphine 10 mg/5 mL Solution Sig: 10-20 mg PO every six (6) hours as needed for pain. 13. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:*10 Tablet, Rapid Dissolve(s)* Refills:*0* 14. Mirtazapine 15 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 15. Heparin Flush 10 unit/mL Kit Sig: One (1) Intravenous once a day. Disp:*30 Flushes* Refills:*2* 16. Normal Saline Flush 0.9 % Syringe Sig: One (1) Injection once a day. Disp:*30 Flushes* Refills:*2* 17. Other Sig: One (1) once a day: Please give POC Care per NEHT Protocol. . Disp:*qs Other* Refills:*2* 18. Needle (Disp) 20 G 20 x [**1-27**] Needle Sig: One (1) Miscellaneous once a week: To be used to access port weekly. . Disp:*30 needle* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Esophageal cancer Secondary: Hypotension, hyperlipidemia Discharge Condition: Hemodynamically stable & afebrile. Discharge Instructions: You were admitted for low blood counts and low blood pressure due to bleeding from you GI tract. You were treated with several blood transfusions. You had an endoscopy, the results of which were discussed with you. Please take all medications as prescribed. Your medications have not been changed while you were in the hospital. You will also be prescribed some anti-nausea medications. Please keep all your outpatient appointments. Please return to the hospital or seek medical advice if you notice new lightheadedness, bloody vomit, black or bloody stools, rapid heart rate, fever, chills or any other symptom for which you are concerned. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2105-1-27**] 9:00 Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**] Date/Time:[**2105-1-27**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2105-1-27**] 10:00 [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**] Completed by:[**2105-2-4**]

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Discharge summary

report

Admission Date: [**2183-4-24**] Discharge Date: [**2183-5-4**] Date of Birth: [**2138-3-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5129**] Chief Complaint: Fevers, diarrhea and knee pain Major Surgical or Invasive Procedure: Pericardiocentesis Thoracentesis History of Present Illness: Mr. [**Known firstname **] [**Known lastname 22221**] is a very nice 45 year-old genlteman with s/p CRT '[**63**] on prednisone and rapamune, DM2, HTN, and gout who comes with fever of 104 at home and knee pain. He was in his prior state of health until 3 days ago when he noted a fever up to 104 at home. Then, a few hours later he noted brown watery diarrhea up to 4-5 per day in large quantities, without any nausea, vomit or abdominal pain. His cough has been at his baseline, non-productive and he was able to do his daily activities. He did not take any medications. He was able to have a few sips of water, but in general he had very poor PO intake. He noted decreasing urine output. Yesterday he started noticing R knee swelling, with pain and some erythema in the skin that matched with his prior gout flaires. He did not notice any improvement and his fevers continued, so he decided to come to the hospital. In the ER his pain was [**10-5**], T 99.6 F, HR 137 BPM, BP 96/64 mmHg, RR 30 X', SpO2 100%. His initial abdominal exam reported severe abdominal pain and inflammed R knee joint. Patient initially received Flagyl and underwent non-contrast abdominal CT scan that did not show any perforation, obstruction or acute pathology. Arthrosenthesis shwoed 16,600 WBC with 98% PMNs, no organisms as well as few needle-shaped negatively birefringent crystals. Pt received "stress dose steroids" with Solumedrol 125 mg. His CXR showed a RML infiltrate. At this point patient received Vanc/Levo/CTX. His BP was as los as 90/60 mmHg and tachycardia up to 130s. He responded to 4 L NS fluid. Given that CT scan showed pericardial effusion, cardiolgy consult was done, who performed an echocardiogram that did not show signs of tamponade. No pulsus was done. Transplant surgery and nephrology were called, but did not see patient. T [**Age over 90 **] F, BP 110/66 mmHg, SpO2 96% 2L. he is being admitted to the ICU for hemodynamic monitoring. Of note, patient undergoes labs every other week at [**Hospital 882**] Hospital and results get faxed to Dr. [**Last Name (STitle) 2106**] and his PCP. [**Last Name (NamePattern4) **] [**4-19**] his creatinine was 3.54, gap of 14 with Na 139, K 4.7, Cl 103, CO2 22, BUN 70. Pt had normal LFTs (AST 28, ALT 17), PTH 149, urine creatinine 37 and protein 109, HCT 30, PLT 189 and WBC 9.2. Rapamune level was 13.3. Past Medical History: ESRD s/p CRT in [**2163**] because of hypoplastic kidneys DM2 Hyperlipidemia HTN Gout Pancreatitis s/p Left hip replacement s/p cholecystectomy Social History: Quit tobacco in [**2163**] and smoke "very heavy" [**1-29**] pack-year for ~10 years. Denies EtOH or drug use. Lives with mother, his sister [**Name (NI) **] is very involved in his care. Not employed. Family History: Adopted. Physical Exam: VITAL SIGNS - Temp 97.4 F, BP 116/69 mmHg, HR 110 BPM, RR 27 X', O2-sat 96% 2 L NC GENERAL - well-appearing man in NAD, comfortable, appropriate, not jaundiced (skin, mouth, conjuntiva) HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, no masses or HSM, pain on deep palpation in RLQ (kidney location) without any other peritoneal signs. 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, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-30**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: Labs at Admission: [**2183-4-24**] 06:40AM BLOOD WBC-12.9*# RBC-3.75* Hgb-9.7* Hct-29.8* MCV-80* MCH-25.8* MCHC-32.4 RDW-17.1* Plt Ct-190 [**2183-4-24**] 06:40AM BLOOD Neuts-79* Bands-0 Lymphs-8* Monos-12* Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2183-4-24**] 06:40AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-2+ Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Ovalocy-1+ Burr-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) **]1+ [**2183-4-25**] 06:00AM BLOOD PT-18.4* PTT-40.3* INR(PT)-1.7* [**2183-4-24**] 10:30AM BLOOD Glucose-101* UreaN-57* Creat-4.7* Na-135 K-4.4 Cl-107 HCO3-11* AnGap-21* [**2183-4-24**] 06:40AM BLOOD ALT-16 AST-41* AlkPhos-50 TotBili-0.8 [**2183-4-24**] 06:40AM BLOOD Lipase-56 [**2183-4-24**] 10:30AM BLOOD CK-MB-3 cTropnT-0.24* [**2183-4-24**] 07:53PM BLOOD Calcium-6.6* Phos-5.7*# Mg-1.4* [**2183-4-24**] 10:30AM BLOOD TSH-0.61 [**2183-4-24**] 10:30AM BLOOD Cortsol-153.0* [**2183-4-24**] 07:22AM BLOOD rapmycn-24.0* [**2183-4-24**] 06:53AM BLOOD Lactate-2.7* K-4.6 Labs at discharge and other pertinent labs: [**2183-5-4**] 06:55AM BLOOD WBC-5.9 RBC-2.98* Hgb-7.3* Hct-24.0* MCV-80* MCH-24.3* MCHC-30.3* RDW-17.8* Plt Ct-306 [**2183-5-2**] 09:05AM BLOOD PT-14.2* PTT-30.3 INR(PT)-1.2* [**2183-5-4**] 06:55AM BLOOD Glucose-97 UreaN-61* Creat-3.2* Na-141 K-4.7 Cl-108 HCO3-23 AnGap-15 [**2183-5-3**] 06:30AM BLOOD LD(LDH)-264* [**2183-4-25**] 06:00AM BLOOD ALT-14 AST-34 AlkPhos-41 TotBili-0.2 [**2183-5-4**] 06:55AM BLOOD Calcium-8.1* Phos-4.3 Mg-2.2 [**2183-5-3**] 06:30AM BLOOD TotProt-4.3* Calcium-8.1* Phos-4.6* Mg-1.6 [**2183-4-25**] 06:00AM BLOOD calTIBC-129* Ferritn-623* TRF-99* [**2183-4-28**] 05:10AM BLOOD TSH-0.34 [**2183-4-25**] 06:39PM BLOOD dsDNA-NEGATIVE [**2183-4-25**] 06:00AM BLOOD C3-124 C4-30 [**2183-4-24**] 07:22AM BLOOD rapmycn-24.0* [**2183-4-24**] 01:05PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 [**2183-4-24**] 01:05PM URINE Blood-MOD Nitrite-NEG Protein-150 Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2183-4-24**] 01:05PM URINE RBC-0 WBC-0 Bacteri-FEW Yeast-NONE Epi-0 [**2183-5-2**] 04:38PM PLEURAL WBC-1344* RBC-[**Numeric Identifier 28737**]* Polys-91* Lymphs-4* Monos-1* Meso-3* Macro-1* [**2183-5-2**] 04:38PM PLEURAL TotProt-1.8 Glucose-119 LD(LDH)-354 Amylase-40 Albumin-1.3 [**2183-4-24**] 07:18AM JOINT FLUID WBC-[**Numeric Identifier 28738**]* RBC-500* Polys-98* Lymphs-0 Monos-2 [**2183-4-24**] 07:18AM JOINT FLUID Crystal-FEW Shape-NEEDLE Locatio-I/E Birefri-NEG Comment-c/w monoso [**2183-4-28**] 03:15PM OTHER BODY FLUID WBC-444* Hct,Fl-2.5* Polys-3* Lymphs-1* Monos-0 Mesothe-6* Macro-90* [**2183-4-28**] 03:15PM OTHER BODY FLUID TotProt-3.1 Glucose-149 LD(LDH)-211 Amylase-31 Albumin-2.1 Imaging Studies: Transthoracic echocardiogram ([**2183-4-24**]): Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a large pericardial effusion. The effusion appears circumferential. No right ventricular diastolic collapse is seen. There is brief right atrial diastolic collapse. Compared with the prior study (images reviewed) of [**2181-7-11**], a previously very small pericardial effusion is now large in size. No clear echocardiographic evidence for tamponade. CT abdomen/pelvis ([**2183-4-24**]): IMPRESSION: 1. Moderate simple-appearing pericardial effusion, new since [**2181-7-27**]. 2. Bibasilar ground-glass opacities consistent with aspiration pneumonia. 3. No evidence of small-bowel obstruction, free air or abscess formation. 4. No abnormalities of the renal transplant on CT. 5. Diverticulosis without diverticulitis. Duplex ultrasound ([**2183-4-24**]): IMPRESSION: 1. Compared to [**2182-10-12**], there are sharper upstrokes and increased, abnormal RIs of the transplant renal arteries, concerning for rejection. 2. No evidence of abscess formation at the right iliac fossa renal transplant. CT CHEST W/O CONTRAST Study Date of [**2183-4-25**] IMPRESSION: 1. Multifocal predominantly basal airspace infiltrate with some associated atelectasis, concerning for infection. Follow up with CXR is recommended. 2. Moderate-sized pericardial effusion. 3. No definate evidence for malignancy within the chest. 4. Healing seventh posterior right-sided rib fracture. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**2183-4-28**] Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are mildly thickened. There is a large pericardial effusion. The effusion appears circumferential. There is brief right atrial diastolic collapse. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Compared with the prior study (images reviewed) of [**2183-4-24**], mitral inflow views suggest impaired filling. The size and location of the pericardial effusion (mostly posterior) are similar. Cardiac Cath [**2183-4-28**] COMMENTS: 1. Pericardiocentesis via the apical approach under echocardiographic guidance with confirmation of catheter placement via flouroscopy and injection of agitated saline was performed. The initial mean pericardial pressure was 14 mmHg, which declined to 8 mmHg after drainage of 320 cc of clear red-tinged fluid. Follow-up echocardiography demonstrated gross resolution of the effusion. FINAL DIAGNOSIS: 1. Successful pericardiocentesis via apical approach. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**2183-4-28**] Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Prior to pericardiocentesis, there is a moderate to large circumferential pericardial effusion. Post-pericardiocentesis, there is a trivial/physiologic pericardial effusion located near the infero-lateral wall. There are no echocardiographic signs of tamponade. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. Right ventricular chamber size and free wall motion are normal. There is a very small pericardial effusion; the pericardial space is somewhat echodense consistent with probable organization. The pericardium appears thickened. The echo findings are suggestive but not diagnostic of pericardial constriction. Compared with the prior study (images reviewed) of [**2183-4-28**], the pericardial effusion is now much smaller. CHEST (PA & LAT) [**2183-4-30**] IMPRESSION: Removal of pericardial drain with increase in cardiac diameter and increased retrocardiac atelectasis, suggesting reaccumulation of pericardial fluid. Increasing left pleural effusion. The right lung opacity is unchanged and might correspond to a parenchymal opacity adjacent to a known rib fracture documented on the CT examination of [**2183-4-25**]. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**2183-5-2**] The left atrium is normal in size. Overall left ventricular systolic function is normal (LVEF 60%). Right ventricular chamber size and free wall motion are normal. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2183-4-29**], no major change. CHEST (PA & LAT) [**2183-5-2**] IMPRESSION: 1. Finding suggestive of possible reaccumulation of pericardial effusion. 2. Persistent large left pleural effusion with compressive atelectasis. CHEST (PORTABLE AP) [**2183-5-2**] No pneumothorax is detected. Compared with [**2183-5-2**], no significant change is detected. Again seen is the loculated pneumothorax at the left base, with underlying collapse and/or consolidation. Also again seen is the ~26 mm nodular opacity in the right mid lung -- ? related to healing rib fracture, as seen on [**2183-4-25**] CT, vs an focal patchy parenchymal opacity also seen on CT. Brief Hospital Course: # Acute on Chronic Renal Failure - CKD Stage IV at baseline with creatinine of 2.5-3.0. He arrived with creatinine 5.1, elevated from 3.5 the week prior. He had sharp upstroke of arterial waveforms and increase of RIs compared to [**2182-9-26**], which was initially concerning for possible rejection. The renal transplant team was consulted and concluded that the most likely cause was to pre-renal renal failure in the setting of diarrhea and dehydration, with a contribution from the sirolimus level being elevated. Sirolimus was stopped, diuretic medications were stopped, he was given IVF and his AoCRF slowly resolved and returned to baseline. He was started on myfortic once the sirolimus levels were <8 and tolerated this medication without side effects. Bactrim was not started while he was an inpatient but a prescription for Bactrim SS was called in to his pharmacy and the patient informed of this. # Pericardial effusion - Patient was found to have new pericardial effusion on presentation CT chest and then again on echocardiogram. On initial TTE there were no signs of tamponade and he was admitted to the MICU for closer monitoring. The etiology was unclear and with broad differential. Multiple tests were done to rule out infections, rheumatologic or malignant processes and were all negative (see result section for specific tests). Sirolimus was considered as a possible etiology for the pericardial effusion as there had been case reports of this. He was subsequently transferred to the floor were surveillance TTE revealed early sign of tamponade. Due to this a cardiology consult was obtained and the patient was taken to the cath lab for urgent pericardiocentesis. He tolerated the procedure well and was transfered to the CCU for monitoring. While in the CCU he developed AF with RVR that was treated with IV diltiazem and subsequently converted to NSR. He was then transfered again to the medical floor were he remained stable and repeat TTE revealed a trivail effusion. His BP meds were adjusted (see medication section for details). # Diarrhea - Patient with watery non-bloody diarrhea without any sick contacts, nausea or vomiting. Initially he had pain in his RLQ, where his transplant is located. Non-con CT scan did not show acute pathology, but this study was limited given the lack of contrast. Patient was treated with Flagyl and his symptoms improved. Flagyl was stopped after 2 days of treatment and symptoms did not recur. # Pulmonary infiltrate - Patient had new infiltrate in RML compared to prior CXRs. CT chest showed bibasilar ground-glass opacities. Since he is immunosuppressed he is at risk of atypical infections. Pt had initially elevated lactate of 2.7 that normalized with fluids 0.8. Induced sputum was attempted 3 times to check for PCP but this was unsuccessful. Patient was started on levofloxacin and Flagyl for concern of aspiration PNA. Additionally, he underwent video swallow study to assess for aspiration risk. This showed no signs of aspiration and flagyl was stopped. He finished a 9 day course of levofloxacin and remained a febrile. # Gout - Pt had a gout flare in the setting of dehydration and possible infection. The right knee was tapped in the ED, fluid analysis consistent with gout. No evidence of septic joint. Pt received steroids in the ER and was continued on his home dose of prednisone thereafter. His pain was treated with prn Dilaudid and it resolved on HD4. # Diabetes Mellitus type 2 - Last A1C of 5.9 on [**10-4**]. Patient was continued on ISS. Glyburide was resumed when his clinical status improved. # Hyperlipidemia - LDL 52, HDL 66, Chol 153, TG 174. Furthermore, statins have shown decrease rejection rate and possibly better outcomes in in-hospital patients. We continued his home dose statin during this admission. # Hypertension - Pt on Toprol XL 100 and amlodipine 5 mg daily at home. Initially his antihypertensives were held in the setting of hypovolemia and ARF from diarrhea. Once stabilized, he was started on metoprolol and this was titrated to HR/BP control. He was discharged on 150 mg of metroprolol succinate daily. Amlodipine was not restarted given that his BP was well controlled with the above regimen and concerns of worsening his LE edema. # Secondary Hyperparathyroidism - Secondary to chronic renal failure Stage IV. We continued his home calcitriol but the dosing was changed to QOD. # Anemia: Patient was found to be anemic but remained at baseline. Iron studies revealed anemia of chronic disease with likely contribution from CKD. Iron repletion was stated. Treatment with epo should be considered as an outpatient. # Code - Full code Medications on Admission: Procrit 10,000 unit/mL QWeek Rapamune 4.5 mg PO Daily Prednisone 10 mg Daily Calcium carbonate 500 mg PO TID Allopurinol 300 mg PO Daily Calcitriol 0.25 mcg PO Daily Lasix 40 mg PO QOD Simvastatin 10 mg PO Daily Omeprazole 20 mg PO Daily Glipizide ER 2.5 mg PO Daily Amlodipine 5 mg PO Daily Metoprolol Succinate 100 mg PO Daily Insulin (humalog) Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO BID (2 times a day). Disp:*240 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2* 10. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO every other day. 12. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous three times a day: per sliding scale. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses Acute on chronic kidney failure secondary to hypovolemia Pneumonia Pericardial effusion, possibly secondary to Rapamune Acute on chronic gouty flare Secondary Diagnoses Chronic kidney disease, stage IV ESRD s/p CRT in [**2163**] because of hypoplastic kidneys Diabetes type II Hyperlipidemia Hypertension Gout Pancreatitis S/p hip replacement s/p cholecystectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital for treatment of pneumonia and possible gastrointestinal infection. You were also found to have acute kidney injury, a gouty flare in the right knee, and a large collection of fluid around the heart. You were treated with antibiotics, intravenous fluids, and your Rapamune was stopped. You underwent a procedure to remove the fluid around your heart as it was begining to cause problems in your heart function. You tolerated this procedure well and without complications. After you were found to have a large amount of fluid around your left lung. This fluid was also drained. Studies from this fluid are still not finalized. Please have Dr. [**Last Name (STitle) 28641**] follow these. You blood sugar was low at times and your insulin dose was adjusted. Please note the following changes to your medications. -STOPPED Rapamune -STARTED Myfortic -CHANGE Calcitriol to every other day -CHANGE Humalog Sliding Scale to the one provided -INCREASE Metoprolol Succinate to 150 mg dialy -STOP Amlodipine -START Iron 300 mg daily -DECREASE Allopurinol to 100 mg daily Followup Instructions: Name:[**Doctor Last Name **] [**Last Name (NamePattern4) 28739**],MD Specialty: Primary Care Address: [**Street Address(2) **], [**Apartment Address(1) 28740**], [**Location (un) **],[**Numeric Identifier 6809**] Phone: [**Telephone/Fax (1) 28736**] When: [**5-8**] at 3pm Department: TRANSPLANT CENTER When: TUESDAY [**2183-5-20**] at 3:40 PM With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "427.31", "787.91", "E933.1", "250.00", "486", "585.4", "E878.0", "276.52", "403.90", "420.99", "423.3", "285.21", "274.01", "584.9", "996.81", "V58.65", "588.81", "511.9" ]

icd9cm

[ [ [] ] ]

[ "34.91", "37.0", "81.91" ]

icd9pcs

[ [ [] ] ]

18583, 18589

12248, 16909

345, 380

19015, 19015

4105, 5131

20319, 20873

3174, 3184

17306, 18560

18610, 18994

16935, 17283

9516, 12225

19198, 20296

3199, 4086

275, 307

408, 2771

5153, 6822

19030, 19174

2793, 2938

2954, 3158

6840, 9499

78,518

144,855

34646+57938

Discharge summary

report+addendum

Admission Date: [**2175-8-14**] Discharge Date: [**2175-9-22**] Date of Birth: [**2095-9-27**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: MVC Major Surgical or Invasive Procedure: exploratory laparotomy, splenectomy [**8-14**] pin placement of R 1st metatarsal fracture [**8-17**] PEG/Trach [**8-22**] IR placement of IVC filter [**8-23**] exploratory laparotomy, washout, repair of gastric perforation [**8-26**] exploratory laparotomy, washout, placement of [**Hospital Ward Name **] tube [**8-28**] ORIF L elbow with ex-fix [**9-1**] IR placement of post-pyloric Dobhoff tube [**9-19**], [**9-20**] History of Present Illness: 79yo F restrained passenger in a high-speed MVA due to her husband, the driver, experiencing a CVA while driving. He expired from his injuries at [**Hospital3 1196**]. She was brought to [**Hospital1 18**] with multiple injuries as a trauma basic. Past Medical History: hysterectomy apparent on CT scan, HTN, hypothyroid, hyperchol Social History: married Family History: n/a Physical Exam: P 87, BP 140/palp, RR 42, 96%. A&Ox3, highly anxious, tachypneic. GCS 15 C-collar in place L chest tender to palpation with crepitus, sternal flail RRR Abd with seatbelt sign, soft Rectal with normal tone, no gross blood hematoma over L prox tib/fib, R dorsum of foot moves all extremities Pertinent Results: Orthopedic survery [**9-21**]: 1. External fixation device applied to the left elbow, unchanged. 2. Comminuted fractures of the coronoid process and lateral epicondyle of the humerus. 3. Healing nondisplaced fracture of the distal radius and of the lunate. Ununited fracture fragment at the dorsum of the wrist. CT Chest [**9-18**]: 1. No relevant change in pleural effusions and bilateral dorsal basal areas of atelectasis. 2. Newly occurred consolidation in the right lung, an infectious genesis is likely. 3. Tracheostomy, removal of nasogastric tube. 4. Decrease of pericardial effusion. 5. Ascites, abdominal drains, status post splenectomy, diastasis of the midline. Brief Hospital Course: 79yo F in MVC, hypotensive upon arrival to ED. FAST scan negative, but CT scanner non-functional. Noted to have a flail chest, intubated in ED and brought initially to TSICU. A TEE demonstrated no cardiac dysfunction, and a repeat FAST scan showed hemoperitoneum. Accordingly, she was brought to the OR for exploratory laparotomy with finding of splenic hemorrhage and thus splenectomy was performed. The remainder of her hospital course, and injuries, will be reviewed here by system: Neuro - no traumatic injury. Patient was sedated as needed during her period of intubation, but was weaned to minimal sedation as vent settings were weaned. At time of discharge, pain/sedation were well controlled on prn roxicet/ativan via g-tube. CV - Episodes of rapid afib, eventually controlled with amiodarone (bolus and drip), currently on amiodarone via g-tube, in normal sinus rhythm. Hemodynamically unstable prior to first exploration secondary to hypovolemia from splenic hemorrhage, then later again unstable during abdominal compartment syndrome, subsequently stable and currently off any pressors for nearly a week. R - initial injuries included rib fractures of L4-10 and R [**2-11**], several of which were displaced, as well as sternal/manubrial fracture, all resulting in flail chest. She remained intubated after initial operation, vent dependent, and s/p trach [**8-22**]. Vent weaned to CPAP/PS with PS setting of 12. Any further weaning causes patient to c/o subjective shortness of breath, although saturation and vent parameters remain normal. Current plan is to wean PS by 1 each night while patient sleeping. GI - s/p PEG placement [**8-22**]. Over the next few days she developed increasing airway pressures, worsening renal failure, as well as a bladder pressure over 30. She eventually became hemodynamically unstable, requiring fluid resuscitation, as well as pressor requirement. She was thus taken for exploratory laparotomy on [**8-26**], finding of gastric perforation at the site of g-tube insertion and bilious ascites. Post-operatively she continued to have respiratory and renal failure with bilious output from her PEG site. She then returned to the operating room on [**8-28**] for exploratory laparotomy, finding no new perforation, and a nasojejunal [**Hospital Ward Name **] tube was passed and two JP drains were placed. JP#1 was bilious, with output decreasing over the remainder of the hospital stay, without changing in quality/quantity as tube feeds were initiated via the [**Hospital Ward Name **] tube. JP#2 was mostly serosanguinous and was removed on [**9-21**]. The abdominal fascia was closed primarily but the skin was left open, initially covered with wet-to-dry and currently being managed with VAC dressing, demonstrating decrease in size and good granulation tissue. GU - Concomitant with hemodynamic instability and significant fluid resuscitation in context of gastric perforation, patient developed acute renal failure. Pt required CVVH from [**8-29**] - [**9-10**], with gradual improvement. Transitioned to intermittent lasix, which ultimately d/c'd a week before discharge. BUN 29 and creatinine 0.8 at time of discharge. H - Currently stable hematocrits (28.7 at time of d/c), platelets (548 at time of d/c), and coagulation. ID - Pt experienced multiple infectious complications, including: UTI (pan-sensitive EColi [**8-15**]), MSSA PNA ([**8-17**], [**8-20**]), enterobacter peritonitis (res Zosyn and cephalosporin), and finally an enterobacter and MRSA line sepsis (positive cultures from catheter tip, urine, and sputum on [**9-11**]). Final infection is being treated with Vanco/Meropenem with 14 day course due to complete on [**9-24**]. Pt currently has R subclavian central line, changed over wire on [**9-22**], which should be removed after completion of antibiotic course. WBC stable at 16.0 at time of discharge. Endo - RISS. on levothyroxine for h/o hypothyroid. FEN - currently receiving tube feeds with post-pyloric Dobhoff. Mild hypernatremia improving with addition of free water via Dobhoff. Spine - fracture of C2 Left transverse process, evaluated by Ortho-Spine consult. No operative intervention indicated, placed in [**Location (un) 2848**]-J collar, to remain until follow-up. Ortho - 1. L elbow dislocation, initially splinted and casted at ICU bedside but redislocated. Therefore went for open reduction internal fixation of left elbow dislocation with placement of hinged external fixator on [**9-1**] by Orthopedics. Ex-fix kept locked in place for 2 weeks, subsequently unlocked to permit ROM on [**9-22**]. 2. Dislocation of first metatarsal cuneiform joint on the right side, s/p pin placement on [**8-17**] by Orthopedics. She was permitted for touchdown weight-bearing beginning [**9-20**]. 3. L2 finger fracture of proximal phalanx, extending into 2nd MCP joint. volar splint applied by Plastics/Hand. 4. intraarticular fracture of R distal radius Proph - IVC filter placement by OR on [**8-23**]. Also on Heparin SQ [**Hospital1 **], as well as Prevacid solutabs. Medications on Admission: Lisinopril 20', Simvastatin 40', Synthroid 75' Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1) injection Injection ASDIR (AS DIRECTED): start at FS > 121 at 2 units. Increase dose by 2 units for every 40mg/dl thereafter. 2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 3. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 4. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) mL Injection [**Hospital1 **] (2 times a day). 5. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs PO Q4H (every 4 hours) as needed. 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 9. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) mL PO Q8H (every 8 hours). 10. Methyl Salicylate-Menthol 15-15 % Ointment [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 11. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed for constipation. 12. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 13. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO PRN (as needed). 14. Lorazepam 0.5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety. 15. Miconazole Nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 16. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Hospital1 **]: Two (2) mL Injection Q8H (every 8 hours) as needed for nausea. 17. Heparin, Porcine (PF) 10 unit/mL Syringe [**Hospital1 **]: One (1) ML Intravenous PRN (as needed): flush. 18. Meropenem 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln Intravenous Q8H (every 8 hours): last dose 9/21. 19. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Hospital1 **]: One (1) gram Intravenous Q 24H (Every 24 Hours): last dose 9/21. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: polytrauma splenic rupture gastric perforation, bile peritonitis enterobacter sepsis/bacteremia from central line respiratory failure renal failure HTN hypothyroid hypercholesterolemia Mult L rib fx [**6-13**], flail chest, R ant rib fx [**2-11**], sternal manubrium and sternal body fx, sm retrosternal hematoma C2 fx Fx R distal radius - intraarticular L hand: Base of L 2nd prox phalanx, poss triquetrum fx R foot: Dorsal dislocation of the base of the first metatarsal Discharge Condition: hemodynamically stable, vented by trach, tolerating tube feeds at goal, stable renal function, afebrile with stable white count being treated for recent line sepsis. Discharge Instructions: [**Name8 (MD) **] MD or return to ER if fever, chills; nausea, emesis, abdominal distension, diarrhea, constipation; change in output from abdominal JP drain; redness, drainage or swelling at any incision. Continue to wean vent as tolerated. Remove CVL after completion of antibiotic course on [**9-24**], as patient should have no further necessity for IV medication via central access. VAC changes to abdominal wound q3 days. Next change due on [**9-22**], the day of discharge, so dressing removed and wet-to-dry applied temporarily for transport. Please replace VAC upon arrival today. Leave abdominal JP drain in place. Strip and record output qshift. Keep head of bed elevated >30 degrees. Followup Instructions: Follow-up in trauma clinic, Dr. [**Last Name (STitle) **], in [**2-6**] weeks. Call [**Telephone/Fax (1) 2359**] for an appointment. Follow-up in Orthopedic Trauma clinic, Dr. [**Last Name (STitle) 1005**] and/or Dr. [**Last Name (STitle) **], on [**10-4**]. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow-up with Orthopedic Spine, Dr. [**Last Name (STitle) 50994**], in 2 weeks. Call [**Telephone/Fax (1) 3736**] or [**Telephone/Fax (1) 1228**] for an appointment. Name: [**Known lastname **],[**Known firstname 7224**] Unit No: [**Numeric Identifier 12780**] Admission Date: [**2175-8-14**] Discharge Date: [**2175-9-22**] Date of Birth: [**2095-9-27**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9036**] Addendum: Addendum to prior d/c summary: CV - pt without dysrhythmic events for at least 2 weeks. [**Month (only) 412**] be off telemetry at rehab. Ortho - L2 finger: continue orthoplast radial gutter. Follow-up in Hand Clinic as below. IV access - correction: R subclavian was placed via new needle stick on [**9-22**], not changed over wire. Discharge Medications: 20. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 21. Dilaudid 1 mg/mL Solution Sig: 0.5-1 mL Injection q3h as needed for breakthrough pain. Discharge Disposition: Extended Care Facility: [**Hospital3 2215**] Northeast - [**Location (un) 437**] Followup Instructions: Follow-up with Hand Clinic in [**2-5**] weeks. Call [**Telephone/Fax (1) 12781**] for an appointment. [**First Name11 (Name Pattern1) 1332**] [**Last Name (NamePattern1) 9039**] MD [**MD Number(2) 9040**] Completed by:[**2175-9-22**]

[ "805.02", "038.49", "865.02", "244.9", "567.81", "816.01", "482.41", "995.91", "V46.11", "041.4", "599.0", "958.4", "825.25", "E879.8", "401.9", "276.0", "584.9", "E812.1", "536.42", "813.42", "427.31", "812.42", "807.4", "041.85", "999.31", "518.5", "807.2", "958.93", "272.0" ]

icd9cm

[ [ [] ] ]

[ "38.7", "41.5", "96.72", "43.11", "79.11", "96.08", "46.85", "96.6", "96.04", "78.12", "89.68", "38.93", "44.61", "54.25", "31.1", "79.17" ]

icd9pcs

[ [ [] ] ]

12635, 12718

2177, 7266

318, 742

10242, 10410

1478, 2154

12741, 13007

1147, 1152

12396, 12612

9746, 10221

7292, 7340

10434, 11139

1167, 1459

275, 280

770, 1021

1043, 1106

1122, 1131

12,164

113,245

53311+59515

Discharge summary

report+addendum

Admission Date: [**2130-2-14**] Discharge Date: [**2130-2-23**] Date of Birth: [**2054-8-27**] Sex: F Service: VSU CHIEF COMPLAINT: Abdominal aortic aneurysm. HISTORY OF PRESENT ILLNESS: This is a patient who has known breast carcinoma with questionable metastatic disease who is receiving radiation therapy and she was brought onto the medical service and evaluated for shortness of breath. A CT scan showed a large chronic dissection of her aorta with an aneurysmal enlargement below the renal. Her left renal artery is noted to come off the false lumen. The patient returns now for elective aortic aneurysm repair. PAST MEDICAL HISTORY: Congestive heart failure, hypertension. The patient has a history of arthritis, history of depression. The patient has undergone a cardiac catheterization on [**2127-5-29**] which showed clear coronary arteries. The patient is a type 2 diabetic, controlled. The patient has pruritus and periorbital edema. PAST SURGICAL HISTORY: Bilateral lumpectomies with radiation therapy and CMP. The patient's ejection fraction is 25%. She also has a history of hyperlipidemia. The patient is a known smoker. She quit 20 years ago. She smoked 13 pack years. She does admit to a gin and tonic at bed time. ALLERGIES: Sulfa. MEDICATIONS ON ADMISSION: Diovan, Coreg, Lasix, simvastatin, Ativan, omeprazole, paroxetine, lisinopril, Colace. PHYSICAL EXAMINATION: Unremarkable. She had Dopplerable DP and PTs bilaterally and palpable DPs bilaterally. HOSPITAL COURSE: The patient was admitted to the preoperative holding area on [**2130-2-14**]. She underwent an abdominal aortic resection. She was transferred to the PACU in stable condition. Her postoperative hematocrit was 32.5, BUN 6, creatinine 0.9. The patient was neurologically intact. She had palpable DPs bilaterally. The patient went into flash pulmonary edema on postoperative day 1 and was transferred to the ICU for continued care from the PACU. The patient remained intubated. The patient's postoperative pain was controlled with epidural infusion. Pressors were weaned off. Lasix for diuresis was begun. Her triple lumen catheter was rewired. She remained in the SICU. Beta-blockade was increased for heart rate management. On postoperative day #3, the patient had an episode of mental status change. A CT was done which was negative for acute bleed or infarct. Ativan was discontinued. She continued to be diuresed for a goal of 1.5 L/24 hours. The patient was extubated on postoperative day 3 and transferred to the VICU for continued monitoring and care. Lopressor was increased and hydralazine was discontinued. Subcu heparin was continued. Physical examination showed diminished breath sounds at the bases. The remaining exam was unchanged. She had palpable DP and PT bilaterally. She was afebrile. Her white count was 8.7, hematocrit 31.8. The patient's EKG postoperatively was without any ST changes. Her troponin was less than 0.01. Ambulation to chair was begun on postoperative day 4. Physical therapy was requested to see the patient in anticipation for discharge planning. The epidural was discontinued. She was converted to oral agents. The patient demonstrated on postoperative day 5 with a much improved lung exam. Chest x-ray was improved. Ambulation was begun. Diet was advanced as tolerated with aspiration precautions. Hyperkalemia was repleted. On postoperative day #6, the patient was weaned by physical therapy. We felt the patient would be able to be discharged to home with physical therapy. The patient continues to progress. She will need to be evaluated for rehab. OT was requested to see the patient to evaluate cognitive of function. The patient will be discharged when medically stable and cleared by physical therapy. DISCHARGE MEDICATIONS: Pentamidine 20 mg b.i.d., metoprolol 50 mg t.i.d., valsartan 150 mg daily, simvastatin 20 mg daily, acetaminophen 325-650 mg q.4-6 hours p.r.n. pain, oxycodone immediate release 2.5-5.0 mg q.4 hours p.r.n. pain, aspirin 81 mg daily, senna tablets 1 b.i.d. p.r.n., Colace 100 mg b.i.d. p.r.n. DISCHARGE DIAGNOSIS: 1. Abdominal aortic aneurysm status post open resection. 2. Postoperative pulmonary edema, resolved. 3. Postoperative confusion, resolved. 4. Type 2 diabetes, diet controlled. 5. History of hypertension, controlled. 6. History of congestive heart failure, last episode prior to this was [**2128-10-28**]. 7. History of cardiomyopathy with systolic dysfunction and diastolic dysfunction. 8. History of hypertension. 9. History of mild coronary artery disease. 10. History of cardiac evaluation status post catheterization on [**2127-6-4**], no coronary artery disease, mild mitral regurgitation with severe systolic ventricular dysfunction, ejection fraction was 26%, mild pulmonary hypertension. 11. Episode of syncope secondary to fall resulting in a subdural hematoma and left wrist fracture on [**Month (only) 359**] [**2128**], resolved. 12. History of breast cancer, bilateral, status post lumpectomies with chemotherapy with CMP and radiation therapy. The patient is a former tobacco smoker. Has not smoked for 14 years. Prior to that was 10 pack-year history. 13. History of mild depression with sleep disorder. The patient should follow-up with Dr. [**Last Name (STitle) 1391**] in 2 weeks' time. She may shower but no tub baths. No driving. She is continued on all medications as directed. She should not lift anything heavier than 2 pounds for the next 4 weeks. She should call his office if she develops fever greater than 101.5, if the wounds become red or drain. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2130-2-20**] 12:30:25 T: [**2130-2-20**] 14:13:42 Job#: [**Job Number 109690**] Name: [**Known lastname **],[**Known firstname 647**] Unit No: [**Numeric Identifier 17983**] Admission Date: [**2130-2-14**] Discharge Date: [**2130-2-22**] Date of Birth: [**2054-8-27**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 231**] Addendum: [**2130-2-21**] patient was reassed by PT and felt she would do better in rehab , since patient lives by herself. Screening was began. [**2130-2-22**] patient transfered to rehab stabled. addendum d/c dx:postop blood loss anemia,transfused. Major Surgical or Invasive Procedure: AAA resection with tube graft [**2130-2-14**] Discharge Disposition: Extended Care Facility: [**Location (un) 1132**] - [**Location (un) 407**] Discharge Diagnosis: postop blood loss anemia, transfused abdominal aortic aneurysem history of hypertension history of DM2, diet treated history of congestive heart failure, compensated [**11-1**] history of cardiomyopaty with systolic and diastolic dysfunction history of mild MR, pulmonary hypertension EF 26% history of breast cancer s/p bilateral lumpectomies, s/p CXT(CMP),XRT history of subdural hematoma secondary to fall with no residual [**9-2**] history of tobacco use, former 13 pkyrs history of depression 13yrs ago postoperative blood loss anemia transfused postoperative pulmonary edema, treated postoperative confusion, resolved with negative head CT for acute process Discharge Condition: stable Discharge Instructions: may shower ,no tub baths ambulate essential distances no lifting >2# x 4 weeks take all medications as directed call if develop fever >101.5 call if incisions become red or drain Followup Instructions: 2 weeks Dr. [**Last Name (STitle) **]. call for an appointment [**Telephone/Fax (1) 236**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2130-2-22**]

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icd9cm

[ [ [] ] ]

[ "38.44", "03.90", "89.68", "99.04", "89.64", "96.71", "99.00" ]

icd9pcs

[ [ [] ] ]

6624, 6701

6553, 6601

7409, 7418

7645, 7895

3802, 4095

6722, 7388

1309, 1397

1526, 3778

7442, 7622

997, 1282

1420, 1508

154, 182

211, 643

666, 973

74,288

173,660

35936

Discharge summary

report

Admission Date: [**2139-11-26**] Discharge Date: [**2139-12-19**] Date of Birth: [**2108-10-17**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Sudden onset headache and Right sided weakness Major Surgical or Invasive Procedure: [**11-24**]: Placement of External Ventricular Drain / right side [**11-25**]: Angiogram and embolization of a-comm aneurysm [**11-29**]: Re-Placed EVD right side [**12-4**] evd removal on right/evd placed on left /cerebral angioplsty [**12-7**] and [**12-8**] cerebral angiogram History of Present Illness: HPI:Pt. is a 31 year old male, who per his mother has been having occipital headaches for the past few weeks. per outside ED report pt. was shoveling manure today when he developed a sudden onset headache and right sided weakness. He was taken to an outside facility where his headache was accompanied by sever N/V and questionable seizure activity and decerebrate posturing, pt. was intubated there after CT scan showed diffuse SAH greatest in the region of the ACOM, and he was transferred to [**Hospital1 18**]. Past Medical History: PMHx: none Social History: Social Hx: + tobacco ( approx. 1-2 packs) pt. rolls own No ETOH Family History: Family Hx:NC Physical Exam: PHYSICAL EXAM: O: T: BP: 133 /70 HR: 50's R: vented 16 O2Sats 100% Gen: Intubated and sedated IN ICU HEENT: Pupils: 2mm, minimally reactive EOMs: unable to eval. Extrem: Warm and well-perfused. Neuro: + cough and gag Mental status:intubated sedated, not following commands Cranial Nerves: I: Not tested Motor: slight decerebrate posturing seen in ED Dishcarge Exam: AOx2-3, MAE with full strength. No prontator drift Pertinent Results: [**2139-11-26**] 12:22AM WBC-22.0* RBC-4.34* HGB-13.9* HCT-39.9* MCV-92 MCH-32.0 MCHC-34.8 RDW-13.9 [**2139-11-26**] 03:16AM PT-13.4 PTT-24.1 INR(PT)-1.2* [**2139-11-26**] 12:22AM GLUCOSE-160* UREA N-11 CREAT-0.8 SODIUM-139 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 [**2139-11-30**] 06:29PM CEREBROSPINAL FLUID (CSF) WBC-1500 HCT,Fl-6.0* Polys-88 Lymphs-2 Monos-8 Macroph-2 CTA [**11-25**] IMPRESSION: 1. Anterior communicating artery aneurysm, 9 x 5 mm. 2. Massive intraparenchymal and intraventricular hemorrhage with hydrocephalus. Small amount of subarachnoid hemorrhage. CT Perfusion [**11-27**] IMPRESSION: 1. Relatively unchanged appearance of diffuse subarachnoid, predominantly right frontal intraparenchymal and extensive intraventricular hemorrhage. Persistent perihemorrhagic edema around the right frontal hematoma causing mild subfalcine herniation measuring up to 7 mm, unchanged. 2. Interval clippage of the anterior communicating artery aneurysm with no signifacnt residual within limits of the sreak artifact from the coils. No other abnormalities noted. CTA [**11-29**]: CONCLUSION: No change in ventricular calibers since study of [**2139-11-29**]. No evidence of new hemorrhage. Status post coiling of anterior communicating artery aneurysm with residual intraparenchymal and intraventricular hemorrhage. The CT perfusion study demonstrates an avascular area corresponding to the right frontal lobe hematoma but no evidence of cerebral ischemia elsewhere. The CTA suggests generalized reduction in caliber of the intracranial arteries with no focal narrowings to suggest vasospasm. Brief Hospital Course: 31M admitted to the ICU on [**11-25**] with no eye opening(attempted however), follows commands in UEs & LLE. PERRL, and EVD in place. He was extubated on [**11-26**] and ICPs were WNL. He had a CTA/Perfusion study which showed no vasospasm or ischemia. He then pulled out his EVD on the night of [**11-27**]. He had a Head CT which showed no worsening hydrocephalus. He did become more lethargic on the [**11-29**] and the EVD was replaced and emperic treatment antibiotics were started for elevated WBCs in the CSF. ICPs WNL however remained bloody. On [**11-30**] he began to become more alert and arousable, following commands although only oriented to self. On [**12-1**] he show improved alertness and orientation. [**12-2**] decreased mental status in the afternoon- CTA+P sugestive of vasospasm began triple H therapy with goal bp 180 pt scheduled for diagnostic angio [**12-4**] showed ACA territory vasospasm. He required continued with a EVD at 10. He remained neurologically orientated x1, followed commands difficult with 2 step commands, motor strength full throughout. He had continuous hyponatremia, he was treated with salt tabs with good effect. On [**12-7**] and [**12-8**] a diagnositic angio showed vasospasm for which he received verapamil. He remained neurologically with some short term memory issues remembering the date and the name of the hospital. On [**12-14**] his EVD was removed and [**12-15**] he was transferred to the neurostep down unit. He progressed well once he was on the floor, he orientated X3, eating well, voiding and having bowel movements. PT and OT were concerned with cognitive abilities and felt he would need 24 hour care. He is being sent home with his parents for 24 hours supervision they have agreed to providing this care. Medications on Admission: None Discharge Medications: 1. Tylenol 325 mg Tablet Sig: Three (3) Tablet PO every [**3-21**] hours. Tablet(s) 2. Keppra 1,000 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: A-comm aneurysm rupture subarachnoid hemorrage(atraumatic) vasospasm / cerebral Discharge Condition: stable Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair, as your staples have been removed. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? 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 on [**2138-12-24**] for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[**2139-12-19**]

[ "435.8", "276.1", "430", "305.1", "331.4", "320.9" ]

icd9cm

[ [ [] ] ]

[ "00.41", "99.29", "88.41", "02.2", "00.62", "39.72" ]

icd9pcs

[ [ [] ] ]

5504, 5510

3465, 5245

367, 649

5634, 5643

1816, 3442

6954, 7517

1328, 1343

5300, 5481

5531, 5613

5271, 5277

5667, 6931

1373, 1593

281, 329

677, 1195

1666, 1797

1607, 1650

1217, 1230

1246, 1312

9,561

141,145

5279

Discharge summary

report

Admission Date: [**2178-12-2**] Discharge Date: [**2178-12-9**] Date of Birth: [**2095-10-10**] Sex: M Service: MEDICINE Allergies: Percodan Attending:[**First Name3 (LF) 1990**] Chief Complaint: Headache, black stool Major Surgical or Invasive Procedure: Colonoscopy Upper Endoscopy History of Present Illness: 83M with PMH of afib on coumadin, ileostomy for unknown reason, who presented from home for headache, nausea, and dark stools. Pt's VNA called [**Company 191**], reporting headache, nausea, and dark stools for three days, with inability to tolerate PO intake. VNA BP 180/80, without postural hypotension. Concern by PCP for GIB given pt on coumadin, referred to ED. Other issues as outpt have been increasing assymetric leg edema and decrease in UOP (with plan for CT scan to r/o IVC obstruction). Other ROS+ nonspecific, fevers, and chills, with headache, ?weeks to months. . In [**Hospital1 18**] ED, vss, 97.1, 75, 181/77, 14, 100%ra, guaiac+ stool from ostomy, +bilious vomit in ED, hct stable at 35. Given 1L NS. CT head showed large b/l subdurals with shift. Neurosurgery evaluated, felt no immediate surgery, with plan on burr hole in a few days. NG lavage not tolerated by patient, not attempted again. INR 2.3, received 1 vial recombinant factor 9, 2ffp (in prep for possible OR), 10mg iv vitamin K. hr 90, 166/73, rr20, 99%ra, access - 1pIV. . While in the MICU the patient was evaluated by GI. He did not require transfusion and Hct remained stable in the low 30s. GI felt that scope was not urgent and could be postponed until after NSURG procedure. In the ICU the patient complained of intermittant headache, serial neurologic exam remained stable. INR was reversed and coumadin held given large bleed. NSURG following patient and feel that will need surgical decompression electively. Patient was started on keppra for sz ppx. Currently the patient complains of feeling tired. Denies pain, SOB, headache, other complaints. Past Medical History: 1. atrial fibrillation 2. anxiety 3. GERD 4. benign prostatic hypertrophy 5. congestive heart failure 6. "redundant" colon - ileostomy Social History: The patient is married and lives with hiswife. He was a department store buyer until he retired at the age of 65. He quit pipe and cigar smoking approximately 40 years ago and does not smoke cigarettes. He denies alcohol use. Family History: Brother died at 61 of coronary artery disease. Father died at 78 of stomach ulcers. Mother died at age [**Age over 90 **] of natural cause. Physical Exam: DISCHARGE PHYSICAL: T: 96.4 BP:124/60 HR:59 RR:16 97% on RA GEN: NAD, pleasant HEENT: EOMI, PERRL, no OP lesions CV: Irregularly irregular, 2/6 SEM at RUSB PULM: CTAB ABD: +bs, soft, NTND, ostomy draining brown-yellow fluid, site non tender, no erythema Ext: no LLE, 2+ distal pulses Neuro: A/O x3 (intermittantly not oriented to place), CN 2-12 intact, [**6-1**] UE/LE strength bilaterally Psych: Appropriate Pertinent Results: IMAGING: NON-CON CT HEAD [**2178-12-2**]: FINDINGS: Bilateral subdural collections are noted along the cerebral hemispheres. The left sided collection is mostly hypodense and chronic appearing though a small amount of hyperdensity is noted along the posterior and inferior aspect, suggesting an acute component. This collection measures up to 2.1 cm in thickness. There is diffuse left sulcal effacement and subfalcine herniation with 10- mm righward shift of midline structures (2:16). A chronic appearing right-sided subdural collection is also noted measuring approximately 11 mm in maximal thickness. A few areas of linear high attenuation are noted within this collection which may represent subdural membranes or a small component of acute bleeding. Associated mass effect is noted with diffuse right sulcal effacement. Slightly hyperdense appearance of the tentorium may be due to calcification, less likely trace layering SDH. There is no evidence of transtentorial herniation with patent basilar cisterns. . The [**Doctor Last Name 352**]- white matter differentiation is preserved, and there is no hydrocephalus. Calcification of the cavernous portions of the carotid arteries and the vertebral arteries bilaterally is noted. The visualized paranasal sinuses and mastoid air cells appear well aerated aside from a small amount of mucosal thickening within the left maxillary sinus. The soft tissues and osseous structures are intact. . IMPRESSION: Bilateral chronic subdural hematomas, left greater than right, with small acute component (more evident on the left). Associated mass effect with rightward shift of midline structures and diffuse sulcal effacement. . . CT ABDOMEN/PELVIS WITH CONTRAST [**2178-12-2**]: ABDOMEN: There is bibasilar, dependent atelectasis. There is a small hiatal hernia. The liver, gallbladder, spleen, adrenal glands, and right kidney are unremarkable. A 2-cm low-attenuation lesion at the upper pole of the left kidney is compatible with a simple cyst. A smaller 3-mm low-attenuation lesion at the lower pole of the left kidney is too small to characterize but most likely represents a simple cyst (2:35). A prominent calcification along the left renal artery is noted. There is diffuse atherosclerotic disease of the abdominal aorta. Note is made of a right lower quadrant ileostomy. There is no evidence of obstruction, free air or fluid within the abdomen. There are scattered mesenteric and retroperitoneal lymph nodes, none of which meet criteria for pathology by CT. A large volume of stool is noted within the cecum. . CT OF THE PELVIS WITH IV CONTRAST: A large volume of stool is noted within the rectum. The prostate, bladder, distal ureters, and sigmoid colon are unremarkable. There is no free fluid within the pelvis. No pathologically enlarged inguinal or pelvic lymph nodes. . OSSEOUS STRUCTURES: There is fusion of the L1 through L3 vertebral bodies and the L4 through L5 vertebral bodies. There is associated degenerative change including vacuum disc phenomena at the L3-4 and L5-S1 levels. Endplate sclerosis is also evident at the T12-L1 and L3-L4 levels. There is no associated spondylolisthesis. . IMPRESSION: 1. Right lower quadrant diverting ileostomy without evidence of obstruction. No acute intra-abdominal or pelvic findings. 2. Small hiatal hernia. . . DISCHARGE LABS: Brief Hospital Course: 83 M with PMH of A-fib on coumadin, and ileostomy for unknown reason who presented from home with report of black stool from ostomy, HA for several weeks and nausea. Found to have bilateral subdural hematomas and guaiac positive stool, hct stable at baseline of low-mid 30's. INR therapeutic on admission at 2.3. Initially admitted to MICU for close neurological monitoring with neurosurgery and GI consults. Was transfered to the floor where he had a colonoscopy and EGD that were normal, showing no evidence of bleeding. Patient was discharged home in stable condition. He is scheduled for follow up CT on [**2178-12-16**]. Neurosurgery will contact patient regarding time of appointment that day. . # GIB/anemia: Admitted to ICU with report of melanotic stool from ostomy. Patient also on coumadin for A-fib, was therapeutic on admission at 2.3 INR was reversed on admission and coumadin held. Hct was stable throughout hospitalization. Per patient, has ostomy for 'redundant colon' though explanation was non-descript. No hx of GIB or upper GI pathology or GERD to explain GIB. CT abd showed no mass or other pathology. Patient underwent colonoscopy and EGD on [**2178-12-7**] which showed no abnormalities. Coumadin was stopped given GIB and subdurals. Hct stable at 32 upon discharge. . # Subdural hematomas: Found on CT scan, appear chronic in nature on imaging. Coumadin reversed on admission and held as above. Patient intially monitored in ICU for frequent neuro checks. He had no change in mental status and his neuro exam remained non-focal throughout his hospitalization. Unclear duration of bleed, no hxistory of trauma and INR not supratherapeutic, appear chronic on CT with smoothing of brain surface. Hematomas also appear heterogenous in texture suggesting a more chronic bleed rather than acute. Seven mm midline shift. Patient likely not signifcantly affected by hematoma given age and probably lower brain volume, larger intracrainial space and chronicity of bleed. Per neurosurgery, no intervention necessary as neuro status is unchanged from baseline and is stable. Will follow up with Dr. [**Last Name (STitle) 739**] on [**2178-12-9**] as out patient with CT scan. Patient continued on Keppra 500mg [**Hospital1 **] for seizure ppx, treatment duration to be determined by neurosurgery outpatient. . # Lower extremity edema: None this morning, pending work up by PCP, [**Name10 (NameIs) **] hx of cirrhosis, renal disease or CHF. Outpatient lasix held while hospitalized give GIB. Restarted on discharge. Deferred workup to outpatient. . # Atrial fibrillation: Rate controlled throughout hospitalization. BB intially held given GIB and restarted before discharge. Continued on digoxin. Coumadin stopped as above given GIB andsubdural hematoma, which will be permanently stopped. . # Urinary urgency/hesitancy: Noted by pcp, [**Name10 (NameIs) **] drawn in ED, with occasional bacteria, with no other evidence of infection. Tamsulosin intitially held in setting of GIB and restarted before discharge. . # Code Status: FULL CODE Medications on Admission: DIGOXIN - 125mcg qd FUROSEMIDE - 20mg qd METOPROLOL SUCCINATE [TOPROL XL] - 150mg qd OMEPRAZOLE - 40 mg qd TAMSULOSIN - 0.4 mg qhs TRAZODONE - 50-100mg qhs:prn WARFARIN - 2 mg qhs ASPIRIN - 81mg AVODART 0.5mg qd Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Chronic Subdural Hematomas GI Bleed . Secondary: Hypertension Discharge Condition: Good, vital sign stable, alter and oriented x3. Discharge Instructions: You were admitted with dark stool and a headache and found to have blood in your stool and bleeding around your brain. It appears that the bleeding around the brain is chronic and has likely been there for a long time. You had a repeat head scan before you left that showed that the bleeding was improving and you did not need surgery while in the hospital. You will need to have a follow-up head CT in 1 week as below. Dr. [**Name (NI) 21547**] office will be in contact with you to definitively schedule a f/u appointment with them next week. . The gastroenterologists did a colonoscopy and an upper endoscopy to look for a bleed in your GI tract and found no source of bleeding. Your blood count remained stable while you were in the hospital. . The following medication changes were made: ***STOPPED: COUMADIN AND ASPIRIN. You should stop taking these. You had bleeding inside your head and in your colon so you cannot be on coumadin ever again. You will need to discuss as an outpatient whether or not you can be restarted eventually on a full dose aspirin for your irregular heartbeat. Please have this conversation with your primary care physician and the neurosurgeons. ***ADDED: KEPRRA. This is to prevent seizures. You have blood around your brain which can cause seizures. You should continue taking this medication at home until the neurosurgeons tell you to stop. ***STOPPED: LASIX. You did not have problems with leg swelling or problems breathing while in the hospital and this medicine was stopped. . No other medication changes were made. You should resume all your other home medications as directed. . If you have shortness of breath, chest pain, severe headache, confusion, dizziness or lightheadedness, fever higher than 100.5 or any other concerning symptom, please seek medical care immediately. . It was a pleasure meeting you and participating in your care. Followup Instructions: Please f/u with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within 1-2 weeks of discharge. His phone number is [**Telephone/Fax (1) 250**]. Radiology: You are scheduled for a repeat CT scan of your head on Wednesday, [**12-16**] at 8:30 am at the [**Hospital Ward Name 516**], [**Hospital Unit Name 1825**], [**Location (un) 470**]. Neurosurgery: You will be contact[**Name (NI) **] by Dr.[**Name (NI) 4674**] office for a follow-up appointment next week. Please call [**Telephone/Fax (1) 1669**] if you do not hear from them in the next 1-2 days. . General Medicine: Provider: [**Name10 (NameIs) 2483**],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 191**] MEDICAL UNIT Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2179-1-8**] 11:00 . Psychiatry: We have called Dr. [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 16293**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to try to set up an outpatient psychiatric appointment for you per your VNA services. Unfortunately, we have been unable to get ahold of either physician. [**Name10 (NameIs) **] will need to call [**Telephone/Fax (1) 21548**] to set up an appointment with Dr. [**Last Name (STitle) 21549**] [**Name (STitle) 16293**] or call [**Telephone/Fax (1) 21550**] to set up an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].

[ "300.00", "401.1", "427.31", "280.0", "285.1", "578.1", "V44.2", "553.3", "432.1", "788.63", "427.1", "V58.61", "530.81", "600.01" ]

icd9cm

[ [ [] ] ]

[ "96.07", "45.13", "99.07" ]

icd9pcs

[ [ [] ] ]

10296, 10353

6363, 9431

292, 322

10468, 10518

3001, 6322

12457, 13949

2411, 2555

9694, 10273

10374, 10447

9457, 9671

10542, 12434

6340, 6340

2570, 2982

231, 254

350, 1989

2011, 2148

2164, 2395

30,490

171,043

49111

Discharge summary

report

Admission Date: [**2189-7-11**] Discharge Date: [**2189-7-21**] Date of Birth: [**2112-12-7**] Sex: F Service: MEDICINE Allergies: Codeine / Percocet / Percodan Attending:[**First Name3 (LF) 1042**] Chief Complaint: Fever Major Surgical or Invasive Procedure: 1. PICC placement History of Present Illness: Patient is a 76 yo female with h/o diastolic CHF, a fib recently started on levaquin 2 days ago for cough and fever. Pt is a nursing home resident and was found to be hypotensive with SBPs in 70s. The pt was recently hospitalized [**Date range (1) 17331**] with acute on chronic diastolic CHF. During her hosptialization she was diuresed with lasix 10 - 20 mg IV throughout the admission and quickly returned to her baseline oxygen needs, satting in the mid to upper 90's on 2LNC. She was discharged on lasix 20 mg PO lasix daily. There was no evidence of infection/pneumonia or COPD flare, and she was not continued on levofloxacin or solumedrol after the initial doses in the ED. The pt was in her USOH until she was started on levaquin as an outpatient two days ago when she developed an increasing cough productive of sputum and fever. O2 requirements have not changed from her baseline 2L NC. She was transferred to the ED after being found incidentally to have a systolic BP in the 70s at her nursing home. Her fluid restriction had been reduced from 1L daily to 2L in the setting of her illness. . In the ED, T Bp HR, RR, O2 sats. She was given 500 cc of NS because they were concerned about volume overload. The pt was found to have ARF with a Cr of 2.6 (up from baseline of 1.1), hyponatremia, and hypotension. The pt spiked temp to 103 however further IVF was held for concern of underlying CHF. She was started on vancomycin and continued on levaquin. On arrival to the [**Hospital Unit Name 153**] the patient was resting quite comfortably with stable vital signs and sating 97% on a 2L NC. Past Medical History: Chronic Diastolic Heart Failure RHD (rheumatic heart disease) Atrial fibrillation Asthma Mental retardation (born premature) Legally blind (strabismus/amblyopia due to prematurity) Seizure d/o Hearing loss OA Anemia Bradycardia Social History: Has lived in homes for MR since [**94**]. Does not smoke, drink, or take drugs. Ambulatory and active at baseline with walker. Active in day program where she makes jewelry. Family History: She has one brother aged 71 who is alive and well. Her parents died in their 60s and 70s from cardiovascular disorders. She has no children Physical Exam: Gen: alert and oriented X3, NAD HEENT: PERRLA, EOMI, dry MM CV: irreg/irreg II/VI SEM Resp: decreased BS R base, dry crackles throughout Abd: soft, NT/ND NABS Ext: trace LE edema Pertinent Results: [**2189-7-12**] 05:29AM BLOOD WBC-7.8 RBC-2.40* Hgb-8.3* Hct-24.7* MCV-103* MCH-34.5* MCHC-33.6 RDW-12.1 Plt Ct-144* [**2189-7-10**] 11:50PM BLOOD WBC-16.0*# RBC-3.00* Hgb-10.1* Hct-30.1* MCV-100* MCH-33.6* MCHC-33.5 RDW-13.4 Plt Ct-169 [**2189-7-10**] 11:50PM BLOOD Neuts-86.1* Lymphs-7.5* Monos-6.0 Eos-0.2 Baso-0.1 [**2189-7-11**] 08:05AM BLOOD PT-27.0* PTT-29.3 INR(PT)-2.7* [**2189-7-10**] 11:50PM BLOOD PT-25.1* PTT-34.9 INR(PT)-2.5* [**2189-7-12**] 05:29AM BLOOD Glucose-114* UreaN-34* Creat-1.6* Na-136 K-4.5 Cl-106 HCO3-24 AnGap-11 [**2189-7-11**] 02:42PM BLOOD Glucose-128* UreaN-42* Creat-1.9* Na-137 K-4.3 Cl-100 HCO3-29 AnGap-12 [**2189-7-11**] 08:05AM BLOOD Glucose-95 UreaN-41* Creat-1.9* Na-140 K-3.3 Cl-105 HCO3-26 AnGap-12 [**2189-7-10**] 11:50PM BLOOD Glucose-136* UreaN-52* Creat-2.6*# Na-131* K-4.5 Cl-91* HCO3-28 AnGap-17 [**2189-7-10**] 11:50PM BLOOD cTropnT-<0.01 proBNP-4868* [**2189-7-12**] 05:29AM BLOOD Calcium-7.5* Phos-2.6* Mg-1.8 [**2189-7-11**] 08:05AM BLOOD Calcium-6.9* Phos-2.1* Mg-1.7 [**2189-7-10**] 11:50PM BLOOD Calcium-9.0 Phos-2.0* Mg-2.0 [**2189-7-11**] 12:32AM BLOOD Lactate-1.7 CXR [**7-10**]: INDICATION: SOB and hypertension. COMPARISON: [**2189-6-25**]. AP UPRIGHT CHEST: Increased pulmonary interstitial streaky opacity is consistent with increased pulmonary edema. Moderate cardiomegaly is stable. There are stable tracheobronchial tree calcifications and aortic arch calcifications. Extensive degenerative disease in the thoracolumbar spine with severe S-shaped rotatory thoracic scoliosis is unchanged. IMPRESSION: Moderate CHF. PROCEDURE: CT chest without contrast on [**2189-7-13**]. COMPARISON: [**2188-3-5**] and [**2189-6-1**]. TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to the subdiaphragmatic area without contrast. Thinner slice 5 mm and 1.25 mm images were reconstructed at different window algorithms. Sagittal/coronal reformatted images were also obtained for further evaluation. HISTORY: 76-year-old woman with septic physiology but no clear source. Suspect pulmonary process,congestive heart failure. Evaluate for pulmonary infectious process. FINDINGS: The study is partly degraded at the lung bases limiting the accurate evaluation of any subtle changes as there exist course but smooth pulmonary reticulation with no bronchiectasis, honeycombing or significant emphysema. In the upper lobes which are not affected by motion artifact, similar areas of reticulation are seen mainly along the periphery unchanged since the chest CTA of [**2188-3-5**]. The heart especially the left atrium is enlarged. The aorta is normal in caliber. Coronary vascular calcification is stable. Pulmonary arteries are enlarged; the trunk measures 33 mm while the right pulmonary artery measures 31 mm. There is a stable small pericardial effusion. There is slight increase of bilateral small bibasilar pleural effusions. There are pathologically enlarged lymph nodes in the mediastinum as well as the hilar regions, essentially unchanged from the prior examination including a 19 mm subcarinal lymph node, 9.2 mm left prevascular lymph node and a 9 mm right upper paratracheal lymph node. The bones do not show any lesions suspicious for malignancy or infection. Note is made of severe degenerative changes, scoliosis of multiple osseous fractures. Limited evaluation of the abdomen shows no abnormality. IMPRESSION: 1) Smooth interstitial thickening at the periphery of the lungs stable since [**2188-2-21**] indicating chronicity, however, its slow progression argues against UIP. 2) No change in the cardiomegaly, aortic calcification. 3) Stable pulmonary hypertension. 4) Multiple enlarged mediastinal and hilar lymph nodes. 5) Slight worsening of bilateral pleural effusions. Brief Hospital Course: The patient was intially admitted to the ICU and received aggressive IVF resuscitation (>9 liters) and empiric piperacillin/tazobactam and vancomycin. Despite culture negative tests, she responded to this therapy with normalization of her labs and improvement in her vital signs. She was transferred to the floor, where she completed a 7 day course of empiric antibiotics without incident. It was also noted that she had acute on chronic diastolic congestive heart failure which may have been triggered by flash pulmonary edema from rapid ventricular response from her atrial fibrillation. She was then aggressively rate controlled with a combination of metoprolol succinate, extended release diltiazem, and low dose digoxin. On discharge, her resting heart rate varied between 50-80 and with activity, peaked at 100. Medications on Admission: 1. Folic Acid 1 mg PO DAILY 2. Fexofenadine 60 mg PO BID 3. Calcium Carbonate 500 mg PO TID 4. Warfarin 1 mg PO Once Daily at 4 PM 5. Aspirin 81 mg PO DAILY 6. Levetiracetam 1500 mg PO BID 7. Gabapentin 900 mg PO TID 8. Furosemide 20 mg PO DAILY 9. Metoprolol Tartrate 50 mg PO BID Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for fever or pain. 4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing or dyspnea. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) grams PO DAILY (Daily): Mix with 8 ounces water, juice, coffee, tea, or soda. 12. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 13. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 16. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO QAM (once a day (in the morning)). 17. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO QPM (once a day (in the evening)). 18. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: 1. Septic shock, resolved 2. Acute renal failure, resolving 3. Acute on chronic diastolic congestive heart failure 4. Atrial fibrillation 5. Chronic interstitial lung disease 6. Seizure disorder 7. Rheumatic heart disease 8. Mental retardation 9. Legally blind 10. Sensorineural hearing loss Discharge Condition: Stable, at baseline dyspnea and well oriented Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please contact the physician on call if you develop worsening shortness of breath, fevers, sweats, chills, or confusion. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16747**], M.D. Phone:[**Telephone/Fax (1) 16748**] Date/Time:[**2189-7-31**] 4:30

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

9569, 9642

6565, 7384

296, 316

9978, 10026

2766, 6542

10297, 10456

2409, 2551

7716, 9546

9663, 9957

7410, 7693

10050, 10273

2566, 2747

251, 258

344, 1949

1971, 2201

2217, 2393

19,755

107,588

13116

Discharge summary

report

Admission Date: [**2113-2-3**] Discharge Date: [**2113-2-13**] Date of Birth: [**2047-8-17**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old woman with recently-diagnosed metastatic colon cancer, admitted to the Medical Intensive Care Unit on [**2113-2-10**]. The patient was initially admitted to the hospital on [**2113-2-3**] after being found down on the floor in her stool-ridden apartment status post fall. The patient described vague prodromal symptoms of "flu-like symptoms" for two to three weeks, which included weakness, lethargy, occasional watery diarrhea, no melena. She was found down, and EMS was called. X-rays of her knee on arrival to the Emergency Department were negative. In the Emergency Department, she was noted to have an elevated white blood count of 48, with a right upper quadrant ultrasound suggesting liver metastases. She was guaiac positive. Abdominal CT scan confirmed liver metastases with a right colonic mass. At that time, she had elevated transaminases and elevated alkaline phosphatase and elevated bilirubin. Her urinalysis was consistent with a urinary tract infection, and she was started on a course of Levaquin. Her stool was subsequently found to be positive for C. difficile, and she was started on a course of Flagyl. With failure of her diarrheal symptoms to resolve and a persistently elevated white blood count, the patient was also treated with oral vancomycin per the Infectious Disease Department's recommendations. On [**2113-2-6**], the patient underwent a colonoscopy which revealed a mass in the distal ascending colon and diverticulosis of the descending colon/proximal sigmoid colon. Cytology was positive for poorly-differentiated adenocarcinoma. The patient's white blood count continued to rise over the course of the next several days, from 48 on admission to 65. Her peripheral blood smear was thought to be consistent with a reactive leukocytosis. On [**2113-2-6**], the patient developed bloody stool. On [**2113-2-8**], the patient had persistent bright red blood per rectum with decreased blood pressure to the 90s systolic. On [**2113-2-8**], she was transfused one unit of packed red blood cells. The Hematology/Oncology service was consulted, and in accordance with the patient's decision to pursue aggressive treatment, they recommended local excision and a treatment of chemotherapy with 5-FU and leucovorin. The Gastroenterology service was reconsulted regarding the gastrointestinal bleed, and they felt that the bright red blood per rectum was likely secondary to a bleeding colonic mass vs. bleeding diverticula. The patient got 5 mg of intravenous vancomycin x 2 for an elevated INR. The patient had ongoing diarrhea, which was not well quanitified. From [**2-9**] to [**2-11**], the patient's creatinine was noted to rise from 1.1 to 1.9. Her white blood count continued to rise, as did her serum lactate level. Her bicarbonate declined. Surgery was consulted regarding question of acute abdomen and possible infarcted bowel. They felt that, given the patient's absence of abdominal pain and nontender abdomen, that no surgery was indicated. From [**2-10**] to [**2-11**], the patient began to complain of increased shortness of breath. Her lungs remained clear, and her respiratory rate was noted to be increased secondary to compensation for her worsening lactic metabolic acidosis. Her urine lytes suggested a pre-renal picture. Antibiotics were expanded on [**2-11**] to include ampicillin. A PICC line was placed that day, complicated by two seven-beat runs of ventricular tachycardia secondary to instrumentation of the atrium or ventricle. The patient also had a question left bundle branch block pattern of 30 seconds duration while undergoing PICC line placement. For low blood pressure, the patient was bolused with normal saline 500 cc x 2 that afternoon. Later that evening, the patient complained of increased shortness of breath when lying flat. She was sent for an abdominal CT. While in the CT scanner, she complained of increased respiratory distress and was ultimately intubated and transferred to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Osteoarthritis 2. History of tonsillectomy 3. Morbid obesity MEDICATIONS ON TRANSFER: 1. Levaquin 500 mg by mouth once daily 2. Colace 3. Senna Both Colace and Senna were being held. 4. Vancomycin 125 mg by mouth four times a day 5. Flagyl 1 gram intravenously every six hours 6. Ampicillin 2 grams intravenously every four hours 7. Tylenol as needed HOME MEDICATIONS: The patient was on pain medications for her osteoarthritis. SOCIAL HISTORY: The patient lived on her own, walked with two canes. She lived in deplorable home conditions. FAMILY HISTORY: Father died of lung cancer. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On admission to the Medical Intensive Care Unit, vital signs: Temperature 97.6, pulse 108, blood pressure 70/30, respiratory rate 18, pulse oxygenation 100% on the ventilator. General appearance: The patient is intubated, sedated, responding to tactile and painful stimuli. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light, sclerae slightly icteric, conjunctiva noninjected. Cardiovascular: Regular rate and rhythm, distant heart sounds, normal S1, S2, no appreciable murmurs. Neck: Flat neck veins. Lungs: Clear bilaterally. Abdomen: Obese, distended, with difficult to assess tenderness secondary to sedation, with hypoactive bowel sounds. Extremities: 1+ edema. Neurologic examination: The patient withdraws to pain, moves all four extremities. Ventilator settings: SIMV with pressure support of 5, tidal volume 600, respiratory rate 20, PEEP of 5, FIO2 of 1. LABORATORY DATA: Initial blood gas on admission to the floor: 7.38/28/383. White blood count 68, hematocrit 34, platelets 273. Sodium 134, potassium 4.0, chloride 93, bicarbonate 18, BUN 40, creatinine 1.6, glucose 92. Urinalysis showed large blood, negative nitrite, 30 protein, negative glucose, trace ketones, small bilirubin, 4 urobilinogen, small leukocytes. INR 2.5. ALT 62, AST 76, alkaline phosphatase 765, total bilirubin 4.7. Urine sodium less than 10, urine creatinine 135, urine osmolality 406. CEA 15, lactate 6.2, CA-19-9 pending. Chest x-ray showed no acute process. CT scan of the abdomen revealed evidence of an umbilical hernia, but no evidence of free air, obstruction, or abdominal perforation, no evidence of biliary dilatation or cholangitis. Blood cultures from earlier in the admission were pending or negative. Urine cultures were pending. Stool cultures were positive for C. difficile on [**2113-2-6**]. Pathology from [**2113-2-7**] revealed invasive adenocarcinoma, poorly differentiated. HOSPITAL COURSE BY SYSTEM: 1. Cardiovascular: The patient presented hypotensive, in hypovolemic vs. septic shock. She was aggressively volume repleted. Her blood pressure initially responded to volume and low-dose dopamine. Over the course of her hospitalization, the patient became increasingly pressor-dependent. She was bolused aggressively with intravenous fluids, and was 14 liters positive by the end of her hospital stay. She remained hypotensive, requiring more aggressive pressor support, despite a jugular venous pressure of 10 to 12. She was initially transitioned from dopamine to Levophed. Dobutamine was later added for inotropic support, and vasopressin for additional blood pressure support. The patient became increasingly hypotensive, with no evidence of intra-abdominal bleed. Although CT scan had initially been negative for abdominal perforation or free air, the patient's belly became increasingly distended, and it was thought that she most likely developed sepsis and acidosis from intra-abdominal perforation. The patient was unable to maintain mean arterial pressures greater than 30 to 40 on the final day or two of her hospitalization. She ultimately coded, developing a rhythm consistent with complete heart block, and was flat lined. At that point, the patient was Do Not Resuscitate/Do Not Intubate, and was not deemed appropriate for cardiopulmonary resuscitation. 2. Pulmonary: The patient presented with respiratory failure, initially thought secondary to inability to compensate for her worsening metabolic acidosis from lactate accumulation. The patient was placed on a ventilator and maintained good oxygenation and ventilation. The patient's pH remained low secondary to her metabolic process. 3. Renal: The patient presented in acute renal failure and eventually became anuric in the setting of her sepsis. She had a worsening lactic acidosis, which was thought secondary to ischemic bowel vs. liver failure vs. generalized hypoperfusion and a low-flow state with acute liver and renal failure. 4. Infectious Disease: The patient presented with overwhelming sepsis as described above. She had been treated earlier in the admission for a urinary tract infection with a six day course of Levaquin. This was not continued in the Intensive Care Unit. Urine cultures just prior to her death were positive for enterococcus. 5. Gastrointestinal: The patient was found to have a large colonic mass with metastases to the liver. Although she had wanted aggressive treatment, including local resection and chemotherapy, she had a likely life expectancy of approximately one year. The patient also had developed a gastrointestinal bleed while on the Medical floor following colonoscopy, thought secondary to bleeding colonic mass. She had been transfused one unit of packed red blood cells. Her hematocrit remained stable, without any recurrent gastrointestinal bleeding while in the Medical Intensive Care Unit. She was also treated while on the floor for C. difficile colitis with Flagyl and later with oral vancomycin. C. difficile antigen was not resent. The patient had gradually worsening liver function tests, consistent with a cholestatic picture. Right upper quadrant ultrasound and CT scan showed no evidence of ductal obstruction or abscess. While in the Intensive Care Unit, she was on broad-spectrum antibiotics to cover possible abdominal vs. biliary process with ampicillin, gentamicin and Flagyl. Blood cultures remained negative. 6. Hematology: The patient was noted to be having microcytic anemia, likely secondary to iron deficiency secondary to chronic gastrointestinal bleed from her colonic mass. Her persistently elevated white blood count was attributed to her C. difficile colitis vs. leukemoid reaction vs. sepsis. She had an elevated INR, reflecting liver failure-induced coagulopathy. She did respond somewhat to doses of vitamin K prior to her arrival in the Medical Intensive Care Unit. 7. Fluids, electrolytes and nutrition: The patient was hypovolemic by examination. She initially responded to fluid resuscitation, but ultimately became septic. Peripheral vasodilation unable to support, and we were unable to support her blood pressure with fluids or pressors. DISPOSITION: The patient ultimately died on [**2113-2-13**]. There had been active communication between the Medical Intensive Care Unit team and the patient's brother, who became her spokesperson. He understood that there was little more that we could offer her, and she was ultimately made Do Not Resuscitate/Do Not Intubate. We tried to keep her alive with pressors until the rest of her family could arrive, but the patient coded from cardiac arrest and was not resuscitated. The autopsy was requested, and permission was granted by the patient's family. DR.[**Last Name (STitle) **],[**First Name3 (LF) 1569**] 12-684 Dictated By:[**Last Name (NamePattern4) 4689**] MEDQUIST36 D: [**2113-2-13**] 22:09 T: [**2113-2-14**] 00:00 JOB#: [**Job Number 40050**]

[ "153.6", "785.59", "276.2", "518.81", "584.9", "285.1", "038.3", "197.7", "426.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "45.25", "96.04" ]

icd9pcs

[ [ [] ] ]

4811, 4879

6870, 11920

4618, 4679

4903, 5611

159, 4211

5635, 6843

4326, 4599

4233, 4301

4697, 4793

18,060

129,093

46567

Discharge summary

report

Admission Date: [**2160-12-5**] Discharge Date: [**2160-12-11**] Date of Birth: [**2108-2-26**] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old gentleman with a history of diarrhea, nausea, cough, and headache times one week who has multiple medical problems who is on Coumadin for aortic valve replacement and mitral valve replacement. His headache symptoms were of a gradual onset not associated with nausea or vomiting, blurry vision, or neck rigidity. PHYSICAL EXAMINATION: Vital signs: Temperature 97??????, heart rate 68, blood pressure 128/76, respirations 20, oxygen saturation 100% on room air. General: He was an emaciated male. He looked older than his chronological age. Head: Atraumatic. Right pupil 5 down to 4, left 6 down to 3. Neck: Supple. Chest: Clear to auscultation. Cardiovascular: S1 and S2. Positive murmur. Abdomen: Protuberant, old well-healed scar. Soft. Positive bowel sounds. Nontender. Extremities: Contracture of the toes. Skin breakdown of the left anterior skin. Pulses: Positive. Back: Nontender. Flank: Nontender. PAST MEDICAL HISTORY: Non-insulin-dependent diabetes mellitus. Coronary artery disease with a myocardial infarction in [**2154**] status post coronary artery bypass grafting times two in [**2155**] with aortic valve replacement and mitral valve replacement. Atrial fibrillation. Congestive heart failure with an ejection fraction of 20-30%. End-stage renal disease status post four failed renal transplants on hemodialysis q.Monday, Wednesday, and Friday. Hypertension. Gout. Hepatitis C. Peripheral vascular disease. PAST SURGICAL HISTORY: Right femoral to popliteal bypass graft. Right patellofemoral popliteal bypass graft. Left femoral to popliteal bypass graft. Coronary artery bypass grafting times two. Hernia repair. Toe amputation. Left arm fistula placement. ALLERGIES: CYCLOSPORIN. LABORATORY DATA: The patient had a head CT in the Emergency Room which showed right frontal subdural hematoma with acute chronic component with mass affect on the adjacent sulci, right lateral ventricle effacement, and 7-8 mm midline shift. HOSPITAL COURSE: The patient was admitted to the Neurosurgical Intensive Care Unit. He was awake, alert, and oriented times three. His cranial nerves were intact. His motor strength was 5 out of 5. Reflexes were normal. His toes were downgoing. Finger-to-nose test and heel-to-shin test were normal. On [**2160-12-6**], the patient underwent right frontal craniotomy for drainage of the subdural hematoma without intraoperative complications. Postoperatively the patient was monitored in the Surgical Intensive Care Unit. His vitals signs were stable. He was afebrile. He was awake, alert, and oriented times three. Prior to surgery, his INR was 3.9. He was corrected with FFP and received dialysis in the SICU prior to going to the OR. He was followed by the Renal and Cardiology Service. He was taken off Coumadin. Repeat head CT on [**2160-12-7**], showed interval decrease in the amount of chronic appearance of the right subdural with the acute component still present and unchanged. There has been improvement in the degree of midline shift. He was transferred to the floor on [**2160-12-7**]. He had a repeat head CT on [**12-9**] which was unchanged. His neurologic status continued to remain stable. He was awake, alert, and oriented times three, and moving all extremities strongly. He was seen by Physical Therapy and Occupational Therapy and found to be safe for discharge to home. His incision was clean, dry, and intact. He will discharged to home with follow-up for his dialysis three times a week. He will follow-up with his cardiologist. He will be restarted on his Coumadin in two weeks after surgery keeping his INR between 1.5 and 2.0. DISCHARGE MEDICATIONS: Amiodarone 100 mg p.o. q.d., Nephrocaps 1 p.o. q.d., Dilantin 100 mg p.o. b.i.d., Allopurinol 100 mg p.o. q.d., Lopressor 12.5 mg p.o. b.i.d., Remegel 800 mg tab 4 tab p.o. t.i.d., Prednisone 5 mg p.o. q.d., Vasotec 10 mg p.o. b.i.d., Zantac 150 mg p.o. q.d., Percocet [**12-3**] tab p.o. q.4 hours p.r.n. for severe headache. DISPOSITION: The patient's vitals signs were stable, and he was afebrile. His attending is actually Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**]. He will be discharged home in stable condition and follow-up with Dr. [**Last Name (STitle) 1132**] in two weeks with repeat head CT at that time. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2160-12-11**] 10:40 T: [**2160-12-11**] 10:37 JOB#: [**Job Number **]

[ "070.51", "V42.0", "V43.3", "431", "585", "250.00", "428.0", "427.31", "583.9" ]

icd9cm

[ [ [] ] ]

[ "01.31", "39.95" ]

icd9pcs

[ [ [] ] ]

3895, 4794

2207, 3871

1685, 2189

540, 1134

174, 517

1157, 1661

10,160

124,889

1510

Discharge summary

report

Admission Date: [**2193-6-5**] Discharge Date: [**2193-6-12**] Service: ICU HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname **] is an 86-year-old gentleman with a history of coronary artery disease status post coronary artery bypass graft, congestive heart failure with an ejection fraction in the 30% range, atrial fibrillation on Coumadin, chronic renal insufficiency, hepatitis C, liver cirrhosis, who presented to the Medical Intensive Care Unit with fever and hypotension on [**2193-6-5**]. The patient was transfused at the [**Hospital6 8862**] approximately two days prior to admission for chronic anemia of uncertain etiology, according to the patient's family. The day following transfusion, the patient was in his usual state of health. The morning of admission, at 1 A.M., the patient began to have rigors and a fever at home. The patient's family describes a fever to 38.5 degrees Celsius in the early morning hours. The patient denied chest pain, shortness of breath, cough, dysuria, nausea, vomiting, diarrhea. He has chronic abdominal pain. It was unclear whether there were any changes in this abdominal pain. Additionally, the patient did not complain of headache or neck stiffness. In the [**Hospital1 69**] Emergency Room, the patient was afebrile and initially had a blood pressure in the 110 range, but became progressively hypotensive with a systolic blood pressure in the 80s, as well as a temperature spike to 102 degrees Farenheit, and oxygen saturation in the 90s. On physical examination in the Emergency Room, there was noted to be right upper quadrant as well as left lower quadrant tenderness without rebound or guarding. It was unclear in discussion with the patient's family whether this was actually a change for him. The patient was noted to have a white count of 17.8, with a left shift and 1 band form. The chest x-ray, urinalysis and blood cultures were performed. Chest x-ray failed to demonstrate infiltrates. Urinalysis demonstrated evidence of urinary tract infection. The patient was given ampicillin, levofloxacin and Flagyl. The patient's daughter, acting as his health care proxy, refused further workup including CT scan and lumbar puncture in the Emergency Room. Additionally, the patient's family refused central venous access. Therefore, in the Emergency Room, the patient was begun on dopamine via peripheral intravenous lines and was transferred to the Intensive Care Unit. PAST MEDICAL HISTORY: Coronary artery disease status post coronary artery bypass graft in [**5-1**], ejection fraction depressed in the 30 to 35% range, polymorphic ventricular tachycardia status post ICD, left ventricular aneurysm, history of hyperparathyroidism status post parathyroid resection, chronic renal insufficiency with a creatinine baseline 1.8 to 1.9 range, anemia for which the patient is followed at the [**Hospital6 1708**], hepatitis C with stable liver mass, hypertension, urinary tract infections, paroxysmal atrial fibrillation, hard of hearing. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: According to the patient's wife and daughter, [**Name (NI) 8863**] [**Name (NI) 8864**] 12.5 mg by mouth twice a day, lasix 20 mg by mouth three times a week, Zestril 2.5 mg by mouth once daily, Coumadin 3 mg by mouth once daily, multivitamin one pill once daily, calcium 250 mg by mouth twice a day, Trental 400 mg by mouth twice a day, Nexium 20 mg by mouth once daily, vitamin D. SOCIAL HISTORY: Retired schoolteacher from [**Country 532**], positive 60 pack year tobacco history, quitting two years ago, denies alcohol use. PHYSICAL EXAMINATION: At the time of admission, temperature was 92.0, heart rate 72, blood pressure 107/42 on 5 mcg of dopamine, respiratory rate 22, oxygen saturation 92 to 93% on room air. In general, an elderly male in distress. The oropharynx was noted to be dry. The lungs were clear. The left radial pulse was decreased. The right radial pulse was regular. The cardiac examination revealed a distant cardiac examination with a normal S1 and S2, a II/VI holosystolic murmur at the apex. Present bowel sounds and an abdominal examination notable for wincing and grimacing with palpation in the right upper quadrant but otherwise non-rigid abdomen, nondistended abdomen. There was no peripheral edema. The neck was noted to be supple. The patient was following commands of his daughter. [**Name (NI) **] was alert, moving all four extremities equally. He was noted to have bibasilar crackles, approximately one-quarter of the way up, otherwise clear to auscultation bilaterally. Please note that the patient's blood pressure on the initial examination by Medicine in the Emergency Room had a blood pressure in the 80s/40s. DATA: White blood count at the time of admission was 17.8, hematocrit 29.8, with a differential on the initial white count of 94% neutrophils, 1% bands, 2% lymphocytes, 2% monocytes, 1% atypical cells. A repeat differential on [**2193-6-6**] at 3:40 A.M. demonstrated 80% neutrophils, 15% bands, 1% lymphocytes, 3% monocytes, as well as 1% metas. A platelet count at admission was 185, with a PT of 20.3 and an INR of 2.9, a PTT of 41.8. Urine at the time of admission was negative for urinary tract infection. A Chem 7 at the time of admission revealed a sodium of 137, potassium 4.6, chloride 103, bicarbonate 19, BUN 57, creatinine 2.2, glucose 84. ALT was 48, AST 59, LDH 271, CK 27 and flat for this admission. Alkaline phosphatase was 274, amylase 131, total bilirubin 1.1, lipase 24, troponin less than 0.3 on multiple measures. Calcium was 8.2, phos 2.5, magnesium 1.6. Albumin was 3.0. A free calcium 67 was 1.12. Blood cultures from [**2193-6-11**] demonstrate no growth to date. Blood cultures from [**2193-6-5**] demonstrate staphylococcus aureus coag-positive, sensitive to oxacillin in four out of four bottles. A sputum from [**2193-6-6**] was felt to be contaminated. Urine culture demonstrated less than 10,000 organisms. RADIOLOGIC DATA: Chest x-ray from [**2193-6-5**] demonstrated no defined consolidation. A PA and lateral from the same date demonstrated interval increase in size of bilateral pleural effusions, incidental note made of degenerative change in the right shoulder. A repeat chest x-ray of [**2193-6-6**] demonstrated findings consistent with asymmetric pulmonary edema. A CT scan performed on [**2193-6-6**] of the abdomen and pelvis demonstrated the following: Bilateral pleural effusions, right greater than left, with a small right subpulmonic component, bibasilar partial collapse, consolidation, right greater than left, low attenuation of focus in the superior aspect of the right lobe of the liver. Evaluation is limited by lack of intravenous contrast, small amounts of free fluid within the pelvis. There is fluid and stranding within the right pericolic gutter. No abdominal pathology is identified. A right upper quadrant ultrasound performed [**2193-6-6**] demonstrates cholelithiasis without evidence for acute cholecystitis, as well as question of liver echotexture and solitary well-defined mass within the right hepatic lobe, consistent with the patient's history of cirrhosis and known hepatic mass. Electrocardiogram from [**2193-6-5**] was read as follows: Atrial fibrillation, intraventricular conduction defect, inferior infarct age undetermined. CARDIOLOGY DATA: Echocardiogram performed on [**2193-6-6**] demonstrated the following: The left atrium is mildly dilated. Left ventricular cavity is mildly dilated. Overall left ventricular systolic function difficult to assess, but probably moderately depressed. Posterolateral and apical hypokinesis was present. The aortic valve leaflets are mildly thickened. Mitral valve leaflets are mildly thickened. Moderate 2+ mitral regurgitation is seen. Due to shadowing, the severity of mitral regurgitation might be significantly underestimated. Moderate 2+ tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. (Vegetations were not commented on.) HOSPITAL COURSE BY SYSTEM: 1. Infectious Disease: The patient, as stated above, was admitted with hypotension and fever, felt to be consistent with sepsis. The patient was originally covered broadly with ampicillin and gentamicin in the Emergency Room. To this regimen, levofloxacin was added. Ultimately the patient's blood cultures revealed gram-positive cocci, later identified as staphylococcus aureus coag-positive, and the patient was begun on vancomycin for the possibility of resistant organisms, however, this was changed to oxacillin rapidly as sensitivities became available. To date, the patient has one set of blood cultures which has demonstrated no growth to date. The patient's transthoracic echocardiogram was done to rule out the possibility of endocarditis, given the patient's history of abnormal valvular morphology as well as recent staphylococcal bacteremia. The patient's family, though they appeared to understand the risks and benefits which were described to them of transesophageal echocardiogram, repeatedly refused to undergo this procedure. The patient's family refused lumbar puncture in the Emergency Room, which was requested by a physician from the Emergency Room given the patient's question of mental status and fever. Ultimately, secondary to concerns surrounding the patient's obvious right upper quadrant tenderness, it was suggested that the patient go for a CT scan of the abdomen and pelvis. The patient's family rejected this suggestion in the Emergency Room, but later were more willing to consider the possibility of abdominal CT, which the patient underwent on [**2193-6-6**]. This study was performed to rule out intra-abdominal source of sepsis. With the patient's initial picture of fever and hypotension, he was assumed to have sepsis secondary to staphylococcus aureus of unknown etiology. The patient rapidly defervesced, and maintained a blood pressure within the normal range on antibiosis, principally vancomycin and then oxacillin, other antibiotics having been discontinued when culture data returned. Given the fact that the patient's family refused transesophageal echocardiography, and given the fact that discussions with Cardiology led to a suggestion for transesophageal echocardiography to further assess for presence of endocarditis, a decision was made to treat the patient as if he did indeed have staphylococcal endocarditis, as the patient's family repeated refused measures, including transesophageal echocardiogram, to assess for the presence of said infection. The current plan is to treat the patient with oxacillin intravenously for the continuance of a six week course. 2. Cardiovascular: The patient was known to have a history of tricuspid as well as mitral regurgitation by an echocardiogram in [**2192**]. The patient was again sent for echocardiography, with a fairly limited study which did not mention in the official report the presence or absence of valvular vegetations. In discussing this study with the Cardiology fellow decided that the safest course of action was to pursue transesophageal echocardiogram to rule out the possibility of endocarditis in this gentleman. The patient's family refused transesophageal echocardiogram, although the risks and benefits of this procedure were described to them. The patient was ruled out for myocardial infarction. The patient was initially maintained on peripheral dopamine for pressor support, as the patient's family refused central access, although the risk of peripheral necrosis or other risks of peripheral administration of dopamine or other pressors were repeatedly explained to them. The patient's family nonetheless refused to allow the patient to have central access established. Echocardiography was repeated during the course of this admission, with a transthoracic echocardiogram with the above-noted results. His antihypertensive medications were initially held at admission, and then restarted prior to the time of his impending discharge. The patient has a history of congestive heart failure with a further history of a low ejection fraction. Lasix was initially withheld from the patient as he was admitted in a state of hypotension. By the time of discharge, however, the patient had been restarted on his outpatient dose of lasix. Examination of the patient's lung fields was often difficult given the patient's refusal to breathe quietly, even through translation, preferring rather to speak loudly with his wife during the course of pulmonary examination. However, the patient was noted to have stable pulse oxygenation throughout the course of this admission, with no episodes of flash pulmonary edema or other concerning pulmonary events to the current date. 3. Renal: The patient's creatinine was noted to be approximately at his baseline. Attempts were made to renally dose medications. 4. Hematology: The patient does admit to chronic anemia of unknown etiology, for which it is believed he has been following at the [**Hospital6 8865**], but has evidently refused any invasive workup at that institution, including bone marrow biopsy. 5. Gastrointestinal: The patient has a history of hepatitis C, with evidence for cirrhosis on imaging, as well as a stable hepatic mass. 6. Access: The patient's family repeated refused central access, although at one point they did consent to central line placement. The patient's family later rescinded this decision. The patient was maintained on peripheral intravenous lines through the course of his stay, with recognition by the medical care team that this represents a suboptimal situation, especially initially in a patient who was septic with low blood pressures on pressor support. The risks of continuing without central access were repeatedly described to the patient's family, who appeared to understand these risks, but refused central access. At the current time, the plan is for placement of PICC access for long-term antibiosis at the time of impending discharge from the hospital. Today, [**2193-6-11**], the patient's wife has for a second time refused PICC placement, notwithstanding the repeated discussion with the medical team regarding the patient's need for long-term antibiosis. CODE STATUS: The patient's family, while stating that they did not want the patient to undergo transesophageal echocardiography, central venous access for pressor support during the period of hypotension and sepsis, or other testing including initially CT scan, did state that they would like all possible measures to be taken to revive the patient should he stop breathing or cease to have a pulse. COMMUNICATION: The [**Hospital 228**] medical care team experience some difficulty in communication with the patient, who speaks a very limited amount of English. The patient's family, including the patient's daughter and wife, speak [**Name2 (NI) 483**] and were often noted to refuse certain aspects of the care of the patient for reasons that were often unclear; for instance, the patient's wife has refused PICC placement today because, in her words, the patient has "a fever," although his temperature has repeatedly been measured at 98.5 by nursing staff today. MEDICATIONS AT THE TIME OF THIS DISCHARGE SUMMARY: Oxacillin 2 grams intravenously every four hours to be continued for the remainder of a five week course to complete a total of six weeks of antibiosis (given the patient's and the patient's family's insistence of avoidance of transesophageal echocardiogram), Protonix 40 mg by mouth once daily, Colace 100 mg by mouth twice a day, Zestril 2.5 mg by mouth once daily, Tums, vitamin D, Coumadin 3 mg by mouth daily at bedtime, Lopressor 12.5 mg by mouth twice a day (this is the dose which the patient's family insists upon, as it was evidently his outpatient dose). DISCHARGE PLAN: At the current time, the discharge plan is still currently in some state of flux, however, it is planned that the patient will be treated with intravenous antibiotics for a total of a six week course, given his and his family's refusal to fully evaluate the patient for the possibility of staphylococcal endocarditis. CONDITION AT THE TIME OF THIS DISCHARGE SUMMARY: Stable. DIAGNOSES TO THE DATE OF THIS DISCHARGE SUMMARY: 1. Staphylococcus aureus sepsis of unclear etiology 2. Cholelithiasis without evidence of cholecystitis 3. Anemia of uncertain etiology, followed at the [**Hospital6 8866**] 4. Hypomagnesemia, repleted as needed Please note that this is an interval dictation. Further information may be found on the patient's page one or as addended in further discharge summary dictations. [**First Name11 (Name Pattern1) 4514**] [**Last Name (NamePattern4) 8867**], M.D. [**MD Number(1) 8868**] Dictated By:[**Name8 (MD) 2058**] MEDQUIST36 D: [**2193-6-12**] 01:31 T: [**2193-6-12**] 02:24 JOB#: [**Job Number 8869**]

[ "427.31", "276.5", "414.00", "424.0", "403.91", "038.11", "428.0", "397.0", "285.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3114, 3498

8170, 15984

3669, 8143

118, 2478

16001, 17078

2501, 3086

3515, 3645

2,512

184,536

49010

Discharge summary

report

Admission Date: [**2143-6-29**] Discharge Date: [**2143-7-10**] Date of Birth: [**2089-3-1**] Sex: M Service: MEDICINE Allergies: Zestril / Nitroglycerin Attending:[**First Name3 (LF) 2387**] Chief Complaint: Shortness of breath, chest pain Major Surgical or Invasive Procedure: Tunnelled hemodialysis catheter placement Cardiac catheterization History of Present Illness: 54 year old man with CAD s/p RCA stent, diastolic CHF, ESRD nearing HD now presents with acute onset of chest pain and SOB. The pt was at a wedding with his family and he was noted to be SOB. He was going to drive home since he wasn't well, although developed worse SOB and now substernal chest pain. Ambulance was called, he was taken to [**Hospital1 18**] ED where he was found to be so SOB that he could hardly talk. Vitals p 108 240/p 40 94 on NRB. He was given morphine, metoprolol IV, bumex 2 mg IV. The pt was intubated. ECG showed baseline LBBB without any clear signs of ischemia. First set of cardiac enzymes were negative. BP was down to 140s sytolic. The pt was transferred to CCU for further care. Past Medical History: ESRD, nearing dialysis although has not yet started. Starting transplant w/u. CAD MI Hepatitis B and C positive HTN RAS s/p stenting. PVD s/p aortobifem, SFA dz osteoarthritis cervical disc disease. LBP after MVA frequent amnesia due to head trauma Anemia gout Social History: He is currently on disability secondary to spinal stenosis. He is separated from his wife and is the primary care giver for 19-year-old child who suffers from developmental delay. He has a brother and a sister who are willing kidney donors. He has a longstanding history of tobacco and is currently trying to quit. He quit using alcohol 15 years ago when he drank socially. Family History: His family history is significant for father who died at 55 from coronary heart disease issues. Physical Exam: VS: Temp: 99.0 BP: 141/44 HR: 76 RR: 20 O2sat: 100 general: intubated, sedated lungs: coarse and crackly throughout heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly extremities: no cyanosis, clubbing or edema Pertinent Results: [**2143-6-29**] 10:20PM WBC-12.8 Hct-30.9 Plt Ct-258 [**2143-6-30**] 12:33PM Hct-25.8 [**2143-7-2**] 11:00PM WBC-13.1 Hct-28.7 Plt Ct-174 [**2143-7-5**] 09:25AM WBC-6.5 Hct-24.1 Plt Ct-162 . [**2143-6-29**] 10:20PM Glucose-184 UreaN-88 Creat-6.7 Na-141 K-4.8 Cl-108 HCO3-15 [**2143-6-30**] 05:02AM Glucose-104 UreaN-90 Creat-7.4 Na-141 K-4.6 Cl-109 HCO3-16 [**2143-6-30**] 12:33PM Glucose-97 UreaN-79 Creat-6.3 Na-140 K-3.6 Cl-105 HCO3-19 [**2143-7-2**] 04:22AM Glucose-97 UreaN-64 Creat-5.3 Na-136 K-3.8 Cl-99 HCO3-21 [**2143-7-5**] 09:25AM Glucose-148 UreaN-73 Creat-6.4 Na-133 K-3.5 Cl-93 HCO3-22 . CK(CPK)-87-->140-->249-->201-->160 TropT-0.04-->0.69-->0.59-->0.82-->0.83 . [**2143-6-30**] 03:10AM ABG 7.21/43/78 [**2143-6-30**] 05:36AM ABG 7.26/37/356 [**2143-6-30**] 01:15PM ABG 7.38/35/180 [**2143-7-2**] 04:39PM ABG 7.36/43/222 . CXR ([**2143-6-29**]): Moderate congestive heart failure. Endotracheal tube in satisfactory position. No evidence of pneumothorax. DIALYSIS CATHETER placement ([**2143-7-3**] ): 1. Successful placement of a 27-cm tip-to-cuff length, 14.5-French dual lumen tunneled hemodialysis catheter via the left subclavian vein. The tip is in the right atrium and ready for use. 2. Limited ultrasound examination of both internal jugular veins showed tight stenosis near the level of the clavicles bilaterally. [**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) ([**2143-7-5**]): Patent bilateral cephalic and basilic veins with diameters as noted above. The brachial arteries are diseased bilaterally with monophasic waveforms. MIBI scan ([**2143-7-8**]): 1. Abnormal myocardial perfusion study showing a moderate sized, severe, predominantly reversible defect of the inferolateral wall. 2. Compared with the prior study of [**2139-11-27**] the defect is both larger in area and more pronounced. 3. The EF has decreased from 46% ([**2139-11-27**]) to today's value of 35%. Cardiac cath ([**2143-7-9**]): 1. One vessel coronary artery disease. 2. Successful stenting of the mid RCA instent restenosis with a 3.0x32mm Taxus stent. Brief Hospital Course: 54 year old male with CAD s/p RCA stent, diastolic CHF, ESRD nearing HD presented with acute CHF likely from hypertensive emergency and subendocardial ischemia. Pt left the hospital AMA. 1. Cardiac a. Coronaries: likely diffuse subendocardial ischemia. NSTEMI unlikely. Was cathed and stented mid RCA instent restenosis. was continued on aspirin and plavix. b. pump: h/o diastolic dysfxn. Had pulmonary edema, hypoxia requiring 100% FiO2 on admission. Improved significantly with dialysis and CVVH. O2 requirements trended down. Was on room air. c. Rhythm: baseline incomplete LBBB that was complete on admission likely secondary to LV strain from hypertension. Now again with incomplete LBBB as BP has been better controlled. 2. ESRD: pt with baseline cr [**4-27**]. Was uremic with metabolic acidosis on admission. Now metabolically better. received calcium acetate for hyperphosphatemia. was on epoeitin. has outpt dialysis set up for qTueThurSat at [**Hospital1 1474**] dialysis. dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 90386**]) will be the nephrologist there. 3. ID: Sputum culture positive for MSSA. Was started on oxacillin x10days. blood cultures did not show any growth. was also HbcAb +ve, HCV Ab +ve. LFTs were normal. 4. Anemia: Hct was 31 on the last day. had received blood transfusion on the day before the discharge. 5.FEN: cardiac healthy diet 6.proph: was on heparin sc, PPI 7.contacts: sister [**Telephone/Fax (1) 102883**]. Mother [**Name (NI) **] [**Telephone/Fax (1) 102884**] 8.Code status: Full code 9.Dispo: patient left hospital against medical advice. We advised him that this could be dangerous to his life. We also tried to give him the discharge paperwork. He was supposed to be seen by transplant surgery for placement of an AV fistula. Medications on Admission: Bumex 1 mg twice daily hydralazine 25 mg qid Plavix 75 mg once daily Imdur 30 twice daily Aspirin PhosLo one tab with meals Renagel 800 mg with meals Protonix 40 mg once daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q2-3H (every 2-3 hours) as needed. Disp:*30 2* Refills:*0* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 8. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*30 2* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: NSTEMI Discharge Condition: Stable Discharge Instructions: Please take all medications as prescribed If you have chest pain ,shortness of breath, dizziness, pain in abdomen please call your primary care provider Please go to all dialysis sessions Followup Instructions: Please make a follow up appointment with Dr [**Last Name (STitle) 5456**] ([**Telephone/Fax (1) 25798**]) Please follow your appointment with Dr [**First Name (STitle) **] (transplant surgery) on [**2143-7-22**]. Please go to [**Hospital1 1474**] Dialysis for dialysis on every Tue, [**Last Name (un) **] and Fri Completed by:[**2143-7-12**]

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icd9cm

[ [ [] ] ]

[ "00.45", "39.95", "99.20", "00.40", "38.95", "96.04", "36.07", "38.91", "96.71", "00.66", "99.04", "88.56" ]

icd9pcs

[ [ [] ] ]

7320, 7326

4345, 6177

315, 383

7377, 7386

2250, 4322

7622, 7966

1819, 1917

6404, 7297

7347, 7356

6203, 6381

7410, 7599

1932, 2231

244, 277

411, 1123

1145, 1408

1424, 1803

75,796

169,593

41268

Discharge summary

report

Admission Date: [**2198-5-18**] Discharge Date: [**2198-5-21**] Date of Birth: [**2125-8-3**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**Doctor First Name 3290**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, this is a 72-year-old female with PMHx afib on coumadin, COPD on 2L NC, DM and dCHF presenting with shortness of breath. She was in her usual state of health until the afternoon of admission when she began to feel fatigued and out of breath while going to bathroom. Symptoms worsened throughout the afternoon; she tried increasing her oxygen to 6L to no relief. She called her PCP who recommended that she come to ED. Otherwise, denies fevers/chills, chest pain. Did have worsening pedal edema at home. . In the ED, she was placed on bipap, initially 10/5/50% which was weaned to 30% prior to transfer to the MICU. She received nebs, 125mg iv solumedrol. CXR was unremarkable. BNP was not elevated. She received 20mg iv lasix (takes 20mg po lasix at home) with 450cc UOP at ED and then another 500cc on arrival to floor. In the ED, BPs were elevated to systolic 200s. She had not taken any of her medications today, including her BP meds. She was given SL nitro x 2 with SBP decreasing to 140s. SBP then arose to 170s and she was placed on nitro gtt. She was admitted to the MICU. . On arrival to the MICU, was net negative 1L. She rapidly improved and was called out to the floor. . On the floor, initial VS were: T 98 BP 173/78 HR 68 RR 23 O2 Sat 98% 3L NC She stated that her breathing felt back at her baseline. No other complaints. Past Medical History: [**2198-1-30**]: in f/u ophth re cataracts diverticulitis: hx colost for this, reversed OSA: bipap at noc Obesity Anemia of Chronic Disease Pedal Edema Type 2 Diabetes Mellitus on Insulin Hypertension Dyslipidemia Chronic kidney insufficiency stage III in f/u Renal [**Hospital1 18**] Atrial fibrillation on Coumadin COPD on home oxygen-dependent Obstructive sleep apnea with BiPAP at night GERD . Past Surgical History: Cataract/leisure glaucoma, colon Procedure [**Hospital1 18**] , [**2198-4-15**] Social History: Lives with husband. Used to be school bus driver. Denies alcohol, smoking, or illicit drugs. Never smoked, significant second hand smoke exposure, no alcohol or drugs. Lives in [**Location 89875**] with husband and usually granddaughter, multiple kids in local area, HHA cleans, daughter feels needs more help at home. Family History: No h/o CKD in family No known lung disease or malignancies. Physical Exam: ADMISSION PHYSICAL EXAM VS: Tmax: 37 ??????C (98.6 ??????F) Tcurrent: 36.7 ??????C (98 ??????F) HR: 66 (63 - 92) bpm BP: 156/89(99) {143/60(85) - 188/89(104)} mmHg RR: 20 (14 - 32) insp/min SpO2: 89% Heart rhythm: SR (Sinus Rhythm) O2 Delivery Device: Bipap mask SpO2: 89% General: Alert, oriented x 3, mildly tachypneic, able to speak in full sentences HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: crackles at bases, no wheezes Abdomen: soft, non-tender, non-distended, bowel sounds present, no rganomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact Discharge exam 97.2 BP 134/62 HR54 RR18 O2 Sat 95 2L NC 76.2kg from 78.2kg General: Alert, oriented x 3, speaking in full sentences HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Poor air movement, bibasilar crackles, prolonged expiratory phase, no wheezing, no rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis; trace edema Neuro: A/Ox3, CNII-XII intact, non focal Pertinent Results: ADMISSION LABS [**2198-5-18**] 06:00PM BLOOD WBC-9.2 RBC-3.47* Hgb-9.2* Hct-31.7* MCV-92# MCH-26.6* MCHC-29.0* RDW-14.6 Plt Ct-297 [**2198-5-18**] 06:00PM BLOOD Neuts-75.9* Lymphs-18.1 Monos-3.6 Eos-2.1 Baso-0.2 [**2198-5-18**] 08:28PM BLOOD PT-25.1* PTT-51.4* INR(PT)-2.4* [**2198-5-18**] 06:00PM BLOOD Glucose-256* UreaN-43* Creat-2.0* Na-144 K-4.9 Cl-97 HCO3-42* AnGap-10 [**2198-5-18**] 06:00PM BLOOD CK(CPK)-204* [**2198-5-18**] 06:00PM BLOOD CK-MB-9 proBNP-279 [**2198-5-18**] 06:00PM BLOOD cTropnT-0.05* [**2198-5-19**] 03:13AM BLOOD CK-MB-7 cTropnT-0.04* [**2198-5-19**] 03:13AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.6 [**2198-5-18**] 06:00PM BLOOD Digoxin-1.8 [**2198-5-18**] 08:26PM BLOOD Type-ART pO2-111* pCO2-104* pH-7.24* calTCO2-47* Base XS-12 [**2198-5-18**] 06:09PM BLOOD Lactate-0.7 Discharge labs [**2198-5-21**] 07:35AM BLOOD PT-15.5* PTT-27.2 INR(PT)-1.5* [**2198-5-21**] 07:35AM BLOOD Glucose-128* UreaN-66* Creat-2.2* Na-139 K-4.9 Cl-93* HCO3-35* AnGap-16 CXR FINDINGS: Single AP portable view of the chest is compared to previous exam from [**2197-3-22**]. Again seen is eventration of the right hemidiaphragm. Instinct pulmonary vascular markings suggesting pulmonary vascular congestion. Blunting of the left lateral costophrenic angle may be due to overlying soft tissues and technique. Cardiac silhouette is enlarged, but stable compared to prior. Osseous and soft tissue structures are unchanged, noting degenerative changes at the left glenohumeral joint. IMPRESSION: Findings suggestive of pulmonary vascular congestion. Brief Hospital Course: Primary Reason for Admission: 72-year-old female with afib on coumadin, COPD on 2L NC, DM, diastolic CHF presenting with shortness of breath. . # Hypoxia: Most likely due to flash pulmonary edema given HTN and rapid improvement with afterload reduction and BiPAP. HTN crisis thought to be secondary to medication non-compliance. In the MICU she was treated with Nitro gtt, Prednisone 60mg PO x1, standing Albuterol/Ipratroprium and Lasix 20mg IV. Her O2 requirement returned to her home dose (2L NC) and she was called out to the floor. Nitro gtt was stopped. On the floor, steroids were d/c'ed and Lasix was held. She was likely not volume overloaded, as her Cr increased with only 1L of diruesis in the MICU. Rather, her presenation was more likely due to an acute change in LV compliance due to high afterload, causing flash pulm edema. Because of rising creatinine, her lasix was held at time of discharge, and should be restarted soon. She has PCP f/u in a few days after d/c. She has a history of dCHF, but no cardiologist. We arranged cards f/u given this admission and her HTN issues. . # Hypertension: Hypertensive to systolic 200s on admission. She was placed on a Nitro gtt with marked improvement in her BP. Her Lasix and Digoxin were held for [**Last Name (un) **]. Her home Amlodipine was continued, with labetolol used for breakthrough HTN. This was switched to metoprolol succinate at discharge. HCTZ and ACEi were held at time of discharge, [**2-15**] [**Last Name (un) **]. She will have very close PCP f/u, who can do lab check and restart these meds when safe. . # [**Last Name (un) **]: Likely pre-renal related to diuresis. Cr 2.2 on discharge. Previously had been 1.5-1.7, however, there is a suggestion from Cr trend that 2.0 may be closer to her new baseline. , though this is unclear. We held ACEi, digoxin, and HCTZ for now, and arranged very close PCP f/u to check her renal function and consider restarting these medications soon. . # DM: Her Lantus was continued. She was placed on ISS in house. . # Atrial fibrillation: Her Dig level on admission was 1.8, which is above goal for her. Her Digoxin was stopped [**2-15**] [**Last Name (un) **], and also unclear indication given dCHF. Metoprolol succinate was started for HTn control and rate control in place of dig. Her Coumadin was continued at a recently increased dose of 7mg daily, though she became supratherapeutic so coumadin was held for a day, then INR dropped to 1.5. We discharged her on 6mg coumadin daily, w/ close PCP f/u and plan for INR check on Friday. . ========================================================= TRANSITIONAL ISSUES # Medication changes - HCTZ and ACEi are currently on hold because of [**Last Name (un) **]. Digoxin also held because of [**Last Name (un) **] and elevated serum dig level. # Coumadin Dosing- will need INR checked at next PCP [**Name Initial (PRE) **]. Coumadin dose has been variable so will need close monitoring # Creatinine - will need lytes and creatinine checked at next PCP [**Name Initial (PRE) **]. Medications on Admission: ALBUTEROL SULFATE [VENTOLIN HFA] - 90 mcg HFA Aerosol Inhaler - 1-2 puffs(s) inhaled every four (4) hours as needed for cough/wheeze/chest congestion/short of breath mdi with dose counter AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day BENAZEPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day DIGOXIN - 250 mcg Tablet - 1 Tablet(s) by mouth once a day FAMOTIDINE - 20 mg Tablet - 1 Tablet(s) by mouth twice a day FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose Disk with Device - 1 inhalation inhaled twice a day FUROSEMIDE - 20 mg Tablet - one Tablet(s) by mouth daily GEMFIBROZIL - 600 mg Tablet - 1 Tablet(s) by mouth twice a day HYDROCHLOROTHIAZIDE - 50 mg Tablet - 1 Tablet(s) by mouth once a day INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 60 units once a day OXYGEN - - 2L/min via NC Cintinuous POTASSIUM CHLORIDE - 10 mEq Tablet Extended Release - 1 Tablet(s) by mouth twice a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 puff inhaled once a day WARFARIN - 7mg daily (recently increased from 5mg for subtherapeutic INR) Discharge Medications: 1. 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* 2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: [**1-15**] Inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. benazepril 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Inhalation twice a day. 7. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO once a day. 8. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 9. warfarin 6 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 10. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 11. apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 12. insulin glargine 100 unit/mL Solution Sig: Sixty (60) units Subcutaneous once a day: please continue taking your insulin as you have done before. . 13. oxygen 2L/nim via Nasal Cannula Continuous Discharge Disposition: Home Discharge Diagnosis: Flash pulmonary edema secondary to hypertension, from medication non-compliance 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 1458**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for shortness of breath and high blood pressure. We think that fluid got into your lungs because of the high blood pressure, and that the high blood pressure was from skipping your medications for high blood pressure. Also, you had a decrease in your kidney function. This was thought to be from medications you were on, and your doctors [**Name5 (PTitle) **] be watching your kidney function. The following changes have been made to your medications: ** stop digoxin ** STOP HCTZ ** START metoprolol succinate [blood pressure control] ** STOP Potassium ** START Taking coumadin at 6mg daily instead of your usual dose. Also follow up with your primary care doctor [**First Name (Titles) 4120**] [**Last Name (Titles) 58785**]g of this. Followup Instructions: Department: [**Hospital3 1935**] CENTER When: WEDNESDAY [**2198-5-23**] at 9:15 AM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: BIDHC [**Location (un) **] When: FRIDAY [**2198-5-25**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 607**], MD [**Telephone/Fax (1) 608**] Building: 545A Centre St. ([**Location (un) 538**], MA) None Campus: OFF CAMPUS Best Parking: Department: CARDIAC SERVICES When: THURSDAY [**2198-5-31**] at 11:40 AM With: [**Name6 (MD) **] [**Name8 (MD) **], 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: BIDHC [**Location (un) **] When: FRIDAY [**2198-5-25**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 607**], MD [**Telephone/Fax (1) 608**] Building: 545A Centre St. ([**Location (un) 538**], MA) None Campus: OFF CAMPUS Best Parking: Department: CARDIAC SERVICES When: THURSDAY [**2198-5-31**] at 11:40 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

10950, 10956

5532, 8573

272, 279

11080, 11080

3957, 5509

12140, 13613

2534, 2596

9735, 10927

10977, 11059

8599, 9712

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2611, 3938

229, 234

307, 1655

11095, 11239

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2196, 2518

51,550

110,229

34111

Discharge summary

report

Admission Date: [**2119-12-8**] Discharge Date: [**2119-12-23**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Aortic valve replacement(#25 [**Company 1543**] mosaic ultra)Coronary artery bypass graft x3(left internal mammary-left anterior descending, saphenous vein graft-Obtuse marginal, saphenous vein graft-diagonal) [**12-11**] History of Present Illness: 88yo man with known aortic stenosis. Progressively worsening dyspnea on exertion, now referred for cardiac surgery Past Medical History: Aortic Stenosis Atrial Fibrillation Chronic renal insufficiancy Hypertension Hiatal hernia s/p repair Hyperparathyroidism s/p transurethral resection prostate Social History: retired pharmacist. lives with wife in [**Name (NI) 21037**], MA Remote tob-quit 25 years ago Rare ETOH use Family History: Father dies of cardiac problems @53yo Physical Exam: VS: 98.1, 97.8, 94/58, 96 a-fib, 22, 100% 2L nc Gen: NAD elderly male HEENT: unremarkable CV: irregularly irregular, no murmur Chest: lung sounds are diminished throughout with crackles Abd: NABS, soft, non-tender, non-distended Ext: 2+pitting edema Incisions: sternal incision healing nicely- c/d/i without erythema or drainage, Right EVH: c/d/i Pertinent Results: [**2119-12-23**] 05:40AM BLOOD WBC-14.0* RBC-3.76* Hgb-11.7* Hct-34.4* MCV-92 MCH-31.0 MCHC-33.9 RDW-16.0* Plt Ct-250 [**2119-12-23**] 05:40AM BLOOD PT-16.1* INR(PT)-1.4* [**2119-12-23**] 05:40AM BLOOD Glucose-117* UreaN-45* Creat-1.8* Na-141 K-4.1 Cl-101 HCO3-29 AnGap-15 Brief Hospital Course: The patient was admitted on [**12-8**] for cardiac catheterization in preparation for aortic valve replacement. He was found to have left main coronary artery disease, as well as stenoses in the right, and LAD coronary arteries. Heparin was initiated and the patient was admitted for AVR, CABG. The patient was brought to the operating room on [**12-11**] where he underwent AVR, CABGx3. Vancomycin was administered for perioperative antibiotic prophylaxis due to prolonged [**Hospital **] hospital stay. Please see dictated operative note for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for further recovery and invasive monitoring. The patient was initially extubated on POD 0, however required reintubation for respiratory failure. He was re-extubated on POD 1. Vasoactive drips were weaned off. The patient was diuresed toward his preoperative weight. Chest tubes and pacing wires were discontinued without complication. Physical therapy was consulted for assistance with post-operative strength and mobility. Coumadin was resumed for atrial fibrillation. The patient had an episode of bradycardia which progressed to a PEA arrest on POD 6. ACLS protocol was initiated. The patient was re-intubated, CPR was performed, multiple drips were started and the patient was resuscitated. The patient stabilized, pressors were weaned and he was extubated again. The electrophysiology service was consulted and determined that the patient was not a candidate for a permanent pacemaker. The patient was eventually transferred to the floor and the remainder of the hospital course was uneventful. He was discharged on POD 12 to [**Hospital1 15454**] Rehab Hospital for pulmonary rehabilitation. Medications on Admission: coumadin 5mg (5days), 2.5mg (2 days), atenolol 50'', enalapril 5', simvastatin 40', zemplar 1' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): Target INR 2-2.5 (Received 2.5mg 12/24&25. 5mg on [**12-22**]&[**12-23**]). Tablet(s) 9. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection QAC&HS. 10. Zemplar 1 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) tx Inhalation Q6H (every 6 hours) as needed. 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) tx Inhalation Q4H (every 4 hours) as needed. 16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-28**] Sprays Nasal TID (3 times a day) as needed. 17. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: s/p AVR(Tissue)CABGx3. [**12-11**] s/p Bradycardic arrest-EP evaluation. [**12-18**] PMH: Atrial Fibrilllation Hypetension Chronic renal Insufficency hyperparathyroid Hyperlipidemia, Rheumatic fever(child) S/p TURP S/P Hiatal hernia repair 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. Followup Instructions: Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 1504**] Dr [**First Name (STitle) 6164**] in [**2-28**] weeks [**Telephone/Fax (1) 4475**] Patient to call for appointments Completed by:[**2119-12-23**]

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icd9cm

[ [ [] ] ]

[ "35.21", "36.15", "88.72", "37.23", "39.61", "96.71", "99.60", "96.04", "36.12", "99.00", "88.56", "38.93" ]

icd9pcs

[ [ [] ] ]

5280, 5352

1699, 3495

289, 513

5636, 5643

1402, 1676

5834, 6051

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3640, 5257

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5667, 5811

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230, 251

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679, 840

856, 965

63,721

124,639

31548

Discharge summary

report

Admission Date: [**2198-11-18**] Discharge Date: [**2198-12-20**] Date of Birth: [**2135-4-2**] Sex: M Service: NEUROSURGERY Allergies: Zosyn Attending:[**First Name3 (LF) 2724**] Chief Complaint: s/p [**2135**]0 feet from ladder to concrete Major Surgical or Invasive Procedure: PEG placement bronchoscopy tracheostomy History of Present Illness: This is a 63 year old male who was on a ladder and fell hitting his torso and head on concrete at approximately 4:50 pm.The patient reports that he is unable to move his legs or arms.He is unable to feel his legs, but states that he has sensation in his hands and arms. The interview/exam was brief as the patient was about to be intubated for airway protection and brought emergently to CT scanner. Past Medical History: none Social History: Lives with wife at home, professor [**First Name (Titles) **] [**Last Name (Titles) **] Family History: Non contributory Physical Exam: Gen: head laceration to occiput, comfortable, NAD. HEENT: Pupils: 3-2mm EOMs:intact Neck: hard collar Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: did not test Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields unable to test III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation unable to test [**Doctor First Name 81**]: Sternocleidomastoid and trapezius- pt unable to move XII: Tongue midline-did not test Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength: patient unable to move legs or arms. Pronator drift-unable to test Sensation: Patient with equal sensation in arms, sensory level to T [**9-24**], No sensation in legs. Coordination:unable to test exam upon discharge: UE motor [**3-21**], LE 0 sensation level approx T9 with occasional "tingling" sensation to BLE Pertinent Results: -CT Chest/Abdomen/Pelvis [**11-18**] 1. No acute osseous injury identified. 2. Mild bibasilar atelectasis. -CT head [**11-18**] 1. No acute intracranial process -CT C Spine [**11-18**] There is a fracture through the right transverse process of C1 vertebral body involving the foramen and the right and left posterior lamina of C1 ([**Location (un) 5621**]-type fracture). The dens is intact. A nondisplaced impaction-type fracture is noted in the lateral mass on the right of the C2 vertebral body. C3 is fractured through the right pars interarticularis extending into the proximal lamina with minimal displacement. The C4 right pedicle is fractured. A small triangular fragment at the right posterior inferior vertebral body corner representsa small avulsive type fracture. Fracture is noted at the right C5 superior articulating facet extending longitudinally through the lamina terminating at the spinolaminar junction. Slight hyperattenuation is noted posterior to the C3-C% vertebral bodies suspicious for epidural hemorrhage. High attenuation is also noted layering along the ventral cord at these levels suggesting subarachnoid hemorrhage. C6 and C7 are intact. There is multilevel disk space narrowing from pre-existing degenerative disease. There is a markedly anteriorly displaced anterior osetophyte at C4-5 suggesting extension-type injury at this level since reduced. This would be congruent with the posterior element fractures noted above (accounting for a rightward tilt to the trauma mechanism). Current alignment is anatomic with cervical lordosis maintained. Marked pervertebral soft tissue swelling noted. -MRI Cervical spine [**11-18**] 1. Hemorrhagic cord contusion with surrounding edema extending from the C2 through the C6 levels. 2. Evidence of extensive ligamentous injury, as described above. 3. Extramedullary intradural hematoma appears to extend to the cervicothoracic junction and at C5 causes leftward mass effect on the cord. 4. Multiple cervical spinal fractures, right more than left, are better detailed on the recent CT of the cervical spine. High signal within the C4-5 and C6-7 disks is also likely related to trauma. -X ray L hand [**11-19**] Fractures of the left small and ring finger metacarpals, as above. ---[**2198-12-1**] 9:00 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2198-12-2**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). ---CTA Chest [**12-2**] 1. Acute isolated right apical subsegmental pulmonary embolism, the clinical significance of which is uncertain. 2. New moderately severe bilateral lower lobe atelectasis. 3. New bilateral small pleural effusions. 4. Right upper and right lower lobe consolidation and clustered nodules are consistent with an acute infection, acute aspiration is also considered possible. ---[**2198-12-2**] 10:52 am BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2198-12-2**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. [**2198-12-5**]: Chest XR: FINDINGS: In comparison with the study of [**12-4**], allowing for the obliquity of the patient, there is no change in the monitoring and support devices. There appears to be some improved aeration in the retrocardiac region at the left base, though some atelectatic change persists. No evidence of vascular congestion or definite acute pneumonia [**2198-12-13**] CTA Chest 1. New segmental PE in vessels supplying right lower lobe posteriorly and lateral right middle lobe. Possible additional subsegmental PE supplying left upper lobe posteriorly. No infarct or new right heart strain. 2. Improvement in right middle and lower lobe peribronchial nodules and consolidation c/w improving infection or resolving aspiration. 3. Persistent bronchial impaction and airway secretions (particularly on the left), with persistent near-complete left lower lobe collapse, which could be due to recurrent aspiration. 4. Nearly resolved bilateral pleural effusions. Brief Hospital Course: Pt initially admitted to the ICU and the trauma service after he was intubated for airway protection following a fall from 20 feet. Multiple cervical spine fractures noted on CT scan and he remained in a hard cervical collar with flat bed rest until his thoracic and lumbar spine could be safely cleared. His exam on admission was limited movement of his R fingers and was able to shrug shoulders, his right side greater than his left side. MRI of cervical spine was consistent with multiple cervical spine fractures and stir changes within the cord from C2-C6 but showed no canal compromise and no role for emergent surgical intervention. Further treatment options of his cervical spine fractures were discussed with attending Dr. [**Last Name (STitle) 548**] and it was decided that patient would remain in a hard cervical collar for treatment of his fractures. He was found to have displaced fracture of his left ring finger and this was reduced by the hand surgery team and placed in a splint. on [**11-22**] he spiked a temp and had increasing secretions. He underwent bronchoscopy and was started on 7 day course of antibiotics for presumed ventilator acquired pneumonia. Ultimately all cultures were negative. He underwent an uncomplicated tracheostomy on [**2198-11-23**]. He was bronched after fever spike to 102.8 on [**11-25**] and these cultures were also negative. He was working with PT and OT and is a good candidate for [**Hospital 74207**] rehab. His antibiotics were discontinued after a 7 day course on [**2198-11-29**]. his upper extremity strength has improved slightly and is now a [**3-23**] in both upper extremities. On [**12-1**] pt was febrile to Tmax of 103 and he underwent bronchoscopy with the SICU team on the morning of [**12-2**], sputum cultures were sent and consistent with GPC. He was restarted on VAP protocol with vancomycin, ciprofloxacin and cefepime. He underwent chest CT on this day and it was positive for subsegmental pulmonary embolism. He was started on heparin IV gtt on the 18th with the goal to bridge to Coumadin. His antibiotics were changed to vancomycin and Zosyn. On [**12-5**], the patient's INR was only at 1.2 despite being on Coumadin therapy for 2 days. because he had a bed at a Rehab facility, the decision was made to d/c the Heparin gtt and utilize Lovenox in conjunction with the Coumadin, until his INR reached the therapeutic level. On [**12-6**], his WBC count dropped to 1.2, from 4 the previous day. This was likely attributed to the Zosyn. This was subsequently d/dc'd as was vancomycin. Levaquin and Flagyl were started as antibiotic coverage. It was decided that he would need to have his WBC count increase prior to discharge to rehab. On [**12-7**] his WBC was 1.7 which was slightly improved. His exam continued to be stable as he awaited a rehab bed On [**12-8**] his WBC was 1.3. Infectious Disease continued to give input and hematology was consulted. He was continued on his current antibiotics but placed on neutropenic precautions. It was ultimately decided that his PE was subsegmental and did not require formal anticoagulation - his Coumadin was discontinued but he remained on Heparin 5000 units sc three times daily. A lower extremity doppler was obtained on [**2198-12-9**] and this showed a superficial thrombus in the right peroneal vein. Hematology team was consulted and they felt his neutropenia was likely medication related. They recommended Neupogen to increase WBC production. He received 1 dose on [**12-10**] and WBC increased on [**12-11**] to 1.8. and was 11.8 on [**12-12**]. His Neupogen was discontinued on [**12-12**]. On [**12-11**] patient had an episode of decreased O2 saturations overnight and required deep suctioning and replacement of his tracheostomy. He had a repeat chest CT on [**12-12**] that showed new segmental PE in right lung and he was started on Lovenox 70mg SC q12 and he obtained an IVC filter on [**12-13**] this was placed without complication. He currently is being anticoagulated with a goal INR of [**3-21**] using a bridge of Lovenox. His INR on [**12-20**] is 1.3 our plan was to give Coumadin 5mg. He was started on full Coumadin on [**12-19**]. On [**12-13**] his WBC increased to 33. Nupogen was held. He continued to spike fevers to 101, but WBC was 11. Patient was pancultured. On [**12-16**] WBC was 16.7, sputum culture grew gram negative rods so ID was reconsulted and they recommended meropenem and linezolid. He was bronched and cultures pending though gram stain showed 1+ GNR and GPC. On [**12-20**] his WBC trended down to 10.6 his antibiotics continue to be Meropenum and Linzolid. We recommend continuing until approximately [**12-30**] for 14 days of coverage. Medications on Admission: None Discharge Medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Month/Year (2) **]: [**2-17**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 2. enoxaparin 80 mg/0.8 mL Syringe [**Month/Day (2) **]: Seventy (70) mg Subcutaneous Q12H (every 12 hours). 3. warfarin 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Once Daily at 4 PM. 4. meropenem 500 mg Recon Soln [**Month/Day (2) **]: Five Hundred (500) mg Intravenous Q6H (every 6 hours). 5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily) as needed for gi prophy. 6. Tylenol 325 mg Tablet [**Last Name (STitle) **]: Six [**Age over 90 1230**]y (650) mg PO every six (6) hours as needed for fever or pain. 7. Dulcolax 10 mg Suppository [**Age over 90 **]: One (1) Tab Rectal once a day as needed for constipation. 8. Colace 100 mg Capsule [**Age over 90 **]: One (1) Capsule PO twice a day. 9. Dilaudid 2 mg Tablet [**Age over 90 **]: 1-2 Tablets PO every 4-6 hours as needed for pain. 10. ibuprofen 800 mg Tablet [**Age over 90 **]: One (1) Tablet PO every eight (8) hours as needed for fever or pain. 11. lorazepam 0.5 mg Tablet [**Age over 90 **]: One (1) Tablet PO every four (4) hours as needed for anxiety. 12. midrodrine [**Age over 90 **]: Five (5) mg every eight (8) hours. 13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Age over 90 **]: Four (4) puffs Inhalation every four (4) hours as needed for wheezing. 14. quetiapine 25 mg Tablet [**Age over 90 **]: 1.5 Tablets PO QHS (once a day (at bedtime)). 15. linezolid 600 mg/300 mL Parenteral Solution [**Age over 90 **]: One (1) Intravenous Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Cervical spine contusion Ventilator aquired pneumonia quadraplegia respiratory failure dysphagia left hand fracture Segmental Pulmonary Embolism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Please wear the cervical collar at all times. Followup Instructions: Follow-Up Appointment Instructions ?????? Please call ([**Telephone/Fax (1) 2726**] to schedule an appointment with Dr. [**Last Name (STitle) 548**] to be seen in 12 weeks. Please follow up with [**Hospital1 18**] hand clinic for fractures Orthopedics Location: [**Hospital Ward Name 23**] 2 Phone: ([**Telephone/Fax (1) 32269**] in 2 weeks. Completed by:[**2198-12-20**]

[ "288.03", "806.04", "E881.0", "E930.8", "997.31", "415.19", "V46.11", "806.09", "873.0", "518.81", "816.00", "787.20" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.93", "31.1", "33.24", "96.6", "38.7", "38.91", "43.11", "33.21", "79.04", "88.51", "96.72" ]

icd9pcs

[ [ [] ] ]

13026, 13096

6513, 11253

316, 358

13285, 13285

2242, 6490

13491, 13866

938, 956

11308, 13003

13117, 13264

11279, 11285

13420, 13468

971, 1119

232, 278

386, 788

1392, 2104

13300, 13396

810, 817

833, 922

2125, 2223

32,228

177,754

31609

Discharge summary

report

Admission Date: [**2169-7-1**] Discharge Date: [**2169-8-11**] Date of Birth: [**2123-11-9**] Sex: F Service: MEDICINE Allergies: Keflex / Levofloxacin / Methotrexate Attending:[**First Name3 (LF) 783**] Chief Complaint: Rash, bleeding Major Surgical or Invasive Procedure: Right IJ Left IJ Lumbar puncture Tracheostomy & PEG Bronchoscopy x 2 Bone marrow biopsy History of Present Illness: History obtained from records. The pt is a 45 yo woman with eczema, rheumatoid arthritis, hypertension, h/o nephrolithiasis recently started on cefazolin for two days followed by levofloxacin for a superinfection of her eczema who intially presented to [**Hospital3 **] Hospital complaining of hemoptysis x 3 days. Initial labs were concerning for pancytopenia with a WBC less than 0.2, Hct of 26 and platelets of 7. She was intubated in the field for airway protection and med-flighted to [**Hospital1 18**] for further evaluation. . In the ED, her VSs were 100, 116, 93/53, 18, 100% vented. She received a 4-pack of platelets, lorazepam 2 IV, acetaminophen 650 and midazolam 2 IV. A CXR revealed ? RUL atelectasis, and a head CT revealed no acute intracranial hemorrhage. Past Medical History: Eczema hypertension nephrolithiasis Rheumatoid arthritis Uterine fibroids Social History: smokes 4 packs/wk. drinks 2 beers/day Family History: adopted Physical Exam: Vitals: T: 97.9 BP: 88/60 P: 109 R: 29 SaO2: 100% General: sedated, intubated Skin: multiple excoriated, erythematous ezcematous lesions all over her skin, no bullous lesions noted HEENT: anicteric, bleeding from conjunctiva, nares and oropharynx Neck: no significant JVD Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales Cardiac: tachycardic, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, NT, ND, normoactive bowel sounds, no splenomegaly Extremities: No edema, 2+ radial, DP pulses b/l Neurologic: sedated, intubated Pertinent Results: [**2169-6-30**] WBC-0.2* RBC-2.19* Hgb-8.3* Hct-23.9* MCV-109* MCH-37.8* MCHC-34.7 RDW-19.4* Plt Ct-5* Neuts-0* Bands-0 Lymphs-92* Monos-0 Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-0 Hypochr-2+ Anisocy-2+ Poiklo-2+ Macrocy-2+ Microcy-OCCASIONAL Polychr-Spheroc-1+ Ovalocy-OCCASIONAL Target-NORMAL Schisto-OCCASIONAL Burr-1+ Tear Dr[**Last Name (STitle) **]1+ Acantho-1+ PT-12.0 PTT-27.3 INR(PT)-1.0 Fibrino-1332* Ret Man-.2* Glucose-100 UreaN-138* Creat-3.7* Na-141 K-4.3 Cl-107 HCO3-12* AnGap-26* ALT-24 AST-50* AlkPhos-63 Amylase-119* TotBili-2.1* Albumin-2.2* | Hapto-337* | Lactate-1.4 Type-ART Temp-37.7 pO2-459* pCO2-23* pH-7.31* calTCO2-12* Base XS--12 . [**2169-8-11**]: WBC 12.3 Hgb 10.6 Hct 31.7 MCV 101 Plt Ct 526 Glu 90 BUN 12 Cr 0.5 NA 138 K 4.6 Cl 104 HCO3 23 Ca-9.9 P-5.1* Mg-2.0 . CHEST X-RAY ([**2169-6-30**]) IMPRESSION: 1. Band of opacity projecting over the right upper chest likely representing atelectasis. However, other underlying processes, including neoplasm or infection can't be excluded. Follow-up radiograph to evaluate clearance or CT chest is recommeded. 2. Likely mild CHF. . BIOPSY ([**2169-6-30**]) #1. Skin, left medial thigh, punch biopsy (A): a. Ulcer with yeasts within ulcer bed, subjacent upper dermis, and focally within superficial dermal small vessel, and abundant surface gram positive cocci (see note). b. Background psoriasiform dermatitis with paucicellular superficial dermal perivascular lymphocytic infiltrate and rare eosinophils (see note). #2. Skin, left medial thigh, direct immunofluorescence: a. No IgG, IgA, IgM, C3 deposits found between keratinocytes of the epidermis or along the basement membrane zone. b. C3 is noted within the scale (? near ulcer) consistent with psoriasiform dermatitis or non-specific if near ulcer. c. Non-specific fibrinogen deposits present in the dermis. #3. Skin, left leg, punch biopsy (B): a. Psoriasiform dermatitis with parakeratotic scale containing neutrophil aggregates. b. No fungi or bacteria seen in PAS, GMS, and Gram stained sections. . Note: No acantholysis or bulla are seen (multiple levels examined). Abundant yeasts are present within the ulcer bed, upper reticular dermis, and one small superficial blood vessel. While this may represent surface colonization, in the setting of pancytopenia, this raises concern for a disseminated yeast infection. Blood cultures may be further illustrative. . The background skin shows a psoriasiform dermatitis, the differential of which includes psoriasis, and as there are rare eosinophils, a psoriasiform drug reaction, and possibly impetiginized atopic dermatitis. . ******************* BONE MARROW BIOPSY ([**2169-7-1**]) ******************* SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY. DIAGNOSIS: Markedly hypocellular marrow in keeping with a hypoplastic / aplastic process, see note. Note: The aplasia may be primary or secondary from a marrow insult from drugs, infection, immune, or toxic/metabolic causes. Clinical correlation recommended. . ******************* CT TORSO ([**2169-7-8**]) ******************* IMPRESSION: Right upper lobe pneumonia. Bilateral pleural effusions associated with atelectasis of the lower lobes. Splenic and left kidney infarcts. Mild fluid overload. Right rib fractures. Mediastinal, axillary and mesenteric lymphadenopathy is likely reactive. . TRANS-THORACIC ECHO ([**2169-7-10**]) IMPRESSION: Normal study. No 2D echocardiographic evidence for endocarditis or pathologic flow identified. Compared with the prior study (images reviewed) of [**2169-7-3**], the findings are similar (heart rate is slower). . MRI HEAD ([**2169-7-14**]) IMPRESSION: Multiple infarcts are identified involving the right frontal and parietal lobe, left frontal lobe and left cerebellar hemisphere. Infarcts in the right frontal lobe in the MCA territory demonstrate enhancement. The findings are indicative of acute/subacute infarcts. The enhancement in the right MCA territory infarct may indicate more subacute nature. Although there are no MRI signs of septic emboli such as abscess, given patient's clinical history, clinical correlation is recommended. Findings were discussed with Dr. [**First Name (STitle) 805**] at the time of interpretation of this study on [**2169-7-13**]. . CT CHEST W/O CONTRAST [**2169-8-3**] IMPRESSION: 1. Improving right upper lobe consolidation with residual opacity likely due to slowly resolving pneumonia. 2. Several bilateral noncalcified lung nodules measuring up to 8 mm. As these were largely obscured by preexisting areas of consolidation atelectasis on the previous study, their time course is uncertain. Differential diagnosis includes previous and active infection (e.g. granulomatous infection) versus metastatic foci. Consider a followup CT scan in four to six weeks to document anticipated complete resolution of the right upper lobe abnormality and to re-assess the lung nodules. Brief Hospital Course: The patient is a 45 yo woman originally admitted on [**7-1**] from an [**Hospital **] transferred from the MICU to the floor on [**7-25**], admitted for pancytopenia with hemoptysis, intubated for airway protection. Her pancytopenia has now resolved, likely due to Mycoplasma infection versus medication-induced aplasia. She had a prolonged and difficult wean from the ventilator, s/p tracheostomy and PEG, now doing well s/p trach decannulation. She has a persistent rash c/w psoriasis, improving on topical steroids. She has hypercalcemia and hyperphosphatemia of unclear etiology, improving on [**Name (NI) **]. . Respiratory failure. The patient presented to OSH on [**2169-6-30**] with hemoptysis which was [**1-20**] new pancytopenia. She was intubated for airway protection before transport here. On bronchoscopy, she initially had bleeding from the RUL. On CXRs and CT, she had had some intermittent right upper lobe collapse vs PNA, and bibasilar atelectasis. During her ICU course at [**Hospital1 18**], she was difficult to wean off the vent due to volume overload, possible mycoplasma infection, and ICU myopathy, with EMG/NCVs showing myopathy with ongoing denervation. She got PEG and tracheostomy on [**2169-7-18**], on [**7-19**] was weaned to trach mask, cleared for PMV on [**7-20**]. Repeat chest CT on [**8-3**] showed resolving RUL consoldiation, also several bilateral noncalcified lung nodules, possibly c/w granulomatous disease. Pulmonary was consulted, and deferred further work-up at this time, and will follow-up with repeat chest CT in 3 months. Her tracheostomy was decannulated on [**8-10**], and she has been saturating in the high 90s at rest and while ambulating with PT. . Pancytopenia: The patient was seen by hematology, and had a bone marrow biopsy, consistent with primary or secondary hypocellular aplasia. She was given supportive transfusions, and treated with leucovorin and filgrastim for her pancytopenia. The likely diagnosis is secondary marrow aplasia, due either to Mycoplasma or drug-induced (levofloxacin vs. Keflex vs. diflunisol vs. Embrel). Her condition improved, and by transfer to the floor her pancytopenia had resolved with normal WBC, and platelets, Hct of 30. On discharge, she had a persistent mild leukocytosis to 12,000, Hct 31, Plt 536. She was discharged on B12 and folate, to follow-up with hematology. If she is to see rheumatology or dermatology for her RA or psoriasis in the future, careful consideration should be made about the use of any immunosuppressive agents given these may have caused her pancytopenia. . Fevers: She had persisent fevers to 101 while in the MICU, which was originally thought to be [**1-20**] febrile neutropenia. She was started on IV vancomycin and ceftazidime for febrile neutropenia on admission, and completed a two-week course. She was also briefly on doxycycline [**Date range (1) 27564**] until serologies for tick-[**Location (un) **] diseases from the OSH came back negative. She was also started on fluconazole for concern for invasive fungal infection (see below). However, after discontinuation of all antibiotics after [**7-12**], she was persistently febrile with no source. Rheumatology was also consulted, and did not believe her presentation was consistent with vasculitis. On review of her fever curve, ID consult noted she had defervesced while on doxycycline. Her Mycoplasma IgM was positive and IgG was weakly negative (670, postive is 770), though it was possible could not mount a proper response due to her recent pancytopenia. She was restarted on doxycycline on [**7-16**] for a two-week course for presumed disseminated Mycoplasma infection, and has since defervesced. . Psoriasis: When she presented to OSH, she had a dramatic desquamating rash that affected her trunk as well as her extremities. She was seen by dermatology, with skin biopsy showing psoriasiform background in the dermis, and an infiltration of fungal organisms, including around dermal vessels. Cultures from her wound biopsy and urine proceeded to grow [**Female First Name (un) **] albicans, sputum showed budding yeast. The patient was therefore treated with fluconazole for 10 days from [**Date range (1) 74297**]. Dermatology was re-consulted on the floor, and recommended topical steroids for psoriasis, and suggested phototherapy on discharge. . Hypercalcemia/Hyperphosphatemia: The patient was noted to have slowly increasing phosphorus levels after transferred to the floor. Her calcium also began to rise. She was placed on a low phosphorus diet, without resolution of these abnormalities. Renal and endocrine were consulted. She has an appropriate renal clearance of calcium and phosphorus, and an appropriately low PTH. Chest CT was concerning for possible granulomatous disease but vitamin D (25, and [**1-12**]) were both low normal. At discharge, there is no clear etiology for her hypercalcemia/phosphatemia. Both these levels have come down and are stable on [**Month/Year (2) **]. PTH-rp and FGF23 mutation analysis are still pending at discharge. Her electrolytes will be monitored by her VNA and PCP, [**Name10 (NameIs) **] she will follow-up with endocrine. . Strokes/Question of Hypercoagulability: Neurology was consulted for difficulty weaning of the ventilator. As stated above, they postulated that possible contributions could include steroid myopathy, and prolonged encephalopathy. Head MRI on [**7-13**] revealed multiple bilateral acute and subacute infarcts. She also was found to have wedge shaped infarcts in her kidyney and spleen on abdominal CT. Several echos showed no intracardiac embolic source. Rheumatology was consulted, and did not think this was consistent with vasculitis. Heme-onc was consulted and a hypercoagulabity workup was done. Anticardiolipin IgG and IgM were weakly positive, but Heme did not think this was consistent with antiphospholipid antibody syndrome as this can be seen with infection and acute illness. She will follow-up with Heme for further outpatient work-up. She appears to have no residual neurological deficits. . Acute Renal Failure: The patient was found to be in ARF on admission. Urine eosinophils were negative, making AIN unlikely. Her presumed diagnosis was ATN, and her creatinine slowly normalized with hydration, with normal renal function at discharge. . Anxiety/Depression: The patient had significant anxiety/depression during her long MICU stay, which possibly contributed to her long wean from the ventilator. On [**7-25**], She was started on an SSRI, with significant improvement in affect and mood on the floor. . FEN: The patient is s/p PEG on [**7-18**]. By transfer to the floor on [**7-25**], she was cleared for a normal diet, and was taking adequate Pos by discharge. She will follow-up with Thoracics for PEG pull on [**8-29**]. Medications on Admission: Omeprazole 20 daily Lisinopril 20 daily Metoprolol 50 [**Hospital1 **] Ciprofloxacin Diflunisal 500 [**Hospital1 **] Prednisone 40mg x3 days ([**2169-6-26**]), then taper Embrel Discharge Medications: 1. AFO Please provide AFO to patient [**Known firstname **] [**Known lastname 37080**], patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for right-sided foot drop. Patient has a size 7.5 inch foot. 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for pruritis. Disp:*30 Tablet(s)* Refills:*2* 6. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*2* 7. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*2* 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 10. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. Disp:*1 tube* Refills:*0* 12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). Disp:*1 tube* Refills:*2* Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: 1) Pancytopenia 2) Respiratory failure s/p tracheostomy and PEG 3) Psoriasis 4) Acute/Subacute Strokes 5) Hyperphospatemia/Hypercalcemia Discharge Condition: The patient's pancytopenia is largely resolved, with a mild persistent anemia, Hct stable at 31. Her tracheostomy was decannulated the day prior to discharge, and she is saturating in the high 90s and able to ambulate well with physical therapy. She is able to eat a regular adult diet, and PEG will be removed [**8-29**]. She continues to have hyperphosphatemia and hypercalcemia, improved since starting [**Month/Year (2) **]. Discharge Instructions: You were admitted because of low blood counts that caused you to bleed from your lungs. You had a bone marrow biopsy to help determine the cause of your low blood counts, which may have been either a medication you were taking (Keflex, Levofloxacin, Embrel, or Diflunisil) or an infection (Mycoplasma). You were given antibiotics for this infection. You were put on a ventilator and got a tracheostomy tube in your neck to help you breathe, which was taken out yesterday. You got a feeding tube in your stomach to help you eat. You had a skin biopsy, which showed that your rash is psoriasis, and you were started on topical steroids. Your labs showed you have high levels of phosphorus and calcium, and you were started on a medication ([**Month/Year (2) **]) to lower these levels. . Please take all new medications as prescribed. Please make sure to attend all follow-up appointments below. The visiting nurses will be drawing labs that your primary care doctor will be monitoring, and he may call you to adjust the dose of [**Month/Year (2) **]. . Please contact your doctor or go to the emergency room if you have fever>101, chills, chest pain, abdominal pain, shortness of breath, bleeding, or any other concerns. Followup Instructions: You have an appointment with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 36086**], at [**Hospital **] Health Center, on [**2169-8-16**] at 3:10pm. His number is [**Telephone/Fax (1) 31979**]. . You have an appointment with Dr. [**Last Name (STitle) 11482**] [**Name (STitle) **], with Thoracic Surgery, for removal of your feeding tube, on [**2169-8-29**] at 11:00am. You should go to [**Hospital Ward Name 23**] [**Location (un) **] for a chest x-ray at 10:30am prior to this appointment. His number is [**0-0-**]. . You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with Dermatology on [**2169-9-7**] at 11:00 am at [**Hospital1 18**] [**Location (un) 55**] at [**Street Address(2) 74298**]. [**Location (un) 55**], MA. His number is ([**Telephone/Fax (1) 31239**]. His office will call you if appointments become available on [**2169-8-29**]. . You have an appointment with Dr. [**First Name4 (NamePattern1) 1726**] [**Last Name (NamePattern1) 7711**] with Endocrinology at 8:30am on [**2169-9-11**]. His office is located at [**Hospital1 18**] [**Last Name (un) 469**] [**Location (un) 436**]. His number is ([**Telephone/Fax (1) 74299**]. . You have an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**] with Hematology on 10:30 am on [**2169-9-22**]. His office is located at [**Hospital1 18**] on [**Hospital Ward Name 23**] [**Location (un) **]. His number is ([**Telephone/Fax (1) 74300**]. . You have an appointment to get a repeat chest CT scan on [**2169-11-2**] at 1:00pm at [**Hospital1 18**] on [**Last Name (un) 469**] [**Location (un) **]. You should not eat for 3 hours before. You then have an appointment with Dr. [**First Name8 (NamePattern2) 4944**] [**Last Name (NamePattern1) **], with Pulmonology on [**2169-11-6**] at 1:00pm. Her number is ([**Telephone/Fax (1) 513**]. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2169-8-11**]

[ "584.5", "275.42", "263.1", "696.1", "518.81", "714.0", "786.3", "434.91", "276.2", "780.6", "401.9", "284.1", "788.20", "288.00", "300.4" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.04", "43.11", "41.31", "96.6", "86.11", "99.05", "96.72", "97.37" ]

icd9pcs

[ [ [] ] ]

15420, 15481

6891, 13773

310, 400

15662, 16096

1969, 6868

17373, 19472

1373, 1382

14001, 15397

15502, 15641

13799, 13978

16120, 17350

1397, 1950

256, 272

428, 1204

1226, 1302

1318, 1357

22,184

142,229

25094

Discharge summary

report

Admission Date: [**2179-9-29**] Discharge Date: [**2179-10-6**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: CABG x4 History of Present Illness: 82 y o male with known history of 3 vessel CAD and recent cath done after abnormal nuclear scan, and was scheduled electively for CABG at [**Hospital3 35813**] Center. Three days ago, he developed chest pain, and was admitted for heparin and treatment for unstable angina. Echo was normal, and patient transferred to [**Hospital1 18**] for urgent CABG. Past Medical History: Coronary Artery Disease Chronic renal insufficiency Abdominal Aortic Aneurysm s/p aortobifem bypass graft Peripheral vascular disease Hypertension Hypercholesterolemia Hiatal Hernia Benign Prostatic Hypertrophy Diverticular disease s/p Bladder surgery s/p Inguinal Herniorrhaphy Social History: quit smoking in [**2141**] occsional ETOH no recreational drugs widowed with 2 children Family History: non-contrib. Physical Exam: awake and alert RRR CTA bilat. abd soft, NT, ND NABS no leg edema 98.4 HR 79 145/70 RR 22 100% on 2L NC Pertinent Results: [**2179-9-29**] 10:05PM BLOOD WBC-8.3 RBC-4.25* Hgb-13.0* Hct-37.1* MCV-87 MCH-30.7 MCHC-35.1* RDW-13.9 Plt Ct-248 [**2179-10-6**] 05:45AM BLOOD WBC-9.5 RBC-3.30* Hgb-9.9* Hct-29.9* MCV-91 MCH-30.1 MCHC-33.2 RDW-14.0 Plt Ct-239 [**2179-9-29**] 10:05PM BLOOD PT-12.9 PTT-25.1 INR(PT)-1.1 [**2179-10-6**] 05:45AM BLOOD Plt Ct-239 [**2179-9-29**] 10:05PM BLOOD Glucose-131* UreaN-28* Creat-1.9* Na-139 K-4.0 Cl-102 HCO3-26 AnGap-15 [**2179-10-4**] 06:10AM BLOOD Glucose-90 UreaN-39* Creat-1.6* Na-136 K-4.0 Cl-99 HCO3-27 AnGap-14 [**2179-9-30**] 07:46PM BLOOD ALT-37 AST-32 LD(LDH)-191 AlkPhos-55 TotBili-0.5 [**2179-9-29**] 10:05PM BLOOD Calcium-9.5 Phos-3.0 Mg-1.9 [**2179-9-30**] 07:46PM BLOOD %HbA1c-6.6* [Hgb]-DONE [A1c]-DONE Brief Hospital Course: Admitted [**9-29**] for urgent CABG with Dr. [**Last Name (STitle) **]. Cardiac cath at OSH revealed 3 VD and EF 55%. Echo showed EF 55% and mild MR. Had more hydration pre-surgery with an elev. creatinine. Underwent CABG X 4 on [**10-1**] with LIMA to Diag, SVG to LAD, SVG to OM, SVG to RCA. Transferred to CSRU in stable condition on a neosynephrine drip. Extubated that evening, and in SR on POD #1 on insulin and nitroglycerin drips. Started lasix diuresis and beta blockade, then transferred to floor. He had some emesis the next evening, but this resolved, and chest tubes were pulled on POD #2. His exam was unremarkable. He continued to work with PT to increase his activity level. Pacing wires removed on POD #3 and remained hemodynamically stable. He did a level 5 on POD #5 and was discharged to home with VNA services. Medications on Admission: zocor 40 mg daily ASA 325 mg daily HCTZ 25 mg daily KCL 20 mEq daily toprol XL 75 mg daily SL NTG prn Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Take in place of Toprol XL. Disp:*60 Tablet(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 30 doses. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 16221**] Hospital Home Care Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Chronic renal insufficiency Abdominal Aortic Aneurysm s/p aortobifem bypass graft Peripheral vascular disease Hypertension Hypercholesterolemia Hiatal Hernia Benign Prostatic Hypertrophy Diverticular disease Discharge Condition: Stable Discharge Instructions: Please return to the hospital or call Dr.[**Name (NI) 3502**] office of you experience chills or fever greater than 101 degrees F. Please call if you notice redness, swelling, or tenderness of your chest wound, or if it begins to drain pus. No heavy lifting or driving until follow up with Dr. [**Last Name (STitle) **]. You may shower. Wash incision with mild soap and waten, then pat dry. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 1112**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Call to schedule appointment. Plan to follow up in 4 weeks. Please follow up with your primary care physician/cardiologist in 2 weeks. Completed by:[**2179-11-17**]

[ "272.0", "593.9", "V12.79", "412", "413.9", "443.9", "401.9", "414.01", "600.00" ]

icd9cm

[ [ [] ] ]

[ "36.15", "99.04", "36.13", "39.61", "89.60" ]

icd9pcs

[ [ [] ] ]

3825, 3895

2005, 2840

279, 288

4207, 4216

1253, 1982

4657, 4943

1095, 1109

2992, 3802

3916, 4186

2866, 2969

4240, 4634

1124, 1234

229, 241

316, 672

694, 974

990, 1079

4,655

158,479

10898

Discharge summary

report

Admission Date: [**2202-7-20**] Discharge Date: [**2202-7-28**] Date of Birth: [**2163-8-26**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 1377**] Chief Complaint: CC: mental status change, fever, code sepsis protocol Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 38yo woman with anxiety, bipolar, ESRD [**2-19**] lithium s/p renal transplant now on HD who presents from MICU after a sepsis workup. She recently was in the hospital for fevers, intraabdominal abscesses and had a subtotal gastrectomy. She was doing well for 6 weeks in [**Hospital1 **] then returned home on [**7-14**]. She has had loose stools then noted to have low-grade temp at HD last monday. Cultures were drawn at HD then that night she had temp to 103.5. She came to the ED. She was febrile to 102.4 and SBP in the 70s. Early goal-directed therapy for sepsis was initiated, and a L subclavian Presept catheter was placed, she was bolused 2L NS, given vancomycin and ceftazadime, and started on norepinephrine as her MAP was <65 in spite of a CVP of 14. Her lactate was 1.5. . She was sent to the MICU. There she was continued on levophed, cultures were sent, and she was started on daptomycin (hx of VRE and MRSA), cefepime, and flagyl. C diff positive so flagyl was continued. Other cx remained NGTD. Cefepime was discontinued but she remains on dapto given her persistent fevers. She has a temp HD line in the right anterior chest. She had an abd CT which showed no abscess but bowel wall thickening c/w colitis (c diff). Her baseline cortisol level was 22.7. Her BP improved (received total of 8-12L IVF) and she was off pressors by [**7-22**]. Received HD on [**7-22**] without issue. Left lower ex noninvasives negative. She had a slight trop leak thought [**2-19**] demand and also in the setting of renal failure. She continued to have fevers up to 101 but remained hemodynamically stable on dapto and flagyl. . Just prior to arrival to floor, she tolerated HD without issue. Currently, she is febrile but otherwise feels quite well. She has had diarrhea but no nausea or abdominal pain. She denies any headache or neck pain, denies CP, SOB, palpitations. She reports L>R lower ex swelling unchanged. No chills or nightsweats. . Past Medical History: Post-transplant lymphoprolif disorder ESRD [**2-19**] lithium toxicity s/p failed renal transplant [**2-19**] PTLD(removed in [**2196**]) Myelofribrosis Thrombocytopenia Anxiety Bipolar disorder s/p subtotal gastrectomy for hyperplastic polyps of the antrum s/p repair of ventral hernia h/o hypothyroidism Social History: Social: no etoh, no tobb. lives with husband. likes to read. Family History: non-contributory Physical Exam: on transfer to [**Doctor Last Name 3271**]-[**First Name4 (NamePattern1) 679**] [**Last Name (NamePattern1) 4869**]: VS: 101.6 108/84 104 20 100% RA Gen: resting calmly, flat affect. NAD, AAO to person, place, month, situation. HEENT: NCAT PERRLA MMM no tender LAD Neck: JVD flat. hematoma on left IJ site. Skin: right tunnelled HD cath has minimal erythema and is nontender. left subclavian is with dressing c/d/i. Cards: RRR II/VI SEM at LUSB nonradiating. nlS1S2 no rubs Chest: CTAB no crackles Abd: midline scar, no large hernia. NT ND bs+ no masses no rebound. ext: warm, well perfused. L>R edema. good pulses bilat Neuro: FROM, no spinal tenderness. EOMI, tongue midline, face symmetric Pertinent Results: [**2202-7-20**] 03:20AM BLOOD WBC-7.0# RBC-3.03* Hgb-10.5*# Hct-30.0*# MCV-99* MCH-34.5* MCHC-34.9 RDW-20.2* Plt Ct-93* [**2202-7-20**] 03:20AM BLOOD Neuts-51.1 Bands-0 Lymphs-34.5 Monos-13.8* Eos-0.2 Baso-0.4 [**2202-7-20**] 03:20AM BLOOD Glucose-95 UreaN-17 Creat-4.0*# Na-137 K-4.1 Cl-95* HCO3-29 AnGap-17 [**2202-7-20**] 03:20AM BLOOD Calcium-8.7 Phos-2.7# Mg-1.4* [**2202-7-28**] 05:10AM BLOOD WBC-5.6 RBC-2.52* Hgb-8.7* Hct-26.8* MCV-107* MCH-34.6* MCHC-32.4 RDW-23.6* Plt Ct-98* [**2202-7-28**] 05:10AM BLOOD Glucose-84 UreaN-16 Creat-4.5*# Na-143 K-3.3 Cl-102 HCO3-33* AnGap-11 [**2202-7-28**] 05:10AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8 [**2202-7-20**] 03:20AM BLOOD TSH-5.6* [**2202-7-21**] 10:59AM BLOOD T4-4.6 T3-39* Free T4-0.73* [**2202-7-20**] 01:30PM BLOOD Cortsol-22.7* [**2202-7-20**] 12:19PM BLOOD Cortsol-11.9 [**2202-7-20**] 03:20AM BLOOD Cortsol-20.2* CT abd/pelvis: CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Limited examination of the lung bases displays interval development of small bilateral pleural effusions and adjacent lower lobe atelectasis. The lungs are otherwise clear. Dialysis catheter terminates within the right atrium. The liver, gallbladder, spleen, stomach with post-surgical changes, pancreas, adrenal glands, and atrophic kidneys appear stable. No abnormal enhancing fluid collections are identified within the abdominal cavity. No free air is noted within the abdominal cavity. No pathologically enlarged nodes are present. There has been no significant interval change in the amount of intra-abdominal ascites. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: There has been interval development of bowel wall thickening involving the ascending, transverse, and descending colon. It is difficult to evaluate for signs of adjacent mesenteric stranding given the diffuse engorgement of the mesentery and pelvic ascites that are slightly increased from prior examination. The uterus, adnexa, and Foley containing urinary bladder appear unremarkable. Appearance of the right saphenous [**Month/Day/Year 5703**] and surgical clips is stable. BONE WINDOWS: No malignant-appearing osseous lesions are identified. IMPRESSION: 1. No abnormal enhancing fluid collections to suggest underlying abscess. Interval development of colitis involving the ascending, transverse, and descending colon most suggestive of C. Difficile. Other infectious, or inflammatory etiologies are also within the differential. Ischemia is unlikely based on the non-vascular distribution. 2. Stable abdominal ascites with progression of pelvic ascites. 3. Interval development of small bilateral pleural effusions and adjacent compressive atelectasis Brief Hospital Course: Sepsis In the ED a central line was placed and early goal-directed therapy initiated with pressors, vancomycin, and ceftazidime. She was admitted to the medical ICU for sepsis and maintained on pressors. Multiple cultures did not grow responsible organism but tests for C.difficile were positive and this was presumed to be the source. Abdominal CT showed bowel wall thickening consistent with colitis. She was initially treated empirically with cefepime, flagyl, and daptomycin but then coverage was narrowed to flagyl PO for C.diff and daptomycin for possible occult line infection (she was initally still having fevers). Once on the floor, fevers resolved and daptomycin was discontinued. She was discharged on Flagyl PO to complete a 14d day course, plus an extra 5 days. . ESRD/Hemodialysis Hemodialysis was continued during her hospitalization. . Hypothyroidism Although she has previously carried a diagnosis of hypothyroidism, she was not on levothyroxine on admission. TSH was elevated at 5.6 and she was started on levothyroxine 100mg. TSH decreased to 4.6. . Myelofibrosis/Anemia Hematocrit was followed and she received 1u of PRBCs with hemodialysis on [**2202-7-28**] as her hematocrit had fallen to 24. No source of bleeding was identified and hct drop was presumed to be due to ESRD and myelofibrosis. . Bipolar Illness/Depression Patient retained a very flat affect throughout hospitalization. Etiology for this affect was unclear. Although there have been several psychiatric medication changes through prolonged rehab/hospital course, she was on the most recent regimen as verified with her husband but affect did not improve. Medications on Admission: 1. Ambien 5 mg PO qhs prn insomnia 2. Divalproex Sodium 750 mg PO QHS 3. LaMOTrigine 50 mg PO QHS 4. Lorazepam 1 mg PO qhs prn 5. Nephrocaps 1 CAP PO DAILY 6. Omeprazole 7. Seroquel 25 mg qhs prn Discharge Medications: 1. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). Tablet(s) 2. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO QHS (once a day (at bedtime)). 3. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID (2 times a day). Disp:*60 Packet(s)* Refills:*2* 4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 days: please take for 6 more days, stop for 3 days, then continue for 5 more days. Disp:*33 Tablet(s)* Refills:*0* 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Miconazole Nitrate 2 % Powder Sig: One (1) Topical once a day as needed: Apply to affected area. Disp:*1 1* Refills:*2* 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary diagnosis C. difficile colitis Sepsis . Secondary diagnoses End-stage renal disease Bipolar Illness hypothyroidism Discharge Condition: Stable Discharge Instructions: You were admitted for workup and treatment of fevers. You were found to have Clostridium difficile colitis, an infection of the colon which was most likely responsible for your fevers. The infection has resolved with antibiotics. You were also found to have a low thyroid hormone level and were started on replacement thyroid hormone (levothyroxine) Followup Instructions: Please follow up with your PCP and your psychiatrist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

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icd9cm

[ [ [] ] ]

[ "99.04", "99.21", "39.95" ]

icd9pcs

[ [ [] ] ]

9160, 9231

6202, 7856

323, 330

9398, 9407

3512, 6179

9807, 9985

2760, 2779

8103, 9137

9252, 9377

7882, 8080

9431, 9784

2794, 3493

229, 285

359, 2335

2357, 2664

2680, 2744

46,114

120,212

20581

Discharge summary

report

Admission Date: [**2122-5-22**] Discharge Date: [**2122-6-1**] Date of Birth: [**2065-1-13**] Sex: F Service: CARDIOTHORACIC Allergies: Phenergan Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2122-5-22**]- Coronary bypass grafting x2 with left internal mammary to left anterior descending artery, reverse saphenous vein graft to obtuse marginal artery and reverse saphenous vein graft to right coronary artery History of Present Illness: 57 year old female with exertional chest pain and shortness of breath. Her chest pain is sometimes accompanied by rapid pulse. Angina does not occur at rest. A recent Myoview stress test in [**2122-4-13**] was positive for ischemia. Referred for coronary revascularization surgery. Past Medical History: - Hypertension - Dyslipidemia - depression - dystonia right hand digits (neuropathy) - insomnia - Hysterectomy - Oopherectomy - s/p Lap Chole - rem. L facial lesion Social History: Race:Caucasian Last Dental Exam:6 months ago Lives alone Occupation:school placement specialist Tobacco: Never ETOH:rarely Family History: Mother died at age 58 from coronary disease. Father had CABG. Brother had CABG at 59. Physical Exam: Pulse: 89, then 102 Resp: 16 O2 sat: 99% RA B/P Right: 149/97, then 160/109 Left: 184/11, then 194/128 Height: 5'1" Weight: 116# General:anxious Skin: Dry [x] healing scratch left inner forearm HEENT: PERRLA [x] EOMI [x]anicteric sclera, OP unremarkable Neck: Supple [x] Full ROM []no JVD; prominent pulsation in sternal notch when supine Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur-none Abdomen: Soft [x] non-distended [x] mild epigastric tenderness (chronically) bowel sounds + [x]; no HSM/CVA tenderness Extremities: Warm [x], well-perfused [x] Edema- none Varicosities: None [x] Neuro: Grossly intact; nonfocal exam; MAE [**6-17**] strengths Pulses: Femoral Right: 2+ ( tender at cath site) Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: none Left:none ** pt is very thin with prominent pulsation in sternal notch when supine Pertinent Results: Post-op [**2122-5-22**] 12:14PM HGB-9.6* calcHCT-29 [**2122-5-22**] 12:14PM GLUCOSE-86 LACTATE-0.6 NA+-139 K+-3.1* CL--112 [**2122-5-22**] 03:50PM FIBRINOGE-165 [**2122-5-22**] 03:50PM PT-17.1* PTT-32.6 INR(PT)-1.5* [**2122-5-22**] 03:50PM PLT COUNT-149* [**2122-5-22**] 05:08PM UREA N-10 CREAT-0.5 CHLORIDE-118* TOTAL CO2-20* Discharge [**2122-5-31**] 06:15AM BLOOD WBC-10.5 RBC-3.62* Hgb-11.0* Hct-32.7* MCV-90 MCH-30.3 MCHC-33.6 RDW-13.4 Plt Ct-397 [**2122-5-31**] 06:15AM BLOOD Plt Ct-397 [**2122-5-24**] 12:56AM BLOOD PT-14.0* PTT-30.1 INR(PT)-1.2* [**2122-5-31**] 06:15AM BLOOD Glucose-98 UreaN-12 Creat-0.8 Na-142 K-5.0 Cl-106 HCO3-27 AnGap-14 [**2122-5-31**] 06:15AM BLOOD Phos-4.0 Mg-2.1 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Annulus: 1.9 cm <= 3.0 cm Aorta - Ascending: 2.6 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 6 mm Hg < 20 mm Hg Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses 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 simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2122-5-22**] at 1300 hours. Post bypass Patient is A paced and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. Trivial mitral regurgitation present. Aorta is intact post decannulation. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Radiology Report CHEST (PA & LAT) Study Date of [**2122-5-28**] 2:40 PM [**Hospital 93**] MEDICAL CONDITION: 57 year old woman with cabg REASON FOR THIS EXAMINATION:interval chnage in left effusion and dilated loops of bowel Final Report PA and lateral chest views were obtained with patient in upright position. Comparison is made with the next preceding similar study of [**2122-5-26**]. Status post sternotomy and multiple surgical clips mostly anterior left mediastinum indicative of previous bypass surgery, unchanged. Heart size has decreased slightly. The pulmonary vasculature is not congested and no signs of new acute parenchymal infiltrates are present. Both lateral pleural sinuses are mildly blunted slightly more on the left than on the right. Corresponding mild-to-moderate degree of blunted posterior pleural sinuses are identified, but the amount of pleural effusion has decreased in comparison with the preceding study of [**2122-5-26**]. Previously described right internal jugular approach central venous line remains in unchanged position. No pneumothorax has developed. On the preceding moderately distended gas-filled large bowel loops (transverse colon and splenic flexure) can be seen indicative of somewhat atonic bowel, but no signs of obstruction. The degree of gas distention has now regressed markedly and some moderately sized fecal masses are identified, all indicating that the bowel function has resumed. Noted are two surgical metallic clips in the central portion of the right upper abdominal quadrant consistent with previous cholecystectomy. IMPRESSION: Comparison is also made with the preoperative PA and lateral chest examination of [**2122-5-20**]. Increase of heart silhouette is best explained with postoperative pericardial effusion - hematoma. Postoperative pleural effusions are regressing. No evidence of pulmonary congestion or acute infiltrates and normalization of temporary distended large bowel loops. DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**] Brief Hospital Course: Ms [**Known lastname **] was a direct admission to the operating room for coronary bypass grafting on [**2122-5-22**]. Please see OR report for details, in summary she had: Coronary bypass grafting x2 with left internal mammary to left anterior descending artery, reverse saphenous vein graft to obtuse marginal artery and reverse saphenous vein graft to right coronary artery. Her bypass time was 69 minutes with a crossclamp of 55 minutes. She tolerated the operation well and was transferred from the operating room to the cardiac surgery ICU in stable condition. She was hemodynamically stable on arrival to the ICU, she remained hemodynamically stable awoke and was extubated on the day of surgery. She remained hemodynamically stable and was transferred to the stepdown floor on POD 3. All tubes,lines and drains were removed per cardiac surgery protocol. Once on the stepdown floor the patient worked with physical therapy to increase her activity and endurance. She was gently diuresed toward her preop weight. She was started on Keflex for lower sternal pole erythema and serous drainage. The remainder of her hospital course was uneventful. She was tolerating a full oral diet, ambulating without assistance and her incisions were healing well. On POD 10 she was discharged to home with VNA services. Medications on Admission: BUPROPION HCL - 100 mg twice a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit once a week ESTRADIOL - 0.5 mg Tablet - 1 Tablet(s) daily FENOFIBRATE - (Prescribed by Other Provider) - Dosage uncertain LISINOPRIL - Dosage uncertain METOPROLOL SUCCINATE - 37.5 mg by mouth daily SERTRALINE - Dosage uncertain SIMVASTATIN - 40 mg Tablet -daily ASPIRIN - 81 mg once a day 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:*1* 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 4. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*1* 5. Bupropion HCl 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*1* 6. Estradiol 1 mg Tablet Sig: 0.5 ( one-half) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 7. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*1* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days. Disp:*24 Capsule(s)* Refills:*0* 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 13. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 14. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain for 3 weeks. Disp:*85 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Coronary artery disease s/p coronary bypass grafting x2 PMH: hypertension, hyperlipidemia, depression, dystonia R digits (neuropathy), insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Sternal wound healing well, no erythema or drainage, on keflex per Dr. [**Last Name (STitle) **] Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: [**Hospital 409**] clinic on [**6-10**] Dr [**Last Name (STitle) **] on Thurs. [**6-25**] @1:30 PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7164**] in [**3-18**] weeks Cardiologist: Dr [**First Name8 (NamePattern2) 2092**] [**Last Name (NamePattern1) **] in [**3-18**] weeks Please call the cardiac surgery office [**Telephone/Fax (1) 1504**] for any questions or concerns. Answering service will page on-call staff during off hours Completed by:[**2122-6-1**]

[ "311", "401.9", "414.01", "780.52", "695.9", "276.2", "411.1", "272.4", "356.9", "293.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11065, 11124

7530, 8845

286, 509

11312, 11312

2274, 5515

12161, 12682

1167, 1254

9279, 11042

5555, 5583

11145, 11291

8871, 9256

11560, 12138

1269, 2255

236, 248

5611, 7507

537, 822

11327, 11536

844, 1010

1026, 1151

11,546

104,867

21271

Discharge summary

report

Admission Date: [**2142-8-22**] Discharge Date: [**2142-8-23**] Date of Birth: [**2074-11-21**] Sex: M Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Elective Right Internal Carotid Artery angioplasty and stenting. Major Surgical or Invasive Procedure: Right Internal Carotid Artery angioplasty and stenting. History of Present Illness: Pt is a 67 yo M with HTN, Hypercholesterolemia, PVD, and recent Right Carotid U/S on [**2142-7-3**] revealing a 95% ulcerated lesion. He was admitted for elective angioplasty and stenting of his right internal carotid by Dr. [**First Name (STitle) **] (enrolled in CREST study). Baseline SBP prior to intervention was 200. Pt is very active at baseline without dyspnea on exerction. Pt denies symptoms of CP/SOB/visual changes/HA/numbness/weakness. Past Medical History: 1. HTN 2. hypercholesterolemia 3. PVD 4. BPH 5. Colonoscopy w/ polypectomy on [**4-22**] 6. h/o melanoma s/p resection 7. s/p hand surgery Social History: Married with 3 children. Employeed as engineer. Quit tob many years ago with a 12 pack year history. EtOH; [**2-20**] drinks per night. Family History: No family h/o premature CAD <55 years of age. Physical Exam: T 96.2 142/60 57 20 Wt 105 kg Sat 99% RA Gen: well appearing, NAD HEENT: MMM, anicteric, PERRL Neck: No JVD CV: brady, regular, normal S1S2. No M/R/G. No S3S4. Lungs: CTAB Abd: obese, soft, NT/ND, pos BS Ext: no C/C/E Neuro: A&Ox4, CN II-XII intact, [**5-23**] UE strength, [**5-23**] dorsi/plantar flexion Pertinent Results: [**2142-8-22**] 05:01PM POTASSIUM-4.1 [**2142-8-22**] 05:01PM CK(CPK)-60 [**2142-8-22**] 05:01PM CK-MB-NotDone [**2142-8-22**] 05:01PM PLT COUNT-143* Brief Hospital Course: Pt is a 67 yo M with HTN, Hypercholesterolemia, PVD, and Right Carotid Stenosis admitted for elective angioplasty and stenting of his right internal carotid by Dr. [**First Name (STitle) **] (enrolled in CREST study). 1. Right Internal Carotid Stenosis. Pt underwent angioplasty and stenting without complications. His BP was maintained at goal between 120 and 150 post procedure without requiring Neosynephrine, Nipride, or Norvasc. Pt had no change in his neurological status post-op or evidence of vagal episodes. He remained on Plavix and ASA. He was seen by Dr. [**Last Name (STitle) **] prior to discharge. 2. HTN. The pt was restarted on Accuretic at dicharge. He is to call Dr. [**First Name (STitle) **] in 4 days with his BP, and will add Norvasc if needed at that time. 3. Hyperchol. LDL of 105. Goal LDL <100. Consider increasing Lipitor 20 as outpatient. Medications on Admission: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Accuretic 20-12.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Accuretic 20-12.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Norvasc 5 mg Tablet Sig: One (1) Tablet PO as per Dr. [**First Name (STitle) **] on Monday. Discharge Disposition: Home Discharge Diagnosis: Right Internal Carotid Artery Stenosis with angioplasty and stenting. Discharge Condition: Stable. Discharge Instructions: Please call your physician if you experience confusion, change in vision, bleeding, or any other problems. Followup Instructions: 1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2142-9-11**] 1:00 2. Please call Dr. [**First Name (STitle) **] on Monday to report your Blood Pressure. Do not take Norvasc unless advised by Dr. [**First Name (STitle) **]. 3. Please follow-up with Dr. [**Last Name (STitle) **] in one month.

[ "433.10", "272.0", "443.9", "V10.82", "600.00", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.90", "39.50" ]

icd9pcs

[ [ [] ] ]

3565, 3571

1848, 2726

402, 460

3685, 3694

1665, 1825

3849, 4278

1271, 1318

3111, 3542

3592, 3664

2752, 3088

3718, 3826

1333, 1646

297, 364

488, 938

960, 1100

1116, 1255

58,433

168,831

53403

Discharge summary

report

Admission Date: [**2177-5-27**] Discharge Date: [**2177-5-29**] Date of Birth: [**2129-10-5**] Sex: F Service: MEDICINE Allergies: Zosyn / Quinolones / Ceftriaxone / Flagyl / Keppra / Lisinopril / Naprosyn Attending:[**First Name3 (LF) 562**] Chief Complaint: swelling of lips Major Surgical or Invasive Procedure: none History of Present Illness: 47F with asthma/COPD, atopic dermatitis, HTN on ACEI, GERD who comes with facial swelling. She was in her prior state of health until yesterday afternoon when she started noticing mild facial swelling. She went to bed and was doing fine, but when she woke up at the normal time she noticed worsening of her lip swelling to the point she was unable to open her mouth. She denies any wheezing, stridor, shortness of breath and states that has been on Lisinopril 20 mg for long time. She denies fever, chills, changes in her voice, drooling, neck pain, hoarseness or any other upper airway symptoms. . Of note, patient was recently admitted for abdominal pain and negative work up including CT abdomen, right upper quadrant ultrasound, and HIDA scan were all performed and within normal limits. Diet was advanced without difficulty, and patient was placed on aggressive bowel regimen with daily bowel movement. She was discharged home 3 days ago. . In the ER her initial VS were T 97.4 F, HR 58 BPM, BP 126/79 mmHg, RR 16 X', SpO2 100% on RA. She was breathing comfortably, but there was a lot of difficulty examining her mouth. ENT and anesthesia were called to assess patient. ENT tried scoping her to assess for vocal cord swelling, but she did not tolerate procedure secondarely to anxiety and dyscomfort. ER tried giving 5 mg of midazolam and re-doing procedure, but patient was still unable to tolerate it. Then, given patient's breathing being stable ENT decided to preoceed with medications only and observation for 1 hour in the ER. Pt received 125 mg of IV solumedrol, 20 mg of IV famotidine, 25 mg of IV diphenydramine and epipen x2 (its unclear if first one went in, so [**Name (NI) **] repeated the dose). She was stable for 1 hour and then is admitted to the ICU for monitoring. She is has a tough access and ER could only get a small IV in R forearm (that is why they gave epineprhine IM). Past Medical History: 1. Asthma/COPD 2. Hypertension 3. GERD 4. Urostomy 5. h/o VRE pyelonephritis 6. Spina bifida (myelomengiocele) 7. Paraplegia (documented, though patient can walk) 8. Depression 9. Mild mental retardation 10. Psychogenic dysarthria and tremor 11. [**Name (NI) **] vs. pseudoseizures - EEG work-up at [**Hospital3 **] in [**2165**] frequent runs of regular bifrontal sharp delta activity although the clinical events which occurred during the record were not associated with EEG change 12. Atopic dermatitis 13. Back pain 14. Genital herpes 15. Uterine fibroid 16. Uterine prolapse 17. Diverticulosis 18. External hemorrhoids Social History: Home: Lives alone in an apartment in [**Location (un) 86**]. She is able to transfer independently with walker. No assistance at home currently, noting that she does everything on her own. She reports compliance with her meds. Tobacco: 1 PPD EtOH: Drinks 2-3 beers a day. Illicits: Denies IVDU ever. History of smoking crack cocaine. Family History: Per previous report: 3 healthy children. Mother - died of lung cancer. Father - killed by his girlfriend. Not in contact with her brother and sister. Physical Exam: VITAL SIGNS - 97.7, 124/78, 54, 18, 99%/RA . GENERAL - well-appearing african american woman in NAD, comfortable, appropriate, not jaundiced (skin, mouth, conjuntiva), breathing comfortably, no use of accesory muscles, slow speaking (hx of MR) HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, edema of face and lips with limited opening ability of mouth NECK - supple LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR nl s1/s2 no mrg ABDOMEN - distended, NABS, diffusely significantly TTP, +rebound EXTREMITIES - 2+ b/l LE edema (patient states baseline) missing toe NEURO - awake, A&Ox3, grossly intact Pertinent Results: Admission Labs: [**2177-5-27**] 07:30PM BLOOD WBC-9.2# RBC-3.96* Hgb-12.8 Hct-39.7 MCV-100* MCH-32.3* MCHC-32.3 RDW-14.9 Plt Ct-245 [**2177-5-27**] 07:30PM BLOOD Neuts-84.4* Lymphs-13.7* Monos-0.5* Eos-0.8 Baso-0.6 [**2177-5-27**] 07:30PM BLOOD PT-11.8 PTT-26.2 INR(PT)-1.0 [**2177-5-27**] 07:30PM BLOOD Glucose-111* UreaN-14 Creat-0.7 Na-136 K-4.5 Cl-107 HCO3-21* AnGap-13 [**2177-5-27**] 07:30PM BLOOD ALT-117* AST-28 LD(LDH)-173 AlkPhos-400* TotBili-0.4 [**2177-5-27**] 07:30PM BLOOD TotProt-7.6 Albumin-4.0 Globuln-3.6 Calcium-8.8 Phos-3.4 Mg-2.1 [**2177-5-27**] 07:30PM BLOOD C3-183* C4-27 Discharge Labs: [**2177-5-29**] 08:05AM BLOOD WBC-8.3 RBC-3.70* Hgb-11.7* Hct-37.1 MCV-100* MCH-31.5 MCHC-31.4 RDW-14.3 Plt Ct-267 [**2177-5-29**] 08:05AM BLOOD Glucose-93 UreaN-13 Creat-0.7 Na-138 K-4.9 Cl-108 HCO3-21* AnGap-14 [**2177-5-29**] 08:05AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.2 KUB [**5-28**] prelim read: no acute process, no free air Brief Hospital Course: #. Angioedema - Patient has bilateral impressive lip and cheek swelling. She had been on an ACEI for "long time" many years. There was no change in diet or specific trigger however it seems that she started Naprosyn the day prior to admission. She was admitted to the ICU for monitoring after failed attempts of visualizing the vocal cords. She was been seen by allergy for likely naproxen induced angioedema. She was started on steroids/antihistamines without much improvement. Her ACE-i was stopped as well as Naproxen and NSAIDs in general. Her respiratory status remained stable and her diet was advanced after transfer to the floor on [**5-28**]. . #. Asthma - Pt w/o any wheezing or SOB. She was continued on Albuterol and on day of discharge Montelukast was restarted . #. HTN - Pt on ACEI and beta-blocker at home. Her ace-inhibitor was held and her beta-blocker was not restarted due to persistent HR in the 50s. [**First Name8 (NamePattern2) 6**] [**Last Name (un) **] can be considered in >1 month if necessary per allergy. . # seizure d/o: Patient was transitioned to Phenytoin IV while NPO and changed to PO at discharge. . # vaginal Prolapse: patient should be evaluted by Gynecology as an outpatient. . #. Code - Full code Medications on Admission: Quetiapine 25 mg PO QHS Citalopram 20 mg PO Daily Colace 100 mg PO B ID Atenolol 25 mg PO Daily Omeprazole 20 mg PO Daily Phenytoin 500 mg PO QHS Lisinopril 20 mg PO Daily Multivitamin PO Daily Motelukast 10 mg PO Daily Simethicone 80 mg PO Daily PRN cramps Thiamine 100 mg PO Daily Bisacodyl 5 mg PO PRN Constipation Senna 8.6 mg PO BID Albuterol 90 mcg PRN q4-6 hrs SOB/Wheezing . ALLERGIES: Piperacillin Sodium/Tazobactam: unknown Quinolones Ceftriaxone Metronidazole Levetiracetam Discharge Medications: 1. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS. 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Phenytoin Sodium Extended 100 mg Capsule Sig: Five (5) Capsule PO QHS. 6. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day as needed for abdominal cramps. 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 11. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*15 Tablet(s)* Refills:*0* 13. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for 3 days: start on [**5-30**]. Disp:*6 Tablet(s)* Refills:*0* 14. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Primary: Angioedema Secondary: asthma HTN [**Month/Year (2) 54422**] Discharge Condition: Mentating well, ambulating independently with limited distance Discharge Instructions: You were admitted to [**Hospital1 69**] because of swelling of your lips. You were admitted to the intensive care unit seen by the allergy doctors. It was determined that you have angioedema, which is an allergic reaction. It may have been due to your Lisinopril or the Naprosyn. For this reason you should stop taking both of these medications and you should not take them again. You should also avoid all NSAIDS including Motrin, Ibuprofen and Advil. While you were here, some of your medications were changed. You should CONTINUE taking: Quetiapine 25 mg at night Citalopram 20 mg daily Colace 100 mg twice a day Omeprazole 20 mg Daily Phenytoin 500 mg at night Multivitamin daily Motelukast 10 mg daily Simethicone 80 mg daily as needed for cramps Thiamine 100 mg daily Bisacodyl 5 mg as needed for constipation Senna 8.6 mg twice a day Albuterol 90 mcg every 4-6 hours as needed for wheezing You should STOP taking: Lisinopril Atenolol You should START taking: Prednisone 40mg daily for the next 3 days. Tylenol (Acetaminophen) as needed for pain. Oxycodone 5mg every 6 hours as needed for pain. Make sure you see your primary care doctor at the appointment below. We also made you an appiontment with Gynecology to follow-up on your prolapse. Followup Instructions: Name: [**Last Name (LF) 5240**],[**First Name3 (LF) 5241**] Location: [**Hospital6 5242**] CENTER Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 798**] Appointment: [**2177-6-2**] 3:00pm Department: OBSTETRICS AND GYNECOLOGY When: TUESDAY [**2177-6-17**] at 8:30 AM With: [**First Name8 (NamePattern2) 156**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2664**] Building: CC CLINICAL CENTER [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: NEUROLOGY When: FRIDAY [**2177-5-30**] at 11:30 AM With: [**First Name11 (Name Pattern1) 12562**] [**Last Name (NamePattern4) 47259**], MD [**Telephone/Fax (1) 3506**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "054.10", "780.39", "781.0", "455.3", "784.51", "530.81", "317", "741.90", "562.10", "618.00", "344.1", "E942.9", "691.8", "493.20", "E935.6", "V44.6", "995.1", "218.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "31.42" ]

icd9pcs

[ [ [] ] ]

8110, 8116

5120, 6365

351, 357

8230, 8295

4152, 4152

9601, 10558

3304, 3455

6901, 8087

8137, 8209

6391, 6878

8319, 9578

4766, 5097

3470, 4133

295, 313

385, 2289

4169, 4749

2311, 2936

2952, 3288

28,126

161,069

27919

Discharge summary

report

Admission Date: [**2165-7-16**] Discharge Date: [**2165-8-4**] Date of Birth: [**2121-5-5**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6743**] Chief Complaint: Advanced ovarian cancer or possibly fallopian tube cancer Major Surgical or Invasive Procedure: 1) total abdominal hysterectomy 2) bilateral salpingo-oophorectomy 3) exploratory laparatomy 4) tumor debulking 5) bowel resection and anastamosis 6) central line placement History of Present Illness: This is a 44-year-old G4P3013 with likely locally advanced ovarian cancer or possibly fallopian tube cancer now with abdominal pain and a CT suggestive of a small bowel obstruction. This patient first developed pelvic discomfort in 11/[**2164**]. She was seen at [**Hospital1 2025**] in [**5-/2165**] diagnosed with presumed PID and discharged home with antibiotics. The cultures per the patient subsequently were negative. She then was admitted to [**Hospital1 18**] [**Date range (3) 68008**] for severe pelvic pain. Ultrasound revealed a complex area 7 cm x 1.6 cm, possible [**Last Name (un) **]. During this admission her pain did not improved with antibiotics therefore on [**2165-6-27**] she had a ultrasound drainage for a presumed [**Last Name (un) **]. The cytology was concerning for the possibility of malignancy. She was discharged home with plan for follow up with gynecology oncology. As an outpatient, she had a CT scan [**2165-7-4**] that showed complex bilateral adnexal masses with extensive free fluid and inflammatory change throughout the pelvis including pelvic omental thickening and a few small omental lymph nodes. Although these findings could be explained by bilateral tubo-ovarian abscess and pelvic phlegmon, malignancy cannot be excluded as the cause. An MRI on [**2165-7-13**] showed a bilateral complex adnexal masses. The cytology final report from the ultrasound guided drainage showed neoplastic cells consistent with mullerian adenocarcinoma. She saw Dr. [**Last Name (STitle) 2028**] (gyn onc) as an outpatient and the plan was for exploratory laparotomy in mid [**Month (only) **]. Today she presented to the ED with lower abdominal pain. The patient reports that she developed sharp constant abdominal pain at 2am. She also had emesis x 3. She took oxycodone with minimal relief of the pain. She only sought medical care at 3pm when she presented to the [**Hospital1 18**] ED. In the ED she was found to have a high grade small bowel obstruction. A NGT tube was placed and GYN ONC was consulted. Currently, she reports she continue to have abdominal discomfort. She reports mild nausea. She has no other complaints. Past Medical History: GynHx: - LMP: [**2165-6-3**], 5 days, q 28 days - [**2154**] asymptomatic chlamydia treated - sexually active with opposite gender. Not stable partner. Often unprotected. - Contraception: PPTL, no hx of hormone use - PAP smear [**2165-5-10**] nl -> no hx of abnl PAP . ObHx: - LTCS x 3 ([**2140**], [**2141**], [**2145**]) - SAB x 1 . Surghx: - LTCS x 3 - PPTL Social History: lives alone. Quit her job in [**2165-3-8**] as a bookkeeper. Reports feeling stressed by the financial strain since that decision. Smokes 1 ppd. No recent alcohol use, typically drinks 2 beers/week. No illicit drugs. Close with her children. Feels safe. No hx of abuse. Family History: -Paternal Aunt with [**Known lastname 499**] cancer at age 40 -PaternalGrandmother w question of endometrial cancer,age unknown -No family history of breast or ovarian cancer. Physical Exam: NAD RRR no m/r/g CTA no w/r/r soft, distended,mildly tender mid abdomen.No rebound.No guarding. No edema Pertinent Results: SERUM ------- [**2165-7-16**] 04:00PM BLOOD WBC-12.9*# RBC-4.55 Hgb-13.6 Hct-39.0 MCV-86 MCH-30.0 MCHC-35.0 RDW-14.2 Plt Ct-406 [**2165-7-17**] 07:40AM BLOOD WBC-10.6 RBC-3.79* Hgb-11.9* Hct-34.4* MCV-91 MCH-31.5 MCHC-34.6 RDW-13.6 Plt Ct-279 [**2165-7-18**] 07:25AM BLOOD WBC-8.2 RBC-3.84* Hgb-11.4* Hct-34.9* MCV-91 MCH-29.8 MCHC-32.7 RDW-13.5 Plt Ct-284 [**2165-7-18**] 06:05PM BLOOD WBC-12.7*# RBC-4.50 Hgb-12.6 Hct-39.4 MCV-88 MCH-28.0 MCHC-32.0 RDW-17.3* Plt Ct-311 [**2165-7-18**] 08:14PM BLOOD WBC-4.6# RBC-4.03* Hgb-11.3* Hct-34.0* MCV-84 MCH-28.0 MCHC-33.2 RDW-17.7* Plt Ct-201 [**2165-7-19**] 04:55AM BLOOD WBC-8.6# RBC-3.92* Hgb-11.1* Hct-33.4* MCV-85 MCH-28.2 MCHC-33.1 RDW-18.4* Plt Ct-224 [**2165-7-19**] 09:28AM BLOOD WBC-10.0 RBC-3.94* Hgb-10.9* Hct-33.4* MCV-85 MCH-27.7 MCHC-32.7 RDW-18.4* Plt Ct-242 [**2165-7-19**] 05:30PM BLOOD Hct-31.0* [**2165-7-19**] 11:35PM BLOOD WBC-9.5 RBC-3.37* Hgb-9.5* Hct-28.5* MCV-85 MCH-28.3 MCHC-33.4 RDW-18.3* Plt Ct-215 [**2165-7-20**] 04:40AM BLOOD WBC-10.7 RBC-3.33* Hgb-9.6* Hct-28.2* MCV-85 MCH-28.8 MCHC-34.1 RDW-17.9* Plt Ct-219 [**2165-7-21**] 05:28AM BLOOD WBC-10.5 RBC-3.06* Hgb-8.7* Hct-26.7* MCV-87 MCH-28.5 MCHC-32.7 RDW-17.6* Plt Ct-211 [**2165-7-22**] 04:49AM BLOOD WBC-7.2 RBC-2.84* Hgb-8.2* Hct-24.6* MCV-87 MCH-28.8 MCHC-33.3 RDW-17.1* Plt Ct-257 [**2165-7-22**] 08:48AM BLOOD WBC-7.1 RBC-2.75* Hgb-8.0* Hct-23.8* MCV-86 MCH-29.2 MCHC-33.8 RDW-17.0* Plt Ct-269 [**2165-7-22**] 03:51PM BLOOD WBC-6.7 RBC-2.91* Hgb-8.4* Hct-25.6* MCV-88 MCH-28.8 MCHC-32.7 RDW-16.8* Plt Ct-330 [**2165-7-23**] 04:48AM BLOOD WBC-7.1 RBC-2.98* Hgb-8.4* Hct-25.8* MCV-87 MCH-28.3 MCHC-32.6 RDW-16.7* Plt Ct-377 [**2165-7-27**] 09:59AM BLOOD WBC-9.7 RBC-3.37* Hgb-9.5* Hct-29.2* MCV-87 MCH-28.3 MCHC-32.6 RDW-16.7* Plt Ct-677*# [**2165-7-18**] 08:14PM BLOOD Neuts-79* Bands-5 Lymphs-8* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2165-7-27**] 09:59AM BLOOD Neuts-68 Bands-1 Lymphs-17* Monos-7 Eos-3 Baso-0 Atyps-0 Metas-2* Myelos-1* Promyel-1* NRBC-1* [**2165-7-21**] 05:28AM BLOOD PT-14.4* PTT-31.7 INR(PT)-1.3* [**2165-7-19**] 04:11AM BLOOD Lactate-1.0 [**2165-7-19**] 09:44AM BLOOD Lactate-0.8 URINE ----- [**2165-7-16**] 04:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.026 [**2165-7-16**] 04:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-TR [**2165-7-16**] 04:20PM URINE RBC-0 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-[**12-26**] [**2165-7-27**] 10:19AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018 [**2165-7-27**] 10:19AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR URINE CULTURE (Final [**2165-7-20**]): NO GROWTH. URINE CULTURE (Final [**2165-7-28**]): NO GROWTH. [**Month/Day/Year 706**] ---------- [**Month/Day/Year **] Report ABDOMEN (SUPINE & ERECT) Study Date of [**2165-7-16**] 4:54 PM IMPRESSION: Nonspecific bowel gas pattern with focal dilated air-filled loop of small bowel with air-fluid level. If there is clinical concern for bowel obstruction, CT is recommended [**Date Range **] Report CT PELVIS W/CONTRAST Study Date of [**2165-7-16**] 5:10 PM IMPRESSION: 1. Large, complex pelvic mass with associated enhancing soft tissue peritoneal nodules and masses consistent with likely ovarian malignancy and peritoneal spread. 2. Distended small bowel loops with air-fluid levels indicating high-grade small-bowel obstruction with a transition point in the deep pelvis at the pelvic mass. 3. Multiple high-attenuation hepatic lesions previously characterized on MR [**First Name (Titles) 3**] [**Last Name (Titles) 68009**]. [**Last Name (Titles) **] Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2165-7-19**] 8:04 AM CONCLUSION: 1. No pulmonary embolism or aortic dissection. Aberrant right subclavian artery is noted as described above. 2. Bibasal effusions and atelectasis in the lower lobes, ascites and free intraperitoneal air most likely are consistent with a recent pelvic surgery. 3. Heterogenous enhancement of the liver of uncertain clinical significance, a CT liver is advised to assess further. [**Date Range **] Report CHEST (PORTABLE AP) Study Date of [**2165-7-20**] 9:19 AM The heart is not enlarged. There is no evidence of failure. Some haziness of the right base is present suggesting a small right effusion. The endotracheal tube has been removed. Position of the other tubes and support lines is unchanged. [**Date Range **] Report BILAT LOWER EXT VEINS PORT Study Date of [**2165-7-20**] 11:02AM IMPRESSION: No evidence of DVT in both lower extremities. [**Date Range **] Report CT PELVIS W/CONTRAST Study Date of [**2165-7-29**] 6:12 PM IMPRESSION: 1. Since prior exam from [**2165-7-16**], patient is status post total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy with significant reduction in tumor burden. 2. Postsurgical changes related to ileocecectomy and retrosigmoid resection. No evidence of bowel obstruction. 3. Enhancing soft tissue with adjacent stranding superior to the bladder with tethering of nearby loops of small bowel, for which residual tumor cannot be excluded. A small linear fluid collection is seen in this region extending to the anterior pelvic wall, which likely represents a postoperative fluid collection, although superinfection cannot be entirely excluded. 4. Multiple lesions within the liver, previously characterized to be of [**Year (4 digits) 68009**] etiology on MRI from [**2165-5-26**]. 5. Postoperative collections measuring up to 1 cm along the anterior abdominal wall incision site. Brief Hospital Course: Ms. [**Known lastname **] was admitted for small bowel obstruction secondary to advanced ovarian or fallopian tube cancer. She had a nasal gastric tube placed and was given IV pain medication as well as antiemetics around the clock. She was taken to the operating room on HD#3 for a Exploratory laparotomy, radical abdominal debulking procedure, total abdominal hysterectomy, bilateral salpingo-oophorectomy, ileocecectomy with reanastomosis, rectosigmoid resection with reanastomosis, right diaphragm stripping, infracolic omentectomy, and mobilization of splenic flexure. The details of the procedure are available elsewhere in a separate operative note. Postoperatively, she remained intubated and was admitted to the intensive care unit for hypotension, for which she received pressors. Her blood pressures normalized on POD#1 off of pressors. Overnight, she developed tachycardia of unclear etiology and a CT chest was performed to rule out a pulmonary embolism, which was negative. She also had bilateral ultrasounds of the lower extremities that was negative for DVTs. She was extubated without complication and transferred to the surgical floor on POD#3. Her postoperative course on the floor was notable for the following: * Desaturation of oxygen The patient was noted to have an oxygen saturation of 88% on RA. She had a chest xray performed, which was negative. Another CT chest was performed to evaluate for pulmonary embolism. This was negative. She was weaned off of oxygen gradually, and was maintaining good saturation on room air starting POD#4 throughout the rest of her hospital stay. * Awaiting return of bowel function/ileus The remains on TPN to this day of discharge without flatus. She was started on sips on POD# 9 and tolerated minimal amount of fluids by mouth. She also tolerated a small amount of regular diet on day of discharge. A CT of the abdomen was performed on POD#11, given persistent ileus to assess for obstruction, which was negative. She experienced nausea and vomiting with oral percocets. This was changed to oral dilaudid. She was eventually tolerating a regular diet and was passing flatus as well as having bowel movements. * ID The patient had a temperature for which she was started on ampicillin, cipro and flagyl by IV. She completed a 10 day course and remained afebrile since start of antibiotic regimen. * Hematology The patient started with a preoperative hematocrit of 33, and received two units of PRBC intraoperatively. Her hematocrit was serially followed postoperatively until noted to be stable. She did not require any additional transfusion. * Left flank pain The patient complained of left flank pain on POD #9. She had a renal ultrasound performed that was unremarkable. Her urinanalysis and culture were without evidence for urinary tract infection. The pain was more associated with movement and improved with palpation, thus was deemed to be musculoskeletal. She was provided heat packs and noted mild improvment. The patient was discharged home on on HD# 20/POD #17 in stable condition. She is afebrile with stable vital signs. Her incision appears without evidence of infection. Around the umbilicus there is a raised 2-3cm area that is without evidence of infection or inflammation. This area was demarcated and monitored for any signs of infection or seroma formation, without complications. The CT of the abdomen showed collection of fluid measuring up to 1 cm along the anterior abdominal wall incision site, which likely will resorb. The patient's pain was controlled on oral dilaudid and ibuprofen regimen. The patient is voiding spontaneously and is ambulant without assistance. Medications on Admission: Oxycodone, Flagyl Discharge Disposition: Home Discharge Diagnosis: Advanced ovarian cancer; poorly differentiated carcinoma with features of transitional cell carcinoma Discharge Condition: Stable Discharge Instructions: - Please call your doctor if you experience fever > 101, chills, nausea and vomiting, worsening or severe abdominal pain, heavy vaginal bleeding, chest pain, trouble breathing, or if you have any other questions or concerns. Please call if you have redness and warmth around the incision, if your incision is draining pus-like material, or if your incision reopens. - No driving for two weeks and while taking narcotic pain medication as it can make you drowsy. - No heavy lifting or strenuous exercise for 6 weeks to allow your incision to heal adequately. - Nothing per vagina (no tampons, intercourse, douching for 6 weeks). - Please keep your follow-up appointments as outlined below. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2165-8-26**] 11:15 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**] Completed by:[**2165-8-4**]

[ "196.2", "198.82", "780.6", "183.0", "997.4", "789.59", "197.6", "427.89", "197.5", "198.89", "560.1", "998.89", "560.9", "197.4", "458.29" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.94", "99.15", "45.72", "38.93", "48.69", "68.49", "48.23", "96.07", "54.4", "45.93", "65.61", "34.81" ]

icd9pcs

[ [ [] ] ]

13176, 13182

9411, 13108

384, 558

13328, 13337

3760, 9388

14077, 14376

3441, 3619

13203, 13307

13134, 13153

13361, 14054

3634, 3741

287, 346

586, 2752

2774, 3137

3153, 3425

16,881

106,037

3748

Discharge summary

report

Admission Date: [**2166-1-28**] Discharge Date: [**2166-1-31**] Date of Birth: [**2091-1-9**] Sex: M Service: CHIEF COMPLAINT: Hypotension with mental status changes. HISTORY OF PRESENT ILLNESS: This is a 74-year-old male with a history of renal cell carcinoma, status post bilateral nephrectomies, on hemodialysis with metastatic disease to the lung, eye, penis, also with coronary artery disease, status post myocardial infarction and a three vessel coronary artery bypass graft, status post AICD pacer for V-fib arrest and congestive heart failure with an EF of 30%, diabetes, hypertension, history of upper gastrointestinal bleed who was in his usual state of health until yesterday at hemodialysis when his blood pressures were noted to the in the 60's but resolved reportedly. Last night when getting up from the toilet after a bowel movement he fell without loss of consciousness but hit his head on the sink and was dizzy. The fire department evaluated him and decided he did not need to come in. He saw Dr. [**Last Name (STitle) 16858**] the morning of admission, was somnolent with blood pressures 50/palp with a weak pulse. He got intravenous fluids and his blood pressure increased to 62/palp. His O2 saturations were 91% on room air, therefore, he was placed on four liters. Per his wife his mental status changes since he hit his head last night but has been weak for several days. Was transferred to the Emergency Room with blood pressures in the 60's, heart rate 93, began Vancomycin 1 gram times one and Ceftriaxone 1 gram intravenous times one, got two liters of normal saline and began a Dopamine drip. Then subsequently Levophed drip which increased his MAPS to 65 but he was tachycardiac to 110 and only alert and oriented times 1-1/2. No elevated white blood count but a left shift without bands. Arterial blood gases was 7.48/41/141 with a lactate of 2.2 on 100% non-rebreather. He was transferred to the MICU for further care. REVIEW OF SYSTEMS: Denies chest pain, diarrhea, headache, rashes, has felt short of breath (sometimes). PAST MEDICAL HISTORY: 1. Renal cell carcinoma, status post bilateral nephrectomies - the right one in [**2164**] and the left in [**2153**]. Status post [**Last Name (LF) 16859**], [**First Name3 (LF) **]-2, Thalidomide with metastases to the lung, status post a left lower lobe resection in [**2165-5-29**], metastases to the right orbit status post [**Year (4 digits) 16859**] in [**2165**], metastases to the penis status post penectomy in [**2158**] with recurrent metastases to the lung. 2. Hemodialysis in [**Location 9583**]. 3. Coronary artery disease. Status post myocardial infarction in [**2164-11-29**], status post three vessel coronary artery bypass graft in [**2165-3-29**]. SVG to left anterior descending, SVG to Patent ductus arteriosus, SVG to diagonal, status post VF arrest with a AICD placement. 4. Congestive heart failure with an EF on [**2166-1-7**] of 30% with mild Aortic regurgitation and MR. 5. Hypertension. 6. Insulin dependent diabetes mellitus Type 2. 7. Stage I colon cancer status post left hemi-colectomy in [**2165-9-29**]. 8. Upper gastrointestinal bleed in [**2164**]. 9. Hypercholesterolemia. 10. Arteriovenous fistula four weeks ago. ALLERGIES: Sulfa causes gastrointestinal upset, Intravenous contrast causes question of rash, also question of allergies to Venofere and Iodine. MEDICATIONS: 1. Glyburide 2.5 mg q day. 2. Aspirin 81 mg q day. 3. Coreg .125 mg twice a day. 4. Plavix 7.5 mg p.o. q day. 5. Mag Oxide 400 mg twice a day. 6. Protonix 40 mg q day. 7. Megace 40 mg q day. 8. Colace 200 mg q day. 9. Nephrocaps one cap q day. 10. Lipitor 20 mg q day. 11. Ativan 0.25 mg q h.s. p.r.n. PHYSICAL EXAMINATION: Temperature 97.3, heart rate 109 to 123, blood pressure 66/36 which increased 80 to 95/39 to 44. Respiratory rate 24 to 25, sating 89 to 94% which increased to 100% on non-rebreather. MAPS from 53 to 61. General alert and oriented times two. Knows place and name, anxious male. Head, eyes, ears, nose and throat: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Oropharynx is dry. Neck is supple. CV: Tachycardiac, regular with occasional premature ventricular contractions, 2/6 systolic ejection murmur. Respirations, bronchial breath sounds at base with decreased bowel sounds. Abdomen soft, normal active bowel sounds, nontender, nondistended. Healed midline incision. Extremities: Right femoral trauma line. No erythema or hematoma. Positive cyanosis to fingertips bilateral. Cool extremities. Palpable pulses in the lower extremities bilaterally. 1+ radial pulse bilaterally. No clubbing or edema in the lower extremities, however, 1+ edema in the upper extremities bilaterally only. Rectal: OB negative per the Emergency Room. SOCIAL HISTORY: The patient is married and lives in [**Hospital1 487**]. He was an antique dealer and has a daughter who lives in [**Name (NI) **]. DATA: White blood count 4.9, hematocrit 26.1, platelets 160 with 97 polys, 0 bands and 1 lymphocytes. INR of 1.4, sodium 141, potassium 3.8, chloride 105, bicarbonate 26, BUN 22, creatinine 3.2. Glucose 177, calcium 8.9, phos of 2.4, mag of 1.9, ALT 8, AST 12, TB 0.5, albumin 2.2, alk phos 130, uric acid of 4.1, LDH 146. CK 8, Troponin 0.3. Arterial blood gases 7.48, 41, 145, 2.2 lactate. Electrocardiogram per report paced, atrial sensed and V-paced to a heart rate of 94. Chest x-ray: Increased consolidation of the left lower lobe atelectasis verses pneumonia, atelectasis of left upper lobe is new, moderate left pleural effusion with extension to the left apex, increase in evidence of congestive heart failure. Head CT without contrast, no intracranial or acute process. Stable since [**2166-1-6**]. Abdominal and pelvic CT without contrast. Large bilateral pleural effusions, left greater than right associated with atelectasis of basis, nodular densities in the lung, the right lower lobe. Renal: Mass. Vertebral lesions - lytic osseous lesions. No Triple A or retroperitoneal bleed. Liver, bowel, gallbladder, pancreas within normal limits and an enlarged spleen. ASSESSMENT: 74-year-old male with hypotension in the setting of metastatic renal carcinoma. Status post nephrectomy, is on hemodialysis, congestive heart failure with an EF of 30% and coronary artery disease. Differential diagnosis includes sepsis however, there is no clear source at this time. Hypovolemia, adrenal insufficiency and question of an myocardial infarction but the electrocardiogram was without changes and the first enzymes were flat. HOSPITAL COURSE: The patient was admitted to the MICU and was hypotensive requiring pressors and placed on Dopamine and Levophed which increased blood pressures. Had a Head CT and Abdominal CT without contrast showing no head bleed, a large left greater than right pleural effusion, metastases to the right lower lobe and an 8x5 cm large renal mass. He was initially maxed out on two pressors but then was titrated only to one, Levophed with blood pressures in the 80's to 90's. Minimally responsive to fluid and blood and placed on stress dose of steroids. The hypotension was of unclear etiology at first. So it was decided to perhaps to have a bedside echo done to rule out tamponade as he did have upper extremity edema with lower extremity edema and this echo showed a right ventricular mass/tumor, 35% EF with wall motion abnormalities. It was unclear what this mass was in the right ventricle an thought it was maybe a clot. We were hesitant to start anti-coagulation without thoroughly ruling out brain metastases with a contrast study. However, he had an allergy to CT contrast and was unable to have an magnetic resonance scan because of his pacer. It was decided that we would pre-medicate him for this supposed allergy to intravenous contrast and go ahead with getting a head CT to rule out a bleed or metastatic disease as well as we were interested in looking at the test in order to rule out inferior vena cava syndrome. He did have his upper extremity edema and when we tried to place a central line into the right IJ the tip ended up being diverted into the right subclavian and it was questioned whether he had elevated pressures or blockage or clot in the SVC. On the morning of [**2166-1-30**] the patient underwent another more formal cardiogram which did not show a clot this time. However, he did undergo the CT which was consistent with a SVC syndrome with collateral flow. The left mainstem bronchus was collapsed secondary to extreme compression of the lymph nodes. He also had multiple lung and now new liver metastasis. There was also extreme compression of the SVC with collateral flow. Multiple discussions were held with the family with the MICU attending as well as with his Oncologist Dr. [**Last Name (STitle) 1729**]. At first the plan was for him to be DNR/DNI however, when the results of the CT showed the rapid progression of metastatic disease and lymphadenopathy compressing the SVC and the right mainstem bronchus it was unable to be treated. The discussion with the family turned towards palliative-comfort care. The family was in agreement that he would be unable to recover from the progression of his cancer and a Morphine drip was started in order to ease his pain. The family was at the bedside when he passed on [**2166-1-31**]. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**Name8 (MD) 210**] MEDQUIST36 D: [**2166-2-9**] 19:13 T: [**2166-2-11**] 11:45 JOB#: [**Job Number 16860**]

[ "197.0", "196.1", "V10.05", "459.2", "197.7", "518.0", "V10.52", "428.0", "511.9" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

6695, 9722

3778, 4879

2001, 2087

144, 185

214, 1981

2109, 3755

4896, 6677

26,647

133,672

56136+56137

Discharge summary

addendum+addendum

Name: [**Known lastname 6050**], [**Known firstname 4497**] Unit No: [**Numeric Identifier 6051**] Admission Date: [**2139-10-27**] Discharge Date: [**2139-11-3**] Date of Birth: [**2092-9-14**] Sex: F Service: Surgery, Gold Team ADDENDUM: She was scheduled for discharge on [**2139-11-3**]. Late that afternoon she began having tachycardia to 130s, hypertension, and tachypnea to a respiratory rate of 35. It was decided at that point to get a CAT scan of the abdomen. The CAT scan revealed a large fluid collection in the left side of the abdomen. A drain was placed, and due to tachypnea and tachycardia the patient was transferred to the Intensive Care Unit. There, she was sedated and intubated upon arrival. She was started on Flagyl, ampicillin, fluconazole, and gentamicin. The fluid collection revealed 4+ gram-negative rods, gram-positive rods, gram-positive cocci, and yeast. She spiked a temperature to 102.6 degrees. Due to persistent tachycardia, she was started on intravenous Lopressor. On Intensive Care Unit day two, her hematocrit was 23.6 and she was transfused 2 units of packed red blood cells. A Clostridium difficile at that point was negative. On Intensive Care Unit day three, she was started on total parenteral nutrition. A repeat CAT scan showed a large decrease in the fluid collection in the abdomen. No communication between the collection and any viscus structure was seen. On Intensive Care Unit day four, the patient was weaned off the ventilator. Her blood pressure and heart rate remained stable, and her urine output was adequate. Due to difficulty with glycemic control, she was started on insulin. On Intensive Care Unit day five, the patient was started on Peptamen tube feeding. On Intensive Care Unit day six, the tube feeding was advanced to goal, and her total parenteral nutrition was discontinued. An earlier chest x-ray on Intensive Care Unit day three revealed an effusion on the left side. A repeat chest x-ray on Intensive Care Unit day six revealed resolution of the effusion. A repeat abdominal CAT scan on [**11-9**], which was Intensive Care Unit day six, again revealed reduction of the fluid collection in the abdomen. On Intensive Care Unit day seven, a clear liquid diet was started, and her oxygen saturations were 99%. On Intensive Care Unit day eight, her temperature was 98.6., and it was decided she could be transferred to the floor. A urine culture and blood culture which were obtained revealed no growth. Ms. [**Known lastname **] arrived on the floor on [**11-12**] in the evening. Her antibiotics were changed to levofloxacin, Flagyl, and fluconazole. Her drain fluid was sent for amylase and total bilirubin. Amylase was 24,030. The total bilirubin was 2.7. On [**11-15**], Ms. [**Known lastname **] was tolerated a regular diet well. On [**11-16**], an abdominal CT scan revealed the fluid collection had become larger in size. On [**11-17**], under CT-guided visualization, a larger drain was placed in the fluid collection. The size of the drain was #16 French. On [**11-18**], a repeat CT scan was performed due to decreased output from the new drain which was placed. This CT scan showed communication with the small bowel and the fluid collection. On [**11-19**], the drain output improved due to proper flushing of the tube. On [**11-20**], Ms. [**Known lastname **] was in stable condition with no nausea, tolerating a regular diet, and afebrile. Her sugar was controlled adequately with NPH insulin. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE FOLLOWUP: She was to follow up with Dr. [**Last Name (STitle) **] in 10 to 14 days. The patient was to have [**Hospital6 2050**] for drain flushings and teaching of drain flushing. Prior to discharge the fluid from the drain was sent for Gram stain and culture which was to be followed up as an outpatient by Dr. [**Last Name (STitle) **]. Visiting nurses will be called by Dr. [**Last Name (STitle) **] to make sure drain flushing is going well. MEDICATIONS ON DISCHARGE: 1. NPH insulin 13 units subcutaneous b.i.d. (the patient was taught insulin injection while in the hospital). 2. Aspirin. 3. Dilaudid 2 mg to 4 mg p.o. q.4-6h. p.r.n. for pain. DISCHARGE DIAGNOSES: 1. Benign cyst in tail of pancreas. 2. Status post pancreatectomy, splenectomy, pancreaticojejunostomy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1255**], M.D. [**MD Number(1) 1256**] Dictated By:[**Name8 (MD) 1561**] MEDQUIST36 D: [**2139-11-20**] 14:14 T: [**2139-11-21**] 09:59 JOB#: [**Job Number 6052**] (cclist) Name: [**Known lastname 6050**], [**Known firstname 4497**] Unit No: [**Numeric Identifier 6051**] Admission Date: [**2139-10-27**] Discharge Date: [**2139-11-20**] Date of Birth: [**2092-9-14**] Sex: F Service: ADDENDUM: The patient will followed by [**Hospital1 328**] VNA, telephone number [**Telephone/Fax (1) 6053**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1255**], M.D. [**MD Number(1) 1256**] Dictated By:[**Name8 (MD) 1561**] MEDQUIST36 D: [**2139-11-20**] 14:42 T: [**2139-11-21**] 15:33 JOB#: [**Job Number **]

[ "E878.2", "518.5", "575.11", "614.6", "427.89", "998.59", "211.6", "458.2", "276.5" ]

icd9cm

[ [ [] ] ]

[ "52.52", "96.04", "41.5", "54.59", "54.91", "52.96", "51.22", "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

4307, 5314

4105, 4286

3581, 3617

3638, 4079

41,245

113,379

7553

Discharge summary

report

Admission Date: [**2156-12-30**] Discharge Date: [**2157-1-7**] Date of Birth: [**2086-3-10**] Sex: M Service: CARDIOTHORACIC Allergies: Actos Attending:[**First Name3 (LF) 1406**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: coronary artery bypass graft x3- LIMA-LAD, SVG to diagonal, obtuse marginal, PDA History of Present Illness: This is a 70-year-old male who presented with chest pain at rest. He has a stress test which was abnormal. He underwent a cardiac catheterization and this demonstrated 3-vessel coronary artery disease with a totally occluded right coronary artery. He had an echocardiogram performed which showed that he had a left ventricular ejection fraction of 30-40%. There was global left ventricular hypokinesis. It was recommended he undergo coronary bypass grafting and after the risks and benefits were explained to him he agreed to proceed. Past Medical History: diabetes mellitus hypertension chronic kidney disease (Cr 1.5-1.7) h/o inferior myocardial infarction with EF 40% coronary artery disease- stent to cx [**2143**] hyperlipidemia Past Surgical History right carotid endarterectomy Social History: Lives with wife [**Name (NI) 595**] speaking retired college professor tobacco: quit 5 years ago; prior 2 cigarettes/day on and off for 20 years. Family History: non contributory Physical Exam: Pulse: 52 SR Resp: 12 O2 sat: 98%RA B/P Right: Left: 145/54 Height: 5'6" Weight: 252lb General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] obese Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] 1+edema b/l LEs, small varicosities bilaterally Neuro: Grossly intact x Pulses: Femoral Right: cath site Left: 1+ DP Right: 1+ Left: 2+ PT [**Name (NI) 167**]: Left: not palpable Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: no bruits Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 27594**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 27595**] (Complete) Done [**2156-12-30**] at 9:31:09 AM PRELIMINARY PREBYPASS No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildl-moderately dilated. There is mild regional left ventricular systolic dysfunction with mild global hypokinesis with more hypokinesis in the distal anterior and anteroseptal walls.. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS There is marginal improvement in LV systolic function. LVEF ~ 50-55%. RV systolic function remains preserved. The study is otherwise unchanged from prebypass. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician [**2157-1-7**] 05:45AM BLOOD WBC-13.0* RBC-3.75* Hgb-10.0* Hct-30.6* MCV-82 MCH-26.6* MCHC-32.6 RDW-13.8 Plt Ct-561* [**2157-1-7**] 05:45AM BLOOD PT-14.3* INR(PT)-1.2* [**2157-1-6**] 06:05AM BLOOD PT-14.1* INR(PT)-1.2* [**2157-1-6**] 06:05AM BLOOD Glucose-169* UreaN-34* Creat-1.6* Na-140 K-4.2 Cl-99 HCO3-31 AnGap-14 [**2157-1-7**] 05:45AM BLOOD UreaN-43* Creat-1.9* K-4.0 [**2157-1-7**] 05:45AM BLOOD Mg-2.3 Brief Hospital Course: On [**2156-12-30**] Mr. [**Known firstname 1975**] [**Known lastname **] underwent a coronary artery bypass grafting times four. This procedure was performed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], please see the operative note for details. He tolerated this procedure well and was transferred in critical but stable condition to the surgical intensive care unit. He was extubated and weaned from his drips. He had atrial fibrillation which resolved with amiodarone boluses and beta blockade. He was transferred to the surgical step down floor and his chest tubes were removed. [**Last Name (un) **] was asked to consult secondary to high insulin requirements and a pre-operative HgbA1C of 7.8. He was placed on U-500 concentrated insulin and an aggressive sliding scale. His epicardial wires were removed. Keflex was initiated for mediastinal incision erythema without drainage. A sleep apnea consult was requested secondary to nocturnal desaturations without bradycardia. Sleep study revealed a mixed sleep apnea. Recommendation is to follow up as an outpatient, and use home oxygen while sleeping in the meantime. Atrial fibrillation/flutter returned. Cardizem was resumed and the patient was started on coumadin. By the time of discharge on POD 8, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. He was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: cardizem cd 300 daily,tricor 145 daily,lasix 60 daily,imdur 60daily,humalog 20 before dinner,RISS,avapro 150 daily,lipitor 80daily,toprol xl 50 daily,NTG prn plavix 75 daily,terazosin 2daily hs,dyazide 37.5/25 daily ,asa 81 daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 3. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily (). 4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 10. Metoprolol Succinate 100 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* 11. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days: sternal wound erythema. Disp:*28 Capsule(s)* Refills:*2* 13. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day: total of 60mg daily. Disp:*90 Tablet(s)* Refills:*2* 14. Insulin Regular Hum U-500 Conc 500 unit/mL Solution Sig: Fifteen (15) units Injection three times daily with meals: titrate up insulin dose every two days to a goal fasting blood sugar of <120 and pre-meal blood sugar of <160 per instructions of the [**Hospital **] clinic. Disp:*qs * Refills:*2* 15. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per sliding scale Subcutaneous four times a day. Disp:*qs * Refills:*2* 16. Cardizem CD 300 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 17. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose will change daily for goal INR [**1-19**]. Disp:*30 Tablet(s)* Refills:*2* 18. Outpatient Lab Work serial PT/INR dx: atrial fibrillation results to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] 19. home oxygen oxygen 2Lpm continuous for portability pulse dose system Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: diabetes mellitus hypertension chronic kidney disease (Cr 1.5-1.7) h/o inferior myocardial infarction with EF 40% coronary artery disease- stent to cx [**2143**] hyperlipidemia Past Surgical History right carotid endarterectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Recommended Follow-up:Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**1-26**] at 1:00 PM Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-18**] weeks [**Telephone/Fax (1) 250**] Cardiologist Dr. [**Last Name (STitle) **] in [**12-18**] weeks [**Telephone/Fax (1) 62**] ***[**First Name8 (NamePattern2) 6480**] [**Last Name (NamePattern1) 2716**], RN- will follow INR/Coumadin dosing for Dr.[**Last Name (STitle) **], Please call daily for INR/Coumadin dosing [**Hospital **] Clinic Dr. [**Last Name (STitle) 3617**] [**2157-3-4**] at 1:30 PM ([**Telephone/Fax (1) 20881**] Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Sleep Center: Thursday, [**2157-1-27**] 3pm, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Telephone/Fax (1) 612**] Completed by:[**2157-1-7**]

[ "327.21", "278.00", "427.31", "511.9", "412", "V15.82", "V58.67", "272.4", "585.9", "518.0", "403.90", "424.0", "V45.82", "327.23", "414.01", "459.81", "250.42", "583.81" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7917, 7992

3782, 5267

283, 366

8264, 8360

2114, 3759

8865, 9827

1363, 1381

5548, 7894

8013, 8243

5293, 5525

8408, 8842

1396, 2095

233, 245

394, 931

953, 1183

1199, 1347

20,353

178,379

7463+55837

Discharge summary

report+addendum

Admission Date: [**2183-10-3**] Discharge Date: [**2183-11-13**] Date of Birth: [**2111-8-13**] Sex: M Service: CARDIOTHORACIC Allergies: Ceclor / Heparin Agents Attending:[**First Name3 (LF) 1267**] Chief Complaint: 72 y/o male w/known CAD, s/p PTCA in [**2171**]. 3 wk. hx. of GI distress/epigastric pain. Adm. to OSH [**2183-10-2**], + enzymes. Tx. to [**Hospital1 18**] for cath. Major Surgical or Invasive Procedure: [**10-4**] CABG X 3 (SVG > LAD, SVG > OM, SVG > PL) (Dr. [**Last Name (STitle) **] [**10-21**] Tracheostomy (Dr. [**Last Name (STitle) 952**] [**10-28**] RIJ permacath placement (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) [**11-7**] PEG placement (Dr. [**Last Name (STitle) **] History of Present Illness: 72 y/o male w/known CAD, s/p PTCA in [**2171**]. 3 wk. hx. of GI distress/epigastric pain. Adm. to OSH [**2183-10-2**], + enzymes. C/O DOE for few years, recent fatigue. Tx. to [**Hospital1 18**] for cath. Past Medical History: known CAD, s/p PTCA [**2171**] DM-2 HTN hypercholesterolemia chronic renal insufficiency (1 kidney since birth) gout s/p cholecystectomy osteo as a child, s/p mult. surgery, locked left hip s/p retinal hemmorhages Social History: married, lives w/wife 30 pk/yr smoker, quit 25 years ago denies ETOH retired Family History: none known Physical Exam: Gen: 25 # wt. loss past year Skin: chronic left leg open area/? infection Lungs: clear Cor: gr. II/VI SEM Abd: benign Extrem: unremarkable Pre-op labs: Creat 2.4 BUN 56 Glucose 216 other labs WNL Pertinent Results: [**2183-11-10**] 02:55AM BLOOD WBC-15.1* RBC-3.45* Hgb-10.1* Hct-30.8* MCV-89 MCH-29.2 MCHC-32.7 RDW-18.4* Plt Ct-146* [**2183-11-10**] 02:55AM BLOOD PT-22.7* PTT-77.5* INR(PT)-3.3 (ON ARGATROBAN) [**2183-11-10**] 02:55AM BLOOD Glucose-60* UreaN-86* Creat-5.6* Na-139 K-4.5 Cl-98 HCO3-27 AnGap-19 [**2183-10-29**] 05:43PM BLOOD ALT-85* AST-24 AlkPhos-144* TotBili-0.8 Brief Hospital Course: Adm. as above, Cardiac cath: 90% LM & 3vCAD, no LV [**Last Name (LF) **], [**First Name3 (LF) **] by echo 30%. IABP placed at cath. To. OR on [**2183-10-4**], for CABG X 3 post op TEE: EF 30%, moderate MR, on propofol, neosynephrine, epinephrine, milrinone, insulin, dobutamine, and amiodarone IV gtts. Initial post-op had rapid AFib, and worsening renal function. POD # 1: IABP D/C'd, worsening acidosis, remained sedated, CVVH started POD # 2: remained on Epi, neo, milrinone, amiodarone, and propofol gtts. POD # 3: weaning vasoactive gtts attempted to wake patient over next few days, but very slow to wake. POD # 4 Cardioverted from AFib Neuro Consult called on POD # 5 due to minimal responsiveness after sedation d/c'd. Head CT showed multiple pld strokes, w/1 area of possible new infarct. After first week: Neuro: has recovered significantly. Presently moves arms independently, is awake and responsive, moves legs, but weakly. Pulmonary: Tracheostomy on [**10-21**] due to prolonged ventilator support. Has been off ventilator since [**10-31**] (on 35% trach mask). Uses Passey Muir valve to speak. Cardiac: in AFib, rate 80-90's, anticoagulated. GI: Had diarrhea initially, CDiff negative, but had rectal tube, and subsequent rectal excoriation. (Colonoscopy on [**10-26**]: rectal ulcers). PEG placed on [**11-7**], tolerating full strength Nepro at 45cc/hour (goal). GU: Permacath placed in Right IJ ([**10-28**]). Transitioned from CVVH to hemodialysis (3X/week), initially became hypotensive during treatments and fluid removal, but has been tolerating the HD treatments well for the past week. Heme: HIT +, all heparin D/C'd, Argatroban started. Coumadin started [**11-8**] (after PEG placed). ID: Sternal wound was locally debrided, and wound is being dressed with collagenase dressings daily. Had MRSA sputum culture, treated with Linezolid for 14 day course. Presently on Levofloxacin for gm neg. UTI (day 5 of 10). Medications on Admission: ASA 325 QD Lipitor 20 QD Lisinopril 10 QD Nifedipine 90 [**Hospital1 **] Doxazosin 4 QD Plavix 75 QD FeSO4 Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QD (). 4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (). 5. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 7. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO ONCE (once) for 1 doses: dose for INR target 2.0. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Coronary Artery Disease Mitral Regurgitation Hypertension Renal Failure Respiratory failure Heparin Induced Thrombocytopenia Superficial Sternal wound infection Discharge Condition: Fair Discharge Instructions: no lifting > 10 # no creams or lotions to incisions Followup Instructions: With Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 656**], and Dr. [**Last Name (STitle) **] upon discharge from rehab With Dr. [**Last Name (STitle) **] when ready for removal of PEG Completed by:[**2183-11-10**] Name: [**Known lastname **],[**Known firstname 672**] Unit No: [**Numeric Identifier 4719**] Admission Date: [**2183-10-3**] Discharge Date: [**2183-11-13**] Date of Birth: [**2111-8-13**] Sex: M Service: CARDIOTHORACIC Allergies: Ceclor / Heparin Agents Attending:[**First Name3 (LF) 4551**] Chief Complaint: Coronary Artery Disease Major Surgical or Invasive Procedure: CABG X 3 Tracheostomy RIJ Permacath placement PEG placement Past Medical History: known CAD, s/p PTCA [**2171**] DM-2 HTN hypercholesterolemia chronic renal insufficiency (1 kidney since birth) gout s/p cholecystectomy osteo as a child, s/p mult. surgery, locked left hip s/p retinal hemmorhages Physical Exam: Alert nonfocal neuro exam. De-conditioned Cor: RRR Lungs: CTA no rales ronchi Abd: Soft and non-distended. Ext: 2+ edema. Wound: Open sternal wound with dry eschar and no cellulitis or infection Brief Hospital Course: Mr. [**Known lastname **] has not had any significant changes in is medical conditions since the time of the last discharge summary on [**2183-11-10**]. He was noted to have a postitive UA and has been started on Levofloxacin. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QD (). 4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (). 5. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 7. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO ONCE (once) for 1 doses: dose for INR target 2.0. 10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 5 days. Discharge Disposition: Extended Care Facility: [**Hospital1 49**] - [**Location (un) 50**] Discharge Diagnosis: Coronary Artery Disease Mitral Regurgitation Hypertension Renal Failure Respiratory failure Heparin Induced Thrombocytopenia Superficial Sternal wound infection Discharge Condition: Fair Discharge Instructions: no lifting > 10 # no creams or lotions to incisions Followup Instructions: With Dr. [**Last Name (STitle) 256**], Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) 4720**] upon discharge from rehab With Dr. [**Last Name (STitle) **] when ready for removal of PEG [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**] Completed by:[**0-0-0**]

[ "274.9", "414.01", "998.59", "V09.0", "410.41", "518.0", "285.9", "578.1", "707.03", "433.31", "041.85", "272.0", "276.2", "041.11", "569.41", "403.91", "E879.0", "E934.2", "455.1", "997.5", "E878.8", "287.4", "250.00", "518.5", "424.0", "427.31", "707.14", "428.0", "276.5", "599.0", "041.89", "V58.67", "584.5", "263.9" ]

icd9cm

[ [ [] ] ]

[ "88.41", "38.91", "31.29", "88.91", "99.05", "33.22", "39.61", "96.72", "38.95", "96.6", "37.61", "88.56", "89.64", "45.23", "88.72", "36.13", "37.21", "86.28", "39.95", "96.04", "99.07", "89.61", "99.04", "38.93", "00.14" ]

icd9pcs

[ [ [] ] ]

7662, 7732

6498, 6727

5960, 6022

7937, 7943

1601, 1970

8043, 8396

1357, 1369

6750, 7639

7753, 7916

3966, 4075

7967, 8020

6275, 6475

5897, 5922

800, 1009

6044, 6260

1263, 1341