ChanBeDu/relevant_section_length · Datasets at Hugging Face

4,276

105,361

28313

Discharge summary

report

Admission Date: [**2109-9-11**] Discharge Date: [**2109-9-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Hypotension, MS change Major Surgical or Invasive Procedure: Endotracheal intubation A-line placed IJ line placed in ED History of Present Illness: [**Age over 90 **] year old woman with h/o HTN, TIA/syncope, right hilar mass, osteoporosis BIBA from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] for hypotension, lethargy. Patient developed diarrhea the day prior to admission, on d.o.a, had one episode of green/bilious emesis. Patient noted to be more lethargic, temp >100 per NH reports and [**Last Name (un) **] called EMS. Of note, patient had been on Cefpodoxime for a UTI (started [**2109-9-5**]). NH vitals: 100.3, HR 120, BP 70/40, RR 20. Patient denied abdominal pain. . In the ED: Tmax 102.2 HR 96, BP 102/46, RR 28, 98% 2 L. Sepsis protocol initiated, central line placed via R subclavian, intubated for airway protection, initially R mainstain intubation, subsequently pulled back with appropriate placement. Patient started on IV Vanco, Cipro and Flagyl. CXR clear without pna or infiltrates, U/A negative. She received ~2.5 L of fluid in the ED and transferred to the East ICU via ambulance. Patient sedated with IV Ativan/Etomidate, 1 amp of bicarb, 1 amp of Ca gluconate, 10 U of insulin, 1 amp of D50 for potassium of 7.0, also given 30 kayexalate. Remained tachy in ED, 99-113, BP came up to 120s-130s, urine output increased [**2043-11-29**] from 7:20 to 9:40--70 ccs over 2.5 hrs. Bowel movement trace guiaic positive in ED. Admitted to [**Hospital Ward Name 332**] ICU. Past Medical History: HTN TIA R Hilar mass, cystic Hx of syncope osteoporosis Social History: Lived in [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], a nursing home. Healthcare proxy: son Family History: noncontributory. Physical Exam: Upon arrival to [**Hospital Unit Name 153**]: Gen: Elderly woman intubated in [**Hospital Unit Name 153**], nonresponsive Heent: moist mucous membranes, PERRL, ~2mm->1.5mm Neck: supple, no JVD appreciable Chest: CTA b/l, no wheezing/rales/rhonchi CVS: nl S1 S2, distant, regular, no m/r/g appreciated Abd: soft, distended, tympanic to percussion, no HSM appreciated, BS+ Ext: cool upper and lower ext, no edema, no cyanosis, trace distal pulses b/l Neuro: intubated and sedated, grimaces to painful stimuli Skin: dry, cool to touch, no rashes, skin breakdown . Pertinent Results: HEME [**2109-9-11**] 06:30AM WBC-13.7* RBC-3.85* HGB-12.2 HCT-35.7* MCV-93 MCH-31.7 MCHC-34.2 RDW-14.8; DIFF: NEUTS-61 BANDS-9* LYMPHS-18 MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-0 repeat: [**2109-9-11**] 11:34AM WBC-7.9 RBC-2.90* HGB-9.0*# HCT-27.2* MCV-94 MCH-31.1 MCHC-33.1 RDW-14.9 DIFF: NEUTS-43* BANDS-19* LYMPHS-17* MONOS-17* EOS-0 BASOS-0 ATYPS-2* METAS-0 MYELOS-1* PROMYELO-1* . CARDIAC [**2109-9-11**] 06:30AM CK-MB-2 cTropnT-0.07* [**2109-9-11**] 06:30AM CK(CPK)-62 [**2109-9-11**] 01:16PM CK-MB-4 [**2109-9-11**] 01:16PM CK(CPK)-175* . CHEMISTRIES [**2109-9-11**] 06:30AM GLUCOSE-141* UREA N-75* CREAT-3.0* SODIUM-145 POTASSIUM-6.1* CHLORIDE-114* TOTAL CO2-12* ANION GAP-25* [**2109-9-11**] 07:11AM GLUCOSE-133* LACTATE-6.7* NA+-147 K+-6.5* [**2109-9-11**] 07:51AM LACTATE-4.3* K+-7.1* [**2109-9-11**] 09:30AM LACTATE-5.7* K+-4.5 [**2109-9-11**] 11:08AM LACTATE-3.7* [**2109-9-11**] 11:46AM LACTATE-3.3* [**2109-9-11**] 01:37PM LACTATE-3.2* . [**Last Name (un) **] STIM baseline value not rcvd; 40 mins and 60 mins values. [**2109-9-11**] 03:30PM CORTISOL-27.9* [**2109-9-11**] 03:50PM CORTISOL-27.8* . BLOOD GASSES . URINE [**2109-9-11**] 07:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . ARTERIAL BLOOD GASSES ON ASSIST CONTROL INTUBATION UNLESS NOTED: [**2109-9-11**] 11:08AM TEMP-36.3 RATES-5/ TIDAL VOL-400 PEEP-5 O2-100 PO2-61* PCO2-27* PH-7.27* TOTAL CO2-13* BASE XS--12 AADO2-640 REQ O2-100 . [**2109-9-11**] 01:37PM TEMP-36.3 RATES-16/10 TIDAL VOL-400 PEEP-5 O2-100 PO2-304* PCO2-23* PH-7.32* TOTAL CO2-12* BASE XS--12 AADO2-401 REQ O2-69 . [**2109-9-11**] 03:35PM TEMP-36.3 TIDAL VOL-400 PEEP-5 O2-50 PO2-118* PCO2-20* PH-7.32* TOTAL CO2-11* BASE XS--13 . [**2109-9-11**] 05:58PM TEMP-36.3 RATES-16/10 TIDAL VOL-400 PEEP-5 O2-100 PO2-112* PCO2-20* PH-7.27* TOTAL CO2-10* BASE XS--15 AADO2-596 REQ O2-96 Brief Hospital Course: This was a [**Age over 90 **] yo woman with six day history of cephalosporin tx for a UTI, who presented with fulminant diarrhea, vomiting, and increasing lethargy. She also soon developed hypotension. She was intubated for airway protection and received pressors and fluids to maintain pressure. Cultures were sent. We changed the code status to DNR based on medical futility, d/w son (health care proxy) who agreed. However, her son felt that we should continue maximal care otherwise. . Notable features of her course include an increasingly distended abdomen and, initially, unresponsiveness without sedation. Her abdomen was visualized via KUB and showed large air collections, although the radiologist was unable to determine with certainty whether this was inside or outside the bowel. She was not stable enough to go to CT for further evaluation. Additionally she was not an appropriate surgical candidate because of her continued instability. . C. diff toxin was positive x2. Blood, stool and urine cultures were otherwise all negative. She was treated with PO metronidazole, PO vancomycin and IV vancomycin. Vancomycin troughs were monitored and were supratherapeutic even on PO vanco alone. We continued with PO metronidazole and PO vancomycin, accounting for reduced clearance. . Over the first several days of her admission she improved clinically somewhat. She was soon able to respond with head nods and shakes to questions; and could move hands and feet on request. She was significantly overbreathing her ventilator, and eventually was weaned off assist control and put on pressure support. However, her abdomen continued to be distended and tympanic. She stopped putting out stool. Her pressures did not continue to improve. She then became less interactive. She became more hypotensive and was given multiple fluid boluses and was put back on levophed. She had an ovoid pupil and was minimally interactive on the morning of the 3rd, and her condition continued to worsen. By the end of her admission she was more than 30 liters net positive, but this did not stop her hypotension. In the evening she begin to have increasing arrhythmias; and her pressures dropped into systolics in the 30s in the first hours of [**2109-8-19**]. After discussion with her son, there was agreement that the goals of care should change; she was extubated, and she expired. . Medications on Admission: Kayexalate 1 time dose given last week, remeron 15 qHS, HCTZ 12.5 MWF, lisinopril 2.5 daily, actinel 35 qWk, compazine, heparin SC BID, cefpedoxime 200 mg [**Hospital1 **], planned 7 day course since [**9-5**], prilosec 20 [**Last Name (LF) 244**], [**First Name3 (LF) **] 81 daily, multivitamin. Discharge Medications: N/A. Discharge Disposition: Expired Discharge Diagnosis: Severe sepsis secondary to C. dificile infection. Discharge Condition: Expired. Discharge Instructions: N/A. Followup Instructions: N/A. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "518.81", "995.92", "287.5", "255.4", "008.45", "585.9", "785.52", "486", "285.29", "276.52", "403.90", "733.00", "038.9", "276.2" ]

icd9cm

[ [ [] ] ]

[ "96.72", "99.04", "38.91", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

7299, 7308

4546, 6923

292, 352

7401, 7411

2596, 4523

7464, 7607

1981, 1999

7270, 7276

7329, 7380

6949, 7247

7435, 7441

2014, 2577

230, 254

380, 1750

1772, 1830

1846, 1965

29,358

127,652

48849

Discharge summary

report

Admission Date: [**2144-6-19**] Discharge Date: [**2144-6-26**] Date of Birth: [**2073-11-20**] Sex: M Service: SURGERY Allergies: Lipitor Attending:[**First Name3 (LF) 1234**] Chief Complaint: hypotension, renal failure Major Surgical or Invasive Procedure: None this admission History of Present Illness: HISTORY OF PRESENT ILLNESS: 70M, discharged from here [**6-14**], was discovered to be hypotensive by his visiting nurse. [**First Name (Titles) **] [**Last Name (Titles) 1834**] a left popliteal artery aneurysm repair with superficial femoral artery to distal above knee bypass complicated by respiratory failure on [**6-1**]. He was treated for pneumonia with Levaquin 750 mg daily, a course which he completed today. According to family, his blood pressure has been dropping in the last two to three days. His family has noticed he has been more confused today than in the past and since yesterday he has been increasingly more short of breath to the point where his O2 saturation dropped into the 70s requiring an increase in his home oxygen to 2 liters by nasal cannula. The patient denies any chest pain or palpitations. He does admit to feeling lightheaded when he stands up. He is voiding normal except for decreased volume. He has had poor p.o. intake since his discharge and he has noticed his left leg continues to remain swollen. Past Medical History: -CAD s/p CABG -abdominal aortic aneurysm -iliac artery aneurysm -ischemic cardiomyopathy -restrictive lung disease, no evidence of obstruction, present for quite some time and likely due to his elevated hemidiaphragm from his initial cardiac surgery -TTE: LVEF 35-40%, inferolateral LV HK with moderate AR -hyperlipidemia -peptic ulcer disease Social History: Social history is significant for the absence of current tobacco use, but prior significant use. Widower. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: PHYSICAL EXAMINATION: GENERAL: NAD VITAL SIGNS: Temperature 97.3, blood pressure 100/60, pulse 83, respiratory rate of 20, O2 sat 93% on 2 liters. HEENT: Oropharynx moist mucous membranes. LUNGS: CTA HEART: Regular rate and rhythm, distant S1 and S2, no murmurs. ABDOMEN: Benign. EXTREMITIES: LLE [**12-4**]+ edema, staples removed, incision/clean/dry/intact Pertinent Results: [**2144-6-25**] 06:12AM BLOOD WBC-7.9 RBC-2.93* Hgb-9.6* Hct-29.4* MCV-101* MCH-32.6* MCHC-32.5 RDW-15.0 Plt Ct-162 [**2144-6-25**] 06:12AM BLOOD Plt Ct-162 [**2144-6-24**] 01:40AM BLOOD PT-14.1* PTT-26.4 INR(PT)-1.2* [**2144-6-25**] 06:12AM BLOOD UreaN-10 Creat-0.9 K-4.0 [**2144-6-24**] 01:40AM BLOOD Glucose-112* UreaN-12 Creat-1.0 Na-145 K-4.0 Cl-104 HCO3-35* AnGap-10 [**2144-6-25**] 06:12AM BLOOD Calcium-8.2* Mg-2.1 Brief Hospital Course: [**6-18**] Evaluated as outpt by Dr. [**Last Name (STitle) **]. Transferred to [**Hospital1 18**] ED with Symptomatic hypotension, Congestive heart failure. Vascular Ed/Admission Assessment: 70M presents with hypotension, ARF, and hypercarbic respiratory failure. Volume status: although he has a CVP of 12 he usually needs higher filling pressures. We will bolus to see how he responds and monitor his oxygenation status. ARF likely pre-renal although his Fena would indicate an element of ATN. His hypercarbic failure is secondary to poor baseline status and fatigue. He may have an underlying infectious process driving his pathologies. PLAN: admit to icu optimize fluid status and wean pressor f/u LLE u/s to r/o dvt bipap to support his ventilation pan culture - start empiric antibiotics for a Wc of 13. TTE to assess EF% Pulm, Renal and Cards consults [**6-19**] Intubated, swan for monitoring. Nephrology consulted for ARF. Etiology prerenal or ATN d/t hypotension. Recommended maintaining fluid balance and pressors. Hold Lasix/Lisinopril Cards consult: Atenolol held, no evidence of cardiac source of hypotension [**Date range (1) 18858**] In ICU, continue Vanco/Flagyl, [**6-23**]:swan dc'd, CTangio ruled out PE.HCO3 gtt, Lopressor started. diet as tol. Physical therapy evaluated pt. Cr trending down. Urine output improving. On O2. On heparin gtt. [**6-24**]-CDiff +, On Flagyl po. Ambulating with PT [**6-25**]- [**6-26**] Tolerating diet. VSS, On O2. (on home O2). Staples discontinued. Patient will follow up with Dr. [**Last Name (STitle) **] next week. Lasix resumed as Cr stable (0.9) for 4 days (following renal recs). Lisinopril held until labs next week. Medications on Admission: Albuterol two puffs q.i.d. p.r.n., aspirin 325 mg once daily, simvastatin 10 mg once daily, Plavix 75 mg once daily, atenolol 50 mg daily, furosemide 20 mg once daily, lisinopril 5 mg once daily, and nitroglycerin p.r.n. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 7. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed: Refills from Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1144**]. Disp:*1 1* Refills:*1* 8. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: 4 puffs Inhalation [**Hospital1 **] (2 times a day). 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:*30 Tablet(s)* Refills:*0* 10. Outpatient Lab Work Fax results to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 17352**] Fax results to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 6443**] 11. Lisinopril 5 mg Tablet Sig: HOLD UNTIL F/U with Dr. [**Last Name (STitle) **] Tablet PO once a day: Hold until repeat labwork and office visit with Dr. [**Last Name (STitle) **]. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Refills from Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1144**]. . Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 70M re-admit for hypotension. S/p L fem-BK [**Doctor Last Name **] bypass w/ PTFE and popliteal aneurysm ligation [**6-10**]. Hospital course c/b two re-intubations, now CDiff (+). . PMH: Intrinsic restrictive lung disease (SpO2 baseline 90%), CAD, cardiomyopathy (LVEF35%), mod pulm HTN, GIB [**1-4**] PUD, PVD, HTN, ^lipids, CRI, Arthritis. PSH: CABG x 2 ('[**11**] & '[**25**], SVGx2), aorto [**Hospital1 **]-iliac aneurysm repair, coil embolization of L hypogastric aneurysm w/ stent CIA to EIA, coil embolization of R hypogastric aneurysm CIA to EIA, stent of prox RCA, stent of LMCA, Appy Discharge Condition: Good Restarted Lasix 20mg daily on [**6-26**]. Continue to hold Lisinopril until office visit and labwork with Dr. [**Last Name (STitle) **] Discharge Instructions: Division of Vascular and Endovascular Surgery Discharge Instructions Continue to take your medications as prescribed. Ambulate daily Return to Emergency Room if you develop and significant increase in coughing or shortness of breath. Return if you develop a fever > 101 or your wound becomes red or has drainage. Return if you develop sudden pain or coolness to your foot. Use your home O2 as needed. Your goal saturation should only be 90%. Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**1-5**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**2-4**] weeks for post procedure check and ultrasound What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: You will need office visit and duplex in 4 weeks with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1241**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2144-7-1**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], DPM Phone:[**Telephone/Fax (1) 1142**] Date/Time:[**2144-7-20**] 12:50 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2145-3-30**] 10:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2145-3-30**] 11:15 Completed by:[**2144-6-26**]

[ "427.89", "V12.71", "038.9", "V45.81", "416.8", "585.9", "414.8", "276.1", "403.90", "008.45", "424.0", "414.00", "584.9", "276.7", "518.81", "V15.82", "V46.2", "272.4", "518.89", "995.92" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "88.72", "38.93", "38.91", "99.04" ]

icd9pcs

[ [ [] ] ]

6343, 6401

2872, 4563

295, 317

7040, 7183

2425, 2849

9957, 10693

1941, 2024

4834, 6320

6422, 7019

4589, 4811

7207, 9360

9386, 9934

2039, 2039

2061, 2406

229, 257

374, 1396

1418, 1763

1779, 1925

2,596

102,869

21074+57216

Discharge summary

report+addendum

Admission Date: [**2149-5-18**] Discharge Date: [**2149-5-24**] Date of Birth: [**2073-9-6**] Sex: M Service: MED Allergies: Lovenox / Zyprexa Attending:[**First Name3 (LF) 783**] Chief Complaint: hypotension and gait disturbance Major Surgical or Invasive Procedure: fluoroscopically guided lumbar puncture History of Present Illness: History per chart and patient. Pt is a 75 yo male with history of recent left temporal lobe CVA, CAD, recent cardiac cath at [**Hospital1 2025**] recently diagnosed hydrocephalus with a 3rd ventricle lipoma who presented to [**Hospital6 4620**] for hypotension and gait disturbances on [**4-30**]. There he was found to have bladder cancer and an appointment was arranged for him to have a definitive resection under Dr. [**Last Name (STitle) 986**] at [**Hospital3 **]. It was during this time that the temporal lobe CVA and NQWMI occurred. After the cardiac cath, [**Hospital1 2025**] Neurology treated him for HSV encephalitis although it seems that HSV was never successfully cultured from any spinal fluid. This treatment with acyclovir, however, resulted in acute renal failure. He was then discharged to a nursing home after this episode resolved. On the evening of [**5-18**], he presented to the [**Hospital 55955**] again for hypotension and mental status changes. After doing with lisinopril and lopressor, both of which were apparently new medications prescribed during the hospital course at [**Hospital1 2025**]. The patient was treated with dopamine at NWH and then sent to [**Hospital1 18**] because no beds were available in the ICU. In the [**Hospital1 18**] ICU, the patient responded to 4LNS with improvement in mental status. Neurology saw the patient and thought that hemodynamic issues were causing the mental status changes and the frontal dementia was secondary to the front infarct and hydrocephalus as demonstrated on another CT. Neurosurgery was consult and they felt a shunt to be unnecessary. The patient was then transferred to the floor for further evaluation. Past Medical History: 1) colelithiasis 2) bladder ca soon to be resected [**5-1**] 3) old left frontal stroke 4) corpus callosum lipoma with hydrocephalus 5) hospital HIT 6) ARF thought to be due to acyclovir 7) DJD of spine 8) osteoarthritis of knee 9) history of PUD status post GI bleed Social History: 1) cigars 2) [**2-25**] shots of brandy per day 3) 11 children 4) wife alive and speaks for him Family History: NC Physical Exam: On admission, the vitals: GEN: lying in bed, no acute distress, appears stated age. HEENT: pupils round and reactive to light bilaterally 2->1.5. neck supple without lymphadenopathy. no JVD. THORAX: clear to auscultation bilaterally. COR: RRR, no m/r/g. ABD: soft, nontender, nondistended, positive bowel sounds. EXT: no edema, no rashes. NEURO: II-XII grossly intact without focal lesions. 4/5 strength throughout, with particular weakness on the LUE and LLL [**1-24**] (could not lift leg more than 4 inches off the bed). No dysmetria on finger to nose. rapid finger tap normal bilaterally as well as rapidly alternating movements. Pertinent Results: [**2149-5-23**] 07:00AM BLOOD WBC-9.3 RBC-3.81* Hgb-11.0* Hct-31.4* MCV-83 MCH-28.9 MCHC-35.0 RDW-14.3 Plt Ct-374 [**2149-5-23**] 07:00AM BLOOD Plt Ct-374 [**2149-5-23**] 05:50PM BLOOD ESR-85* [**2149-5-23**] 07:00AM BLOOD Glucose-87 UreaN-9 Creat-1.0 Na-144 K-3.6 Cl-108 HCO3-30* AnGap-10 [**2149-5-22**] 08:00AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.8 [**2149-5-23**] 05:50PM BLOOD TSH-1.5 [**2149-5-23**] 05:50PM BLOOD Free T4-1.4 [**2149-5-23**] 05:50PM BLOOD CRP-6.39* Brief Hospital Course: 1) Mental status changes/Gait disturbance: Neurology and neurosurgery were immediately consulted and a head CT performed on [**5-19**] which showed no intraparenchymal or extraaxial hemorrhage, no shift of normally midline structures, and no mass efect or hydrocephalus. Neurology felt the mental status changes could be attributed to a combination of sequelae from the previous CVA and was unsure of normal pressure hydrocephalus. When the patient was transferred to the floor, the patient's mental status seemed to have improved. He was alert and oriented to person/place/date. Over the following days, mental status continued to improve as he was able to conduct a detailed conversation about his favorite sports teams, the news, and his family. Of note, the patient has a baseline personality which tends to be slightly aggressive, sarcastic, and "frontally disinhibited". His wife says that his personality is essentially unchanged s/p CVA but there very well might be an aspect of post infarct personality change. On [**5-22**], a head MRI was performed at the recommendation of neurosurgery to assess whether the patient had NPH which was causing mental status changes and gait disturbance. MRI showed a pericallosal lipoma (which was seen on CT [**5-19**]) which extended into the lateral ventricles bilaterally. Despite a patent aqueduct of Sylvius, there seemed to be mild ventricular enlargement and sulcal widening, both of which were noted to be possibly due to atrophy. An old left frontal lobe infarction was present with some T2 abnormalities in both cerebral hemispheres, likely representing microvascular infarctions. No abnormal intracranial enhancement is detected on the post-gadolinium images. No diffusion weighted studies were performed. Due to the mild hydrocephalus, neurosurgery remained uncertain about the utility of shunt placement and recommended a large volume lumbar puncture. Since it was reported that [**Hospital1 2025**] Neurology was unable to perform the LP at the bedside and IR guidance was necessary, fluoroscopically guided LP was pursued at the [**Hospital1 **] as well. Fluoro-guided LP was performed on [**5-23**] at the Pain Clinic without complication and CSF was sent for further study. Results were largely unremarkable with respect to chemistries. There were no WBC and 1 RBC. Opening pressure was 49 while sitting and the approximately 30cc's of CSF were drained. Although the patient was sitting and opening pressures are not necessarily accurate unless lying down, neurology felt the possibility of NPH was not to be excluded. The patient remained horizontal for 6 hours without post-tap headache and his gait was tested in front of his family and friends. It was unclear whether or not gait improved, but the family noted certain improvement in his mental status. The issue of a shunt placement was discussed with the patient's wife as well as his other family members and it was agreed that they would like to pursue more conservative management of the patient's mental status changes and gait disturbance. Since a shunt placement is not without risk and it is unclear whether the LP undoutedly relieved the patient's symtoms, the plan is to have a follow up appointment with neurosurgery to assess gait, perform LP if indicated, reassess, and if there is improvement, more aggressively consider placement of a shunt. The patient himself was amenable to this and has stated he will keep a mental note of his gait improvement/regression at rehab. 2) Left sided weakness upper and lower extremities: On admission to the floor, the patient was noted to have left sided weakness of his upper and lower extremities. This had not been documented previously and an xray of his left hip was order to r/o fracture. Xray was negative. To follow up, Neurology was consulted and insofar as the MRI findings were not anatomically consistent with left sided weakness, it was thought the patient could have exacerbation of an old right lacunar infarct. Nonetheless, diffusion weighted images were not recommended because it was questionable how management would change. ESR, CRP, and SPEP were ordered with the thought that the patient could have a vasculitis. Unfortunately, the results that returned are difficult to interpret given the patient's bladder cancer and vasculitis has not been ruled out. The likely cause of the patient's possibly recurring CVA's are his known cardiac vessel disease. 3) Hypotension: After transfer to the floor, the patient was never hypotensive. IV fluids were made ready in case he had a hypotensive episode. Metoprolol was started at 25 mg but an ACE inhibitor was not. Please consider restarting the patient's ACE inhibiter at rehab or afterward should blood pressures and renal function remain stable as this would likely improve long term cardiac function. 4) Bladder cancer: The patient had a significant about of RBC in his urine (255 on [**5-21**]). This was attributed to his bladder cancer. The patient has a follow up appointment with Dr. [**Last Name (STitle) **] and the family has been instructed to follow up on this issue with urgency. The patient was noted to be iron deficient and this was felt to be secondary to urinary blood loss secondary to the patient's bladder cancer. 5) CAD: The patient was kept on aspirin, lipitor, aspirin, and beta blocker. He did not complain of chest pain, shortness of breath, palpitations, or lower extremity swelling. 6) Nutrition: The patient passed a swallow test in the ICU. His diet was slowly advanced on the floor and at discharge, the patient was able to tolerate a normal house diet. His appetite remained guarded, but his wife explained this has been a chronic issue. 7) DVT prophylaxis: The patient was given sc heparin for DVT prophylaxis and assisted out of bed as often as possible by nursing and PT. From [**Date range (1) 40197**], the patient's Hct remained in the upper 20's and this was worrisome for HIT which the patient reported experienced while at an outside hospital. Heparin was discontinued and the patient's Hct remained stable around 31-33. 9) Dispo: The patient is being discharged today to [**Hospital1 **]. Please follow up on his gait disturbance and if possible, assess relatively frequently so that neurosurgery can more accurately evaluate for shunt placement. Also, the patient has been instructed to follow up on his bladder cancer with Dr. [**Last Name (STitle) **] as urgently as possible. Medications on Admission: 1) nitroglycerin tabs prn 2) niferex 150 mg by mouth once a day 3) ativan 1 mg by mouth every 4 hours as needed 4) ecasa 325 mg by mouth once a day 5) MVI one tab by mouth once a day 6) thiamine 100 mg by mouth once a day 7) folic acid 1 mg by mouth once a day 8) lopressor 100 mg by mouth once a day 9) lisinopril 10 mg by mouth once a day Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (once a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet 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. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO X1 PRN as needed for Leg pain. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: hydrocephalus, bladder cancer, CVA Discharge Condition: good Discharge Instructions: 1) Please [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Name: [**Known lastname 9699**],[**Known firstname 63**] Unit No: [**Numeric Identifier 10486**] Admission Date: [**2149-5-18**] Discharge Date: [**2149-5-24**] Date of Birth: [**2073-9-6**] Sex: M Service: MED Allergies: Lovenox / Zyprexa Attending:[**First Name3 (LF) 758**] Chief Complaint: hypotension and gait disturbance Major Surgical or Invasive Procedure: 1) fluoroscopically guided lumbar puncture Brief Hospital Course: see previous. Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] Discharge Diagnosis: 1) hydrocephalus 2) possible NPH 3) lipoma at the corpus callosum 4) stroke 5) bladder cancer 6) anemia Discharge Condition: good Discharge Instructions: 1) Please follow up with Dr. [**Last Name (STitle) 10487**] your urologist regarding your bladder cancer 2) Please follow up with a neurosurgeon in [**1-25**] weeks regarding your gait disturbance and mental status to reassess the utility of shunt placement 3) Please notify an Emergency Department and/or your PCP should you experience any of the following symptoms: vertigo, headache, chest pain, shortness of breath, increased difficulty walking, mental status changes, difficulty with speech or vision, or sudden weakness. Followup Instructions: Neurology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 810**] Neurosurgery: [**Telephone/Fax (1) 10488**] Primary Care Physician Please call your previous PCP or follow up with Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 23**] [**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**] MD, [**MD Number(3) 765**] Completed by:[**2149-5-24**]

[ "342.90", "276.5", "458.29", "280.0", "599.7", "584.9", "785.50", "331.4", "185" ]

icd9cm

[ [ [] ] ]

[ "99.04", "03.31" ]

icd9pcs

[ [ [] ] ]

12013, 12094

11975, 11990

11907, 11952

12246, 12252

3182, 3651

12827, 13265

2501, 2505

10576, 11132

12115, 12225

10210, 10553

12276, 12804

2520, 3163

11835, 11869

373, 2079

2101, 2371

2387, 2485

16,361

167,908

51758

Discharge summary

report

Admission Date: [**2168-5-11**] Discharge Date: [**2168-5-13**] Service: ICU CHIEF COMPLAINT: Respiratory distress. HISTORY OF PRESENT ILLNESS: The patient is a 78 year old male with a history of chronic obstructive pulmonary disease, esophageal cancer, status post resection, parotid mass, status post resection and neck dissection, who presents with acute shortness of breath. The patient was found by daughter earlier on the evening of admission sitting on front porch with his head slumped over. The patient was able to answer questions but was lethargic. Per daughter, the patient has been complaining of increasing shortness of breath times two weeks prior to admission and also productive cough. EMS was called, and the patient was brought to the Emergency Department for further evaluation. EMS gave the patient nebulizers and placed on high flow oxygen. Oxygen saturation was 90 to 94%. The Emergency Department immediately placed the patient on CPAP for "hypoxemia" without arterial blood gases. The patient was given Levofloxacin 500 mg intravenous times one in the Emergency Department. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease on home oxygen at five liters nasal cannula. 2. Meningitis. 3. History of esophageal carcinoma, status post resection in [**2150**]. 4. Status post right parotidectomy. 5. Status post right radical neck dissection with cervical advancement flap in [**10-25**]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Colace. 2. Remeron. 3. Nicoderm. 4. Prednisone 20 mg p.o. q.d. 5. Lasix 20 mg p.o. q.d. 6. Albuterol. 7. Atrovent. 8. Flovent. 9. Tremerase 25 mg. FAMILY HISTORY: Brother who died of liver or pancreatic cancer. Father died of "old age". SOCIAL HISTORY: The patient is widowed and lives alone in [**Location (un) 86**]. Positive tobacco, three packs per day, and positive ETOH, quit in [**2144**]. PHYSICAL EXAMINATION: On physical examination, temperature was 101.7, blood pressure 119/65, heart rate 116, oxygen saturation 94% on BiPAP. In general, an elderly male with face mask on BiPAP. Head, eyes, ears, nose and throat - no lymphadenopathy, jugular venous distention flat, unable to be properly assessed due to postsurgical changes. Chest - Coarse breath sounds bilaterally. Cor tachycardic. The abdomen is soft, nontender. Extremities positive edema. Neurologically, alert and was able to answer questions. LABORATORY DATA: Significant for white blood cell count of 11.2, potassium 6.5, creatinine 7.1. Urinalysis negative. Arterial blood gases revealed pH 7.39, 42 and 112 on CPAP. Chest x-ray - no infiltrate, possible cephalization. Electrocardiogram revealed sinus tachycardia at 114. Echocardiogram revealed ejection fraction greater than 55%. HOSPITAL COURSE: The patient was admitted to the SICU service. It was unclear what the patient's respiratory distress was due to, had been short of breath times two weeks, and there was no strong evidence of infection. The patient was diuresed empirically and covered with Levofloxacin for infection. The patient was continued on CPAP. On [**2168-5-13**], the patient was continuing to require mask ventilation. The patient's code status was DNR/DNI and, after speaking with the patient's daughter at length, the daughter felt that it would be in the patient's best interest to change goals of care to comfort measures only. The patient also had worsening renal failure of unclear etiology although his creatinine had appeared to be rising in the past. The patient ruled out for myocardial infarction during this hospitalization as well. The patient was started on a Morphine drip for comfort. His medications, telemetry and intravenous fluids were discontinued. On [**2168-5-13**], at 1:47 p.m., the patient was found to be unresponsive and not to be breathing spontaneously. He had no heart sounds and no pulse. The patient's pupils were dilated and fixed. The patient was pronounced at 1:47 p.m.. The patient's daughter was spoken to and declined postmortem examination at the time of death. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease. 2. Esophageal cancer. 3. Respiratory failure. CONDITION ON DISCHARGE: The patient expired. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**Last Name (NamePattern1) 218**] MEDQUIST36 D: [**2168-6-26**] 15:10 T: [**2168-6-27**] 19:48 JOB#: [**Job Number 107207**]

[ "V10.03", "V15.82", "496", "276.7", "428.0", "518.81", "584.9" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

1691, 1767

4134, 4226

1514, 1674

2819, 4113

1953, 2801

105, 128

157, 1120

1142, 1488

1784, 1930

4251, 4533

58,930

151,122

30269

Discharge summary

report

Admission Date: [**2151-7-26**] Discharge Date: [**2151-7-30**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1943**] Chief Complaint: SOB, transfer for ST elevations Major Surgical or Invasive Procedure: Endotracheal intubation and extubation Mechanical ventilation Cardiac catheterization History of Present Illness: Ms. [**Known lastname 72067**] is an 89 year old female with severe asthma, HTN, HL, DM, and CAD who was admitted to the MICU due to acute SOB and ST elevations. She is now being transferred to the floor. She has frequent exacerbations of her asthma and was recently treated at [**Hospital3 **] for a COPD/asthma exacerbation. She was discharged home and developed acute SOB, diaphoresis, and HTN in the ambulance. Her ECG at the time showed ST elevations in the lateral wall and she was given NTG, lasix, ASA, and taken back to [**Location (un) **]. She was found to be hypoxic and agitated and intubated for airway protection. She was then started on a nitro gtt and heparin gtt due to ST elevations and transferred to [**Hospital1 18**]. In the [**Hospital1 18**] ED, she was found to be hypertensive to 225/118 and was admitted to the MICU on versed and a heparin gtt (nitro gtt had been weaned off due to downtrending BPs). In the MICU, she was noted to have diffuse ST elevations and a code STEMI was called. She was taken to the cath lab and found to have no flow-limiting lesions but elevated filling pressures and was felt to have Takotsubo's cardiomyopathy with an estimated EF 40%. She was diuresed in the MICU with 40mg IV lasix and also given insulin and D50 for hyperkalemia. Her course was also complicated by agitation and the patient pulling out her PICC line and EJ IV access. She was also hitting and scratching the nurses this morning and was given haldol 2mg IM x 1 at 5:30am with excellent calming effect. She also had hypernatremia and was given 1L D5W yesterday. She currently has no IV access and has not had labs drawn since yesterday. She was switched from IV beta blocker to oral this morning. Currently she states that she is mildly short of breath but feeling much better than previous. She has no other complaints, other than wanting to go home. REVIEW OF SYSTEMS: She denies any headaches, confusion, chest pain, palpitations, cough, abdominal pain, nausea, vomiting, diarrhea, constipation, or urinary symptoms. She has a foley catheter in place. Past Medical History: - Hypertension - Hyperlipidemia - Diabetes - s/p thyroid surgery - h/o severe asthma, no PFTs in our system, recently on steroid taper - h/o CRI - h/o blood clot in the leg several years ago Social History: States she smoked 1ppd x most of her life, cannot give quit date history (once she said [**2119**], once she said 1 month ago). Denies EtOH use. Denies other drug use. Lives alone in [**Location (un) **], MA and has a sister in NC. Had one daughter who passed away recently from asthma exacerbation. Family History: OSH transfer note states that she has a family history of premature CAD and that both her parents are deceased. SHe states that parents died of old age and "a natural death." She has 2 sisters who are in NC but she doesn't know about their health. Physical Exam: Vitals: 98.1 84 148/79 23 98%RA General: Disheveled African-American elderly female in NAD. Eyelids with slight drooping bilaterally and eyes with haziness diffusely. HEENT: Sclera anicteric, MMM, oropharynx clear but with poor dentition Neck: Supple with JVP 9-10cm Lungs: Decreased air movement throughout with low-pitched expiratory wheezes bilaterally and faintly. CV: Regular rate with marked ectopy, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Does have extra skin hanging on abdomen suggestive of previous weight loss. Ext: Warm, well perfused, no clubbing, cyanosis. RUE edema just below the elbow. Pertinent Results: Admission Labs: [**2151-7-26**] 04:40AM WBC-13.9*# RBC-3.38* HGB-10.2* HCT-32.9* MCV-97 MCH-30.3 MCHC-31.1 RDW-16.2* [**2151-7-26**] 04:40AM NEUTS-93.9* LYMPHS-3.9* MONOS-1.3* EOS-0.8 BASOS-0.1 [**2151-7-26**] 04:40AM PLT COUNT-224 [**2151-7-26**] 04:40AM PT-11.7 PTT-32.0 INR(PT)-1.0 [**2151-7-26**] 04:40AM ALT(SGPT)-25 AST(SGOT)-42* CK(CPK)-61 ALK PHOS-99 TOT BILI-0.5 [**2151-7-26**] 04:40AM GLUCOSE-124* UREA N-34* CREAT-1.5* SODIUM-142 POTASSIUM-5.4* CHLORIDE-110* TOTAL CO2-24 ANION GAP-13 [**2151-7-26**] 04:40AM cTropnT-0.20* [**2151-7-26**] 04:40AM CK-MB-5 [**2151-7-26**] 03:31PM LACTATE-1.0 K+-5.5* Discharge Labs: [**2151-7-30**] 05:15AM BLOOD WBC-8.3 RBC-3.46* Hgb-10.3* Hct-32.2* MCV-93 MCH-29.7 MCHC-31.9 RDW-15.8* Plt Ct-182 [**2151-7-30**] 05:15AM BLOOD PT-11.5 PTT-27.0 INR(PT)-1.0 [**2151-7-30**] 05:15AM BLOOD Glucose-89 UreaN-50* Creat-1.6* Na-142 K-3.8 Cl-103 HCO3-32 AnGap-11 [**2151-7-27**] 04:31PM BLOOD CK-MB-5 cTropnT-0.55* [**2151-7-30**] 05:15AM BLOOD Calcium-10.6* Phos-2.3* Mg-2.1 Studies: CT Head [**2151-7-26**] : No acute intracranial hemorrhage or mass effect. CXR [**2151-7-28**]:As compared to the previous examination, there is no relevant change. Due to projection effect, the cardiac silhouette appears slightly larger than before. However, no evidence of pulmonary edema is seen. Moderate tortuosity of the thoracic aorta. No newly occurred focal parenchymal opacity suggesting pneumonia. No pleural effusions, no pneumothorax. TTE [**2151-7-27**]: 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. There is mild regional left ventricular systolic dysfunction suggested with distal septal and apical hypokinesis. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2149-7-15**], a mild regional wall motion abnormality is now seen suggestive of CAD. CARDIAC CATH [**2151-7-26**]: 1. Coronary angiography of this right dominant system revealed no significant coronary artery disease. The LMCA appeared normal. The LAD, LCx, and RCA had minor luminal irregularities with marked tortuosity. 2. Limited resting hemodynamics demonstrated low-normal systemic arterial blood pressure (SBP 109 mm Hg). There was no gradient upon pullback of the catheter from the LV into the aorta. 3. Left ventriculography revealed marked distal anterior, apical, and distal inferoapical severe hypokinesis/ akinesis with contraction of the basal segments, with an estimated LVEF of 40%. There was no mitral regurgitation. FINAL DIAGNOSIS: 1. No significant angiographically apparent coronary artery disease. 2. Marked LV apical dysfunction consistent with Takotsubo cardiomyopathy. RUE Ultrasound [**2151-7-29**]: No evidence of DVT of the right upper extremity. Brief Hospital Course: 89 year old female with dCHF, HTN and severe asthma requiring recurrent ED visits currently on prednisone taper, transferred from OSH with respiratory distress intubated for airway protection and ECG changes now s/p clean cardiac catheterization. #. Respiratory distress: Patient has had recurrent exacerbations of COPD vs asthma requiring repeated treatment with steroids. She carries diagnosis of asthma and smoked 1 pack per week in past and has been on spiriva. She improved rapidly with steroids IV which were transitioned to oral. There was no documentation of hypercapnia or hypoxia prior to intubation so unclear if she actually had respiratory failure or was just intubated for airway protection given ECG changes. Wheezing and air movement improved with nebulizers and steroids and she extubated without difficulty on [**7-27**]. Given elevated BP requiring nitro gtt prior to intubation, may have had some component of flash pulmonary edema as well but CXR was clear without evidence of volume overload or pneumonia. She was also given lasix 40 IV x 1 and then 20 PO x 1 for some mild component of volume overlaod but was satting well on room air prior to trasnfer to floor. She is being discharged on a prednisone taper as well as standing nebulizer treatments. #. ECG changes/Takotsubo's Cardiomyopathy: ECG with ST elevations in V2-6 and positive troponins which peaked at 0.58 then trended down. Cardiology was consulted and Code STEMI was called on arrival to the MICU and she was taken for cardiac catheteterization. She was also initially started on heparin gtt and integrillin drip. There were no flow limiting lesions so heparin and integrillin stopped. ECG changes and positive troponin felt to be due to Takotsubo's cardiomyopathy. She was started on ASA 325 daily, metoprolol, and an ACE-inhibitor. She should have an repeat TTE in [**5-18**] weeks. #. HTN: Was initially hypertensive on nitro gtt prior to trasnfer which was quickly weaned off in ED and BP remained improved and normalized back on home regimen HCTZ, Imdur and amlodipine. She was also started on an ACE-inhibitor and beta blocker, which can be uptitrated after discharge as needed. #. Chronic diastolic CHF: Known diastolic dysfunction with EF >55% in the past and EF now depressed 40% on LV gram done in cath lab but repeat formal TTE with improved EF. BB and ACE were started. #. [**Last Name (un) **]: Cr 1.7 from baseline 1.2-1.3 which improved slightly with gentle diuresis. FEurea 34%. It was felt that her renal function was likely worsened by dye load but stable at time of transfer. She was given NAC after her contrast load. #. Hyperkalemia: K 6.8 increased from 5.4 on admission. Possibly related to worsening renal function vs acidemia from progressive hypercarbia. Improved with insulin/D50, lasix, bicarb and calcium gluconate. #. Anemia: Hematocrit remained at baseline 32. #. Delirium: Was combative and agitated [**7-28**] post-extubation which responded well to 2mg IM haldol and she was alert oriented and cooperative at time of floor transfer and subsequently thereafter. #. Code Status: She was full code during this hospitalization Medications on Admission: mdur 60mg PO daily Amlodipine 10mg PO daily Folic acid 1mg PO daily Albuterol nebs q4 hours prn HCTZ 12.5mg Po daily Spiriva 1 cap IH daily Colace 100mg PO BID Prednisone 10mg PO taper (currently 20mg dose (taper [**7-20**]) Discharge Medications: 1. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Nebulization Inhalation Q6H (every 6 hours). 5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day for 1 days: Take 3 tablets (60mg) daily for 1 day, then take 2 tablets (40mg) daily for 3 days, then take 1 tablet (20mg) daily for 3 days, then take 10mg daily for 3 days. 8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Nebulization Inhalation Q6H (every 6 hours). 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Insulin Lispro 100 unit/mL Solution Sig: Per sliding scale Subcutaneous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Primary Diagnoses: - Chronic obstructive pulmonary disease exacerbation - Takotsubo's cardiomyopathy - Hyperkalemia - Delirium - Anemia - Acute kidney injury Secondary Diagnoses: - Hypertension - Type 2 diabetes mellitus - Hyperlipidemia - Chronic kidney disease, stage 3 - H/o blood clot in the leg several years ago Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with shortness of breath. You were intubated and placed on a ventilator for a few days. You underwent a cardiac catheterization which showed that you did not have a heart attack and you do not have significant coronary artery disease. You were also treated for an exacerbation of your COPD. Changes to your medications: ADDED albuterol nebulizers every 4 hours ADDED ipratropium nebulizers every 4 hours ADDED lisinopril 2.5mg by mouth daily ADDED metoprolol tartrate 12.5mg by mouth twice daily STOP Spiriva (you should restart this medication when you stop taking ipratropium nebulizers) ADDED aspirin 325mg by mouth daily START insulin sliding scale while at rehab Followup Instructions: You are being discharged to a rehabilitation facility. You should be followed by the physician at your rehab facility while you are there. You should have your electrolytes checked in one week and creatinine checked in one week. You should have follow-up echocardiogram in 1 week. When you are discharged, please call your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17029**], to schedule a follow-up appointment at [**Telephone/Fax (1) 17030**].

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icd9cm

[ [ [] ] ]

[ "96.71", "37.22", "88.55" ]

icd9pcs

[ [ [] ] ]

12057, 12143

7446, 10603

294, 381

12505, 12505

4047, 4047

13419, 13906

3042, 3291

10878, 12034

12164, 12323

10629, 10855

7197, 7423

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4694, 7180

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12344, 12484

13047, 13396

2310, 2495

223, 256

409, 2291

4063, 4677

12520, 12665

2517, 2709

2725, 3026

80,265

139,055

26985

Discharge summary

report

Admission Date: [**2154-4-20**] Discharge Date: [**2154-4-24**] Date of Birth: [**2075-11-27**] Sex: F Service: MEDICINE Allergies: Augmentin / Atacand Attending:[**First Name3 (LF) 443**] Chief Complaint: OSH transfer for STEMI Major Surgical or Invasive Procedure: Cardiac cath History of Present Illness: 78yo female with multiple medical problems including type 2 diabetes mellitus, coronary artery disease, hyperlipidemia, hypertension, peripheral vascular disease, and AAA was transferred from an OSH with a STEMI. . In [**2-15**], patient recently fell at home from "legs buckling under her because of neuropathy" and was sent to rehab. While in rehab, she tripped on the stairs and broke her ankle with no subsequent surgical intervention. At rehab, she endorsed 2 separate episodes of epigastric burning over the past 2 weeks that lasted a short amount of time and was relieved by oxygen and vomiting. Today she had another episode which she describes as an epigastric type burning sensation associated with nausea and vomiting. The character of the episode was similar to the previous episodes; however this episode lasted longer. She also endorsed pain radiating to her back and shortness of breath. . Upon initial evaluation by EMS at 11:09am, her vital signs were HR 58, BP 92/48, RR 16, and 88% on 2L. She was taken to [**Hospital 28941**] and arrived at 12:15pm. Upon arrival at [**Hospital3 **], vital signs were BP 131/53, HR 86, RR 18, temp 98.4, and pulse ox 100% (unclear how much supplemental O2 she received). She received SL NG x 1, ASA 325mg PO x 1, nitro gtt at 10mcg, dilaudid .5mg IV x 1, plavix 660mg PO x 1, and heparin drip. ECG at the OSH demonstrated STE in II, III, and avF with reciprocal STD in I, avL, V1, and V2. . She was med flighted to [**Hospital1 18**] where she was transferred to the cath lab and received aspirin 325mg PO, heparin bolus, integrelin, and potassium. She was found to have a subtotal occlusion in the mid left circumflex for which she received a bare metal stent. . Of note, she was admitted to [**Hospital1 18**] on [**2151-3-15**] for a cardiac catheterization and she was found to have 95% stenosis of her left circumflex with a "miniscule" RCA with 30% mid segment stenosis. . Patient is on oxygen at baseline for COPD-usually 2L but recently increased to 2.5L. She also endorsed increased lower extremity swelling since her ankle fracture 3 weeks ago. She describes leg weakness and chronic back pain. . 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. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for presence of chest pain, dyspnea on exertion, ankle edema, but absence of palpitations, paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope. Past Medical History: 1. Hypertension 2. Hyperlipidemia 3. Type 2 Diabetes Mellitus 4. h/o Tobacco Abuse 5. Peripheral Vascular Disease 6. Abdominal Aortic Aneurysm 7. Asthma 8. Breast Cancer - treated with right mastectomy and tamoxifen 9. COPD . Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension . Pacemaker/ICD: not applicable Social History: Social history is significant for the absence of current tobacco use. Pt quit smoking in [**2136**]. There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death. She is a widower and lives alone. She has three sons and a daughter. Family History: . - Mother - CAD at age 70yo; died at age 82yo from CVA - Sister - Rheumatic [**Name (NI) 3495**] Disease - died from heart problems at age 49 - Sister - CABG in her 60s Physical Exam: VS - T 96 HR 57 BP 122/53 RR 18 100%4L Gen: WDWN elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 7 cm but obese habitus. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB but anteriorly Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c, 3+ peripheral edema to b/l knees. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. 6x5 inches of indurated hematoma in right groin. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Pertinent Results: Admission Labs [**2154-4-20**] 04:52PM BLOOD WBC-13.3* RBC-3.30* Hgb-8.8* Hct-27.6* MCV-84 MCH-26.8* MCHC-31.9 RDW-15.3 Plt Ct-621* [**2154-4-20**] 04:52PM BLOOD Glucose-126* UreaN-16 Creat-0.7 Na-143 K-4.5 Cl-101 HCO3-35* AnGap-12 [**2154-4-20**] 04:52PM BLOOD CK-MB-NotDone cTropnT-0.06* [**2154-4-20**] 04:52PM BLOOD Calcium-8.7 Phos-4.7* Mg-1.9 [**2154-4-21**] 08:01AM BLOOD calTIBC-174* VitB12-253 Folate-14.9 Ferritn-23 TRF-134* [**2154-4-21**] 08:01AM BLOOD Triglyc-168* HDL-20 CHOL/HD-4.2 LDLcalc-29 Reports/Imaging 3/14Cath COMMENTS: 1. Selective coronary angiography of this left dominant system revealed one vessel coronary artery disease. The LMCA had no angiographically apparent disease. The Lcx had a subtotal 95% occlusion at the mid vessel. The LAD had minimal diffuse disease throughout. The RCA was nondominant, small vessel without any angiographically apparent disease. 2. Limited resting hemodynamics revealed moderate systemic hypertension with a central pressure of 160/67 mmHg. 3. Successful primary angioplasty (direct stenting) of the mid LCX with a 3.0x18 mm Vision BMS. Final angiography revealed 0% residual stenosis without dissection or distal emboli. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Moderate systemic hypertension. 3. Successful BMS stenting to Lcx. . [**2153-4-22**] The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is basal inferior/infero-lateral hypokinesis with overall preserved left ventricular ejection fraction (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**2-8**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 78yo female with a history of multiple medical problems including type 2 diabetes mellitus, hypertension, and peripheral vascular disease was admitted with STEMI and had a bare metal stent placed to the left circumflex. . #. CAD now s/pSTMEI: Has multiple risks for CAD as detailed above. Her history of multiple episodes of epigastric pain appears most consistent with unstable angina. Patient had STE in inferior region but has left dominant system. Patient had BMS to LCx and now is chest pain free. She was continued on aspirin. Although patient was concerned about starting statin because of prior myopathy on different formulations, she agreed to try Crestor which she tolerated without adverse reaction. Fasting lipid panel showed LDL at goal. Started ACEI at low dose and no adverse reaction so increased to 5mg PO qday. Also started metoprolol at 12.5 mg PO BID which she tolerated well. . #Hematoma: Patient developed a 6x4 inch hematoma in right groin s/p cath. Her hematocrit droped initially and required 3 units of blood. Throughout this she was hemodynamically stable. Her hematocrit stabilized and hematocrit checks were done only daily. . #. Pump: Patient appears mildly hypervolemic on admission but difficult to assess secondary to body habitus and post cath flat positioning. Patient was previously on multiple anti-hypertensive agents at her rehab facility, including hydralazine, CCB, and nitrate. Patient was transitioned to ACEI and beta blocker regimen given that she was post STEMI. She had an echocardiogram that showed preserved EF and inferior/infero-lateral hypokinesis. Slowly resumed home furosemide after she was stabilized. . #. Rhythm: Patient remains slightly bradycardic but in normal sinus rhythm. Her heart rate improved after MI to be normocardic. She was monitored on telemetry via cardiology protocol without events. . #. Type 2 Diabetes Mellitus: A1C on admission was 6% which was at goal. Continued home insulin which was long acting Lantus in house, 20U at night. Did not require any insulin on sliding scale. Discontinued actos as it was not needed based on in house blood sugars. #. Vitamin D deficiency:Stable, continue vitamin D supplementation . #. GERD:Stable-continue prevacid . #. Glaucoma- continue xalatan eye drops and genteal eye drops . #. COPD: on 2L oxygen at baseline- continue xopenex, flovent, and atrovent . #. Anxiety: Continued 0.25mg PO prn alprazolam as patient was stable on home regimen. . #. Pain: c/o back pain chronically worsened with lying flat post cath, continue gabapentin 100mg PO qhs, percocet prn pain. . #. Right ankle fracture: Seen by PT and walking boot applied. Pt states this feels heavy but is able to participate in PT. She has WBAT on this ankle and pain is well controll with percocet prn. Medications on Admission: 1. Levemir 20 units SC qhs 2. Diltiazem 300mg PO daily 3. Vitamin D 800 units PO daily 4. Actos 15mg PO qAM 5. Prevacid 30mg PO daily 6. Xalatan eye gtt 2 drops ou qhs 7. gabapentin 100mg PO qhs 8. Xopenex inh q4h prn 9. Tylenol 325-650mg PO q4h prn 10. MOM 30mL PO daily prn 11. Lasix 80mg PO daily (recently increased from 40mg daily on [**2154-4-3**]) 12. Potassium 20mEq PO daily 13. Imdur 30mg PO daily 14. Flovent 1 puff [**Hospital1 **] 15. Xopenex tid prn 16. Atrovent inh qid standing 17. Hydralazine 10mg PO qid 18. Xanax .25mg qhs Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Insulin Detemir 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation q8h prn () as needed for shortness of breath. 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-8**] Drops Ophthalmic PRN (as needed). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*15 Tablet(s)* Refills:*2* 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 15. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 18. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 20. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 21. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 22. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day for 2 [**Hospital1 4319**]. Discharge Disposition: Extended Care Facility: [**Hospital1 66324**] Discharge Diagnosis: ST Elevation Myocardial Infarction Coronary Artery Disease Diabetes Mellitus type 2 Glaucoma Chronic Obstructive Pulmonary Disease Anxiety Discharge Condition: stable Discharge Instructions: You had a heart attack and required a cardiac catheterization to assess the arteries that feed blood to your heart. One of these arteries were blocked and you received a bare metal stent to this artery. You have been started on Plavix and it's very important that you take Plavix every day for one month. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix unless Dr.[**Name (NI) 3733**] tells you to. You developed a large collection or blood in your right groin after the sheaths were taken out in the catheterization lab. This was controlled by holding pressure on your right groin. You needed to have some blood transfusions to replace the blood that was lost. We have changed the following medicines: 1. Plavix: to keep the stent from clotting off 2. Lisinopril: to lower your blood pressure 3. Metoprolol: to lower you heart rate and help your heart recover from the heart attack. 4. Rosuvastatin: to decrease cholesterol levels. 2. Stop taking Hydralazine, Actos and Diltiazem . Please call Dr. [**Last Name (STitle) **] if you notice any more swelling or bruising at the right groin site, if you develop a fever or cough, if you have chest pain or trouble breathing or for any other unusual symptoms. Followup Instructions: Primary Care: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 66325**]:[**Telephone/Fax (1) 66326**] Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Hospital3 25148**] Center [**Hospital1 66327**] [**Location (un) **], [**Numeric Identifier 66328**] Telephone: ([**Telephone/Fax (1) 66329**] Date/Time: [**5-2**] at 1:00pm Endocrinology: Dr. [**First Name (STitle) 66330**] [**Name (STitle) **] Phone: Phone: ([**Telephone/Fax (1) 66331**] [**Hospital1 66332**] Center, [**Location (un) **] NH Completed by:[**2154-4-24**]

[ "530.81", "414.01", "V58.66", "365.9", "300.00", "V10.3", "401.9", "250.00", "998.12", "441.4", "272.4", "443.9", "724.2", "268.9", "285.9", "410.41", "493.20" ]

icd9cm

[ [ [] ] ]

[ "00.40", "99.20", "00.45", "88.53", "37.22", "36.06", "88.56", "00.66" ]

icd9pcs

[ [ [] ] ]

12539, 12587

7063, 9850

303, 317

12770, 12779

4844, 6031

14078, 14714

3718, 3889

10443, 12516

12608, 12749

9876, 10420

6048, 7040

12803, 14055

3904, 4825

241, 265

345, 3054

3076, 3395

3411, 3702

1,178

132,240

24358+57396

Discharge summary

report+addendum

Admission Date: [**2114-4-2**] Discharge Date: [**2114-4-9**] Date of Birth: [**2035-9-16**] Sex: M Service: MEDICINE Allergies: Streptokinase Attending:[**First Name3 (LF) 2074**] Chief Complaint: syncope, ventricular fibrillation arrest Major Surgical or Invasive Procedure: Pacemaker/ICD implantation History of Present Illness: 78 M with h/o CAD s/p several PTCA reportedly single vessel balloon angioplasty with no stents, HTN, hypercholesterolemia, h/o V Fib arrest in [**2101**], DM who presented to OSH after witnessed episode of syncope lasting 10 minutes. EMS called by wife. The EMS found patient with bradycardia 30-40s. At the outside hospital ED, the patient was felt to be 2:1 AV block. He was reportedly stable in the outside ED. He was admitted to the outside hospital CCU for close monitoring given the AV block. In the CCU, the patient suddenly had polymorphic VT felt to be torsades which degenerated into coarse VF, and then fine VF. He given IV magnesium and atropine, and CPR was administered. The entire episode lasted 2 minutes and he spontaneosly converted back to bradycardic sinus rhythm. Emergent transvenous pacer wire placed by the staff cardiologist. He was then noted to have monomorphic VT, therefore Lidocaine and lopressor were administered. He underwent cardiac catheterizationon [**2114-4-2**], the day of transfer which noted totally occluded RCA, and disease in both LAD and Left Circumflex. Of note, the patient never experienced chest pain or shortness of breath. Past Medical History: Diabetes CAD - s/p multiple MIs, PTCA in [**2098**], [**2102**] VF Cardiac arrest [**2101**] Arrhythmia (nos) DVT, s/p IVC filter Glaucoma BPH Hyperlipidemia Social History: Patient lives with wife. [**Name (NI) **] is a WWII veteran. Retired airline pilot. Drinks 1 beer or wine daily. Nonsmoker. Family History: Non-contributory Brief Hospital Course: 78 M s/p Ventricular fibrillation arrest 12+ years ago, with h/o CAD s/p single angioplasty, DM who presents with syncope found to have 2:1 AV block transferred to [**Hospital1 18**] after V tach/ V Fib arrest at [**Hospital3 45967**] for possible CABG. Pt transferred after initial stabilization with temporary pacer wire insertion and lidociane drip started. Patient underwent cardiac catheterization at [**Hospital3 45967**] prior to transfer which showed totally occluded Right coronary artery with good collateral flow and significant, but not obstructive disease in both the LAD and the Left Circumflex. Based on the catheterization findings, the patient was transferred to [**Hospital1 18**] for possible CABG and pacemaker implantation. 1. Cardiac: Coronary Artery Disease: It was initially felt that the patient's 3 vessel coronary artery disease might be the etiology of his V tach/ V fib arrest. Therefore the patient was transferred for urgent revascularization. However, after his cardiac enzymes were cycled and he ruled out for myocardial ischemia (with the highest troponin being 0.04), his cardiovascular disease was felt to be non-acute. The cardiac catheterization films were reviewed with the interventionalists and the cardiovascular surgeons(Dr. [**Last Name (STitle) **] who initially decided that even though, he was not having active myocardial ishcemia, a CABG would be reasonable, especially given the patient needed a pacemaker and performing the CABG would be simpler prior to lead implantation by electrophysiology. However, the patient's mental status waxed and waned while he was awaiting cardiac CABG. Re-evaluation of the patient's mental status included a head CT which was negative and a neurology consult. After much discussion with neurology and CT surgery, a decision was made not to perform CABG during this admission. The basis for this decision was threefold: 1) the patient would be at significant risk of a worsened mental status post cardiac bypass surgery, 2) cardiac enzymes and EKGs supported there was no acute myocardial ischemia, but rather chronic coronary artery disease, and 3) the urgent issue was pacemaker and AICD implantation given his heart block. It was felt it would be prudent to implant the pacemaker and AICD and arrange cardiology and CT surgery follow up for possible future elective CABG depending on patient's mental status and symptoms of cardioascular disease. In the meantime, maximal medical management of his cardiovascular disease would be the goal. The patient was continued on ASA, B-Blocker, Statin, and started on an ACE-I during the admission. Dual chamber PM/ICD was placed [**4-6**]. He is now A sensed, V paced. He will follow up in device clinic in 7 days and complete 7 days antibiotics. Of note, during the CABG work-up, he had left carotid ultrasound which was reportedly negative. His pre-op CXR during this admission was clear. RHYTHM: At the outside hospital, the patient was noted to be in 2:1 AV block. A temporary pacer wire was placed as transition to permanent pacemaker. EP consulted and placed PM/ICD on [**2114-4-6**]. His lidocaine was discontinued on arrival to prevent CNS toxicity. PUMP: No evidence of CHF on exam during this admission. By report past EF was 35%. Inpatient Echo showed: Left atrium mildly dilated, mild symmetric left ventricular hypertrophy with normal cavity size and moderate global hypokinesis and septal dysnchrony. In addition, right ventricular chamber size and free wall motion are normal. The aortic root and ascending aorta are mildly dilated. The aortic valve leaflets appeared structurally normal with good leaflet excursion and no aortic regurgitation. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-19**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. DM: Patient was monitored with fasting sugars QID and administered Humalog SS while awaiting CABG. He was transitioned to po meds on discharge. GLAUCOMA: Patient was continued on his multiple eye drops for his history of closed angle glaucoma. h/o DVT: Per pt DVT was in setting of trauma and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter was placed for this. Further history was not able to be obtained. MENTAL STATUS: Treated with ativan and zyprexa. He responded the best to zyprexa. Haldol was avoided to prevent QTc prolongation. h/o BRBPR at outside hospital, guaiac negative by report: Pt states that he has history of hemarrhoids. He described noticing blood on toilet tissue and small amount in bowel. He denied worrisome signs to suggest GI malignancy. His hct was stable and guaiac negative at OSH. FEN: cardiac diet recommnended. PROPHYLAXIS: PPI, Heparin SQ TID, and bowel regimen was administered during the hospital stay Medications on Admission: Glyburide 5 mg po daily Amiodarone 200 mg po daily Hydrochlorothiazide 25 mg po daily Cardizem CD 1 tabelt daily Lopressor 50 mg po daily Zocor 20 mg po daily Flomax 0.4 mg po daily Aspirin 325 mg po daily Alphagan gtt Xalatan gtt Cosopt gtt Discharge Medications: 1. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*60 Tablet, Sublingual(s)* Refills:*0* 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 8. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 9. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for 5 days. Disp:*10 Capsule(s)* Refills:*0* 10. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of Rode Island Discharge Diagnosis: Ventricular Tachycardia/Ventricular Fibrillation Cardiac Arrest Atriaventricular conduction abnormality Coronary Artery Disease Pacemaker Implantation Discharge Condition: Stable Discharge Instructions: Please take all medications as directed. Please follow up with appointments listed below. If you have chest pain that lasts longer than 15 minutes, you need to go to the emergency room for evaluation immediately. Followup Instructions: Please call your primary care doctor to arrange appointment to check-in with him after your recent hospitalization. You will need to return to [**Hospital3 **] to have your pacemaker checked approximately 2 weeks after discharge. Please follow up with Dr. [**Last Name (STitle) 2230**], a cardiovascular surgeon, at [**Hospital3 45967**]. Please also call Dr. [**Last Name (STitle) 61691**], a cardiologist, to make an appointment to follow up on your cardiovascular disease. Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2114-4-13**] 2:00 Completed by:[**2114-4-7**] Name: [**Known lastname 400**],[**Known firstname 1937**] Unit No: [**Numeric Identifier 11147**] Admission Date: [**2114-4-2**] Discharge Date: [**2114-4-9**] Date of Birth: [**2035-9-16**] Sex: M Service: MEDICINE Allergies: Streptokinase Attending:[**First Name3 (LF) 1090**] Addendum: Discharge instruction amended with specifics on followup appointments. Discharge Medications: 1. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*60 Tablet, Sublingual(s)* Refills:*0* 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 8. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 9. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for 4 days. Disp:*8 Capsule(s)* Refills:*0* 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* 12. Glipizide 2.5 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO at bedtime: this medication replaces glyburide. Disp:*30 Tab, Sust Release Osmotic Push(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of Rode Island Discharge Diagnosis: Ventricular Tachycardia/Ventricular Fibrillation Cardiac Arrest Atriaventricular conduction abnormality Coronary Artery Disease Pacemaker Implantation Discharge Condition: Good - no further episodes of VT/VF, no chest pain, or shortness of breath, ambulating with assistance. Discharge Instructions: Please take all medications as directed. Please follow up with appointments listed below. If you have chest pain that lasts longer than 15 minutes, you need to go to the emergency room for evaluation immediately. Stop taking glyburide - you will be starting glipizide instead. Followup Instructions: 1. Please followup with Dr. [**Last Name (STitle) 11148**] ([**Telephone/Fax (1) 11149**]) Tuesday [**2114-4-17**] at noon. Please bring a copy of your discharge summary as well as a list of all your medications. You should have your urine re-checked at your PCP appointment to make sure the blood in your urine has resolved. (This was likely due to trauma from the catheter that was in your bladder). You should also have your creatinine drawn there to evaluate your kidney function. At that point, talk to Dr. [**Last Name (STitle) 11148**] about your diabetes medication. 2. You will need to return to [**Hospital3 **] to have your pacemaker checked approximately 2 weeks after discharge. Provider: [**Name10 (NameIs) 1727**] CLINIC Where: [**Hospital6 189**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 1728**] Date/Time:[**2114-4-13**] 2:00 3. Please follow up with Dr. [**Last Name (STitle) 11150**], a cardiovascular surgeon, on [**2114-4-19**] at 10AM. Please call [**Telephone/Fax (1) 11151**] (Ext 6508) to confirm time and location. 4. Please also follow up with Dr. [**Last Name (STitle) 11152**], a cardiologist, on Tuesday [**2114-4-10**] 4:30 PM. Call [**Telephone/Fax (1) 11153**] Tuesday morning to confirm the location and time of your appointment. Please bring a copy of your discharge summary and a list of all your medications to that appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1094**] MD [**MD Number(1) 1095**] Completed by:[**2114-4-9**]

[ "V12.51", "426.13", "401.9", "286.9", "293.0", "428.0", "250.00", "414.01", "780.2", "276.5", "272.0" ]

icd9cm

[ [ [] ] ]

[ "37.94" ]

icd9pcs

[ [ [] ] ]

11506, 11555

1928, 6303

313, 342

11750, 11855

12181, 13718

1887, 1905

10071, 11483

11576, 11729

6864, 7107

11879, 12158

233, 275

370, 1548

6318, 6838

1570, 1730

1746, 1871

44,538

132,115

51732+59377

Discharge summary

report+addendum

Admission Date: [**2104-7-21**] Discharge Date: [**2104-7-29**] Date of Birth: [**2024-2-5**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2104-7-24**] Coronary bypass grafting x5 with left internal mammary artery to left anterior descending coronary artery; reversed saphenous vein single graft from aorta to the first diagonal coronary artery; reversed saphenous vein single graft from aorta to the first obtuse marginal coronary artery; as well as reverse saphenous vein double sequential graft from the aorta to the posterior descending coronary artery and posterior left ventricular coronary artery History of Present Illness: 80 year old with extensive history of coronary artery disease transferred from OSH in setting of NSTEMI after being found to have three vessel disease.Patient has long history of CAD, with non-Q wave MI and POBA to LAD and D1 in [**2083**], DES to RCA x 2 in [**4-/2097**] presented to OSH on [**2104-7-17**] with chest pain. Patient has long history of stable angina with activity (one flight of stairs), described as a mild chest pressure, non radiating, lasts less than 3 minutes and is relieved by rest. Last thursday ([**2104-7-17**]) while emptying the dishwasher, he experienced [**8-11**] substernal chest pain, radiating to the left elbow associated with diaphoresis. No SOB, no dizziness, no nausea/vomiting. The pain was not relieved with rest and was not relieved after taking NTG x2. He called 911 and was transported to [**Hospital3 **] Hospital by ambulance. There is a note that refers to the patient having ST elevations during the amblunace ride, but no EKG demonstrating ST changes were in the chart. . At [**Hospital3 635**] hospital, he had an EKG that demonstrated ST depressions in anterior leads, and positive troponins (no lab records in transfer chart, note refers to peak troponin I as 3.5) and was taken directly to the cath lab. Coronary catherization revealed 3 vessel disease, specifically 30% stenosis in LMT, 80% stenosis in mid LAD, 70% stenosis in ramus, 60% in stent stenosis in both RCA stents. Cardiac surgery was consulted and recommended CABG but the patient requested transfer to [**Hospital1 18**]. On [**2104-7-20**] he had a bleed from his cath site, with SBP in the 90s and HCt 32 -> 29. Hemostasis was achieved with pressure, heparin and nitro drips were stopped, plavix was stopped (last dose on [**2104-7-19**]) and 2U PRBC were transfused without complication. CT abdomen demonstrated no intraperitoneal or retroperitoneal bleeds. A carotid U/S was negative for carotid stenosis. Patient was transferred to [**Hospital1 18**] on [**2104-7-21**] in stable condition. Dr.[**Last Name (STitle) 914**] was conulted for coronary revascularization. Past Medical History: Coronary Artery Disease s/p NSTEMI [**2083**] s/p POBA to prox LAD and D1 then repeat PTCA 4 months later for ISR at LAD and D1; DES to RCA x2 [**2097**] Borderline Diabetes Mellitus TIA [**2096**] Gout Dyslipidemia s/p skull fracture as child in setting of trauma Hypertension Past Surgical History: s/p Right cheek basal cell CA excision s/p posterior thorax excision of benign compound nevus [**5-/2095**] s/p RUE atypical nevus/melanoma s/p multiple concussions- as child Social History: Tobacco history: never smoker Retired, used to work at Polaroid doing research. Lives on [**Location (un) 21541**] with his wife. [**Name (NI) **] has 4 kids. Family History: No family history of early MI, arrhythmia, or sudden cardiac death; otherwise non-contributory. Physical Exam: Pulse:69 Resp: 20 O2 sat: 97% RA B/P Right:109/56 Left: Height:5'9 Weight:88KG General: NAD, ALERT AND COOPERATIVE Skin: Dry [X] intact [X] SCAR UPPER MID BACK HEENT: PERRLA [X] EOMI []X Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] NO Murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema Varicosities: None [X] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +1 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left:+2 Carotid Bruit Right: NONE Left: NONE Pertinent Results: [**2104-7-24**] Echo: PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with anterior and anterolateral apical segments. 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 aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. 1. Biventricular function is normal. 2. MR appears improved 3. Aortic contours appear intact post decannulation 4. Other findings are unchanged Abd U/S [**2104-7-23**]: 1. No intra- or extra-hepatic bile duct dilatation. 2. Cholelithiasis without evidence for acute cholecystitis. 3. Probable hemangioma in the left lobe of the liver. 4. No ascites. [**2104-7-21**] 05:15PM BLOOD WBC-10.0 RBC-3.67* Hgb-11.6* Hct-33.4* MCV-91# MCH-31.6 MCHC-34.8 RDW-14.3 Plt Ct-398# [**2104-7-28**] 05:15AM BLOOD WBC-10.6 RBC-2.63* Hgb-8.1* Hct-24.1* MCV-92 MCH-30.9 MCHC-33.8 RDW-14.8 Plt Ct-297 [**2104-7-21**] 05:15PM BLOOD PT-13.0 PTT-26.5 INR(PT)-1.1 [**2104-7-24**] 12:58PM BLOOD PT-14.3* PTT-36.7* INR(PT)-1.2* [**2104-7-21**] 05:15PM BLOOD Glucose-112* UreaN-17 Creat-1.2 Na-134 K-4.9 Cl-98 HCO3-27 AnGap-14 [**2104-7-28**] 05:15AM BLOOD Glucose-112* UreaN-28* Creat-1.2 Na-134 K-4.3 Cl-100 HCO3-23 AnGap-15 [**2104-7-21**] 05:15PM BLOOD ALT-94* AST-93* CK(CPK)-24* AlkPhos-258* TotBili-0.6 [**2104-7-24**] 05:50AM BLOOD ALT-55* AST-34 LD(LDH)-186 AlkPhos-197* Amylase-28 TotBili-0.6 [**2104-7-21**] 05:15PM BLOOD CK-MB-NotDone cTropnT-0.23* [**2104-7-22**] 12:50PM BLOOD %HbA1c-6.3* Brief Hospital Course: On [**7-24**] Mr.[**Known lastname **] went to the operating room and underwent Coronary Artery Bypass Grafting x 5(Left internal mammary artery grafted to left anterior descending artery/Saphenous Vein grafted to Diagonal/Obtuse Marginal/Post . descending artery/PLB). Cross clamp time= 78 minutes. Cardiopulmonary Bypass Time= 91 minutes. Please refer to Dr.[**Name (NI) 9379**] operative report for further details. Mr.[**Known lastname **] [**Last Name (Titles) 8337**] the procedure well and was transferred to the CVICU in stable but critical condition, requiring pressors to optimize hemodynamic support. He awoke neurologically intact and was extubated without difficulty. All lines and drains were discontinued in a timely fashion. Beta-Blockers, statin, aspirin and diuresis was initiated. He continued to progress and on POD#2 he was transferred to the step down floor for further monitoring. Physical therapy consulted and evaluated. He had a brief episode of atrial fibrillation on POD#2 which was eventually converted to sinus rhythm with beta-blockers and amiodarone. During his post-op course he worked with physical therapy for strength and mobility. On POD#4 he appeared to be doing well and was cleared by Dr. [**Last Name (STitle) 914**] for discharge to home with VNA. Of note, he had scant drainage from superior pole on discharge day and was started on a 7 day course of antibiotics. All follow up appointments were advised. Medications on Admission: HCTZ 12.5mg PO daily ASA 325mg PO daily metoprolol tartrate 50mg PO (Rx is for [**Hospital1 **] but patient taking daily) simvastatin 40mg PO daily plavix 75mg PO daily (held for possible cabg, last dose [**2104-7-19**]) Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 2. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. 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* 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*1* 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for sternal drainage for 7 days: first dose given this AM in hospital. Disp:*27 Capsule(s)* Refills:*0* 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take 400mg [**Hospital1 **] x 7 day. Then 200 [**Hospital1 **] x 7 days. Finally 200mg QD until stopped by cardiologist. Disp:*60 Tablet(s)* Refills:*1* 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 Myocardial Infarction (per-op) Borderline Diabetes Mellitus NSTEMI [**2083**] s/p POBA to prox LAD and D1 then repeat PTCA 4 months later for ISR at LAD and D1; DES to RCA x2 [**2097**] TIA [**2096**] Gout Dyslipidemia s/p skull fracture as child in setting of trauma Hypertension Past Surgical History: s/p Right cheek basal cell CA excision s/p posterior thorax excision of benign compound nevus [**5-/2095**] s/p RUE atypical nevus/melanoma s/p multiple concussions- as child Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Wound check on [**Hospital Ward Name 121**] 6 in 1 week Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) **] Dr. [**Last Name (STitle) **] in [**1-4**] weeks Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-5**] weeks Follow up with your dentist this week regarding dental extractions- should be performed within 2 weeks Completed by:[**2104-7-28**] Name: [**Known lastname **],[**Known firstname **] K Unit No: [**Numeric Identifier 17508**] Admission Date: [**2104-7-21**] Discharge Date: [**2104-7-29**] Date of Birth: [**2024-2-5**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1543**] Addendum: Mr.[**Known lastname **] was held from discharge on [**7-28**] due to new serous sternal drainage, expressed with vigorous cough. He was placed on Keflex empirically, and held for further observation. [**7-29**] Dr.[**Last Name (STitle) **] cleared Mr.[**Known lastname **] for discharge to home with VNA. Upon examination, a pinpoint amount of serous drainage was expressed. Sternum stable, no [**Doctor Last Name **] or click, no elevated WBC ct or fever. Medication dose changes from the discharge summary dated [**7-28**] will be: Lasix 20 mg tabs, 1 tab by mouth twice daily x 14 days. Mr.[**Known lastname **] was advised of follow up appointments, including a wound check in 1 week from discharge on [**Hospital Ward Name **] 6. Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 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. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(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. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:*45 Tablet(s)* Refills:*1* 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for sternal drainage for 7 days: first dose given this AM in hospital. Disp:*27 Capsule(s)* Refills:*0* 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take 400mg [**Hospital1 **] x 7 day. Then 200 [**Hospital1 **] x 7 days. Finally 200mg QD until stopped by cardiologist. . Disp:*60 Tablet(s)* Refills:*1* 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 6688**] Followup Instructions: Wound check on [**Hospital Ward Name **] 6 in 1 week Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) **], PLEASE CALL FOR APPOINTMENT Dr. [**Last Name (STitle) 13907**] in [**1-4**] weeks Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1129**] in [**2-5**] weeks Follow up with your dentist this week regarding dental extractions- should be performed within 2 weeks [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2104-7-29**]

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45192

Discharge summary

report

Admission Date: [**2152-1-9**] Discharge Date: [**2152-1-15**] Service: MEDICINE Allergies: Sulfonamides Attending:[**First Name3 (LF) 14145**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: s/p pacemaker implantation History of Present Illness: [**Age over 90 **] F with multiple falls, s/p LAD stent [**8-11**], s/p MI x2, LVEF 50% 2/04, hyperlipid, HTN, presenting after she fell down today. She states that she wears a wrist brace for carpal tunnel syndrome, and the brace slipped off of her walker as she was ambulating, and she fell down on the carpet. She had a brief feeling before she fell, that she was going to fall, she describes this as a "weak" feeling. No LOC, no head or body trauma. For the past few months, she has been feeling fatigued but not lightheaded, no cough, no dysuria. Her last fall was one year ago. She has had no N/V/D, and slightly decreased PO intake over the past few months. . In the ED, Cr 0.9, Hct 35.6. UA negative, CXR pend. Her vitals were stable on admission, but she went into AFIB with RVR with HR 140s with BP 120s. She was placed on Diltiazem gtt with HR 80s, BP 100-110. She has no history of AFIB, and has never gone into AFIB before as far as she knows. On exam she only had LE edema. She had a troponin leak of CK 184, MB 11, Trop 0.17. felt to be associated with rate related ischemia. CT Head negative for head trauma or bleed s/p fall. Heparin gtt was started. . Over the past two years, she has had a decline in her balance, and has arthritis in her R knee. She denies any lightheadedness, dizziness, visual disturbances, CP, palpitations, or headaches associated with these falls. . On the way to the floor, patient developed [**1-19**] SSCP. EKG shows 2mm STE V1-V4, which may be mildly worse than the anteroseptal STEs on previous EKGs. Past Medical History: Hypertension, difficult to control Hypercholesterolemia Arthritis Single L kidney. Right kidney non-functional s/p RF ablation adrenal adenoma CAD, s/p LAD stent([**8-11**]), s/p MI x 2, LVEF 50%([**2-13**]) Diverticula recent admit [**Date range (1) 17057**] for generalized weakness Hemangiomas in Liver Social History: Pt lives in senior housing building [**State **]. She has lived there 20 years. She has 3 sons, 1 in [**State 4565**], 1 in [**Hospital1 392**] and another in [**Location (un) 4310**] who are not very involved. She has 1 grand-daughter who is " very busy." She has a housekeeper 1.5 hours a week. She also has a shopper who helps her with groceries once a week and has a companion who accompanies her outside the building 2 x/ week on errands. She has 1 meal a day provided. No ETOH, tobacco Family History: NC Physical Exam: VS: 96.4 / 141/65 / 69 / 20 / 100% 2Lnc GEN: Elderly female, pleasant, in no acute distress. HEENT: EOM intact, moist mm, JVD 6 cm, no LAD, OP clear, no thyromegaly LUNGS: CTAB HEART: 1/6 SEM (not noted several months ago), RRR, no r/g ABD: Mild tenderness LLQ, soft, +BS, ND, NT to palpation over LLQ EXTR: Trace LE edema, 2+ DP bl NEURO: CN 2-12 tested and intact, [**5-13**] motor SKIN: No rash Pertinent Results: [**2152-1-8**] 07:10PM PT-11.9 PTT-27.5 INR(PT)-1.0 [**2152-1-8**] 07:10PM PLT COUNT-253 [**2152-1-8**] 07:10PM NEUTS-79.8* LYMPHS-15.3* MONOS-3.1 EOS-1.1 BASOS-0.7 [**2152-1-8**] 07:10PM WBC-8.6 RBC-3.93* HGB-12.3 HCT-35.6* MCV-91 MCH-31.4 MCHC-34.7 RDW-14.0 [**2152-1-8**] 07:10PM CALCIUM-9.4 PHOSPHATE-2.9 MAGNESIUM-1.9 [**2152-1-8**] 07:10PM CK-MB-11* MB INDX-6.0 cTropnT-.17* [**2152-1-8**] 07:10PM CK(CPK)-184* [**2152-1-8**] 07:10PM GLUCOSE-131* UREA N-23* CREAT-0.9 SODIUM-132* POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-25 ANION GAP-15 [**2152-1-8**] 08:10PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**2152-1-8**] 08:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [**2152-1-8**] 08:10PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2152-1-9**] 01:10AM CK-MB-12* MB INDX-6.6* cTropnT-0.25* [**2152-1-9**] 01:10AM CK(CPK)-181* [**2152-1-9**] 05:40AM PT-13.0 PTT-150* INR(PT)-1.1 [**2152-1-9**] 05:40AM PLT COUNT-214 [**2152-1-9**] 05:40AM NEUTS-67.1 LYMPHS-26.0 MONOS-4.8 EOS-1.3 BASOS-0.7 [**2152-1-9**] 05:40AM WBC-7.3 RBC-3.69* HGB-12.0 HCT-33.4* MCV-91 MCH-32.7* MCHC-36.0* RDW-14.5 . CT head [**2152-1-8**]- There is no intracranial hemorrhage, mass effect, or shift of the normally midline structures. Again redemonstrated is a small chronic infarct with volume loss in the posterior right frontal lobe. Mild periventricular cerebral white matter hypodensity is consistent with chronic microvascular ischemic changes. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Again seen is a small symmetric ovoid metallic density at the anteromedial aspect of the right globe likely related to lens implant. The visualized mastoid air cells and paranasal sinuses are clear. The osseous structures are unremarkable. . pCXR [**2152-1-8**]- No acute cardiopulmonary abnormality. . Lumbar films: IMPRESSION: Diffuse degenerative changes of the L-spine with no evidence for compression fracture. . Catheterization: . 1. One vessel coronary artery disease (unchanged). 2. Normal LV diastolic function. 3. Diffuse slow flow consistent with microvascular dysfunction. 4. Continue medical management. . Echo: . Impression: moderate concentric left ventricular hypertrophy with normal ejection fraction and at least mild diastolic dysfunction . Compared with the findings of the prior report (images unavailable for review) of [**2148-7-29**], left ventricular wall thickness is increased, now with evidence of diastolic dysfunction. Brief Hospital Course: [**Age over 90 **] F with multiple falls, s/p LAD stent [**8-11**], s/p MI x2, LVEF 50% 2/04, hyperlipid, HTN, presenting after a fall. . # Fall: Likely etiology is mechanical, but concern for cardiac causes, such as AFIB or ischemia. - CT head negative. - L-spine xray negative for compression fracture. - Small trop leak in setting of Afib with RVR. - Infectious w/u negative-cxr wnl, U/A negative. - TSH was noted to be elevated at 9.5, but FT4 was normal @ 1.1. . # Rhythm: AFIB with RVR in ED, quickly resolved to NSR on floor. Dr. [**Last Name (STitle) **], her outpatient cardiologist saw the patient and recommended switching to Sotolol for rate control and antiarrhythmic properties. - slight troponin leak in setting of RVR. - Was initially heparinized, but when enzymes trended down, no more Afib/rvr, no ecg changes c/w ischemia, heparin gtt d/c'd. - pt. not a candidate for long-term anticoagulation given fall risk. - she was continued on sotolol, and on [**1-12**], while awaiting discharge to rehab hospital in otherwise stable condition, she was found by her nurse "slumped in her chair, unresponsive". Code Blue (cardiac arrest) was called. On arrival to bedside, she was found unresponsive, on back board in bed. She was not breathing. After jaw thrust maneuver, she began breathing spontaneously. There was no palpable pulse. Chest compressions were started. After two compressions, she wailed in pain, and began speaking and answering questions. Her BP was measured at approx. 70 systolic. Her rhythm on the ACD was idioventricular rhythm at a rate of 37. She was givne one mg. of atropine, and approximately 5 minutes later, her BP was measured at 115 systolic, with HR response to 50's, sinus. - she was transferred to the CCU for closer monitoring. - she went to cath (results unchanged from prior) - she then went to the EP lab for pacemaker placement for symptomatic bradycardia attributed to medication-induced sinus arrest on the background of sick-sinus syndrome. - she had her pacer placed without complication, and was transfered back to the floor. - she was continued on sotolol - she was discharged to rehab two days following pacer placement. . # Ischemia: subtle ECG changes, Troponin leak is likely due to AFIB with RVR 140s. Cath as above. # Pump: last echo [**2148**] showed normal pump function - Echo repeated (above). - Continued on asa, ccb, statin, [**Last Name (un) **], nitrate, sotolol. Medications on Admission: Aspirin 81mg qdaily Metoprolol 12.5mg po BID Benicar 20mg po BID Lipitor 10mg po QHS Imdur 15mg po BID Senna 1 tab po BID Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). Disp:*60 Tablet, Sublingual(s)* Refills:*2* 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: 0.5 Tablet Sustained Release 24HR PO BID (2 times a day). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 6. Olmesartan 20 mg Tablet Sig: One (1) Tablet PO bid (). Disp:*60 Tablet(s)* Refills:*2* 7. Aspirin 325 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* 8. Psyllium Packet Sig: One (1) Packet PO BID (2 times a day). Disp:*60 Packet(s)* Refills:*2* 9. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO at bedtime. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Last Name (un) 1687**] House Discharge Diagnosis: NSTEMI, Sick-sinus syndrome, sinus arrest due to medications, s/p pacemaker implantaion. Discharge Condition: Stable Discharge Instructions: Take all medications as prescribed Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2152-1-19**] 2:00 . You must make an appointment with your PCP [**Last Name (LF) **],[**First Name3 (LF) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 2936**] upon discharge from rehab. Completed by:[**2152-1-15**]

[ "E942.0", "427.81", "401.9", "V45.82", "427.31", "272.4", "E885.9", "412", "427.5", "414.01", "276.1", "410.71" ]

icd9cm

[ [ [] ] ]

[ "88.55", "37.83", "37.22", "37.72", "88.52" ]

icd9pcs

[ [ [] ] ]

9731, 9789

5735, 8183

229, 258

9922, 9931

3132, 5712

10014, 10327

2695, 2699

8356, 9708

9810, 9901

8209, 8333

9955, 9991

2714, 3113

181, 191

286, 1837

1859, 2166

2182, 2679

9,856

149,562

6917

Discharge summary

report

Admission Date: [**2190-2-27**] Discharge Date: [**2190-3-14**] Date of Birth: [**2116-2-10**] Sex: M Service: Medicine DIAGNOSIS: Mobile obstruction with adhesions. HISTORY OF PRESENT ILLNESS: This is a 74-year-old gentleman who presented with three days of abdominal pain and distention. No nausea or vomiting. The pain started three days prior to admission and was diffuse followed by abdominal distention. He had no fevers or chills but did not have decreased appetite. He noted the increased distention and was brought to the [**Hospital1 69**] Emergency Room for evaluation. PAST MEDICAL HISTORY: (Notable for) 1. Nissen fundoplication in [**2175**]. 2. Bilateral inguinal hernia repairs. 3. Peripheral neuropathy. 4. Question Charcot [**Doctor First Name **] tooth disease. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: None. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.6, pulse 105, blood pressure 158/78, respiratory rate 40. Lungs were clear to auscultation bilaterally. Heart had a regular rate and rhythm. Abdomen was firm and distended with mild right-sided tenderness. No guarding. No percussion tenderness. Rectal examination revealed normal tone, normal prostate, heme-negative. Extremities were warm. LABORATORY ON ADMISSION: White blood cell count of 7.5, hematocrit was 45, platelets of 179. Sodium was 139, potassium was 3.4, chloride was 100, bicarbonate was 21, BUN was 57, creatinine was 1.6, sugar was 176. ALT was 59, AST was 78, alkaline phosphatase was 111, total bilirubin was 3.5, direct bilirubin was 1.8, amylase was 411, lipase was 660. Abdominal x-ray showed dilated loops of small bowel with air/fluid levels. Abdominal CT showed dilated small bowel with small pockets of free air, positive pneumatosis, and positive portal venous gas with distended small bowel. HOSPITAL COURSE: The patient was admitted with a diagnosis of small-bowel obstruction with a secondary diagnosis of ileus secondary to gallstone pancreatitis. He was admitted and given IV fluids and ampicillin, ceftriaxone, and Flagyl IV antibiotics and made n.p.o. He was taken to the operating room on [**2190-2-28**], with a preoperative diagnosis of small-bowel obstruction and a postoperative diagnosis of small-bowel obstruction. The operation was lysis of adhesions. Findings included adhesive bands crossing the small bowel at the inferior portion of the prior midline incision. The bowel was decompressed and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube was placed. It was noted that there were some areas of ischemic bowel, but nothing was gangrenous. The plan was to take the patient back for a second look operation the next day. He was admitted to the surgical intensive care unit, intubated and sedated; otherwise, stable. He did well. He was continued on propofol overnight and morphine for comfort and kept n.p.o. with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube and NG-tube to low wall suction. On [**3-1**], he was taken back for a second look. No resection was necessary. Findings included small bowel which was viable, some submucosal hemorrhage. All small bowel was viable. He was returned back to the intensive care unit, intubated and sedated and continued on ampicillin, ceftriaxone, and Flagyl. In the surgical intensive care unit his sedation was weaned, and he was extubated on [**2190-3-8**]. He was also started on total parenteral nutrition during his surgical intensive care unit stay. Also of note, on [**3-5**], he spiked a fever to a temperature maximum of 101.5 overnight with a concomitant increase in white blood cell count to 5900. It was thought that the fever was likely due to pneumonia, and sputum cultures were taken which eventually grew out Citrobacter. An infectious disease consultation was called, and they recommended starting levofloxacin IV and continuing ampicillin and Flagyl at that time. He was transferred to the floor on [**2190-3-8**], in stable condition, and his [**Hospital Ward Name **] tube was slowly discontinued while on the floor. The [**Hospital Ward Name **] tube finally came out on [**2190-3-11**], and he was started on a clear liquid diet which he tolerated well. His diet was advanced on [**3-13**] to a regular diet which he also tolerated well, and he was also switched to all of his p.o. medications. He was getting out of bed and continuing to progress, so the decision was made to transfer him to the postanesthesia care unit to the care of Dr. [**First Name (STitle) 679**] for further treatment and rehabilitation. His IV antibiotics, and he was continued on p.o. Levaquin on discharge. MEDICATIONS ON DISCHARGE: 1. Levaquin 500 mg p.o. q.d. until [**3-19**]. 2. Hydralazine 20 mg p.o. q.i.d. 3. Lasix 40 mg p.o. q.d. 4. Albuterol 7 cc and 7 cc normal saline q.4h. p.r.n. 5. Mucomyst 3 cc and 5 cc normal saline q.4h. p.r.n. 6. Haldol 2 mg IV q.4h. p.r.n. FOLLOWUP: He was instructed to follow up with Dr. [**Last Name (STitle) **] and to call for an appointment in about one week. On a regular diet. No physical activity restrictions. Potential for full recovery. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1379**] Dictated By:[**Last Name (NamePattern1) 16498**] MEDQUIST36 D: [**2190-3-13**] 17:18 T: [**2190-3-14**] 08:31 JOB#: [**Job Number 26051**]

[ "356.9", "560.1", "997.3", "560.81", "286.9", "577.0", "486", "569.83", "568.89" ]

icd9cm

[ [ [] ] ]

[ "99.15", "54.59", "54.12", "96.72", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

4736, 5472

876, 904

1886, 4710

214, 606

1309, 1868

628, 849

67,144

164,508

36052

Discharge summary

report

Admission Date: [**2173-6-2**] Discharge Date: [**2173-6-16**] Date of Birth: [**2119-7-9**] Sex: F Service: CARDIOTHORACIC Allergies: Shellfish Derived / Iodine; Iodine Containing / Betadine / Clonidine Attending:[**First Name3 (LF) 1505**] Chief Complaint: Known coronary artery disease with worsening dyspnea on exertion Major Surgical or Invasive Procedure: status post Coronary artery bypass grafting x 2(saphenous vein grafted to Ramus/obtuse Marginal)/Mitral Valve repair (#26mm St.[**Male First Name (un) 923**] Saddle ring)-[**6-9**] History of Present Illness: 53 yo white female with known CAD, s/p stents x 5 11.08 after AMI. Recurrent DOE last few days with walking 200 ft. Some chest pressure associated with this. Ruled out at [**Hospital **] Hospital. Cath today to show recurrent RI/Cx stenosis.Mild MR, inf-basal hypokinesis.LVEF~50%. Transferred for surgery. Past Medical History: Hypertension IDDM- (developed diabetes after 3rd pregnancy, multiple episodes of DKA) Esophageal ulcers Tobacco Abuse: 1 pack every 3 days History of cocaine abuse: clean x 1 yr (on parole for drugs) Social History: Social history is significant for tobacco abuse. One alcoholic drink per month. Clean from cocaine x 1 yr- periodically drug tested. Lives in [**Location 13588**] with daughter and sister. [**Name (NI) 6419**] mother and grandmothers had myocardial infarctions. Family History: Non-contributory Physical Exam: Physical Exam Pulse: Resp:16 O2 sat: B/P Right:120/60 Left: 122/62 Height:65" Weight:68kg General:WDWN in NAD 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-no Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [**Name (NI) 167**]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Right:n Left:n Pertinent Results: [**2173-6-15**] 06:10AM BLOOD WBC-5.8 RBC-3.51* Hgb-10.7* Hct-29.8* MCV-85 MCH-30.4 MCHC-35.9* RDW-14.0 Plt Ct-278# [**2173-6-3**] 06:05AM BLOOD WBC-5.3# RBC-3.93* Hgb-10.9* Hct-33.0* MCV-84 MCH-27.9 MCHC-33.1 RDW-13.8 Plt Ct-253 [**2173-6-9**] 05:45PM BLOOD PT-13.0 PTT-34.8 INR(PT)-1.1 [**2173-6-3**] 06:05AM BLOOD PT-12.1 PTT-21.8* INR(PT)-1.0 [**2173-6-15**] 06:10AM BLOOD Glucose-165* UreaN-18 Creat-0.6 Na-137 K-5.4* Cl-102 HCO3-27 AnGap-13 [**2173-6-3**] 06:05AM BLOOD Glucose-259* UreaN-18 Creat-0.6 Na-141 K-4.3 Cl-105 HCO3-29 AnGap-11 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81808**] (Complete) Done [**2173-6-9**] at 4:34:28 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2119-7-9**] Age (years): 53 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Prosthetic valve function. Right ventricular function. Valvular heart disease. ICD-9 Codes: 440.0, V43.3, 424.1, 396.9, 424.0 Test Information Date/Time: [**2173-6-9**] at 16:34 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD Test Type: TEE (Complete) 3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 30% to 40% >= 55% Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire is seen in the RA. No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Top normal/borderline dilated LV cavity size. Moderate regional LV systolic dysfunction. RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall hypokinesis. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (?#). No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Abnormal mitral valve. Moderate to severe (3+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The left ventricular cavity size is top normal/borderline dilated. There is moderate regional left ventricular systolic dysfunction with severely hypokinetic inferior mid and basal and infero-septal wall. There is mild hypokinesis of the remaining segments (LVEF = 30-40 %). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. The mitral valve is abnormal. Moderate to severe (3+) mitral regurgitation is seen. There is no pericardial effusion. POST CPB: Globally normal [**Hospital1 **]-ventricular systolci function with background inotropix support. Annuloplasty ring seen in the mitral position. Stable with good leaflet excursion. Mild MR. [**First Name (Titles) 81809**] [**Last Name (Titles) **].No other change Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2173-6-10**] 13:13 ?????? [**2167**] CareGroup IS. All rights reserved. Brief Hospital Course: [**6-9**] Ms.[**Known lastname **] [**Last Name (Titles) 1834**] coronary artery bypass grafting x 2 (saphenous vein grafted to Ramus/Obtuse Marginal)/Mitral Valve repair (#26mm St.[**Male First Name (un) 923**] Saddle ring) with Dr.[**Last Name (STitle) **]. Cross clamp time = 82 minutes/ Cardiopulmonary bypass time = 103 minutes. Please refer to Dr[**Last Name (STitle) **] operative report for further details. She was transferred to CVICU on Epinephrine to augment hemodynamics. She awoke neurologically intact and was extubated without difficulty. All lines and drains were discontinued in a timely fashion. On POD#2 she was transferred to the step down unit for further monitoring. [**Last Name (un) **] consulted preop for glucose control and followed postoperatively as well. Beta-blocker started when blood pressure would tolerate. Gentle diuresis initiated. Narcotics discontinued secondary to hallucinations. Pain controlled with Ultram and Ibuprofen. The remainder of her postoperative course was essentially uneventful. Ms.[**Known lastname **] continued to progress and on POD# 7 she was cleared for discharge to rehab for further increase in strength, endurance, and activities of daily living. All follow up appointments were advised. Medications on Admission: ToprolXL 50mg/D,lisinopril 20mg/D, Lasix 40mg/D, ASA 325mg/D, Pepcid 20mg/D, Zocor 80mg/D, Lantus 24units HS,aspart SSI.plavix 75mg/D Prednisone 20mg TID/mucomyst 600mg TID after cath Plavix - last dose: [**2173-5-31**] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 13. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) Subcutaneous ACHS. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] House - [**Location (un) 13588**] Discharge Diagnosis: status post Coronary artery bypass grafting x 2(saphenous vein grafted to Ramus/obtuse Marginal)/Mitral Valve repair (#26mm St.[**Male First Name (un) 923**] Saddle ring)-[**6-9**] Acute myocardial infarction '[**72**] with stents x5/Insulin dependent diabetes/HTN/chronic left shoulder pain Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) **],[**First Name3 (LF) **] J [**Telephone/Fax (1) 75256**] in 1 week please call for appointment Dr [**Last Name (STitle) 8579**] in [**2-23**] weeks please call for appointment Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3071**]) Completed by:[**2173-6-16**]

[ "412", "414.01", "250.92", "424.0", "401.9", "E878.8", "305.1", "719.41", "521.00", "V58.67", "996.72" ]

icd9cm

[ [ [] ] ]

[ "23.19", "35.24", "39.61", "36.12" ]

icd9pcs

[ [ [] ] ]

9949, 10075

7265, 8520

398, 581

10411, 10418

2117, 5560

10930, 11373

1438, 1456

8792, 9926

10096, 10390

8546, 8769

10442, 10907

5609, 6741

1471, 2098

294, 360

609, 919

941, 1142

1158, 1422

6752, 7242

79,851

171,573

44434

Discharge summary

report

Admission Date: [**2103-1-16**] Discharge Date: [**2103-1-27**] Date of Birth: [**2050-1-17**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2290**] Chief Complaint: Difficulty in breathing Major Surgical or Invasive Procedure: Intubation with sedation thoracentesis History of Present Illness: 52 yo female with history of [**Location (un) 805**] Syndrome, atrial fibrillation, CHF (? diastolic, last EF 70%), history of MVR, recent recurrent PNAs, and severe COPD, who presents with shortness of breath. She had a recent admission to [**Hospital1 18**] from [**Date range (1) 70560**] for HAP; during that admission, she was treated for HAP x2. Her admission was complicated by Afib with RVR. Her brother reports that she seemed to improve at rehab initially. She finished her antibiotics approximately 5 days prior to admission. Two days prior to admission the patient reported worsening breathing and increased sputum production, although she was having a hard times coughing it up. The patient's brother (and HCP) did not notice her wheezing more. Per [**Hospital1 1501**], CXR showed RLL PNA, and she has been running low grade temps of 99. She was started on Levaquin 3 days prior to admission without improvement, so she was sent to the ED. She was slightly more hypoxic, increased O2 requirement from 2-4L. In the ED, the patient reported chest pain only with cough. She denied other symptoms. . In the ED, initial VS were: 97.5 120 168/108 20 94% 4L NC. Her EKG showed rapid Afib, no other changes. On exam, she was A&Ox3 and was conversant. She had poor airflow and decreased breath sounds at bases. Over course of ED, she developed worsening respiratory distress with tachypnea and lots of accessory muscle use. She did not desat. The ED started bipap, but she didn't tolerate well; her O2 sats decreased to 86%. They were considering intubating her... Her CXR showed RLL pneumonia very similar to previous CXR. She was given Vancomycin 1gm IV x1 and Cefepime for HAP. She was given diltiazem 10mg IV x1 for afib with RVR, and HR improved to 90s. She did not have any hypotension. She was given 2L of IVF in ED. She has one peripheral IV. She was placed briefly on BIPAP but desaturated to 86% and looked more uncomfortable. ABG showed 7.16/72/87/27. She was intubated in the ED and transferred here. Past Medical History: [**Location (un) 805**] Syndrome- "elfin" facial appearance, developmental delay, depression DM [**1-3**] steroids Afib CHF COPD Diverticulitis CAD MVR malnutrition, on Megace Social History: She was at Bostonian [**Hospital1 1501**] after last discharge. Generally, lives in [**Hospital1 **] with 2 brothers. [**Name (NI) **] brothers, no longer able to walk or take care of ADLs; decline in last few months since recurrent PNAs. Not working. Former smoker, smoked [**12-3**] PPD for 30 years, quit 2 years ago. No EtOH or ilicit drugs. Family History: CAD. No other congenital abnormalities in the family Physical Exam: Admission labs: GEN: thin, frail appearing woman, intubated, alert, opens eyes to voice and follows commands, calm HEENT: PERRL, EOMI, anicteric, MMM, JVD flat. RESP: bilat rhonchi diffusely worse on right. CV: rapid rate, irregular S1 and S2 wnl, no m/r/g ABD: +b/s, soft, mildly distended, nt, no masses or hepatosplenomegaly EXT: trace pedal edema, wwp SKIN: no rashes/no jaundice/no splinters NEURO: alert, following commands, squeezes hands, moves feet on command. . At the time of discharge her physical exam: GEN: thin, frail appearing woman HEENT: PERRL, EOMI, anicteric, MMM, JVD flat. RESP: decreased breath sounds throughout, no wheeze or rhonchi CV: irreg irreg, nl S1 S2 ABD: +b/s, soft, NTND EXT: no edema SKIN: no rashes/no jaundice/no splinters NEURO: A&Ox3, nonfocal Pertinent Results: Admission labs: [**2103-1-16**] 07:10PM WBC-13.4* RBC-3.90*# HGB-11.4*# HCT-37.6# MCV-96 MCH-29.2 MCHC-30.3* RDW-15.9* [**2103-1-16**] 07:10PM NEUTS-78.8* LYMPHS-16.6* MONOS-3.4 EOS-0.8 BASOS-0.4 [**2103-1-16**] 07:10PM DIGOXIN-1.3 [**2103-1-16**] 07:10PM cTropnT-0.02* [**2103-1-16**] 07:10PM GLUCOSE-90 UREA N-14 CREAT-0.7 SODIUM-142 POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-32 ANION GAP-15 [**2103-1-16**] 10:54PM LACTATE-3.2* [**2103-1-16**] 10:54PM TYPE-ART PO2-87 PCO2-72* PH-7.16* TOTAL CO2-27 BASE XS--4 Labs at the time of discharge: WBC 13.2 Hct 27.6 Plt 466 Na 145 K 4.3 Cl 103 CO2 38 BUN 16 Cr 0.7 Ca 8.0 Mg 2.5 INR 1.4 PTT 60.2 . Right Pleural Fluid: NEGATIVE FOR MALIGNANT CELLS. . CTA chest [**2103-1-17**]: Although this study was not designed for subdiaphragmatic evaluation, images of the upper abdomen demonstrate reflux of contrast into the intrahepatic IVC and hepatic veins, and an apparent filling defect in the intrahepatic IVC. Nonadditional abnormalities are identified. IMPRESSION: 1. Two new, large, left atrial thrombi. Confirmation with transesophageal echo was recommended. No evidence of pulmonary embolism. 2. Filling defect within the intrahepatic IVC, which is incompletely imaged but could represent mixing artifact. However, further evaluation with ultrasound of the intrahepatic IVC is recommended to exclude clot. 3. Possible left lower lobe pneumonia. Clinical correlation is recommended. 4. Stable large right pleural effusion and small left pleural effusion. . CT head without contrast [**2103-1-17**]: IMPRESSION: No acute intracranial process. . [**2103-1-17**] Gallbladder/liver U/S: IMPRESSION: No evidence of filling defect within the intrahepatic IVC. . [**2103-1-18**] MR head w/o contrast IMPRESSION: No evidence of acute infarction. Moderate microangiopathic small-vessel disease. . [**2103-1-19**] TTE The left atrium is dilated. The right atrium is dilated. A possible left atrial thrombus vs mass is seen (best visualized in parasternal views) which measures 1.4 x 0.8 and appears to adhere to the wall of the left atrium. This cannot be readily visualized with Definity contrast due to shadowing artifact. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The mitral valve leaflets are mildly thickened. The mitral valve shows characteristic rheumatic deformity. A mitral annuloplasty ring is seen. . Compared with the prior study (images reviewed) of [**2102-12-5**], the left atrial mass appears new. This focused study did not [**Year (4 digits) 4656**] valvular structure and function or ventricular function. . If clinically indicated, a TEE may better assess the size and location of the mass/thrombus. . [**2103-1-17**] MRI head There is no evidence of hemorrhage or areas of slow diffusion to suggest acute infarction. Bilateral scattered foci of T2 and FLAIR hyperintensities with confluent signal changes in the periventricular white matter extending into the brainstem consistent with moderate microangiopathic small vessel disease. A punctate focus of FLAIR and T2 prolongation is demonstrated in the right thalamus, suggesting an old lacunar infarct. The ventricles and sulcal configuration are age appropriate. There is no mass or mass effect. The visualized paranasal sinuses are clear. IMPRESSION: No evidence of acute infarction. Moderate microangiopathic small-vessel disease. . [**2103-1-17**] Liver U/S No evidence of filling defect within the intrahepatic IVC . CXR ([**2103-1-26**]): FINDINGS: In comparison with the study of [**1-23**], there has been substantial decrease in the right pleural effusion. Severe chronic pulmonary disease persists with coarse interstitial markings. No definite acute focal pneumonia is appreciated. Brief Hospital Course: 52 yo female with h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Syndrome, Atrial fibrillation, CHF (? diastolic, last EF 70%), history of MVR, recent recurrent PNAs and severe COPD presented with shortness of breath. She was intubated for hypoxic respiratory failure and CTA chest was negative for PE but showed a question of a LLL PNA and sputum grew MSSA. Thoracentesis in the intensive care unit yielded serosanguinous fluid 850cc which was concerning for malignancy, cytology was negative. After her thoracentesis she was easily extubated and transferred to the floor. . # SOB/COPD - As above, her SOB on presentation was severe enough to require intubation. Regarding the etiology of her sympotms, much of her shortness of breath is likely due to her severe and chronic COPD as well as significant pulmonary hypertension. Her acute worsening on admission was likely due to her pleural effusion with possible contribution of a MSSA pneumonia. Her pleural effusion was drained for 800 cc in the intensive care unit and her breathing did improve. She was also treated with 7-days of vancomycin and 5-days of levofloxacin for possible pneumonia though it is not clear if this was a definite contributor in this case. Her shortness of breath continued to trouble her and her pleural effusion re-accumulated. We decided to put her on prednisone given her continued symptoms for a planned slow taper. For her pleural effusion, it was drained again on [**2103-1-25**] by interventional pulmonology for about 650 cc. Both times the fluid was consistent with a transudative exudate. Culture from the first drainage remained negative. The etiology of her effusions is not clear. She is scheduled to see pulmonary in follow-up in the end of [**Month (only) 958**] and it is very important that she make this appointment. She should continue on nebulizer therapy, advair, prednisone taper. Her weight should be monitored carefully and lasix titrated to keep her weight stable so that she does not accumulate any fluid. Of note, it is very important that she continue to receive oxygen therapy for her pulmonary hypertension as well as her COPD in order to maintain her oxygen saturations above 92%. - prednisone 40 mg daily, plan for slow taper with decrease by 10 mg qweek down to 10 mg daily. At that time, she should see pulmonary and they should help to determine further decreases in her steroids. - continue xopenex, spiriva, advair - closely monitor weight. - continue O2 to maintain sats >92%, she should have oxygen at all times. . # Left atrial thrombus - A CTA was done on admission that was negative for a pulmonary embolism but did show a question of a left atrial thrombus versus mass. A TEE was attempted while she was intubated but the cardiologists were unable to pass the probe secondary to a very small esophagus. A TTE was then performed but this was unable to distinguish between an atrial thrombus and an atrial mass. This issue was discussed with the TEE fellow, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 95245**], who spoke with the echo attending. They felt that given the fact that Ms. [**Known lastname 17926**] had an echocardiogram 1-month ago that was negative for this clot/mass, that it was most consistent with a clot and not a mass. A TEE would be very difficult to obtain in this patient and would require a pediatric probe. As such, she was scheduled to see a cardiologist in follow-up and will have an echocardiogram at that time to ensure the clot has resolved. She is being anticoagulated. She is currently on a heparin drip with coumadin bridge. When her INR is greater than 2, the heparin drip can be discontinued and she should continue on coumadin until she sees the cardiologist. Megace was discontinued due to the possibility that this may contribute to the formation of a clot. . # Atrial fibrillation w/rvr - The patient's heart rate was only poorly controlled with her home regimen. As a result, her nodal blockate was increased. She is currently on metoprolol 25 mg every six hours and diltiazem 60 mg every six hours. On these doses of medications, her heart rate was well controlled. She was continued on her digoxin without any changes. As above, she was anticoagulated. . #Anisocoria: Pt. was noted to have anisocoria on day after admission which appeared to be new, she was evaluated by neurology and MRI head was negative for acute infarction. Her anisocoria is most likely [**1-3**] a horner's syndrome [**1-3**] trauma from intubation. . # DM - Her finger sticks were initially well controlled on sliding scale insulin. However, once she was on steroids her finger sticks were more elevated. She was started on lantus and this was increased to 20 units qHS at the time of discharge with sliding scale humalog prior to meals. I suspect that this will need to be decreased as her steroids are tapered and this should be watched carefully. . # chronic diastolic CHF - She was given several doses of IV lasix to aid with diuresis and her home lasix was increased to 60 mg daily. Her weight should be monitored carefully and attempts should be made to keep her euvolemic . # Malnutrition - as above, megace was discontinued given the atrial thrombus. Medications on Admission: (per [**Hospital1 1501**]) Digoxin 0.125mg PO daily Diltiazem 45mg PO Q6hr Colace 100mg PO BID Ferrous Sulfate 325mg PO BID Advair 500/50 1 puff [**Hospital1 **] Lasix 40mg PO daily Mucinex 600mg PO BID Guaifenesin cough syrup prn Ibuprofen 400mg PO Q6hrs Prn pain Lactulose 30ml PO TID PRN Xopenex 1 neb PO Q6hrs and Q2hrs;prn Megase 400mg PO daily Metformin 1000mg PO bid Metoprolol Tartrate 25mg PO BID Singular 10mg PO QHS Spiriva 18mcg PO daily Levaquin 250mg PO daily, started [**2103-1-14**] Vitamin B12 1000mcg PO daily Vitamin D 800 units PO daily Ambien 10mg PO QHS Novolog sliding scale at meals MVI Miralax PRN Bisacodyl 10mg PR daily PRN Milk of magnesia PRN KCL 40meq daily Tylenol 325mg 1-2 tabs PO Q4h prn Asorbic Acid 500mg PO BID (notably no longer on coumadin) Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. therapeutic multivitamin Liquid Sig: Five (5) cc PO DAILY (Daily). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. guaifenesin 600 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: Three (3) ML Inhalation Q4hrs () as needed for wheezing, sob. 12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 13. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 15. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 16. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 17. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 18. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): continue 40 mg daily through [**2-2**], then decrease to 30 mg daily through [**2-9**] then decrease to 20 mg dialy through [**2-16**] then decrease to 10 mg daily through [**2-23**]. Continue at 10 mg daily until you see a pulmonary physician and are instructed to decrease further. 19. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: titrate warfarin dose for inr goal of [**1-4**]. 20. insulin glargine 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous at bedtime: will need to be titrated based on FSBG. Disp:*100 units* Refills:*2* 21. furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 22. heparin (porcine) in NS 10 unit/mL Kit Sig: Six Hundred Fifty (650) units/hr Intravenous once a day for 2 days: titrate heparin drip per ptt . Discharge Disposition: Extended Care Facility: [**Hospital1 **] Lower [**Doctor Last Name 4048**] Discharge Diagnosis: # S. aureus (MSSA) Healthcare associated pneumonia # Pleural effusions (sterile) # L atrial thrombus # Atrial fibrillation # Severe COPD # Chronic CHF (presumed diastolic) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with shortness of breath, and you were diagnosed with pneumonia and a pleural effusion. You required intubation in the ICU, but your breathing improved with a thoracentesis (removal of the fluid around your lungs). You were also found to have a blood clot in your heart, for which you were treated with heparin and coumadin. You will need to follow-up with pulmonary in one month and will also need to follow-up with cardiology. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2103-2-21**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], 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: PULMONARY FUNCTION LAB and PULMONARY FOLLOW-UP When: THURSDAY [**2103-2-22**] at 8:40 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: THURSDAY [**2103-2-22**] at 9:00 AM

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icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "34.91", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

16352, 16429

7774, 13041

328, 368

16645, 16645

3894, 3894

17269, 17928

3021, 3075

13872, 16329

16450, 16624

13067, 13849

16796, 17246

3606, 3875

265, 290

396, 2438

3910, 7751

16660, 16772

2460, 2638

2654, 3005

21,626

186,644

26022

Discharge summary

report

Admission Date: [**2113-1-15**] Discharge Date: [**2113-1-23**] Date of Birth: [**2048-11-18**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Thoracoscopy, pleural biopsy, placement 24F chest tube, placement pleurx catheter History of Present Illness: 64 yo W w/50 pkyr smoking hx has had several months of increasing SOB and cough was seen at OSH and found to have new L pleural effusion w/ complete lung collapse. Patient was transferred to [**Hospital1 18**] thoracics service for consideration of VATS. Thoracentesis performed on day of admission revealed 2L of dark brown fluid with pH7 and glucose 1. IP was consulted and they performed thoracoscopy with pleural biopsy, drainage of 2L additional fluid and placement of 24F chest tube and pleurx. Pleurodiesis was not performed [**3-2**] substantial pleural scarring. . The patient developed SOB this AM w/ABG of 7.32/52/72 on NRB. Patient demonstrated tachypnea and increased WOB. CTA demonstrated substantial bil ground glass opacities, L hydropneumothorax; this was felt c/w re-expansion pulmonary edema. Patient was given 40 lasix w/substantial improvement SOB. Past Medical History: s/p partial thyroidectomy, s/p cesarean-section, ? anxiety Social History: Patient is 1ppd smoker x50 years, only stopping 3 months ago with her onset of SOB. She was drinking significant amounts of EtOH nightly and smoking for many years. Her first husband died 13 years ago, her second husband died approx 13 months ago. She has multiple children and a supportive family. Family History: Mother with [**Name2 (NI) 64650**], Father died of CAD, grandfather and uncle both died of Lung Cancer Physical Exam: Day of transfer: Tm97.9 Tc96.6 Afib 143 (100-150) 115/60 NAD, confused, appears comfortable MMM, neck supple, L subclav c/d/i Diffuse wheezing, insp and exp crackles Tachy, irreg irreg Soft, nt, nd, nabs Warm X 4 w/pulses X 4 Confused Pertinent Results: [**2113-1-22**] 04:14AM BLOOD WBC-13.6* RBC-3.61* Hgb-9.5* Hct-27.7* MCV-77* MCH-26.2* MCHC-34.2 RDW-15.4 Plt Ct-414 [**2113-1-21**] 03:43AM BLOOD Neuts-90.9* Lymphs-5.9* Monos-3.0 Eos-0 Baso-0.2 [**2113-1-22**] 04:14AM BLOOD Plt Ct-414 [**2113-1-22**] 04:14AM BLOOD Glucose-155* UreaN-37* Creat-0.6 Na-140 K-3.6 Cl-97 HCO3-35* AnGap-12 [**2113-1-20**] 04:02AM BLOOD ALT-15 AST-26 LD(LDH)-334* AlkPhos-136* TotBili-1.0 [**2113-1-19**] 04:17AM BLOOD GGT-44* [**2113-1-22**] 04:14AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9 [**2113-1-20**] 03:39AM BLOOD Type-ART pO2-61* pCO2-54* pH-7.36 calHCO3-32* Base XS-2 . . Micro: No growth on urine, pleural fluid, blood. . TTE: 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 2. There is a trivial/physiologic pericardial effusion. . ABDOMEN ULTRASOUND: No comparisons. The liver is normal in echotexture and without focal masses. There is no intra or extrahepatic biliary ductal dilatation. The aorta is of normal caliber throughout its visualized course. The pancreas and spleen are unremarkable. The gallbladder contains multiple stones, but no distention or wall edema. The common bile duct is normal measuring 5 mm. The main portal vein is patent with appropriate direction of flow. The right kidney measures 10.9 cm, and the left kidney measures 11.1 cm. There is no renal mass, stone, or hydronephrosis. There is no free fluid. This study is limited due to patient body habitus. IMPRESSION: Cholelithiasis without evidence of acute cholecystitis. . [**1-20**] CTA: CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: There are multiple enlarged mediastinal lymph nodes. For example, two adjacent right paratracheal nodes measure 16 x 12 and 15 x 13 mm in axial dimensions, respectively. More superiorly, a right upper paratracheal lymph node measures 15 x 13 mm, and a subcarinal node measures 28 x 17 mm. There is also lymphadenopathy in the right hilum, with a node measuring up to 18 x 11 mm. There is no axillary lymphadenopathy. It is difficult to assess for left hilar lymphadenopathy because of the presence of a partially collapsed left lung. The heart, great vessels, and pericardium are unremarkable. There is no pericardial effusion or evidence of pulmonary embolism. There is a moderately large pneumothorax in the left hemithorax, in spite of the presence of a chest tube. There is also a small left pleural effusion. In the left hemithorax, neither the lower or upper lobe has fully reexpanded and both appear surrounded by visceral pleural thickening, particularly the upper lobe. There are also atelectatic changes within the residual lobes and ground glass opacity. In the right lung, there are multiple areas of ground glass opacity and septal thickening. In comparison to the chest radiographs, this appearance has progressed over two days, and although the appearance is nonspecific by imaging, pulmonary edema is suspected. Limited views of the upper abdomen are unremarkable. BONE WINDOWS: There are no suspicious lytic or blastic lesions. IMPRESSION: 1. Persistent hydropneumothorax on the left, in spite of the presence of the chest tube. 2. Partially collapsed left upper and lower lobes, which are surrounded by visceral pleural thickening. The differential for this appearance includes metastatic disease, primary lung cancer, mesothelioma, and potentially lymphoma. 3. Mediastinal and hilar lymphadenopathy. 4. Diffuse patchy ground glass opacities and septal thickening in the right lung, progressive over two days, which may represent pulmonary edema, given its rapid onset. . Pleural fluid cytology: Non-small cell carcinoma, consistent with pulmonary primary; see note. Note: The tumor cells are positive for CK7 and TTF-1 and negative for CK20. This profile is consistent with a pulmonary primary. . Pleural biopsy: Pending Brief Hospital Course: At the time admission to the MICU following previous hospital course documented in HPI, the patient was experiencing an acute exacerbation of her SOB. CTA was obtained c/w lymphangitic spread vs. pulmonary edema. Given the temporal relation to chest tube placement, it was hoped that the patient was experiencing re-expansion pulmonary edema that could be improved with lasix diuresis. The patient did initially experience some relief with lasix, suggesting that this was at least a component of her shortness of breath. Given diffuse disease evident in the lung, infiltrate could not be radiographically ruled out, so the patient was maintained on vancomycin, azithromycin and zosyn for broad coverage given her severe ilness. . On the patient's second day in the MICU, cytology returned on his efussion for NSCLC, thus stage IIIB "wet" / stage IV. No dominant mass was clearly visible on CT, raising the possibility of breast cancer. Oncology was consulted and discussed case and its prognosis with family and MICU team. However, given patient's extremely poor functional status with ongoing hypoxia, the MICU team did not feel that she would be an appropriate candidate for chemotherapy, even palliative, at this time. A decision was made to await the results of pleural biopsy, which remain pending at time of transfer. At the time of diagnosis of metastatic cancer, the patient decided that she wished to be DNR/DNI. . On the patient's second MICU day, she developed afib w/RVR to 130s. This was poorly rate controlled with IV boluses of metoprol, followed by diltiazem, so the patient was started on a diltiazem drip. The patient remained in the 120s, so amiodarone was loaded in an attempt at rhythm control, and to assist w/nodal blockade. Ca and atropine were maintained at the bedside given use of multiple nodal blocking agents, but the patient never converted to sinus. . The larger MICU plan of care had been to reverse any treatable causes of shortness of breath, notably infiltrates via antiobiotics, pulmonary edema with diuretics, and COPD exacerbation with steroids, atrovent and albuterol. TTE was obtained and was within normal limits. After several days, the patient continued to become increasingly SOB despite above measure. Both rate control and rhythm control strategies for afib had failed. Thus, the team discussed the poor prognosis for return to a good functional level and poor prognosis for survival beyond the short term. The patient's children and medical team decided that cardioversion would not be indicated given lack of improvement to either quality of quantity of life. . Given poor prognosis, patient's three children agreed that she should be CMO. Chest tube was removed. Of note, her pleurx catheter was left in place as it was not causing discomfort and was a tunnelled line. A morphine drip was initiated in addition to the fentanyl patch that had already been started a day before. These combined opioids were succesful in controlling both pain and dypnea. Fentanyl patch was not converted back to morphine given wide range of pharmacoconversion and success of current comfort regimen. . The patient's family requested transfer to [**Hospital3 6592**] to allow more family and friends to visit and for the patient to be closer to home. Dr. [**Last Name (STitle) **] kindly accepted the patient, and transfer was arranged via ambulance. Medications on Admission: xanax, albuterol, paxil Discharge Medications: 1. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 2. Morphine in D5W 1 mg/mL Parenteral Solution Sig: One (1) Intravenous TITRATE TO (titrate to desired clinical effect (please specify)): At 5mg/hr at time of transfer. 3. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 4. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) 2.5mg IV Injection [**Hospital1 **] (2 times a day) as needed: For agitation/confusion. Not used this hospitalization. 5. Lorazepam 2 mg/mL Syringe Sig: One (1) .5-5mg Injection Q2H (every 2 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 **] [**Hospital1 1501**]/[**Hospital 6136**] Hospital Group - [**Location (un) **] Discharge Diagnosis: Stage IV Non small cell lung cancer Discharge Condition: Hemodynamically stable, but dying Discharge Instructions: Comfort measures as detailed in discharge summary and per accepting physician [**Name Initial (PRE) 64651**]. Followup Instructions: Transfer to [**Hospital3 **] Completed by:[**2113-3-20**]

[ "512.8", "493.20", "427.31", "518.82", "799.02", "V15.82", "514", "197.2", "V66.7", "574.20", "162.3" ]

icd9cm

[ [ [] ] ]

[ "34.91", "97.41", "38.93", "93.90", "34.24", "34.04" ]

icd9pcs

[ [ [] ] ]

10170, 10292

6063, 9468

350, 434

10372, 10408

2130, 6040

10566, 10626

1753, 1857

9542, 10147

10313, 10351

9494, 9519

10432, 10543

1872, 2111

291, 312

462, 1339

1361, 1421

1437, 1737

13,033

192,298

43275

Discharge summary

report

Admission Date: [**2183-1-12**] Discharge Date: [**2183-1-20**] Date of Birth: [**2148-4-23**] Sex: M Service: [**Hospital Ward Name **]/ICU CHIEF COMPLAINT: Uncontrolled hypertension. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a pleasant 34 year-old gentleman with multiple admissions for uncontrolled hypertension, gastroparesis, nausea, vomiting, who was transferred to the [**Hospital Ward Name 332**] Intensive Care Unit from the regular floor on the [**Hospital Ward Name **] for uncontrolled hypertension. The patient was admitted on [**2183-1-12**] for gastroparesis, nausea, vomiting, elevated blood pressure, was started on a nitroglycerin drip and his blood pressure continued to remain elevated and was maxed out on a nitroglycerin drip. On [**2183-1-17**] the Intensive Care Unit resident from the [**Hospital Ward Name **] was called to evaluate the patient and at that time the concern was that he would probably need to start intravenous Labetalol and/or intravenous Nipride and so the patient was transferred to the unit for better control of his blood pressure. By the time the patient came to the unit his blood pressure was well controlled on the intravenous nitroglycerin and so therefore no further medications were started. Briefly the patient has a history of type 1 diabetes complicated by autonomic neuropathy, gastroparesis, chronic renal insufficiency, coronary artery disease, hypertension. PAST MEDICAL HISTORY: 1. Type 1 diabetes. 2. Gastroparesis. 3. Malignant hypertension. 4. Autonomic neuropathy. 5. Coronary artery disease. 6. Chronic renal insufficiency baseline creatinine between 1.7 and 1.9. 7. History of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies any tobacco, alcohol or drug abuse. The patient lives in [**Location 686**] and is currently unemployed. The patient lives with his girlfriend [**Name (NI) 450**] [**Name (NI) **]. PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature 98.6. Pulse 84. Blood pressure 148/68. Respiratory rate 16. O2 sat 98% on room air. General, the patient at this time appears uncomfortable, but in no acute respiratory distress. HEENT pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Mucous membranes are moist. Lungs clear to auscultation bilaterally. Heart S1 and S2, 2 out of 6 systolic ejection murmur heard best along the left sternal border. Abdomen soft, mild tenderness to deep palpation in the epigastric area, no hepatosplenomegaly, positive bowel sounds. Neurological alert and oriented times three. Cranial nerves II through XII tested grossly intact. Extremities no clubbing, cyanosis or edema. Good pulses throughout. LABORATORIES ON ADMISSION: White blood cell count 5.5, hematocrit 28.4, glucose 105, platelets 212, sodium 139, potassium 4.0, chloride 105, bicarb 25, BUN 19, creatinine 1.7, calcium 9.8, phosphorus 4.1, magnesium 1.6. HOSPITAL COURSE: 1. Hypertension: The patient presents with uncontrolled hypertension despite being on a nitroglycerin drip and the concern was for starting intravenous Labetalol and so the patient was transferred to the unit. By the time the patient reached the unit his blood pressure was stable and the nitroglycerin drip was weaned off in the next three to four days. The patient began to tolerate po and so was started on his po regimen the following day after being transferred to the Intensive Care Unit. The patient's blood pressure remained at his baseline throughout his unit stay and no further intravenous nitroglycerin was required. The patient has had multiple workups in the past including pheochromocytoma, thyroid disorder, renal artery stenosis, hypoaldosteronism, [**Location (un) 3484**] disease all of which have been negative to date. The patient is very closely followed by both the hypertension specialists Dr. [**Last Name (STitle) 18608**] and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] from endocrinology both of whom had nothing new to add. On the day of discharge the patient was back on his po regimen of his antihypertensives. 2. Diabetes: The patient has known type 1 diabetes and once the patient began to tolerate po he was switched back to his home regimen. The patient's finger sticks remained within normal limits. 3. Renal: The patient has known chronic renal insufficiency with baseline creatinine between 1.7 and 1.9 most likely secondary to a combination of both diabetes and hypertension. During the hospital course the patient's creatinine remained stable. 4. Gastrointestinal: The patient initially was NPO secondary to nausea and vomiting, which was thought to be from his gastroparesis. However, the patient's symptoms improved within 24 hours after being transferred to the unit and the patient started tolerating po well. The patient was restarted on all of his po medications. DISCHARGE DIAGNOSES: 1. Uncontrolled hypertension. 2. Diabetes. 3. Chronic renal insufficiency. 4. Autonomic neuropathy. DISCHARGE STATUS: The patient is being discharged to home from the Intensive Care Unit. The patient is stable at the time of discharge. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg po q day. 2. Protonix 40 mg po q day. 3. Clonidine patch q week. 4. Erythromycin 250 mg po q 6. 5. Sertraline 50 mg po q day. 6. Reglan 10 mg po q 6. 7. Lopressor 150 mg po b.i.d. 8. Lisinopril 10 mg po b.i.d. 9. Glargine 5 units subq q.h.s. 10. Ativan 2 mg po q 4 to 6 hours prn. 11. Morphine IR 50 mg po q 4 to 6 hours prn. 12. Amlodipine 5 mg po q.d. FOLLOW UP: The patient is to follow up with his primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] as per routine schedule. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**] Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2183-1-20**] 12:05 T: [**2183-1-20**] 12:13 JOB#: [**Job Number 93220**]

[ "593.9", "401.0", "536.3", "414.01", "250.61", "337.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5037, 5281

5304, 5688

3070, 5016

5700, 6138

180, 208

237, 1463

2858, 3052

1485, 1807

1824, 2048

52,899

155,731

35390

Discharge summary

report

Admission Date: [**2178-6-25**] Discharge Date: [**2178-6-30**] Date of Birth: [**2102-7-16**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Demerol Attending:[**First Name3 (LF) 1936**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Intubation with Mechanical Ventilation History of Present Illness: The patient is a 75 year old female with a history of COPD (on home O2,) CAD s/p recent NSTEMI, AF on coumadin, vagal sinus arrest s/p PPM who was transfered from an OSH after presenting with shortness of breath. In [**2178-3-29**] the patient underwent a closed reduction of a right hip dislocation, and her hospitalization was complicated by a report of bilateral PNA and COPD exacerbation. She was discharged on a course of antibiotics and a prednisone taper. One week following discharge, the patient had worsening shortness of breath, orthopnea, and worsening lower extremity edema. She was initially treated for a recurrent COPD exacerbation, but when cardiac markers cycled back as positive, she was transfered to [**Hospital1 18**] on [**2178-4-21**] for cardiac catheterization. . The patient underwent cardiac catheterization, which revealed diffuse obstructing LAD disease, and 4 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] were placed. An echocardiogram after the event showed regional wall motion abnormalities with an EF of 40%. The patient required ICU admission following catheterization due to hypoxia. The etiology of her respiratory failure was believed due to heart failure, as well as a COPD exacerbation. With increased sputum production and wheezing, the patient was treated with antibiotics and a prednisone taper. . During the hospitalization she had a 20 second asystolic episode, likely secondary to vagal episode. Code blue was called but patient quickly recovered blood pressure, heart rate and respirations wihtout intervention. Review of tele appeared to have sinus brady and slowing before 20sec pause then sinus tachycardia with recovering of pulse. A PPM was placed. . The patient has done well in subsequent follow up. She may have had a a recent hospitalization from God [**Hospital **] Medical Center with a recent CHF exacerbation. Per report, she had complaints of 2 days of shorntess of breath, with sudden worsening the day of presentation. Notes say that her symptoms worse with laying flat. The patient actived EMS, and on their arrival vitals of HR 132, BP 200/80, RR 24, 88% on unknown oxygen. She was described as having pursed lips, audible wheezes, and respiratory distress. She was taken to [**Hospital3 3583**] for futher evaluation. While at [**Hospital3 3583**], her O2 sats were reported at 100%. She became apneic and unrespponsive. After a difficult intubation, she was successfully intubated, and transfered to [**Hospital1 18**] for further evaluation. . In the ED, initial vs were: T 99.1, HR 100 BP 110/57, 100% on the vent. She was sedated with propofol, given levofloxacin and vancomycin with a question of an infiltrate on LLL. The patient was admitted to the MICU for further manegment. Past Medical History: COPD on home O2 at one pt, and required intubation in the past Bilateral Hip replacement Wrist fracture Anxiety Depression GERD Social History: Lives with her husband, 40 pack year smoking history, currently still smokes about 5 cigarretts a week. Retired school nurse. Family History: No early family history of CAD. Physical Exam: VS: 104/57 97.9 82 20 91%1L GEN: NAD, sitting up eating HEENT: clear OP, MMM Neck: Supple, no obvious JVD Lungs: B/L insp. crackles and decreased breath sounds throughout lung fields CV: RRR, nl S1/S2, -m/r/g, distant heart sounds Abd: S/NT/NT/nabs Ext: -c/c/e, w/wp Neuro: AAO x 3 Pertinent Results: [**2178-6-27**] 07:40AM BLOOD WBC-9.2 RBC-3.27* Hgb-9.2* Hct-28.5* MCV-87 MCH-28.2 MCHC-32.3 RDW-16.3* Plt Ct-260 [**2178-6-26**] 04:04AM BLOOD WBC-8.1 RBC-3.40* Hgb-9.6* Hct-29.1* MCV-86 MCH-28.3 MCHC-33.1 RDW-15.5 Plt Ct-263 [**2178-6-25**] 03:55AM BLOOD WBC-14.5*# RBC-3.88* Hgb-11.0* Hct-34.6* MCV-89 MCH-28.3 MCHC-31.7 RDW-15.9* Plt Ct-292 [**2178-6-26**] 06:27AM BLOOD PT-27.3* PTT-28.6 INR(PT)-2.7* [**2178-6-25**] 03:55AM BLOOD PT-32.8* PTT-30.9 INR(PT)-3.4* [**2178-6-27**] 07:40AM BLOOD Glucose-103 UreaN-29* Creat-0.9 Na-141 K-3.6 Cl-102 HCO3-30 AnGap-13 [**2178-6-26**] 04:04AM BLOOD Glucose-165* UreaN-27* Creat-0.8 Na-140 K-3.5 Cl-102 HCO3-29 AnGap-13 [**2178-6-25**] 03:55AM BLOOD Glucose-122* UreaN-21* Creat-1.1 Na-143 K-4.6 Cl-103 HCO3-29 AnGap-16 [**2178-6-25**] 09:12PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2178-6-25**] 01:37PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2178-6-25**] 03:55AM BLOOD cTropnT-0.02* [**2178-6-25**] 03:55AM BLOOD CK-MB-NotDone proBNP-2455* CHEST (PORTABLE AP) Study Date of [**2178-6-26**] 3:37 AM: Bibasilar opacities improved, likely due to resolving edema, less likely pneumonia given rapid change. No other change. [**2178-6-29**] Stress Echo: No anginal symptoms with borderline ischemic ST segment changes. Slow junctional tachycardia noted toward peak exercise with sinus rhythm noted thereafter. Appropriate heart rate and blood pressure response to the Dobutamine infusion. Echo report sent separately. The patient received intravenous dobutamine beginning at 15 mcg/kg/min, increasing to 30mcg/kg/min and 45 mcg/kg/min in 3 minute stages plus 0.25 mg atropine. The test was stopped because the target heart rate was achieved. In response to stress, the ECG showed borderline ischemic ST changes (see exercise report for details). There were normal blood pressure and heart rate responses to stress. Resting images were acquired at a heart rate of 64 bpm and a blood pressure of 112/60 mmHg. These demonstrated regional left ventricular systolic dysfunction with hypokinesis of the inferior wall. The remaining segments are contract well. Right ventricular free wall motion is normal. Doppler demonstrated no aortic stenosis, aortic regurgitation or significant mitral regurgitation or resting LVOT gradient. At mid-dose dobutamine [15 mcg/kg/min; heart rate 63 bpm, blood pressure 148/96 mmHg), there was appropriate augmentation of all left ventricular segments. At peak dobutamine stress [45 mcg/kg/min and 0.25 mg atropine; heart rate 114 bpm, blood pressure 154/60 mmHg), no new regional wall motion abnormalities were identified. Baseline abnormalities persist. IMPRESSION: Borderline ECG changes with 2D echocardiographic evidence of prior myocardial infarction without inducible ischemia to achieved workload. Brief Hospital Course: 75 year old female with a history of COPD, CAD s/p recent NSTEMI, AF on coumadin, vagal sinus arrest s/p PPM who was transfered from an OSH after presenting with shortness of breath s/p MICU stay and intubation, likely due to pulmonary edema with CHF as a result of her existing CHF with a possibly occult ischemic event. The patient had a stress echo done which demonstrated no new ischemia, but the patient was sent home with close instructions to follow up with her primary care provider. # Chronic systolic heart failure: Patient was also thought to have suffered from flash pulmonary edema from her chronic systolic heart failure. Though her CXR looked clear, the patient responded to 180mg IV Lasix in the ED, and then was continued on lasix while on the floor. She continued to have good urine output on her home regimen of lasix. While in the hospital she also had her carvedliol continued. Unclear as to the inciting event, possibly an occult ischemic event which was not able to be seen via cardiac enzymes, which were negative. The patient did have some new lateral ST-depressions on EKG. The patient had a dobutamine stress test which showed no new ischemia, but evidence of prior MI. # COPD: The patient was initially treated with IV solumedrol in the MICU and started on Levofloxacin for a presumed COPD exacerbation with a possible PNA trigger. It was likely that at the outside hosptial, the patient was given too much oxygen and had consequent CO2 retention, a decreased breathing drive, and subsequent O2 desaturation. The patient was extubated and called out to the floor with no difficulties in saturation and no dyspnea. She was continued on nebulizers while on the floor as needed. However, upon further review of the patient's history, it did not seem as though the patient had truly suffered from a COPD exacerbation. The patient had a sudden onset of symptoms that cleared with lasix and did not endorse any symptoms of a possible PNA prior to her hospitalization (no fevers, cough, sputum production, URI sxs, etc.). Also, had a relatively clear lung exam on the floor. Hence, levofloxacin was discontinued and the steroids were stopped. The patient was continued on nebulizers and had her O2 requirements on the floor suggested at 90-93%. Also, attempted to get PFT's from [**Hospital3 417**] and attempted to call pt's pulmonologist, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 80661**]). # CAD: No chest pain or shortness of breath, EKG's in MICU were negative, we continued her asa at 81mg daily, her plavix, and her statin. # Atrial Fibrillation: No episodes of tachycardia, INR became subtherapeutic because the patient was placed on a decreased dose of warfarin due to her being initially placed on levofloxacin. Her warfarin was increased back to her home dosage of 6.5 mg per day upon discharge. Of note, there was question regarding whether patient truly needs to be on coumadin. She was arranged to have f/u with her Cardiologist. At discharge, her INR was subtherapeutic and patient was arranged to have INR rechecked by PCP following discharge. # Fe deficiency anemia: She has persistantly had slow HCT drop. No active bleed during this admission; however, it was felt that patient should follow-up with PCP regarding outpatient colonoscopy and EGD. She is on ASA, plavix, and coumadin. She was discharged on iron supplementation, instructed to use an OTC bowel regimen. # Anxiety: cont home clonazepam 0.5 mg TID:PRN # Depression: cont home paroxetine Medications on Admission: 1. Clonazepam 0.5 mg PO q AM. 2. Clonazepam 0.5 mg PO every four 3. Paroxetine HCl 20 mg PO DAILY 4. Nexium 40 mg PO once a day. 5. Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **] 6. Tiotropium Bromide 18 mcg Capsule DAILY 7. Multivitamin PO DAILY 8. Clopidogrel 75 mg PO DAILY 9. Cholecalciferol 800 unit DAILY 10. Calcium Carbonate 500 mg TID W/MEALS 11. Atorvastatin 80 mg once a day. 12. Lasix 20 mg PO once a day. 14. Albuterol Sulfate 90 mcg HFA Aerosol Inhaler 2 puffs inhaled every 4 hours as needed for wheezing or SOB 15. Warfarin 1 mg 16. Carvedilol 6.25 mg PO BID 17. Aspirin 81 mg DAILY Discharge Medications: 1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety, insomnia. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary: Pulmonary Edema, Congestive Heart Failure Secondary: Right hip dislocation status post closed reduction [**4-6**] Bilateral Hip replacement Coronary Artery Disease status post 4 drug eluting stentis in the setting of NSTEMI in [**4-6**] Atrial Fibrillation Sinus bradycardia with vagally induced arrest s/p PPM [**4-6**] Anxiety Depression GERD Discharge Condition: Stable, ambulating, eating, drinking, and voiding without complaints. Discharge Instructions: You were admitted because you were having shortness of breath and were sent in from an outside hospital with shortness of breath. Upon arrival here you were found to have a normal blood pressure and with normal oxygen saturation. You had your breathing tube removed when you arrived to our medical intensive care unit and tolerated being without mechanical ventilation very well. You were then given medications to remove the fluid from your body and received a cardiac stress test which showed....Please set up an appointment with your primary care physician 1 to 2 weeks post discharge. We have started a medication called Lisinopril at 2.5 mg daily. If you have any severe chest pain, severe shortness of breath, nausea, vomiting, diarrhea, constipation, or any loss of consciousness, please contact your primary care physician [**Name Initial (PRE) 2227**]. Additionally, weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs, and adhere to 2 gm sodium diet. Followup Instructions: 1. Please set up an appointment with your primary care attending in 1 to 2 weeks. 2. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2178-8-31**] 9:00 3. Provider: [**Name10 (NameIs) 3941**] CALL TRANSMISSIONS Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2178-9-7**] 12:00

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Discharge summary

report

Admission Date: [**2195-4-14**] Discharge Date: [**2195-4-17**] Date of Birth: [**2123-12-24**] Sex: F Service: MEDICINE Allergies: Atorvastatin / Penicillins / Codeine / Oxycodone Attending:[**First Name3 (LF) 2290**] Chief Complaint: Left leg swelling/edema Major Surgical or Invasive Procedure: None History of Present Illness: 71F with history of CHF, CAD, afib on coumadin, ESRD on HD and COPD presenting with pain, swelling and erythema on the left leg. Patient has had chronic ulcers of the left and right leg since last [**Month (only) 216**] and had been on vancomycin for 2 week course completed on [**2195-2-19**]. Today noted increased swelling and pain in the left calf, which had changed from previous baseline as she had not had pain in the leg before No f/c. No n/v/d. No CP/SOB. The blisters on her legs occasionally drain non purulent fluid, but she reports no increased drainage over the past few days. Was given a dose of vancomycin at HD. . In the ED, initial VS were: 8 98 64 131/113 16 99%. Patient was not given any additional antibiotics given recent dose at HD. Underwent LLE ultrasound which showed no evidence of DVT, but substantial subcutaneous edema. Patient was to be admitted to floor, but repeat vitals showed BP of 80/50. Patient was asymptomatic at that time without CP/SOB, lightheadedness or visual changes. Was given a 500cc bolus and responded to 89/50. Subsequently admitted to MICU for further monitoring of vital signs. . On arrival to the MICU, patient is alert and oriented, in NAD. Notes minimal pain and swelling in the left calf. Denies f/c. Denies CP/SOB. Of note, she reports multiple week history of cough for which she was started on doxycycline by her PCP [**Last Name (NamePattern4) **] [**4-10**]. Otherwise has no other complaints. Past Medical History: - Hypertension - Hyperlpidemia - Ventricular tachycardia s/p ICD implantation [**2193-4-1**] ([**Company 2275**] Cognis 100-D Dual chamber-ICD) - Heart failure, systolic and diastolic, EF 35% - Atrial fibrillation on warfarin - Coronary artery disease - COPD - Psoriasis - Gout - Allergic rhinitis - Hypokalemia (in past) - Anemia, normocytic - ESRD - Obesity - Cataract - Colon polyps - Diverticulosis of colon with hemorrhage Social History: -Former tobacco [**12-1**] pack per day x 25 years -Previous alcohol use: quit 2 years ago -Denies recreational drug use or other toxic habits -Lives alone. Is able to complete her ADLs. Family History: [**Name (NI) 2280**], mother with 'heart trouble' Physical Exam: Vitals: T: 97.6 BP: 91/57 P: 65 R: 26 O2: 98% General: Alert, oriented, no acute distress HEENT: 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: Decreased breathsounds diffusely, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: trace pitting edema bilaterally in lower exytremities, healed ulcers on right lower extremity without drainage, LLE with surrounding erythema blanching, minimal serosanguineous drainage from ulcers, 1+ DP pulses bilaterally Neuro: alert and oriented x 3, moving all extremities Physical Exam on Discharge: VS: 97.7, 91/68, 88, 18, 96RA General: Alert, oriented, no acute distress, sitting up in bed comfortable HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Systolic murmur heard at the RUSB, regular rate and rhythm, normal S1 + S2 Lungs: CTAB anteriorly Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext:Right leg healed ulcers on right lower extremity without drainage, LLE with minimal erythema, much regressed from the border. Pt with decreased edema of the leg compared to yesterday 1+DP pulse, and still with 2+pitting edema in the thigh. Small 1mm ulcer without purulence draining out of it. Tender to palpation. Neuro: alert and oriented x 3, moving all extremities Pertinent Results: Admission Labs: [**2195-4-14**] 12:57PM PT-21.9* INR(PT)-2.1* [**2195-4-14**] 04:55PM PLT SMR-LOW PLT COUNT-85* [**2195-4-14**] 04:55PM NEUTS-84.1* LYMPHS-10.2* MONOS-5.3 EOS-0.3 BASOS-0.2 [**2195-4-14**] 04:55PM WBC-8.4# RBC-3.99* HGB-11.6* HCT-38.6 MCV-97 MCH-29.0 MCHC-29.9* RDW-17.0* [**2195-4-14**] 04:55PM GLUCOSE-137* UREA N-10 CREAT-2.5*# SODIUM-142 POTASSIUM-3.1* CHLORIDE-98 TOTAL CO2-34* ANION GAP-13 [**2195-4-14**] 05:02PM LACTATE-2.0 [**2195-4-14**] 08:24PM LACTATE-1.6 Discharge Labs: [**2195-4-17**] 06:28AM BLOOD WBC-4.4 RBC-3.99* Hgb-12.0 Hct-40.3 MCV-101* MCH-30.0 MCHC-29.7* RDW-17.4* Plt Ct-94* [**2195-4-17**] 06:28AM BLOOD Glucose-95 UreaN-12 Creat-3.0*# Na-133 K-3.7 Cl-94* HCO3-29 AnGap-14 [**2195-4-17**] 06:28AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 [**2195-4-16**] 06:29AM BLOOD Vanco-13.0 [**2195-4-14**] 05:02PM BLOOD Lactate-2.0 Micro: Blood culture [**2195-4-14**] PENDING Imaging: [**2195-4-14**] LENI- IMPRESSION: Limited examination due to patient discomfort and extensive subcutaneous edema with no evidence of deep venous thrombosis in the left common femoral, superficial femoral, or popliteal veins. [**2195-4-14**] CXR- Severe cardiomegaly has worsened, but pulmonary edema has cleared. Pleural effusion is small if any. Right supraclavicular dual-channel [**Month/Day/Year 2286**] catheter ends in the region of the superior cavoatrial junction, unchanged. Transvenous right atrial pacer and right ventricular pacer defibrillator leads are in standard placements. No pneumothorax or appreciable pleural effusion. Brief Hospital Course: 71F with history of CHF, CAD, afib on coumadin, ESRD on HD and COPD presenting with LLE cellulitis. . # Cellulitis - patient with chronic ulcers on left lower extremity presented with inreased pain and erythema and elevated WBC consistent with cellulitis. She was recently treated for cellulitis in that leg with vancomycin on previous hospitalization in [**2194-1-28**]. After two days of vancomycin, she had marked improvement in the leg with decreased erythema in color and was dramatically receeding from the marked border below the area. There was still [**12-1**]+pitting edema in the left thigh, but improved compared to admission when it was harder and was obscuring the anatomical markings of the knee on extension. LENI of the leg was negative for DVT. She was seen by vascular surgery during this admission, who did not feel that surgery was indicated and agreed with the proposed medical management. -Vancomycin dosed with HD x 2 weeks (last day [**4-28**]) -Ciprofloxacin 500mg po qday x 2 weeks (last day [**4-28**]) . #Hypotension - patient hypotensive to SBPs in 80s. In the ED there was concern that she was possibly septic, so she was admited to the ICU. She received 1.5L of IV fluids and her BP repsonded well. Her baseline blood pressure is in the low 90s systolic. After being on the floor she continued to have lower blood pressures and was asymptomatic with them. -She will require monitoring of her blood pressure during [**Month/Year (2) 2286**] sessions . # Afib - on amiodarone and coumadin as outpatient. Stable. INR therapeutic at 2.1 on admission. Continued on home medications - cont warfarin and amiodarone . # CAD - Continued on amiodarone, pravastatin and SLNGT . # COPD - on spiriva, alubterol and fluticasone at home. Also uses 2L NC at night at home. Has had cough for the past [**3-6**] weeks and recently started on doxycycline on [**4-10**], which was continued for planned 7 day course total and will be completed on [**4-16**]. No worsening SOB. CXR showed no evidence of PNA . # chronic sytolic CHF - Continued on home furosemide dose. Patinet is not on ACEI prior to this admission, and this was not started given her hypotension. . # ESRD - Continued on HD schedule of T-TH-SAT. She received an extra ultrafiltration session on [**4-17**] (friday) to try to remove more fluid from her left leg. . Transitional Issues: Pending labs/studies: Blood cultures from [**2195-4-14**] Medications started: 1. Vancomycin (antibiotic) to be given with [**Month/Day/Year 2286**] through [**4-28**]. Ciprofloxacin 500mg by mouth once a day through [**4-28**] Medications changed: none Medications stopped: None Follow-up needed for: ***You will need to have your INR checked at [**Month/Year (2) **] on Saturday [**4-18**] as you just started ciprofloxacin which can cause changes in this*** 1. Monitoring of vancomycin levels at [**Month/Year (2) **] Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Medications on Admission: Senna-Gen 8.6 mg Tab 2 Tablet(s) by mouth at bedtime - Spiriva with HandiHaler 18 mcg & inhalation Caps 1 Capsule(s) inhaled once a day - cholecalciferol (vitamin D3) 1,000 unit Cap 1 Capsule(s) by mouth once a day - Calcium 500 500 mg calcium (1,250 mg) Tab - pravastatin 20 mg Tab 1 Tablet(s) by mouth DAILY - allopurinol 100 mg Tab 1 Tablet(s) by mouth EVERY OTHER DAY - doxycycline hyclate 100 mg Cap 1 Capsule(s) by mouth [**Hospital1 **] - Vitamin B-1 50 mg Tab - albuterol sulfate HFA 90 mcg/Actuation Aerosol Inhaler 1 HFA(s) inhaled every six (6) hours - furosemide 80 mg Tab 1 Tablet(s) by mouth twice a day - amiodarone 200 mg Tab 1 Tablet(s) by mouth once a day - Nitrostat 0.3 mg Sublingual Tab 1 Tablet(s) sublingually every five minutes up to 3 times as needed as needed for chest pain - ferrous gluconate 325 mg (37.5 mg iron) Tab 1 Tablet(s) by mouth DAILY (Daily) - zolpidem 5 mg Tab 1 Tablet(s) by mouth HS (at bedtime) - tramadol 50 mg Tab 1 Tablet(s) by mouth for pain - docusate sodium 100 mg Cap 1 (One) Capsule(s) by mouth twice a day - warfarin 1 mg Tab 1 Tablet(s) by mouth once a day - Flovent HFA 110 mcg/Actuation Aerosol Inhaler 2 Aerosol(s) inhaled twice a day - B complex-vitamin C-folic acid 400 mcg Tab 1 Tablet(s) by mouth DAILY Discharge Medications: 1. Senna-Gen 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 2. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 3. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 4. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. Vitamin B-1 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual every five minutes with chest pain, take up to 3 as needed for chest pain. 12. ferrous gluconate 325 mg (36 mg iron) Tablet Sig: One (1) Tablet PO once a day. 13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 15. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA). 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Flovent HFA 110 mcg/actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 19. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day: on [**Doctor First Name 2286**] days take after your [**Doctor First Name 2286**] session. Disp:*11 Tablet(s)* Refills:*0* 20. vancomycin 1,000 mg Recon Soln Sig: sliding scale dose Intravenous with [**Doctor First Name 2286**]: based on Vanc trough drawn at [**Doctor First Name 2286**]. To be given through [**2195-4-28**]. Disp:*qs * Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary: Cellulitis Secondary: Atrial fibrillation, Chronic systolic heart failure, End stage renal disease on [**Name (NI) 2286**] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 2251**], It was a pleasure taking care of you here at [**Hospital1 18**]. You were admitted to the hospital because you were found to have an infection of the skin on your left leg. While you were in the emergency room your blood pressure was on the lower side so you were in the ICU for a night to make sure it didn't drop further and it was stable (your blood pressure at baseline runs very low and you were asymptomatic throughout your ICU stay). You were then transferred to the regular medical floor where you were stable. You received [**Hospital1 2286**] on your regularly scheduled timing, and received an extra session on Friday. Transitional Issues: Pending labs/studies: Blood cultures from [**2195-4-14**] Medications started: 1. Vancomycin (antibiotic) to be given with [**Month/Day/Year 2286**] through [**4-28**]. Ciprofloxacin 500mg by mouth once a day through [**4-28**] Medications changed: none Medications stopped: None Follow-up needed for: ***You will need to have your INR checked at [**Month/Year (2) **] on Saturday [**4-18**] as you just started ciprofloxacin which can cause changes in this*** 1. Monitoring of vancomycin levels at [**Month/Year (2) **] Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 2261**] When: Thursday, [**4-30**], 2:00 PM Department: VASCULAR SURGERY When: FRIDAY [**2195-5-15**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "585.6", "V45.11", "V58.61", "427.31", "V45.02", "272.4", "682.6", "428.0", "V49.86", "428.22", "459.81", "414.01", "287.5", "285.9", "278.00", "707.19", "496", "562.10", "366.9", "V15.82", "403.91" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

11952, 12023

5644, 7995

334, 340

12198, 12198

4048, 4048

13674, 14221

2512, 2563

9945, 11929

12044, 12177

8656, 9922

12348, 13018

4563, 5621

2578, 3264

3292, 4029

13039, 13651

271, 296

368, 1840

4064, 4547

12213, 12324

1862, 2291

2307, 2495

72,633

173,943

713

Discharge summary

report

Admission Date: [**2192-11-24**] Discharge Date: [**2192-12-7**] Date of Birth: [**2110-10-24**] Sex: F Service: CARDIOTHORACIC Allergies: Nitroglycerin Attending:[**First Name3 (LF) 922**] Chief Complaint: syncope Major Surgical or Invasive Procedure: [**2192-11-28**] aortic valve replacement (23 mm CE pericardial)/ coronary artery bypass graft(SVG-RCA)/ ligation left atrial apppendage/Maze History of Present Illness: This 82 year old Russian speaking female with known critical aortic stenosis was admitted after a syncopal episode today while at a museum. She was with her daughter and family friend, she felt slightly dizzy and then had episode of loss of consciousness where she fell into the arms of the family. There was no trauma or head injury. The physician family friend thought the patient was pulseless so she initiated CPR, but the pt regained a pulse and consciousness within ~15 seconds. Pt also had bowel and bladder incontinence during this episode. Past Medical History: hypertension Dyslipidemia Coronary artery disease s/p circumflex [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5303**] in [**Location (un) 4551**] ([**2186**]). Critical aortic stenosis Moderate mitral regurgitation. Moderate tricuspid regurgitation. chronic Atrial fibrillation. s/p radical mastectomy [**2156**] with radiation and adjuvant chemotherapy Multinodular Goiter Social History: She does not smoke or drink. She is a retired physicist. Family History: noncontributory Physical Exam: Admission: VS: T=98.0 BP=120/60 HR=98 RR=18 O2 sat=100RA 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, no JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. II/VI sys murmur throughout precordium. No r/g. No thrills, lifts. No S3 or S4. LUNGS: no breast tissue s/p old mastectomies, no pain to palpation, Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: Prebypass The left atrium is dilated. Mild spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). A probable thrombus is seen in the left atrial appendage. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is severe symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**2192-11-27**] at 1000 am. Post bypass Patient is AV paced and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. Bioprosthetic valve seen in the aortic position. Leaflets move well and the valve appears well seated. There is no aortic insufficiency. Peak gradient across the valve is 6 mm Hg . There is moderate mitral regurgitation. There is moderate tricuspid regurgitation. Aorta intact post decannulation. The left atrial appendage has been ligated. [**2192-12-7**] 07:20AM BLOOD WBC-8.0 RBC-3.75* Hgb-11.1* Hct-33.4* MCV-89 MCH-29.5 MCHC-33.1 RDW-15.5 Plt Ct-277 [**2192-12-7**] 07:20AM BLOOD PT-23.7* INR(PT)-2.3* [**2192-12-7**] 07:20AM BLOOD PT-23.7* INR(PT)-2.3* [**2192-12-6**] 05:52AM BLOOD PT-28.4* INR(PT)-2.8* [**2192-12-5**] 04:58AM BLOOD PT-19.4* PTT-31.0 INR(PT)-1.8* [**2192-12-4**] 06:37AM BLOOD PT-15.5* PTT-30.3 INR(PT)-1.4* [**2192-12-3**] 04:36AM BLOOD PT-15.5* PTT-30.2 INR(PT)-1.4* [**2192-12-2**] 04:17AM BLOOD PT-16.3* PTT-32.2 INR(PT)-1.4* [**2192-12-1**] 03:46AM BLOOD PT-19.3* PTT-36.2* INR(PT)-1.8* [**2192-12-7**] 07:20AM BLOOD Glucose-90 UreaN-19 Creat-1.1 Na-143 K-4.2 Cl-100 HCO3-34* AnGap-13 Brief Hospital Course: The patient consented to surgery at this time, having refused in [**Month (only) 359**] when initially seen by cardiac Surgery.Ms. [**Known lastname 5304**] was taken to the Operating Room and underwent Aortic Valve Replacement (#23mm Pericardial)/Coronary Artery Bypass Graft x 1(Saphenous vein grafted to Right Coronary Artery)/Suture ligation of Left Atrial Appendage/MAZE procedure.Cardiopulmonary Bypass time= 139 minutes. Cross clamp time= 110 minutes. Please refer to Dr[**Last Name (STitle) 5305**] operative report for further details. She weaned from bypass on Propofol and was transferred to the CVICU. She awoke neurologically intact and was extubated without difficulty. Beta-blocker and Amiodarone was initiated. Transient junctional rhythm occurred and beta blocker was was temporarily discontinued. Low dose Amiodarone was continued per Dr.[**Last Name (STitle) 171**]. POD#1 she was oliguric and had a metabolic acidosis which required large volume resuscitation along with a Sodium Bicarbonate drip. The acidosis resolved and she continued to progress. The right CT continued to have copious drainage and wa left in after mediastinal tubes and pacing wires were removed. Low dose B-Blocker was reinstated and tolerated well. Dosing was optimized for rate control. Anticoagulation was resumed on POD#3 with Coumadin. Her rhythm went back into Atrial Fibrillation and beta blocker was increased.. POD#4 she was transferred to the step down unit for further monitoring. Physical therapy was consulted for evaluation and assesment. The CT continued to produce 2 liters daily and a CXR revealed a trapped right lowere lobe. Dr. [**Last Name (STitle) **] was consulted. The CT was clamped for 24 hours and serial CXRs revealed filling of the basilar space with fluid, but no significant accumulation or pneumothorax. The CT was then opened, drained 50cc and removed. Dr. [**Last Name (STitle) 5306**] has agreed to follow and manage Coumadin as before, with an INR goal of [**2-7**]. Follow up with Drs. [**Last Name (STitle) 914**], [**Name5 (PTitle) 171**], [**Name5 (PTitle) 5306**] and [**Doctor Last Name **] were arranged as well as the wound clinic here. A PA and lateral film demonstarted.... She was therapeutic on Coumadin and ready for discharge. Arrangements were made for follow up, Coumadin will be controlled by her primary care physician. Medications on Admission: Warfarin (dose-adjusted to INR [**2-7**]) Lipitor 10 mg daily Aricept 5 mg nightly enalapril 5 mg daily metoprolol 100 mg twice daily spironolactone 25 mg daily torsemide 20 mg [**Hospital1 **] aspirin 81 mg daily. Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 7. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2* 10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 weeks. Disp:*30 Tablet(s)* Refills:*0* 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Aortic stenosis coronary artery disease s/p aortic valve replacement/coronary artery bypass s/p circumlex stenting mitral regurgitation tricuspid regurgitation chronic atrial fibrillation hypertension dyslipidemia h/o breast cancer s/p radical mastectomy [**2156**] s/p chemotherapy and chest radiotherapy multinodular goiter Discharge Condition: ambulatory, alert and oriented Discharge Instructions: no lotions, creams or powders on any incision shower daily and pat incisions dry call for fever greater than 100.5, redness, drainage, or weight gain of 2 pounds in 2 days or 5 pounds in one week no driving for one month and off all narcotics no lifting greater than 10 pounds for 10 weeks take all medications as directed Followup Instructions: Dr. [**Name (NI) 5307**] in [**1-6**] weeks ([**Telephone/Fax (1) 5308**]) Dr. [**Last Name (STitle) 171**], appointment [**2192-12-19**] at 12:40pm Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**Last Name (STitle) **] in 4 weeks (see same day as Dr. [**Last Name (STitle) 914**] [**Hospital Ward Name 121**] 6 wound clinic in 2 weeks Completed by:[**2192-12-7**]

[ "780.2", "423.9", "V58.61", "788.5", "E878.2", "427.31", "V10.3", "272.4", "428.32", "518.0", "428.0", "458.29", "V15.3", "241.1", "997.5", "414.01", "401.9", "424.1", "584.5", "512.1", "276.2" ]

icd9cm

[ [ [] ] ]

[ "35.21", "36.11", "39.61", "88.56", "37.27", "37.36", "37.22" ]

icd9pcs

[ [ [] ] ]

8737, 8823

4677, 7056

289, 433

9193, 9226

2277, 4654

9597, 9997

1512, 1529

7321, 8714

8844, 9172

7082, 7298

9250, 9574

1544, 2258

242, 251

461, 1014

1036, 1421

1437, 1496

23,657

137,894

13523

Discharge summary

report

Admission Date: [**2145-12-21**] Discharge Date: [**2145-12-22**] Date of Birth: [**2112-11-14**] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil / Hydralazine Attending:[**First Name3 (LF) 8404**] Chief Complaint: Nausea and vomiting x5 days. Reason for MICU transfer: Diabetic ketoacidosis. Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 21822**] a 33-year-old man with type I diabetes mellitus, ESRD on dialysis on the transplant list, and frequent admissions (9 admissions in [**2145**]) for diabetic gastroparesis who presented in the early morning with nausea and vomiting for five days. His initial vitals in the emergency room were T 100.0, HR 100, BP 191/103, RR 16, satting 100% on RA. Labs were notable for white count of 4.5 with normal differential, hematocrit of 29.4 (from baseline mid to high 30s), and platelets of 259. Initial electrolytes showed a sodium of 127, bicarb of 24, BUN of 47, and creatinine of 11.2. Anion gap was 18. Blood acetone level was "moderate" and urinalysis was not obtainable as patient was not making urine. Patient was initially given 8 units of lispro insulin, per his home sliding scale regimen. Due to difficult IV access issues, he did not receive intravenous fluids initially. However, after an EJ was placed, he was given 1L of normal saline and an insulin drip started. He was treated also with morphine 2 mg intravenously and Zofran 6 mg intravenously. Renal was contact[**Name (NI) **] in the emergency room and recommended gentle IVF resuscitation since patient is anuric at baseline; per renal, patient may not need dialysis today. A repeat chemistry panel at time of admission showed an anion gap narrowed to 17, with serum glucose of 311 (down from 448). Per ED report, patient is getting a slow insulin drip. Vitals at time of admission are T 98, HR 88, BP 150/85, RR 20, 100% on room air. Of note, patient was recently admitted to [**Hospital1 18**] [**Date range (1) 40897**] for nausea, vomiting, and abdominal pain. He was initially admitted to the medical ICU with anion gap of 25. He was placed on insulin drip at 7u/h with finger sticks q1h and later transitioned to glargine and lispro sliding scale. Infectious workup during that admission was negative. Notably, an [**Date range (1) 461**] during that admission showed an EF of 30-35% with global hypokinesis and regional inferior akinesis. He followed up with Dr. [**Last Name (STitle) **] in cardiology clinic about one week prior to this and according to that note, there is plan for cardiac catheterization and repeat [**Last Name (STitle) 461**]. Regarding DKA etiology, pt endorses taking his insulin Lantus and SSI. Denies any localizing infectious etiology. ROS: Currently, patient endorses abdominal pain [**8-17**] and back pain that is increasing since being moved from ED. At home, had poor PO intake since Thursday, and n/v for the past week with abd pain since yesterday; these appear to be chronic complaints. No f/c/ns, no flu sxs, no cough, SOB, CP, palpitations, diarrhea, dysuria, skin or joint problems. Past Medical History: # DM I diagnosed at age 17, seen at [**Last Name (un) **] - complicated by nephropathy, gastroparesis, and retinopathy # ESRD/CKD, secondary to hypertension and diabetes type I # Chronic systolic congestive heart failure # Gastroparesis seen on gastric emptying study [**5-/2137**] # Hypertension # Anemia # Depression # S/p appendectomy in [**Month (only) 205**]/[**2144**] Social History: Patient lives in [**Location 686**] with girlfriend of 4 years; no chilren. Has h/o smoking, most recently was smoking pack q2wks but is trying to quit and hasn't smoked for past couple weeks. No EtOH, drugs. Is ambulatory, does his ADL's. Family History: Grandfather with DM and CAD. Denies other family with DM. Physical Exam: 95.8 84 151/88 99% on RA Tired appearing but doesn't look ill. Clear historian, soft spoken. Doesn't appear volume overloaded EOMI, no scleral icterus Mouth very dry appearing Has R EJ well placed, not bleeding CTAB no w/c/r/r Has [**Last Name (LF) **], [**First Name3 (LF) **] shaped systolic murmur clearly heard through precordium with different sound to S2 at the apex. Radial pulses palpable Abd diffusely tender to palpation without particular localization, but is soft not rigid, non obese, BS+, no rebound No BLE edema, extrems are warm and well perfused CN2-12 intact, no focal neuro deficits noted, moving all extremities and clear, lucid conversation Pertinent Results: [**2145-12-22**] 05:35AM BLOOD WBC-4.6 RBC-3.01* Hgb-9.1* Hct-25.5* MCV-85 MCH-30.1 MCHC-35.6* RDW-13.4 Plt Ct-203 [**2145-12-21**] 12:07PM BLOOD WBC-4.7 RBC-3.19* Hgb-9.7* Hct-27.3* MCV-86 MCH-30.5 MCHC-35.7* RDW-13.3 Plt Ct-234 [**2145-12-21**] 12:50AM BLOOD WBC-4.5 RBC-3.50* Hgb-10.1*# Hct-29.4* MCV-84 MCH-28.8 MCHC-34.4 RDW-13.6 Plt Ct-259 [**2145-12-21**] 12:50AM BLOOD Neuts-64.7 Lymphs-24.1 Monos-7.3 Eos-3.1 Baso-0.8 [**2145-12-22**] 05:35AM BLOOD Ret Aut-1.7 [**2145-12-21**] 12:07PM BLOOD Ret Aut-1.4 [**2145-12-22**] 05:35AM BLOOD Glucose-68* UreaN-52* Creat-12.5* Na-130* K-4.4 Cl-93* HCO3-26 AnGap-15 [**2145-12-21**] 05:38PM BLOOD Glucose-210* UreaN-50* Creat-11.5* Na-127* K-4.2 Cl-89* HCO3-25 AnGap-17 [**2145-12-21**] 12:07PM BLOOD Glucose-173* UreaN-49* Creat-11.5* Na-128* K-3.7 Cl-89* HCO3-25 AnGap-18 [**2145-12-21**] 08:00AM BLOOD Glucose-195* UreaN-49* Creat-11.7* Na-131* K-3.8 Cl-90* HCO3-28 AnGap-17 [**2145-12-21**] 04:25AM BLOOD Glucose-311* UreaN-50* Creat-11.7* Na-129* K-4.2 Cl-88* HCO3-24 AnGap-21* [**2145-12-21**] 12:50AM BLOOD Glucose-448* UreaN-47* Creat-11.2*# Na-127* K-4.4 Cl-85* HCO3-24 AnGap-22* [**2145-12-21**] 12:07PM BLOOD LD(LDH)-201 CK(CPK)-121 TotBili-0.6 [**2145-12-21**] 08:00AM BLOOD CK(CPK)-121 [**2145-12-21**] 12:50AM BLOOD ALT-39 AST-24 CK(CPK)-151 [**2145-12-21**] 12:50AM BLOOD Lipase-82* [**2145-12-21**] 12:07PM BLOOD CK-MB-3 cTropnT-0.16* [**2145-12-21**] 08:00AM BLOOD CK-MB-2 cTropnT-0.15* [**2145-12-21**] 12:50AM BLOOD CK-MB-3 cTropnT-0.16* [**2145-12-22**] 05:35AM BLOOD Calcium-7.5* Phos-6.5* Mg-1.4* [**2145-12-21**] 12:07PM BLOOD Calcium-8.1* Phos-6.1* Mg-1.5* Iron-166* [**2145-12-21**] 12:50AM BLOOD Calcium-8.6 Phos-5.0*# Mg-1.5* [**2145-12-21**] 12:07PM BLOOD calTIBC-215* Hapto-17* Ferritn-1418* TRF-165* [**2145-12-21**] 12:07PM BLOOD Acetone-NEGATIVE [**2145-12-21**] 12:50AM BLOOD Acetone-MODERATE [**2145-12-21**] 12:07 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): [**2145-12-21**] cxr FINDINGS: In comparison with the study of [**11-19**], there is still substantial enlargement of the cardiac silhouette. However, no evidence of vascular congestion, pleural effusion, or acute focal pneumonia. Brief Hospital Course: 33-year-old man with history of insulin dependent diabetes, end-stage renal disease on dialysis, and frequent admissions for gastroparesis, now presents with nausea and vomiting x5 days, labs concerning for ketoacidosis. 1. DKA: Unclear precipitant without signs of cardiac ischemia (given cardiac history) or infection. Pt reported compliance with insulin. Gap was closed by admission to [**Hospital Unit Name 153**] and pt easily transitioned to subQ Lantus and Humalog sliding scale at home doses. Tolerated PO's without problems and [**Name (NI) **] stabilized in 100's before discharge. Vitals stable and pt symptomatically improved by discharge. Unable to make f/u appt with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] MD, Dr. [**Last Name (STitle) 978**] however he was contact[**Name (NI) **] and stated he'll help us make f/u with [**Name8 (MD) **] NP or [**Name8 (MD) **] educator. Pt was also given phone number to contact [**Name (NI) **] and stressed importance of medical f/u. 2. Nausea, vomiting, abdominal pain: Known history of gastroparesis on gastric emptying study [**5-/2137**] vs sxs of DKA. Had CTAP without contrast the month before admission that was negative to explain symtpoms. No fevers, WBC count, or diarrhea to suggest infectious etiology. N/V/Pain resolved with resolution of DKA. Tolerating full diet upon d/c. No prokinetics used while in the ICU. 3. End-stage renal disease on dialysis: Pt is [**Name (NI) **]/Thurs/Sat at [**Location (un) **] in [**Location (un) **]. IVF's were repleted cautiously for DKA given bordeline anuria. Received HD x1 while admitted. 4. Systolic congestive heart failure: Per recent cards note, suspect non-ischemic cardiomyopathy and plan per consult this month was to proceed with cardiac catheterization. Pt currently on Carvedilol, Lisinopril, and Amlodipine. Per consult note, no current apparent benefit to adding statin. Was given cautious IVF's given low EF and ESRD/borderline anuria. EKG/CE's negative for ACS. 5. Anemia: Baseline in the 30's but seen to be mid 20's this admission, likely due to some element of hemodilution, end stage renal disease, and iron study labs suggestive of ACD. Hemolysis labs were negative. Reticulocyte count <2.0. Guiac was negative. Continue to trend CBC with EPO per renal recs. Was not hemodynamically significant. Full code this admission. Medications on Admission: - amlodipine 10 mg once daily - lisinopril 40 mg once daily - omeprazole 20 mg once daily --> states he only takes this prn - sevelamer carbonate 800 mg three times daily with meals --> didn't state he was taking this, but is noted in records - oxycodone 5 mg every six hours as needed --> states will also take Percocet prn - carvedilol 50 mg twice daily - insulin glargine 15 units once daily - humalog insulin per sliding scale four times daily with meals . Discharge Medications: 1. amlodipine 5 mg Tablet [**Location (un) **]: Two (2) Tablet PO DAILY (Daily). 2. lisinopril 20 mg Tablet [**Location (un) **]: Two (2) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Location (un) **]: One (1) Capsule, Delayed Release(E.C.) PO once a day as needed for heartburn. 4. carvedilol 25 mg Tablet [**Location (un) **]: Two (2) Tablet PO twice a day. 5. sevelamer carbonate 800 mg Tablet [**Location (un) **]: One (1) Tablet PO three times a day: with meals. 6. Lantus 100 unit/mL Solution [**Location (un) **]: Fifteen (15) units Subcutaneous once a day: Please continue taking this as you were before admission. 7. Humalog 100 unit/mL Solution [**Location (un) **]: One (1) injection Subcutaneous three times a day: Please continue taking this as you were before admission, three times daily before meals according to your sliding scale. 8. Percocet 5-325 mg Tablet [**Location (un) **]: One (1) Tablet PO once a day as needed for pain: Continue taking this as you were before admission. Discharge Disposition: Home Discharge Diagnosis: Primary: Type 1 Diabetes Diabetic Ketoacidosis Secondary diagnoses: End stage renal disease on hemodialysis Anemia Chronic systolic congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 18**] with diabetic ketoacidosis (DKA) which was treated with IV fluids and insulin. We were unsure the exact cause of this episode of DKA as you had no signs of infection and endorsed compliance with your insulin regimen. Regardless, your blood sugars and acid levels were improved by discharge and you should be sure to follow up closely with Dr. [**Last Name (STitle) 978**] at the [**Last Name (un) **] Diabetes Center. Also, be SURE to take your insulin as directed to prevent this from happening again. No changes were made to your medication regimen and you should continue to take your medications as prescribed. Again be SURE TO TAKE YOUR INSULIN as prescribed. Followup Instructions: As you were discharged after-hours, and we were unable to make an appointment with you to see Dr. [**Last Name (STitle) 978**]. However, we spoke with him and he will have his people call you to schedule an appointment with a nurse practitioner [**First Name (Titles) **] [**Last Name (Titles) **] educator in the next week or two. If you do not hear from them, please call: [**Telephone/Fax (1) 40898**]. You have the following appointments previously scheduled: Department: TRANSPLANT When: MONDAY [**2146-1-17**] at 2:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: FRIDAY [**2146-1-28**] at 2:35 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 24385**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] [**Hospital Ward Name **] Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**] Completed by:[**2145-12-22**]

[ "V49.83", "362.01", "585.6", "428.0", "250.53", "536.3", "583.81", "311", "250.63", "285.21", "250.43", "425.4", "V58.67", "250.13", "428.22" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10786, 10792

6832, 9213

394, 400

10994, 10994

4594, 6541

11874, 13102

3831, 3891

9726, 10763

10813, 10861

9239, 9703

11144, 11851

3906, 4575

10882, 10973

6576, 6809

276, 356

428, 3158

11009, 11120

3180, 3557

3573, 3815

25,825

112,834

19231+57030

Discharge summary

report+addendum

Admission Date: [**2118-12-15**] Discharge Date: [**2119-1-4**] Date of Birth: [**2052-6-27**] Sex: M Service: CHIEF COMPLAINT: Hypothermia. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old gentleman who was found outside his home with a core temperature of 82 degrees. He was transferred to the [**Hospital1 188**] Emergency Department for further resuscitation. The patient was initially treated in the Trauma Bay. A three-way bladder irrigation system was set up. A left chest tube was placed, and a nasogastric tube was placed. The nasogastric tube, chest tube, and three-way bladder irrigation system was used to lavage warm water in order to rewarm the patient. During the patient's resuscitation, he became agitated and he was intubated for airway protection. During the placement of the three-way catheter there was concern of a false passage. Urology was called to evaluate the situation. They performed a bedside ureterocystoscope which showed two to three false passages. The urethralcatheter was left in place, and the Foley was placed to gravity. PAST MEDICAL HISTORY: 1. Ethanol abuse. 2. History of poor nutrition. 3. Questionable baseline dementia. PAST SURGICAL HISTORY: None. MEDICATIONS ON ADMISSION: None. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Initial physical examination revealed the patient's temperature was 29.9 Celsius, his pulse was 100, his blood pressure was 107/67, his heart rate was 116, his respiratory rate was 26, and no oxygen saturations recorded on 6 liters by face mask. Cardiovascular examination revealed a regular rate and rhythm. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended. There was questionable cyanosis. There was no edema. The pupils were equal and reactive. The extraocular muscles were intact. The tympanic membranes were clear. PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's initial hematocrit was 27. Coagulations revealed his prothrombin time was 13, his partial thromboplastin time was 28, and his INR was 1.2. Initial arterial blood gas was 7.3/16/347/8 and -15. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Trauma Service with the initial diagnosis of hypothermia. After transfer to the Intensive Care Unit, the patient was noted to have a rigid and distended abdomen with the findings of a large amount of ascites/free fluid within in the intraperitoneal cavity and free air within the space of Retzius and/or intraperitoneal. It was decided the patient would go to the operating room for an exploratory laparotomy. In the operating room, the bowel was noted to be normal. The fluid was clear with no signs of pus, succus, and/or blood. Urology was consulted for the evaluation of a possible bladder injury. A dye study and retrograde cystogram were performed which did not show any signs of extravasation within the peritoneum and/or retroperitoneal space. The abdomen was left opened. The patient was transferred back to the Intensive Care Unit in stable condition. On hospital day four, the patient was brought back to the operating room and had an exploratory laparotomy and closure of his abdominal wall. The patient's metabolic acidosis improved over time. The patient's bladder pressure following the abdominal closure was 8 cm of water. The Podiatry Service was also consulted at this time for debridement of a keratotic lesion on his left foot which was done without complications. At the end of the removal of the keratotic lesion, Podiatry signed off. The patient was started on total parenteral nutrition for nutrition while his bowel function returned. The patient also had a bronchoscopy to evaluate his pulmonary function which showed purulent secretions from the left lower lobe. A bronchoalveolar lavage was performed. On [**12-20**], a chest tube was placed in the right chest to relieve an increasing effusion. The procedure was done under sterile technique without complications. Throughout the patient's hospitalization, he intermittently dropped his PO2 into the 60 to 40 range. The patient had a computed tomography angiogram which was negative and multiple chest x-rays which showed a diffuse interstitial pattern versus pneumonia. The patient was started on Zosyn as the bronchoscopy washings were growing gram-negative rods. On postoperative days seven and eight, the patient continued to improve his respiratory status. The patient was transfused several units of packed red blood cells for a hematocrit of less than 30. On postoperative day eight, the patient was extubated. The patient was then transferred to the floor and had a bedside swallow evaluation which concluded that the patient should remain nothing by mouth at this time with an nasogastric tube for nutrition. On the floor, the patient became tachypneic and required suctioning, chest physical therapy, and face mask. The patient's oxygen saturations dropped into the 80s with a nonrebreather. At this time, the patient was transferred to the Intensive Care Unit for further monitoring and possible intubation. An arterial line was placed at this time. The patient was given Ativan for agitation. He was continued on a pulmonary toilet as well as chest physical therapy. Tube feeds were on hold. Intravenous fluids were started. A chest x-ray showed a diffuse interstitial pattern; acute respiratory distress syndrome versus pneumonia. Shortly after transfer to the Intensive Care Unit, the patient was intubated. During that time, the patient spiked a temperature and was pan-cultured. His white blood cell count also went from 8 to 15. It was thought that the patient may have aspirated and/or had a continuing process from his initial insult. At that time, the patient was evaluated for tuberculosis and also for Legionella. The tuberculosis was negative. The Legionella was still pending at the time of this dictation. The patient was also started on Levophed for presumed systemic inflammatory response syndrome versus sepsis. The patient's tachycardia which started prior to his Intensive Care Unit admission (in the 130 range) continued. It did not respond to fluid boluses or sedation but did respond to diltiazem as a rate control [**Doctor Last Name 360**]. The patient was ruled out for a myocardial infarction. An electrocardiogram was normal. His troponin was less than 0.03. Also, with a question of line sepsis, the patient's central line was removed and a new pulmonary artery catheter line was placed with a new site. The patient was started on broad spectrum antibiotics; particularly vancomycin 1000 mg and Zosyn 4.5 mg three times per day. During the patient's Intensive Care Unit stay, he required Levophed for blood pressure control to keep his mean above 60. He also remained tachycardic which then responded to propofol and/or diltiazem. The patient's urine output during the entire time remained brisk. Urine electrolytes and sodium electrolytes were not consistent with diabetes insipidus. During this time, the patient was also checked for adrenal insufficiency and pheochromocytoma; both of which were within the normal range. The patient had a repeat echocardiogram done by the anesthesia cardiologist which showed no valvular dysfunction and a normal ejection fraction. The patient was continued on broad spectrum antibiotics. His respiratory function improved over the next several days. On [**12-29**], the Swan-Ganz catheter was changed to a triple lumen catheter. The patient's propofol was weaned. He remained tachycardic in the 100 to 120 range. As his Levophed was also weaned, his mean reached a plateau of between 55 and 60 range. On [**1-1**], a Medical Intensive Care Unit consultation was obtained to evaluate his tachycardia, hypotension, and brisk urine output as all tests had been negative. On [**1-2**], the patient was extubated without incident. The patient remained extubated and continued to do well. During this time, the patient was continued on tube feeds. After the patient was to goal with the tube feeds, he had an increased amount of diarrhea. Clostridium difficile was negative times five. At this time, Imodium was added to the tube feeds to decrease the diarrhea. If this does not work, he will have his tube feeds decreased to half strength. On [**1-3**], the patient was stable enough to be transferred to the floor. The patient was off all pressors, and his agitation was controlled with Ativan. Physical examination on transfer to the floor revealed the patient's temperature maximum was 100.3 degrees Fahrenheit, 98, his blood pressure was 104/54, his heart rate was 119, his respiratory rate was 20, and his oxygen saturation was 96%. Ins-and-outs revealed 2900 in and 2800 out. Laboratories revealed the patient's white blood cell count was 8.4. His hematocrit was 31.3. Chemistry-7 revealed the patient's sodium was 141, potassium was 4.1, chloride was 113, bicarbonate was 19, blood urea nitrogen was 15, creatinine was 0.7, and his blood glucose was 112. His calcium was 7.8, his magnesium was 2.4, and his phosphate was 2.1. The patient was alert and followed commands throughout his extremities. The pupils were equal and reactive. Respiratory examination revealed the lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm with tachycardia. The abdomen was soft, nontender, and nondistended. There were positive bowel sounds. The incision was clean, dry, and intact. There was 1+ edema. Over the course of the [**Hospital 228**] hospital course, his platelets also were low in the range of 40 to 50. The patient had a heparin-induced thrombocytopenia which was sent and was negative. Within several days of the initial hospitalization, his platelets drifted up to the 50 to 100 range and were not an issue throughout the remainder of his hospitalization. DISCHARGE DIAGNOSES: 1. Hypothermia. 2. Status post chest tube placement for warm water lavage. 3. Status post three-way Foley placement for warm water lavage. 4. Status post right chest tube placement for effusion. 5. Acute respiratory distress syndrome with pneumonia. 6. Hypotension. 7. Status post exploratory laparotomy with retrograde cystogram which was normal. 8. Status post exploratory laparotomy with closure of the abdomen. 9. Poor nutrition. 10. History of alcohol abuse. 11. Questionable dementia. [**Last Name (LF) **],[**First Name3 (LF) **] E. M.D. [**MD Number(1) 10637**] Dictated By:[**Last Name (NamePattern4) 959**] MEDQUIST36 D: [**2119-1-4**] 07:39 T: [**2119-1-4**] 07:46 JOB#: [**Job Number 52401**] Name: [**Known lastname 9751**], [**Known firstname 77**] Unit No: [**Numeric Identifier 9752**] Admission Date: [**2118-12-15**] Discharge Date: [**2119-1-19**] Date of Birth: [**2052-6-27**] Sex: M Service: [**Hospital1 1098**]/MEDICINE ADDENDUM: Continues hospital course from approximately [**2119-1-8**], through discharge on [**2119-1-19**]. The patient was transferred to the Internal Medicine service where he was continued on Zosyn and Linezolid for a reported possible hospital acquired pneumonia and a reported positive VRE from rectal swab. The patient was having spiking temperatures overnight to approximately 101.2. He was not recultured at this time as all previous cultures had been negative so far. Infectious disease was consulted at this time. The patient's white blood cell count was 3.5 to 4.5 range. Also of note, the patient underwent a voiding cystogram. This was obtained to evaluate for possible bladder injury during his resuscitation. This was negative for any leaking of contrast. The patient's Foley catheter was discontinued and a condom catheter was placed. The patient was worked up by infectious disease for question of fevers of unknown origin due to his negative cultures and his continuing spiking of fevers. Infectious disease recommended to discontinue all antibiotics in the setting of an eosinophilia which was suggestive of drug fever. The patient remained off all his antibiotics during the rest of his hospital stay with complete resolution of his fevers and resolution of his eosinophilia. The patient's pleural effusions were stable followed by chest x-ray. Also pulmonary consultation was obtained to conduct an ultrasound guided thoracentesis for diagnostic purposes. The thoracentesis revealed 90,000 plus red blood cells and approximately 900 white blood cells. This was determined to be an exudate. Cultures grew very scant colonies of Methicillin resistant Staphylococcus aureus which was thought to be possible contaminant. Cytology was negative. A CT chest was repeated showing stable free flowing bilateral pleural effusions. Infectious disease has recommended to not treat the Methicillin resistant Staphylococcus aureus culture unless the patient deteriorated clinically, which he did not. A RPR was also obtained and was negative. Nutrition continued to follow the patient as well with recommendations for tube feeds and supplemental TPN. His nasogastric tube was discontinued. His diet was advanced after successful swallow evaluation with a video swallowing imaging. Pureed foods were added, eventually soft foods were added. Though the patient's oral intake was below ideal, he continued on his soft food diet as well as liquids by mouth. He had no further hypoxic or hypotensive episodes in his hospital stay. There were no further fevers during the hospital course. He remained on Lovenox subcutaneous for deep vein thrombosis prophylaxis. Due to increasing abdominal pain on his examination later in the hospital course, surgery was reconsulted since the patient was several weeks postoperative. Surgery determined that the patient was stable on examination and had no acute surgical issues. The patient was noted to have a mild hepatitis with AST, ALT, about twice normal range, and the possibilities of his previous alcohol abuse or reaction to Zosyn were both entertained. Also, a monospot and [**Doctor Last Name **]-[**Doctor Last Name **] virus studies were conducted. These were negative. His sacral ulcers, Stage I to II, were treated with rotation while in bed and local wound care and these have improved. He remained in sinus tachycardia for several more days. This did resolve by the time of discharge. His heart rate remained in the 80s for several days. His anemia was followed. Guaiac stools were negative. Folate and B12 were all supplemented. Hematology workup for question of malignancy and lymphoma will be started as an outpatient. His mental status has improved during the hospital course. He does remain confused per family. Physical therapy was also consulted and worked with the patient multiple times, especially during the last several days of his hospital course, making significant progress. The patient was out of bed and ambulatory during this time. He was noted to have oral thrush on his examination over the past few days. He was started on a regimen of Fluconazole 200 mg p.o. for a ten day course. His HIV status remains unknown. It was recommended but was not obtained during this hospital stay. It should be evaluated in the future with his consent. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To an acute rehabilitation facility. DISCHARGE DIAGNOSES: 1. Anemia. 2. Respiratory failure requiring intubation. 3. Pleural effusions. 4. Drug fever. 5. Altered mental status. 6. Sacral ulcer, Stage I to II. 7. Splenomegaly of unknown origin. 8. Oral Candidiasis. MEDICATIONS ON DISCHARGE: 1. Vitamin D. 2. Zinc supplements. 3. Vitamin C supplements. 4. Megace. 5. Fluconazole. 6. TUMS. 7. Loperamide. 8. Tylenol. 9. Miconazole Powder. FOLLOW-UP PLANS: The patient has an appointment scheduled with infectious disease clinic, pulmonology clinic for evaluation and ongoing assessment of his pleural effusions, as well as hematology clinic for an anemia workup and evaluation. Appointments have been made for him at the infectious disease clinic. He was given his information, as well as telephone number to find the location. Also, for pulmonology clinic, appointment was made and hematology clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 343**] for a new patient workup. He will also have follow-up with his primary care physician, [**Name10 (NameIs) 9753**] Dr. [**First Name (STitle) **] or Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], of internal medicine clinic, [**Telephone/Fax (1) 9754**], and he can call to make an appointment once he is discharged from his rehabilitation. [**Doctor Last Name **] [**Name6 (MD) 909**] [**Name8 (MD) **], M.D. [**MD Number(1) 348**] Dictated By:[**Name8 (MD) 6945**] MEDQUIST36 D: [**2119-1-23**] 17:39 T: [**2119-1-23**] 18:18 JOB#: [**Job Number 9755**]

[ "486", "511.9", "276.2", "518.5", "707.0", "991.6", "305.00", "996.76", "112.0" ]

icd9cm

[ [ [] ] ]

[ "89.64", "34.04", "38.93", "54.25", "96.72", "57.32", "96.49", "00.14", "96.04", "54.62", "54.11", "34.91" ]

icd9pcs

[ [ [] ] ]

15552, 15768

15794, 15950

1269, 2192

1235, 1242

2221, 10004

15968, 17113

149, 163

192, 1102

1124, 1211

15465, 15531

83,129

142,625

53841+59554

Discharge summary

report+addendum

Admission Date: [**2195-6-17**] Discharge Date: [**2195-6-26**] Date of Birth: [**2138-5-12**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Mild dyspnea Major Surgical or Invasive Procedure: Mitral Valve Repair (#34 CE Physio Ring), PFO Closure, Maze [**2195-6-18**] History of Present Illness: 56 year old female with known heart murmur who developed palpitations this past winter. She was found to have paroxysmal atrial fibrillation and was referred to Dr. [**Last Name (STitle) 80724**] for evaluation. Anticoagulation was started with coumadin. Initial echocardiogram suggested significant mitral regurgitation. A transesophageal echocardiogram was then obtained which revealed moderate to severe mitral valve regurgitation and prolapse with severe left atrial enlargement. Over the past month, she reports progressive dyspnea on exertion and PND. Given the severity of her disease, she has been referred for surgical evaluation for a mitral valve repair vs. replacement with a MAZE procedure. She admits today for Heparin bridge with plans for OR in the AM. Past Medical History: Atrial fibrillation Hypertension Mitral regurgitation Primary pulmonary hypertension Pancreatitis Lyme's disease Past Surgical History: 1. Appendectomy 2. Abdominal surgery, ?pancreatic pseudocyst removal Social History: Lives with: Husband in [**Name2 (NI) 1727**] Contact:[**Name (NI) 4906**], [**Name (NI) **] Phone #[**Telephone/Fax (1) 110478**]. NO CELL PHONES. Occupation: Gardener Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx: Other Tobacco use: ETOH: < 1 drink/week [] [**2-10**] drinks/week [x] >8 drinks/week [] Illicit drug use: Denies. 2-3 beers/week. Family History: No Premature coronary artery disease. Sister and mother with MVP. Physical Exam: T 97.7 BP 136/98 HR 72 AF R 18 98% RA Ht: 5'6" Wt 115# General: AAO x 3 in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [x] grade IV/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]. Well healed abdominal scar. Extremities: Warm [x], well-perfused [x] Edema - none Varicosities: Significant bilateral lower extremitiy varicosities. Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit - Negative Pertinent Results: TEE [**2195-6-18**] Conclusions Prebypass The left atrium is dilated. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. There is mild LVH. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are myxomatous. There is moderate/severe bileaflet leaflet mitral valve prolapse. Severe (4+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2195-6-18**] at 1330. Post bypass Patient is in sinus rhythm and receiving an infusion of phenylephrine. Annuloplasty ring seen in the mitral position. It appears well seated and there is no mitral regurgitation. Mean gradient across the mitral valve is 3 mm Hg. LVEF= 45%. Aorta is intact post decannulation. Rest of examination is unchanged. . [**2195-6-23**] 05:26AM BLOOD WBC-6.2 RBC-3.25* Hgb-9.9* Hct-30.3* MCV-93 MCH-30.4 MCHC-32.6 RDW-12.9 Plt Ct-134*# [**2195-6-22**] 04:34AM BLOOD WBC-4.6 RBC-2.75* Hgb-8.8* Hct-25.7* MCV-94 MCH-32.0 MCHC-34.2 RDW-13.3 Plt Ct-78* [**2195-6-23**] 05:26AM BLOOD PT-12.0 INR(PT)-1.1 [**2195-6-22**] 04:34AM BLOOD PT-11.7 INR(PT)-1.1 [**2195-6-21**] 08:00AM BLOOD PT-11.3 INR(PT)-1.0 [**2195-6-20**] 06:20AM BLOOD PT-11.5 PTT-30.3 INR(PT)-1.1 [**2195-6-24**] 04:55AM BLOOD UreaN-13 Creat-0.6 Na-136 K-4.1 Cl-96 [**2195-6-23**] 04:45PM BLOOD Na-135 K-3.5 Cl-93* [**2195-6-23**] 05:26AM BLOOD Glucose-110* UreaN-15 Creat-0.7 Na-136 K-3.8 Cl-97 HCO3-33* AnGap-10 Brief Hospital Course: The patient was brought to the Operating Room on [**2195-6-18**] where the patient underwent Mitral Valve Repair, PFO Closure, Maze with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Thrombocytopenia developed and coumadin was held. Platelet count rose and Coumadin was resumed. The patient was transferred to the telemetry floor for further recovery. Pacing wires were discontinued. When chest tubes were placed to waterseal, she developed moderate bilateral pneumothoraces. Tubes were placed back to suction and progressed more slowly. Eventually Chest tubes were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Warfarin 7.5 mg PO DAILY stopped [**5-13**] for surgery 3. Vitamin D 3000 UNIT PO DAILY 4. Ultra InflamX Plus 360 *NF* (nut. tx., met.dis.,mvi, min #4) [**1-5**] scoops Oral daily Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR Coumadin for AFib Goal INR [**2-6**] First draw [**2195-6-25**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [**Last Name (STitle) 80724**] fax: [**Telephone/Fax (1) 110479**] 2. Warfarin 7.5 mg PO DAILY stopped [**5-13**] for surgery RX *Coumadin 2 mg daily Disp #*60 Tablet Refills:*2 3. Aspirin EC 81 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg daily Disp #*30 Tablet Refills:*0 5. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain RX *Dilaudid 2 mg q3h Disp #*40 Tablet Refills:*0 6. Lactulose 30 mL PO TID:PRN constipation RX *Generlac 10 gram/15 mL daiily Disp #*1 Bottle Refills:*0 7. Lorazepam 0.25 mg PO Q8H:PRN anxiety RX *Ativan 0.5 mg every eight (8) hours Disp #*20 Tablet Refills:*0 8. Metoprolol Tartrate 12.5 mg PO BID Hold for HR<60, SBP<90 RX *metoprolol tartrate 25 mg twice a day Disp #*60 Tablet Refills:*0 9. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg daily Disp #*30 Tablet Refills:*0 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 17 gram/dose daily Disp #*1 Bottle Refills:*0 11. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg daily Disp #*30 Tablet Refills:*0 12. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *tramadol 50 mg every four (4) hours Disp #*40 Tablet Refills:*0 13. Ultra InflamX Plus 360 *NF* (nut. tx., met.dis.,mvi, min #4) [**1-5**] scoops Oral daily 14. Vitamin D 3000 UNIT PO DAILY 15. Amlodipine 10 mg PO DAILY RX *amlodipine 10 mg daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: SMMS visiting nurses Discharge Diagnosis: Atrial fibrillation Hypertension Mitral regurgitation Primary pulmonary hypertension Pancreatitis Lyme's disease Past Surgical History: 1. Appendectomy 2. Abdominal surgery, ?pancreatic pseudocyst removal Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**], [**2195-7-29**] 1:30 Cardiologist Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) 80724**], [**2195-7-14**] at 2:20p Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] C [**Telephone/Fax (1) 110480**] in [**4-9**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR Coumadin for AFib Goal INR [**2-6**] First draw [**2195-6-25**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [**Last Name (STitle) 80724**] fax: [**Telephone/Fax (1) 110479**] Completed by:[**2195-6-24**] Name: [**Known lastname 13952**],[**Known firstname **] Unit No: [**Numeric Identifier 18094**] Admission Date: [**2195-6-17**] Discharge Date: [**2195-6-26**] Date of Birth: [**2138-5-12**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 741**] Addendum: Mrs. [**Known lastname **] remained in the hospital for 2 more days due to hypotension. Medications were adjusted. Lopressor and Amlodipine were stopped. As blood pressure recovers, Lopressor may be resumed. Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR Coumadin for AFib Goal INR [**2-6**] First draw [**2195-6-25**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [**Last Name (STitle) 18095**] fax: [**Telephone/Fax (1) 18096**] 2. Warfarin 7.5 mg PO DAILY stopped [**5-13**] for surgery RX *Coumadin 2 mg 1 Tablet(s) by mouth daily Disp #*60 Tablet Refills:*2 3. Aspirin EC 81 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain RX *Dilaudid 2 mg [**1-5**] Tablet(s) by mouth q3h Disp #*40 Tablet Refills:*0 6. Lactulose 30 mL PO TID:PRN constipation RX *Generlac 10 gram/15 mL 30 mL by mouth daiily Disp #*1 Bottle Refills:*0 7. Lorazepam 0.25 mg PO Q8H:PRN anxiety RX *Ativan 0.5 mg 0.25 mg by mouth every eight (8) hours Disp #*20 Tablet Refills:*0 8. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth daily Disp #*1 Bottle Refills:*0 10. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *tramadol 50 mg 1 Tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 12. Ultra InflamX Plus 360 *NF* (nut. tx., met.dis.,mvi, min #4) [**1-5**] scoops Oral daily 13. Vitamin D 3000 UNIT PO DAILY 14. Amiodarone 200 mg PO DAILY RX *amiodarone 200 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: SMMS visiting nurses [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2195-6-26**]

[ "458.29", "416.8", "429.5", "401.9", "285.9", "745.5", "427.31", "424.0", "287.49" ]

icd9cm

[ [ [] ] ]

[ "37.33", "39.61", "35.12", "35.33", "35.71" ]

icd9pcs

[ [ [] ] ]

12318, 12492

4486, 5856

324, 402

8116, 8284

2610, 4463

9156, 10638

1823, 1891

10661, 12295

7888, 8001

5882, 6206

8308, 9133

8024, 8095

1906, 2591

271, 286

430, 1202

1224, 1337

1447, 1807

55,844

175,238

35077

Discharge summary

report

Admission Date: [**2136-9-2**] Discharge Date: [**2136-9-17**] Date of Birth: [**2098-7-10**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: Trauma s/p motorcycle crash on dirt bike Major Surgical or Invasive Procedure: None History of Present Illness: 38M s/p motorcycle crash on dirt bike. No loss of consciousness. Unhelmeted. Past Medical History: EtOH Abuse Social History: Pt is a 38 yo married male with 3 children Pt has had a ETOH problem for 17 years Physical Exam: 97.8, 86, 112/70, 18, 95% RA Gen: Pt a&o x3, cooperative. HEENT: EOMI, PERRLA Neck: full rom w/o tenderness. Chest: CTAB. Tender. CV: RRR. Abd: soft, nt, nd, + bs Neuro: Pt able to ambulate, moving all extremities. Pertinent Results: Radiology Report CLAVICLE LEFT PORT Study Date of [**2136-9-3**] 9:49 AM FINDINGS: In comparison with the chest study of this date, there is little change in the appearance of the fracture with overriding of the distal third of the clavicle. Radiology Report CHEST (PORTABLE AP) Study Date of [**2136-9-4**] 4:37 PM Evaluation of the skeletal structures demonstrates now clearly the presence of a fracture in the left lateral axillary line of the right- sided ninth rib. Comparison with the previous study demonstrates clear progression of this density in the right lower lung field and considering patient's history diagnosis of a lung contusion is suggested. Also on the right side there is no evidence of any pneumothorax. Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2136-9-4**] 5:09 PM IMPRESSION: 1. Filling defect in left upper segment branch is suggestive of pulmonary embolism. 2. Multifocal pneumonia 4. 6-mm non-obstructing calculus in right kidney. Radiology Report BILAT LOWER EXT VEINS PORT Study Date of [**2136-9-5**] 12:43 PM IMPRESSION: No deep venous thrombosis in right or left common femoral, superficial femoral, or popliteal veins. Radiology Report CT HEAD W/O CONTRAST Study Date of [**2136-9-5**] 9:15 PM IMPRESSION: 1. No acute intracranial hemorrhage. 2. Small 1 cm depressed skull fracture of the left parietal cortex. Brief Hospital Course: Mr. [**Known lastname 22627**] was admitted on [**2136-9-2**] after a dirt-bike crash at high speeds, unhelmeted. No LOC. He was found to have left rib fractures #[**4-6**], L clavicle fracture, and a small anterior PTX. While in the hospital, the his L upper extremity was assessed by orthopedics and treated with a sling and pain control. His small anterior PTX was treated with O2 as in was small and spontaneously improved. The rib fractures were treated with pain control and serial XRays ruled out pulmonary contusions. Mr. [**Known lastname 80126**] course was complicated by a Strep Pneumo pneumonia, which was successfully treated with nafcillin for a complete course during his hospital stay. Due to increasing oxygen requirement a CTA was done to rule out a pulmonary embolus. A small filling defent was seen in a solitary segmental branch and the pt was then placed on a heparin drip and transitioned to coumadin for anticoagulation. However, after several days passed with anticoagulation, the CTA was reviewed and it was decided that anticoagulation was not required in light of the degree of CT findings. Mr.[**Known lastname 80126**] disposition was complicated by placement issues as the pt made comments of having suicidal ideations. Both psychiatry as well as social work were heavily involved during his hospital course. In the end, with the aid of the social worker, it was decided that Mr.[**Known lastname 22627**] would be dicharged to stay with a friend until a rehabilitation facility would accept him as an inpatient. The pt is on several waiting lists for drug/[**Hospital **] rehab and will go to AA and will continue efforts to move up on waiting lists. Medications on Admission: none Discharge Medications: 1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: left calvical fracture, left rib fractures [**4-6**] Discharge Condition: Good Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. Activity: No heavy lifting of items [**9-12**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. No driving while taking narcotic pain medicine. Followup Instructions: Please call the office of Dr. [**Last Name (STitle) **] to schedule a follow-up appointment at ([**Telephone/Fax (1) 22750**]

[ "303.01", "807.05", "V62.84", "860.0", "481", "415.19", "305.91", "E821.2", "810.00" ]

icd9cm

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icd9pcs

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27014

Discharge summary

report

Admission Date: [**2199-10-3**] Discharge Date: [**2199-10-10**] Date of Birth: [**2144-10-4**] Sex: F Service: MEDICINE Allergies: Ativan / Amoxicillin / Bactrim / Codeine / ibuprofen / Lamictal / naproxen / Tetanus Toxoid,Fluid / Cephalexin / Peanuts / Sulfa (Sulfonamide Antibiotics) / golytely / citrate of magnesia / Lithium Attending:[**First Name3 (LF) 15397**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 54 y/o F w/ PMH of lithium-induced ESRD on PD, hemorrhoids, tracheal stenosis, and hypertension recently discharged on [**9-24**] after transplant [**Doctor First Name **] admit for diverticulitis (treated conservatively w/ levo flagyl) who p/w fever to 101 at home and four episodes of BRBPR over the past two days. Denies melena. She also reports some light-headedness. On presentation to the ED she was found to be hypotensive to 77/38 (SBp 130's baseline), after 1L IVF bolus her BP increased to the 100's. She was afebrile upon presentation; after sending cultures she was given levo/[**Last Name (un) 2830**]/vanc for broad spectrum coverage in the ED. She denies N/V, denies changes in bladder or bowel habits, denies abdominal pain. She reports that her PO intake has been normal. Her sister who is her primary caregiver [**First Name (Titles) **] [**Last Name (Titles) 66407**] her today and states that the dwells have been clear for her peritoneal [**Last Name (Titles) 2286**], however given the episode of fever 2 days ago her [**Last Name (Titles) 2286**] nurse did start her on vancomycin with PD. She recieved one dose of this prior to presentation. Infectious ROS neg for headaches, neg stiffness, cough, chest pain, diarrhea, abdominal pain, + for dysuria, calf swelling nor rashes. . ED was also concerned about Hct slight drop from 25.4 last week to 23 in context of guaic + marroon stool. They ordered her for 2 units of blood and hung the 2nd unit up in ICU. In the ED, a CXR showed new cardiomegaly and bedside u/s: no cardiac effusion. Transplant surgery felt no surgical indications and that repeat imaging of abdomen was not needed. . Renal consulted: "Please send fluid from PD catheter for cell counts, gram stain and culture. Document what the fluid looks like. Is there abdominal pain? If the fluid returns positive for infection (>100 WBCs), call me again and we can discuss IP antibiotics." . In ED VS were 98.0 95 102/58 21 100 on transfer Labs were remarkable for WBC WNL, lactate 2.9, Interventions: Vanc, [**Last Name (un) **], Levo, UCx, Blood Cx, CXR . ROS: (+) Per HPI Past Medical History: tracheostomy [**5-/2198**] for prolonged respiratory failure hyponatremic seizure following GoLytely prep [**5-/2198**] ESRD for lithium toxicity on HD bipolar GERD HTN breast cancer diverticulosis . PSH: parathyroidectomy with reimplantation in left arm left foot surgery in [**2180**] right knee surgery in [**2191**] lumpectomy for breast cancer (DCIS) status post radiation repeat mammograms were all negative history of tonsillectomy in the past Social History: - Tobacco: Never - Alcohol: Previously occasionally - Illicits: Denies - Occupation/Recent travel/sick contacts: denies Family History: Mother with ovarian CA Father with CAD Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.6 96 105/65 21 98% 2L GENERAL: AOx3, NAD HEENT: MMM. no LAD. no JVD. neck supple. HEART: RRR S1/S2 heard. no murmurs/gallops/rubs. LUNGS: mild crackles at bases B/L ABDOMEN: soft, PD catheter in place, no erythema around site, nontender. Foley in place w/ pus in tube. Rectal deferred by patient. Stated she already received on in the ED. EXT: wwp, 2+ pitting edema B/L to knees NEURO/PSYCH: CNs II-XII intact. strength and sensation in U/L extremities grossly intact. gait not assessed. . DISCHARGE PHYSICAL EXAM: Gen: awake, alert, NAD CV: RRR, no m/r/g LUNGS: CTAB ABDOMEN: +BS, soft, NT, distended EXT: WWP, 1+ bilateral edema Pertinent Results: ADMISSION LABS: [**2199-10-2**] 11:00PM BLOOD WBC-9.6# RBC-2.08* Hgb-6.8* Hct-22.8* MCV-109* MCH-32.6* MCHC-29.8* RDW-19.9* Plt Ct-172 [**2199-10-2**] 11:00PM BLOOD Neuts-92.1* Lymphs-3.9* Monos-3.6 Eos-0.2 Baso-0.1 [**2199-10-3**] 09:24AM BLOOD PT-17.8* PTT-34.2 INR(PT)-1.7* [**2199-10-2**] 11:00PM BLOOD Glucose-116* UreaN-45* Creat-7.4*# Na-132* K-3.8 Cl-94* HCO3-28 AnGap-14 [**2199-10-2**] 11:00PM BLOOD ALT-8 AST-14 AlkPhos-334* TotBili-0.1 [**2199-10-2**] 11:00PM BLOOD Lipase-14 [**2199-10-2**] 11:00PM BLOOD Albumin-2.3* [**2199-10-3**] 09:24AM BLOOD Calcium-7.9* Phos-3.9 Mg-1.7 [**2199-10-2**] 11:41PM BLOOD Lactate-2.9* MICRO: [**10-2**] Blood culture x 2 - No growth FINAL URINE CULTURE (Final [**2199-10-6**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. OF TWO COLONIAL MORPHOLOGIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. AMPICILLIN SENSITIVITIES PERFORMED ON REQUEST.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S C. difficile DNA amplification assay (Final [**2199-10-9**]): Reported to and read back by DR. [**Last Name (STitle) 13212**],[**Last Name (un) **] PAGER [**Numeric Identifier 13213**] @ 09:40 [**2199-10-9**]. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). IMAGING: [**10-2**] CXR: FINDINGS: The lungs are poorly inflated. There is vascular cephalization but no focal opacities concerning for pneumonia. Assessment of the left lung field is limited by stable severe cardiomegaly. A large, fluid filled Morgagni hernia at the right cardiophrenic angle is unchanged. Two tiny locules of air within the hernia are seen in the lateral radiograph which were also present in the CT abdomen from [**2199-9-18**]. There is no pleural effusion or pneumothorax. IMPRESSION: Vascular cephalization but no evidence of acute cardiopulmonary process. Stable large Morgagni hernias with locules of air, unchanged from [**2199-9-18**]. [**10-4**] ECHO: Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No pericardial effusion. Grossly normal biventricular systolic function. Compared with the prior study (images reviewed) of [**2193-6-17**], comparable findings are similar. \ DISCHARGE LABS: [**2199-10-10**] 07:45AM BLOOD WBC-5.6 RBC-2.77* Hgb-9.0* Hct-28.5* MCV-103* MCH-32.4* MCHC-31.5 RDW-18.9* Plt Ct-148* [**2199-10-7**] 08:05AM BLOOD PT-12.6* INR(PT)-1.2* [**2199-10-10**] 07:45AM BLOOD Glucose-98 UreaN-52* Creat-6.8* Na-131* K-3.4 Cl-91* HCO3-29 AnGap-14 [**2199-10-10**] 07:45AM BLOOD Calcium-7.8* Phos-4.8* Mg-1.6 [**2199-10-3**] 03:30AM URINE Color-YELLOW Appear-Cloudy Sp [**Last Name (un) **]-1.022 [**2199-10-3**] 03:30AM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG Urine: [**2199-10-3**] 03:30AM URINE RBC-114* WBC->182* Bacteri-MOD Yeast-NONE Epi-0 [**2199-10-3**] 03:30AM URINE WBC Clm-OCC Ascites: [**2199-10-3**] 06:50PM ASCITES WBC-4* RBC-1* Polys-53* Lymphs-4* Monos-39* Eos-1* Mesothe-3* [**2199-10-3**] 06:12PM OTHER BODY FLUID TotProt-0.2 Na-132 K-3.5 Amylase-4 Albumin-LESS THAN GRAM STAIN (Final [**2199-10-3**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2199-10-6**]): NO GROWTH. Brief Hospital Course: 54 yo female with PMH of lithium-induced ESRD on PD, recently discharged on [**9-24**] admit for diverticulitis (treated conservatively w/ levo and flagyl) p/w fevers, BRBPR and hypotension found to have UTI. No recurrence of BRBPR. Active issues: # Hypotension: Patient was initially hypotensive to the 70s/30s (tachy to 100s) in the ED. Antibiotics were started, she was fluid resuscitated and transferred to the ICU where she was briefly on pressors. Pressors were quickly weaned and she was found to have frank pus in her urine (see below). She was soon transferred out to the floor and remained hemodynamically stable through the rest of the admission. Work-up for other infectious sources was negative (blood cultures, CXR, [**Month/Year (2) 2286**] fluid). # BRBPR: Patient had episode of bright red blood per rectum prompting her initial presentation to the ED. Patient's hematocrit remained stable, she did not require transfusion and had no recurrence of bleeding. # UTI: Patient noted to have frank pus in her urine. Culture was sent and she was started on meropenem due to recent hospitalizations and penicillin allergy. Culture reveal E.coli. Due to patient allergies, she completed a 7 day course of meropenem in the hospital. # C. diff colitis: Prior to discharge, patient had several episodes of diarrhea and was found to be positive for C. diff. She was discharged with a 14 day course of flagyl. Chronic issues: # ESRD: [**2-7**] lithium toxicity. Continued peritoneal [**Month/Day (2) 2286**] with support from renal fellow. Continued MVI, calcitriol. # Hyponatremia: Subacute. Peritoneal [**Month/Day (2) 2286**] adjusted per renal team. # Elevated INR: Unclear etiology: ?nutrition vs. intrinsic liver vs. abx effect. Received vitamin K. # Bipolar disorder: Continued lithium, olanzapine, SSRI # GERD: continued PPI Transitional issues: -WIll complete 14 day course of flagyl for C.diff. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Docusate Sodium 100 mg PO BID 2. Fluoxetine 20 mg PO DAILY 3. Lithium Carbonate 150 mg PO DAILY 4. OLANZapine 10 mg PO DAILY 5. Calcitriol 0.25 mcg PO DAILY 6. Heparin Dwell (1000 Units/mL) 1000 UNIT DWELL UNDEFINED each 1 liter dwell IP for fibrin 7. Lactulose 30 mL PO BID 8. Lorazepam 1 mg PO HS:PRN insomnia 9. Miconazole Powder 2% 1 Appl TP [**Hospital1 **] 10. Tucks Hemorrhoidal Oint 1% 1 Appl PR PRN hemorrhoidal pain 11. Vitamin D 50,000 UNIT PO 1X/WEEK (TU) 12. Epoetin Alfa 40,000 units SC Q MONDAY 13. Senna 1 TAB PO BID:PRN constipation 14. OLANZapine 5 mg PO ASDIR Please assess patient for leg tingling, restlessness and give this additional dose. Will likely need while doing CAPD 15. Topiramate (Topamax) 25 mg PO DAILY 16. DIALYVITE 800 *NF* (B complex-C-folic acid-Zn) 0.8 mg Oral daily 17. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Calcitriol 0.25 mcg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Ferrous Sulfate 325 mg PO DAILY 4. Fluoxetine 20 mg PO DAILY 5. Lactulose 30 mL PO BID Please hold for loose stools. [**Month (only) 116**] need to be held in the setting of C. diff colitis. 6. Lithium Carbonate 150 mg PO DAILY 7. OLANZapine 10 mg PO DAILY 8. Senna 1 TAB PO BID:PRN constipation 9. Topiramate (Topamax) 25 mg PO DAILY 10. DIALYVITE 800 *NF* (B complex-C-folic acid-Zn) 0.8 mg Oral daily 11. Epoetin Alfa 40,000 units SC Q MONDAY 12. Lorazepam 1 mg PO HS:PRN insomnia 13. Miconazole Powder 2% 1 Appl TP [**Hospital1 **] 14. OLANZapine 5 mg PO ASDIR Please assess patient for leg tingling, restlessness and give this additional dose. Will likely need while doing CAPD 15. Tucks Hemorrhoidal Oint 1% 1 Appl PR PRN hemorrhoidal pain 16. Vitamin D 50,000 UNIT PO 1X/WEEK (TU) 17. Heparin Dwell (1000 Units/mL) 1000 UNIT DWELL UNDEFINED each 1 liter dwell IP for fibrin 18. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 14 Days Start date [**10-9**] RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp #*42 Tablet Refills:*0 19. Outpatient Lab Work Please check Chem 10 on Monday [**10-14**] at [**Month/Day (4) 2286**] unit. Results to be faxed to: Name: [**Last Name (LF) **],[**First Name3 (LF) 177**] A. (MD) Phone: [**Telephone/Fax (1) 66403**] Fax: [**Telephone/Fax (1) 66408**] Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Urinary tract infection Bright red blood per rectum C. difficile colitis 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 66401**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with feeling fatigue and after passing blood while trying to have a bowel movement. When you came to the emergency department your blood pressure was low and you were admitted to the Intensive Care Unit. We gave you IV fluids and medications to support your blood pressure and you got better. We found that you had a urinary tract infection and started you on antibiotics. You continued to get better with treatment of your infection. You finished your antibiotics for the urinary tract infection, but were found to have developed an infection in your bowels, leading to diarrhea. You will need to take a different antibiotic for two weeks to treat this infection. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 177**] A. Location: [**Location (un) **] INTERNAL MEDICAL ASSOC. Address: [**Street Address(2) 66404**], [**Location (un) **],[**Numeric Identifier 66405**] Phone: [**Telephone/Fax (1) 66403**] ** Please call your PCP above to make a follow up appointment for this hospitalization for sometime in the next week. Department: TRANSPLANT CENTER When: THURSDAY [**2199-10-24**] at 1 PM With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage **Please follow-up with your [**Hospital Ward Name 2286**] center on Monday [**10-14**] at your regularly scheduled appointment.

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icd9cm

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12721

Discharge summary

report

Admission Date: [**2108-3-24**] Discharge Date: [**2108-4-27**] Date of Birth: [**2044-3-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 974**] Chief Complaint: Perforated diverticulitis with diffuse peritonitis and free air Major Surgical or Invasive Procedure: Left hemicolectomy, splenectomy, removal of Marlex mesh, and ventral hernia repair and end transverse colostomy Exploratory laparotomy with repair of fascial dehiscence, insertion of a Surgisis Gold mesh Cardioversion History of Present Illness: 63M with extensive PMH who presented to [**Hospital 39249**] Hospital with a several day history of increasing lower abdominal pain, nausea, and anorexia. CT showed free intraperitoneal air. Transferred to [**Hospital1 18**] per patient request for further evaluation and treatment. Past Medical History: Myasthenia [**Last Name (un) 2902**] CAD s/p CABG [**2091**] Hypertension Dyslipidemia Atrial flutter/fibrillation Diabetes Mellitus Ventral abdominal hernia s/p MVA in [**2092**]. Lower back pain, has l-spine compression fractures GI bleed Social History: Quit tobacco [**2094**]; rarely drinks alcohol; lives with his wife; Currently on disability, former director of an exercise company Family History: Grandmother with pacemaker, no other known heart disease Physical Exam: Admission PE- [**2108-3-24**] 112 108/70 20 100% Toxic, AOx3. MM Dry Tachy, irreg Decreased BS on L Distended, obese (+)diffuse, TTP w/ rebound and guarding LLQ>R side No CCE. 1+/= distal pulses Pertinent Results: Admission Labs ----------------- [**2108-3-24**] 08:05AM BLOOD WBC-16.2* RBC-3.36* Hgb-9.5* Hct-30.4* MCV-91 MCH-28.4 MCHC-31.4 RDW-16.7* Plt Ct-232 [**2108-3-24**] 08:05AM BLOOD Neuts-91* Bands-6* Lymphs-1* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2108-3-24**] 08:05AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Spheroc-OCCASIONAL Ovalocy-2+ Schisto-1+ Tear Dr[**Last Name (STitle) **]1+ [**2108-3-24**] 08:05AM BLOOD PT-12.5 PTT-28.0 INR(PT)-1.1 [**2108-3-24**] 08:05AM BLOOD Plt Smr-NORMAL Plt Ct-232 [**2108-3-24**] 03:47PM BLOOD Fibrino-524* [**2108-3-24**] 08:05AM BLOOD Glucose-117* UreaN-37* Creat-0.9 Na-147* K-4.8 Cl-113* HCO3-25 AnGap-14 [**2108-3-24**] 03:47PM BLOOD CK(CPK)-20* [**2108-4-3**] 01:38AM BLOOD Lipase-241* [**2108-3-24**] 03:47PM BLOOD CK-MB-NotDone cTropnT-0.10* [**2108-3-24**] 03:47PM BLOOD Calcium-8.3* Phos-4.5# Mg-1.6 Discharge Labs -------------------- [**4-27**]: WBC 22.5; HCT: 33.6; PLT: 554; [**4-25**]: Na:138 CL:99 K:4.3 HCO3:29 BUN:13 Creat:0.6 Gluc:173 Operative Note [**2108-3-24**] PREOPERATIVE DIAGNOSES: Perforated diverticulitis with diffuse peritonitis and free air. POSTOPERATIVE DIAGNOSES: Perforated diverticulitis with diffuse peritonitis and free air, with large retroperitoneal abscess extending into the splenic hilum. PROCEDURES: Left hemicolectomy, splenectomy, removal of Marlex mesh, and ventral hernia repair and end transverse colostomy. ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Numeric Identifier 39250**], [**Doctor First Name 39251**] [**Doctor Last Name 39252**], RES, beeper number [**Serial Number 39253**]. ANESTHESIA: General. HISTORY: This elderly male with significant comorbidities of severe coronary artery disease, having had an acute episode with stenting in [**2108-1-9**], now on Plavix, and additionally having a chronic course of myasthenia [**Last Name (un) 2902**], which is requiring large steroid doses, presented to the emergency department in transfer from [**Hospital 8125**] Hospital, having had a history of approximately 2 weeks of lower abdominal pain, which got dramatically worse during the night, awakened him from sleep. His wife took him to the [**Name (NI) 8125**] Hospital where he was generally unstable. They immediately determined that they would transfer him to [**Hospital1 **] after a CAT scan revealed that he had massive free air. The patient also is quite obese. He additionally had a large epigastric hernia which was resulting from his sternotomy from previous cardiac surgery. This, under CT, had evidence of the transverse colon being in it, but it did not appear to be incarcerated. The SMA and [**Female First Name (un) 899**] appeared to be opened prior to surgery. There was little inflammatory reaction, but a large amount of air in the retroperitoneum as well as in the abdomen. At surgery he was found to have a fecal peritonitis, with ruptured abscess in the descending colon. There was obviously a ruptured diverticulitis, which had created a well walled off abscess that extended up the descending colon mesentery, into the splenic hilum. Consideration was to do a diverting transverse loop colostomy. However, the size of the abscess was rather dramatic and attempting to drain this laterally we actually got feculent material out of it, actual fecal matter and so therefore it was felt that we really needed to resect this area. With that the left colon was mobilized. This abscess extended all the way up in the splenic hilum, and in the course of mobilization of the splenic hilum had some bleeding, ultimately necessitating splenectomy, although initially we tried to control this with argon beam and packing. Because the left colon was still involved, the patient had the left hemicolectomy, with the sigmoid colon transected at the region of the high rectum, mid-sigmoid area, which was free from any inflammatory process. Because of the large abscess the colon was actually removed along the colon itself to avoid injury to the ureters. The abscesses were drained out diffusely. Upon coming around to the middle colic artery, taking down the left branch of the middle colic, we got into good bowel with no more abscess. At that point it was decided we would transect and pass the specimen off. Turning back attention to the splenic hilum, it was bleeding and therefore, he had the splenectomy additionally. Additionally, the patient had a recurrent ventral hernia with Marlex mesh, which was actually intraperitoneal, attached to the left lateral costal margin. This was excised and fascia was mobilized, so that we could actually effect epigastric closure primarily. DESCRIPTION OF PROCEDURE: Under adequate general endotracheal anesthesia, following a 4 liter bolus with central line getting therapy getting a CVP up to 4, the patient was brought urgently to the operating theatre, where he was placed under general anesthesia. A midline incision was created and upon entering the abdomen and observing the incredible amount of retroperitoneal process, this was extended superiorly and inferiorly to allow complete midline incision. The patient had a significant obesity, making this exposure difficult. At this point then attention was turned to the large amount of pus in the left gutter. The mid descending colon actually had a rather prominent hole in it, which was perforated on the mesentery. The mesentery perforated freely into the abdominal cavity. This large abscess cavity extended up along the descending mesentery, and into the splenic hilum retropancreatic as well. Based on that it was elected upon trying to drain this that we were going to be unsuccessful, once we recognized all the fecal matter that was in it. Based on this the sigmoid was identified and found to be without any inflammation in the midportion and distally. It was transected with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3224**] at that point, we simply took colon out along the level of the secondary arcades, through most of the way up around the left. Attempts at mobilizing the splenic flexure and draining this retroperitoneal abscess up around the pancreas yielded some bleeding off the inferior pole of the spleen, as well as behind the spleen. This was initially controlled with argon beam and packing, as the colectomy was completed. Vascular pedicles were controlled throughout the case with 2- 0 silk ligatures in continuity, followed by 2-0 silk suture ligature to the vessel remaining in situ. Having accomplished the colectomy to the transverse colon, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3224**] was utilized again to transect. The specimen was passed off the field. Attention was turned back to the left upper quadrant, at which point the patient still had some bleeding and we were unable to control the hilum well, where the abscess was extending into it. So carefully taking down the short gastrics with 2-0 silk ligatures in continuity, followed by suture ligature, and the hilum could be dissected out to the 2 major branches. This was taken down and secured with two 2- 0 silks, followed by a 2-0 silk transfixion suture, to both branches. The spleen was then amputated at the level of the spleen and removed. There was still some bleeding in the inferior port of hilum. The pancreas could not be identified because of the diffuse edema and pus that was coming out from behind it, so a right-angle clamp was placed on the actual arterial bleeding site and a 2-0 silk suture ligature was placed, and this controlled the bleeding. Pus continued to come out from behind the pancreas. A retropancreatic space was mobilized a bit more to clean this out. Upon completion of this maneuver, as well as cleaning out the mesentery, the patient actually became quite a lot more stable. At this point in time the left upper quadrant was again packed, after diffuse irrigation along the left side of the abdomen with warm saline was completed. After this packing, the attention was turned to the superior aspect of the abdomen, where he had his old ventral hernia. He had a Marlex mesh, which was there attached. This was dissected out of the abdominal wall. He had a lot of omentum and actually the transverse colon had been previously taken out of this hernia. This was all taken out of the hernia sac. The sac was resected. The peritoneal edges were identified and freshened, and the skin was mobilized back to allow fascial closure, which was relatively easily accomplished. Consideration for a component separation was entertained. However, it was decided because of the diffuse infection, as well as the immunocompromised state, that this would not be prudent. At this point in time then we marked a reasonable right-sided colostomy site. The transverse colon could be easily brought down to this level. The distal colon was debrided to allow a good segment to go through the abdominal wall. At this point then we turned our focus back on the left upper quadrant, which was having no further bleeding. This was all copiously irrigated. Because of the pancreas and the abscess it was elected to go and put [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain there, and this was brought out through a separate stab wound incision. At this point then the stoma site was fashioned. The colon was pulled out through that and matured with 3-0 PDS after fascial closure. The fascial closure was effected by running double looped PDS through the lengthy abdominal wall incision. The skin was closed with staples. Again the abdomen had been copiously irrigated. The small bowel had been evaluated thoroughly. The stomach been evaluated. Consideration for a feeding tube was entertained, however it was elected to get him off the table and get him back to the ICU for further resuscitation. An NG tube was placed and in good position. It was noted the patient had an estimated 800 cc blood loss. He received 4000 crystalloid in the operating room, in addition to 4000 he received prior to surgery. He had 3 units of blood, 500 cc of Hespan, 2 units of albumin that is 500 cc at 5% albumin, and his urine output at the end of the case was 1000 cc. Sponge, needle and instrument counts were correct times 2. The patient had sterile dressings applied, and was returned immediately to the ICU for continued resuscitation on the ventilator, and to slowly wean him off the ventilator, because of the myasthenia [**Last Name (un) 2902**] issue. Operative Note- [**2108-4-12**] PREOPERATIVE DIAGNOSIS: Fascial dehiscence. POSTOPERATIVE DIAGNOSIS: Fascial dehiscence. PROCEDURE: Exploratory laparotomy with repair of fascial dehiscence, insertion of a Surgisis Gold mesh. ASSISTANTS: [**Doctor First Name 15738**] [**Doctor Last Name 15737**], RES and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RES ANESTHESIA: General endotracheal. HISTORY: This 64-year-old male, with myasthenia [**Last Name (un) 2902**], having presented with sepsis, a free abdominal perforation of a large retroperitoneal diverticular abscess, had a left hemicolectomy along with splenectomy to adequately drain the retroperitoneum approximately 10-14 days ago. This morning on rounds, he had some serous fluid coming out of his wound. Subsequent CT revealed that he had a fascial dehiscence. The patient was brought back to surgery to prevent evisceration. At surgery, he was found to have necrotic fascia. This was trimmed away to good fascia. We were unable to pull this back together without tension. Therefore, it was elected, after consultation with 2 different surgeons, to place a Surgisis Gold mesh. This was placed in an anterior fascial position as opposed to a preperitoneal position because of the lack of omentum and the appearance of the bowel. Upon completion of the placement which was secured with transfixing abdominal wall sutures with 0 PDS, as well as running circumferentially around the graft with 0 Prolene running suture, the skin was reclosed with staples. PROCEDURE: Under adequate general endotracheal anesthesia, the patient was prepped and draped in the usual fashion. The wound was opened as noted above. The colostomy had been secured off by an Ioban drape. At this point then, the attention was turned to the fascial defect. The bowel was present in the subcutaneous space, but did not appear to be grossly contaminated. The fascia was grasped superiorly and was circumferentially dissected so we debrided back to good fascial edges. Having accomplished this, the sutures were actually found to be intact, however pulled out of the necrotic fascia. At this point, the inferior sutures were removed, and a large tailed running suture was left in place as this dehiscence only occurred over approximately 10 cm, and the remainder of the wound field appeared both on CT and within our examination to be adequately intact. At this point then, transfixing sutures with #1 PDS were placed through the abdominal wall, making sure we did not injure any bowel. A large piece of fat from the inferior preperitoneal area was brought up and sewn to the preperitoneal fat superiorly to try to protect the bowel with 3-0 Vicryl. At this point then, the Surgisis mesh was placed and secured to the circumferential anchoring sutures and trimmed to a reasonable size. At this point then, Prolene was utilized to do a running suture circumferentially around the graft to secondarily hold it. This was tacked to the anterior fascia, and these sutures were not across the width of the abdominal wall. At this point then, the area was irrigated out. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed because the subcutaneous space was potentially infected, and the skin was closed with staples and Steri-Strips and a sterile dressing was applied. Sponge, needle and instrument count were correct x2, and the patient was then transported back to the intensive care unit for bronchoscopy because of a left lower lobe atelectasis noted on CT. The patient tolerated the procedure well, had 100 cc of urine output, and had 1000 cc of crystalloid during the course of the case. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13037**] Brief Hospital Course: [**Known firstname 122**] [**Known lastname 7493**] was transferred to [**Hospital1 18**] on [**2108-3-24**]. He was taken to the operating room where he underwent a left hemicolectomy, splenectomy, removal of Marlex mesh, ventral hernia repair, and end transverse colostomy. He was taken to the ICU postoperatively for further resuscitation. He remained intubated. Neurology was consulted for postoperative management of his myasthenia [**Last Name (un) 2902**]. Vancomycin/Zosyn/Fluconazole were provided for empiric coverage. Stress dose steroids were given. At POD 1 Hct was stable at 24.2. Urine output was WNL. At POD 3 the patient was weaned from the ventilator but required ventilatory support and reintubation. Plasmapheresis catheters were placed and plasmapheresis was administered per neurology. Tube feedings were started. At POD 4 purulent drainage was cultured from the abdominal drain. He was afebrile, with good urine output, and stool from ostomy. At POD 5 a bronchoscopy was performed for RUL and LLL collapse which was negative for evidence obstruction or infectious source. Abdominal drain culture was (+) enterococcus/pseudomonas. Fluconazole was stopped. At POD 7 he remained intubated. TFs were increased to goal. At POD 9 his WBC was elevated at 36.2. CT Abdomen/Pelvis showed two small fluid pockets two small for drainage without evidence of leak or obstruction. Plasmapheresis was provided. At POD 12 he was transfused for a HCT of 21.4 He was extubated without event. At POD 17 he remained extubated and was transferred to the floor. Repeat video swallow was completed with approval for thickened liquids. Abdominal drain culture was (+) for pseudomonas/Citrobacter. Sputum cultures were (+) MRSA/Klebsiella. At POD 18 he had fascial dehiscence which was noted on exam and (+) per CT scan. He was taken to the operating room where he underwent an exploratory laparotomy with repair of fascial dehiscence with mesh. He tolerated the procedure well and was taken to the ICU intubated. At POD 20/2 he was febrile and with decreased urine output which responded to fluid bolus. He remained intubated. He was cardioverted for atrial flutter. Cardiac enzymes were negative. At POD 24/6 he was afebrile and extubated without event. Repeat swallow evaluation allowed for regular diet. At POD 26/8 he was transferred to the floor. Infectious disease was consulted for abx coverage recommendations. At POD 30/12 WBC was elevated at 33.2. Central line was removed and PICC was placed. He was afebrile and clinically looked well. He was OOB to chair and tolerating a diet. Repeat CT scan was performed to assess interval change in fascial repair site which was negative for compromised fascial integrity. [**Last Name (un) **] was consulted. At POD 32/14 Plavix was restarted. Abdominal drain was discontinued. WBC remained elevated at ~30 but he was afebrile and was clinically doing well. At POD 33/15 he was discharged to RHCI IN [**Location (un) **] ([**Hospital **] Hospital of [**Location (un) **] and Islands) in good condition. He remained with PICC line for one week of abx coverage per ID recommendations. In regards to medications, his Azathioprine was held until follow up with Dr. [**First Name (STitle) **] due to his elevated WBC count. Pyridostigmine Bromide dose was continued at 30mg q3H and we decided not to increase to his usual home dose per inpatient neurology recommendations. This could be decided at a later date by Dr. [**First Name (STitle) **]. He remained on Amiodarone. Digoxin/Toprol were not restarted. He was to follow up with Drs. [**Last Name (STitle) **], [**Name5 (PTitle) **] and [**Name5 (PTitle) 7047**]. Medications on Admission: ASA, plavix, pred 60', imuran 50", rosuvastin 10, pyridostigmine 60q3 & 180qhs, dig 125', glyburide 5', toprol 100', zestril 5', lasix 20prn, feso4, percocet prn Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): [**Month (only) 116**] stop when walking at least 3-4 times per day. 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. 7. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 1 weeks. 8. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 1 weeks. 9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. . 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. 11. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Ferrous Sulfate 325 (65) mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 13. Pyridostigmine Bromide 60 mg Tablet Sig: 0.5 Tablet PO q 3H: Every three hours. 14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 16. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 17. Novolin R 100 unit/mL Solution Sig: Per Sliding Scale Injection Per Sliding Scale. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: Myasthenia [**Last Name (un) **] Perforated Diverticulitis Retroperitoneal Abscess Peritonitis Post-op Wound Dehiscence Atrial Flutter/Fibrillation s/p cardioversion Discharge Condition: Good Discharge Instructions: Please return or contact for: * Fever (>101 F) or chills * Abdominal Pain * Nausea or Vomiting * Inability to pass gas or stool * Shortness of breath * Chest Pain * Redness or drainage from incision site * Any other concerns You may shower. Gently wash incision and pat dry. No bathing or immersion for 2 weeks. No lifting over 15 pounds or abdominal stretching exercises for 4-6 weeks. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in clinic ([**Hospital Unit Name **]- [**Location (un) 3202**]) on [**2108-5-8**] at 9:45 am. Please call [**Telephone/Fax (1) 2359**] for any questions or concerns. Please follow up with Dr. [**First Name (STitle) **]. [**Telephone/Fax (1) 28219**] Please follow up with Dr. [**Last Name (STitle) 7047**]. [**Telephone/Fax (1) 3183**] Completed by:[**2108-5-1**]

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icd9cm

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icd9pcs

[ [ [] ] ]

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22360, 22783

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19950, 21572

21728, 21896

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274, 339

627, 913

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1194, 1329

55,971

163,329

24567

Discharge summary

report

Admission Date: [**2167-1-30**] Discharge Date: [**2167-2-11**] Date of Birth: [**2088-8-30**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 11839**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: Right IJ placement [**2167-1-30**] History of Present Illness: 78yo female w/ well-differentiated lung cancer s/p recent cyber knife radiation, COPD, and Afib on dabigatran here w/ increasing cough productive of green sputum. Two nights prioir to admission she began having fevers. She has a chronic cough, but it worsened and became productive of green sputum. She always has some wheezing. Seen yesterday at [**Hospital 392**] rehab and nursing center and started on ceftriaxone, azithromycin and methylprednisolone 4mg QID. CXR and UA there were normal, WBC count 18K. When her respiratory symptoms worsened, she was transferred to the ED. In the ED, initial vs were: T 98.4 P 110 BP 92/59 R 18 O2 sat 100% RA. She spiked to 102.4 and was found to have ronchi at left base. Exam notable for irregularly irregular heartrate and a L-sided facial droop on exam. Labs showed WBC count of 32,000, lactate 1.8. CXR had LLL pneumonia. Got 1gm vanc, 750mg levaquin. Seen by neurology who thought she had a Bell's Palsy and recommend a non-urgent MRI head. She dropped her pressures to SBPs in the 70s-80s. R IJ CVL placed. Got 2L IV fluids, 1gm Tylenol. Vital signs prior to transfer were HR 105 BP 111/64 on .03mg/min norepinephrine, O2 sat 99% 2L. On the floor, she described a vague malaise, but cannot specify further. She says her breathing is near her baseline. Denies lightheadedness, chest pain, nausea, vomiting, diarrhea or dysuria. She has had occasional constipation. Denies rash, myalgias or arthralgias. Denies diplopia or weakness. She has been walking normally. Past Medical History: Hypertension Asthma Chronic Obstructive Pulmonary Disease (pt Dr. [**Last Name (STitle) **] Vitamin D defficiency Adenocarcinoma of lung well differentiated (followed by Dr. [**Last Name (STitle) **] in Rad/Onc, no plan for chemotherapy), s/p radiation w/ Dr. [**Last Name (STitle) **] finishing [**2166-12-23**] to LLL. Afib diagnosed [**12/2166**] Left sided Bell's palsey with facial droop - finding is long standing of years duration, it is noted on [**11/2166**] [**Hospital1 18**] admission and confirmed with patient's son and daughter-in-law on this admission Social History: Usually lives with son and daughter-in-law at home, independent, walks without cane/walker. Recently at [**Hospital 392**] rehab since discharge [**2167-1-9**]. - Tobacco: never - Alcohol: none - Illicits: none Family History: Denies history of COPD, asthma, cardiac disease, diabetes Physical Exam: Vitals: 105 BP 111/64 on .03mg/min norepinephrine, O2 sat 99% 2L General: Alert, oriented, mild respiratory distress HEENT: Sclera anicteric, MMM, oropharynx clear, right sided mild swelling and left sided facial droop Neck: supple, JVP not elevated, no LAD Lungs: Scattered wheezes throughout, crackles at bilateral bases. Decreased breathsounds at left base with dullness to percussion. CV: Tachy, irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild epigastric and RUQ tenderness, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission: [**2167-1-30**] 02:41PM BLOOD WBC-31.8*# RBC-3.70* Hgb-12.1 Hct-35.3* MCV-96 MCH-32.8* MCHC-34.3 RDW-14.4 Plt Ct-240# [**2167-1-30**] 02:41PM BLOOD Neuts-92.8* Lymphs-2.8* Monos-3.7 Eos-0.3 Baso-0.2 [**2167-1-30**] 02:41PM BLOOD Glucose-140* UreaN-20 Creat-0.8 Na-136 K-3.8 Cl-99 HCO3-26 AnGap-15 [**2167-1-30**] 02:41PM BLOOD ALT-20 AST-18 AlkPhos-63 Amylase-44 TotBili-1.4 On Transfer: [**2167-1-31**] 04:52AM BLOOD WBC-23.4* RBC-3.34* Hgb-11.1* Hct-32.5* MCV-97 MCH-33.1* MCHC-34.1 RDW-14.0 Plt Ct-214 [**2167-1-31**] 04:52AM BLOOD Neuts-95.9* Lymphs-2.0* Monos-1.9* Eos-0.2 Baso-0.1 [**2167-1-31**] 04:52AM BLOOD Glucose-133* UreaN-15 Creat-0.5 Na-137 K-3.7 Cl-105 HCO3-21* AnGap-15 [**2167-1-31**] 04:52AM BLOOD PT-16.6* PTT-45.1* INR(PT)-1.5* [**2167-1-31**] 04:52AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.8 Imaging: CHEST (PA & LAT) Study Date of [**2167-1-30**] 2:54 PM IMPRESSION: Left lower lobe pneumonia, new compared with [**2167-1-5**]. . HEAD CT W/O CONTRAST: IMPRESSION: 1. No acute intracranial process. 2. Small vessel ischemic disease. 3. Prominent sulci and ventricles, likely age-related involutionary changes. . CTA CHEST [**2-1**]: IMPRESSION: 1. No evidence of SVC abnormality. 2. New left lower lobe patchy airspace opacity and tree-in-[**Male First Name (un) 239**] opacity in the right lung suggests multifocal infection. 3. Limited evaluation of the known left lower lobe lung cancer with new nodules in the right upper and lower lobes that could represent metastatic disease versus infection. 4. Cholelithiasis. CXR [**2167-2-8**] Left lower lobe consolidation is again noted slightly more prominent on todays study compared to [**2167-2-5**], but markedly improved since initial presentation on [**1-30**], [**2166**]. There is no pleural effusion. Right IJ line projects over the mid svc. . CXR [**2167-2-10**]:There is a right central venous catheter with the tip overlying the mid SVC. There is persistent consolidation of the left lung base, unchanged in appearance compared to prior. No new focal consolidation is appreciated. Fiducial markers are again seen in the posterior basal segment of left lower lobe overlying an area of known bronchogenic carcinoma. The bilateral upper lobes and right lung are clear. The cardiomediastinal and hilar contours are within normal limits. There is no vascular engorgement or pleural effusion. IMPRESSION: Stable appearance of the left lower lobe consolidation. Central venous catheter with the distal tip in the mid SVC. . Labs on discharge: [**2167-2-11**] 05:28AM BLOOD WBC-15.9* RBC-3.60* Hgb-11.4* Hct-34.9* MCV-97 MCH-31.7 MCHC-32.7 RDW-14.5 Plt Ct-235 [**2167-2-11**] 05:28AM BLOOD Glucose-111* UreaN-18 Creat-0.5 Na-136 K-3.6 Cl-100 HCO3-28 AnGap-12 [**2167-2-11**] 05:28AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.1 [**2167-2-9**] 03:28PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 [**2167-2-9**] 03:28PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG Brief Hospital Course: 78yo female with history of lung cancer s/p recent radiation admitted with pneumonia, COPD exacerbation, fever, hypotension, and atrial fibrillation with RVR on dabigatran. The patient was evaluated in the emergency room and blood, sputum, and urine cultures were sent. Admission CXR revealed a LLL pneumonia that was treated as hospital acquired with vancomycin, cefepime, and levofloxacin; because she was admitted from a rehab facility. She was admitted initially to the [**Hospital Unit Name 153**] with hypotension requiring levophed and IVF. She was quickly weaned off pressors, stabalized, and tranferred to the floor the following morning; where she was treated with frequent nebulizers and po steroids as well as antibiotics. Though initially stable, the patient subsequently triggered four times in 24 hours for respiratory decompensation and afib with RVR requiring transfer back to the unit. The episodes were manifest by marked wheezing and tachypnea to the high 20's and low 30's (though the patient maintained O2 saturation on RA). Her wheezing was treated with nebulizers and O2. During these decompensations, her HR became elevated in the 150's to 160's in Afib and she became hypotensive to SBP's in the high 80's to low 90's with the first 3 episodes (although she maintained mentation and urine output). During the 4th trigger, the patient remained normotensive despite her RVR. The patient's HR was controlled initially with metoprolol po and IV, but she was subsequently changed to diltiazem at the time of her [**Hospital Unit Name 153**] transfer in case the beta blocker was contributing to her COPD exacerbation. With rate control in the 100's the patient's blood presure recovered to baseline. She was transferred back to the [**Hospital Unit Name 153**] and treated with with CPAP, frequent nebulizers, steroids, and the addition of advair. Her antibiosis was narrowed to Vancomycin / Levofloxacin on [**2167-2-3**] based on her MRSA positive sputum culture from [**2167-1-30**]. She stabalized over the next four days and was transferred back to the hospital floor. . #) MRSA Pneumonia and Sepsis: Admission CXR revealed a LLL pneumonia that was treated as hospital acquired with vancomycin, cefepime, and levofloxacin; because she was admitted from a rehab facility. She was admitted initially to the [**Hospital Unit Name 153**] with hypotension requiring levophed and IVF. She was quickly weaned off pressors, stabalized and tranferred to the floor. Over the next 24 hours, the patient triggered 4 times and was readmitted to the [**Hospital Unit Name 153**] (details above). Antibiotics were narrowed to Vancomycin / Levofloxacin on [**2167-2-3**] based on sputum culture results that returned positive for MRSA obtained on admission [**2167-1-30**]. The patient's WBC count was 31.8 on admission [**2167-1-30**] and normalized gradually. WBC count did start to trend up on [**2167-2-7**] and repeat fever work-up including f/u cxrs were done to evaluate for the development of an effusion or abscess and these were none revealing.Wbc trending down on discharge adn elevated wbc count likely due to prednisone.Pt completed a 10 day course of levofloxacin on [**2167-2-10**] and will complete a 14 day course of vancomycin on [**2167-2-13**]. Vanco trough was obtained on [**2167-2-8**] and was withion target range (17).Pulmonary consult also followed patient while on the floor and recommended pulmonary rehab. . #) Asthma/COPD exacerbation: The patient's pneumonia exacerbated longstanding severe COPD with marked wheezing and tachypnea. She has expiratory wheezes on exam, though she also has a significant component of upper airway wheezing. She was covered with IV steroids and nebs. Omeprazole was started while on high-dose steroids.Pt to continue a prednisone taper with 10 mg decrements q 3 days , on d/c pt completed second day of 50 mg dose. Patient was also started on spiriva in addition to advair. . #) Afib with RVR: Dabigatran was continued throughout the patient's hospitalization. The patient had poor rate control initially on her baseline po metoprolol which had been continued after admission. During triggers for respiratory decompensation and afib with RVR, the patient was treated with metoprolol IV during the acute episodes, but subsequently changed to diltiazem on readmission to the [**Hospital Unit Name 153**] [**2167-2-2**]. She is discharged on diltiazem 75 mg QID with rate control in the 80's to 90's. . #) Left-sided CNVII nerve palsey with facial droop: Thought to be new on her admission and seen by neurology. A head CT without contrast was obtained for further work up and was negative on [**2167-1-30**]. On further review and scrutiny of past medical records, it was determined that the patient's facial palsey is long standing of years duration. This was confirmed through Mandarin interpretor with the patient's son and daughter-in-law on this admission. In addition, it is noted in [**Hospital1 18**] records on her [**2166-11-22**] admission. . #)Questionable Facial plethora: There was initial concern that the patient had developed facial swelling in the days prior to her hospitalization. A chest CT was obtained and was negative for SVC syndrome. . #) Lung Cancer: Well differentiated lung cancer, s/p cyberknife by radiation oncology. Continued management per her outpatient physicians.Pt will need a f/u chest CT scan in [**2-25**] weeks to assure resolution of left lower infiltration. . #)Diarrhea: Patient developed loose stools during hospital stay after a bowel regimen was initiated for constipation. Stools for c.diff were obtained and negative, [**Company **] he time of d/c second stool for c.dif still pending, however, after discontinuing bowel regimen diarhhea has subsided. Medications on Admission: 1. Vitamin D3 2,000 units daily 2. montelukast 10 mg PO daily 3. fluticasone-salmeterol 500-50 mcg/dose [**Hospital1 **] 4. ipratropium bromide 17 mcg/Actuation 1-2 puffs Q4-6hrs PRN 5. albuterol sulfate 90 mcg 1-2 puffs Q4-6hrs PRN 6. dabigatran etexilate 150mg [**Hospital1 **] (? not on nursing home sheets) 7. metoprolol succinate 25 mg daily Discharge Medications: 1. dabigatran etexilate 75 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. diltiazem HCl 30 mg Tablet Sig: 2.5 Tablets PO QID (4 times a day). 7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day for 1 days: cont taper as followed: 50 mg daily x1 day then 40 mg daily x 3 days then 30 mg po daily x 3 days then 20 mg po daily x 3 days and then 10 mg po daily x 3 days and then stop. 10. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 12. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 3 days: to complete on [**2167-2-13**]. 13. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: Pneumonia Severe Chronic Obstructive Pulmonary Disease Hypertension Asthma Vitamin D defficiency Adenocarcinoma of lung well differentiated (followed by Dr. [**Last Name (STitle) **] in Rad/Onc, no plan for chemotherapy), s/p radiation w/ Dr. [**Last Name (STitle) **] finishing [**2166-12-23**] to LLL. Atrial fibrillation diagnosed [**12/2166**] Left sided Bell's palsey with facial droop Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: You were admitted with a hospital acquired MRSA pneumonia that made your breathing worse. You were treated with antibiotics, nebulizers, steroids, advair,spiriva and singulair Your atrial fibrillation was causing a rapid heart rate. You were initially continued on your metoprolol, but this was changed to diltizem for better control of your heart rate. . The following changes have been made to your medications: Your metoprolol was discontinued You were started on: Diltiazem 75 mg four times daily to control your rapid heart rate Fluticasone-Salmeterol Diskus (500/50) 1 puff twice daily for your breathing Spiriva Prednisone taper , discharge on 50 mg daily with taper by 10 mg decrements every 3 days. vancomycin to complete on [**2167-2-13**] Followup Instructions: Department: PULMONARY FUNCTION LAB When: MONDAY [**2167-3-2**] at 12:30 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: MONDAY [**2167-3-2**] at 1 PM With: DR. [**Last Name (STitle) **] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "427.31", "268.9", "493.22", "351.0", "162.8", "401.9", "482.42" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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6548, 12321

318, 355

14779, 14901

3512, 6019

15737, 16294

2733, 2792

12719, 14247

14366, 14758

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2807, 3493

266, 280

6039, 6525

383, 1898

14916, 14938

1920, 2489

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9,558

148,529

14710

Discharge summary

report

Admission Date: [**2157-5-27**] Discharge Date: [**2157-6-9**] Date of Birth: [**2099-11-17**] Sex: F Service: MEDICINE Allergies: Compazine / Darvocet-N 100 / Percocet Attending:[**First Name3 (LF) 3913**] Chief Complaint: febrile neutropenia Major Surgical or Invasive Procedure: central line placement s/p PICC placement on [**6-8**] History of Present Illness: From [**Hospital Unit Name 153**] admit note: "57 yo woman with long h/o mycosis fungoides/cutaneous T cell lymphoma found to have an anaplastic T-cell lymphoma for which she has undergone 4 cycles of CHOP, XRT and then salvage ESHAP chemotherapy for which she was discharged to home 2 days prior. She presents to the ED with diarrhea, nausea, emesis and skin breakdown. Upon arrival to the ICU, Pt feels better. No loaclizing compliants. . ED Course: In the ED, she had fever to 100.9, HR 121, BP 149/82, RR 20, 99% RA. Initiated sepsis protocol and had central line placed, 2L IVF and given vancomycin/ceftriaxone. Immediately prior to transfer, her lactate level decreased to 1.4 from 4.4, and she remained hemodynamically stable." . [**Hospital Unit Name 153**] course: admitted to the [**Hospital Unit Name 153**] overnight, IVF given, vital signs stable. Potassium repletion. Lactate decreased to 1.3 this AM. Pt reports that she feels "better today". She says that she had increased volume of loose stools at home over the last 2 days. Some nause and vomiting as well, and her lips have been dry, cracking, and sore. At time of exam she denies any pain, SOB, or GI upset. Stable for transfer to the floor. She is day + 11 after ESHAP. Past Medical History: ONC History: - late [**2131**]'s: first diagnosed with cutaneous T cell lymphoma - nitrogen mustard therapy, PUVA, localized XRT X1 to back of neck - approx 1 yr ago: fatigue, wt loss of 50lbs (with diarrhea; GI work up negative), R axillary mass; biopsy showed anaplastic T cell lymphoma; underwent 4 cycles of CHOP completed [**1-14**]. She did have some response to this treatment, but then had regrowth of R axillary node and R supraclavicular node. She was then treated with XRT (to axilla and medistinum), completed [**2157-3-18**] - late [**4-14**] redevelopment of Gi symptoms, fatugue, weight loss, with PET scan showing uptake in mediastinum, bilateral hila, lung bases, with the most uptake seen in the celiac axis. - ESHAP [**5-/2157**] . PMH: Squamous cell carcinoma seborrheic keratosis cutaneous T-cell lymphoma GERD tonsillectomy C-section DVT; no current anti-coagulation Social History: Married, 2 sons. Lives in [**Location 620**]. Works in food service at the High School. No EtOH, tobacco or IVDA. Family History: Strong h/o CAD - father died 39 MI, mother died 66 MI, Brothers died at 57 and 59 of MI. Physical Exam: Admission to BMT: Gen: awake, lying in bed, cachetic, ill-appearing woman in NAD Skin: warm, dry; multiple keratotic lesions on arms; dry cracking skin on lips, hands, feet - lips with bleeding HEENT: NCAT, PERRL, EOMI, anicteric, OP clear except lips as described, MM mildly dry Neck: supple, no JVD, no LAD Card: RRR, nl S1/S2, no m/r/g Pulm: CTAB, no w/r/c Abd: soft, NT/ND, + BS no organomegaly Ext: warm, 2+ edema B LE, R arm with 2+ edema, significantly larger than L arm, full DP/radial pulses b/l neuro-A, OX3, CNs [**2-20**] grossly intact B, no focal deficit, answers questions and follows commands appropriately Pertinent Results: Admission: [**2157-5-26**] 09:30AM BLOOD WBC-2.6*# RBC-4.03*# Hgb-11.0* Hct-33.2*# MCV-82 MCH-27.3 MCHC-33.2 RDW-17.6* Plt Ct-287 [**2157-5-27**] 06:55PM BLOOD Neuts-72* Bands-12* Lymphs-16* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2157-5-27**] 06:55PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL [**2157-5-27**] 09:00PM BLOOD PT-15.6* PTT-20.4* INR(PT)-1.4* [**2157-5-27**] 06:55PM BLOOD Gran Ct-150* [**2157-5-26**] 09:30AM BLOOD ALT-19 AST-17 AlkPhos-174* TotBili-0.7 [**2157-5-26**] 09:30AM BLOOD Albumin-2.4* Calcium-8.2* Phos-3.9 Mg-2.0 UricAcd-1.9* [**2157-5-27**] 06:46PM BLOOD Lactate-4.4* [**2157-5-27**] 08:45PM BLOOD Lactate-2.1* . Discharge: . [**5-27**] CXR: no evidence of pna, effusions . [**5-28**] US UE: Intraluminal thrombus of the right subclavian, axillary and brachial veins. The right internal jugular vein is patent. . Micro: [**5-25**] Catheter tip: STAPH AUREUS COAG +. >15 colonies OF TWO COLONIAL MORPHOLOGIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. PSEUDOMONAS AERUGINOSA. >15 colonies. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- <=0.25 S CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM------------- <=0.25 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TOBRAMYCIN------------ <=1 S VANCOMYCIN------------ <=1 S . [**5-27**] Blood Cx: negative [**5-27**] Urine Cx: negative [**6-4**] Blood Cx: negative [**6-5**] Blood Cx: [**1-12**] with MRSA [**6-6**] Blood Cx: negative [**6-7**] Blood culture no growth to date . [**6-1**] and [**6-5**] Stool: negative for C Diff . [**6-6**]: Central line catheter tip no growth . Imaging: [**5-30**] KUB: Distended air-filled colon with air-fluid levels. The differential includes low colonic obstruction with a competent ileocecal valve or a functional dilated colon. . [**5-30**] ECHO: The left atrium is elongated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . [**6-7**] Echo: The left atrium is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2157-5-30**], no change. . [**6-2**] KUB: The left atrium is elongated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . [**2157-6-8**] CXR: There has been interval placement of a left-sided PICC line with the tip malpositioned in the left subclavian vein extending distally towards the axillary vein. Allowing for differences in technique, the appearance of the lungs is not significantly changed. There is no effusion or consolidation. IMPRESSION: Malpositioned left PICC line. Results were discussed with the floor immediately following completion of the study. . [**2157-6-8**]: CLINICAL INFORMATION: 57-year-old woman with lymphoma, and malpositioned PICC line, needs PICC line reposition. PROCEDURE/FINDINGS: The procedure was performed by Dr. [**First Name (STitle) 379**] [**Name (STitle) **] and Dr. [**Last Name (STitle) 12166**]. Dr. [**Last Name (STitle) 12166**], the attending radiologist was present and supervising throughout the procedure. The patient was placed supine on the angiographic table. The left arm and pre-existing PICC lines were prepped and draped in the standard sterile fashion. Scout film demonstrated the tip of the pre-existing PICC line is in the subclavian vein. A 0.018 Glidewire was advanced through the PICC line and the PICC line was repositioned with the tip in the superior vena cava under fluoroscopic guidance. The lumen was flushed and the line was secured with skin with StatLock. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Pre-existing PICC line in the left arm was repositioned with the tip in the superior vena cava. The line is ready to use. . Day prior to Discharge Labs: WBC 8.9 Hct 27.6 Plt 312 Brief Hospital Course: #. Infection: Ms [**Known lastname **] was febrile and neutropenic on admission. She had been started on neupogen as an outpatient after her chemotherapy. At time of admission her U/A showed mod bacteria w/ [**3-13**] WBC; no leuk esterase or nitrites. Her primary symptoms were frequent and large quantity diarrhea. She was admitted to the ICU overnight for possible sepsis, was stable, and then called out the BMT floor the next morning. Subsequently her line tip culture from [**5-25**] grew MRSA, and pan-sensitive pseudomonas. KUB revealed a dilated colon. Blood and urine from admission were no growth. Stool c diff was negative. She was treated with vancomycin, cipro, flagyl, and cefepime for 7 days. Her fevers quickly resolved, her cell counts recovered to normal within 6 days, and all antibiotics were discontinued. She remained afebrile off antibiotics, but did have a low-grade temp of 99.8. One surveillence culture from [**6-5**] grew MRSA but surveillance cultures thereafter were negative. Her central line was pulled and she was restarted on vancomycin while speciation was pending, and the catheter tip with no growth. Stool was sent again for c. diff, and was negative. Plan to complete 2 week course of Vancomycin. TTE done and no valve vegetations seen on [**6-7**]. New PICC line was placed and adjusted by Interventional Radiology on [**6-8**] in left arm was well-positioned and functioning. . # R arm swelling: her right arm was significantly larger than her left on exam at time of transfer from ICU to BMT. An US of the right arm showed a DVT in the brachial, axillary, and subclavian veins. She was started on a heparin drip with no bolus, and subsequently transitioned to lovenox 1.5mg/kg QD for discharge. While on anticoagulation she was transfused as needed to keep her platelets greater than 50. Her platelet count had come up before discharge so she was no longer requiring transfusions. She was discharged on lovenox for a 14 day course (concern of anti-coagulation with low platelet count). . # Diarrhea: Ms [**Known lastname **] had had several weeks of nausea, vomiting and diarrhea ascribed to B symtoms prior to her chemotherapy, which had been treated with reglan and lomotil. On admission to BMT she was found to have a dilated colon on KUB. Given concern for possible c difficile colitis, reglan and lomotil were discontinued, she was made NPO, and started on TPN. She did well on this regimen, and her symptoms completely resolved. Repeat KUB revealed improved resolution of her colonic dilation. She was slowly started back on po intake, and was tolerating po intake without TPN before discharge, without diarrhea. . #. Acute Lymphoma: Ms. [**Known lastname **] is s/p salvage ESHAP. She was continued on supportive treatment for nausea, vomiting, and diarrhea which have been long-standing issues for her - attributed to B symptoms of her lymphoma. Given her dilated colon, her lomotil was discontinued, and she was made NPO with TPN as discussed above. Her cell count reached it's nadir during her stay, and then recovered. As soon as her ANC was greater than 1000, her neupogen was discontinued. She was also transfused as needed to keep her hematocrit greater than 25, and her platelet count greater than 50 (given anti-coagulation). She was no longer requiring transfusions at time of discharge. She will continue to follow with Dr. [**Last Name (STitle) **] for further treatment planning. . # CTCL: Ms [**Known lastname **] has a long history of CTCL (since the 80's). She follows with Dr. [**Last Name (STitle) 1728**] of Dermatology. After her chemo, while neutropenic, her skin condition, fragile at baseline, deteriorated with diffuse erythema, and areas of desquamation on her buttocks, back, and arms. Wound care and dermatology were consulted, and she was seen by Dr. [**Last Name (STitle) 1728**]. She was treated per their recommendations. With this treatment, and the recovery of her cell counts, her skin improved greatly. She will continue to follow with Dr. [**Last Name (STitle) 1728**]. . #. FEN: She was initially NPO, with IVF and TPN, then transitioned slowly back to a regular diet as described above. Her electrolytes were monitored and she was on repletion scales. She was initially quite hypokalemic, but this quickly resolved as her diarrhea resolved. . #. PPx: She was on protonix and heparin/lovenox . #. Code: full Medications on Admission: Neupogen 300 mcg QD Metoclopramide 10 mg WITH MEALS prn Triamcinolone Acetonide 0.025 % Cream TID Loperamide 2 mg QID prn Folic Acid 1 mg DAILY Multivitamin Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q 24H (Every 24 Hours) for 14 days. Disp:*14 doses* Refills:*1* 3. bed Fully electric hospital bed with side rails; air mattress; required for treatment and prevention of skin breakdown. 4. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*qs * Refills:*2* 5. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous every twelve (12) hours for 12 days. Disp:*24 * Refills:*0* 6. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day) for 7 days. Disp:*qs 1* Refills:*0* 7. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: 5-10 MLs PO Q8H (every 8 hours) as needed. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: febrile neutropenia lymphoma mycosis fungoides malnutrition Discharge Condition: stable, normal white blood cell count, afebrile, eating and drinking, ambulating. Discharge Instructions: Please call your doctor or return to the hospital if you have a temperature greater than 100.3 fahrenheit, nausea, vomiting, diarrhea, inability to eat or drink, or any other health concern. Followup Instructions: You have a scheduled follow-up appointment with: [**Name6 (MD) **] [**Name8 (MD) 43296**], MD Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2157-6-16**] 9:00 . Provider: [**Name11 (NameIs) 5558**],[**Name12 (NameIs) 5557**] HEMATOLOGY/ONCOLOGY-CC9 Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2157-6-16**] 9:00 . Please call Dr. [**Last Name (STitle) 1728**] to schedule Dermatology follow-up in the General [**Hospital **] Clinic within the next 3 weeks ([**Telephone/Fax (1) 1971**]). Completed by:[**2157-6-9**]

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icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "99.05", "99.04" ]

icd9pcs

[ [ [] ] ]

15247, 15296

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6677+6678

Discharge summary

report+report

Admission Date: [**2137-12-9**] Discharge Date: [**2137-12-11**] Date of Birth: [**2087-8-15**] Sex: M Service: LIVER TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old Vietnamese gentleman status post liver transplant on [**2137-11-15**] for hepatitis C and hepatocellular carcinoma now presents with increasing liver function tests. The patient denies any pain, nausea, vomiting, fevers or chills, diarrhea, complaints. PAST MEDICAL HISTORY: 1. Hepatitis C. 2. Hepatocellular carcinoma. 3. Post necrotic cirrhosis. 4. Acute rejection. PAST SURGICAL HISTORY: Status post liver transplant MEDICATIONS: 1. Bactrim double strength one tab po q.d. 2. Calcium carbonate 500 mg po b.i.d. 3. Colace 100 mg po b.i.d. 4. Fluconazole 400 mg po q day. 5. MMF 1000 mg po b.i.d. 6. Protonix 40 mg po q day. 7. ____________ 450 mg po b.i.d. 8. Vitamin D 400 units q.d. 9. Neoral 175 mg b.i.d. 10. Prednisone taper now on 20 mg b.i.d. PHYSICAL EXAMINATION: The patient is pleasant, cooperative and in no acute distress. Vital signs temperature 98.1. Pulse 60. Blood pressure 190/102. 16. 97% on room air. HEENT mucous membranes are moist. No exudates. No erythema. Neck is supple. No carotid bruits. Cardiovascular regular rate and rhythm. No murmurs. Normal S1 and S2. Respirations clear to auscultation bilaterally. Abdomen soft, nondistended. Liver edge is 1 to 2 cm below rib cage by percussion. No tenderness. Wound is clean, dry and intact. Extremities warm and well perfuse, no edema. Modeling around ankles. Neurological alert and oriented times three. LABORATORY: CBC 11.8, hematocrit 43.3, platelets 198, sodium 135, potassium 4.9, chloride 94, bicarb 27, BUN 38, creatinine 1.0, glucose 125, AST 45, ALT 123, alkaline phosphatase 256, total bilirubin 3.3, direct bilirubin 1.7, albumin 4.3. HOSPITAL COURSE: The patient was admitted to Transplant Service. He had an ultrasound done, which showed increased echogenicity suggestive of question rejection versus hepatitis unchanged from the last ultrasound ten days prior. The patient had liver biopsy performed on the floor, which came back the same day with no acute rejection. On hospital day number two the patient was taken to the GI Suite where endoscopic retrograde cholangiopancreatography was performed. The patient was found to have smooth constriction of the middle third of the common bile duct, which was dilated, stented and sphincterotomy was performed. The patient was tolerated the procedure well and was transferred back to the floor in stable condition. The patient was kept NPO overnight with maintenance intravenous fluids. On hospital day number two he was afebrile. Vital signs were stable. He was started on regular diet and tolerated without complications. He passed one slightly tarry stool, however, his vital signs are stable. He had a procedure the previous day. His hematocrit is stable. No concerns. The patient will be sent home and follow up as an outpatient. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient is discharged to home with VNA for wound check and medication supervision. FOLLOW UP: The patient should have laboratories drawn on [**2137-12-12**]. The patient should see Dr. [**Last Name (STitle) **] in clinic in one week. MEDICATIONS ON DISCHARGE: 1. Bactrim double strength one tab po q day. 2. Calcium carbonate 500 mg po b.i.d. 3. Colace 100 mg po b.i.d. 4. Fluconazole 400 mg po q day. 5. Protonix 40 mg q.d. 6. ______ Ganciclovir 450 mg b.i.d. 7. Prednisone taper 20 mg b.i.d. 8. MMF 1000 mg po b.i.d. 9. Neural 150 mg po b.i.d. 10. Levofloxacin 500 mg po q.d. times seven days. DISCHARGE DIAGNOSES: 1. Hepatocellular carcinoma. 2. Hepatitis C. 3. Status post liver transplant. 4. Hypertension. 5. Increased liver function tests. 6. Common bile duct stricture status post endoscopic retrograde cholangiopancreatography stenting. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Last Name (STitle) 7487**] MEDQUIST36 D: [**2137-12-11**] 14:11 T: [**2137-12-11**] 14:28 JOB#: [**Job Number 25474**] Admission Date: [**2137-12-12**] Discharge Date: [**2137-12-15**] Date of Birth: [**2087-8-15**] Sex: M Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old Vietnamese speaking gentleman status post liver transplant on [**2137-11-15**] for hepatitis C and hepatocellular carcinoma who was discharged on [**2137-12-11**] after endoscopic retrograde cholangiopancreatography, common bile duct dilatation On discharge the patient was feeling fine. He was afebrile. Vital signs were stable. His hematocrit was 89.1. Prior to discharge the patient had once slightly blackened stool, which was attributed to slight bleeding after his endoscopic retrograde cholangiopancreatography. The patient returned on [**2137-12-12**] after passing two large melanotic stools and feeling much weaker then usual. The patient at that time denied any any other complaints. PAST MEDICAL HISTORY: 1. Hepatitis C. 2. Hepatocellular carcinoma. 3. Post necrotic stenosis. 4. Acute rejection. 5. Common bile duct stricture status post stenting and sphincterotomy. PAST SURGICAL HISTORY: Status post liver transplant [**2137-11-15**]. MEDICATIONS ON ADMISSION: 1. Bactrim double strength one tab po q day. 2. Calcium carbonate 500 mg po b.i.d. 3. Colace 100 mg po b.i.d. 4. Fluconazole 400 mg po q day. 5. Protonix 40 mg po q day. 6. Valcyte 450 mg po b.i.d. 7. Prednisone taper currently 20 mg po b.i.d. 8. CellCept [**Pager number **] mg po b.i.d. 9. Neural 150 mg po b.i.d. 10. Levofloxacin 500 mg po q day. PHYSICAL EXAMINATION: The patient is pleasant, cooperative, tired looking. His blood pressure is 90/52, heart rate 110 to 120. Cardiovascular regular rate and rhythm. Clear to auscultation bilaterally. Abdomen soft, nontender, nondistended, wound clean, dry and intact. Rectal examination guaiac positive. LABORATORIES ON ADMISSION: White blood cell count 18.6, hematocrit 26.3 (down from 39.1 the day before), platelets 224, sodium 133, potassium 5.5, chloride 99, CO2 24, BUN 58, creatinine 1.0, glucose 228, calcium 8.8, phosphorus 5.2, magnesium 1.6, AST 55, ALT 34, alkaline phosphatase 219, total bilirubin 2.4, total protein 5.1, albumin 3.0, amylase 44, PT 13.1, PTT 29.7, INR 1.1. HOSPITAL COURSE: The patient was admitted to the Transplant Service. He was emergently transfused 2 units of blood and placed in the Surgical Intensive Care Unit. Gastroenterology consult was emergently called who felt that the bleeding might be from the sphincterotomy site. An esophagogastroduodenoscopy was performed in the CICU and found a significant amount of bleeding from the sphincterotomy site. An injection of epi was performed, which seemed to stop the bleeding. The esophagogastroduodenoscopy otherwise was unremarkable. Overnight the patient spiked a fever to 102.7 and he needed another unit of packed red blood cells for a falling hematocrit. On hospital day number two the patient's heart rate is still in the low 100s. His blood pressure improved to have reached 125/60. He received 3 more units of packed red blood cells, because his hematocrit kept bouncing back. He was started on Ampicillin, Levofloxacin and Flagyl for presumed infection from endoscopic retrograde cholangiopancreatography. His Prednisone was switched to 25 mg po q day per Prednisone taper. On hospital day number three the patient is afebrile and vital signs are stable. His heart rate is in the 80s. He received 1 more unit of blood overnight, because of fallen hematocrit and because his hematocrit was bouncing, otherwise his laboratories were unremarkable. His white blood cell count decreased to 11.3. The patient's gastric lavage showed small streaks of blood, otherwise unremarkable. He was continued on Ampicillin, Levofloxacin and Flagyl. He was transferred to the floor. The patient's diet was advanced to regular, which he tolerated well. He is passing regular stools. He denies any complaints. On hospital day number four the patient is afebrile and vital signs are stable. His white blood cell count is 11. His hematocrit finally stabilized around 36. Liver function tests was within normal limits. His alkaline phosphatase stabilized at 122. Due to high Cyclosporin level his Neural dose was decreased to 125 a day. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is discharged to home with VNA for wound check and medication administration and supervision. FOLLOW UP: The patient will come back to the [**Hospital 1326**] Clinic on Wednesday [**2137-12-18**] for a follow up. MEDICATIONS ON DISCHARGE: 1. Bactrim double strength one tab po q day. 2. Fluconazole 400 mg po q day. Protonix 40 mg po q day. 3. Colace 100 mg po q.d. 4. Valcyte 450 mg po b.i.d. 5. Vitamin D 400 units po q day. 6. Calcium carbonate 500 mg po b.i.d. 7. Levofloxacin 500 mg po q day for seven days. 8. Prednisone 25 mg po q.d. (Prednisone taper see attached sheet). 9. Neural 125 mg po b.i.d. 10. CellCept [**Pager number **] mg po b.i.d. DISCHARGE DIAGNOSES: 1. Status post liver transplant. 2. Hepatitis C. 3. Hepatocellular carcinoma. 4. Common bile duct stricture status post endoscopic retrograde cholangiopancreatography and stenting. 5. Status post gastrointestinal bleed. 6. Intervention induced anemia. 7. Hypomagnesemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Last Name (STitle) 7487**] MEDQUIST36 D: [**2137-12-16**] 09:02 T: [**2137-12-16**] 09:14 JOB#: [**Job Number 25475**]

[ "285.1", "V42.7", "V10.07", "998.11", "998.59" ]

icd9cm

[ [ [] ] ]

[ "44.43", "45.13" ]

icd9pcs

[ [ [] ] ]

9325, 9869

8870, 9304

5450, 5816

6533, 8562

5375, 5423

8734, 8843

5839, 6142

4426, 5156

6157, 6515

5179, 5351

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69,215

199,637

35825

Discharge summary

report

Admission Date: [**2130-11-24**] Discharge Date: [**2130-12-2**] Date of Birth: [**2073-4-4**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: seizures Major Surgical or Invasive Procedure: L craniectomy History of Present Illness: [**Known firstname **] [**Known lastname 81464**] is a 57-year-old right-handed man, with recent onset of seizure, who is seen in consultation as requested by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for evaluation of a left temporal and left insula mass. His neurological problem began in [**2130-9-20**] when he did not feel well and had a change in his mood. He was started on trazodone 150 mg and Lisinopril 10 mg daily. On [**2130-10-30**], when he was tying his shoelace, he experienced an abnormal taste in his mouth, followed by blurry, bright, and yellow vision. He did not feel well and decided not to go to work. He was taken to [**Hospital 81465**] Hospital and was hospitalized there from [**2130-10-31**] to [**2130-11-2**]. He was started on Keppra but he discontinued the anticonvulsant by himself. Over time, he experienced progressively more frequent seizures, but each episode lasted a bit shorter than before. He did not have full-blown loss of consciousness, nausea, vomiting, imbalance, or fall. Due to his progressively more frequent episodes he decided to come to the emergency room at [**Hospital1 18**] on [**2130-11-24**]. Past Medical History: He has hypertension and anxiety but no diabetes or COPD. Social History: mechanic, married, has 3 children. He quitted smoking several years ago (smoked for 10 years 5 cigaretted/day), occasional drinks, smokes marijuana 3-4 times/ month Family History: mother had depression and died of unknown cause at 83 years old. No history of of brain disorders in the family Physical Exam: O: T: 98.9 BP:154 / 87 HR: 70 R 17 97 O2Sats RA Gen: WD/WN, pale, comfortable, NAD. HEENT: Pupils: equal and reactive to light [**3-23**] EOMs Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-20**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-24**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 1 Left 2 2 2 2 1 Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: [**2130-11-24**] 04:00PM GLUCOSE-83 UREA N-28* CREAT-1.3* SODIUM-141 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13 [**2130-11-24**] 04:00PM estGFR-Using this [**2130-11-24**] 04:00PM WBC-5.6 RBC-4.32* HGB-13.5* HCT-37.5* MCV-87 MCH-31.3 MCHC-36.1* RDW-13.0 [**2130-11-24**] 04:00PM NEUTS-57.6 LYMPHS-33.5 MONOS-6.4 EOS-2.2 BASOS-0.3 [**2130-11-24**] 04:00PM PLT COUNT-231 Brief Hospital Course: Pt was admitted for close neurologic monitoring. He underwent MRI which showed FLAIR hyperintensity but no gadolinium enhancement in the left insula and left temporal lobe.Patient also had LP puncture performed by Dr. [**Last Name (STitle) 724**] with no evidence of infectious cause. Pt was then readied for the OR and on [**11-29**] underwent left craniectomy; tumor was ressected - final pathology revealed an oligodendroglioma. Patient was monitored closely in immediate post op period, was stable and was ultimately transferred to the wards with non-focal neurological exam. His diet and activity were advanced. Incision was clean and dry. He transitioned to PO pain medication. He was seen by Pt and cleared for discharge to home. appropriate follow up was arranged. Medications on Admission: -trazodone 150mg -lisinopril 20mg -citalopram 40mg Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 2. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours: take 2 tablets tonight at 6pm. then take 1 tablet four times tomorrow. Disp:*6 Tablet(s)* Refills:*0* 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: left temporal tumor; final pathology result pending Discharge Condition: Stable Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ??????Please return to the office in [**6-29**] days (from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on XXXXXXX. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will / will not need an MRI of the brain with/ or without gadolinium contrast. If you are required to have a MRI, you may also require a blood test to measure your BUN and Cr within 30 days of your MRI. This can be measured by your PCP, [**Name10 (NameIs) **] please make sure to have these results with you, when you come in for your appointment. Completed by:[**2131-2-23**]

[ "585.9", "070.54", "191.2", "403.90", "345.50" ]

icd9cm

[ [ [] ] ]

[ "03.31", "01.59" ]

icd9pcs

[ [ [] ] ]

5516, 5522

3828, 4606

328, 344

5618, 5627

3415, 3805

7827, 8956

1842, 1956

4708, 5493

5543, 5597

4632, 4685

5651, 7804

1971, 2248

280, 290

372, 1562

2541, 3396

2263, 2525

1584, 1643

1659, 1826

41,758

125,574

40115

Discharge summary

report

Admission Date: [**2126-1-31**] Discharge Date: [**2126-2-12**] Date of Birth: [**2059-10-1**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Exertional CP, multivessel disease, respiratory arrest Major Surgical or Invasive Procedure: [**2126-2-7**] Coronary artery bypass graft x 3 with the left internal mammary artery to the left anterior descending artery and reverse saphenous vein graft to the left posterior descending artery and the first diagonal artery. History of Present Illness: (Patient intubated and sedated all information obtained from medical records) 66 year old male who presented to OSH with 6 months of exertional angina. Pain increased and persisted on [**1-30**] therefore he went to his PCP for further evaluation, he also complained of Shortness of braeth and arm pain on arrival at his PCP. [**Name10 (NameIs) **] showed ST depressions in the lateral leads, therefore EMS was called and he was transferred to the [**Hospital1 **] ED for further evaluation. 3 SLNTG were given by EMS with some improvement in his symptoms. In the [**Hospital1 **] ED, he was hypertensive and tachycardic, continued to complain of arm pain. Trops elevated to 0.24. He was taken emergently to cath lab, where he was found to have multivessel disease. After the case, patient began coughing and was dyspnic, began coughing blood-tinged sputum. He was treated for pulmonary edema with 40 IV lasix however he then went into respiratory arrest and required intubation. He recieved 1 mg Atropine for bradycardia and a swan and IAPB were placed on cath lab table. PCWP was 15mmHg following initial diuresis, getting IVF at 50cc/hr. Cardiac output 4.0 with index of 1.8. He was given 1g Ancef for perclose coverage. On arrival to the CCU, the pt is intubated, sedated, non-responsive to voice. Unable to obtain ROS due to sedation. Referred to cardiac surgery for revascularization. Past Medical History: Diabetes Dyslipidemia Hypertension Chronic Kidney disease(baseline creatinine 1.7) Obstructive sleep apnea Anemia Obesity Social History: Lives with:wife Occupation: works in the car industry Tobacco:distant use, unknown amount ETOH:unknown Family History: brother with CAD Physical Exam: General: intubated, sedated with IABP in CCU Skin: Dry [x] intact [x] no rash HEENT: PERRLA [] EOMI [] left pupil fixed 3mm, right round and reactive to light Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur + rub of IABP Abdomen: Soft [x] non-distended [softly distended] non-tender [x] bowel sounds + [x] Extremities: Warm [] not warm- cool, well-perfused [] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2+ (cath site) Left: IABP DP Right: doppler Left: doppler PT [**Name (NI) 167**]: doppler Left: -- Radial Right: -- Left: A-line Carotid Bruit Right: 2+ Left: 2+ no bruits appreciated Pertinent Results: [**2126-2-7**] Echo: Prebypass: No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. There is mild regional left ventricular systolic dysfunction with hypokinesia of the apical and mid portions of the inferior walls. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50% %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2126-2-7**] at 1100am. Post bypass: Patient is A paced. Biventricular systolic function is unchanged. Aorta is intact post decannulation. Moderate mitral regurgitation persists. . [**2126-1-31**] Carotid U/S: There is 60-69% stenosis within the internal carotid arteries bilaterally. [**2126-2-10**] CXR PA and Lat: Cardiomediastinal silhouette is stable with unremarkable appearance of post-sternotomy wires and surgical clips. There is no change in the left lower lobe consolidation most likely representing atelectasis accompanied by small amount of pleural effusion. Right pleural effusion is small, unchanged. [**2126-2-11**] 04:37AM BLOOD WBC-9.7 RBC-3.48* Hgb-10.0* Hct-30.2* MCV-87 MCH-28.8 MCHC-33.2 RDW-15.2 Plt Ct-418 [**2126-2-11**] 04:37AM BLOOD Glucose-88 UreaN-42* Creat-1.6* Na-137 K-3.9 Cl-104 HCO3-25 AnGap-12 [**2126-2-9**] 02:42AM BLOOD ALT-77* AST-45* LD(LDH)-398* AlkPhos-84 Amylase-28 TotBili-0.4 [**2126-2-9**] 02:42AM BLOOD Lipase-17 [**2126-2-11**] 04:37AM BLOOD Mg-2.2 [**2126-2-12**] 05:33AM BLOOD Hct-28.7* [**2126-2-12**] 12:47PM BLOOD Creat-1.6* Na-140 K-3.8 Cl-104 [**2126-2-12**] 05:33AM BLOOD ALT-145* AST-99* LD(LDH)-372* AlkPhos-104 Amylase-47 TotBili-0.3 [**2126-2-12**] 05:33AM BLOOD Lipase-42 [**2126-2-1**] 09:26AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-NEGATIVE [**2126-1-31**] 02:28AM BLOOD %HbA1c-8.1* eAG-186* Brief Hospital Course: The patient was admitted to the hospital with 6 months of crescendo angina s/p NSTEMI in the setting of 3 vessel coronary artery disease, complicated by cardiogenic shock, hypoxemic respiratory failure and acute kidney injury, consistent with AKIN stage II. He developed metabolic acidosis and hyperkalemia with worsening oliguria. His hyperkalemia was as high as 7.4 and was accompanied with peaked T-waves. Nephrology was consulted and he underwent one cycle of intermittent hemodialysis. His creatinine began to decrease to his baseline of 1.7 and his cultures were all negative. He was brought to the operating room on [**2126-2-7**] where the patient underwent coronary artery bypass graft x 3 with the left internal mammary artery to the left anterior descending artery and reverse saphenous vein graft to the left posterior descending artery and the first diagonal artery. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. Creatinine remained around his baseline of 1.7 with good response to diuresis. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with visiting nurse services on post operative day 5 in good condition with appropriate follow up instructions. Statins were not restarted because of elevated LFTs. These should be rechecked with his PCP before restarting. Medications on Admission: Aspirin 325mg daily Glyburide 1.25 [**Hospital1 **] Metformin 500 [**Hospital1 **] Quinapril 20 mg q day Simvastatin 20 mg daily oxaprozin 600 [**Hospital1 **] (NSAID) MV vitamin C glucosamine Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): 75 mg three times a day . Disp:*270 Tablet(s)* Refills:*0* 8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*qs qs* Refills:*0* 9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 11. Statin Due to elevated LFT was unable to resume statin will need to be reevaluated as outpatient 12. Outpatient Lab Work Please have Chem 7 drawn with results to Cardiac surgery office [**2-15**] office phone # [**Telephone/Fax (1) 170**] Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Preoperative Pulmonary edema Preoperative Transaminitis Preoperative acute kidney injury with hyperkalemia Preoperative non ST elevation myocardial infarction Diabetes Mellitus Dyslipidemia Hypertension Chronic Kidney disease(baseline creatinine 1.7) Obstructive sleep apnea Anemia Obesity Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema +1 bilateral lower extremities Preop weight 92.3 kg current 93.2 kg Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointmentsP: Surgeon: Dr. [**Last Name (STitle) **] (for Dr. [**Last Name (STitle) **] Thursday [**2-28**] @ [**Hospital1 **] 9:00 AM ***Cardiologist:Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 1295**] [**2-25**] at 12:00 noon [**Hospital1 **] Heart Center [**Telephone/Fax (2) 6256**] Primary Care Dr. [**Last Name (STitle) 37063**] [**3-7**] at 9 AM **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2126-2-12**]

[ "995.94", "276.7", "410.71", "427.32", "570", "585.3", "428.31", "327.23", "276.2", "518.81", "285.21", "492.0", "414.01", "584.9", "507.0", "287.5", "427.31", "428.0", "427.89", "403.90", "250.00", "785.51", "272.4" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "39.61", "36.15", "97.44", "96.71", "36.12" ]

icd9pcs

[ [ [] ] ]

9073, 9136

5333, 7380

365, 595

9531, 9813

3070, 5310

10653, 11265

2296, 2314

7623, 9050

9157, 9510

7406, 7600

9837, 10630

2329, 3051

271, 327

623, 2015

2037, 2160

2176, 2280

11,229

165,559

5518

Discharge summary

report

Admission Date: [**2168-12-8**] Discharge Date: [**2168-12-15**] Date of Birth: [**2128-7-21**] Sex: F Service: MEDICINE Allergies: Phenergan / Compazine / Reglan / Haldol Attending:[**First Name3 (LF) 4654**] Chief Complaint: Gastroparesis Major Surgical or Invasive Procedure: EGD History of Present Illness: 40 y/o woman with PMH notable for type I DM complicated by gastroparesis with multiple prior admissions for abdominal pain who presented to [**Hospital3 **] earlier this evening due to ongoing nausea/vomiting, epigastric abdominal pain, and inability to tolerate po. At [**Hospital1 392**], KUB showing no obstruction, guaiac neg. Went to [**Hospital1 34**] 3 days ago. Received IV dilaudid, able to tol PO, recommended DC home. Insisted on IV pain meds and tx to [**Hospital1 18**]. Dr. [**Last Name (STitle) 8840**] felt not medically necessary, while attempting xfer, pt eloped with portocath accessed, in lobby took out portocath needle and left ama-without signing papers, without flushing. . In our ED, initial vs were: 98.6 86 137/87 100%ra. Patient was given ativan 1 mg IV X 1, zofran 4 mg IV X 1, dilaudid 1 mg IV X 1. She was also treated with pyridium 100 mg PO X 1 and levaquin 500 mg PO X 1 as well as benadryl 25 mg IV X 1. Urine pregnancy test was negative. Pt had transient episode of hypotension to 80's after pain medication. CT abdomen performed/no obstruction. Secondary to elevated glucose, AG gap pt needing insulin gtt (s/p 20 units IV insulin, gap to 15. Also, s/p 4L IVF. SBP 90-100's, pulse 100s. Past Medical History: - Diabetes (Type 1): Diagnosed in [**2145**] at the age of 17, complicated by mild retinopathy. Severe gastroparesis. Her DM is managed with insulin, Lantus and NovoLog by Dr. [**Last Name (STitle) 10088**] at [**Last Name (un) **]. - Gastroparesis. Required a feeding tube as recently as '[**65**]. Prior Botox injection in [**2164**], s/p gastric pacemaker placement in [**2164-6-19**]. She is followed very closely by Dr. [**Last Name (STitle) 10689**]. - Hypertension. - Panic attacks. - h/o Anemia - Genital herpes. - Anal dysplasia followed by the infectious disease clinic. - Fibromyalgia. - Diabetic mastopathy. She is followed by Dr. [**Last Name (STitle) **] [**Name (STitle) 22283**] in the [**Hospital **] [**Hospital **] Clinic through [**Hospital6 33**]. She underwent a lumpectomy in [**2167-2-19**] and was diagnosed with diabetic mastopathy. This lumpectomy was of the right breast. - h/o SBO Social History: Currently not working, but former sales manager for [**Company 22280**]. Takes care of her mother with [**Name (NI) 2481**] disease during the day. Not married and no children. Denies alcohol, tobacco, and drug use. Family History: Her father has type 2 diabetes mellitus. Her mother has [**Name (NI) 2481**] disease. Her brother has diabetes and her sister suffers from [**Name (NI) 4522**] disease. A maternal uncle and maternal grandmother both died from MIs at age 50. Physical Exam: VS: afebrile, HR 102, BP 127/62 Gen: NAD, pleasant HEENT: No oropharyngeal erythema or exudate. CV: RRR, no m/r/g. Pulm: CTAB. Abd: +BS. Soft, moderate tenderness diffusely. No guarding or rebound. Extrem: No c/c/e. Pertinent Results: Admission Labs: [**2168-12-8**] 02:18AM WBC-7.8# RBC-3.91* HGB-11.4* HCT-34.8* MCV-89 MCH-29.2 MCHC-32.8 RDW-14.8 [**2168-12-8**] 02:18AM GLUCOSE-458* UREA N-25* CREAT-1.4* SODIUM-136 POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-20* ANION GAP-24* [**2168-12-8**] 02:18AM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-64 TOT BILI-0.6 [**2168-12-8**] 02:18AM LIPASE-16 [**2168-12-8**] 02:18AM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-4.5# MAGNESIUM-1.8 [**2168-12-8**] 02:18AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2168-12-8**] 02:18AM PLT COUNT-444* [**2168-12-8**] 02:18AM URINE RBC-[**6-28**]* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 . CT ABD: IMPRESSION: No evidence of obstruction or perforation. No acute intra- abdominal pathology. Similar-appearing CT scan when compared to [**2166-11-13**]. [**12-12**] EGD: Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated her understanding and signed the corresponding consent forms. A physical exam was performed. The patient was administered conscious sedation. Supplemental oxygen was used. The patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the third part of the duodenum was reached. Careful visualization of the upper GI tract was performed. The procedure was not difficult. The patient tolerated the procedure well. There were no complications. Findings: Esophagus: Normal esophagus. Stomach: Contents: Clear, slightly bilious fluid was seen in the stomach body. Mucosa: Normal mucosa was noted in the whole stomach. Cold forceps biopsies were performed for histology at the stomach antrum. Duodenum: Mucosa: Normal mucosa was noted. Cold forceps biopsies were performed for histology at the second part of the duodenum. Impression: Retained fluids in stomach Normal mucosa in the duodenum (biopsy) Normal mucosa in the whole stomach (biopsy) Otherwise normal EGD to third part of the duodenum Recommendations: A letter with the biopsy results will be sent to you in [**11-1**] days. Discontinue Protonix IV. Switch to ranitidine 150 mg [**Hospital1 **]. EGD Bx: DIAGNOSIS: Gastrointestinal mucosal biopsies, two: A. Antrum: Antrum/fundic mucosa, within normal limits. B. Duodenum: Within normal limits. Brief Hospital Course: 40 yo female with a PMH of DM1 with severe gastroparesis who presents with abdominal pain and dysuria found to be in DKA and having severe gastroparesis. DKA treated with gap closed as below, prolonged hospitalization for severe gastroparesis - including EGD eval with nml mucosa including nml antral/duodenal bx (random bx). Slow coarse for recovery, noted difficult to control DM with [**Last Name (un) **] following. Pt stable at time of d/c and wished to return home. Will need close f/u with [**Hospital 387**] clinic. # DKA/AG acidosis/DM1, uncontrolled with complications: Pt with an acidosis based on HCO3 level upon admission. Initially had a gap with elevated glucose. The patient was initiated on an Insulin drip and was fluid resuscitated. The patient was subsequently transitioned to SQ Insulin following her BS<200. The patient was not taking good POs in the ICU, however her GAP remained close. On the medicine service, her diet was advanced. The [**Last Name (un) **] consult service agreed with her current home regimen initially. Pt later given gastroparesis wished for more a full liquid [**Doctor First Name **] diet, but occasionally would have toast/light solids. Nutrition was also consulted to aide pt with home education on such a diet. At end pt tolerated solid foods but more conservative diet. - final DM regime [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations were for Lantus 10u am, 9u pm, with humolog with all meals based on insulin:carb ratio 1:15 at breakfast and lunch, and 1:20 at dinner with sensitivity factor 1:50. Pt has both adequate supplies of lantus and humologue at home. Please not pt's BS very difficult to control, when regime was 13/12 had noted am hypoglycemic level at upper 50s on am - so regime titrated from there (lantus reduced but more pm SSI adjusted). Pt will need close f/u, may need insulin pump in future? # Acute mental status change/chest pain - [**12-14**] pt with increased [**Month/Year (2) **] - not feeling her self and out of control, with clouded thought process - consistant with prior use of reglan - gets effects occasionally. Overall feel reglan has exacerbated her underlying [**Month/Year (2) **] disorder with this metabolic effect. Pt's CP on that day also most likely related to [**Month/Year (2) **] - given DM checked EKG. Note pt was r/o for MI [**2-20**] to tachycardia when pt initially was admitted - EKG re-checked [**12-14**] -no changes. -d/c reglan on [**12-14**] with pt's mental status returning to baseline on [**12-15**] and stable -ekg checked an without changes # Gastroparesis: Etiology of the patients severe abdominal pain. similar to past episodes of gastroparesis. Treated with dilaudid (for pain control), ativan, zofran. The patient was seen by the GI service and Dr. [**Last Name (STitle) 10689**] and she was started on Erythromycin IV in-patient initially, given Dilaudid (which was rapidly downtitrated and converted to po) and ativan for pain and [**Last Name (STitle) **]. In addition she was written for Zofran for nausea. The patient underwent EGD on [**12-12**] that grossly was unremarkable with nml mucosa - bx taken of duodendum and stomach (duodendum with prior concern of possible sprue), both bx came back with nml mucosa. -d/ced protonix and started H2 blocker po bid as without any evid of ulcers on EGD on [**12-12**] (Rx given) -d/c IV erythromycin on [**12-12**] -started reglan 10mg qid for 2 wk course with f/u with Dr. [**Last Name (STitle) 10689**]/PCP following on [**12-12**], however given AMS as above - d/ced reglan [**12-14**] -d/c stool softeners [**12-14**] with pt with loose stools - resolved at time of d/c -sx stable, though vary - pt prefers to cont her care at home - feels can control with po meds # UTI?: UA positive; culture not sent from ED. She has had E.coli resistant to cipro in the past (but several years ago). She was given levoflox in the ED but likely vomited this up. Antibiotics were later discontinued. Repeat U/A and urine cx checked - no evid of UTI. # Hypertension: Held atenolol, clonidine given hypotension on admission. These were restarted, BP subsequently controlled when pain also controlled. Atentolol currently [**1-20**] home dose, but BP currently controlled - pt to be d/c on full dose with BPs in upper nml range at time of d/c with HR in 90s. PCP to [**Name Initial (PRE) **]/u in [**1-20**] weeks. # [**Date Range **]/fibromyalgia: Continue ativan as above. Continue duloxetine and buspirone. Patient needs close outpatient psych f/u. Returned to home dose of ativan at 2mg qam on [**12-14**] - to cont as outpt with PCP to further adjust. Medications on Admission: [**Month/Year (2) **] 81 mg daily atenolol 50 mg daily ativan 2 mg QAM prn buspirone 20 mg TID cleocin gel clonidine 0.1 mg [**Hospital1 **] dicyclomine (uses infequently) duloxetine 20 mg [**Hospital1 **] flonase 1-2 puffs [**Hospital1 **] dilaudid 2 mg [**Hospital1 **] prn pain - taking infrequently at home lantus 13 U [**Hospital1 **] loestrin 1.5/30 daily novolog four times daily NULEV (never uses) omeprazole 20 mg daily zofran prn Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) tab PO BID (2 times a day). 2. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. [**Hospital1 9766**] EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Buspirone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Ativan 2 mg Tablet Sig: One (1) Tablet PO qAM as needed for [**Hospital1 **]. Disp:*30 Tablet(s)* Refills:*0* 8. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain: For breakthrough pain. 9. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**1-20**] nasal puffs Nasal twice a day. 10. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO once a day: USE DOSE AND FREQUENCY AS NEEDED BY PRIOR INSTRCUTIONS FROM DR. [**Last Name (STitle) **]. 11. Cleocin T 1 % Gel Sig: One (1) application Topical once a day: As needed per prior home regimen. 12. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous qAM. 13. Lantus 100 unit/mL Solution Sig: Nine (9) units Subcutaneous Qpm. 14. Humalog 100 unit/mL Solution Sig: One (1) units Subcutaneous four times a day: Use per sliding scale with 1:15 insulin:carb for breakfast and lunch, and 1:20 for dinner, and 1:50 for sensitivity factor. 15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 16. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q3H (every 3 hours) as needed for pain. 17. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Diabetic Ketoacidosis Gastroparesis [**Last Name (STitle) **] with hx of panic attacks HTN Fibromyalgia h/o SBO Discharge Condition: Vital Signs Stable Discharge Instructions: Return to ED if unable to hold down any pills or fluids, high fevers, significant abdominal distention, high blood sugars that do not improve with home sliding scale and increased water intake. And if your abdominal pain is not controlled with your po dilaudid at home. Please note and make close follow-up appointments as below. If you require dilaudid medication for pain - you can NOT operate any heavy machinary including a car or use any alcohol products concurrently during that time period of use (nothing within 24hour of use). Followup Instructions: Please call your PCP: [**Name10 (NameIs) 2879**],[**Name11 (NameIs) 2878**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] and set-up a f/u appointment in [**1-20**] weeks for f/u for your blood pressure and gastroparesis sx - they can also assist along with [**Hospital **] clinic for your DM. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2168-12-28**] 1:30 Provider: [**Name10 (NameIs) 306**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2169-1-3**] 4:00 Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2169-1-27**] 1:55 [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**] Completed by:[**2168-12-15**]

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icd9cm

[ [ [] ] ]

[ "45.16", "38.93" ]

icd9pcs

[ [ [] ] ]

12616, 12622

5663, 10356

315, 320

12778, 12799

3252, 3252

13396, 14224

2758, 3000

10847, 12593

12643, 12757

10382, 10824

12823, 13373

3015, 3233

262, 277

348, 1575

3268, 5640

1597, 2509

2525, 2742

6,527

186,016

30555

Discharge summary

report

Admission Date: [**2102-2-21**] Discharge Date: [**2102-2-27**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: [**2-21**] Pelvic artery embloization [**2-24**] ORIF left wrist History of Present Illness: 85 year old female s/p fall, slipped on ice, no reported LOC. Taken to an area hospital and found to have a left wrist fracture and pelvic fracture; she was transferred to [**Hospital1 18**] for further care. Past Medical History: Renal insufficiency (Baseline creatinine 1.8) HTN Afib Osteoporosis MI, stroke Colon cancer, s/p resection Odontoid fx [**2093**] Social History: Widowed Lives with her son Independent prior to fall, drives Family History: Noncontributory Pertinent Results: [**2102-2-21**] 09:33PM CK-MB-4 cTropnT-0.03* [**2102-2-21**] 09:33PM HCT-27.7* [**2102-2-21**] 09:33PM PT-14.3* PTT-25.7 INR(PT)-1.3* [**2102-2-21**] 06:28PM GLUCOSE-137* UREA N-27* CREAT-1.4* SODIUM-146* POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-26 ANION GAP-16 [**2102-2-21**] 06:28PM CALCIUM-8.9 PHOSPHATE-4.2 MAGNESIUM-2.1 CHEST (SINGLE VIEW) Reason: eval RUL [**Hospital 93**] MEDICAL CONDITION: 85 year old woman with ?RUL process. Please perform after surgery with Ortho today REASON FOR THIS EXAMINATION: eval RUL INDICATION: Evaluate right upper lobe process. COMPARISON: [**2102-2-23**]. PORTABLE CHEST RADIOGRAPH Cardiac and mediastinal contours appear stable, with persistent enlargement of the cardiac silhouette and atherosclerotic calcifications in the aorta again noted. Persistent right upper lobe consolidation is identified. Small bilateral pleural effusions also again seen. IMPRESSION: Persistent right upper lobe consolidation, again concerning for pneumonia. CHEST (PORTABLE AP) Reason: lung pathology [**Hospital 93**] MEDICAL CONDITION: 86 year old woman with pelvic fractures, desaturation. REASON FOR THIS EXAMINATION: lung pathology AP CHEST, 10:24 A.M., [**2-23**] HISTORY: Pelvic fractures and desaturation. IMPRESSION: AP chest compared to [**2-22**]: Persistent consolidation in the right upper lobe concerning for pneumonia. Left lower lobe atelectasis has improved. Small bilateral pleural effusions and severe cardiomegaly, unchanged. PELVIS (AP ONLY) Reason: pelvic injury [**Hospital 93**] MEDICAL CONDITION: 85 year old woman s/p fall REASON FOR THIS EXAMINATION: pelvic injury INDICATION: 85-year-old female status post fall. No prior studies for comparison. ONE-VIEW PELVIS: Evaluation is somewhat limited by overlying bowel loops. A Foley catheter and contrast are seen within the bladder. The greater trochanter of the left femur is incompletely evaluated. There are minimally displaced bilateral superior and inferior pubic ramus fractures. IMPRESSION: 1. Bilateral superior and inferior pubic ramus fractures. [**Numeric Identifier 7536**] EMBO NON NEURO [**2102-2-21**] 9:10 AM Reason: embolization of bleeding pelvic vessels Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 85 year old woman s/p fall from standing p/w pelvic fx and hematoma with signs of active bleeding REASON FOR THIS EXAMINATION: embolization of bleeding pelvic vessels INDICATION FOR EXAM: This is an 85-year-old woman status post falling from standing position with pelvic fracture and hematoma with signs of active bleeding. RADIOLOGISTS: This procedure was performed by Drs. [**Last Name (STitle) 15785**] and [**Name5 (PTitle) **], the attending radiologist, who was present and supervising throughout the procedure. PROCEDURE AND FINDINGS: After informed consent was obtained from the patient explaining the risks and benefits of the procedure, the patient was placed supine on the angiographic table, and the right groin was prepped and draped in the standard sterile fashion. Using fluoroscopic guidance and palpatory technique, access was gained into the right common femoral artery with a 19-gauge needle after injection of 5 cc of 1% lidocaine. A 0.035 [**Last Name (un) 7648**] wire was then advanced through the needle into the distal part of the aorta and the needle was then exchanged for a 5 French vascular sheath that was connected to a continuous side arm flush. A 5 French C2 Cobra glide catheter was then advanced into the abdominal aorta and it was placed at the level of L4 and a pelvic angiogram was then performed. Pelvic angiogram demonstrates a small area of 3 mm pseudoaneurysm in the vascular territory of the right internal iliac artery. Based on these diagnostic findings, it was decided that the patient would benefit from Gelfoam embolization of that branch and selective catheterization of that providing the pseudoaneurysm was performed using a 5 French Siemens catheter. Five cc of Gelfoam slurry was then injected into the branch communicating with the pseudoaneurysm until hemostasis was achieved. The catheter was then removed, the 5 French vascular sheath was removed and manual compression was held for 15 minutes until hemostasis was achieved into the right groin. The patient tolerated the procedure well. Moderate sedation was provided by administering divided doses of 25 mcg of fentanyl and 0.5 mg of Versed throughout the total intraservice time of one hour, during which the patient's hemodynamic parameters were continuously monitored. IMPRESSION: 1. Pelvic angiogram demonstrates a 3 mm pseudoaneurysm in the vascular territory of the right internal iliac artery. 2. Successful embolization with Gelfoam slurry performed. A cystogram was performed via a previously placed Foley catheter . Injection of 250 cc of saline and dilute contrast was performed to fill the bladder and for assessment of possible rupture. Serial pelvic images were then performed under fluoroscopic guidance in oblique positions pre and post void and demonstrated no areas of extravasation of contrast or leakage. Not of bladder diverticuli . IMPRESSION: Normal Cystogram less bladder diverticuli. Brief Hospital Course: She was admitted to the Trauma service. She was immediately taken to the angiography suite following abdominal CT scan which showed a pelvic arterial bleed. Following this procedure she was taken to the Trauma ICU for close observation. Orthopedics was consulted for her left wrist fracture, she was taken to the OR on [**2-24**] for ORIF of this fracture. She is to remain non weight bearing on her left upper extremity. She will need to be fitted for an orthoplast splint in 10 days. Her pubic rami fracture was determined to be non operative; she can be weight bearing as tolerated on her right lower extremity and touch down weight bearing on her left lower extremity. Once confirmed with her primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**], her home meds were restarted with the exception of the Coumadin. Resuming the Coumadin was discussed with Dr. [**Last Name (STitle) 131**] and once her acute illness is resolved he would like to restart this. She was started on ASA 325 daily and Heparin 5,000u tid for DVT prophylaxis. Physical and Occupational therapy were consulted and have recommended short term rehab. The patient has continued to remain stable, has tolerated a regular diet, and her labs have normalized.She will be WBAT for her lower extremities and NWB for her left upper extremity. Medications on Admission: Coumadin 2 mg q pm Atenolol 25 mg qd Digoxin .125 mg qd Lasix 20 mg qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for losse stools. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP <110; HR <60. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 10. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours as needed for pain. 11. Calcium 500 mg Tablet Sig: One (1) Tablet PO three times a day. 12. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: s/p Fall Left wrist fracture Pubic rami fracture Pelvic arterial bleed Discharge Condition: Stable Discharge Instructions: DO NOT bear any weight on your left upper extremity. You may bear weight as tolerated on your right lower extremity and touch-down weight bear on your left lower extremity. Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Orthopedics for your pelvic fractures . Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in 10 days with Dr. [**Last Name (STitle) **], Orthopedics to be fitted for an orthoplast splint for your left wrist. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up with your primary doctor, Dr. [**Last Name (STitle) 131**] after discharge from rehab for restarting your coumadin. Completed by:[**2102-2-27**]

[ "813.42", "427.31", "733.00", "808.2", "E885.9", "V10.05", "403.90", "585.9", "902.9" ]

icd9cm

[ [ [] ] ]

[ "88.47", "99.29", "88.48", "79.32" ]

icd9pcs

[ [ [] ] ]

8572, 8613

6063, 7417

269, 337

8728, 8737

859, 1232

8959, 9451

823, 840

7538, 8549

3115, 3213

8634, 8707

7443, 7515

8761, 8936

221, 231

3242, 6040

365, 575

597, 729

745, 807

79,300

168,176

39952+58336

Discharge summary

report+addendum

Admission Date: [**2109-11-12**] Discharge Date: [**2109-12-6**] Date of Birth: [**2053-3-12**] Sex: F Service: MEDICINE Allergies: Heparin Agents / Cephalosporins / Penicillins / Linezolid Attending:[**First Name3 (LF) 12174**] Chief Complaint: Worsening liver function at OSH Major Surgical or Invasive Procedure: Placement of right-sided temporary hemodialysis catheter. [**2109-11-19**] Diagnostic Paracentesis [**11-15**] CVVH [**11-25**]- [**12-3**] Intubation and sedation [**11-23**]- 11/3 L IJ placement [**11-24**] Massive Blood transfusion [**11-24**] History of Present Illness: Ms [**Known lastname 87863**] is a 56 year-old female with hx of HCV cirrhosis being transferred to [**Hospital1 18**] for an expedited liver transplant work up. . She was initially admitted to [**Hospital 1474**] hospital on [**10-24**] for weakness and increasing pain and redness of her lower extremity wounds. She was treated for the cellulitis with vancomycin. She had encephalopathy which cleared with lactulose. The patient was also found to have an E. coli UTI that was treated with cefazolin, then ceftriaxone. . At [**Hospital1 1474**], the patient was noted to have creatinine 2.4. Nephrology was consulted and felt that the patient had HRS, for which she was started on midodrine and octreotide. She was also noted to have a rising biliruin which was most recently 17.3. RUQ ultrasound showed some gallbladder wall thickening, but MRCP was reportedly negative for any biliary abnormalities. The patient was transferred to [**Hospital1 18**] for initiation of a liver transplant work-up. . Of note, the patient had a two week hospitalization at [**Hospital 6451**] Hospital prior to her admission at [**Hospital1 1474**] for hepatic encephalopathy, which was felt to be related to running out of lactulose. . On the floor, the patient complained of pain in her lower extremity ulcers. She noted intermittent abdominal pain in her hernia which was position and was not present at the current time. . Review of systems: (+) Per HPI. Also, has had intermittent left-sided headaches. (-) Denies fever. Has had "mild chills". Denied cough, shortness of breath. Denied chest pain or tightness. Denied dysphagia, nausea, vomiting, diarrhea, or constipation. No BRBPR or dark stools. No visual changes, focal weakness, tingling, or numbness. Past Medical History: Heparin-induced thrombocytopenia Cirrhosis Abdominal hernia Stage IV lower extremity ulcers Hypertension Hypothyroidism Hepatitis C Cholecystitis Brain aneurysm s/p coiling MRSA Cellulitis Social History: Lives with daughter. Had another daughter who died. Not married, but has a partner x 25 years. -tobacco: former smoker -EtOH: sober x 20 years -Drugs: former heroin use. Stopped 15 yeras ago. Family History: No known family history of liver disease. Physical Exam: Vitals: T 98.3: BP 99/38: P 64: R 20: O2 99%/RA General: NAD. Speech slow. HEENT: Icteric sclerae. MMM. OP clear. Neck: supple Lungs: CTA anteriorly CV: RRR. Normal s1, s2. No M/G/R. Abdomen: +BS. Large infraumbilical hiatal hernia. Otherwise, soft. Distended. Non-tender. No R/G. Ext: 3+ pitting edema to knees. Large stage 4 LE ulcers (12/9 cm on left shin, 5x4.5cm on right skin, also with ulcer on right heel). All ulcers with granulation tissue in base. Skin: Spider angiomata. Neuro: Alert, oriented to "hospital". Could name [**Hospital1 **] when given multiple choice. Oriented to month and year. Can name days of week forward and backward. CN II-XII intact. Strength 5/5 throughout upper and lower extremities. +tremor. No asterixis. Pertinent Results: Summary of previous OSH labs: [**2109-4-30**]: Cr 0.8-1.0 [**2109-5-2**]: Cr 1.67, TBili 1.7 [**2109-9-12**]: Cr 3.0, TBili 1.7, DBili 0.6, INR 1.4 [**2109-9-16**]: Cr 2.3, TBili 1.0, DBili 0.6, AP 79, AST/LT 35/11, INR 1.5 [**2109-9-20**]: Cr 1.5 [**2109-11-13**] 04:00AM BLOOD WBC-10.6 RBC-3.20* Hgb-9.3* Hct-28.3* MCV-89 MCH-28.9 MCHC-32.7 RDW-18.6* Plt Ct-113* [**2109-12-4**] 05:37PM BLOOD WBC-8.3 RBC-2.57* Hgb-7.6* Hct-23.8* MCV-93 MCH-29.4 MCHC-32.1 RDW-22.2* Plt Ct-54* . [**2109-11-13**] 04:00AM BLOOD PT-30.8* PTT-51.1* INR(PT)-3.1* [**2109-12-4**] 05:37PM BLOOD PT-54.4* PTT-68.6* INR(PT)-6.0* . [**2109-12-4**] 05:37PM BLOOD ALT-23 AST-40 LD(LDH)-113 AlkPhos-87 TotBili-31.4* [**2109-11-20**] 12:02PM BLOOD HBcAb-POSITIVE [**2109-11-13**] 04:00AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HAV Ab-NEGATIVE [**2109-11-13**] 11:06AM BLOOD AMA-NEGATIVE [**2109-11-13**] 11:06AM BLOOD [**Doctor First Name **]-NEGATIVE [**2109-11-13**] 04:00AM BLOOD CEA-31* [**2109-11-13**] 04:00AM BLOOD IgG-1711* IgA-568* IgM-82 [**2109-11-13**] 12:30PM BLOOD HIV Ab-NEGATIVE [**2109-11-13**] 12:30PM BLOOD Ethanol-NEG [**2109-11-13**] 04:00AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2109-11-13**] 04:00AM BLOOD HCV Ab-POSITIVE* . MRI lower extremity Wet Read: DSsd WED [**2109-11-20**] 5:35 PM Bilateral cellulitis/fasciitis, L > R. No evidence of abscess. Large ulceration over left tibia, but does not definitely communicate with tibia. [**Name2 (NI) **] definite signal abnormality in tibia, though evaluation is limited due to motion artifact, and lack of postcontrast images. . Bone scan IMPRESSION: 1. No evidence of osteomyelitis. 2. Diffuse pattern of tracer uptake in soft tissues may relate to patient''s body habitus. Brief Hospital Course: 56 y/o with HCV cirrhosis admitted from OSH for expedited transplant workup. Her course was c/b possible osteomylitis. It was determined that she was not a transplant candidate [**2-26**] social issues. Pt developed a RUQ PICC associated DVT. Line was removed and Hematology was consulted. The decision was made to treat DVT w argatroban. Pt hemorrhaged from stool, LE wounds, line sites and vagina requiring ICU transfer and massive transfusion protocol. She presented to the ICU with massive GI bleed in the setting of Argatroban use, developed respiratory distress and was intubated. She was extubated and tolerated NC/RA well. She was diuresed with CVVH to optimize her fluid status after multiple transfusions and being volume overloaded. She started to become hypotensive requiring phenylephrine. On the phenylephrine she started to develop abdominal pain. Her ICU course is outlined below. After multiple family meetings in the ICU the patient and her family decided to pursue comfort care measures and patient made DNR/DNI. . # LE ulcers: Pt had chronic b/l LE ulcers present on admission. Pseudomonas positive on culture on admission. MRI was equivocal for osteomyelitis so bone scan was obtained which was negative. ID team provided consult and recommended full treatment with Amikacin and cefepime given possibility of deep infection. She was started on this antibiotic regimen after initiating hemodialysis on [**11-19**]. Vascular and plastic surgery teams consulted with recommendation to consider grafting once medically stable. Abx were discontinued when pt was made CMO in the ICU on [**12-3**]. . # Resp failure: Thought secondary to hypoperfusion from hypovolemic shock vs aspiration. Was intubated for approx. 3 days, but tolerated extubation well. Had been on CVVH to remove excess fluid, which was successful in equilibrating the fluid status of the patient on length of stay, but d/c-ed after it clotted and she developed hypotension. Pt was tolerating RA well at time of transfer out of ICU on [**12-3**]. . #Abdominal Pain- patient had developed abdominal pain in the setting of phenylephrine use in ICU. Concerning for ischemic bowel. After family meetings per above have stopped drawing labs after CMO status implemented on [**2109-12-3**]. Appreciated palliative care recs on pain control according to the following: HYDROmorphone (Dilaudid) 2.5-5 mg/hr IV DRIP TITRATE TO comfort, with 1-2 mg boluses for breakthrough pain. Also covered using Methadone 5 mg IV Q6H. . #Hypotension: Remained in sinus rhythm (not secondary to AVNRT); required increased phenyephrine. At time of transfer out of ICU, SBP??????s were stabilized in the 90??????s. For source of hypotension, likely [**2-26**] sepsis. After family/patient meeting have discontinued all blood pressure support and antibiotics. . # ARF: consistent with Hepatorenal syndrome, was getting HD before transfer. Started CVVH ([**11-25**]) in effort of remove fluid per above; d/c-ed [**12-2**] due to clotting of filter and hypotension. . # GIB: On transfer both red blood per NG and BPBPR, likely was diffuse oozing in the setting of supratheraputic argatroban. She occasionally required pRBC, platelets and cryo on the floor for oozing and supratherapeutic INR. Massive transfusions required on [**11-24**], the patient received a total of 12 RBC, 11 units of FFP, 4 of platelets, and 4 of cryo. Given 1 unit additional cryo on [**12-2**] due to fibrinogen level of 70. Stopped monitoring labs due to patient??????s wishes for comfort measures only on [**2109-12-3**]. . #[**Name (NI) 27812**] Pt had one episode of AVNRT; given adenosine 5mg followed by 5mg IV metoprolol and 25mg po metoprolol and stayed in sinus rhythm for the remainder of stay. Discontinued metoprolol at 12.5mg TID because of hypotension, given IV Lopressor PRN tachycardia. . # HCV cirrhosis: Per vascular, leg ulcers should not be barrier to transplant; graft will be postponed until medically stable. Patient was told she was not a transplant candidate because of social issues. . # Soft tissue infection: continued cefepime and amkican until patient decided for comfort measures only. Bone scan and MRI showed no evidence of osteomylitis. . # HIT: per heme, resent serotonin assay as pt did have heparin flushes. Hct grossly stable in low 30s but 23 yesterday and transfused 1 unit. Continued to hold heparin and agatroban. 2nd Serotonin assay was negative. Medications on Admission: albuterol neb 1.25 mg Q4H atenolol 25 mg daily docusate 100 mg [**Hospital1 **] furosemide 20 mg twice daily hydroxyzine 25 mg TID lactulose 30 mL Q6H Mg Oxide 400 mg [**Hospital1 **] methadone 100 mg daily midodrine 10 mg with meals multivitamin 1 cap daily octreotide 100 mcg TID pantoprazole 40 mg daily phytonadione 10 mg daily KCl 20 meq daily Na bicarbonate 650 mg [**Hospital1 **] spironolactone 25 mg [**Hospital1 **] triamcinolone topical [**Hospital1 **] Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Primary: Hepatorenal syndrome HCV Cirrhosis Secondary: Osteomyelitis of Bilateral Shin splints. Discharge Condition: Expired Discharge Instructions: The pt was admitted to [**Hospital1 18**] with worsening liver failure found at [**Hospital 1474**] hospital. This was likely due to worsening cirrhosis. She had worsening function in her kidneys. We began to evaluate her for liver transplantation but she was not deemed to be eligible for transplantation given poor social supports. She eventually made herself CMO and passed away. Family was notified. Followup Instructions: Expired Name: [**Known lastname 13933**],[**Known firstname 5550**] Unit No: [**Numeric Identifier 13934**] Admission Date: [**2109-11-12**] Discharge Date: [**2109-12-6**] Date of Birth: [**2053-3-12**] Sex: F Service: MEDICINE Allergies: Heparin Agents / Cephalosporins / Penicillins / Linezolid Attending:[**First Name3 (LF) 5520**] Addendum: Of note, daughter [**Name (NI) **] [**Name (NI) 13935**] declined post-mortem study. Discharge Disposition: Expired [**Name6 (MD) **] [**Last Name (NamePattern4) 5521**] MD [**MD Number(2) 5522**] Completed by:[**2109-12-6**]

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icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "96.71", "38.91", "54.98", "96.6", "54.91", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

11507, 11655

5405, 9832

352, 601

10530, 10540

3634, 5382

10993, 11484

2813, 2856

10348, 10357

10410, 10509

9858, 10325

10564, 10970

2871, 3615

2058, 2376

281, 314

629, 2039

2398, 2588

2604, 2797

61,932

165,934

15105

Discharge summary

report

Admission Date: [**2159-7-16**] Discharge Date: [**2159-7-20**] Date of Birth: [**2093-11-29**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 20640**] Chief Complaint: inicidental finding of PE Major Surgical or Invasive Procedure: IVC filter placement History of Present Illness: 65yo gentleman with PMHx sig. of metastatic melenoma to the brain s/p resection in [**5-3**] and brain XRT completed [**6-2**] who presents with incidental massive bilateral PEs on routine restaging outpatient CT scan. Pt reports that he has had mild SOB in the past couple of days wtih assoc. pleuritic chest/back. He thought this was due to known pleural mets on the right back. He denied any fever, chills, cough, nausea, vomiting, abdominal pain, changes in bowel habits, pedal edema, leg cramping. No prior personal or fhx of clotting disorders. No swelling in his legs. Has had some headaches off and on for the last 2 weeks as his out pt decadron dose was tappered. Last dose of steriods was 2 days ago (was on a 1/2mg for last week). Reports some weakness in right leg with foot drop since brain surgery. Has also been having some sinus congestion for last couple of weeks, taking benadryl sinus PRN. In the ED, initial VS were: 97.7 99 126/89 28. He was satting 83% on RA, now 99% on NRB. ABG on NRB was 7.48/28/208. Neurosurg was consulted and agreed with heparin gtt with close monitoring of neuro status. EKG showed a t wave inversion in V2, otherwise unchanged, NSR at 96 bmp. Was given 1/2mg of diluadid IV for his pain. Past Medical History: 1. Melanoma on left posterior neck s/p resection 3 yrs ago, with metastases to brain dx [**5-3**] s/p resection and whole brain radiation and R axillary lymph nodes. Nodes have been noted to imcraese in size. 2. Diverticulitis s/p partial bowel resection in [**2145**]. 3. Left foot surgery to repair arch. PAST ONCOLOGIC HISTORY (Per onc note): 1. Melanoma removed from the left posterior neck in [**2156**], this was a superficial spreading melanoma, 0.3 mm in depth, [**Doctor Last Name 10834**] level II, lateral margins were involved by melanoma in situ, ulceration was absent. Perineural invasion was absent, tumor infiltrating lymphocytes were absent. There was less than 1 mitosis per mm2. This was stage T1a, Nx Mx melanoma. No adjuvant therapy was recommended. 2. The patient presented on [**2159-5-6**] with weakness of right arm. He was seen [**Hospital6 2561**] and head CT showed hemorrhage in the left temple region in the area of a mass. The patient was transferred to [**Hospital1 18**] for further care. 3. Left-sided high frontal craniotomy on [**2159-5-9**] with removal of left frontal cystic melanoma, right-sided craniotomy on [**2159-5-14**] with resection of right parietal melanoma. Pathology from these lesions showed metastatic melanoma with tumor cells positive for S-100, MART-1 and HMB-45. 4. Staging CT of the torso on [**2159-5-7**] showed a left lobe lung mass measuring 2.9 x 2.1 cm, several enlarged right axillary lymph nodes measuring up to 2.5 x 2.2 cm were found. Social History: Pt is married. He is a former smoker, quit 25 yrs ago, smoked <1ppd x 20 years. He has up to a couple of glasses of wine with dinner. No drug use. Family History: No family history of blood clots. Mother with breast cancer. Physical Exam: t- 99.2, hr-101, bp- 142/74, rr-28 O2-91% GEN- white male, NAD, talkative HEENT- MMM, clear OP NECK: scar on left side, no LAD Axilla- large firm mass in right axilla, appx grapefruit size CHEST: CTA CV: tachy, no m, 2+ pulses ABD: soft, NT, ND, +BS EXT: no c/c/e, bruise in nail bed on right index NERUO: intact cranial nerves [**3-8**], notable exam with pronator drift in right arm, and 4/5 strength in right toe dorsiflexion, otherwise strength 5/5, sensation intact, finger to nose intact, gait not assessed, rapid movements with hands intact Pertinent Results: CT torso [**2159-7-16**]--PRELIM: 1. Urgent incidental finding: Massive bilateral PE, more on the right. 2. Significant intreval increase in size of the metastatic deposits at the R axilla. 3. Minimal increase in size of the LLL lung lesion. Brief Hospital Course: 65 yo M with metastatic melanoma to the brain who presents with massive bilateral PEs incidentally found on staging CT scan. # Bilateral PEs: Patient was hemodynamically stable and satting mid-90s on 4L NC. Given risk for head bleed in setting of brain metastases, he was admitted to the ICU for observation with initiation of a heparin gtt. He was monitored overnight without event, and a CT of his head was negative for bleed after being therapeutic on heparin. # Metastatic melanoma: Pt is awaiting new MRI head results to determine eligibility for chemotherapy. Keppra was continued for seizure prophylaxis. - MRI head when on the floor CODE: FULL, confirmed with patient Communication: [**Name (NI) **] [**Name (NI) 44091**] (wife, [**Name (NI) 382**] Medications on Admission: Dexamethasone taper, stopped [**2159-7-15**] along with pantoprazole and Bactrim DS that were also recently stopped Benadryl as needed. Levetiracetam 500 mg twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: Submassive Bilateral Pulmonary Embolism Seconday Diagnoses: Metastatic Melanoma, Deep veinous thrombosis Discharge Condition: Good Discharge Instructions: You were admitted with large blood clots in your lungs. After discharge from the hospital, you must remain on anticoagulation medicines until advised otherwise by your doctor. In addition, you need to use oxygen while at home until your need for supplemental oxygen decreases. Followup Instructions: PCP: [**Name10 (NameIs) 3050**],[**Name11 (NameIs) 1730**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 26774**] Oncology: [**Doctor Last Name **] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2159-7-21**] 5:15 Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2159-7-23**] 10:30 Completed by:[**2159-7-21**]

[ "453.41", "172.4", "197.2", "415.19", "198.3", "V15.3", "196.3", "V58.65" ]

icd9cm

[ [ [] ] ]

[ "88.51", "38.7" ]

icd9pcs

[ [ [] ] ]

5195, 5253

4209, 4974

300, 323

5421, 5428

3942, 4186

5753, 6162

3296, 3358

5274, 5274

5000, 5172

5452, 5730

3373, 3923

235, 262

351, 1588

5293, 5400

1610, 3116

3132, 3280

62,603

181,514

12025

Discharge summary

report

Admission Date: [**2143-7-19**] Discharge Date: [**2143-8-8**] Date of Birth: [**2096-10-13**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 695**] Chief Complaint: confusion Major Surgical or Invasive Procedure: [**2143-7-26**]: Orthotopic deceased donor liver transplant (piggyback), common bile duct to common bile duct with no T-tube, portal vein to portal vein, common hepatic artery (donor) to proper hepatic artery (recipient ). [**2143-7-30**]: Hepatic Angiogram History of Present Illness: The patient is a 46M with h/o alcoholic cirrhosis, refractory ascites requiring paracentesis, on the transplant list who was referred to the Emergency Department for altered mental status. The patient lives in an [**Hospital3 **] facility where he requires assistance with most ADLs. Noted at nursing facility to be having visual hallucinations over past 3-4 days (e.g. seeing people who are not there). Came in to radiology for scheduled paracentesis but could not perform due to AMS. Labs were drawn and sent to ED. The patient denies any cough, shortness of breath, abdominal pain, dysuria, fevers or chills. Does note decreased frequency of BMs over the past few days as well as decreased energy. Claims he has not been receiving his lactulose. Knows he is in [**Hospital1 18**] but confused as to place and gives incoherent, tangential story when asked about why he is currently in the hospital. . Of note, patient was discharged from the hospital last week after being admitted for poor nutition and new compression fracture. Course was complicated by worsening hepatic hydrothorax requiring thoracentesis and atrial fibrillation with RVR that resolved with switching to propanolol. Dobhoff was placed x 2 but was pulled out both times so he was discharged without enteral feeding and encouraged to improve his PO intake. His lactulose was increased at the time of discharge to five times a day dosing. He was oriented and intermittently confused but largely appropriate on discharge. . In the ED, triage vitals were 98 ??????F, Pulse: 79, RR: 19, BP: 108/54, O2Sat: 95. Labs notable for WBC count of 10.2, INR: 3.8, bili: 14.8. UA negative. EKG with LVH and repol changes similar compared to prior. Chest x-ray with slightly enlarged moderate-to-large right pleural effusion and small left pleural effusion. Attempted to perform diagnostic paracentesis but did not have adequate window. Patient not given any medication. . ROS: per HPI, notes increased gingival bleeding, constipation and bloating; denies bone pain, hematochezia, melena Past Medical History: - Alcohol cirrhosis c/b esophageal varices (grade III) with bleed s/p banding in [**7-/2142**], ascites/SBP ([**5-/2142**]), encephalopathy, rectal varices - Alcoholic hepatitis [**2-/2141**] - Recurrent hepatic hydrothorax - Hemolytic anemia on prednisone - Type 2 diabetes mellitus - Hypertension - Hyperlipidemia - Strep viridans and MSSA bacteremia s/p Vancomycin X 2 weeks [**5-/2142**] - Alcohol abuse (last drink [**2142-3-13**]) - GERD - Depression/anxiety - OSA on CPAP - Atrial fibrillation s/p cardioversion not on anticoagulation Social History: Currently lives at a rehab facility, where per documentation he requires assistance with most ADLs (bathing, ambulating, dressing) though he can eat independently. He has never smoked and denies IVDU, but used cocaine, ecstasy and special K prior to [**2122**]. He is close to a brother and sister both live in the area. He is currently unemployed. He denies current tobacco or alcohol use, states last EtOH was [**2142**]. Family History: Patient states that father and mother likely both had EtOH abuse. His father died of an infection, his mother passed away of complications from CVA 2 years ago. Physical Exam: ADMISSION EXAM: GENERAL: Well appearing in NAD. Jaundiced HEENT: Sclera icteric. dried blood around mouth and on tongue CARDIAC: RRR with slight SEM, hyperdynamic precordium, JVP halfway up neck LUNGS: decreased breath sounds on right ~[**4-14**] of the way up, no crackles on left ABDOMEN: Distended but soft, non-tender to palpation or percussion. Dullness to percussion over dependent areas but tympanic anteriorly. No HSM or tenderness appreciated. EXTREMITIES: no edema b/l. 2+DPs, cool at fingertips, no clubbing or cyanosis NEUROLOGY: no asterixis, CNs intact, strength intact throughout Pertinent Results: On Admission: [**2143-7-19**] WBC-10.2 RBC-2.57* Hgb-9.6*# Hct-29.2* MCV-114* MCH-37.3* MCHC-32.9 RDW-17.7* Plt Ct-59* PT-38.7* INR(PT)-3.8* Glucose-112* UreaN-29* Creat-0.7 Na-135 K-4.0 Cl-100 HCO3-28 AnGap-11 ALT-32 AST-66* AlkPhos-172* TotBili-14.8* DirBili-6.4* IndBili-8.4 Albumin-2.9* Calcium-10.9* Phos-2.9 Mg-1.9 TSH-1.2 T4-2.5* PTH-49 At Discharge: [**2143-8-8**] WBC-6.6 RBC-3.00* Hgb-10.0* Hct-29.9* MCV-100* MCH-33.4* MCHC-33.6 RDW-18.1* Plt Ct-85* PT-10.5 PTT-28.9 INR(PT)-1.0 Glucose-186* UreaN-23* Creat-0.6 Na-136 K-4.4 Cl-101 HCO3-30 AnGap-9 ALT-78* AST-25 AlkPhos-110 TotBili-1.1 Calcium-8.5 Phos-3.7 Mg-1.4* tacroFK-8.8 CT HEAD: FINDINGS: There is no evidence of hemorrhage, edema, masses, or infarction. The ventricles and sulci remain normal in size and configuration. Mucosal thickening in posterior left ethmoid air cells remains. The right sphenoid sinus has a new air-fluid level within it. The mastoid air cells remain clear. IMPRESSION: Paranasal sinus inflammatory changes, otherwise normal study. . RUQ U/S: FINDINGS: The liver is coarsened and nodular, compatible with history of cirrhosis. Tiny hepatic cyst measuring 9 mm is seen in the left lobe. A hypoechoic indeterminate lesion is seen in the right lobe measuring 8 x 7 mm. The common duct measures 5 mm. Sludge and stones are seen in the gallbladder with mild mural thickening and wall edema which is nonspecific in the setting of ascites and underlying cirrhosis. The pancreas is poorly assessed due to overlying bowel gas. The imaged aorta and IVC are normal in caliber. Spleen remains enlarged measuring 19.6 cm. Small right pleural effusion and a small to moderate amount of intra-abdominal ascites are again demonstrated. Doppler assessment with spectral analysis of the hepatic vasculature was performed with patent main portal vein and right and left major branches with hepatopetal flow. Main hepatic artery is patent with brisk systolic upstroke and appropriate waveform. Right, middle and left hepatic veins are patent as well as the IVC and splenic vein. IMPRESSION: 1. Cirrhotic liver with unchanged small to moderate ascites and splenomegaly with patent vessels. 2. Right pleural effusion. 3. Gallbladder sludge and stones. Wall edema is nonspecific in the setting of underlying liver disease and ascites. 4. 8mm hypodensity in the right lobe, indeterminate - further assessment by contrast enhanced CT or MRI is recommended on a non-emergent basis when clinical circumstance allows. . SPINE X-RAY: FINDINGS: Comparison is made to prior study from [**2143-7-5**]. There is again seen a compression deformity at T9, which appears relatively stable allowing for differences in positioning and technique since the prior study. No additional compression deformities are seen. There is generalized demineralization. The cardiac silhouette is upper limits of normal. Visualized portion of the lung fields are grossly clear. Brief Hospital Course: 46M with EtOH cirrhosis c/b encephalopathy, varices, SBP, ascites, and hepatic hydrothorax on the transplant list admitted with altered mental status with hallucinations concerning for hepatic encephalopathy. . #ALTERED MENTAL STATUS: He was admitted with reduced attention and impaired orientation with asterixis on exam. His [**Year (4 digits) **] were presumed to be due to hepatic encephalopathy. Head CT was negative. RUQ U/S revealed patent portal vasculature. Thoracentesis of pleural fluid with cell count not consistent with spontaneous bacterial empyema and culture negative. Several urinalysis were bland and culture negative. Multiple blood cultures negative. There was limited ascites on ultrasound to sample. He was found to have worsenig hypercalcemia. Endocrine service was consulted and he was given zoledronic acid with improvement in his calcium. His propranolol was held as this can potentially contribute to altered mental status. He was given frequent lactulose and continued on rifaxamin with slow improvement of his mental status. . #BRBPR: Patient was noted to have bright red blood per rectum on [**7-25**], felt most likely to be from lower source. Exam showed bright red blood around rectum without stool. NG lavage was performed which was not suggestive of upper GI source. He remained hemodynamically stable without tachycardia or hypotension. Patient received vitamin K, 1u pRBCs, 1u platelets, 1u FFP, and 1u cryoprecipitate. This has been stable post transplant . #ETOH CIRRHOSIS: Cirrhosis has been complicated by grade I varices, encephalopathy, ascites, hepatic hydrothorax, and SBP in the past. He was continued on cipro, omeprazole, thiamine, folate and multivitamin. Lasix was held out of concern for hypovolemia due to high volume of diarrhea. On [**2143-7-26**] the patient received an ABO compatible liver transplant. He was taken to the OR with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. At the time of surgery, the patient was noted to have a small shrunken cirrhotic liver. There was about 4 liters of clear ascites. He had marked portal hypertension. He required 2 units of fresh frozen plasma, 5 units of packed red cells, 1 unit of platelets, 300 cc of Cell [**Doctor Last Name **]. He tolerated the procedure well and was transferred to the ICU, still intubated. In the early post op period, a liver ultrasound was performed per protocol. Initially the portal vein was showing turbulent flow. A repeat was obtained two days later, with new report of absent diastolic flow seen in the region of the main hepatic artery. No arterial waveforms could be identified in the right or left lobes of the liver. Due to the concern for hepatic artery stenosis, the patient underwent a hepatic angiogram. Per the angiogram report, there is no signifcant hepatic arterial anastomatic stenosis and no thrombosis. The patients liver enzymes have trended back to normal, and no further action was warranted at this time. At the time of liver transplant, the patient received induction immunosuppression to include cellcept, solumedrol 500 mg intra-op with protocol taper and tacrolimus was started on the evening of POD 1. Levels have been followed daily with adjustments to dosing as indicated. The patients lateral drain has been removed, however the medial drain has continued with high volume output.. Most recently the drainage is approximately 1 liter dialy of serous ascitic fluid. As his weight has trended back to operative weight, replacements have not been done recently. Continue to follow. #HYPERCALCEMIA: This is longstanding and thought to be secondary to hyperparathyroidism from adenoma. Appeared to be worsening over the past several months. The endocrine service was consulted. He was started on zoledronic acid with improvement in his calcium level. Following transplant the calcium level was initially low. he received one large dose infusion of calcium, and was briefly treated with calcitriol and calcium carbonate. These have been discontinued as calcium trends towards normal consistently. . #HEMOLYTIC ANEMIA: Hematocrit is stable and near baseline. He was continued on prednisone and bactrim prolphylaxis. Prednisone taper is part of immunosuppressive management. Must consider long term steroid need. . #DMII: Continued HISS. To address post operative nutritional needs, the patient has been started on tube feedings via post pyloric feeding tube, with carbohydrate consistent oral intake and glucerna, which have been well tolerated. The tube has required replacement due to accidental removal by patient. Tube is now bridled. . Hyperkalemia: Post transplant the patient has had elevated potassium recently. The tube feeds were changed to a low K formula and the patient was started on florinef with good results and normalization of the potassium. . AFib: Patient has history of atrial fibrillation. Beta blocker has been increased and hold parameters lowered. It is quite improtant for patient to receive the beta blocker on a standing basis, as he has converted in and out of AFib without it. . #T9 COMPRESSION FRACTURE: Patient is on chronic steroids though most recent DEXA was negative for osteoporosis. He was continued on vitamin D. Continued on lidocaine patch for pain control. Received zoledronic acid during this stay. . Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Ciprofloxacin HCl 500 mg PO Q24H 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. FoLIC Acid 3 mg PO DAILY 4. Furosemide 120 mg PO DAILY 5. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR [**Hospital1 **] 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 40 mg PO DAILY 8. PredniSONE 15 mg PO DAILY 9. Rifaximin 550 mg PO BID 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Thiamine 100 mg PO DAILY 12. Venlafaxine XR 150 mg PO DAILY 13. Vitamin D 400 UNIT PO DAILY 14. Lidocaine 5% Patch 1 PTCH TD DAILY apply to back 15. Propranolol 40 mg PO BID hold for sbp<100, hr<55 16. Bisacodyl 10 mg PR HS:PRN constipation 17. Glucerna *NF* (nut.tx.gluc.intol,lac-free,soy; nut.tx.glucose intolerance,soy) 237 mL Oral TID 18. Psyllium 1 PKT PO TID 19. Senna 2 TAB PO BID:PRN constipation 20. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 21. Lactulose 45 mL PO 5X/DAY Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY 2. NPH 20 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 3. PredniSONE 20 mg PO DAILY Follow Prednisone taper from transplant clinic 4. Omeprazole 40 mg PO DAILY 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 6. Thiamine 100 mg PO DAILY 7. Venlafaxine XR 150 mg PO DAILY 8. Vitamin D 400 UNIT PO DAILY 9. Fluconazole 400 mg PO Q24H 10. Fludrocortisone Acetate 0.1 mg PO DAILY 11. Metoprolol Tartrate 25 mg PO BID hold for sbp < 95 or HR < 60 12. Mycophenolate Mofetil 1000 mg PO BID 13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain 14. Tacrolimus 3 mg PO Q12H 15. ValGANCIclovir 900 mg PO Q24H 16. Docusate Sodium 100 mg PO BID:PRN constipation Hold for loose stools 17. Furosemide 120 mg PO DAILY 18. Glucerna *NF* (nut.tx.gluc.intol,lac-free,soy; nut.tx.glucose intolerance,soy) 237 mL Oral TID Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: ETOH cirrhosis now s/p liver transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, inability to tolerate tube feeds, problems or dislodgement of feeding tube, drain output greater than one liter daily or any other concerns. Trough prograf to be sent Friday [**8-9**] by Coutier to [**Hospital1 18**] lab, then q Monday/Thursday labs with trough prograf to [**Hospital1 18**] and all other lab results faxed to the transplant clinic at [**Telephone/Fax (1) 697**]. Please drain and record the JP drain output three times daily and more often as necessary. Please call if the drain output exceeds one liter daily. Also please call if the drain output stops suddenly, turns green in color, becomes bloody or develops a foul odor. Patient may shower. No tub baths or swimming. Place new drain sponge around the drain exit site daily, do not allow wet dressing to sit on skin. Monitor the drain exit site for redness, drainage or bleeding. No lifting greater than 10 pounds Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2143-8-15**] 11:00. [**Last Name (NamePattern1) **], [**Hospital **] Medical Building, [**Location (un) **], [**Location (un) 86**], MA [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2143-8-8**]

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icd9cm

[ [ [] ] ]

[ "34.91", "96.08", "96.6", "00.93", "88.47", "50.59" ]

icd9pcs

[ [ [] ] ]

14673, 14744

7435, 7655

312, 572

14828, 14828

4467, 4467

16074, 16520

3670, 3833

13804, 14650

14765, 14807

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263, 274

600, 2647

5116, 7412

4481, 4811

14843, 14987

2669, 3212

3228, 3654

16,550

193,614

2060

Discharge summary

report

Admission Date: [**2158-1-9**] Discharge Date: [**2158-2-1**] Service: MEDICINE Allergies: A.C.E Inhibitors Attending:[**First Name3 (LF) 11217**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Ultrasound guided PICC line placement on [**2158-1-13**] History of Present Illness: Mr [**Known lastname 11202**] is an 85 yo male, h/o CHF with BiV pacer, CAD, COPD/restrictive lung disease, CRI who presented to [**Hospital1 18**] [**2158-1-9**] with 1 week of fever, chills, sweats, productive cough, that worsened further with intractable nausea, vomiting and abdominal pain. He denied CP, pleuritic CP, LE edema or SOB. He had spent the previous 2 weeks visiting his wife daily at [**Hospital1 18**] and then her rehab center. In the ED, he was found to be mildly febrile to 100.6, saturating adequately on room air. KUB showed non-specific bowel gas pattern but no evidence of obstruction. CXR showed mild bilateral pleural effusions with patchy LLL consolidation, c/w infiltrate. He was admitted to medicine for treatment of pna and further care. Past Medical History: 1. VT arrest in [**2149**], single chamber ICD placed at that time, DDD placed for sick sinus, BiV upgrade [**5-12**], prior pacer infections with MSSA 2. CAD: cath in [**2157**] showing 2VD; diffusely diseased LAD, proximally occluded LcX and proximally occluded RCA; both with filling from collaterals 3. CHF: TTE [**2-12**] with EF=30-35%, mild symmetric LVF, 1+ MR, 1+ TR, mild AS; AK/HK of basal inferior and inferolateral walls 4. h/o MRSA bacteremia, PNA 5. COPD dx but restrictive lung disease on PFTs with FEV1 0.93 (54% predicted) nl DLCO 6. CRI: b/l creatinine= mean 2.5 7. Hyperlipidemia 8. h/o Gallstone pancreatitis 9. PVD, stent to left iliac in [**2154**] Social History: Italian is primary language, quit cigarettes 40 years ago, no ETOH use, lives with wife, retired Family History: +DM, HTN, CAD Physical Exam: PE: VS-100.6 80 126/62 18 95% RA Gen: well-appearing pleasant male, sitting in bed with NC O2, able to speak in full sentences. A&Ox3 (knows name, "[**2158**]," "[**Hospital3 **]") HEENT: PERRL; left eye with superficial corneal lesion, MM dry, OP clear Neck: no JVD appreciated Lungs: diffuse wheezing and basilar crackles (from anterior exam), no rhonchorous breath sounds CV: 2/6 SEM at LUSB, no r/g, no TTP over left side/pacer, no fluid pocket appreciated Abd: soft, protuberant; with mild TTP in bilateral lower quadrants, no rebound or guard; guaiac neg as per ED note Extr: no c/c/e; dry skin bilaterally in LEs, PT 2+ bilat Neuro: grossly intact, MS as above Pertinent Results: [**2158-1-9**] 09:55AM BLOOD WBC-15.1* RBC-6.23* Hgb-12.4* Hct-38.8* MCV-62* MCH-19.9* MCHC-31.9 RDW-18.2* Plt Ct-915* [**2158-1-10**] 09:31AM BLOOD WBC-16.0* RBC-5.53 Hgb-10.8* Hct-35.2* MCV-64* MCH-19.5* MCHC-30.7* RDW-18.4* Plt Ct-799* [**2158-1-11**] 02:33AM BLOOD WBC-24.9*# RBC-5.64 Hgb-10.8* Hct-36.0* MCV-64* MCH-19.1* MCHC-29.9* RDW-18.5* Plt Ct-862* [**2158-1-13**] 11:40AM BLOOD WBC-32.0* RBC-6.24* Hgb-12.3* Hct-39.2* MCV-63* MCH-19.7* MCHC-31.4 RDW-18.7* Plt Ct-974* [**2158-1-16**] 06:15AM BLOOD WBC-25.8* RBC-6.02 Hgb-11.7* Hct-38.0* MCV-63* MCH-19.5* MCHC-30.9* RDW-18.9* Plt Ct-884* [**2158-1-19**] 03:08AM BLOOD WBC-29.7*# RBC-5.56 Hgb-11.1* Hct-33.8* MCV-61* MCH-19.9* MCHC-32.8 RDW-19.5* Plt Ct-624* [**2158-1-23**] 06:08AM BLOOD WBC-32.3* RBC-4.90 Hgb-10.1* Hct-30.5* MCV-62* MCH-20.5* MCHC-32.9 RDW-19.7* Plt Ct-341 [**2158-1-25**] 05:17AM BLOOD WBC-22.8* RBC-4.34* Hgb-8.7* Hct-26.8* MCV-62* MCH-20.1* MCHC-32.6 RDW-20.0* Plt Ct-318 [**2158-1-31**] 03:43AM BLOOD WBC-10.9 RBC-4.76 Hgb-9.4* Hct-30.2* MCV-64* MCH-19.8* MCHC-31.1 RDW-20.6* Plt Ct-297 [**2158-1-9**] 09:55AM BLOOD Glucose-127* UreaN-23* Creat-2.1* Na-143 K-3.3 Cl-104 HCO3-24 AnGap-18 [**2158-1-10**] 09:31AM BLOOD Glucose-215* UreaN-31* Creat-2.6* Na-146* K-3.8 Cl-112* HCO3-22 AnGap-16 [**2158-1-11**] 02:33AM BLOOD Glucose-162* UreaN-39* Creat-3.0* Na-142 K-4.4 Cl-107 HCO3-19* AnGap-20 [**2158-1-12**] 04:55AM BLOOD Glucose-177* UreaN-58* Creat-3.3* Na-142 K-4.0 Cl-106 HCO3-20* AnGap-20 [**2158-1-13**] 11:40AM BLOOD Glucose-147* UreaN-74* Creat-3.6* Na-142 K-4.4 Cl-105 HCO3-21* AnGap-20 [**2158-1-14**] 11:15PM BLOOD Glucose-119* UreaN-80* Creat-3.4* Na-142 K-4.4 Cl-106 HCO3-22 AnGap-18 [**2158-1-18**] 04:00AM BLOOD Glucose-236* UreaN-91* Creat-3.2* Na-146* K-3.1* Cl-106 HCO3-27 AnGap-16 [**2158-1-19**] 03:08AM BLOOD Glucose-249* UreaN-88* Creat-3.0* Na-149* K-3.9 Cl-110* HCO3-28 AnGap-15 [**2158-1-21**] 05:46AM BLOOD Glucose-194* UreaN-84* Creat-2.7* Na-153* K-3.0* Cl-114* HCO3-25 AnGap-17 [**2158-1-22**] 06:35AM BLOOD Glucose-193* UreaN-78* Creat-2.5* Na-148* K-3.2* Cl-111* HCO3-24 AnGap-16 [**2158-1-23**] 10:07PM BLOOD Glucose-92 UreaN-61* Creat-2.3* Na-147* K-3.3 Cl-110* HCO3-26 AnGap-14 [**2158-1-26**] 05:31AM BLOOD Glucose-106* UreaN-56* Creat-2.1* Na-141 K-4.0 Cl-106 HCO3-24 AnGap-15 [**2158-1-31**] 03:43AM BLOOD Glucose-101 UreaN-30* Creat-2.1* Na-146* K-3.4 Cl-112* HCO3-27 AnGap-10 [**2158-1-9**] 09:55AM BLOOD ALT-5 AST-7 CK(CPK)-36* AlkPhos-176* Amylase-31 TotBili-0.9 [**2158-1-9**] 10:50PM BLOOD ALT-7 AST-9 LD(LDH)-330* CK(CPK)-34* AlkPhos-169* TotBili-0.7 [**2158-1-12**] 04:55AM BLOOD ALT-8 AST-11 LD(LDH)-333* AlkPhos-141* TotBili-0.4 [**2158-1-17**] 02:27AM BLOOD ALT-7 AST-5 CK(CPK)-17* AlkPhos-98 TotBili-0.8 [**2158-1-23**] 10:07PM BLOOD ALT-8 AST-6 LD(LDH)-273* AlkPhos-108 TotBili-0.6 [**2158-1-10**] 09:31AM BLOOD calTIBC-251* Ferritn-45 TRF-193* [**2158-1-18**] 02:35PM BLOOD calTIBC-205* Ferritn-173 TRF-158* [**2158-1-12**] 04:55AM BLOOD %HbA1c-7.1* [Hgb]-DONE [A1c]-DONE [**2158-1-10**] 09:31AM BLOOD TSH-1.7 [**2158-1-18**] 02:35PM BLOOD PTH-88* [**2158-1-13**] 11:27AM BLOOD ANCA-NEGATIVE B [**2158-1-13**] 11:27AM BLOOD [**Doctor First Name **]-NEGATIVE . RADIOLOGY [**Last Name (un) **] US [**2158-1-9**] Cholelithiasis without evidence of acute cholecystitis. . CXR [**2158-1-9**] 1. New, patchy increased parenchymal opacities localizing to both lower lobe consistent with pneumonia. 2. Bilateral pleural effusions. Mild left ventricular heart failure . CXR [**2158-1-26**] 1. Persistent consolidation, right base. 2. No overt failure. . ECHO [**2158-1-13**] 1. The left atrium is moderately dilated. The right atrium is moderately dilated. 2. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 3. The aortic valve leaflets are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. 4. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-9**]+) mitral regurgitation is seen. 5. There is moderate pulmonary artery systolic hypertension. 6. Compared with the findings of the prior study (images reviewed) of [**2157-2-28**], LV function and pulmonary hypertension are worse. . Brief Hospital Course: Mr. [**Known lastname 11202**] is an 85yo Man with CAD s/p BIV pacer and ICD, CHF (EF 20%), COPD, who initially presented to the hospital on [**1-9**] with abdominal pain and was found to have LLL pneumonia. He was admitted to the floor but was initially transferred to the unit on [**2158-1-9**] for O2 desats. The MICU team felt he had severe volume overload, decompensated CHF and hypoxia which improved with diuresis shortly after arrival. He was also started on solumedrol to treat potential COPD exacerbation as well and by the following AM was feeling quite better and satting 96% on 5L NC. All were attributed to underlying pna in LLL treated with levofloxacin/vancomycin for presumed CAP vs MRSA. On night of [**1-10**], he had 1.5 min of VT on tele, while asymptomatic and hemodynamically stable. He was seen by EP who had his outpatient dose of amiodarone restarted. EP eval confirmed VT on interogattion of ICD. On [**1-11**] Cr noted to be 3.0 up from 2.6 felt to be [**2-9**] over diuresis. He was transferred to the floor on evening of [**2158-1-12**]. On [**2158-1-12**] he was again transferred to the MICU from the floor s/p flash pulmonary edema requiring NRB mask. Patient was diuresed with Lasix drip. He required bipap intermittently in the unit for desaturations. . Pt returned to the medicine floor [**1-16**] but was again transferred to the ICU on [**1-17**] for hypotension (70s/40s), thought to be due to possible overdiuresis and while on multiple antihypertensives. Pt's antihypertensives were held and was placed on Levophed for one day for BP support, but his BP has remained stable since then and he tolerated reinitiation of Bblocker, hydral, and nitrates. During his hypotensive episode, pt was empirically given stress dose steroids, which were then switched to prednisone taper (also for COPD exacerbation). He was also desaturating from 90s on RA to 95% on shovel mask. He failed speech and swallow eval, and was treated for aspiration pneumonia. He had an NGT placed and started tube feeds ice, as he was found to aspirate these as well during swallow eval. . The pt was transferred out of the unit on [**2158-1-20**]. He has since been steadily improving. Below is a summary of his subsequent hospitalization. . # ID: Pt had a LLL PNA on CXR. He completed a 14 day course of Levo/Vanco on [**2158-1-23**] and 14 day course of flagyl on [**2158-1-31**]. His hypoxia improved markedly over the ten days prior to his discharge. He maintained O2sat>92% on RA for the week prior to discharge. . # CHF: The pt was initially decompensated on admission but was successfully diuresed. He was followed by the renal service. An echo performed on [**2158-1-13**] revealed an EF of 20%. His fluid goal was 300-500cc negative and furosemide was adjusted on a daily basis. In the week prior to discharge, the pt was maintained on furosemide 80mg IV bid. On the day prior to discharge, the pt was started on furosemide 80mg po bid and was found to be more overloaded. As a result, he was switched to furosemide 120mg po bid. Aggressive overdiuresis in this patient should be avoided given his propensity to go into pre-renal failure. At the same time, given his poor ejection fraction, holding diurectics should be done with caution given his recent history of flash pulmonary edema. . # Renal failure: This was thought to be acute on chronic. This was thought to be secondary to poor cardiac output and CHF exacerbation leading to hypoperfusion. In the week prior to discharge, the pt's creatinine markedly improved to his baseline of ~2.5. On the day prior to discharge, his creatinine was 2.1. . # Hypotension: The patient did not have any issues with hypotension after he was transferred to the floor. As he had received stress dose steroids during his hypotensive episode, he was started on prednisone taper of prednisone 30mg for 5 days, 20mg for 3 days, then 10mg 3 days, then 5mg for 3 days. . # h/o Ventric Tachycardia: Episodes of Vtach occurred in setting of decompensated CHF, likely secondary to some demand ischemia, but ruled out for MI. He was continued on amiodarone at 100mg Qday, lytes were kept at K >4.5, Mg >2.5 and theophylline was discontinued. His primary cardiologist, Dr. [**Last Name (STitle) **] can determine if theophylline could be restarted as outpatient. . # CAD: Pt was ruled out for MI during this hospitalisation on various occasions. He continued on nitrate, betablocker, ASA, lipitor, plavix. He might benefit from [**First Name8 (NamePattern2) **] [**Last Name (un) **] in the future. This should be considered as an outpatient. . # Hypernatremia: In the week prior to discharge, the patient had hypernatremia up to Na=153. The pt tolerated 2l of D5W at 100cc/hour for 4-5 days. Two days prior to discharge, the pt's sodium was 151 and he received 2.4l of D5W. This brought his sodium down to 146. The pt should be encouraged to drink water. His electrolytes should be checked regularly. . # Anemia - New iron deficiency anemia has been present as of [**7-12**] with concurrent long-stanging severe microcytosis. This is most consistent with thalassemia with exacerbation due to new iron deficiency. The pt should be seen as an outpatient for colorectal cancer evaluation per PCP [**Name Initial (PRE) 8469**]. . # Hyperglycemia: The patient was started on Lantus in the setting of persistent hyperglycemia and HbA1c of 7.0. He was started on Lantus 60u at lunch but this had to be halved in the week prior to discharge due to decreased food intake. This may need to be adjusted as his oral intake improves. He should continue on ISS humalog with goal BS 80-120. . # Thrombocytosis: This was likely secondary to acute infection. This resolved, . # h/o recent Hematuria: The pt had some gross hematuria after introduction of Foley. this was thought to be secondary to Foley trauma and no further work-up was initiated. This should be followed up as an outpatient if this recurs. . # PPX: He received PPI, bowel meds, SQ hep, pain regimen, fall precautions . # FEN: regular diet . # FULL code . Medications on Admission: Isosorbide 20 mg TID Amiodarone 100 mg daily Plavix 75 mg Hydralazine 25 mg TID ASA 325 mg Lipitor 40 mg Lasix 120 mg qam, 80 mg qhs (?80 [**Hospital1 **]) Minocycline 100 mg Protonix 40 mg Toprol 25 mg Theophylline 100 mg TID Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Pneumonia Congestive Heart failure Acute Renal failure Type II diabetes Discharge Condition: Stable Discharge Instructions: worsening shortness of breath, abdominal pain or increase in your lower extremity edema. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 6680**] [**Telephone/Fax (1) 608**]. She will see you at [**Hospital3 537**]. . You should follow-up with Dr. [**Last Name (STitle) 1860**] (nephrologist) [**Telephone/Fax (1) 60**] . You should follow-up with Dr. [**Last Name (STitle) **] (cardiologist) [**Telephone/Fax (1) 7332**] . Completed by:[**2158-2-1**]

[ "250.00", "491.21", "276.0", "518.81", "428.0", "427.1", "507.0", "584.9", "585.9", "276.51" ]

icd9cm

[ [ [] ] ]

[ "93.90", "38.93" ]

icd9pcs

[ [ [] ] ]

13324, 13395

6982, 13046

238, 296

13511, 13520

2641, 6959

13658, 14022

1922, 1937

13416, 13490

13072, 13301

13544, 13635

1952, 2622

184, 200

324, 1094

1116, 1791

1807, 1906

65,556

167,905

38077

Discharge summary

report

Admission Date: [**2116-6-8**] Discharge Date: [**2116-6-20**] Date of Birth: [**2056-3-1**] Sex: M Service: MEDICINE Allergies: Lyrica / Lipitor Attending:[**First Name3 (LF) 6565**] Chief Complaint: pancreatic cancer, with liver mets Major Surgical or Invasive Procedure: None History of Present Illness: 60yoM with h/o DM2, ? CHF, EtOH/polysubstance abuse, homeless, bipolar d/o who is transferred to OMED service from General Surgery for further management of metastatic pancreatic cancer. . He was admitted to OSH [**2116-5-29**] for treatment of polysubstance abuse who developed RUQ pain in setting of elevated LFT's. RUQ U/S showing CBD dilated to 1.6 cm with sludge. ERCP was attempted on [**6-2**] but team was unable to cannulate the ampulla. Patient was referred to [**Hospital1 18**] where Dr. [**Last Name (STitle) **] successfully performed ERCP finding a single tight stricture that was 25 mm long was seen at the lower third of the common bile duct. Brushings were taken and a 5cm 10FR Cotton [**Doctor Last Name **] pancreatic stent placed, and sphincterotomy was performed, which helped relieve some of his pain. Cytology of brushings revealed highly atypical glandular cells suspicious for adenocarcinoma. Original plan was for a whipple procedure but pt then had CTA abdomen which showed some small liver lesions and lung nodules, likely metastatic, and so now no longer a surgical candidate. There was also a plan for u/s guided liver Bx, and pt had liver u/s showing several tiny right lobe nodules consistent with metastatic disease, but unable to safely localize for biopsy. . Of note, CEA was 4.9 (0-4) and CA [**25**]-9 was 2268. . Therefore, he is transferred to OMED for further management including ? Gemcitabine discussed by the Heme Onc fellow, possible comfort focused care. Palliative care has been consulted. . Review of systems: Per HPI, otherwise he states he has lost about 10 lbs in the past few days (?), is having epigastric abdominal pain, and increased twitching of his arms and legs that has only started in the past couple days. Otherwise, no f/c/ns, no vision changes, no SOB/CP/orthopnea/PND. He states his BLE's aren't swollen although they look edematous. No n/v/d/c/BM changes, no dysuria. Past Medical History: DM2--was taking Glipizde before admission CHF--was told he has CHF after his legs got swollen and he had orthopnea, but doesn't know what underlying process is responsible. MRSA osteomyelitis R hip polysubstance abuse bipolar disord s/p R hip replacement and R femur surgery L great toe amputation--stepped on a nail and eventually had toe amp cystgastrostomy ([**2081**]) The pt was told 1.5 years ago that may have pancreatic cancer and left without further followup. Social History: Homeless x2 yrs after death of daughter [**2114**] and wife threw him out, then began abusing alcohol, benzodiazepines, crystal meth. Denies alcohol use since [**2116-3-2**]. Smokes a few cigarettes daily. Estranged from 3 sons, but one son and sister are present at hospital today. Family History: Mother: died at 53 from unknown cancer, father died at 51 Physical Exam: 98.3 146/70 68 16 Dipping to high 80's on RA --> 98% 2L Appears drowsy but is conversational, eyelids half shut. States he hasn't slept well for days since admission. No distress, no accessory muscle use, pleasant, conversant. Slightly jaundiced but sclera not overtly icteric. He has random twitching motions of his upper extremities. PERRLA, EOMI, mouth very dry appearing Jugular pulsations noted at 4-5cm below ear at 30 degrees Bilateral wet sounding crackles up to mid lung field bilaterally, poor air movement overall RRR with early peaking systolic murmur at BUSB's. Normal radial and DP's appreciated Abd obese but not distended or tight, tenderness to deep palpation epigastric and RUQ, otherwise not tender BLE with pitting edema to the mid shin. L great toe is amputated and 2nd L toe is malformed. CN 2-12 intact with no facial droop or dysarhtria. Spontaneously moving all four extremities. Appears tired but still conversant. Pertinent Results: [**2116-6-19**] 07:35AM BLOOD WBC-9.1 RBC-3.28* Hgb-9.7* Hct-30.4* MCV-93 MCH-29.7 MCHC-32.1 RDW-14.9 Plt Ct-197 [**2116-6-18**] 06:35AM BLOOD WBC-9.6 RBC-3.49* Hgb-10.0* Hct-32.3* MCV-93 MCH-28.6 MCHC-30.9* RDW-14.6 Plt Ct-198 [**2116-6-17**] 07:05AM BLOOD WBC-9.8 RBC-3.54* Hgb-10.4* Hct-33.5* MCV-95 MCH-29.4 MCHC-31.0 RDW-14.7 Plt Ct-227 [**2116-6-16**] 06:35AM BLOOD WBC-11.0 RBC-3.57* Hgb-10.3* Hct-33.3* MCV-93 MCH-28.8 MCHC-30.9* RDW-14.5 Plt Ct-238 [**2116-6-15**] 05:06AM BLOOD WBC-18.4*# RBC-3.56* Hgb-10.6* Hct-32.6* MCV-92 MCH-29.8 MCHC-32.4 RDW-14.6 Plt Ct-269 [**2116-6-14**] 03:56AM BLOOD WBC-10.8 RBC-3.31* Hgb-9.9* Hct-30.2* MCV-91 MCH-29.9 MCHC-32.6 RDW-14.6 Plt Ct-220 [**2116-6-13**] 05:55PM BLOOD WBC-10.5 RBC-3.15* Hgb-9.3* Hct-28.9* MCV-92 MCH-29.4 MCHC-32.1 RDW-14.3 Plt Ct-229 [**2116-6-13**] 06:45AM BLOOD WBC-11.8*# RBC-3.22* Hgb-9.6* Hct-29.6* MCV-92 MCH-29.7 MCHC-32.3 RDW-14.4 Plt Ct-268 [**2116-6-12**] 06:05AM BLOOD WBC-7.6 RBC-3.23* Hgb-9.7* Hct-29.6* MCV-92 MCH-30.0 MCHC-32.7 RDW-14.3 Plt Ct-248 [**2116-6-11**] 05:50AM BLOOD WBC-6.6 RBC-3.23* Hgb-9.9* Hct-29.0* MCV-90 MCH-30.6 MCHC-34.0 RDW-14.8 Plt Ct-216 [**2116-6-10**] 06:15AM BLOOD WBC-5.8 RBC-3.17* Hgb-9.7* Hct-28.8* MCV-91 MCH-30.7 MCHC-33.8 RDW-14.3 Plt Ct-192 [**2116-6-9**] 01:27AM BLOOD WBC-7.5 RBC-3.06* Hgb-9.1* Hct-27.4* MCV-89 MCH-29.7 MCHC-33.3 RDW-14.3 Plt Ct-210 [**2116-6-13**] 05:55PM BLOOD Neuts-81.2* Lymphs-11.4* Monos-5.2 Eos-2.0 Baso-0.2 [**2116-6-9**] 01:27AM BLOOD Neuts-64.7 Lymphs-27.0 Monos-4.2 Eos-3.8 Baso-0.3 [**2116-6-17**] 07:05AM BLOOD PT-14.6* PTT-24.4 INR(PT)-1.3* [**2116-6-19**] 07:35AM BLOOD Glucose-202* UreaN-34* Creat-1.1 Na-144 K-3.4 Cl-102 HCO3-31 AnGap-14 [**2116-6-18**] 06:35AM BLOOD Glucose-201* UreaN-39* Creat-1.0 Na-141 K-3.3 Cl-101 HCO3-29 AnGap-14 [**2116-6-17**] 07:05AM BLOOD Glucose-176* UreaN-42* Creat-1.2 Na-138 K-4.3 Cl-97 HCO3-34* AnGap-11 [**2116-6-16**] 06:35AM BLOOD Glucose-188* UreaN-34* Creat-1.1 Na-140 K-3.7 Cl-101 HCO3-31 AnGap-12 [**2116-6-15**] 05:06AM BLOOD Glucose-164* UreaN-27* Creat-1.3* Na-138 K-4.0 Cl-98 HCO3-30 AnGap-14 [**2116-6-14**] 03:56AM BLOOD Glucose-193* UreaN-25* Creat-1.7* Na-138 K-4.1 Cl-101 HCO3-31 AnGap-10 [**2116-6-13**] 05:55PM BLOOD Glucose-139* UreaN-25* Creat-1.8* Na-140 K-4.2 Cl-100 HCO3-28 AnGap-16 [**2116-6-13**] 06:45AM BLOOD Glucose-195* UreaN-23* Creat-1.9* Na-138 K-4.2 Cl-96 HCO3-32 AnGap-14 [**2116-6-12**] 06:05AM BLOOD Glucose-141* UreaN-19 Creat-1.5* Na-142 K-3.8 Cl-100 HCO3-34* AnGap-12 [**2116-6-19**] 07:35AM BLOOD ALT-38 AST-58* LD(LDH)-305* AlkPhos-297* TotBili-2.9* [**2116-6-18**] 06:35AM BLOOD ALT-41* AST-67* AlkPhos-313* TotBili-3.6* [**2116-6-17**] 07:05AM BLOOD ALT-47* AST-101* LD(LDH)-346* AlkPhos-320* TotBili-4.3* [**2116-6-16**] 06:35AM BLOOD ALT-30 AST-83* LD(LDH)-311* AlkPhos-246* TotBili-5.1* [**2116-6-15**] 05:06AM BLOOD ALT-34 AST-61* AlkPhos-286* TotBili-8.2* [**2116-6-14**] 03:56AM BLOOD ALT-41* AST-72* AlkPhos-256* TotBili-6.4* [**2116-6-11**] 05:50AM BLOOD Lipase-8 [**2116-6-10**] 06:15AM BLOOD Lipase-7 [**2116-6-9**] 01:27AM BLOOD Lipase-5 [**2116-6-19**] 07:35AM BLOOD Calcium-8.2* Phos-2.4* Mg-2.0 [**2116-6-18**] 06:35AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1 [**2116-6-17**] 07:05AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.3 [**2116-6-16**] 06:35AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1 [**2116-6-9**] 01:27AM BLOOD Triglyc-80 [**2116-6-9**] 01:27AM BLOOD TSH-1.2 [**2116-6-9**] 01:27AM BLOOD CEA-4.9* [**2116-6-13**] 03:51PM BLOOD Type-ART pO2-67* pCO2-53* pH-7.41 calTCO2-35* Base XS-6 [**2116-6-13**] 01:32PM BLOOD Type-ART pO2-81* pCO2-57* pH-7.38 calTCO2-35* Base XS-6 [**2116-6-13**] 08:26PM URINE Color-[**Location (un) **] Appear-Hazy Sp [**Last Name (un) **]-1.017 [**2116-6-13**] 08:26PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-8* pH-5.5 Leuks-NEG [**2116-6-13**] 08:26PM URINE RBC-<1 WBC-25* Bacteri-NONE Yeast-NONE Epi-0 TransE-2 [**2116-6-13**] 8:26 pm URINE Site: CLEAN CATCH **FINAL REPORT [**2116-6-15**]** URINE CULTURE (Final [**2116-6-15**]): NO GROWTH. echo The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. CT ABD PELVIS IMPRESSION: 1. Ill-defined hypodense mass in the pancreatic head and uncinate process, that is difficult to discretely measure but a rough estimate would be 2.8 cm. There is associated marked porta hepatis, retroperitoneal, and mesenteric lymphadenopathy as well as numerous hypodense liver lesions, pulmonary nodules, and pleural-based nodules. Constellation of findings are highly suspicious for pancreatic adenocarcinoma with metastatic disease. Note that there is no evidence of vascular involvement from the primary mass. 2. Pancreatic head calcifications consistent with chronic pancreatitis as well as marked atrophy of the pancreatic body and tail which are related to chronic pancreatitis or chronic obstruction from the mass. 3. Small left greater than right pleural effusions. 4. Duodenal lipoma. RUQ US CONCLUSION: Several tiny right lobe nodules consistent with metastatic disease, but unable to be successfully localized for safe ultrasound-guided biopsy. If clinically necessary, repeat feasibility ultrasound is recommended in approximately four weeks, at which time targeting may be more safe and feasible for biopsy. CXR FINDINGS: As compared to the previous radiograph, the pre-existing interstitial opacities in both lungs have increased in extent. The simultaneous visualization of small Kerley B lines suggest interstitial fluid overload. No larger pleural effusions are visible. Mild cardiomegaly. Brief Hospital Course: 60yoM with h/o DM2, CHF?, bipolar d/o, substance abuse and homeless; with newly diagnosed metastatic pancreatic cancer. . Pt was admitted from Surgery to OMED where he was admitted for transaminitis and RUQ pain and found to have metastatic pancreatic cancer, not candidate for Whipple. He was admitted for dispo/hospice. He developed obtundation and hypoxia and spent some time in the [**Hospital Unit Name 153**]. Likely due to too much pain medication, however aspiration also considered and pt covered broadly with Vanc/Zosyn. PE also considered so pt started on Lovenox but goals of care at this point were comfort and pt did not get CTA. In [**Name (NI) 153**] pt noted to be consistently hypoxic in the 80's on non rebreather mask. Given clinical picture and goals of care being comfort, pt was called out to floor satting in the 80-90's on NRB, however when he took off the mask, noted to quickly desaturate to 60-70's, even as low as 30% noted, and get SOB. Therefore, he was dependent on the NRB. CXR showing diffuse interstitial infiltrates in all lung fields. It was explained to the pt that he was NRB dependent and if he took it off, he would pass away. . On [**2116-6-20**] pt was seen in am rounds not wearing his mask and not wanting to wear it. He appeared sleepy and using accessory muscles but did not appear in distress. He persistently denied any Morphine and repeatedly insisted "Leave me alone." He passed away at 10:40 am. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased [**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**] Completed by:[**2116-6-20**]

[ "197.0", "305.00", "197.7", "305.90", "V43.64", "799.02", "276.2", "428.0", "415.19", "157.0", "250.02", "428.32", "V60.0", "296.80", "E935.2", "584.9", "V66.7", "507.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11779, 11788

10278, 11727

310, 316

11840, 11850

4134, 10255

11907, 12072

3090, 3149

11750, 11756

11809, 11819

11874, 11884

3164, 4115

1903, 2280

236, 272

344, 1884

2302, 2774

2790, 3074

14,416

179,576

10453

Discharge summary

report

Admission Date: [**2162-1-7**] Discharge Date: [**2162-1-20**] Date of Birth: [**2107-9-8**] Sex: M Service: CA [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: This is a 54 -year-old gentleman with multiple medical problems, including diabetes, hypertension, hyperlipidemia, and peripheral vascular disease, status post bilateral femoral popliteal bypasses, presenting with unstable angina and increased shortness of breath. Cardiac catheterization showed three vessel disease and an ejection fraction was moderately depressed. The patient was admitted to the Medical service and referred to Cardiac Surgery for surgical revascularization. PAST MEDICAL HISTORY: Coronary artery disease, status post percutaneous transluminal coronary angioplasty times one, peripheral vascular disease, status post bilateral femoral popliteal bypasses, hypertension, hyperlipidemia, peripheral neuropathy, diabetes insulin dependent. ADMITTING MEDICATIONS: Include Lipitor 20 mg q HS, Actos 45 mg a day, Celebrex 200 mg a day, Neurontin 300 mg a day, Atenolol 25 mg a day, Monopril 20 mg a day, and NPH 90 units subcutaneous q AM and 60 units subcutaneous q PM. Ciprofloxacin and clindamycin started during his medical admission. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: On admission, alert and oriented male in no acute distress. Head and neck examination is unremarkable. Cardiovascular examination: regular rate and rhythm without murmurs. Lungs were clear to auscultation bilaterally. Extremity examination was significant for bilateral healed femoral popliteal incisions. In the left lower extremity there is a demarcated area of erythema and edema / induration. There were no palpable distal pulses and the patient had pain in the left shoulder upon abduction. The abdomen was mildly distended, but soft and nontender. ADMISSION LABORATORY DATA: White count on admission was 7.6, hematocrit 26, platelets 288,000. HOSPITAL COURSE: Prior to surgery, the patient was seen by Dermatology for his left lower extremity edema and erythema. Diagnosis of elephantiasis nostra verrucosa. Treatment was topical MetroGel to affected area [**Hospital1 **]. The patient also had an area of erythema on his right pretibial area which was diagnosed as necrobiosis lipoidica diabeticorum. This was just followed with plan for treatment on an outpatient basis. Infectious Disease was consulted and they placed the patient on clindamycin and ciprofloxacin for his presumed left lower extremity cellulitis. Th[**Last Name (STitle) 1050**] was brought to the Operating Room on [**2162-1-11**] for coronary artery bypass graft times three by Dr. [**Last Name (Prefixes) **]. The patient tolerated the procedure well and there were no complications. The patient was transferred to the Cardiac Intensive Care Unit postoperatively for hemodynamic monitoring. He remained hemodynamically stable and afebrile, was extubated on postoperative day zero. The patient was transferred to the floor on postoperative day one and he did well. Chest tube, pacing wires, central line, and Foley catheter were removed without any problems. The patient worked with Physical Therapy and was able to achieve level 5 ambulation. The patient's postoperative course was complicated only by sternal drainage which he developed several days after surgery. The patient's white count remained normal and he remained afebrile throughout the postoperative course. Cultures were sent of the fluid which had no organisms on gram stain and culture showed only sparse growth of gram positive cocci, believed to be contaminant from the skin. The skin remained healthy appearing and the sternum remained stable. The patient was watched several extra days at the hospital for this sternal drainage and he remained without any sign of infection. [**Last Name (un) **] Diabetes service was consulted to manage his insulin regimen. Finally, on postoperative day nine, the patient was felt to be safe to go home with a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 11197**] the wound on a daily basis with dressing changes. DISPOSITION: The patient was discharged on [**2162-1-20**]. He had completed his course of ciprofloxacin and clindamycin as per Infectious Disease for a complete two week course. DISCHARGE MEDICATIONS: Include Lopressor 100 mg po bid, NPH insulin 100 units subcutaneous q AM, 50 units subcutaneous q HS, Lasix 20 mg po q day times seven days, potassium chloride 20 mEq po q day times seven days, aspirin 81 mg po q day, Percocet one to two tablets po q four to six hours prn, Colace 100 mg po bid, Zantac 150 mg po bid, Actos 45 mg po q day, and Lipitor 20 mg po q HS, MetroGel 1% [**Hospital1 **] to left lower extremity. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass graft times three. 2. Left lower extremity cellulitis. DISCHARGE STATUS: The patient was discharged home with [**Hospital6 407**] services as previously mentioned. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 33441**] MEDQUIST36 D: [**2162-1-20**] 10:10 T: [**2162-1-20**] 10:21 JOB#: [**Job Number 34542**]

[ "250.82", "401.9", "272.4", "710.1", "428.0", "414.01", "457.1", "411.1", "709.3" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "88.56", "88.53", "37.23", "36.12" ]

icd9pcs

[ [ [] ] ]

4814, 4823

4844, 5339

4370, 4792

1999, 4346

1323, 1981

186, 669

692, 1300

80,160

180,496

6445

Discharge summary

report

Admission Date: [**2112-7-27**] Discharge Date: [**2112-8-5**] Date of Birth: [**2078-4-25**] Sex: F Service: NEUROSURGERY Allergies: Percocet / Statins-Hmg-Coa Reductase Inhibitors / Dilaudid / silk tape / Dicloxacillin / lactose Attending:[**First Name3 (LF) 5084**] Chief Complaint: Infection of Baclofen pump Major Surgical or Invasive Procedure: I+D L-Spine, removal IT baclofen pump and catheter on [**2112-7-27**]. History of Present Illness: [**Known firstname **] [**Known lastname 24791**] is a 34 y/o female previously seen by Dr. [**Last Name (STitle) **] in the neurosurgery clinic on [**2112-7-25**] with c/o drainage from the incision site. She was accompanied by her husband and friend. She was previously seen by Dr. [**Last Name (STitle) **] at [**Hospital3 2358**] and treated for presumptive meningitis although there was no obvious infection of the intrathecal baclofen pump at that time. She has done well since then and still looks good today, but had some drainage yesterday apparently with some cloudy, reddish brown material that oozed out of an opening in her back. There was some serous fluid very lightly in and around some area where maybe there was an opening, but could not express anything she was afebrile. The abdominal part of the pump looks perfectly fine. There is a little bit of erythema near the area in her back possibly from pushing or pressure or placing a dressing there. It does not look obviously infected. She underwent a CT scan of the lumbar area which showed a superficial collection, approximately 1 to 1.5 cm below the surface of the skin and dermis layers as well as above the fascial layer. It is about 6 x 5 x 2-3 cm in size. She underwent a CT-guided needle biopsy which has been finalized as sparse growth of methicillin resistant staph aureus. She presents for an I & D and removal of baclofen pump hardware and tubing. Past Medical History: multiple sclerosis, relapsing-remitting- diagnosed [**2096**] Social History: Pt. is a nurse. Denies tobacco and illicits. Weekend EtOH in moderation. Family History: No FH of MS. Physical Exam: awake,a+ox3 PERRL, EOMI face symmetric, tongue midline moves UE's with full strengths left lower extremity in cast right lower extremity 0/5 back incision- dsg c/d/i abdomen- sutures c/d/i Pertinent Results: [**7-29**] CXR: IMPRESSION: Left PICC terminates in the left brachiocephalic vein just short of the SVC origin and needs to be advanced. [**8-3**] LENS Bilateral lower extremity examinations negative for DVT. [**8-5**] CXR: PICC line terminated in RA. final read pending Brief Hospital Course: Ms. [**Known lastname 24791**] was admitted to [**Hospital1 18**] and was taken to the OR with Dr. [**Last Name (STitle) **]. The lumbar wound was explored, washed out and hardware was completely removed. She was taken to the ICU post operatively for baclofen withdrawal monitoring. She was started on PO baclofen (10mg), prednisone taper and was given ativan prn. ID was consulted and she was started on vancomycin. On [**7-28**] she complained of pain and spasms but was neurologically stable. Her ativan dose was increased. On [**7-29**] her vanco level was noted to be 9.9 so ID recommended increasing her dose to 1500mg [**Hospital1 **]. On [**7-30**] she was again neurologically stable but complained of spasms in her LE's. Her PO baclofen was increased to 20mg. On [**8-1**] the patient reported improved muscle spasms. She was requiring significantly less ativan for spasticity so she was transferred out to the step down unit. On [**8-2**] Baclofen dose was increased to 30mg QID. Prednisone was tapered to 30mg x 3 days. She was started on Fluconazole for a yeast infection and Nystatin for thrush. Valium currently 15mg PO Q4 hours prn muscle spasm. On [**8-3**] Valium tapered to 10mg PO every four hours with Valium 5mg PO every four hours as needed for muscle spasm. LENS negative. On [**8-4**] she was neurologically stable but continues with complaints of muscle spasms. She has been well maintained on Valium 10mg Q4 hours with an additional 5mg as needed. She worked with physical therapy who determined she could be discharged to home with PT services. On [**8-5**] the patient agreed to discharge home. Medications on Admission: Xanax 1 mg tablet - one to two Tablet(s) by mouth as needed for anxiety. Baclofen intra-thecal 725mcg QD (Not Taking as Prescribed: pt states she takes 500mcg intrathecal daily prn.) - Dosage uncertain. Citalopram 20 mg tablet 1 [**12-28**] Tablet(s) by mouth at bedtime. Vitamin B 1,000 mcg/mL Solution - Inject 1cc monthly Bentyl dosage unknown. One tablet by mouth daily. Vitamin D Dose unknown one tablet by mouth daily. Furosemide 40mg one tablet by mouth daily take 3 hours after waking for lower extremity edema. Dicyclomine 20mg by mouth every 6 hours. Oxybutynin 5mg by mouth three times daily. Ibuprofen 800mg by mouth three times daily prn. Metoprolol 50mg by mouth daily. Imipramine 20mg by mouth every night. Rituximab (twice yearly. Solumedrol (twice yearly). Provigil 200mg by mouth daily. Junel 1.5/30 one tablet by mouth daily. Gentamicin 40mg/mL solution. Mix 240mg gentamycin in 500 mL sterile saline for intravesical use. Levothyroxine 100mcg by mouth daily. Prednisone dose and frequency unknown. Discharge Medications: 1. Artificial Tears 1-2 DROP BOTH EYES PRN dryness 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Citalopram 40 mg PO DAILY Home med 4. Diazepam 10 mg PO Q4H RX *diazepam 10 mg 1 ttablet by mouth q4hr Disp #*90 Tablet Refills:*0 5. DiCYCLOmine 20 mg PO QID 6. Docusate Sodium 100 mg PO BID 7. Fluconazole 200 mg PO Q24H 8. Furosemide 40 mg PO DAILY 9. 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. RX *Heparin Lock 10 unit/mL Per PICC care daily Disp #*30 Syringe Refills:*0 10. Hydrocodone-Acetaminophen (5mg-500mg [**12-28**] TAB PO Q6H:PRN pain RX *hydrocodone-acetaminophen 5 mg-500 mg [**12-28**] tablet(s) by mouth q4hr Disp #*60 Tablet Refills:*0 11. Imipramine 20 mg PO HS 12. Lactaid *NF* (lactase) 2 tabs Oral prn dairy Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 13. Levothyroxine Sodium 100 mcg PO DAILY 14. Metoprolol Succinate XL 50 mg PO DAILY 15. Nystatin Oral Suspension 5 mL PO QID:PRN thrush RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day Disp #*1 Bottle Refills:*0 16. Oxybutynin 5 mg PO TID 17. PredniSONE 20 mg PO DAILY 20mg [**8-5**], [**8-6**], [**8-7**]. 10mg x3 days. 5mg x3 days. 2.5mg x3 days. 1mg x3 days then d/c Tapered dose - DOWN RX *prednisone 5 mg 4 tablet(s) by mouth daily Disp #*19 Tablet Refills:*0 18. Provigil *NF* (modafinil) 200 mg Oral Daily Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 19. Ranitidine 150 mg PO DAILY RX *ranitidine HCl 150 mg 1 tablet(s) by mouth daily Disp #*45 Tablet Refills:*0 20. Senna 1 TAB PO BID:PRN constipation 21. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 22. Vancomycin 1500 mg IV Q 12H RX *vancomycin 500 mg infuse into picc Q12hr Disp #*38 Packet Refills:*0 23. ZYRtec *NF* 10 mg Oral daily Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 24. Outpatient Lab Work Qweekly Serum CBC w/ diff, Chem7, ESR, CRP, LFTs, vancomycin level. Please fax results to [**Hospital **] clinic [**Telephone/Fax (1) 1419**]. 25. Baclofen 40 mg PO QAM RX *baclofen 20 mg 2 tablet(s) by mouth QAM Disp #*20 Tablet Refills:*0 26. Baclofen 40 mg PO QHS RX *baclofen 20 mg 2 tablet(s) by mouth at bedtime Disp #*14 Tablet Refills:*0 27. Baclofen 30 mg PO BID Please give 40mg Qam and Qhs, then 30mg [**Hospital1 **] in between RX *baclofen 10 mg 3 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 28. Diazepam 5 mg PO Q4H:PRN spasm RX *diazepam 5 mg 1 tablet by mouth q4hrs Disp #*20 Tablet Refills:*0 29. Junel 1.5/30 (21) *NF* (norethindrone ac-eth estradiol) 1.5-30 mg-mcg Oral Daily Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 30. PredniSONE 1 mg PO DAILY Duration: 3 Days start after 2.5mg dose Tapered dose - DOWN RX *prednisone 1 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Baclofen pump infection. Yeast Infection Spastic Paralysis 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: ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 10.5?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow Up Instructions/Appointments ??????Please return to the office in 14 days (from date of surgery) for removal of your sutures. This appointment can be made with the Physician Assistant or [**Name9 (PRE) **] Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ?????? You should call Dr. [**Last Name (STitle) **]. [**Last Name (un) 24792**] at ([**Telephone/Fax (1) 24793**] in a month or 2 to dicuss any future need for phenol or botox injections. ?????? You should call your Neurologist, Dr. [**Last Name (STitle) 8760**] with any medication questions. ?????? Qweekly Serum CBC w/ diff, Chem7, ESR, CRP, LFTs, vancomycin level. Please fax results to [**Hospital **] clinic [**Telephone/Fax (1) 1419**]. ?????? You will need to have an MRI of your lumbar spine prior to your appointment with Infectious Disease. Please call the [**Hospital **] clinic to schedule an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**] and to schedule the MRI. Completed by:[**2112-8-5**]

[ "V85.35", "112.0", "340", "V15.88", "280.9", "564.1", "344.9", "369.4", "996.63", "401.9", "V58.69", "341.0", "E878.1", "278.00", "344.1", "530.81", "041.12", "292.0", "112.1", "443.9", "V13.02", "288.60", "V15.51", "244.9" ]

icd9cm

[ [ [] ] ]

[ "03.98", "86.05", "38.93", "86.07", "38.97" ]

icd9pcs

[ [ [] ] ]

8710, 8762

2655, 4286

387, 459

8865, 8865

2356, 2632

9909, 11089

2118, 2132

5358, 8687

8783, 8844

4312, 5335

9041, 9886

2147, 2337

321, 349

487, 1925

8880, 9017

1947, 2011

2027, 2102

15,977

107,856

46426

Discharge summary

report

Admission Date: [**2183-6-11**] Discharge Date: [**2183-7-1**] Date of Birth: [**2128-1-12**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfonamides Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion. Major Surgical or Invasive Procedure: [**2183-6-24**] - CABGx3 (Left internal mammary artery to left anterior descending artery, vein graft to posterior descending artery, vein graft to ramus) [**2183-6-11**] - Cardiac Catheterization History of Present Illness: Ms. [**Known lastname 449**] is a 55 year-old female with a history of diabetes, hypertension, hyperlipidemia and current tobacco use who presents with dyspnea and chest discomfort for cardiac cath. Recently admitted ([**2183-4-28**] - [**2183-5-2**]). At that time, she had complaints of SOB, cough and chest discomfort. A pneumonia was diagnosed. In addition, an echo was done and showed and LVEF of 40% with severe focal hypokinesis of the distal half of the septum and apex. Since that admission, she underwent stress testing which showed a reversible anterior wall and fixed apical defects. LVEF was noted to be 31%. Over the last two weeks, the patient notes worsening DOE and occasional exertional chest discomfort. She can recall one specific episode approximately 2 weeks ago when she had severe DOE during which she could not walk more than [**3-15**] steps without severe shortness of breath. She also noted "heart fluttering" during this time. That evening she felt exhausted and slept for the rest of the day. In addition to the above, the patient also reports nightly PND (wakes up hours after falling asleep). After waking, she will sit up and her symptoms improve. She used one pillow at night. She is being admitted for cardiac cath and possible PCI. Past Medical History: 1. Coronary artery disease: - Cardiac Risk Factors: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension, (+)Tobacco use 2. Diabetes mellitus: Diagnosed [**2170**] - Complicated by neuropathy - A1c ([**4-16**]) 10.4% 3. Hypertension 4. Hyperlipidemia - TC 267, LDL 184, HDL 71, TG 58 ([**4-16**]) - Statin started [**4-16**] 5. Hypothyroidism - TSH 8.7 ([**2-16**]) levothyroxine increased 150 --> 175mcg/day 6. Asthma 7. Depression 8. Hepatitis C: - Genotype 3a - Viral load 6,050,000 IU/mL ([**11-14**]) - Chronically elevated LFTs - Albumin 3.2, INR 1.1 ([**6-16**]) - Liver bx ([**3-/2175**]): Portal chronic inflammation with lymphoid nodule formation, interface hepatitis, increased fibrosis with early septa, lobular necroinflammation activity and patchy steatosis consistent with chronic hepatitis C, grade [**3-15**], Stage2. 9. Alcohol and substance abuse (history of) 10. Arthritis 11. Uterine fibroid, s/p Myomectomy 12. s/p removal of a benign tumor from the back 13. s/p ear surgery [**90**]. s/p resection of a benign cyst from the axilla Social History: Patient is single and lives alone. Her son [**Name (NI) **] [**Name (NI) 449**] will accompany her to the hospital. He can be reached on his cell at [**Telephone/Fax (1) 98624**] or at home: [**Telephone/Fax (1) 98625**]. Patient is followed by Caregroup VNA. She has a smoking history (currently 1 pack every other day); previously quit 5 years ago but restarted in [**2180**]. Previous history of alcohol and drug use; none for 16 years. She is not currently working, in part because she has bad peripheral neuropathy. Family History: No family history of cancer. No history of DM, HTN, hyperlipidemia. Physical Exam: Physical exam on admission [**2183-6-11**]: vitals - T 97.3, BP 127/50, HR 76, RR 16, 96% on 2 liters. gen - obese female, lying flat in no distress heent - no carotid bruits, no conjunctival palor, no icterus cv - rrr, no murmurs, rubs, gallops, no S3/S4 pulm - clear bilaterally, no wheeze abd - soft, non-tender, obese ext - warm, 1+ edema bilaterally pulses - 2+ femoral, DP/PT groin - no hematoma, bruit, midly TTP Discharge Vitals 97, 135/73, 80 SR, 18, 98% RA, wt 111 kg Neuro A/O x3 generalized weakness nonfocal Pulm CTA except decrease left base Cardiac RRR no murmur/rub/gallop Sternal incision healing no erythema no drainage Abd Soft, NT, ND, + BS BM [**7-1**] Ext warm pulses palpable edema +2 L > R, blisters rt lle Inc EVH left healing Pertinent Results: [**2183-6-30**] 08:03PM BLOOD WBC-12.6* RBC-3.27* Hgb-10.4* Hct-30.9* MCV-94 MCH-31.9 MCHC-33.8 RDW-14.6 Plt Ct-286 [**2183-6-25**] 03:40AM BLOOD WBC-22.6* RBC-3.17*# Hgb-10.2*# Hct-29.3* MCV-93 MCH-32.3* MCHC-34.9 RDW-15.6* Plt Ct-178 [**2183-6-11**] 07:50AM BLOOD WBC-13.8* RBC-4.21 Hgb-13.3 Hct-40.3 MCV-96 MCH-31.7 MCHC-33.1 RDW-14.3 Plt Ct-242 [**2183-6-19**] 04:56AM BLOOD Neuts-69.0 Lymphs-24.5 Monos-4.3 Eos-1.5 Baso-0.7 [**2183-6-30**] 08:03PM BLOOD Plt Ct-286 [**2183-6-28**] 04:50AM BLOOD PT-11.6 PTT-31.9 INR(PT)-1.0 [**2183-6-11**] 09:25AM BLOOD PT-12.5 PTT-37.4* INR(PT)-1.1 [**2183-6-11**] 07:50AM BLOOD Plt Ct-242 [**2183-6-30**] 08:03PM BLOOD Glucose-147* UreaN-16 Creat-0.9 Na-133 K-4.9 Cl-99 HCO3-25 AnGap-14 [**2183-6-11**] 09:25AM BLOOD Glucose-139* UreaN-18 Creat-0.8 Na-141 K-3.8 Cl-106 HCO3-26 AnGap-13 [**2183-6-25**] 09:13AM BLOOD ALT-61* AST-97* AlkPhos-97 Amylase-38 TotBili-0.6 [**2183-6-17**] 07:58AM BLOOD ALT-120* AST-122* LD(LDH)-375* CK(CPK)-219* AlkPhos-205* Amylase-50 TotBili-0.4 [**2183-6-28**] 04:50AM BLOOD Calcium-7.7* Phos-3.6 Mg-2.2 [**2183-6-14**] 07:35AM BLOOD calTIBC-335 Ferritn-219* TRF-258 [**2183-6-11**] 09:25AM BLOOD %HbA1c-7.9*# [**2183-6-11**] 09:25AM BLOOD Triglyc-94 HDL-58 CHOL/HD-2.5 LDLcalc-69 [**2183-6-14**] 07:35AM BLOOD Ammonia-111* [**2183-6-11**] 09:25AM BLOOD TSH-6.0* [**2183-6-14**] 07:35AM BLOOD AFP-5.6 RADIOLOGY Final Report CHEST (PA & LAT) [**2183-6-30**] 8:53 AM CHEST (PA & LAT) Reason: evaluate effusion [**Hospital 93**] MEDICAL CONDITION: 55 year old woman s/p cabg x3 REASON FOR THIS EXAMINATION: evaluate effusion HISTORY: 55-year-old woman status post CABG x3. COMPARISON: [**2183-6-26**]. CHEST, PA AND LATERAL: Cardiac, mediastinal, and hilar contours are stable status post median sternotomy and CABG. There is stable enlargement of cardiac silhouette. Pulmonary vasculature is unremarkable. The left hemidiaphragm appears elevated, however, there is an increased distance between this contour and the gastric bubble consistent with a subpulmonic effusion. This is moderate in size. A small right pleural effusion is also noted. There is associated left lower lobe atelectasis and right mid lung linear atelectasis. Osseous and soft structures are unchanged. IMPRESSION: Moderate left and small right pleural effusions which are larger than [**2183-6-26**]. Left effusion likely has subpulmonic component. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 5004**] THAM DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: MON [**2183-6-30**] 4:37 PM Cardiology Report ECG Study Date of [**2183-6-24**] 5:50:22 PM Sinus rhythm Delayed R wave progression - is nonspecific Nonspecific T wave abnormalities - cannot exclude in part ischemia - clinical correlation is suggested Since previous tracing of [**2183-6-20**], further ST-T wave changes present Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 77 154 76 [**Telephone/Fax (2) 98626**] 10 15 Cardiology Report ECHO Study Date of [**2183-6-24**] PATIENT/TEST INFORMATION: Indication: Abnormal ECG. Chest pain. Congestive heart failure. Coronary artery disease. Shortness of breath. Status: Inpatient Date/Time: [**2183-6-24**] at 12:57 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW 1-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **] MEASUREMENTS: Left Ventricle - Ejection Fraction: 35% to 39% (nl >=55%) Aorta - Valve Level: 2.4 cm (nl <= 3.6 cm) INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Depressed LAA emptying velocity (<0.2m/s) Cannot exclude LAA thrombus. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast in the body of the RA. 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 thicknesses and cavity size. Moderate regional LV systolic dysfunction. No LV mass/thrombus. Moderately depressed LVEF. Transmitral Doppler and TVI c/w Grade III/IV (severe) LV diastolic dysfunction. LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior - hypo; mid anteroseptal - hypo; anterior apex - hypo; septal apex - hypo; apex - hypo; RIGHT VENTRICLE: Mild global RV free wall hypokinesis. Focal apical hypokinesis of RV free wall. AORTA: Simple atheroma in ascending aorta. Simple atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. 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 received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The patient was under general anesthesia throughout the procedure. Conclusions: PRE-CPB: The left atrium is mildly dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). A left atrial appendage thrombus cannot be excluded. No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with anteroapical and antroseptal moderate hypokinesis.. There is mild hypokinesis of the remaining segments. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is moderately depressed. Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. There is mild global right ventricular free wall hypokinesis. There is focal hypokinesis of the apical free wall of the right ventricle. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. POST-CPB: On infusions of epinephrine, milrinone, phenylephrine. Improved biventricular systolic function on inotropic support. LVEF now 45%. Anteroapical and anteroseptal hypokinesis is improved. RV systolic function is normal with normal RV apical wall motion. MR is trace. AI is trace. Post decannulation contour of the aorta is preserved. LV diastolic function is improved post bypass on inotropes. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2183-6-24**] 16:05. [**Location (un) **] PHYSICIAN: Brief Hospital Course: Ms. [**Known lastname 449**] was admitted to the [**Hospital1 18**] on [**2183-6-11**] for a cardiac catheterization. This revealed left main and severe three vessel coronary artery disease. Heparin was started given her ulcerated left main disease. Given the severity of her disease, the cardiac surgical service was consulted for surgical revascularization. Ms. [**Known lastname 449**] was worked-up in the usual preoperative manner. A carotid duplex ultrasound was obtained which showed a 40-59% right internal carotid artery stenosis and a less than 40% left internal carotid artery stenosis. Given her history of hepatitis C, the hepatology service was consulted for assistance in her care. A liver biopsy was obtained which showed changes that were consistent with chronic viral hepatitis with grade 2 inflammation/activity and stage 3-4 fibrosis. She was classified as having Child's score A cirrhosis. Ms. [**Known lastname 449**] developed blood in her stool on heparin and a gastroenterology consult was obtained. An ultrasound of her abdomen was obtained which showed a coarse liver with no change in a hyperechoic lesion in the right lobe of liver which may represent a granuloma or a scar from previous trauma. A CT scan was obtained and showed no significant abnormalities or changes. A colonoscopy and upper endoscopy were performed which showed gastritis and diverticuli. A biopsy was obtained which showed an adenoma which will need to be addressed following her heart surgery. On [**2183-6-17**], Ms. [**Known lastname 449**] had an acute episode of pulmonary edema requiring intubation and diuresis. She was successfully extubated the following day. Haldol was used for aggitation and the psychiatry service was consulted. Seroquel was added with some improvement in her mood. After her white blood cell count returned to [**Location 213**], she was cleared for surgery. On [**2183-6-24**], Ms. [**Known lastname 449**] was taken to the operating room where she underwent coronary artery bypass grafting to three vessels. Postoperatively, she was taken to the intensive care unit for monitoring. On postoperative day one, Ms. [**Known lastname 449**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. Gentle diuresis was initiated.Chest tubes on POD #2.pacing wires removed POD #3.Transferred to the floor on POD #4 to begin increasing her activity level. Cleared for discharge to rehab on POD #7. Pt. is to make all follow-up appts. as per discharge instructions and wear mammary support bra at all times. Medications on Admission: Medications on admission: 1. Aspirin 325mg daily every morning 2. Plavix 75mg daily every morning 3. Lipitor 40mg daily every morning 4. Atenolol 50mg daily every morning 5. Lisinopril 20mg, two tablets every morning 6. Furosemide 40mg daily every morning 7. Imdur 30mg daily every morning 8. Nitroglycerin SL 0.3mg as needed 9. Humulin N 60 units every morning, 30 units at 8pm 10. Humalog 20 units every morning 11. Sliding scale Humalog four times a day 12. Gabapentin 600mg two tablets three times a day 13. Glyburide 5mg daily every morning 14. Levoxyl 175mcg daily every morning 15. Bupropion SR 150mg daily every morning 16. Trileptal 300mg two tablets twice a day 17. Advair diskus 500-50 one puff twice a day 18. Albuterol nebulizer three to four times a day as needed . Medication on transfer to CCU: ASA 325 po daily Atorvastatin 40 mg po daily Metoprolol 37.5 [**Hospital1 **] po daily furosemide 40 mg po daily Lisinopril 20 mg po daily Isosorbide dinitrate 10 mg po tid Gabapentin 1200 mg po tid Oxcarbazine 600 mg po bid Colace Advair Atrovent Pantoprazole 40 mg po bid Ativan prn Supropion 150mg po qam Levothyroxine 200 mcg po daily SSI NPH 60 qam 30 qpm Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 10. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 14. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 16. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 17. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 18. insulin sliding scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice 61-109 mg/dL 0 Units 0 Units 0 Units 0 Units 110-140 mg/dL 2 Units 2 Units 2 Units 2 Units 141-199 mg/dL 4 Units 4 Units 4 Units 4 Units 200-239 mg/dL 6 Units 6 Units 6 Units 6 Units 240-280 mg/dL 8 Units 8 Units 8 Units 8 Units 19. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35) 35 units Subcutaneous once a day: QAM only. 20. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) 30 units Subcutaneous at bedtime: Q PM only. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: CAD s/p CABGx3 Hyperlipidemia HTN Insulin dependent diabetes Asthma Prior alcohol and substance abuse Hepatitis C Hypothyroidism Depression Arthritis obesity diverticulosis colon adenoma 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) Call with any questions or concerns. 8) WEAR MAMMARY SUPPORT BRA AT ALL TIMES. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] ([**Last Name (STitle) **]) in 1 month. Call ([**Telephone/Fax (1) 4044**] Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2183-7-14**] 11:50 Follow-up with cardiologist Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 2934**] Follow up in 4 weeks with GI Drs. [**Name5 (PTitle) 1940**]/Moss for colon adenoma [**Telephone/Fax (1) 463**]. Completed by:[**2183-7-1**]

[ "414.01", "311", "562.12", "211.3", "V11.3", "584.9", "571.5", "293.0", "493.90", "411.1", "412", "288.60", "518.81", "428.0", "535.50", "401.9", "272.4", "244.9", "278.00", "305.1", "250.60", "357.2" ]

icd9cm

[ [ [] ] ]

[ "39.61", "96.71", "88.53", "38.91", "88.56", "36.12", "45.25", "36.15", "45.16", "89.60", "50.11", "37.22", "96.04" ]

icd9pcs

[ [ [] ] ]

17897, 18051

11795, 14396

299, 497

18282, 18288

4283, 5773

19044, 19526

3424, 3493

15619, 17874

5810, 5840

18072, 18261

14448, 15596

18312, 19021

7478, 11736

3508, 4264

239, 261

5869, 7452

525, 1799

11772, 11772

1821, 2870

2886, 3408

65,176

173,812

38920

Discharge summary

report

Admission Date: [**2115-2-13**] Discharge Date: [**2115-4-6**] Date of Birth: [**2079-6-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: Abdominal pain, distention Major Surgical or Invasive Procedure: Diagnostic Paracentesis x 3 PICC line placement x 2 Endotracheal Intubation x 3 Arterial Line Placement x 2 Left IJ CVL History of Present Illness: 35 yo M with cerebral palsy who initially presented [**2115-2-13**] with abdominal pain and distention to an OSH. CT scan was performed and was reported as diffuse bowel edema, gastric varices, ascites and a pancreatic cyst. He reportedly had no associated nausea, vomiting, diarrhea, hematemesis, hematochezia, jaundice, fevers or dysuria. Also reported no recent weight loss, no NSAIDs or ASA use. In ED, his initial vitals temp 98.0 HR 100 BP 83/59 RR 20. He then received Unasyn at the OSH. Foley placed, recieved IVF and was transferred to [**Hospital1 18**]. Patient was non-verbal, in distress. Per family, patient had multiple admissions prior for constipation, with a recent drainage of a pancreatic cyst this past year in [**Hospital3 **]. He has a bowel movement everyday except on the day of presentation to the OSH. He tolerated PO and was at his baseline the night of his presentation. His abdomen was distended and painful to palpation according to his mother, which is why she brought her son to the OSH. Upon transferred to [**Hospital1 18**] [**2-13**] and admitted to the SICU team given concern for an acute surgical abdomen. Diagnostic paracentesis ([**2-13**]) with WBC [**Numeric Identifier **] (no growth so thought to be [**1-15**] inflammatory state), Lipase 216, Amylase 141. He was started on Vanco/Zosyn/Flagyl for suspected peritonitis and ischemic bowel with translocation. He was then intubated [**2115-2-14**] (in the ED) for respiratory failure. A left subclavian line was placed on [**2-14**]. He was then given Phenytoin but this was transitioned to Keppra the same day. On [**2-15**] Vitamin K 1mg was infused. TPN started [**2115-2-15**]. He was continued on maintenance IVF with intermittent bolus but on [**2-16**] was given Lasix. On [**2-16**] he was started on Heparin gtt for SMV thrombus. Did have diarrhea, but improving over the course of admission. [**2115-2-16**] with 3L therapeutic / diagnostic paracentesis (negative culture to date, WBC 1390). Concerning his respiratory status, he was extubated [**2-17**] (s/p 4 days of mechanical ventilation) and re-intubated [**2-18**] given increased secretions and concern that he was unable to protect his airway. On [**2-18**] Warfarin was started and Flagyl was discontinued. On [**2-19**] Tobramycin was added for suspected untreated infection given lower blood pressures. Upon transfer there is no positive culture data. Patient has been febrile > 100.5 on [**2-10**] and [**2-19**] but without leukocytosis. Also with persisent tachycardia > 100 bpm except for [**2-16**] and [**2-20**]. CTA Abdomen / pelvis with SMV thrombus, Vascular surgery consulted and thought it was likely a chronic issue given degree of collaterals and probably due to chronic pancreatic inflammation with associated vascular congestion and slowing. Given no acute surgical issues, patient was transferred to the Medical ICU team on [**2115-2-20**]. Upon initial evaluation, family at bedside confirms that he felt unwell for about one week prior to admission. He is nonverbal at baseline, but will push your hand away if you push his abdomen and he's in pain. Otherwise, no localizing symptoms. Past Medical History: Cerebral Palsy Seizure disorder Chronic anemia - Hct 35 GIB in [**2110**] h/o liver cyst drainage ([**2113**], [**Hospital3 7362**]) H/o Laproscopic cholecystectomy H/o pancreatic cyst drainage with chronic pancreatitis Social History: Lives at home with family, goes to school 5 days a week, no recent travels, no smoke/drink/IVDU. Family History: NC, Maternal grandmother had DM, paternal grandfather had HTN, parents healthy. Physical Exam: Upon transfer to MICU 98.3, 79, 100/70, 22, 100% SIMV [**9-20**], 12, TV 300, 50% CVP 13 Gen: Thin, no apparent distress but slight tearing in left eye; alert HEENT: Sclera anicteric, eyes sunken, MMM, ET in place Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, flat, patient pushes hand away with palpation in LUQ/LLQ, bowel sounds present, no guarding, unable to assess rebound tenderness GU: Foley in place Ext: warm, very thin, cannot palpate radial pulses or DP b/l, no cyanosis or edema Pertinent Results: ADMISSION LABS: [**2115-2-13**] 12:25PM BLOOD WBC-8.8 RBC-3.91* Hgb-10.7* Hct-34.6* MCV-89 MCH-27.4 MCHC-31.0 RDW-20.8* Plt Ct-202 [**2115-2-13**] 12:25PM BLOOD Neuts-83* Bands-11* Lymphs-4* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2115-2-13**] 12:25PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL Macrocy-1+ Microcy-1+ Polychr-NORMAL [**2115-2-13**] 12:25PM BLOOD Plt Smr-NORMAL Plt Ct-202 [**2115-2-13**] 12:25PM BLOOD Glucose-92 UreaN-13 Creat-0.5 Na-142 K-4.4 Cl-108 HCO3-25 AnGap-13 [**2115-2-13**] 12:25PM BLOOD ALT-15 AST-20 AlkPhos-146* TotBili-0.1 [**2115-2-13**] 12:25PM BLOOD Albumin-2.1* [**2115-2-19**] 07:59PM BLOOD Vanco-6.1* [**2115-2-20**] 10:05AM BLOOD Tobra-0.7* [**2115-2-21**] 06:00AM BLOOD Vanco-72.3* ----------------- DISCHARGE LABS: ----------------- STUDIES: [**2115-2-13**] CXR: 1. Low lung volumes. No focal consolidation. 2. Small bowel wall thickening and dilation, better evaluated on the outside hospital CT. . [**2115-2-15**] KUB: IMPRESSION: No evidence of free air. There is a relative paucity of bowel gas on this study; distended loops of fluid-containing small bowel cannot be excluded. . [**2115-2-16**] CTAP: IMPRESSION: 1. Diffusely abnormal gastrointestinal tract with mucosal hyperenhancement and wall thickening. Given the finding of SMV occlusion, findings are highly concerning for venous congestion/ischemia. An element of shock bowel could also be a possibility. 2. Hyperenhancement of the adrenal glands and narrowed distal aorta, iliac and femoral vessels, suggesting hypovolemia/shock. Correlate clinically. 3. Sequelae of chronic pancreatitis with a rim-enhancing fluid collection in the region of the pancreatic head, likely representing pseudocyst. This may be the etiology of SMV thrombosis. 4. Diffusely abnormal hepatic parenchyma, consistent with the history of hepatitis. Partially occlusive right portal vein thrombus. 5. Small bilateral pleural effusions, increased from the prior exam. Ground- glass and nodular opacities at the lung bases suggesting infection. . [**2115-2-19**] TTE: Technically limited study; Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. At least mild to moderate aortic stenosis is present (but cannot be fully quantified). No aortic regurgitation is seen. There is no pericardial effusion. . [**2115-2-26**] Renal US 1. Small size and echogenic appearance of the kidneys consistent with chronic, diffuse parenchymal disease. No hydronephrosis. 2. Ascites. . [**2115-3-6**] Abdomen US IMPRESSION: Small ascites. Again noted probable pseudocyst in the midline and collateral vessels related to the SMV thrombosis. . [**2115-3-7**]: KUB Multiple dilated loops of large and small bowel, more prominent is colonic dilation. Findings are concerning for large bowel obstruction. . [**2115-3-9**]: KUB Interval increase in gaseous distension of a segment of colon in the lower abdomen. Appearance is nonspecific, but distal colonic obstruction cannot be excluded and further evaluation by CT should be considered. . [**2115-3-10**]: KUB There has been apparent placement of a rectal tube (recommend clinical correlation with recent procedural history). There has been decrease in degree of distention of a prominent loop of bowel in the lower mid abdomen, likely representing sigmoid colon, with decrease in maximal diameter from about 10 cm to 8.6 cm in transverse width. Other air- filled loops of small and large bowel appear relatively similar to the recent radiograph. By report, there is clinical concern for perforation. Either an upright or left lateral decubitus abdominal radiograph would be recommended to evaluate for free intraperitoneal air. Alternatively, a CT could be performed. . [**2115-3-11**]: CT Abd/Pelvis INDICATION: 35-year-old man with known microperforation, small-bowel obstruction and colonic dilatation. Increased abdominal distention. TECHNIQUE: CT imaging of the abdomen and pelvis was performed following the administration of oral and intravenous contrast. Multiplanar reconstructions were generated. COMPARISON: Comparison is made to prior CT performed [**2115-2-24**]. FINDINGS: CT ABDOMEN: Small bilateral basal pleural effusions have decreased in size in comparison to the prior CT. There has also been partial resolution of atelectasis and consolidation in the basilar segments of both lower lobes. A nasogastric tube is in situ with tip in the gastric body. There is moderate gaseous distention of the stomach. There is marked distention of the sigmoid colon with gas and debris, although mural thickening is less prominent than on CT performed [**2115-2-16**]. A rectal catheter is in situ. The remainder of the colon is less distended than the sigmoid colon, but also contains fluid and gas throughout. No discrete transition point is identified within the large bowel. The small bowel is not significantly dilated. No free fluid or gas is seen within the abdomen or pelvis. The patient is status post cholecystectomy. No focal parenchymal abnormality is identified in the liver. The pancreas is atrophic in appearance as on prior scan. Calcifications are again identified at the pancreatic head. A 1.7 cm x 1.4 cm cystic lesion at the pancreatic head seen on the prior CT is again identified, but is of higher attenuation than on the previous scan. A cortical cyst at the mid pole of the right kidney measuring 1.4 cm x 1.2 cm is unchanged from prior study. No other focal renal lesion is seen. The adrenal glands and spleen are normal in appearance. A small amount of free fluid is seen in the abdomen and pelvis, which has decreased in comparison to the prior CT scan. Small bowel dilatation is less prominent than on the prior scan. There is occlusion of the superior mesenteric vein at the level of the pancreas (series 2, image 28), but the proximal portion of the vein remains patent. Extensive collateral vessels are again identified in the perigastric area. The portal vein and left and right portal branches are patent. CT PELVIS: No pelvic lymphadenopathy is seen. The urinary bladder appears unremarkable, but is pushed anteriorly by the distended rectum and sigmoid colon. Marked degenerative changes are seen in the thoracolumbar spine with scoliosis convex to right. IMPRESSION: 1. Marked distention of the rectum and sigmoid colon with gas and fluid. The distention is more marked than on the prior scan [**2115-2-24**], but the degree of mural thickening in the sigmoid colon has decreased in comparison to CT [**2115-2-16**]. A catheter is in situ within the lumen of the distatl sigmoid colon. Mild distention with gas and fluid in the remainder of the colon. 2. No free intraperitoneal gas is seen. Ascites has decreased in volume in comparison to the prior CT. 3. Occlusive thrombus is again identified in the distal portion of the superior mesenteric vein. The portal vein remains patent. [**2115-3-12**]: Portable Abdomen HISTORY: colonic distension with rectal tube SUPINE ABDOMEN: There is marked dilation of large bowel, with sigmoid colon measuring up to 9.8 cm, overall unchanged when compared to prior study. There is no free intraperitoneal air or pneumatosis. Surgical clips are seen in the right upper quadrant. The bladder is filled with contrast. The rectal tube is not seen on today's study. IMPRESSION: Unchanged marked colonic/sigmoid dilation. [**2115-3-13**]: Portable Abdomen HISTORY: Vomiting. COMPARISON: Multiple priors including [**2115-3-12**]. SUPINE AND UPRIGHT ABDOMEN: Unchanged marked dilation of large bowel with sigmoid colon measuring up to 10 cm in diameter, may represent chronic air swallowing pattern. There is no free intraperitoneal air or pneumatosis. Surgical clips are seen in the right upper quadrant. Nasogastric tube is seen in appropriate position. IMPRESSION: Unchanged marked large bowel dilation. [**2115-3-13**]: CT Abd/Pelvis CLINICAL INDICATION: History of SMV occlusion and large bowel obstruction, with worsening abdominal distention and new hypotension. TECHNIQUE: MDCT of the abdomen and pelvis was performed following the uneventful administration of nonionic intravenous contrast and oral contrast. Comparison exam is dated [**2115-3-11**]. FINDINGS: Limited images of the lung bases demonstrate small left pleural effusion, unchanged and trace right pleural fluid. There is bibasilar atelectasis, left greater than right. A feeding tube is seen terminating in the third portion of the duodenum. Compared to the prior exam, there is increased abdominal ascites, which is slightly hyperdense, measuring 30 Hounsfield units in some areas. There has been interval development of marked colonic wall thickening involving the ascending colon, descending colon, sigmoid and rectum. The transverse colon appears relatively spared. There is an area of mass-like hyperdense thickening of the descending/transverse colon junction (2:63). Additionally, hyperdensity is seen tracking along the descending colonic wall, likely representing hemorrhage. Compared to the prior exam, there is decreased distention of the rectum and sigmoid colon. A rectal tube is now in place. There is a new hyperdense left retroperitoneal collection extending from just inferior to the left kidney into the pelvis, interposed between the rectum and bladder and displacing the bladder anteriorly and inferiorly. There are a few foci of gas in the left rectus muscle. Additionally, there is a focus of gas which appears to be intraperitoneal (2:62), that was not clearly present on the prior exam. It is not clear whether this is extraluminal or not. There is no contrast extravasation. There are prominent small bowel loops with diffuse distention, but no evidence of transition point. The small bowel is non-thickened. Again noted are numerous venous collaterals related to known SMV occlusion. The portal vein again reconstitutes and is patent, as is the splenic vein. The pancreas is atrophic with multiple calcifications in the region of the head, consistent with chronic pancreatitis. The gallbladder is surgically absent. There is a right renal cyst. The left kidney, adrenal glands and spleen are unremarkable. PELVIS: The bladder contains a Foley catheter with contrast and foci of gas. There are no pathologically enlarged lymph nodes. There is diffuse mild anasarca. Bone windows demonstrate scoliosis and degenerative changes of the spine. There are no focal suspicious lesions. IMPRESSION: 1. Interval development of marked colonic thickening involving the ascending colon, descending colon, sigmoid and rectum, concerning for colitis, possiblby on the basis of venous obstruction. There is hyperdense mass-like thickening at the junction of the descending colon and transverse colon, which is new from the prior exam and consistent with hemorrhage. Hyperdensity is also seen along the descending colonic wall, also likely representing hemorrhage. There is a focus of gas which appears to be within the peritoneal cavity (2:62), not present on the prior study. This is not clearly extraluminal and no oral contrast extravasation is seen, although perforation cannot be fully excluded. 2. Interval development of a large left retroperitoneal hematoma extending in the pelvis. 3. Prominent small bowel distention diffusely, consistent with ileus. 4. Increased abdominal ascites, slightly hyperdense, suggesting a component of hemoperitoneum. 5. Numerous collateral vessels related to known SMV occlusion. This appears stable from the prior exam, and the portal vein is patent and reconstituted. [**2115-3-15**]: PICC LINE PLACEMENT INDICATION: IV access needed for IV access and fluids. The procedure was explained to the patient. A timeout was performed. RADIOLOGIST: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] performed the procedure. Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4154**], the attending radiologist who was present and supervising throughout. TECHNIQUE: Using sterile technique and local anesthesia, the left brachial vein was punctured under direct ultrasound guidance using a micropuncture set.Hard copies of ultrasound images were obtained before and immediately after establishing intravenous access. A peel-away sheath was then placed over a guidewire and a double-lumen PICC line measuring 36 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French double-lumen PICC line placement via the left brachial venous approach. Final internal length is 36 cm, with the tip positioned in SVC. The line is ready to use. After placing the left-sided PICC line, the right PICC line, which is thought to be infected, was removed and the tip sent for culture and sensitivities. Sterile dressings applied. [**2115-3-17**]: Portable Abdomen HISTORY: Improving SBO, known dilated colon. Abdominal distention. SUPINE & UPRIHT ABDOMEN: Slightly improvement of diameter of prominent loops of large bowel measuring up to 6.4 cm and previously measured up to 11 cm. There is no free intraperitoneal air or pneumatosis. IMPRESSION: Slightly improvement of mildly dilated loops of large bowel. No free intraperitoneal air. [**2115-3-19**]: Left Wrist LEFT WRIST CLINICAL HISTORY: Trauma and pain. AP and lateral films of the wrist and a somewhat motion limited AP film of the forearm were obtained. On the somewhat oblique lateral film there is a vertical lucency projected at the anterior aspect of the radius which is probably artifactual. No fracture is seen on the AP view. The carpal bones are normally aligned. IMPRESSION: The study is somewhat technically limited. No definite fracture is seen. If the patient's symptoms persist, a repeat view might be of use. [**2115-3-19**]: LEFT HUMERUS CLINICAL HISTORY: Fracture. AP, oblique and scapular Y views of the left humerus were obtained. There is a fracture in the region of the surgical neck of the humerus with medial displacement of the shaft relative to the humeral head. A catheter likely a PICC line, is noted. IMPRESSION: There is a mildly displaced fracture in the region of the surgical neck of the left humerus. [**2115-3-20**]: CT Torso CLINICAL INDICATION: History of cerebral palsy with SMV occlusion, partial small-bowel obstruction, colonic and retroperitoneal hemorrhage with worsening abdominal distention, tenderness, hematocrit drop and fever. TECHNIQUE: MDCT of the chest, abdomen and pelvis was performed following the uneventful administration of nonionic intravenous contrast and oral contrast. Comparison exam is dated [**2115-3-13**]. FINDINGS: CHEST: There are small bilateral pleural effusions, increased from the prior exam. There are calcifications of the aortic valve, and the ascending aorta is ectatic, measuring 3.9 cm. The descending aorta is normal in caliber. A right-sided venous catheter terminates in the SVC. There are no pathologically enlarged thoracic lymph nodes. Lung windows demonstrate compressive atelectasis. There are no focal nodules or masses. The central airways are patent. ABDOMEN: The liver, spleen, left kidney, adrenal glands are unremarkable. The gallbladder is surgically absent. There is a stable right renal hypodensity. Again noted is atrophy of the pancreas with calcifications in the head, consistent with chronic pancreatitis. A feeding tube terminates in the duodenum. Compared to the prior exam, there has been interval resolution of small bowel dilatation. Colonic wall thickening has also improved, with minimal residual thickening in the descending colon in the area of prior hemorrhage. There is increased abdominal ascites. Again noted is occlusion of the superior mesenteric vein, with numerous collaterals. The portal veins are patent. Left retroperitoneal hemorrhage is stable. PELVIS: Previously seen hemorrhage interposed between the rectum and bladder is resolved. There is increased pelvic ascites with some layering high density posteriorly. There is stable rectal and sigmoid thickening. There are no pathologically enlarged lymph nodes. Bone windows demonstrate degenerative changes and scoliosis, without focal suspicious lesion. IMPRESSION: 1. Interval resolution of small bowel dilatation, and near interval resolution of high density thickening of the descending colon. Persistent sigmoid and rectal thickening. Increased abdominal and pelvic ascites with some layering high density posteriorly. Stable left retroperitoneal bleed and interval resolution of hemorrhage seen between the rectum and bladder. 2. Small bilateral pleural effusions, increased from the prior exam. 3. Stable occlusion of the SMV, with numerous collaterals. 4. Dilatation of the ascending aorta and marked calcification of the aortic valve for the patient's age. This finding could indicate a bicuspid valve. [**2115-3-24**]: CTA CHEST AND CT ABDOMEN AND PELVIS WITH CONTRAST INDICATION: 35-year-old man with sudden onset of hypoxia, tachypnea and fever since yesterday. Known SMV clot, evaluate for PE. COMPARISON STUDY: CT torso from [**2115-3-20**] and chest x-ray from [**2115-3-24**]. TECHNIQUE: MDCT of the chest, abdomen and pelvis was performed following the uneventful administration of nonionic intravenous contrast. Coronal, sagittal and multiple oblique reformatted images were reviewed per PE protocol. FINDINGS: CHEST: The endotracheal tube is in satisfactory position. An NG tube terminates within the stomach. The ascending aorta is mildly ectatic at 3.8 cm. The descending aorta is normal in caliber. A left-sided PICC line terminates in the SVC. There are no enlarged axillary, mediastinal or hilar lymph nodes. There is new patchy multifocal airspace consolidation, particularly within the left upper lobe and medial segment right middle lobe consistent with pneumonia. There are increased moderate bilateral pleural effusions with compressive atelectasis. There is no pulmonary embolism within the main, lobar or segmental pulmonary arteries. ABDOMEN: There is new ill-defined area of hypoattenuation within segment V of the liver measuring 2.8 x 3.5 cm. This may represent a developing abscess. There is stable marked ascites. The patient is status post cholecystectomy. The spleen, pancreas and adrenal glands are unremarkable. The kidneys have symmetric nephrograms. There is a 1.2 cm low attenuating lesion within the mid pole right kidney, incompletely assessed on this contrast-enhanced study. There is no evidence of small-bowel obstruction. There is stable thickening of the sigmoid colon and rectal wall. There is continued dilation of the colon. There is a stable left retroperitoneal hemorrhage which now appears more organized. Bone windows show degenerative change and scoliosis without focal suspicious lesion. IMPRESSION: 1. New bilateral patchy pneumonia, particularly within the left upper lobe and right middle lobe. 2. New ill-defined 2.8 x 3 cm hypoattenuating lesion in segment V of the liver. This may be secondary to a developing abscess. Follow-up ultrasound is recommended in 3 days. 3. Persistent sigmoid and rectal thickening with stable marked abdominal and pelvic ascites. 4. Stable left retroperitoneal bleed, more organized. 5. Increased moderate bilateral pleural effusions. [**2115-3-25**]: Transthoracic Echocardiogram The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. There is mild to moderate global left ventricular hypokinesis suggested(LVEF = 45 %). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2115-2-19**], the patient is more tachycardic. The LV systolic function now appears depressed. The aortic valve gradient appears similar. If indicated, a TEE would better clarify the basis and severity of the aortic stenosis (as well as global LV systolic function). [**2115-3-27**]: RUQ Ultrasound INDICATION: 35-year-old man with possible liver abscess, to assess for interval change. COMPARISON: CT torso, [**2115-3-24**]. FINDINGS: Liver has a normal echotexture without evidence of focal liver lesions. The hypoenhancing lesion, seen in the prior CT scan, is not visualized in the ultrasound study. This likely represents an infarct of the liver, secondary to compromised blood supply through the right portal vein. There is no intrahepatic or extrahepatic biliary dilatation. Patient is status post cholecystectomy. Common duct measures 5 mm. A moderate amount of right pleural effusion and ascites are seen. IMPRESSION: 1. No son[**Name (NI) 493**] correlate corresponding to the hypoenhancing lesion seen on prior CT of [**2115-3-24**] is seen. Lesion seen on CT could represent an infarct secondary to compromised blood supply through the right portal vein, which appears nearly occluded. 2. Right pleural effusion and ascites. [**2115-4-2**]: Transthoracic Echocardiogram Right ventricular chamber size is normal. with mild global free wall hypokinesis. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. IMPRESSION: Moderately thickened and deformed aortic valve leaflets with moderate to severe stenosis. At least moderate mitral regurgitation. Small echodensity in the left atrium adjacent to the anterior leaflet of the mitral valve (clip [**Clip Number (Radiology) **]) which appears consistent with artifact from mitral annular and valvular calcification; however, a small vegetation cannot be excluded. Mild global biventricular hypokinesis. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Compared with the prior study (images reviewed) of [**2115-3-25**], the findings are similar. [**2115-4-3**]: Video Oropharyngeal Swallowing Study INDICATION: 35-year-old man with pneumonia, assess for aspiration. VIDEO OROPHARYNGEAL SWALLOWING FLUOROSCOPY: Oropharyngeal swallow fluoroscopy was performed in conjunction with the speech and swallow division. This is a limited study with nectar and thick consistencies of barium only used. No aspiration or penetration was noted for nectar or thick consistencies. IMPRESSION: Limited study with no aspiration or penetration for thick and nectar consistencies. For additional details, please see OMR speech and swallow division note. [**2115-4-5**]: Portable CXR AP CHEST, 09:48 A.M., [**4-5**] HISTORY: Shortness of breath, question interval change. IMPRESSION: AP chest compared to [**3-27**] through [**4-4**]: Pulmonary edema has cleared from the periphery of the lungs. Central consolidation persists. Whether this is pneumonia or pulmonary edema is radiographically indeterminate. Small bilateral pleural effusions are presumed. Heart size is normal. Mediastinal vascular engorgement persists. No pneumothorax. Nasogastric tube ends in the third portion of the duodenum. Brief Hospital Course: # Abdominal pain: The patient presented with abdominal pain. The patient was found to have a pancreatic cyst, SMV thrombus, ascites and diffuse bowel thickening. The pancreatic cyst was seen on prior images and felt to be unchanged in appearance. The SMV thrombus appeared chronic in nature. He was started on anticoagulation that will need to be continued for at least 6 months. This should be followed by the vascular surgeons. The ascites had a diagnostic tap which showed a leukocytosis. He was broadly covered with vancomycin and zosyn for secondary peritonitis. No bacteria grew on cultures. He had a total of 2 weeks of this course. The patient also had diffuse bowel thickening that was of unknown etiology but concerning for edema vs inschemia. He had a low lactates so edema more likely. The patient had a CTAP on [**2-25**] which showed partial small bowel obstruction vs ileus and gas in the bowel suggestive of a microperforation. Surgery was contact[**Name (NI) **] and the patient was kept on intermittent low suction and remained NPO. He received another 2 weeks of antibiotics with ciprofloxacin and metronidazole. After he finishes his course of antibiotics he will need another imaging study to evaluate for ascites. If he does have ascites he will need a paracentesis with cell count and differential. The patient passed speech and swallow and was fed with PO food. His pain was controlled with IV morphine and tylenol. At the time of discharge the patient had no evidence of abdominal pain and was not requiring analgesics. . # GIB: On [**3-13**], Mr. [**Known lastname 32665**] developed coffee-ground emesis, abdominal pain, Hct drop (30.8 to 24.6) and hypotension to SBPs in the 60s, and was transferred to the MICU. He received 3 units of pRBCs in response to Hct drop with appropriate response. He was seen by GI and the general surgery service, and CT scan of the abdomen was obtained showing retroperitoneal bleed. Anticoagulation for SMV thrombosis was held, and the patient's abdominal pain improved steadily over 48 hours, at which time his family felt that he was back to his baseline and abdominal distension (appreciated on transfer) had resolved. NGT placed to suction showed no further evidence of UGIB, so endoscopy was deferred. The patient was initially placed on low-dose phenylephrine to maintain SBP > 75, but this was weaned within 48 hours. SBPs remained low (upper 70s-90s) but this was consistent with patient's recent baseline and small size. He was observed in the unit for an additional 24 hours, during which time Hct and BPs remained stable, and he was called out to the floor. There were no more GIB episodes since then. His hct has been stable during the rest of his hospital stay. . # Humeral fracture: The patient was noted to have left arm pain after he got a new PICC line in the MICU. A x-ray of the LUE was done, which showed left humeral fracture. It was unclear what caused the fracture. The suspicion is that the fracture occured when he was down in the radiology department to get PICC line. Patient was seen by orthopedics, who recommended a repeat shoulder film. After all the imaging was obtained, orthopedics recommende...... . # Nutrition: The patient presented with a very low albumin level suggesting very poor nutrition status. The patient was started on TPN and remained NPO. As his abdominal pain improved he was started on slow tube feeds which he tolerated well. The patient passed a speech and swallow evaluated and ate PO food and the NGT was discontinued. He will need to continue TPN for the next month. He should also consider a PEG tube as his prior nutrition was inadequate. . # Acute renal failure: The patient has a baseline of 0.4-0.5. His creatinine peaked at 1.2. The most likely etiology was thought to be secondary to ATN secondary to nephrotoxic [**Doctor Last Name 360**]. IVF failure to return Cr to baseline. He had medications renally dosed and nephrotoxins were avoided. . # Anemia: The patient has a baseline Hct of 35. He was guaiac and NG lavage negative on admission. He required multiple transfusions for Hct under 21. He showed some anemia of chronic disease/iron deficiency anemia. No evidence of hemolysis and B12, folate normal. Will need iron supplementation as an outpatient. Patient had GIB and RP hematoma on anticoagulation on [**3-13**], and anticoagulation was stopped. Patient was transferred to MICU and required 3u pRBC transfusion. His hct has been stable during the rest of his hospital stay. . # Respiratory failure: The patient was intubated for respiratory failure. The patient had a LLL infiltrate on CXR. He was treated with vancomycin and zosyn for HAP/VAP. The patient was extubated and quickly weaned to room air with normal oxygen saturation. . # SMV occlusion: This appears to be chronic given the number of collaterals. He will need to be maintained on anticoagulation for 6 months per vascular surgery. He was on a lovenox bridge to warfarin with a goal INR of [**1-16**]. . # Seizure disorder: The patient was started on fosphenytoin and phenobarbital. His levels were adjusted. He had daily episodes of "absence seizures". He will need close follow up as an outpatient. outpatient Neurology Openheimer ([**Hospital1 3597**]). . # Hypotension: The patient has a baseline systolic blood pressure in the 80s. The patient remained near his baseline as an inpatient. . MICU Course [**Date range (1) 86346**] . # Hypoxemia: The patient was transferred to MICU with tachypnea and hypoxia on [**2115-3-23**]. He was initially started on BiPap and did well for several hours, even weaning off of the BiPap. Unfortunately, the patient became increasingly hypoxemic and required intubation on [**2115-3-24**]. Imaging at that time was consistent with multilobar pneumonia with sputum growing MRSA. The patient completed an 8 day course of vancomycin, cefepime, and flagyl on [**2115-3-31**]. . Pleural effusions were also noted on imaging, likely due to fluid resuscitation for hypotension in the setting of albumin of 2.3, so the patient was aggressively diuresed with lasix boluses. . Prior to extubation, the patient was made DNR/DNI after long discussion with family. After optimization, the patient was extubated on [**2115-3-30**] to face mask and nasal cannula. Oxygen requirement thought due to pulmonary edema, mucous plugging and secretions, also restrictive with low lung volumes in setting of ascites. . During the patient's last several days in the MICU, he had improvement in O2 requirement with continued gentle diuresis. . The patient was started on standing lasix 40mg PO BID. . # Yeast bacteremia: The patient was noted to have low grade fevers. On [**3-29**], a urine culture regurned with > 100k yeast. On [**3-31**], a blood culture returned that was also growing yeast We suspected possible urogenital source with hematogenous spread. Heart rate and blood pressure currently at baseline. Normal WBC count, lactate. . The patient was initially started on micafungin while speciation and identification were finalized. The infectious disease service was consulted and followed the patient. The yeast was speciated as [**Female First Name (un) **] albicans that was fluconazole sensitive. On the day of discharge the patient was started on fluconazole and micafungin was discontinued. He should have LFTs monitored every three days while on fluconazole for a total course of 14 days. . The patient's lines and foley catheter were replaced during this time. A new PICC line was placed on [**2115-4-5**]. . The patient had daily surveillance blood cultures that did not show evidence of any further fungemia. . Dilated fundoscopic exam on [**4-2**] neg for apparent chororetinal lesions with signif corneal scarring. Recommend repeat DFE in 2 weeks of if patient having ANY procedure requiring general anesthesia. On lacrilub gtts. . #Fevers: The patient had daily low grade febrile episodes despite broad spectrum antibiotics. Completed treatment for pulmonary infection with 8 day course of vancomycin, cefepime, flagyl. SBP possible but 3 taps have not been c/w SBP. PE considered but no evidence on CTA. CT read as possible liver abscess but repeat RUQ ultrasound read as more consistent with infarct. C. Diff has been negative. The low grade fevers were then though to be due to positive urine and blood culture growing yeast. Repeat cultures of blood, urine ngtd. . # Tachycardia: The patient had persistent tachycardia into the 110s that was likely hyperdynamic in setting of fever and infection. Volume status appeared grossly euvolemic; pt mentating at baseline and maintaining urine output. Echo with evidence of depressed cardiac fxn, ? tachycardia induced cardiomyopathy. The patient's baseline HR has been consistently 100-115 bpm. . It should also be noted that the patient's baseline systolic blood pressure is between 80-100 mmHg. We were obtaining blood pressures via a thigh cuff as this more likely represented his true blood pressure. . # Anemia/bleed: Pt with retroperitoneal bleed and CT evidence of hemorrhage into bowel wall, also gastric varices c/b GIB earlier in admission. He was transfused 1 unit pRBCs [**3-25**] with appropriate bump and has remained stable since. . His hematocrits were trended daily and stools were guaiac negative. . He was continued on PO pantoprazole and iron supplementation. . # Liver lesion. The patient had a Noted on abdominal CT with concern for possible ischemia/infarction vs abscess. Abdominal U/S [**3-27**] not consistent with abscess. . # Left humeral fx: Likely d/t trauma sustained during radiology. Patient briefly received morphine for pain control and also continued to receive lidoderm patches for comfort. No lab draws were conducted on the left arm. There was no indication for surgical intervention. . # SMV thrombus: The initial plan for the SMV thrombus was for anticoagulation x 6 months, but in the setting of recent GI and RP bleed all anticoagulants were discontinued. . The patient was restarted on heparin SQ for DVT prophylaxis. . # Seizure disorder: No recent reports of seizures. The patient was maintained on his home doses of phenobarbitol and fosphenytoin. Drug levels were checked frequently and were in the therapeutic window. . # Cerebral palsy: Stable mental status. Interactive with family but nonverbal at baseline. . FEN: continue tube feeds while fully transitioning to PO diet cleared for nectar thick liquids, pureed solids; needs 1:1 observation (mother may need to feed). OK to try crushed meds, but may not take reliably. . Medications on Admission: Medications (Upon admission) Miralax prn Phenobarbital 32.4 mg TAB [**12-15**] am, 1PM Dilantin (Extended caps) 75mg in am 100mg in pm Ferrous Fumarate 324 mg Tabs daily MVI daily Cyproheptadine HCL 4mg tabs 0.5 tab in AM, 0.5 tabs in PM Prilosec 20mg daily Celexa 20mg daily Zovirax 5% oint (acyclovir) q2hr while awake x 4 days prn cold sore vitamine D 400 Unit Caps Medications (Upon transfer to MICU service) Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN low oxygen sats Piperacillin-Tazobactam 4.5 g IV Q8H Midazolam 0.5-1 mg IV Q4H:PRN comfort of ETT Fentanyl Citrate 12.5-100 mcg IV Q2H:PRN pain Pantoprazole 40 mg IV Q12H Magnesium Sulfate IV Sliding Scale Calcium Gluconate IV Sliding Scale LeVETiracetam 1000 mg IV Q12H Insulin SC (per Insulin Flowsheet) Sliding Scale Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Acetaminophen 325 mg PO/NG Q6H:PRN fever, pain Potassium Chloride IV Sliding Scale Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **] Tobramycin 220 mg IV Q24H Vancomycin 1250 mg IV Q 12H Heparin IV Sliding Scale Warfarin 5 mg PO/NG DAILY16 Discharge Medications: 1. Miconazole Nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 2. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed for itching. 3. Cortisone 1 % Cream [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed for itching. 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 5. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Hospital1 **]: One (1) teaspoon PO DAILY (Daily). 6. Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Cap PO TID (3 times a day). 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze. 8. Acetaminophen 650 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**12-15**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 10. Phenobarbital 30 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day). 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 12. Phenytoin 50 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2) Tablet, Chewable PO Q 8H (Every 8 Hours). 13. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Last Name (STitle) **]: One (1) Appl Ophthalmic QID (4 times a day) as needed for dry eyes. 14. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection [**Hospital1 **] (2 times a day). 15. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 16. Morphine 2 mg/mL Syringe [**Hospital1 **]: [**1-17**] milligrams milligrams Injection Q4H (every 4 hours) as needed for Pain. 17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 19. Fluconazole 400 mg IV Q24H 20. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary: (1) Hypoxic Respiratory Failure (2) Health Care Associated Pneumonia (3) Fungemia (4) Fungal Urinary Tract Infection (5) Retroperitoneal Bleed (6) Superior Mesenteric Vein Thrombus (7) Large Bowel Obstruction (8) Acute Peritonitis (9) Hypotension (10) Sepsis (11) Left Humerus Fracture (12) Gastric Varices (13) Ascites (14) Ileus (15) GI Bleed Secondary: (1) Cerebral Palsy (2) Seizure Disorder (3) Anemia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive (nonverbal) Activity Status: Bedbound. Discharge Instructions: Mr. [**Known lastname 32665**], It was a pleasure to care for you during your hospitalization at the [**Hospital1 69**]. During this hospitalization, you were treated for a superior mesenteric vein thrombus with blood thinning agents, but unfortunately you had bleeding in your abdomen that required the blood thinning medicines to be stopped. During this hospitalization, you also had difficulty breathing, likely due to pneumonia and fluid overload, that required intubation and ventilator assistance. You further had a pneumonia, and required medications to keep your blood pressure in a normal range. An infection was found in your blood as well as your urine (yeast) and you were treated with anti-fungal medications. Unfortunately, your left arm was broken during this hospitalization. Please continue to take all of your medicines as previously prescribed before this hospitalization. Do not take any blood thinning (anticoagulant) medications. The following medications have been added to your regimen: (1) Fluconazole 400mg IV ever 24 hours x 14 days Followup Instructions: You are being discharged to a rehab facility. Please contact your primary care physician for [**Name Initial (PRE) **] follow up appointment in [**12-15**] weeks. Completed by:[**2115-4-9**]

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Discharge summary

report

Admission Date: [**2121-8-7**] Discharge Date: [**2121-8-18**] Date of Birth: [**2067-6-19**] Sex: M Service: MEDICINE Allergies: Morphine / adhesive tape Attending:[**Last Name (un) 2888**] Chief Complaint: Fever and tachypnea Major Surgical or Invasive Procedure: NONE History of Present Illness: 54 year old male with CAD, DM, CHF, and CKD was at his baseline state of health until he fell from his chair car yesterday, striking his right hip and head. According to the patient, who is a poor historian, he denies loss of consciousness, but has continued right hip pain. According to the staff at his rehab facility, he refused to go to the hospital. Today, the patient reports feeling "sick" and nauseous. He also reports having chest pain while moving his wheelchair that lasted 5 minutes, radiated down his left arm, but did not make him short of breath, sweaty, or nauseous. According to the staff at his rehab facility, he was febrile to 101.6, tachypnic and diaphoretic and was convinced to go to the ED. FSBS 154. He denies shortness of breath at any point in the last few days. He denies subjective fever, chills, cough or sore throat. In the ED, initial VS were: T 98.1 HR 58 BP 95/48 RR 20 100% 4L Nasal Cannula. His temperature spiked at 100.4. He had good rectal tone. His labs were notable for WBC 9.5, H/H 10.2/30.1 (baseline ~[**9-23**]), Pro BNP 3622, Cr 2.6 (baseline ~1.6 [**2117**]), BUN 72, AG 12. Trop 0.14 (has been 0.1-0.2 in the past), UA 1 WBC, 0 Epi, mod bact, cast 9. Blood and urine cultures sent. ABG 7.43/38/99 with lactate 1.7. He was given 1 L NS, vancomycin 1gm, cefepime 1gm, and lasix 40mg IV. The patient was placed on CPAP. Non contrast CT head, CT C-spine, CT chest, and CT Abd/pelvis were prelim reads as negative except for wedge fracture of L1 without retropulsion, likely subacute on chronic. Also right sided small-bowel-containing inguinal hernia. The patient arrived in the MICU on CPAP. After it was removed, the patient reported feeling like his normal self. He denied any shortness of breath, chest pain, or abdominal pain. Past Medical History: hypothyroidism Insulin-dependent diabetes mellitus since [**2082**] Peripheral neuropathy s/p R mid foot amputation Retinopathy w/ hx detached R retina Coronary artery disease, status post silent MI - EF >55%, cardiac cath [**5-1**]: L circumflex [**Last Name (un) **] 40% stenosis, proximal RCA 30% stenosis Peripheral vascular disease Chronic left heel ulcer Breast lipoma s/p removal Hypertension MRSA + Social History: Denies smoking, alcohol and tobacco use. Used to work in a mail room in [**Location (un) 86**] but could not after an accident. Now is living in nursing home v. rehab. Family History: Father passed away from MI, but had DM. Mother also passed away from MI. Physical Exam: #ADMISSION PHYSICAL EXAM: General: Alert, oriented x3, no acute distress HEENT: Scabs on scalp, sclera anicteric, MMM, oropharynx clear, pupils equal round reactive Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Breath sounds diminished bilateral lower/middle lobes, bilateral upper lobes clear, no crackles or wheezes appreciated, dull to percussion throughout. Abdomen: Soft, diffusely tender to palpation, distended, hypoactive bowel sounds present, no organomegaly. Skin breakdown under bilateral breasts, erythematous exanthems on abdomen. GU: Foley in place Ext: Warm, well perfused, 2+ radial pulses bilaterally, fingers contracted, no clubbing, cyanosis or edema. Multiple sites of skin breakdown on right lower leg, raised weeping lesions. Heel ulcer right foot. Diminished leg hair. Neuro: Asterixis present . #DISCHARGE PHYSICAL EXAM: Vitals: T98.6, BP (143-156)/(76-79), HR 61-67, RR 18-20, O2 sat 97% RA. General: Alert, oriented x3, no acute distress HEENT: Scabs on scalp, sclera anicteric, MMM, oropharynx clear, pupils equal round reactive Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Chest: Breath sounds diminished bilateral lower/middle lobes, bilateral upper lobes clear, minimal scattered crackles, no wheezes appreciated, dull to percussion throughout. Abdomen: Soft, NT/ND, bowel sounds present, no organomegaly. Skin breakdown under bilateral breasts, erythematous exanthems on abdomen. GU: Foley in place Ext: Warm, 2+ radial pulses bilaterally, fingers contracted, no clubbing, cyanosis or edema. Lower extr: 2+ bilateral lower extremity edema. Pulses not palpable [**12-26**] edema. s/p left BKA, RIGHT LEG IN CAST (previously: 1.5cm ulcer with necrotic edges on sole of R foot. Stasis dermatitis on RLE, dressings c/d/i). Pertinent Results: #ADMISSION LABS: [**2121-8-6**] 11:28PM PT-12.8* PTT-33.0 INR(PT)-1.2* [**2121-8-6**] 11:28PM PLT COUNT-249 [**2121-8-6**] 11:28PM NEUTS-78.7* LYMPHS-15.1* MONOS-3.3 EOS-2.5 BASOS-0.3 [**2121-8-6**] 11:28PM WBC-9.5# RBC-3.90* HGB-10.2* HCT-32.1* MCV-82 MCH-26.3* MCHC-31.9 RDW-15.0 [**2121-8-6**] 11:28PM ALBUMIN-3.6 CALCIUM-8.0* PHOSPHATE-3.2# MAGNESIUM-2.3 [**2121-8-6**] 11:28PM CK-MB-2 proBNP-3622* [**2121-8-6**] 11:28PM cTropnT-0.14* [**2121-8-6**] 11:28PM LIPASE-9 [**2121-8-6**] 11:28PM ALT(SGPT)-17 AST(SGOT)-26 CK(CPK)-120 ALK PHOS-111 TOT BILI-0.3 [**2121-8-6**] 11:28PM GLUCOSE-207* UREA N-72* CREAT-2.6* SODIUM-139 POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16 [**2121-8-6**] 11:37PM LACTATE-1.7 [**2121-8-6**] 11:37PM PO2-99 PCO2-38 PH-7.43 TOTAL CO2-26 BASE XS-0 COMMENTS-GREEN TOP [**2121-8-7**] 12:04AM URINE MUCOUS-RARE [**2121-8-7**] 12:04AM URINE HYALINE-9* [**2121-8-7**] 12:04AM URINE RBC-7* WBC-1 BACTERIA-MOD YEAST-NONE EPI-0 TRANS EPI-<1 [**2121-8-7**] 12:04AM URINE RBC-7* WBC-1 BACTERIA-MOD YEAST-NONE EPI-0 TRANS EPI-<1 [**2121-8-7**] 12:04AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2121-8-7**] 12:04AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2121-8-7**] 03:58AM TYPE-[**Last Name (un) **] PO2-193* PCO2-39 PH-7.41 TOTAL CO2-26 BASE XS-0 COMMENTS-GREEN TOP [**2121-8-7**] 05:05AM PLT COUNT-181 [**2121-8-7**] 05:05AM WBC-8.4 RBC-3.85* HGB-10.5* HCT-31.4* MCV-81* MCH-27.2 MCHC-33.5 RDW-15.1 [**2121-8-7**] 05:05AM CK-MB-4 cTropnT-0.16* [**2121-8-7**] 05:05AM CK(CPK)-110 [**2121-8-7**] 05:05AM GLUCOSE-191* UREA N-70* CREAT-2.3* SODIUM-140 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-28 ANION GAP-11 [**2121-8-7**] 11:19AM %HbA1c-7.6* eAG-171* [**2121-8-7**] 11:19AM CK-MB-3 cTropnT-0.18* [**2121-8-7**] 11:19AM CK(CPK)-100 . #PERTINENT LABS: [**2121-8-17**] 05:35AM BLOOD WBC-11.2*# RBC-3.86* Hgb-10.5* Hct-31.5* MCV-82 MCH-27.2 MCHC-33.2 RDW-15.8* Plt Ct-449* [**2121-8-15**] 01:00PM BLOOD WBC-5.9 RBC-4.05* Hgb-10.9* Hct-33.2* MCV-82 MCH-26.9* MCHC-32.8 RDW-15.5 Plt Ct-454* [**2121-8-14**] 05:04AM BLOOD WBC-6.0 RBC-3.72* Hgb-10.0* Hct-30.7* MCV-83 MCH-26.9* MCHC-32.6 RDW-15.3 Plt Ct-390 [**2121-8-13**] 09:15AM BLOOD WBC-6.1 RBC-3.87* Hgb-10.3* Hct-31.5* MCV-81* MCH-26.7* MCHC-32.8 RDW-15.0 Plt Ct-338 [**2121-8-12**] 01:15PM BLOOD WBC-5.4 RBC-3.83* Hgb-10.3* Hct-31.6* MCV-83 MCH-27.0 MCHC-32.7 RDW-14.8 Plt Ct-330 [**2121-8-12**] 05:26AM BLOOD WBC-5.0 RBC-3.64* Hgb-9.7* Hct-29.5* MCV-81* MCH-26.7* MCHC-33.0 RDW-14.9 Plt Ct-289 [**2121-8-11**] 07:38AM BLOOD WBC-5.0 RBC-4.01* Hgb-10.9* Hct-32.8* MCV-82 MCH-27.2 MCHC-33.3 RDW-14.7 Plt Ct-309 [**2121-8-10**] 05:37AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.1* Hct-27.3* MCV-82 MCH-27.2 MCHC-33.3 RDW-14.4 Plt Ct-211 [**2121-8-9**] 05:25AM BLOOD WBC-5.9 RBC-3.79* Hgb-10.1* Hct-30.7* MCV-81* MCH-26.8* MCHC-33.0 RDW-14.7 Plt Ct-225 [**2121-8-8**] 04:27AM BLOOD WBC-5.8 RBC-3.66* Hgb-10.0* Hct-29.8* MCV-82 MCH-27.3 MCHC-33.5 RDW-14.8 Plt Ct-209 [**2121-8-7**] 05:05AM BLOOD WBC-8.4 RBC-3.85* Hgb-10.5* Hct-31.4* MCV-81* MCH-27.2 MCHC-33.5 RDW-15.1 Plt Ct-181 [**2121-8-11**] 07:38AM BLOOD Neuts-45* Bands-0 Lymphs-39 Monos-10 Eos-6* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2121-8-9**] 05:25AM BLOOD Neuts-55.4 Lymphs-32.6 Monos-6.6 Eos-5.0* Baso-0.4 [**2121-8-11**] 07:38AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Tear Dr[**Last Name (STitle) 833**] [**2121-8-12**] 05:26AM BLOOD PT-11.1 PTT-34.3 INR(PT)-1.0 [**2121-8-10**] 05:37AM BLOOD PT-10.8 PTT-33.5 INR(PT)-1.0 [**2121-8-9**] 01:36PM BLOOD ESR-87* [**2121-8-18**] 05:30AM BLOOD Glucose-211* UreaN-64* Creat-2.1* Na-137 K-4.2 Cl-98 HCO3-31 AnGap-12 [**2121-8-17**] 05:35AM BLOOD Glucose-58* UreaN-60* Creat-1.9* Na-140 K-3.9 Cl-101 HCO3-28 AnGap-15 [**2121-8-16**] 05:35AM BLOOD Glucose-91 UreaN-55* Creat-1.9* Na-143 K-4.3 Cl-103 HCO3-29 AnGap-15 [**2121-8-14**] 09:00PM BLOOD Glucose-121* UreaN-55* Creat-2.1* Na-140 K-5.0 Cl-101 HCO3-28 AnGap-16 [**2121-8-14**] 05:04AM BLOOD Glucose-76 UreaN-59* Creat-1.8* Na-144 K-4.2 Cl-105 HCO3-34* AnGap-9 [**2121-8-12**] 01:15PM BLOOD Glucose-367* UreaN-63* Creat-1.9* Na-142 K-4.6 Cl-104 HCO3-30 AnGap-13 [**2121-8-11**] 07:38AM BLOOD Glucose-159* UreaN-69* Creat-2.0* Na-143 K-4.7 Cl-105 HCO3-28 AnGap-15 [**2121-8-10**] 05:37AM BLOOD Glucose-244* UreaN-76* Creat-2.1* Na-136 K-4.3 Cl-101 HCO3-29 AnGap-10 [**2121-8-9**] 05:25AM BLOOD Glucose-113* UreaN-79* Creat-2.6* Na-139 K-4.5 Cl-103 HCO3-29 AnGap-12 [**2121-8-8**] 04:27AM BLOOD Glucose-206* UreaN-74* Creat-2.4* Na-138 K-4.4 Cl-103 HCO3-25 AnGap-14 [**2121-8-7**] 05:05AM BLOOD Glucose-191* UreaN-70* Creat-2.3* Na-140 K-4.0 Cl-105 HCO3-28 AnGap-11 [**2121-8-8**] 04:27AM BLOOD ALT-12 AST-20 LD(LDH)-305* AlkPhos-103 TotBili-0.5 [**2121-8-7**] 11:19AM BLOOD CK(CPK)-100 [**2121-8-7**] 08:15PM BLOOD CK-MB-3 cTropnT-0.13* [**2121-8-7**] 11:19AM BLOOD CK-MB-3 cTropnT-0.18* [**2121-8-7**] 05:05AM BLOOD CK-MB-4 cTropnT-0.16* [**2121-8-18**] 05:30AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.4 [**2121-8-16**] 05:35AM BLOOD Calcium-8.6 Phos-5.3* Mg-2.5 [**2121-8-14**] 09:00PM BLOOD Calcium-9.0 Phos-5.4* Mg-2.4 [**2121-8-13**] 09:15AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.5 [**2121-8-12**] 05:26AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.7* [**2121-8-11**] 07:38AM BLOOD Calcium-8.3* Phos-4.1 Mg-2.8* [**2121-8-10**] 05:37AM BLOOD Calcium-8.0* Phos-4.4 Mg-2.6 [**2121-8-9**] 05:25AM BLOOD Calcium-8.3* Phos-4.8* Mg-2.5 [**2121-8-8**] 04:27AM BLOOD Albumin-3.4* Calcium-7.8* Phos-3.9 Mg-2.5 [**2121-8-7**] 11:19AM BLOOD %HbA1c-7.6* eAG-171* [**2121-8-7**] 03:58AM BLOOD Type-[**Last Name (un) **] pO2-193* pCO2-39 pH-7.41 calTCO2-26 Base XS-0 Comment-GREEN TOP [**2121-8-12**] 06:28PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008 [**2121-8-9**] 02:31PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.009 [**2121-8-7**] 12:04AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012 [**2121-8-12**] 06:28PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2121-8-9**] 02:31PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2121-8-7**] 12:04AM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2121-8-12**] 06:28PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 [**2121-8-9**] 02:31PM URINE RBC-53* WBC-2 Bacteri-FEW Yeast-NONE Epi-<1 [**2121-8-7**] 12:04AM URINE RBC-7* WBC-1 Bacteri-MOD Yeast-NONE Epi-0 TransE-<1 [**2121-8-12**] 06:28PM URINE CastHy-15* [**2121-8-9**] 02:31PM URINE CastHy-35* [**2121-8-7**] 12:04AM URINE CastHy-9* . #MICROBIOLOGY: [][**2121-8-6**] 11:29 pm BLOOD CULTURE # 1. **FINAL REPORT [**2121-8-12**]** Blood Culture, Routine (Final [**2121-8-12**]): NO GROWTH. . [][**2121-8-6**] 11:29 pm BLOOD CULTURE # 2. **FINAL REPORT [**2121-8-12**]** Blood Culture, Routine (Final [**2121-8-12**]): NO GROWTH . [][**2121-8-7**] 12:04 am URINE **FINAL REPORT [**2121-8-8**]** URINE CULTURE (Final [**2121-8-8**]): NO GROWTH. . [][**2121-8-8**] 4:20 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days SENSITIVITIES PERFORMED ON REQUEST.. WORK UP PER DR.[**Last Name (STitle) 16107**] #[**Numeric Identifier 16108**]. Aerobic Bottle Gram Stain (Final [**2121-8-9**]): Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16109**] @ 1815 ON [**8-9**] - [**Numeric Identifier 16110**]. GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2121-8-9**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. . [][**2121-8-8**] 5:50 pm BLOOD CULTURE #2. **FINAL REPORT [**2121-8-14**]** Blood Culture, Routine (Final [**2121-8-14**]): NO GROWTH. . [][**2121-8-9**] 2:31 pm URINE Source: Catheter. **FINAL REPORT [**2121-8-10**]** URINE CULTURE (Final [**2121-8-10**]): NO GROWTH. . [][**2121-8-9**] 2:31 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2121-8-11**]** MRSA SCREEN (Final [**2121-8-11**]): No MRSA isolated. . [][**2121-8-10**] 1:00 pm BLOOD CULTURE **FINAL REPORT [**2121-8-16**]** Blood Culture, Routine (Final [**2121-8-16**]): NO GROWTH. . [][**2121-8-11**] 7:38 am BLOOD CULTURE 1 OF 2. **FINAL REPORT [**2121-8-17**]** Blood Culture, Routine (Final [**2121-8-17**]): NO GROWTH. . [][**2121-8-12**] 5:26 am BLOOD CULTURE **FINAL REPORT [**2121-8-18**]** Blood Culture, Routine (Final [**2121-8-18**]): NO GROWTH. . [][**2121-8-17**] 3:09 pm TISSUE Site: SKIN GRAM STAIN (Final [**2121-8-17**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Preliminary): Reported to and read back by DR. [**Last Name (STitle) **] [**2121-8-18**] 12:28PM. GRAM POSITIVE COCCUS(COCCI). RARE GROWTH. ANAEROBIC CULTURE (Preliminary): ACID FAST SMEAR (Final [**2121-8-18**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. . #STUDIES: []ECG Study Date of [**2121-8-6**] 11:26:16 PM Sinus rhythm with P-R interval prolongation. Occasional ventricular premature contraction. Poor R wave progression across the precordium. Cannot exclude old anteroseptal myocardial infarction. Possible left anterior fascicular block. Compared to the previous tracing of [**2118-8-25**] ventricular premature contraction is now noted, axis is more leftward. Otherwise, no significant changes. Read by: DAS,SAUMYA Intervals Axes Rate PR QRS QT/QTc P QRS T 71 272 112 400/419 34 -41 81 . []CHEST (PORTABLE AP) Study Date of [**2121-8-6**] 11:30 PM FINDINGS: The lung volumes are low with secondary widening of the cardiomediastinal silhouette. There is no pleural effusion, no pneumothorax. No lung consolidation. Repeat study with deep inspiration is recommended, since assessment of edema is difficult with low lung volumes. . []CT HEAD W/O CONTRAST Study Date of [**2121-8-6**] 11:45 PM FINDINGS: CT OF THE HEAD: There is no evidence of hemorrhage, edema, mass effect, or infarction. The ventricles and sulci are normal in size and configuration. The [**Doctor Last Name 352**]-white matter differentiation is well preserved. There is no calvarial or skull base fracture. The paranasal sinuses and mastoid air cells are clear. There is bilateral vertebral artery and cavernous carotid artery calcification. IMPRESSION: Mild arterial atherosclerotic calcification. Otherwise normal study. . []TTE [**2121-8-7**] Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size and wall thickness with preserved global left ventricular systolic function. Mildly dilated ascending aorta and aortic arch. No clinically significant valvular regurgitation or stenosis. Mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2118-8-23**], it appears that the global left ventricular systolic function may have diminished slightly vs the prior study, but the image quality is markedly worse on the current study and thus a direct comparison of all previously measured parameters cannot be made. . []ECG Study Date of [**2121-8-7**] 9:18:18 AM Normal sinus rhythm with frequent premature atrial contractions. A-V conduction delay with P-R interval equal to 0.25 seconds. Left anterior fascicular block. Non-specific ST-T wave abnormalities. Delayed R wave transition. Compared to the previous tracing of [**2121-8-6**] no diagnostic change. TRACING #1 Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **] Intervals Axes Rate PR QRS QT/QTc P QRS T 90 [**Telephone/Fax (3) 16111**]/414 69 -47 90 . [] CT C-SPINE W/O CONTRAST Study Date of [**2121-8-7**] 12:12 AM FINDINGS: CT OF THE SPINE: The height of the vertebral bodies of the C-spine is preserved. No prevertebral soft tissue swelling. There is no evidence of fracture or malalignment. Secretions are seen in the hypopharynx at the level of the piriform sinuses. There are no significant degenerative changes. The lung apices are clear. The thyroid gland is normal. CT has limited resolution for intraspinal soft tissue abnormalities. If there are new neurological findings after trauma, an MR may be helpful to identify abnormalities such as disk protrusions or hematoma. IMPRESSION: No evidence of fracture or malalignment. Secretions in hypopharynx at the level of the piriform sinuses. . []CT ABD & PELVIS & CHEST W/O CONTRAST Study Date of [**2121-8-7**] 1:02 AM FINDINGS: CT OF THE CHEST: There is no pneumomediastinum, mediastinal hemorrhage, pericardial or pleural effusion. There are atherosclerotic calcifications of the coronary arteries. There is no mediastinal, hilar, or axillary lymphadenopathy. The right middle lobe bronchus is slightly narrowed. There are bibasilar atelectatic changes. There are no suspicious pulmonary nodules. The pulmonary artery is enlarged, likely due to pulmonary hypertension with prominent vascular hila. There is no evidence of pericholecystic fluid or wall thickening. There are no focal hepatic lesions, however, evaluation is limited without intravenous contrast. The pancreas is atrophic. The spleen and both kidneys are normal. There is no retroperitoneal or mesenteric lymphadenopathy. There are mild atherosclerotic calcifications at the [**Female First Name (un) 899**] and external iliac arteries. The stomach, and large bowel are normal. Moderate amount of stool throughout colon. CT OF THE PELVIS: There is a right small bowel-containing inguinal hernia and a left fat-containing inguinal hernia. No free fluid and no free air. The prostate gland, seminal vesicles, and urinary bladder are normal. A Foley catheter is seen in the urinary bladder. Diverticulosis, but no diverticulitis. There is a severe, likely chronic compression fracture of the L1 vertebral body of unknown chronicity without significant retropulsion and moderate multilevel facet degenerative changes. IMPRESSION: 1. Almost complete wedge compression fracture of L1 without retropulsion into the spinal canal, more likely subacute or chronic. 2. Right nonobstructed small bowel containing inguinal hernia. 3. Bibasilar lung opacities, likely atelectasis. 4. Prominent pulmonary artery. . []CHEST (PORTABLE AP) Study Date of [**2121-8-7**] 7:18 AM FINDINGS: As compared to the previous radiograph, the lung volumes remain low. Despite the low lung volumes, the findings are suggestive of mild-to-moderate pulmonary edema. Newly occurred areas of atelectasis at the left lung base. . []ECG Study Date of [**2121-8-8**] 8:55:58 AM Normal sinus rhythm with A-V conduction delay. Left anterior fascicular block. Delayed R wave transition. No diagnostic change from tracing #1. TRACING #2 Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **] Intervals Axes Rate PR QRS QT/QTc P QRS T 83 [**Telephone/Fax (3) 16112**]/424 31 -40 85 . [] FOOT 2 VIEWS RIGHT Study Date of [**2121-8-9**] 3:45 PM FINDINGS: Prior exam dated [**2109-3-25**] demonstrates transmetatarsal amputation of all digits. In the interval there has been increased vascular calcifications and increased osteopenia. There is no periosteal reaction to suggest osteomyelitis but MR would be more sensitive. There is irregularity of the distal tibia compatible with a fracture. This is only seen on the lateral film. This finding was called to Dr. [**Last Name (STitle) 11924**] at the time of discovery at 8 a.m. by Dr. [**Last Name (STitle) 410**] by phone. . []CHEST (PA & LAT) Study Date of [**2121-8-9**] 3:45 PM FINDINGS: Lung volumes continue to be low but are slightly improved compared to the study from two days prior. There is improved aeration at the bases and decreased vascular plethora, however, there is still an element of pulmonary vascular redistribution and mild cardiomegaly. Thus, mild fluid overload is likely. . []ECG Study Date of [**2121-8-16**] 1:42:54 AM Baseline artifact. Sinus rhythm with marked P-R interval prolongation and intraventricular conduction delay. Left ventricular hypertrophy with strain type pattern. Left axis deviation with left anterior fascicular block. Delayed anterior R wave progression may be due to left ventricular hypertrophy, but prior anteroseptal myocardial infarction cannot be excluded. Compared to the previous tracing of [**2121-8-8**] the rate is slower. Downsloping ST segment depression has given way to ST segment flattening in lead I. T wave inversions are similar in lead aVL. ST segments are flatter in leads V3-V6 of uncertain significance. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Intervals Axes Rate PR QRS QT/QTc P QRS T 61 296 116 450/451 21 -45 95 . [] CHEST (PA & LAT) Study Date of [**2121-8-17**] 6:37 PM IMPRESSION: AP chest compared to [**2117-2-1**] through [**2121-8-12**]: Region of scarring in the right middle lobe has been present to some degree for several years. There is also a region of chronic atelectasis in the left lower lobe. Overall, there are no new focal findings to suggest pneumonia. Low lung volumes are probably due in part to vascular dilatation in the lungs and top normal heart dimensions. . []KNEE (2 VIEWS) RIGHT Study Date of [**2121-8-17**] 6:50 PM FINDINGS: No acute fracture or dislocation. Cast material projects over the proximal right tibia and fibula. Bone demineralization Prominent atherosclerotic calcifications. Lack of tangential or standing views renders evaluation of the joint spaces suboptimal. IMPRESSION: 1. No acute fracture or dislocation. 2. Prominent atherosclerosis. 3. Bone demineralization. . []TIB/FIB (AP & LAT) RIGHT PORT Study Date of [**2121-8-18**] 3:26 PM FINDINGS: In comparison with the study of [**8-17**], there is cast about somewhat obscuring what appears to be a complex fracture of the ankle with involvement of the distal tibial shaft as well as the medial malleolus. Brief Hospital Course: []BRIEF CLINICAL COURSE: 54 year old male with CAD, CHF, and PVD presents with fever and tachypnea, initial c/f sepsis and sent to MICU, quickly stabilized and sent to floor for optimization of CHF exacerbation and continuation of r/o ACS. He continued to spike fevers without an identifiable source, ID consulted, serial cultures negative and antibiotics held. Patient defervesced over the 3 days prior to discharge and was evaluated by derm for stasis dermatitis of RLE, and evaluated by ortho for distal tib/fib fracture that was placed in a cast. . []ACTIVE ISSUES: . # ACUTE ON CHRONIC DIASTOLIC CHF EXACERBATION: New oxygen requirement previously requiring cpap. Initial admission CXR consistent with pulmonary edema and crackles on exam. The patient received 20mg Lasix IV on arrival to the floor and another 40mg IV at 1300 on [**2121-8-8**], was started on 60mg IV lasix [**Hospital1 **] on [**2121-8-9**]. The patient was started on daily 60mg torsemide on [**2121-8-12**]; got extra dose of 60mg IV lasix afternoon of [**2121-8-12**]. Transitioned to 60mg torsemide [**Hospital1 **] [**2121-8-14**] with daily net negatives of ~2L. Creatinine and electrolytes remained stable throughout his inpatient diuresis and repeat CXR showed interval improvement in lung fields, vascular congestion, and no evidence of a pneumonia. Clinically, the patient had no O2 requirement in the 48 hours leading up to discharge, denies SOB, dyspnea or orthopnea. . # FEVER/SIRS LIKELY [**12-26**] DIABETIC FOOT ULCER: Meets SIRS criteria for fever, tachycardia likely [**12-26**] diabetic foot ulcer. Possible other sources included urine, cellulitis, or PNA. Received a dose of vancomycin and cefepime in ED. Although the tachypnea could be CHF exacerbation, the patient has risk factors for health care associated pneumonia. CXR suboptimal given pulmonary edema and body habitus. The patient was placed on vancomycin, ciprofloxacin, metronidazole on [**2121-8-9**]: covering for MRSA, gm-, pseudomonas, anaerobes given ulcer & high risk for infection, diabetes, peripheral vascular disease. This regimen was stopped on [**2121-8-10**] given no clear etiology for fevers. The patient was afebrile X 24 hours and recultured on [**2121-8-10**] and [**2121-8-11**] per ID recs and will restart Vanc and cefepime if he spikes >101. Wound care consulted, recs implemented and podiatry was consulted, rec'd continuing current regimen. We ruled out chronic RLE osteomyelitis with foot and leg plain films. The patient had an elevated ESR 87. X-ray of RLE, revealed tib-fib fracture, consulted ortho cast placed [**2121-8-13**]. Derm consulted for large RLE wound with weeping, little concern for infectious source given good wound care. Repeat CXR, final read no e/o PNA. F/u blood cultures, GPCs in clusters from blood cultures, speciation of S. epi likely contaminant since [**11-25**] bottle sets; ID consulted. 1st urine culture negative, repeat UA/Ucx negative for growth. . #STASIS DERMATITIS: PAtient with chronic (since [**2119**]) large right lower extremity lesion that encompasses the entire ventral surface of the shin, with keloid formations, tense bullae and areas of weeping serosanguinous discharge; little clinical suspicion for infection given good wound care. Derm consulted and saw patient; diagnosis of stasis dermatitis. PAtient refused biopsy on first attempt, then allowed biopsy which preliminarily came back + for GPCs, with plans to follow up in derm clinic. . # CHEST PAIN: On the day of admission he reports having 5 minutes of chest pain with radiation down his left arm without nausea, sweating or exacerbation with movement. The chest pain had resolved on admission and his EKG did not have ischemic changes. His troponin was elevated at 0.14 which is near baseline for him. Troponins trended up to 0.18 but his CKMB was normal at 2-4. He did not have any other episodes of chest pain. . #HYPERTENSION: Patient's BP meds stopped on arrival to the MICU [**12-26**] hypotension and c/f septic picture. SBPs > 170 on arrival to the floor. Switched from metoprolol to coreg 12.5 on [**2121-8-13**]. We continued the patient on amlodipine, hydralazine 40mg TID, isosorbide dinitrate 20mg TID. . # BRADYCARDIA: On the morning of admission to the MICU he had an episode of bradycardia to the 30-40s with nausea and diaphoresis, but did not have an further episodes while in the MICU. Unclear [**Name2 (NI) 16113**], very transient, but in the setting of a troponinemia and known right coronary disease, concern for possible SA node dysfunction secondary to NSTEMI. Also possible is vasovagal episode. troponins downtrending and known to be baseline elevated in past [**12-26**] CKD. Once on the floor, the patient's heart rate never dipped below the 70's and he had no more episodes of symptomatic bradycardia. . #DISTAL TIBIA/FIBULA FRACTURE: Likely [**12-26**] fall prior to admission. Patient did not complain of right lower extremity pain out of proportion to his baseline pain with the stasis dermatitis. The patient received a foot x-ray out of concern for osteomyelitis after podiatry saw patient and gave wound care recs. Foot x-ray negative for osteomyelitis but revealed possible distal tib/fib fracture. Repeat leg x-ray of right lower extremity showed distal tib/fib fracture. Orthopedics saw patient and decided not to operate, and opted for short casting instead. . # TACHYPNEA: On admission his CXR was c/w pulmonary edema secondary to CHF but could not rule out pneumonia or a PE. Because of his kidney failure he was unable to get a CTA to rule out a PE. Because he was febrile in the ED he was given one dose of vancomycin and cefepime to cover for health care associated pneumonia but these antibiotics were discontinued in the MICU because he did not have evidence of infection. Repeat chest X-ray revealed no evidence of pneumonia. Patient had no supplemental O2 requirement in the days leading up to discharge, with normal respiratory rates, no increased work of breathing and O2 sats >95% on room air. . # ACUTE ON CHRONIC CKD: Unclear history of CKD, Cr elevated on admission to 2.6, up from recent baseline value 1.6. I/O's trended and at discharge the patient's creatinine was 1.8 and the patient's urine output was WNL. . # L1 COMPRESSION FRACTURE: Possible acute exacerbation of chronic injury. We continued his home pain regimen of oxycontin and oxycodone. . # HIP PAIN: Secondary to fall. CT-abdomen/pelvis revealed no hip fracture or other pathology. Pain control as above. . []TRANSITIONAL ISSUES: -patient will f/u with orthopedics in 2 weeks with Dr. [**Last Name (STitle) **] for eval of distal tib/fib fracture -patient will f/u with dermatology as an outpatient; prelim biopsy results showed GPCs on gram stain, final report pending. -patient will f/u with [**Last Name (un) 387**] providers as an outpatient -patient will f/u with Dr. [**Last Name (STitle) **] for cardiology med management and optimization on [**8-26**]. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from rehab records. 1. Baclofen 10 mg PO TID 2. Oxycodone SR (OxyconTIN) 10 mg PO Q12H hold for sedation or rr<10 3. Multivitamins W/minerals 1 TAB PO DAILY 4. Amlodipine 10 mg PO DAILY 5. Aspirin 325 mg PO DAILY 6. Metoclopramide 5 mg PO TID:PRN nausea 7. Levothyroxine Sodium 100 mcg PO DAILY 8. Polyethylene Glycol 17 g PO DAILY 9. Docusate Sodium 100 mg PO TID 10. Bisacodyl 10 mg PO DAILY:PRN constipation 11. Quetiapine Fumarate 50 mg PO HS 12. Quetiapine Fumarate 25 mg PO BID:PRN agitation 13. Prochlorperazine 10 mg PO Q6H:PRN nausea 14. Acetaminophen 650 mg PO Q4H:PRN pain or fever 15. Clopidogrel 75 mg PO DAILY 16. Pantoprazole 40 mg PO Q24H 17. Atorvastatin 80 mg PO DAILY 18. Ferrous Sulfate 325 mg PO DAILY 19. Gabapentin 300 mg PO DAILY 20. Tamsulosin 0.4 mg PO HS 21. HydrOXYzine 50 mg PO Q8H:PRN itch 22. MetFORMIN (Glucophage) 500 mg PO DAILY 23. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 24. Glargine 48 Units Breakfast Insulin SC Sliding Scale using REG Insulin 25. Lactulose 15 mL PO DAILY 26. Senna 2 TAB PO BID 27. Furosemide 20 mg PO BID 28. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN SOB 29. Metoprolol Succinate XL 50 mg PO DAILY 30. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 31. Fluocinolone Acetonide 0.01% Cream 1 Appl TP [**Hospital1 **] 32. Isosorbide Dinitrate 5 mg PO TID Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 2. Amlodipine 10 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Baclofen 10 mg PO TID 5. Bisacodyl 10 mg PO DAILY:PRN constipation 6. Clopidogrel 75 mg PO DAILY 7. Docusate Sodium 100 mg PO TID 8. Ferrous Sulfate 325 mg PO DAILY 9. Gabapentin 300 mg PO DAILY 10. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN SOB 11. Lactulose 15 mL PO DAILY 12. Levothyroxine Sodium 100 mcg PO DAILY 13. Metoclopramide 5 mg PO TID:PRN nausea 14. Multivitamins W/minerals 1 TAB PO DAILY 15. Oxycodone SR (OxyconTIN) 10 mg PO Q12H hold for sedation or rr<10 16. Pantoprazole 40 mg PO Q24H 17. Polyethylene Glycol 17 g PO DAILY 18. Prochlorperazine 10 mg PO Q6H:PRN nausea 19. Quetiapine Fumarate 50 mg PO HS 20. Quetiapine Fumarate 25 mg PO BID:PRN agitation 21. Senna 2 TAB PO BID 22. Tamsulosin 0.4 mg PO HS 23. Acetaminophen 650 mg PO Q4H:PRN pain or fever 24. Fluocinolone Acetonide 0.01% Cream 1 Appl TP [**Hospital1 **] 25. HydrOXYzine 50 mg PO Q8H:PRN itch 26. MetFORMIN (Glucophage) 500 mg PO DAILY 27. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain hold for sedation or RR < 10 28. Isosorbide Dinitrate 20 mg PO TID hold for sbp < 100 29. HydrALAzine 40 mg PO TID hold for SBP < 100 30. Aspirin 81 mg PO DAILY 31. Glargine 50 Units Breakfast Insulin SC Sliding Scale using REG Insulin 32. Torsemide 60 mg PO DAILY hold for SBP < 90 33. Carvedilol 12.5 mg PO BID hold for SBP < 100 or HR < 60 Discharge Disposition: Extended Care Facility: [**Hospital1 **] Nursing & Therapy Center - [**Hospital3 4414**] ([**Hospital3 4414**] Rehabilitation and Nursing Center) Discharge Diagnosis: acute on chronic dCHF exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 16114**], It was a pleasure taking care of you. You were admitted to the [**Hospital1 69**] for having low blood pressures and breathing rapidly. There was concern that you may have had an infection and you were placed on antibiotics and transferred to the intensive care unit. You quickly stabilized and were transferred to the cardiology unit out of concern that you may have had some fluid overload. We gave you medicine to increase your urination to get some of that fluid off. You improved significantly and were stable enough to go back to your extended care facility. We wish you the best. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2121-8-26**] at 2:00 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 6738**], 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: ORTHOPEDICS When: THURSDAY [**2121-8-28**] at 3:20 PM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: THURSDAY [**2121-8-28**] at 3:40 PM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DERMATOLOGY When: WEDNESDAY [**2121-9-24**] at 10:00 AM With: [**Doctor First Name **]-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8476**], MD, PHD [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "86.11" ]

icd9pcs

[ [ [] ] ]

34066, 34214

24139, 24695

302, 309

34293, 34293

4752, 4753

35125, 36348

2753, 2827

32603, 34043

34235, 34272

31168, 32580

34469, 35102

2868, 3733

14290, 14290

12122, 14122

14323, 24116

30709, 31142

243, 264

24710, 30688

337, 2118

4769, 6653

14159, 14253

34308, 34445

6669, 12078

2140, 2548

2564, 2737

3758, 4733

54,969

137,885

4916

Discharge summary

report

Admission Date: [**2165-5-23**] Discharge Date: [**2165-5-28**] Service: NEUROSURGERY Allergies: Penicillins / Aspirin / Sulfa (Sulfonamides) / Levofloxacin / Vioxx / Morphine Attending:[**First Name3 (LF) 1271**] Chief Complaint: Witnessed Fall Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] year old female with baseline Dementia and Alzheimer's Disease who stood up at Rehab this morning and fell and hit her head. She was at the Rehab because she had recently had another fall at home in which she fractured her hip. She live at home with her daughter with the assistance of a home health aide. Past Medical History: # Renal cell carcinoma s/p nephrectomy [**2153**] # RLL lung nodule noted in [**2155**], disappeared per [**7-27**] CT scan. # Myelodysplastic syndrome # Anemia, h/o Vitamin B12 deficiency, baseline Hct 27-31 over the past 3 years # Thrombocytopenia, baseline plt 50-120 over the past 3 years # Alzheimer's disease # GERD # h/o UTIs # Hypertension # h/o orthostatic hypotension/syncope # Depression # s/p patellar surgery # s/p appendectomy # s/p cholecystectomy Social History: The patient is a retired nurse [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) 5976**]. She has several children and lives with her daughter, [**Name (NI) 20471**] [**Name (NI) 1538**]. She denies alcohol and tobacco use. Family History: There is no history of anemia or other blood disorders. Her aunt had [**Name2 (NI) 499**] cancer, brother had thyroid cancer, and first cousin had breast cancer. Physical Exam: Gen: pt moaning, not following commands, eyes closed HEENT: Pupils: 4.5-3 EOMspt does not participate Neuro: Mental status: pt with baseline dementia, Alzheimer's disease, not following commands, eyes closed, moaning, non- verbal Orientation: patient not oriented to person, place, or date. Language: intermittent moaning only Naming intact/recall: pt unable to participate Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4.5 to 3 mm bilaterally. III, IV, VI: Extraocular movements unable to test V, VII: Facial strength/sensation unable to test VIII,IX, X,[**Doctor First Name 81**], XII: unable to test due to poor mental status Motor: pt moves all extremities on bed spontaneously, not to command Pertinent Results: [**2165-5-24**] 12:20AM BLOOD WBC-11.8*# RBC-2.37* Hgb-8.2* Hct-25.4* MCV-107* MCH-34.8* MCHC-32.5 RDW-16.9* Plt Ct-64* [**2165-5-23**] 10:23AM BLOOD Neuts-83.9* Lymphs-9.3* Monos-5.3 Eos-1.4 Baso-0.2 [**2165-5-24**] 04:54AM BLOOD Plt Ct-108*# [**2165-5-24**] 12:20AM BLOOD Glucose-129* UreaN-30* Creat-1.1 Na-142 K-4.5 Cl-110* HCO3-24 AnGap-13 [**2165-5-23**] 10:23AM BLOOD CK(CPK)-48 [**2165-5-24**] 12:20AM BLOOD Albumin-3.7 Calcium-8.7 Phos-3.8 Mg-1.9 [**2165-5-23**] 08:11PM BLOOD Type-ART pO2-234* pCO2-41 pH-7.39 calTCO2-26 Base XS-0 Brief Hospital Course: Ms [**Known lastname **] was admitted to the ICU for q 1 hour neuro checks, she was loaded with Dilantin and a CTA showed no aneurysmal cause of bleed. Her BP<160,Platlet count goal > 80, PCO2 goal 35-45, INR< 1.4. On hospital day 1 Ms [**Known lastname **] was following commands in Spanish and moving all extremities symmetrically. A follow-up CT showed extensive SAH unchanged from admission. Family discussions were held and it was decided to extubate Ms [**Known lastname **] as she was requiring very little respiratory support. The family also received support from She was DNR but the family wanted to reconsider intubating if needed. She was successfully extubated however she had excessive secretions requing frequent suctioning. A trial of CPAP and BIPap was done, the patient continued with respiratory distress and chose to have the patient reintubated. A repeat CT was done that showed minimal improvement in the SAH blood no strokes were evident. The patient had a poor neurological exam, she did not follow commands and had minimal movement. The family decided to extubate her and she was made CMO. She passed away on [**2165-5-28**] in the presence of her family. Medications on Admission: . Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation Q4H (every 4 hours) as needed. 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 5. Gabapentin 250 mg/5 mL Solution Sig: One (1) PO DAILY (Daily). 6. Memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO twice a day. 8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as needed. 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO three times a day. 11. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain: do not exceed 4 grams in 1 day. 12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q24H (every 24 hours) for 3 weeks: complete a total of 4 weeks (28 days) post-op (Or on [**4-1**]). 16. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Traumatic SAH Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2165-5-28**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

5622, 5631

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305, 311

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109,696

47426

Discharge summary

report

Admission Date: [**2201-5-2**] Discharge Date: [**2201-5-22**] Date of Birth: [**2128-4-1**] Sex: M Service: [**Last Name (un) **] PROCEDURES DURING ADMISSION: None. ADMISSION DIAGNOSES: History of EtOH abuse. Parotid tumor. DISCHARGE DIAGNOSES: Intracranial hemorrhage status post fall. Alcohol withdrawal. Respiratory arrest on the floor requiring intubation. Urinary tract infection. Aspiration pneumonia. Post head injury confusion. Failure to pass swallow evaluation requiring total parenteral nutrition. HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old male with past medical history significant for EtOH abuse and parotid tumor status post surgery, who was transferred to [**Hospital1 69**] after a fall. The patient had been drinking wine and had an unwitnessed fall. The patient was found at the base of 14 stairs on a tile floor with unknown loss of consciousness. Patient complained of right elbow pain. PAST MEDICAL HISTORY: Parotid tumor. PAST SURGICAL HISTORY: Parotid surgery. MEDICATIONS ON ADMISSION: 1. Amitriptyline. 2. Serax. 3. Librium. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile, heart rate in the 100s, blood pressure is in the 120s/90s. He was saturating 100 percent on room air. GCS of 14. His head was atraumatic. He had no facial deformities. His neck had a C collar in place. There was no tracheal shift. There were no step-offs. His heart was regular. His lungs were clear. His abdomen was soft, nontender, nondistended. His rectal has normal tone, is guaiac negative. His extremities had no deformities. He was tender over his right elbow. He had a right hand abrasion. His back was nontender, no step- offs and no deformities. Motor [**4-29**] grossly intact in all four extremities. LABORATORIES ON ADMISSION: Hematocrit of 41.3. He had a sodium of 150. His creatinine was normal at 0.7. His INR was 0.9. X-RAYS: His CT of his head revealed small amount of subdural blood with a small amount of subarachnoid blood. There were no bony abnormalities. There was no midline shift. CT of the C spine was negative. CT of his abdomen and pelvis is negative. His TLS films: There was a question of L5-S1 anterolisthesis old versus new. His right humerus film was negative. His right wrist film was negative. Chest x-ray was negative as was his pelvis x-ray. HOSPITAL COURSE: The patient was admitted on [**2201-5-2**] to the Intensive Care Unit for q1h neurologic checks. He was seen in consultation by Neurosurgery, who recommended a MRI of his brain with gadolinium on hospital day one to assess for bleed versus meningeoma. They also recommended a MRI of his spine given the abnormalities on his TLS film. The patient's original ICU course was significant for tachycardia, which was thought to be secondary to DT's. This was treated with a CIWA protocol. The patient also required intubation for his MRI given his severe agitation and inability to remain still. The patient went for his MRI, which revealed likely old L5-S1 anterolisthesis and spondylosis. The MRI of his C spine was negative as well. His C collar was removed and his TLS was cleared. The patient was extubated. He continued to do well, and was transferred on the floor. On the floor, he continued to have significant confusion. He was seen in consultation by the Neurology team, and they felt that maybe he was withdrawing from his Ativan, and therefore his Ativan dose was increased. He also had some respiratory issues including a bout of stridor as well as low sats. His chest x-ray did show a question of a right lower lobe infiltrate versus atelectasis, however, his ABGs were normal and the patient continued to saturate well. He was treated with Decadron and racemic epi for his stridor, which improved and his nasogastric tube was removed, which had been giving him tube feeds. The patient did improve somewhat, however, on [**2201-5-16**], the patient was found in his room with a heart rate in the 30s, unresponsive. A code was called and the patient was resuscitated. He was intubated and transferred to the Intensive Care Unit, where a central venous line was placed and he was resuscitated for a low CVP. Also of significance, the patient did have a urine culture, which is positive for Staph and Enterococci as well as one positive blood culture. Originally these were both treated with vancomycin, however, when they came sensitive to Levaquin, his antibiotics were changed. His ICU course was significant for the fact that the patient self extubated on [**2201-5-18**]. He did well with this, however, and did not require intubation. His last day in the unit was essentially otherwise uneventful. He continued to improve. His confusion cleared, and his Ativan was weaned. He did undergo a swallow evaluation on [**2201-4-21**], which revealed some coughing with liquids as well as soft solids, so it was decided to continue him NPO. At discharge, the plan is to either continue the TPN and allow the patient to re-undergo a swallow evaluation at rehab or to likely place a Dobbhoff versus a PEG for tube feeds. The patient was seen in consultation by ENT given his small amount of stridor, and they did not see any anatomic abnormality, however, they did see some minimal erythema. It was felt that the patient should be on Protonix b.i.d. for likely reflux. The patient is stable at discharge. He should follow up with Neurosurgery as well as in the Trauma Clinic. We will place the exact follow-up instructions in the page one. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Ativan 0.5 mg IV q.h.s. prn insomnia. 2. Protonix 40 mg IV q.12h. 3. Lopressor 5 mg IV q.6h. 4. Levofloxacin 500 mg IV q.24h. for a total of 10 days. This will end on the [**2-23**]. Regular insulin-sliding scale. 6. Heparin 5000 units subQ b.i.d. [**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**] Dictated By:[**Last Name (NamePattern1) 56208**] MEDQUIST36 D: [**2201-5-22**] 09:09:08 T: [**2201-5-22**] 09:30:38 Job#: [**Job Number **]

[ "852.09", "599.0", "038.19", "507.0", "518.0", "291.0", "303.91", "995.91", "486" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.60", "94.62", "38.91", "96.04", "99.15", "96.71" ]

icd9pcs

[ [ [] ] ]

5633, 5642

273, 544

5665, 6188

1068, 1169

2440, 5611

1024, 1042

211, 251

573, 961

1867, 2422

984, 1000

73,385

135,402

38702

Discharge summary

report

Admission Date: [**2191-3-18**] Discharge Date: [**2191-4-21**] Date of Birth: [**2165-2-1**] Sex: M Service: NEUROSURGERY Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 78**] Chief Complaint: Gun Shot Wound (Self-Inflicted) Major Surgical or Invasive Procedure: Right Craniectomy Evacuation of Right Epidural Hematoma Left Frontal Bolt Placement Left Central Line Placement Tracheostomy PEG placment Picc line insertion Bronchial alveolar lavage [**Location (un) 4569**] nest IVCF placement / non retrievable History of Present Illness: 26-year-old man presenting with single, self-inflicted through-and-through gunshot wound with entry through the left occiput and exit via the right occiput. Patient has a history of severe depression. Was at a party on [**2191-3-17**] and, per EMS report, fired a single shot to the head from a handgun. He was initiallyresponsive with EMS, but by the time [**Location (un) 7622**] arrived had a GCS of 3. Past Medical History: Depression Social History: N/A Family History: N/A Physical Exam: Exam on Admission: HR:40 BP:90/60 Resp:bagged O(2)Sat:88% low Constitutional: unresponsive Head / Eyes: bilateral GSW's with brain matter,right pupil 4mm, left pupil 2mm and not responsive ENT / Neck: combitube in place Chest/Resp: Clear to auscultation Cardiovascular: bradycardic GI / Abdominal: Soft, Nontender, Nondistended Musc/Extr/Back: No cyanosis, clubbing or edema Neuro: unresponsive Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae On discharge: OFF VENT opens eys to voice/ conjugate gaze with ? purposeful eye movements vs roving / ? looks towards voice of examiner / pupils [**7-14**] bilaterally / chewing motion at times / ? suckiung reflex at times / weakly attempts to localize with LUE / some spontaneous right hand movement noted / triple flexion bilateral LE / no commands / no attempt to verbalize / ?orientation - no Y/N responses. Pertinent Results: Cardiology Report ECG Study Date of [**2191-3-18**] 8:39:04 AM Sinus rhythm. Peaked T waves in the precordial leasd. Cannot rule out hyperkalemia. Otherwise, no other diagnostic abnormality. No previous tracing available for comparison. Radiology Report CTA HEAD W&W/O C & RECONS Study Date of [**2191-3-18**] 2:55 AM Final Report INDICATION: 26-year-old male with gunshot wound to head FINDINGS: Extensive bullet shrapnel and soft tissue swelling are seen overlying a comminuted, displaced skull fracture of the posterior and left lateral skull. The fracture extends inferiorly to the level of the posterior fossa, without definite involvement of the bilateral carotid canals and jugular foramen. Superiorly, severe comminution is noted with significant 1.5-2 cm outer displacement of posterior skull fragments and extension into the left frontal bone. The fracture lines extend superiorly to involve the left frontal and temporal bones. There is extensive intracranial shrapnel seen in the supratentorial region, primarily along the right aspect of the superior tentorium cerebelli. There is associated pneumocephalus, with locules of gas seen along the right posterior cerebral convexity and right tentorium cerebelli. There is severe outward displacement of two fracture fragments in the bilateral posterior skull. This is associated with large bilateral subgaleal hematomas, soft tissue swelling, and subcutaneous emphysema. Within the skull, there is a large right subdural hematoma occupying the superior right cerebral convexity. This produces mass effect with slight effacement of the right lateral ventricle and 6 mm leftward shift of the normal midline structures. Hemorrhage is seen tracking along the bifrontal convexity anteriorly and posteriorly along the tentorium cerebelli and left pericerebellar region. There is diffuse effacement of sulci, consistent with diffuse cerebral edema. The ventricles and basal cisterns also appear tight. There is no subfalcine or uncal herniation. There is partial opacification of the bilateral mastoid air cells. Fluid is seen in the bilateral sphenoid, ethmoid, and frontal sinuses. There is mild mucosal thickening of the bilateral maxillary sinuses, with isolated retention cysts seen bilaterally. The ostiomeatal units are not definitely visualized bilaterally due to patient motion, but appear occluded bilaterally. HEAD CTA: The carotid and vertebral arteries and their major branches appear patent throughout their courses, with no evidence of aneurysms, stenosis, dissection, or occlusion. Note is made of a dominant left vertebral artery. The venous sinuses are not opacified on this phase of imaging, and venous sinus injury cannot be ruled out. This would be of high suspicion in a patient with comminuted basilar skull fracture and subdural hemorrhage. IMPRESSION: 1. Gunshot wound injury with severe comminuted skull fracture and intracranial bone/shrapnel. Bilateral large subgaleal hematomas. 2. Right subdural hemorrhage with moderate mass effect. 3. Diffuse sulcal effacement, suggesting diffuse cerebral edema. No evidence of herniation. 4. Intact intracranial arterial circulation. Given the pattern of injury, there is high suspicion for venous sinus injury. CT venogram can be ordered if there is high clinical suspicion. Neurophysiology Report EEG Study Date of [**2191-3-19**] IMPRESSION: This telemetry captured no pushbutton activations, and routine sampling and automated detections showed no epileptiform features or electrographic seizures. The background was severely suppressed, initially showing a burst suppression pattern and later with an encephalopathic-appearing slow background, followed by a more suppressed period again but without sharper features. In all, the recording indicates a widespread encephalopathy. Anoxia and pentobarbital are two possible explanations. During the early encephalopathic period, the background was more suppressed on the left. Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [**2191-3-18**] 2:34 PM FINDINGS: New left subclavian vascular catheter terminates within the proximal superior vena cava, with no visible pneumothorax. Lungs are grossly clear except for a small residual area of atelectasis in the right upper lobe, which was previously completely collapsed on earlier study at 3:49 a.m.. Radiology Report CTA HEAD W&W/O C & RECONS Study Date of [**2191-3-21**] 10:48 AM FINDINGS: CT: Again seen is a bullet in the posterior left occipital soft tissues, with extensive streak artifact that limits visualization. There is a comminuted, displaced skull fracture of the posterior skull, which extends from the skull vertex to the posterior fossa. There is extensive intracranial shrapnel seen in the supratentorial region. Changes of right frontal craniectomy are also seen. There are bilateral frontal subgaleal hematomas, left greater than right, with associated soft tissue swelling and subcutaneous emphysema. A drain and multiple staples are noted in the soft tissues. Multiple areas of subdural, intraparenchymal, and subarachnoid hemorrhage are similar in appearance. There is extensive sulcal effacement and blurring of the [**Doctor Last Name 352**]-white matter junctions, consistent with diffuse cerebral edema. Hypodense areas noted in the bilateral parietal lobes and right occipital lobe are unchanged and may represent ischemia/infarcts. There is no evidence of subfalcine or uncal herniation. There is no shift of the normal midline structures. There is bilateral mild thickening and air-fluid levels in the maxillary, sphenoid, and frontoethmoid sinuses. The mastoid air cells are partially opacified bilaterally. HEAD CTA: Visualization is limited by poor bolus injection. The intracranial carotid and vertebral arteries and their branches opacify with no evidence of aneurysm, stenosis, or occlusion. The intracranial vessels appear slightly decreased in caliber, which may represent poor bolus technique versus minimal-to-mild diffuse vasospasm. IMPRESSION: 1. Possible minimal diffuse vasospasm of the intracranial arteries- assessment limited due to artifacts and suboptimal bolus timing . 2. Paranasal sinus disease. 3. Comminuted skull fracture with unchanged subdural, subarachnoid, and intraparenchymal hemorrhage. Hypodense areas in the brain parenchyma, as detailed above- can relate to ischemia/infarction/ trauamtic injury; grossly unchanged; accuarte assessment limited due to artifacts. 4. Some degree of diffuse cerebral edema without herniation. Correlate with ICP/clincially. Radiology Report UNILAT UP EXT VEINS US LEFT Study Date of [**2191-3-23**] 5:35 PM IMPRESSION: 1. No evidence of deep venous thrombus. 2. Superficial thrombus in the distal left cephalic vein and the left basilic vein. Radiology Report BILAT LOWER EXT VEINS PORT Study Date of [**2191-3-23**] 2:55 PM IMPRESSION: No evidence of DVT bilaterally. Finding compatible with hematoma in the left groin. Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 85979**],[**Known firstname **] [**2165-2-1**] 26 Male [**Numeric Identifier 85980**] [**Numeric Identifier 85981**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mtd SPECIMEN SUBMITTED: BULLET FRAGMENT, ENTRANCE SITE FOREIGN BODY. Procedure date Tissue received Report Date Diagnosed by [**2191-3-30**] [**2191-3-30**] [**2191-4-1**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mrr?????? DIAGNOSIS: Entrance site foreign body: Fibrin with acute inflammation and nonpolarizing foreign material. Radiology Report CT HEAD W/ & W/O CONTRAST Study Date of [**2191-4-4**] 11:29 AM FINDINGS: Again seen is severely comminuted skull fractures with slight interval improvement of apposition of bony fragments. Multiple intracranial shrapnels are again identified with the main bullet fragment located in the left occipital region. Extensive streak metal artifacts significantly limit evaluation. There has been interval placement of a ventricular drain with tip terminating in the third ventricle. A new crescentic 5-mm hypodense subdural collection overlying the left frontal lobe demonstrates no rim enhancement, and may be related to insertion of the ventricular drain. Patient is status post right frontal craniotomy. A previously hyperdense epidural collection abutting the right frontal convexity demonstrates no significant change in size or configuration considering differences in angulation, but now appears more hypodense as compared to [**2191-3-27**]. In addition, large areas of hypoattenuation within bilateral frontoparietal lobes are essentially unchanged. In the right frontotemporal region just superior to the right lateral ventricle is a focal area of hyperdensity (3, 21) with surrounding edema that has increased in size as compared to most recent prior exam. The overlying left scalp wound with hypoattenuating underlying collection is unchanged within limitations of streak artifact and differences in angulation. Post-contrast images demonstrate areas of hypoattenuation with rim enhancement adjacent to a bullet fragment along the posterior falx near the vertex (3, 24). These areas appear to be confluent and form a linear tract that may be extra-axial and contiguous with the left extracranial collection. This appearance may represent a bullet tract with meningeal enhancement, but is highly suspicious for infection with abscess formation. Clinical correlation is indicated. There is no midline shift. Basal cisterns are largely preserved. Additional areas of intraparenchymal and subarachnoid hemorrhage are as described previously. Air-fluid levels in the sphenoid and maxillary sinuses are improved. There is persistent partial opacification of mastoid air cells bilaterally. Ethmoid air cell opacification is improved. IMPRESSION: 1. Stable appearance of left extracalvarial soft tissue edema with underlying fluid collection contiguous with new confluent linear areas of hypoattenuation with rim enhancement adjacent to a bullet fragment along the posterior falx near the vertex. Such appearance could represent a bullet tract with meningeal enhancement, but is highly suspicious for super infection with abscess formation. Clinical correlation is recommended, with tapping and culture as a consideration. Followup is recommended. 2. New small crescentic 5-mm hypodense collection overlying left frontal lobe may be related to interval insertion of a ventricular drain traversing through this area and terminating within the third ventricle. 3. Unchanged right frontal epidural collection except for now increased hypodense appearance to the collection. 4. Large areas of hypoattenuation within bilateral frontal and parietal lobes demonstrate no significant change. 5. Right posterior apical hyperdensity with surrounding edema has significantly increased in size since [**2191-3-27**] (2, 21). 6. Severely comminuted skull fracture and multiple bullet fragments are unchanged. Radiology Report BILAT LOWER EXT VEINS Study Date of [**2191-4-5**] 9:38 AM IMPRESSION: 1) Diffuse bilateral DVT as above, left > right. 2) Hematoma in the left groin at the level of the left greater saphenous vein is stable since [**2191-3-23**]. Findings were discussed with Dr. [**Last Name (STitle) 37564**] by phone at the time of dictation. [**Known lastname **],[**Known firstname **] [**Medical Record Number 85982**] M [**2-5**] Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2191-4-6**] 12:43 PM Final Report INDICATION: Patient is a 26-year-old male with history of tachypnea and hypoxias with prolonged immobilization. Evaluate for pulmonary embolism. No indication for the abdomen and pelvis given. EXAMINATION: CT of the torso with intravenous contrast. COMPARISONS: No prior studies are available for direct comparison. TECHNIQUE: Helically acquired axial images were obtained from the thoracic inlet to the mid abdomen after the administration of 130 mL of Optiray intravenous contrast using a CTA protocol. Subsequently, helically acquired axial images were obtained from the lung bases to the pubic symphysis after the administration of contrast using a CTE protocol. Sagittal and oblique reformations were obtained. FINDINGS: CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: There is extensive pulmonary embolism extending from the right main pulmonary artery into the lobar branches including the right upper lobe, middle lobe,and lower lobe branches. In addition, there is a left-sided pulmonary embolism extending from the left upper lobe branch into the lingular and upper lobe segmental branches. The thoracic aorta is unremarkable with no evidence of aortic dissection or intramural hematoma. The patient is noted to be status post left subclavian line central venous catheter placement with tip terminating within the mid SVC. The patient is status post tracheostomy in standard position. Tracheobronchial tree is patent to the subsegmental levels. There is patchy nonspecific ground-glass opacification scattered throughout the lungs. In addition, there are areas of linear atelectasis involving the right greater than the left base. The heart is unremarkable with no evidence of pericardial effusion. There is no significant axillary, hilar, or mediastinal lymphadenopathy. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The patient is status post percutaneous gastrotomy tube placement. The liver, gallbladder, spleen, pancreas, both adrenal glands, both kidneys, and visualized portions of intra-abdominal small and large bowel are unremarkable. There is no intra-abdominal free air or free fluid. There is no significant retroperitoneal or mesenteric lymphadenopathy. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, prostate, and seminal vesicles are unremarkable. The bladder is collapsed about a Foley catheter. BONE WINDOWS: The visualized osseous structures are unremarkable with no suspicious lytic or sclerotic foci identified. IMPRESSION: 1. Extensive bilateral pulmonary emboli involving the right main pulmonary artery extending into all of the lobar branches, and involving the left upper lobar branch extending into the segmental branches. 2. Nonspecific scattered ground-glass opacification seen within the lungs, for which differential includes infectious or inflammatory causes. Bibasilar likely linear atelectasis. 3. Support hardware in standard positions with tracheostomy, percutaneous gastrotomy, and central venous catheter in standard positions. [**Known lastname **],[**Known firstname **] [**Medical Record Number 85982**] M [**2105-2-4**] Radiology Report [**Numeric Identifier 3174**] INTERUP IVC Study Date of [**2191-4-7**] 12:30 PM Final Report (Revised) INDICATION: 26-year-old male with gunshot wound to the head, bilateral lower extremity DVTs, and bilateral pulmonary emboli. Requesting placement of IVC filter. IMPRESSION: 1. Venogram demonstrating inferior vena cava measuring 30 mm in diameter along with large left retroaortic renal vein. 2. Successful placement of [**Location (un) 74164**] nest filter below the left retroaortic renal vein and above the confluence of the common iliac veins. [**Known lastname **],[**Known firstname **] [**Medical Record Number 85982**] M [**2-5**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2191-4-8**] 9:02 AM IMPRESSION: 1. Interval removal of a left frontal approach intraventricular drain without evidence of hydrocephalus. A crescentic 5-mm hypodense collection overlying left frontal lobe probably related to prior drain placement persists. 2. Parietovertex hypoattenuating areas in communication with an overlying subgaleal wound on the left appears less prominent as compared to four days prior, but are not fully evaluated on this non-contrast study with adjacent metal streak artifacts. 3. Unchanged severe comminuted skull fracture with multiple bullet fragments and intracranial hemorrhage. 4. Persistent right frontal epidural collection, now isodense to the brain parenchyma. 5. Hypoattenuating areas within bilateral frontoparietal lobes and right occipital lobe appear stable. 6. Right posterior apical hyperdensity is less conspicuous as compared to [**2191-3-27**]. 7. No evidence new hemorrhage or infarction. No significant midline shift. [**Known lastname **],[**Known firstname **] [**Medical Record Number 85982**] M [**2105-2-4**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2191-4-8**] 9:02 AM NON-CONTRAST HEAD CT: There has been interval removal of a left frontal approach intraventricular drain since [**2191-4-4**]. Ventricles are patent without evidence of hydrocephalus. A crescentic 5-mm hypodense subdural collection overlying the left frontal lobe which may be related to prior ventricular drain placement is unchanged. Previously identified rim-enhancing hypoattenuating linear collections in the left parietovertex region adjacent to a bullet fragment in communication with a subgaleal collection is not fully evaluated on this non-contrast CT with significant metal streak artifact, although the overlying left subgaleal collection appears less prominent. Right frontal craniotomy is unchanged. A small epidural collection abutting the right frontal convexity is stable in size and configuration but appears more isoattenuating. Large areas of hypoattenuation in bilateral frontoparietal lobes appear stable. There is persistent hypoattenuation within the right occipital lobe, compatible with vasogenic edema or ischemic change. A focal area of hyperdensity as previously identified within the right frontotemporal region (2, 21) with surrounding vasogenic edema now appears less conspicuous as compared to four days prior. Severe comminuted skull fracture with the main bullet fragment in the posterior left occiput with multiple intracranial shrapnels and additional areas of intraparenchymal and subarachnoid hemorrhage are as described previously. Air-fluid levels within the sphenoid and maxillary sinuses are unchanged. Mastoid air cells are persistently opacified bilaterally, left greater than right. Ethmoid air cells are persistently opacified, left greater than right. There is no new focus of hemorrhage, or infarction. There is no significant midline shift. IMPRESSION: 1. Interval removal of a left frontal approach intraventricular drain without evidence of hydrocephalus. A crescentic 5-mm hypodense collection overlying left frontal lobe probably related to prior drain placement persists. 2. Parietovertex hypoattenuating areas in communication with an overlying subgaleal wound on the left appears less prominent as compared to four days prior, but are not fully evaluated on this non-contrast study with adjacent metal streak artifacts. 3. Unchanged severe comminuted skull fracture with multiple bullet fragments and intracranial hemorrhage. 4. Persistent right frontal epidural collection, now isodense to the brain parenchyma. 5. Hypoattenuating areas within bilateral frontoparietal lobes and right occipital lobe appear stable. 6. Right posterior apical hyperdensity is less conspicuous as compared to [**2191-3-27**]. 7. No evidence new hemorrhage or infarction. No significant midline shift. [**Known lastname **],[**Known firstname **] [**Medical Record Number 85982**] M [**2-5**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2191-4-10**] 6:06 AM A roughly 3-cm wide region of opacity in the left lower lung is visible once again and there is a suggestion of more consolidation in the right lower lung zone projecting just superior to the diaphragm, both strongly suggestive of active pneumonia. Upper lungs are clear. Heart size normal. No pleural effusion. Right subclavian or PIC line ends just before the junction of the brachiocephalic veins. Tracheostomy tube unchanged in position, tip abutting the right tracheal wall. No pneumothorax or appreciable pleural effusion. Radiology Report CT HEAD W/ & W/O CONTRAST Study Date of [**2191-4-12**] 10:50 AM CT HEAD WITHOUT AND WITH CONTRAST: While there is no large focus of hemorrhage or abnormal enhancement in the left frontal lobe, on the thin section images, subtle enhancement is possibly present in the parasagittal location. ( se 103, im 50-52). Assessment is limited due to artifacts. A small 5 mm crescentic hypodense extra-axial collection over the left frontal lobe previously attributed to placement of an intraventricular shunt appears unchanged. A small epidural collection along the right frontal convexity and right frontal craniotomy remain stable in appearance. Large areas of confluent hypoattenuation within bilateral frontoparietal lobes remain unchanged. Previously hypoattenuating area within the right occipital lobe now demonstrates some encephalomalacia like changes. This could be related to edema or ischemic changes in this region. Previously identified hyperdense focus in the right parietal lobe appears less conspicuous, consistent with normal evolution of hemorrhage (2, 21). No new focus of hemorrhage is identified within the limitation of severe metal streak artifacts. There is no significant midline shift or mass effect. There is no acute hydrocephalus. Severely comminuted skull fracture with main bullet in the posterior left occiput with multiple intracranial shrapnels are unchanged. Air-fluid levels within the sphenoid and ethmoid sinuses persist. Air-fluid level in the right maxillary sinus and complete opacification of the left maxillary sinus are again identified. There is persistent opacification of the left mastoid air cells. Right mastoid air cells are aerated. IMPRESSION: 1. Severely limited exam due to metallic streak artifacts. Within that limitation, subtle enhancement in the left frontal parasaggital location is possible/ Consider f/u. No large new hemorrhage or collection. 2. No evidence of new hemorrhage since a day prior. 3. Stable left frontal extra-axial hypodense fluid collection and right frontal epidural collection status post right frontal craniotomy. 4. Expected evolution of bifrontoparietal and right occipital hypodensities. 5. Unchanged severe comminuted skull fracture with multiple bullet fragments. [**Known lastname **],[**Known firstname **] [**Medical Record Number 85982**] M [**2-5**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2191-4-17**] 5:48 AM FINDINGS: Comparison is made to the prior study from [**2191-4-15**]. Tracheostomy is present with the tip at the thoracic inlet. Right subclavian catheter terminates at the junction of the brachiocephalic and superior vena cava. There is a right perihilar consolidation as well as left lower lobe and right lower lobe airspace opacities suggestive of aspiration or pneumonia. This has progressed since the prior study. Heart and mediastinum are within normal limits. labs COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2191-4-18**] 02:12AM 11.8* 3.06* 8.8* 26.4* 86 28.7 33.2 17.4* 344 Source: Line-A line DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2191-4-11**] 02:07AM 90* 0 2* 6 0 0 1* 1* 0 DIFF ADDED 10:13AM RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Ovalocy Burr [**2191-4-11**] 02:07AM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL DIFF ADDED 10:13AM BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2191-4-18**] 02:12AM 344 Source: Line-A line [**2191-4-18**] 02:12AM 34.1* 3.5* Source: Line-A line BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2191-3-24**] 01:05AM 893*1 Source: Line-arterial VERIFIED BY DILUTION INHIBITORS & ANTICOAGULANTS AT LMWH [**2191-4-11**] 12:16PM 87 0.161 LEVELS SHOULD BE OBTAINED 4-6 HRS AFTER LAST SUBCUTANEOUS DOSE OF LMWH.;THERAPEUTIC RANGES FOR VENOUS THROMBOSIS: 0.6-1.0 U/ML FOR [**Hospital1 **] DOSING. Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2191-4-18**] 02:12AM 104*1 24* 0.5 136 4.1 101 26 13 Source: Line-A line IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES ESTIMATED GFR (MDRD CALCULATION) estGFR [**2191-4-17**] 01:33AM Using this1 Source: Line-arterial Using this patient's age, gender, and serum creatinine value of 0.6, Estimated GFR = >75 if non African-American (mL/min/1.73 m2) Estimated GFR = >75 if African-American (mL/min/1.73 m2) For comparison, mean GFR for age group 20-29 is 116 (mL/min/1.73 m2) GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [**2191-4-13**] 01:50PM 408* Source: Line-CVL OTHER ENZYMES & BILIRUBINS Lipase [**2191-4-9**] 06:01AM 73* Vancomycin @ Trough CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2191-4-18**] 02:12AM 9.0 4.6* 2.1 Source: Line-A line HEMATOLOGIC Hapto [**2191-3-24**] 01:05AM 315* Source: Line-arterial LIPID/CHOLESTEROL Cholest Triglyc [**2191-3-28**] 02:30AM 173*1 Source: Line-tlc Brief Hospital Course: The patient was taken to the operating room for an emergent R hemicraniectomy for decompression/evacuation of epidural hematoma. A Bolt device was placed for careful ICP monitoring. He went immediately post op to the Trauma ICU. His post operative Head CT demonstrated extensive R parietal and smaller L parietal stroke. Concurrently,his ICPs began to increase into the 30s. 3% HTS and Mannitol were both started. His ICPs remained elevated into the 30s for over 24 hours. The decision was made to d/c both the 3% and the Mannitol, as his Osms were 322 and his Na was 154. He was place in a pentobarb coma on the morning of [**3-20**]. On the morning of [**3-21**], his Bolt became dislodged as he was being turned. It was repositioned by Dr. [**Last Name (STitle) **]. His ICP readings subsequently read in the low teens. He continued to have no neurologica exam or no pupillary response, as he was in a heavy pentobarb coma. A repeat head CT did not demonstrate any change in the R parietal infarct, or any further edema or herniation. The pentobarb and paralytics were d/c'd on [**3-21**] in order to obtain an accurate neurological exam. On [**3-22**] the EEG reads were reported as having no cortical activity. His exam is poor but unreliable given the recent pentobarb dosing. [**3-22**] a pentobarb level was sent. [**Date range (1) 71671**] exams remained poor. On the morning of [**3-25**] it was noted that he now had pupils that were reactive 7mm to 6mm. He was placed on CPAP for 2 hours and demonstrated respiratory drive and remained without corneals, gag, or cough. His Bolt was removed, his EEG was discontinued, and he underwent placement of trach and PEG. From [**3-25**] to [**3-30**] the patient began to withdraw or posture right upper extremity and have spontaneous eye opening. and no movement in LUE or bilateral lower extremities. On [**3-30**] he had an EVD placed after his entry and exit wounds were noticed to be leaking CSF. The wounds were cleaned and closed in the OR. On [**3-31**] CSF sample was sent for persistant fevers. On examination he exhibited flexion of RUE to noxious stimuli, no movement in RLE and LE bilaterally There was minimal drainage of CSF on [**2191-4-1**]. Surgical staples were removed. Over the weekend of [**4-2**] and [**4-3**], his Neurological exam remained stable. No source of fever was identified, and his temperature Decreased to 100.1. He remained clamped with ICPs in normal range for 24 hours. On [**4-4**] is left sided wound was found to have greenish drainage and a csf collection. He was brought to the OR for a wound washout and was found to have liquified brain matter no sign of infection. Wound culture had a negative gram stain. Final cultures were not conclusive for CNS infection. A CTA of the chest was performed for tachypnea and the pt was noted to have multiple PE's - an IVCF was placed. He was placed back on the ventilator and then was able to return to trach mask on [**2191-4-17**]. A new picc line was inserted on [**2191-4-18**] and all remaining sutures and staples were removed. The wounds are all well healed. Final ID recs are to continue the cipro and zosyn for a total of 15 days. Plan is for return in 6 weeks for cranioplasty / he will need to stop his coumadin 5 days before admission with transition to heparin drip for pre-op management of dvt/PE. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever / pain. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 4. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for corneal protection. 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 8. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q6H (every 6 hours) as needed for fevers. 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed for Wheezing. 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. Levetiracetam 100 mg/mL Solution Sig: Ten (10) PO BID (2 times a day). 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Lidocaine (PF) 10 mg/mL (1 %) Solution Sig: One (1) ML Injection Q4H (every 4 hours) as needed for cough. 14. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 15. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 17. Tobramycin 700 mg IV Q24H Duration: 5 Days End after last dose [**2099-4-23**]. Piperacillin-Tazobactam 4.5 g IV Q8H Duration: 5 Days End after last dose 3/14 Discharge Disposition: Extended Care Facility: [**Hospital **]Rehab Discharge Diagnosis: Traumatic Brain Injury Respiratory Failure Dysphagia Post Operative Fever Post Operative anemia requiring transfusion DVT, Right and left peroneal veins Pulmonary embolism VAP pneumonia / RESISTENT PSEUDOMONAS IN SPUTUM Urinary tract infection Decubitus ulcer Possible CNS infection Discharge Condition: NEUROLOGICALLY STABLE / SLIGHTLY IMPROVED Discharge Instructions: *******HAVE PATIENT STOP COUMADIN 5 DAYS BEFORE RETURN TO [**Hospital1 18**] AND TRANSITION TO HEPARIN DRIP FOR PREP FOR CRANIOPLASTY / SURGERY*********** General 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. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? Your Coumadin (Warfarin)/ INR should be followed in rehab and then by your PCP after your discharge from rehab. ?????? You have been discharged on Keppra (Levetiracetam) for seizure prophylaxis, 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 arrange for direct admisison to [**Hospital1 18**] in 6 weeks for your cranioplasty with Dr. [**First Name (STitle) **]/ Neurosurgeon. ??????You will need a CT scan of the brain with and without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[**2191-4-21**]

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icd9cm

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icd9pcs

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1967

Discharge summary

report

Admission Date: [**2132-2-6**] Discharge Date: [**2132-2-13**] Date of Birth: [**2054-5-21**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 371**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2132-2-6**]: ERCP with sphincterotomy and stent placement [**2132-2-8**]: ERCP with prior stent removal, new stent placement, balloon sweep with extraction of multiple stones [**2132-2-12**]: Laproscopic cholecystectomy History of Present Illness: 77 M with history of HTN, HL, CAD s/p CABG, Afib, DMII, presents with acute onset of diffuse abdominal pain, nausea, and vomiting. . Mr [**Known lastname 10821**] was in usual state of health until lunch yesterday when he developed poor appetite and nausea that worsened throughout the day. In the evening he developed acute onset abdominal pain in the epigastrium that radiated to his back. He had two episodes of non bloody emesis prompting self referral to the ED. He denies any fevers, chills, CP, SOB, dyspnea, diarrhea, BRBPR, melena. He endorses single episode of small of amount his blood in his urine. . In the ED inital vitals were, 96.8 92 156/68 18 89%. Physical exam was notable for tender RUQ and epigastrum. Labs showed leukocytosis to 17.4. lipase of 4050, and elevated LFTs and bilirubin. CT scan showed concern for cholecystitis as it showed distended gallbladder with multiple stones with small foci of air in nondependent areas. There was no definitive evidence of wall thickening, stranding or duct dilation. Patient then spiked a fever to 101.5. Surgery and ERCP were consulted given concern for an impacted stone and cholangitis. He received a total of 3 L of IV fluids, unasyn 3g IV, morphine 10 mg, and zofran. Tentative plan is to have INR reversed with FFP and go for ERCP. Vitals prior to transfer: 76 108/50 17 95% 2L . On arrival to the ICU, initial vitals were: 97.6 82 121/52 95% RA 17. He reported 0/10 pain. He appeared comfortable and was accompanied by his wife. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough. Denies chest pain, chest pressure, palpitations, or weakness. Denies diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: HTN HL DMII CAD s/p CABG Afib on coumadin ?CHF - EF 45% in [**2127**] Glaucoma elevated PSA w/ high grade intraephithelial neoplasm Social History: Lives with his wife. Used to work as a cutter in the garment industry many years ago. - Tobacco: quit in [**2115**], smoked since 20s - Alcohol: none - Illicits: none Family History: Significant for coronary artery disease as well as Type II diabetes Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.6 82 121/52 95% RA 17 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, with faint crackles at the bilateral lung bases, without wheeze or rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, trace tenderness in epigastrium, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema On discharge: Vitals: 97.2 64 136/70 95% RA 20 General: Alert, oriented, no acute distress Lungs: Clear to auscultation bilaterally, with faint crackles at the bilateral lung bases, without wheeze or rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, appropriately tender at lap sites. bowel sounds present, no rebound tenderness or guarding, no organomegaly. lap sites with primary dressings c/d/i Ext: warm, pink, well perfused, no edema Pertinent Results: LABS: On admission: [**2132-2-6**] 12:40AM BLOOD WBC-17.4*# RBC-2.77* Hgb-9.7* Hct-28.4* MCV-103* MCH-34.9* MCHC-34.0 RDW-17.1* Plt Ct-346# [**2132-2-6**] 12:40AM BLOOD Neuts-82* Bands-5 Lymphs-7* Monos-3 Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-1* [**2132-2-6**] 12:40AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**2132-2-6**] 12:40AM BLOOD PT-27.5* PTT-39.3* INR(PT)-2.6* [**2132-2-6**] 12:40AM BLOOD Glucose-306* UreaN-31* Creat-1.2 Na-140 K-3.7 Cl-100 HCO3-25 AnGap-19 [**2132-2-6**] 12:40AM BLOOD ALT-30 AST-67* AlkPhos-140* TotBili-1.6* DirBili-1.3* IndBili-0.3 [**2132-2-6**] 12:40AM BLOOD Lipase-4050* [**2132-2-6**] 12:40AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.8 [**2132-2-6**] 03:12PM BLOOD Type-ART pO2-58* pCO2-34* pH-7.43 calTCO2-23 Base XS-0 [**2132-2-6**] 12:54AM BLOOD Lactate-2.9* IMAGING: [**2-6**] CXR: IMPRESSION: Central pulmonary vascular congestion with moderate interstitial edema, concerning for cardiac decompensation. [**2-6**] CT abdomen: IMPRESSION: 1. Distended gallbladder containing multiple gallstones and gas. Even with lack of significant wall thickening, the findings are concerning for early cholecystitis. A HIDA examination can be considered if there is a need for further confirmation. 2. Multiple hypodense pancreatic lesions likely representing side branch IPMNs. MRCP is recommended for further characterization. 3. No intra- or extra-hepatic bile duct dilation. 4. Large bilateral inguinal hernias. 5. Enlarged prostate. [**2-6**] ERCP Cannulation of the biliary duct was successful and deep after a guidewire was placed. Contrast medium was injected resulting in complete opacification. Several 5 mm round stones that were causing partial obstruction were seen at the common bile duct. Given gallstone pancreatitis, decision was made to perform a sphincterotomy. A careful, limited sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Pus and sludge was noted to extrude from the common bile duct. Given cholangitis, decision was made to place a stent rather than stone extraction. A 7cm by 10FR plastic biliary stent was placed successfully. [**2-8**] ERCP A plastic stent placed in the biliary duct was found in the major papilla - this was removed. A previous sphincterotomy was seen and the ampulla appeared open. There was some mild oozing at the papilla from previous sphincterotomy - A gold probe was applied for hemostasis successfully. Multiple small stones were seen in the common bile duct. Balloon sweep x 4 was performed with extraction of multiple stones successfully. Final cholangiogram was without filling defects. A 8cm by 10FR plastic biliary stent was placed successfully. Mutiple large stones were seen in the gallbladder. Brief Hospital Course: 77 M with h/o HTN, HL, CAD s/p CABG, Afib, CHF, DMII presented from OSH with abdominal pain concerning for pancreatitis and cholangitis as a result of gallstone obstruction. ACTIVE ISSUES BY PROBLEM: #. Ascending cholangitis: classic presentation with RUQ pain, fevers, leukocytosis, elevated LFT (total bili), and evidence of gallstones on imaging. ERCP and surgery both consulted immediately on admission. Started on ciprofloxacin and flaygyl initially, then changed to zosyn on hospital day 2. Coumadin held and attempted INR reversal with 4 units FFP (however INR still 3.5) prior to ERCP. ERCP on [**2-6**] showed frank pus coming from the ampulla, stones in the common bile duct, and evidence of pancreatitis. Sphincterotomy performed and stent placed, however stone still left in the duct. After procedure, pt developed rising billirubin (max TBilli 9). He had a second ERCP with removal of several stones in the common bile duct. Prior stent was removed and new stent placed. Some small oozing of blood was noted at ampulla which was cauterized. Pt tolerated procedure well and will have follow up with GI outpatient for stent removal and elective cholecystectomy. #. Gallstone Pancreatitis: Lipase to 4050 on admission, ERCP pancreatogram consistent with active pancreatitis. Likely secondary to gallstones. Pt initialy NPO and given IVF. His diet was advanced after second ERCP. # Pneumonia/Pulmonary Edema: After first ERCP procedure, pt noted to develop O2 requirement. Likely multifactorial: pulm edema from aggressive IV hydration in pt with sHF as well as pneumonia. He was given lasix and initially covered broadly with zosyn and vancomycin. However, it was felt that his O2 requirement was more likely from pulmonary edema than pneumonia, so his vancomycin was discontinued and he was continued on lasix prn for diuresis. # Anemia: History of chronic anemia with complete w/u by PCP in past revealing anemia of chronic disease. Baseline hct ~ 30, hct 28 on admission but has dropped to as low as 20 now in the setting of ERCP and IV fluids. He was transfused 1 UPRBC. Bleeding source was likely from sphincterotomy site which had some blood oozing visualized on second ERCP. The area of oozing was cauterized and HCT remained stable at 31.1 on discharge. #. Systolic CHF - EF 45% in [**2127**] w/ pt report of h/o of CHF although no hospitalizations. Mild crackles on exam, slight volume overload on initial CXR. In setting of aggressive IV hydration, pt became volume overloaded with pulmonary edema. He was diuresed with 20mg IV lasix up to [**Hospital1 **]. #. HTN - Initialy held home antihypertensives while inhouse given concern for cholangitis. Systolics increased on hospital day 2, could restart amlodipine then atenolol as tolerated #. HL - Hold statins for now given elevated LFTs. Restarted postoperatively. #. DMII: held metformin and glipizide, insulin sliding scale for now. Home DM medications restarted prior to discharge when tolerating a regular diet. #. CAD - s/p CABG 3V disease. Held aspirin initially given procedures, and held statin, bb, ace-inhibitor in setting of acute infection. All medications restarted prior to discharge when stable. #. Afib - Primarily in sinus. Was given FFP and Vit K for INR reversal in setting of ERCP. Coumadin held perioperatively and restarted at 4 mg at discharge. Bridged with lovenox SC (therapeutic dosing), started the morning of discharge. Plans for VNA to check INR on [**2132-2-15**]. Surgery course: Mr. [**Known lastname 10821**] was taken to the operating room on [**2132-2-12**] and underwent a laparoscopic cholecystectomy. Please see operative report for details of this procedure. Postoperatively, his care was transferred to the acute care surgery service. He tolerated the procedure well and was extubated upon completion. He was subsequently taken to the PACU for recovery. He was transferred to the surgical floor hemodynamically stable. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. He was initially given IV fluids postoperatively, which were discontinued when he was tolerating PO's. His diet was advanced on the morning of POD#1 ([**2-13**]) to regular, diabetic diet, which he tolerated without abdominal pain, nausea, or vomiting. His home diabetes medications were restarted at that time. His home antihypertensive medications were also restarted. The morning of [**2-13**] his INR was 1.5, and he was started on lovenox to bridge to coumadin for discharge. VNA services were set up to continue lovenox teaching. He was voiding adequate amounts of urine without difficulty. He was encouraged to mobilize out of bed and ambulate as tolerated, which he was able to do independently. His pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. On [**2132-2-13**], he was discharged home with scheduled follow up in [**Hospital 2536**] clinic on [**2132-2-28**] and follow up with his PCP [**Last Name (NamePattern4) **] [**2132-2-18**]. Medications on Admission: amlodipine 5 mg daily atenolol 150 mg daily enalapril 40 mg daily gemfibrozil 600 mg daily glipizide 15 mg daily HCTZ 25 mg daily lovastatin 40 mg daily metformin 1000 mg [**Hospital1 **] warfarin 4 mg daily aspirin 81 mg daily multivitamin 1 tablet daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. lovastatin 20 mg Tablet Sig: Two (2) Tablet PO daily (). 4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. atenolol 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. enalapril maleate 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: Do not exceed > 4000 mg of tylenol in 24 hours. [**Month (only) 116**] cause sedation. Disp:*10 Tablet(s)* Refills:*0* 10. Lovenox 80 mg/0.8 mL Syringe Sig: 0.7 mL Subcutaneous twice a day: To be administered until INR therapeutic on coumadin. Goal INR [**3-14**]. Disp:*14 syringes* Refills:*0* 11. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 12. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. glipizide 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 15. Outpatient [**Name (NI) **] Work PT/INR, please draw [**2132-2-15**] and fax results to Dr.[**Name (NI) 10822**] office: Phone: [**Telephone/Fax (1) 1144**] Fax: [**Telephone/Fax (1) 6443**] Goal INR 2.0-3.0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Gallstone pancreatitis and cholelithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with gallstone pancreatitis and cholelithiasis. You underwent two ERCP's and then had your gallbladder removed laparoscopically. You tolerated the procedure well and are now being discharged home with the following instructions: Your coumadin was held while you were in the hospital. You should restart your coumadin tonight at your regular home dose (4 mg). Your INR will be drawn tomorrow by the VNA and the results will be sent to your PCP's office, who will continue to manage your coumadin dosing. Because it may take a few days for your blood levels to be therapeutic on the coumadin, you are being bridged with lovenox until that time. Please administer the lovenox twice/day as instructed until your PCP's office tells you to stop the lovenox injections. ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside, but avoid traveling long distances until you see your [**Location (un) 5059**] at your next visit. Don't lift more than [**11-24**] lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. You may start some light exercise when you feel comfortable. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. Heavy exercise may be started after 4 weeks, but use common sense and go slowly at first. HOW YOU [**Month (only) **] FEEL: You may feel weak or "washed out" for 4 weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your [**Month (only) 5059**]. YOUR INCISION: Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steristrips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay. Your incisions may be slightly red around the stitches. This is normal. You may gently wash away dried material around your incision. It is normal to feel a firm ridge along the incision. This will go away. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your [**Month (only) 5059**]. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. Ove the next 6-12 months, your incision will fade and become less prominent. YOUR BOWELS: Constipation is a common side effect of narcotic pain medicaitons. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your [**Month (only) 5059**]. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your [**Name2 (NI) 5059**]. You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your [**Name2 (NI) 5059**] about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your [**Name2 (NI) 5059**] has said its okay. If you are experiencing no pain, it is okay to skip a dose of pain medicine. Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your [**Name2 (NI) 5059**]: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your [**Name2 (NI) 5059**]. DANGER SIGNS: Please call your [**Name2 (NI) 5059**] if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound Followup Instructions: Department: DIGESTIVE DISEASE CENTER When: MONDAY [**2132-3-10**] at 9:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], 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 Department: PODIATRY When: MONDAY [**2132-2-18**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: [**Hospital1 18**] [**Location (un) 2352**] When: MONDAY [**2132-2-18**] at 12:10 PM With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2132-2-28**] at 3:45 PM With: ACUTE CARE CLINIC with Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2132-2-20**]

[ "427.31", "286.9", "272.4", "285.29", "V58.61", "250.00", "576.2", "576.1", "574.61", "V45.81", "428.23", "414.00", "428.0", "401.9", "995.91", "577.0", "584.9", "038.9" ]

icd9cm

[ [ [] ] ]

[ "51.85", "51.87", "51.88", "51.23" ]

icd9pcs

[ [ [] ] ]

13764, 13839

6901, 11947

317, 542

13925, 13925

4035, 4042

19546, 21059

2839, 2908

12254, 13741

13860, 13904

11973, 12231

14076, 19523

2948, 3517

3531, 4016

2099, 2478

262, 279

570, 2080

4056, 6878

13940, 14052

2500, 2634

2650, 2823

43,043

125,851

37723

Discharge summary

report

Admission Date: [**2105-1-14**] Discharge Date: [**2105-1-23**] Date of Birth: [**2067-12-13**] Sex: F Service: SURGERY Allergies: Latex / Formaldehyde Attending:[**First Name3 (LF) 1556**] Chief Complaint: Patient admitted for weight reduction surgery. Major Surgical or Invasive Procedure: Status Post Laparoscopic Gastric Bypass with subsequent exploratory laparoscopy for hemoperitoneum. History of Present Illness: [**Known firstname **] has class III morbid obesity with weight of 285 pounds as of [**2104-11-24**] with her initial screen weight on [**2104-11-17**] at 288.2 pounds, height of 62 inches and BMI of 52.2. Her previous weight loss efforts have included recently completing 6 months of [**Hospital1 3278**] Health Plan's "I Can Change" program, Weight Watchers in [**2103**], 3 months of South Beach diet in [**2103**] losing 5 pounds, 18 months of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] Loss in [**2101**] losing 40 pounds that she maintain for two months and 6 months of Slim-Fast in [**2085**] losing 15 pounds that she quickly regained. She has not taken prescription weight loss medications or used over-the-counter ephedra-containing appetite suppressants/herbal supplements. She was not certain of her age at age 21 but states that her lowest adult weight was 242 pounds with her highest weight 290 pounds back in [**Month (only) 404**] of this year. She weighed 280 pounds over a year ago. She states she has been struggling would wait since childhood at the age of 6 and attributes her weight gain to birth of her 2 children. Past Medical History: :dyslipidemia with elevated triglycerides, urinary stress incontinence, osteoarthritis of the left knee, eczema and gallbladder disease (cholelithiasis) in [**2091**]. She has symptoms of sleep disorder breathing. Social History: She denied tobacco or recreational drug usage, used to have one alcoholic beverage every two to 3 months but not now, drinks a 12-ounce to 32 ounce ice coffee daily 5 days a week and has 20-ounce Diet Coke daily 5 days a week. She is employed as a patient account representative at [**Hospital3 418**] Medical Center in [**Location (un) 701**]. She is married living with her husband age 48, daughter age 10, son age 7 and mother age 60. Family History: Her family history is noted for father deceased age 60 of cancer, hyperlipidemia, diabetes; mother living age 60 with hyperlipidemia, arthritis and obesity; grandmother live in age 88 with stroke and diabetes; brother living age 30 with obesity. Physical Exam: Her blood pressure was 120/78, pulse 97, respirations 14 and O2 saturation 99% on room air. On physical examination [**Known firstname **] was casually dressed and in no distress. Her skin was warm, dry with no rashes, there was mild eczema, no other lesions. Sclerae were anicteric, conjunctiva clear, pupils were equal round and reactive to light, fundi were normal, mucous membranes were moist, tongue was pink and the oropharynx was without exudate or hyperemia. Trachea was in the midline and the neck was supple with full range of motion, no adenopathy, thyromegaly or carotid bruits. Chest was symmetric and the lungs are clear to auscultation bilaterally with good air movement. Cardiac exam was regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. The abdomen was obese but soft and non-tender, non-distended with no appreciable masses or hernias, there was a large right side incision scar now well healed, horizontal 5 cm incision above the umbilicus also well healed and there was a mild pannus. There was no spinal tenderness or flank pain. Lower extremities were without edema, venous insufficiency or clubbing, perfusion was good. There was no evidence of joint swelling or inflammation of the joints. There were no focal neurological deficits and her gait was normal. Pertinent Results: [**2105-1-16**] 01:01AM BLOOD WBC-13.1* RBC-3.03* Hgb-9.1* Hct-26.1* MCV-86 MCH-30.0 MCHC-34.8 RDW-14.0 Plt Ct-305 [**2105-1-22**] 06:50AM BLOOD WBC-8.4 RBC-3.10* Hgb-9.1* Hct-27.1* MCV-87 MCH-29.5 MCHC-33.7 RDW-14.5 Plt Ct-454* [**2105-1-15**] 09:25AM BLOOD PT-14.5* PTT-23.3 INR(PT)-1.3* [**2105-1-15**] 07:13PM BLOOD PT-13.9* PTT-20.3* INR(PT)-1.2* [**2105-1-17**] 04:41PM BLOOD PT-12.2 PTT-21.1* INR(PT)-1.0 [**2105-1-22**] 06:50AM BLOOD Plt Ct-454* [**2105-1-16**] 01:01AM BLOOD Glucose-134* UreaN-14 Creat-1.5* Na-140 K-4.1 Cl-110* HCO3-26 AnGap-8 [**2105-1-20**] 07:14AM BLOOD Glucose-92 UreaN-12 Creat-1.1 Na-141 K-3.9 Cl-109* HCO3-19* AnGap-17 [**2105-1-17**] 04:17AM BLOOD Calcium-7.4* Phos-3.0 Mg-1.7 [**2105-1-22**] 06:50AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7 Upper Gi Study [**2105-1-20**] No evidence of leak or obstruction following gastric bypass. Brief Hospital Course: Patient admitted and underwent a laparoscopic Gastric bypass on [**2105-1-14**]. On postoperative day one patient was noted to have a great deal of drainage out of her JP drain. She also became tachycardic. On [**2105-1-15**] she was taken back to the operating room for Laparoscopic exploration and evacuation of hematoma, control of staple line bleed. Postoperatively she was monitored closely. Her blood level stabilized and she was slowly advanced to a Bariatric stage 3 diet. She had trouble with nausea and was treated with intravenous fluids and antiemietics. On postoperative day 7 her JP drain was pulled and hydration as well as stage 3 diet was discussed extensively with patient. On postoperative day 8 she was discharged to home with follow up with Dr. [**Last Name (STitle) **] in one week. Medications on Admission: Venlafaxine 75 mg twice daily for depression; Vesicare 10 mg in the morning for bladder control; Zyrtec 10 mg at bedtime as needed for seasonal allergies; Ibuprofen 600 mg as needed, Tylenol as needed for knee pain; Aviane-28 for birth control; multivitamins with minerals daily, vitamin D 1000 units daily and Vitron-C one half tablet by mouth daily Discharge Medications: 1. Roxicet 5-325 mg/5 mL Solution Sig: [**5-25**] ml PO every four (4) hours as needed for pain. Disp:*500 ml* Refills:*0* 2. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day. Disp:*500 ml* Refills:*0* 3. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day. Disp:*600 ml* Refills:*0* 4. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please crush. 5. Multivitamin Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: obesity Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: Stay on Stage III diet until your follow up appointment. Do not self advance diet, do not drink out of a straw or chew gum. Medication Instructions: Resume your home medications, CRUSH ALL PILLS. You will be starting some new medications: 1. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. 2. You should begin taking a chewable complete multivitamin with minerals once a day. No gummy vitamins. 3. You will be taking Zantac liquid 150 mg twice daily for one month. This medicine prevents gastric reflux. 4. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. 5. You must not use NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen. These agents will cause bleeding and ulcers in your digestive system. Activity: No heavy lifting of items [**10-30**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], RD,LDN Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2105-1-29**] 12:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2105-1-29**] 1:15 Completed by:[**2105-1-23**]

[ "998.12", "715.36", "272.8", "E878.2", "625.6", "584.9", "311", "278.01", "285.1", "V85.4" ]

icd9cm

[ [ [] ] ]

[ "54.21", "99.04", "44.38" ]

icd9pcs

[ [ [] ] ]

6494, 6500

4812, 5622

328, 430

6571, 6571

3925, 4789

8747, 9083

2331, 2578

6026, 6471

6521, 6521

5648, 6003

6740, 7306

2593, 3906

242, 290

8390, 8724

458, 1617

6540, 6550

7331, 8378

6585, 6692

1640, 1857

1873, 2315

13,940

137,769

43837

Discharge summary

report

Admission Date: [**2192-12-12**] Discharge Date: [**2192-12-26**] Service: CHIEF COMPLAINT: Lower GI bleed and cramps. HISTORY OF PRESENT ILLNESS: This 78-year-old female with clots in her bowel movements at night. She called EMS secondary to weakness. Patient was found to be lightheaded with a blood pressure of 90/palp. Patient denies any melena, but does admit to some nausea and vomiting tonight. The patient does not recall any hematemesis, history of GI bleed or abnormal EGD/colonoscopy in the past year. Patient denies any chest pain, shortness of breath, palpitations, or loss of consciousness. She denies any symptoms or exposure to food that would be consistent with colitis. She says that her normal stool is a light beige color. After 1.5 liters of normal saline, her heart rate was 104 and blood pressure was 95/50. Patient was called by the Medical ICU to evaluate for GI bleeding and low blood pressure. While in the emergency room, the patient received Protonix, one unit packed red blood cells, FSP times two, two liters normal saline and one gram of Ceftriaxone. Once patient was transferred from the ICU to the Medical Floor on [**2192-12-15**], she had received four units of packed red blood cells and four units of FSP for her GI bleeding. Patient was also given vitamin K to reverse her INR of 55 while her Coumadin was held. ALLERGIES: None. MEDICATIONS: 1. Coumadin 5 mg p.o. q.h.s. 2. Verapamil one pill. 3. Ativan. PAST MEDICAL HISTORY: 1. Aortic valve replacement in [**2186**]. 2. Right lower lobectomy for a lung cancer five years ago. 3. Ectopic pregnancy. 4. Breast cancer with lumpectomy in [**2181**]. 5. Bilateral carotid bruits. 6. Chronic obstructive pulmonary disease. SOCIAL HISTORY: She smokes half a pack a day for the past 60 years. She is still currently smoking, but denies any alcohol use. FAMILY HISTORY: There is no history of colon cancer or coronary artery disease. There is a sister with congestive heart failure. Family history also includes carcinoma. PHYSICAL EXAMINATION: Vitals on admission showed a temperature of 98.1 F, pulse 104, blood pressure 90/60 to 105/55, respiratory 18, 100% on four liters and 92% on room air. Generally this is an elderly female in no acute distress. Head, eyes, ears, nose and throat: Anicteric eyes. Pupils are equal, round and reactive to light and accommodation and extraocular muscles are intact. Bruise on the right neck. Neck is supple without lymphadenopathy. Cardiovascular: Regular rate and rhythm. Normal S1, S2. There is a III/VI systolic ejection murmur. Chest: Decreased breath sounds and some wheezes on the expiratory phase. Abdomen: There are some bowel sounds. It is nontender, nondistended with no organomegaly. Extremities: No cyanosis, clubbing or edema noted. Neurologically intact. LABORATORY DATA ON ADMISSION: White count 23.6, hematocrit 27.9, platelets 410. Sodium 139, potassium 5, chloride 101, bicarbonate 21, 39 for BUN, 1.2 creatinine, 144 for glucose. INR is 54. Chest x-ray shows some postsurgical changes with questionable right pleural effusion. EKG is with a heart rate of 104 at sinus tachycardia, normal axis. Some ST-T wave changes in II, aVF, V2 through V6. There is some increased voltage between V3 to V5. HOSPITAL COURSE: 1. GASTROINTESTINAL: For her GI bleed, she received four units of packed red blood cells and her hematocrit increased to 32.4. It remained stable at this level. She was also given a Proton pump inhibitor. Patient also had signs of cholecystosis on physical examination where patient started to become jaundice and on lab exams with ALT in the 70s, ASTs in the 100s, alkaline phosphatase in the 600s, and total bilirubin in the 10s. She was given Levaquin, Vancomycin and Flagyl for possible cholangitis. Work up for the cholecystosis included a CT Scan of the abdomen which revealed a distended gallbladder, marked intra and extrahepatic duct dilatation, common bile duct and pancreatic duct dilatation, normal pancreas. This lead to a ERCP which revealed a bleeding pancreatic mass in the duodenum with pancreatic duct and common bile duct dilatation. These findings were reinforced by an EGD that was sent for the GI bleeding that revealed a duodenal papillary mass. During the first ERCP, her duodenal papillary was stented with a plastic stent. Later on a second ERCP was done to place a metallic stent instead. A CTA of the pancreas was then done revealing a 3 by 3.5 pancreatic mass with liver lesions and intrahepatic duct dilatation. Biopsy from the first ERCP revealed an adenocarcinoma. Further staining revealed that this was indeed a primary pancreatic adenocarcinoma. After stenting was placed, ALT then went back down to 52, AST went back down to 69, alkaline phosphatase went back down to 498 and total bilirubin went back down to 4.2. Patient also became progressively less jaundice. A CEA level was checked and found to be at 9.8. A CA99 levels were checked and are still pending upon discharge. Patient was seen by both Hospice and Oncology in the hospital. She is to follow up with Oncology on [**2193-1-3**] with Dr. [**Last Name (STitle) 150**]. 2. CARDIOVASCULAR: For the patient's aortic valve replacement, she was anticoagulated with heparin with PTT goal of 50 to 70. Once all her procedures were completed, she was put back on a Coumadin regimen of 5 and 7.5 mg alternating. Her INR then became 2.7 upon discharge. 3. PULMONARY: Patient was given incentive spirometry and Combivent inhalers for her chronic obstructive pulmonary disease. Her chronic obstructive pulmonary disease much improved with the Combivent, Flovent and Beclomethasone inhaler regimen. DISCHARGE DIAGNOSES: 1. Pancreatic cancer. 2. Aortic valve replacement. 3. Chronic obstructive pulmonary disease. 4. Breast cancer status post right mastectomy. 5. Lung cancer status post right lower lobe lobectomy. MEDICATIONS: 1. Warfarin 7.5 mg on Monday, Wednesday and Friday and 5 mg on Tuesday, Thursday, Saturday and Sunday. 2. Lorazepam 0.5 to 1 mg p.o. q. four to six hours p.r.n. anxiety. 3. Flovent 110 mcg two puffs inhaler b.i.d. 4. Protonix 40 mg p.o. q.d. 5. Combivent one to two puffs t.i.d. 6. Beclomethasone dipropionate two puffs inhaler b.i.d. 7. Levofloxacin 500 mg p.o. q.d. until [**2192-12-29**]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 4270**] MEDQUIST36 D: [**2192-12-28**] 02:34 T: [**2193-1-1**] 10:12 JOB#: [**Job Number 43236**]

[ "428.0", "790.92", "157.0", "496", "560.9", "576.1", "197.7", "285.1", "578.9" ]

icd9cm

[ [ [] ] ]

[ "45.24", "97.55", "51.14", "51.87", "38.93", "45.13" ]

icd9pcs

[ [ [] ] ]

1894, 2050

5753, 6367

3319, 5732

2073, 2868

102, 130

159, 1474

2883, 3302

1496, 1746

1763, 1877

6392, 6693

58,640

153,364

39331

Discharge summary

report

Admission Date: [**2100-8-8**] Discharge Date: [**2100-8-13**] Date of Birth: [**2062-9-29**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4095**] Chief Complaint: s/p hanging Major Surgical or Invasive Procedure: none History of Present Illness: 37yo male with history of polysubstance abuse and bipolar disorder who was found by his wife hanging on the back porch of his home. Per history given by wife, pt has been having increasing anxiety and psychiatrist has changed doses of his medications, tripleptal and adderall. He was feeling that his mood was unstable for the last few days. He does have history of cutting and polysubstance abuse but wife denies any recent drug use with the exception of alcohol on night prior to admission. On morning of admission, he and his wife had a disagreement after which he became uncharacteristically upset and asked her to help him hurt himself. He then left the house; she followed approximately 1-2 minutes later and found him hanging in the back yard in the shower deck. The wife was able to get him down using a knife. Per her recollection, this entire event took less than 5 minutes. She found him blue in the lips and face which quickly resolved. He gasped for air and had a few episodes of vomiting. He was found by EMS hypoxic and unconscious and taken to [**Location (un) 21541**] Hospital. He was intubated usng succ/etomidate and given 1gm ceftriaxone, acetaminophen 975mg PR, propofol gtt. Labs were significant for WBC 14.8, ABG 7.28/ 39/ 286/ 17, Urine tox positive for alcohol, amphetamine, opiates. CT head/neck showed no fracture but mild soft tissue stranding within the superficial soft tissues of the lateral neck. He was transferred to [**Hospital1 18**] ED where initial VS were:100.0 86 113/71 18 100%. He was febrile to 103.8 and given 1g vancomycin and 2g cefepime as well as 30mg ketorolac for rigors. CTA head/neck showed no vascular injury or dissection Review of systems: Per wife, denies fevers/chills, cough, rhinorrhea, chest pain, SOB, joint aches, myalgias, abdominal pain, diarrhea Past Medical History: Cellulitis MRSA abscess Vasectomy Bipolar disorder Depression/anxiety Cutting Polysubstance abuse Social History: Lives with wife and 6yo daughter. Also has three other children with another woman. Works for TLFine Woodworking doing wood working and plumbing. History of substance abuse (cocaine, heroine). Relapse on IV suboxone one year ago but clean since then. Very minimal alcohol use but drank last night. Family History: Father: [**Name (NI) 3730**] (does not know what kind), died in his 50s Mother: mental health issues Mother with breast cancer. Physical Exam: INITIAL PHYSICAL EXAM General: intubated, sedated, not responding to stimuli HEENT: PERRL, no scleral palor or icterus, left periorbital echymosis Neck: in C-collar, linear abrasions across neck CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Chest: indentations in skin without erythema or swelling Abdomen: soft, non-tender, non-distended, bowel sounds present GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, multiple superficial cuts on legs/feet. Multiple areas of erythema including bilateral medial elbow and right medial ankle. Track marks on left upper extremity. Neuro: PERRL, on sedation, unresponsive DISCHARGE PHYSICAL EXAM General: Awake and alert Oriented x3 HEENT: PERRL, no scleral palor or icterus, left periorbital echymosis CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Neuro: PERRL, CNII-XII intact Pertinent Results: ADMISSION LABS [**2100-8-8**] 08:25AM BLOOD WBC-4.8 RBC-4.36* Hgb-13.4* Hct-37.2* MCV-85 MCH-30.7 MCHC-35.9* RDW-13.7 Plt Ct-209 [**2100-8-8**] 08:25AM BLOOD Plt Ct-209 [**2100-8-8**] 08:25AM BLOOD PT-11.5 PTT-30.0 INR(PT)-1.1 [**2100-8-8**] 08:25AM BLOOD Fibrino-237 [**2100-8-8**] 03:02PM BLOOD Glucose-96 UreaN-13 Creat-0.7 Na-137 K-3.4 Cl-108 HCO3-23 AnGap-9 [**2100-8-8**] 03:02PM BLOOD Glucose-96 UreaN-13 Creat-0.7 Na-137 K-3.4 Cl-108 HCO3-23 AnGap-9 [**2100-8-8**] 08:25AM BLOOD CK(CPK)-1124* [**2100-8-8**] 08:25AM BLOOD Lipase-19 [**2100-8-8**] 03:02PM BLOOD CK-MB-89* MB Indx-1.3 cTropnT-0.07* [**2100-8-8**] 03:02PM BLOOD Calcium-7.2* Phos-3.1 Mg-1.7 [**2100-8-8**] 06:20PM BLOOD Albumin-3.1* [**2100-8-8**] 08:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2100-8-8**] 08:51AM BLOOD Type-ART Temp-39.9 Rates-/14 Tidal V-550 PEEP-5 FiO2-100 pO2-459* pCO2-42 pH-7.38 calTCO2-26 Base XS-0 AADO2-211 REQ O2-44 -ASSIST/CON Intubat-INTUBATED [**2100-8-8**] 08:27AM BLOOD Glucose-89 Lactate-1.9 Na-133 K-3.2* Cl-100 calHCO3-26 [**2100-8-8**] 08:25AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2100-8-8**] 08:25AM URINE RBC-0 WBC-0 Bacteri-FEW Yeast-NONE Epi-0 MICRO STUDIES URINE CULTURE [**2100-8-8**] NEGATIVE BLOOD CULTURE [**2100-8-8**] X2 PENDING PERTINENT LABS AND STUDIES [**2100-8-11**] 05:55AM BLOOD CK(CPK)-8401* [**2100-8-12**] 06:15AM BLOOD CK(CPK)-5188* [**2100-8-10**] 04:03PM BLOOD CK(CPK)-[**Numeric Identifier 86965**]* [**2100-8-10**] 06:00AM BLOOD CK(CPK)-[**Numeric Identifier 86966**]* [**2100-8-9**] 08:00PM BLOOD CK(CPK)-[**Numeric Identifier 86967**]* [**2100-8-9**] 01:16PM BLOOD CK(CPK)-[**Numeric Identifier **]* [**2100-8-9**] 08:00PM BLOOD CK(CPK)-[**Numeric Identifier 86967**]* [**2100-8-9**] 12:00AM BLOOD CK-MB-126* MB Indx-1.0 cTropnT-0.02* [**2100-8-9**] 04:10AM BLOOD CK-MB-100* MB Indx-0.8 cTropnT-0.02* [**2100-8-8**] 06:20PM BLOOD CK-MB-133* MB Indx-1.2 cTropnT-0.04* [**2100-8-9**] 12:00AM BLOOD CK-MB-126* MB Indx-1.0 cTropnT-0.02* [**2100-8-8**] 08:25AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-POS mthdone-NEG DISCHARGE LABS: [**2100-8-13**] 06:10AM BLOOD WBC-6.9 RBC-4.42* Hgb-12.8* Hct-39.4* MCV-89 MCH-29.0 MCHC-32.5 RDW-13.8 Plt Ct-322 [**2100-8-13**] 06:10AM BLOOD Glucose-104* UreaN-10 Creat-0.7 Na-140 K-4.1 Cl-106 HCO3-25 AnGap-13 [**2100-8-13**] 06:10AM BLOOD CK(CPK)-2330* [**2100-8-13**] 06:10AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.9 RADIOLOGY STUDIES CXR [**2100-8-8**] Right hilar/perihilar opacity may reflect combination of right lower lobe atelectasis and aspiration, although infection or contusion not excluded in appropriate clinical setting. CTA HEAD AND NECK [**2100-8-8**] 1. Head CT shows no acute abnormalities. If there is continued suspicion for hypoxic injury, an MRI can be performed for better assessment. 2. CT angiography of the head and neck shows no abnormalities. In particular, no vascular injury or dissection seen. 3. Mild atelectatic changes are seen at visualized both posterior lungs. CXR [**2100-8-10**] IMPRESSION: Significant interval improvement in aeration of the lungs with persistent right perihilar and left lower lobe opacity, likely atelectasis. Small residual left effusion. Brief Hospital Course: 37yo male with history of polysubstance abuse and bipolar disorder s/p hanging complicated by rhabdomyolysis. ACUTE CARE # Hypoxia: Patient was intubated for hypoxemic respiratory failure after hanging himiself. CXR was also concerning for PNA. Patient will complete course of augmentin for possible pneumonia. # Pneumonia: Patient was treated for likely aspiration PNA initally with Vanc/Zosyn then narrowed to augmentin. Day 1 = [**2100-8-8**]. He was discharged on augmentin to be completed on [**8-22**]. # Elevated CK: Likely from muscle injury from self hanging or being on backboard for extended period. Trop peaked at 0.07 but flat MBI is reassuring as is EKG that does not show ischemic ST changes. The patient's CK peaked at 16,000, this trended down with IVF and no [**Last Name (un) **] occurred. CK was 2,000 on the day of discharge with normal Cr at 0.7. # Suicide attempt: Patient is s/p hanging as described in HPI. The patient was evaluated by psychiatry, who recommended inpatient psychiatry when medically cleared. Patient was section 12'd and had 1:1 monitoring during his hospitalization. He was discharged to inpatient psychiatry service at [**Hospital **]. # Polysubstance abuse: Urine tox positive for amphetamines and opiates. Serum tox negative. [**Name (NI) 1094**] wife denies recent substance abuse, but in speaking to patient, he endorses recent IV opiate abuse. Urine tox at OSH also showed positive opiates, though this was before he received fentanyl. ISSUES OF TRANSITIONS IN CARE - final blood culture - NGTD at the time of discharge - complete course of antibiotics for pneumonia, to be completed on [**2100-8-22**] - psychiatry follow up after in patient psychiatry - Communication: Wife [**First Name9 (NamePattern2) 86968**] [**Name (NI) 86969**])[**Telephone/Fax (3) 86970**] - Code: Full (confirmed with wife) Medications on Admission: Trileptal, recently increased from 200 to 350BID, Adderall (wife believes pt recently stopped taking these) Suboxone Discharge Medications: 1. Amoxicillin-Clavulanic Acid 875 mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Primary: bipolar disorder, suicide attempt Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 86969**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for attempting suicide and treated for medical complications that resulted. You were followed by psychiatry who recommended inpatient treatment. You will be transferred to a psychiatry hospital to continue treatment. Followup Instructions: as directed by psychiatry hospital

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icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

9540, 9583

7329, 9194

315, 321

9670, 9670

4000, 6181

10177, 10215

2639, 2769

9362, 9517

9604, 9649

9220, 9339

9821, 10154

6197, 7306

2784, 3981

2063, 2181

264, 277

349, 2044

9685, 9797

2203, 2303

2319, 2623

2,215

185,614

28032

Discharge summary

report

Admission Date: [**2104-7-18**] Discharge Date: [**2104-7-28**] Date of Birth: [**2037-7-9**] Sex: F Service: UROLOGY Allergies: Aspirin Attending:[**First Name3 (LF) 6440**] Chief Complaint: Pelvic mass. Major Surgical or Invasive Procedure: Anterior pelvic exenteration, ileal ureteral conduit. History of Present Illness: This is a 66-year-old female with a history of pelvic tumor who underwent biopsy in the cystoscopy suite approximately 3 weeks prior to this procedure. Pathology was significant for a poorly differentiated malignancy of uncertain origin. After appropriate discussion in the outpatient setting and consultation in the GYN oncology clinic, it was decided that surgical therapy would be the 1st initial step. The patient understood the risks and benefits, and decided to proceed. Prior to proceeding to the operating room, the patient was correctly identified and consented appropriately. All questions were answered. Past Medical History: Positive for stroke x2, anemia, asthma, hypertension, and abnormal uterine bleeding in addition to the aforementioned issues. . SURGICAL HISTORY: She had thyroid surgery in the past. Social History: She is a homemaker, smokes 1 pack a day. Denies alcohol or substance abuse. Family History: Sister died of cancer in [**2100**], type unknown, positive for hypertension, diabetes. Pertinent Results: [**2104-7-27**] 04:31AM BLOOD WBC-8.0 RBC-2.90* Hgb-9.3* Hct-27.9* MCV-96 MCH-32.1* MCHC-33.4 RDW-15.5 Plt Ct-321 [**2104-7-26**] 05:30AM BLOOD WBC-7.5 RBC-2.83* Hgb-9.2* Hct-26.5* MCV-94 MCH-32.4* MCHC-34.6 RDW-15.5 Plt Ct-316 [**2104-7-20**] 06:02AM BLOOD Neuts-77.8* Lymphs-18.6 Monos-3.2 Eos-0.3 Baso-0.1 [**2104-7-28**] 05:00AM BLOOD Plt Ct-369 [**2104-7-17**] 01:30PM BLOOD Bleed T-7 [**2104-7-28**] 05:00AM BLOOD Glucose-77 UreaN-5* Creat-0.5 Na-138 K-4.0 Cl-104 HCO3-28 AnGap-10 [**2104-7-27**] 04:31AM BLOOD Glucose-118* UreaN-3* Creat-0.5 Na-139 K-4.1 Cl-106 HCO3-24 AnGap-13 [**2104-7-22**] 04:42AM BLOOD Calcium-7.7* Phos-1.9* Mg-1.8 [**2104-7-19**] 02:15PM BLOOD Type-ART Temp-38.2 PEEP-5 pO2-166* pCO2-32* pH-7.37 calTCO2-19* Base XS--5 -[**Month/Day/Year **]/CON Intubat-INTUBATED [**2104-7-18**] 03:00PM BLOOD Glucose-183* Lactate-3.8* Na-137 K-3.6 Cl-111 calHCO3-22 [**2104-7-18**] 03:00PM BLOOD Hgb-11.8* calcHCT-35 [**2104-7-18**] 03:00PM BLOOD freeCa-0.99* . . [**2104-7-21**] 10:35 pm BLOOD CULTURE VENIPUNTURE. **FINAL REPORT [**2104-7-27**]** AEROBIC BOTTLE (Final [**2104-7-27**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2104-7-27**]): NO GROWTH. . . [**2104-7-25**] 10:24 am STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT [**2104-7-27**]** CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2104-7-27**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. . . [**2104-7-27**] 4:03 pm SWAB Source: abd wound. GRAM STAIN (Final [**2104-7-27**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Pending): ANAEROBIC CULTURE (Pending): . . Brief Hospital Course: Ms [**Known lastname 43251**] was admitted on [**2104-7-18**]. She was prepared and consented for surgery as per standard. In the operating room, estimated blood loss was 1500cc. She received 2 units of packed red blood cells and 5 litres of intravenous fluids in total. The surgery was done in conjunction with the GYN service. Operative notes are available on OMR. There were no complications during the surgery. However, the Pt had transient hypotension during the procedure and was put on Levophed. Upon completion, Ms [**Known lastname 43251**] was taken to the [**Hospital Ward Name 332**] ICU, where she was monitored closely. Pt was transfered to the [**Hospital Unit Name 153**] hemodynamically stable, not on pressors, and intubated. Initially, she was drowsy, on propofol. IN the [**Hospital Unit Name 153**], the following events occured: . . 1)Respiratory status- Pt extubated without events. Is currently sating well on 3L NC. . 2)S/P cystectomy- Transfused 1 U pRBC yesterday for post-op Hct drop 35.1 --> 32.8 --> 28.8. Responded to Hct of 30.5. Started on dilaudid PCA yesterday, and increased basal rate for pain control. Pt has ileoconduit and continues to have adequate urine output. s/p Cefazolin 1g IV q8 hrs X 3 doses for post-op prophylaxis. . 3)[**Name (NI) 12329**] pt's bp stable, no longer on pressors, continue to monitor . 4)Hypothyroidism- stable as outpt, continue Levothyroxine 137.5 mcg . 5)Asthma - Albuterol/Atrovent MDIs prn. Resume home meds (Advair). . 6)[**Name (NI) 1623**] pt NPO, pt has NG tube. Tube feeds were held as was expecting NGT to be d/c'd. Will f/u c surgery regarding length of need for NGT. If pt continues to require NGT, will start tube feeds. Will monitor lytes and replete prn . 7) Access: PIV. may d/c a-line as BPs now stable, d/c central venous catheter. . . Once Ms [**Known lastname 43251**] was stable, she was then transfered to the floor (12 Resiman) where she continued to progress. The ostomy nurse visited her to [**Known lastname **] with changing her ostomy bag - an interpreter was required, and at first, Ms [**Known lastname 43251**] did not make much of an effort to learn how to change her bag independently. Upon discharge, this did not improve greatly, as Ms [**Known lastname 43251**] was under the impression her bag would be changed for her on a regular basis. She was assigned a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] with ostomy and wound care upon discharge. . Her pain was moderately well-controlled. She was using a PCA for the intial 3 days on the floor but had difficulty understanding how to use it; hence, her pain levels ranged from minimal to extremely high. She was then switched on to IV morphine PRN, and her pain was controlled better. . On [**7-26**], Ms [**Known lastname 43251**] began to complain of abdominal pain and there was slight evidence of cellulitis at her midline incision. She was started on Ancef, and the following day, three staples were removed to drain a potential seroma. Upon opening the wound, no fluid was drained and no seroma to be found. The wound was packed with iodoform and changed twice daily from then on (wet to dry). Ms [**Known lastname 43251**] stated her pain did decrease with this opening. A swab was taken from the wound. . Ms [**Known lastname 43251**] complained of continous vaginal discharge, which the GYN service believed would decrease with time. She was given pads and mesh underwear upon discharge to [**Known lastname **] with this discharge. . Medications on Admission: Atenolol 20 QD, Advair, Albuterol, Lipitor 20 QD, Plavix 75 QD (stopped prior to OR), Naprosyn prn, Levothyroxine 137 mcg Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for headache, pain, T > 101.0. Disp:*50 Tablet(s)* Refills:*0* 2. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Disp:*28 Capsule(s)* Refills:*0* 3. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for upset stomach. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Cefazolin in Dextrose (Iso-os) 1 g/50 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours). 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation for 10 days. Disp:*20 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Pelvic mass. Discharge Condition: Stable. Discharge Instructions: You are being prescribed a narcotic pain medication. DO NOT DRIVE OR OPERATE HEAVY MACHINERY WHILE TAKING THIS MEDICATION. IT [**Month (only) **] MAKE YOU DROWSY. Contact a physician for fever >100.5, bleeding or increasing redness from incisions, difficulty swallowing or breathing, headache, nausea or vomiting, double or blurry vision, or any other concerns. Please continue all home medications and those given to you by your surgeon. You have been given an antibiotic for which you must complete its entire course. Followup Instructions: Please arrange a follow-up appointment with Dr. [**Last Name (STitle) 365**] by calling ([**Telephone/Fax (1) 6441**]. Please arrange a follow-up appointment with Dr. [**Last Name (STitle) 2406**] by calling ([**Telephone/Fax (1) 18994**]. Completed by:[**2104-7-28**]

[ "458.29", "275.2", "285.1", "244.9", "275.3", "401.9", "V18.0", "518.5", "998.59", "305.1", "195.3", "493.90" ]

icd9cm

[ [ [] ] ]

[ "40.3", "71.5", "56.51", "68.8", "38.93", "99.04", "70.4" ]

icd9pcs

[ [ [] ] ]

8418, 8475

3175, 6699

279, 334

8531, 8540

1407, 3152

9111, 9382

1298, 1388

6871, 8395

8496, 8510

6725, 6848

8564, 9088

227, 241

362, 979

1001, 1187

1203, 1282

68,225

131,457

36572

Discharge summary

report

Admission Date: [**2197-10-18**] Discharge Date: [**2197-10-20**] Date of Birth: [**2153-2-10**] Sex: F Service: MEDICINE Allergies: Bactrim / Erythromycin / Nsaids Attending:[**First Name3 (LF) 1943**] Chief Complaint: Drug overdose Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: 44 y.o. woman with a history of prescription drug abuse, bipolar disorder, recently admitted for multiple drug overdose. Per emergency department note, the patient apparently took a mixture of 0.1mg Clonidine, Suboxone, and Gabapentin. Pt was found in the homeless shelter with altered mental status and a prescription of Suboxone. In the emergency department the patient was intubated for apnea. A toxicology consult recommended supportive care. Pt received an amp of bicarb given EKG showed prolonged QRS. Following amp of bicarb repeat EKG showed no change in QRS. Of note pt was recently admitted to the ED after experiencing headaches and seizure. She was noted to have an elevated lactate as well as an anion gap which closed the following day. At that time she also talked to a resident requesting demerol for a headache, when told it was an inappropriate medication, she became unhappy and accused the medical team of not trusting her. She repeated this request to multiple providers. Per her PCP, [**Name10 (NameIs) **] has received various narcotics from different prescribers around the city. She was also tested positive for Methadone which she denied taking. In the ED, initial vital signs: T 98.8, HR 94, BP 109/75, RR 14, Sat 100%. Per ED note, the patient's RR was depressed at 10bpm, slurred speech was noted. In the [**Name (NI) **] pt was noted to have no leukocytosis, U/A was negative, Lactate 1.4, +serum TCA level. Negative urine tox. Pt was noted to be altered on presentation and was given narcan. Given continued concern pt was intubated for airway protection for apnea. Tox consult was obtained and recommended supportive care. Pt had an EKG which showed a QRS of 108, he received an amp of bicarb and an EKG was repeated which showed no changed. CXR in the ED showed right mainstem intubation and the tube was pulled back. Pt was originally on Versed/Fentanyl for sedation. Past Medical History: 1. Recurrent bouts of bronchitis. 2. Hypothyroidism. 3. Bipolar disorder, well controlled on her current medications. 4. Anxiety. 5. History of appendectomy. 6. Status post ectopic pregnancy. 7. Status post four back surgeries in [**2185**], [**2186**], [**2187**] and [**2192**]. Per recent imaging, evidence of L5-S1 posterior fusion and anterior fusion with intravertebral discs 8. Status post anoxic brain injury with damage to the basal ganglia status post MVA [**2187**]. 9. Migraine Headache 10. Status post repair of rectocele at the [**Hospital1 **] in 02/[**2197**]. 11. Status post cystocele repair. 11. History of lower extremity DVT treated with 4 months of coumadin. Social History: Social Hx: Lives in shelter. Originally from [**Location (un) 9012**], was a hairdresser, but is currently unemployed and on disability (lives p/t with fiance). Tobacco 1/2ppd x 20 or so yrs EtOH: denies Drugs: denies. Family History: MS (distant relatives). [**Name2 (NI) **] seizure history. 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, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2197-10-18**] 09:30PM BLOOD WBC-5.8 RBC-3.78* Hgb-10.7* Hct-30.9* MCV-82 MCH-28.3 MCHC-34.6 RDW-13.6 Plt Ct-286 [**2197-10-18**] 09:30PM BLOOD Neuts-63.0 Lymphs-28.3 Monos-4.5 Eos-3.6 Baso-0.4 [**2197-10-18**] 09:30PM BLOOD PT-12.4 PTT-29.5 INR(PT)-1.0 [**2197-10-18**] 09:30PM BLOOD Glucose-92 UreaN-12 Creat-0.8 Na-140 K-3.6 Cl-105 HCO3-27 AnGap-12 [**2197-10-19**] 01:06AM BLOOD Albumin-3.3* Calcium-8.1* Phos-2.9 Mg-1.9 Iron-37 [**2197-10-19**] 01:06AM BLOOD LD(LDH)-142 [**2197-10-19**] 01:06AM BLOOD calTIBC-278 VitB12-262 Folate-7.0 Ferritn-13 TRF-214 [**2197-10-19**] 01:06AM BLOOD TSH-6.0* [**2197-10-18**] 09:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-POS Brief Hospital Course: This is a 44 y.o. woman presenting with presumed drug overdose that required intubation initially for apnea. #. Overdose: Pt presented with overdose with + urine tox for TCAs. Suspected pt overdosed on 0.1 mg Clonidine, Suboxone, Gabapentin. On admission pt was very lethargic with periods of apnea. Given pt was not hypotensive and Suboxone contains Narcan, her overdose was initially suspected to be from Gabapentin and Amitriptyline causing CNS depression. Pt tested positive for TCAs at a potentially toxic level. Pt's QRS have remained borderline high and unchanged after amp of HCO3. Her ECG was monitored in the ICU and remained stable without signs of a prolonging QRS. Toxicology was consulted and recommended supportive care. Psychiatry was also consulted who felt that this did not represent a suicide attempt, that the patient did not meet inpatient criteria and that the 1:1 sitter could be discontinued. Social work was also consulted for addiction services. The patient was not interested in a detox program at this time. #. Prescription drug abuse: Patient repeatedly asked for a variety of drugs, including demerol, dilaudid, klonopin, Suboxone and antibiotics. She has a documented history of drug seeking behavior, both on a previous admission ending [**2197-10-17**] and with one of her PCPs here at the [**Hospital1 18**], Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] discovered by contacting her pharmacy that she had been filling narcotic prescriptions from multiple different providers. We contact[**Name (NI) **] her PCP at [**Name9 (PRE) **] Hospital, Dr. [**Last Name (STitle) 45392**] (phone# [**Telephone/Fax (1) 14771**], fax# [**Telephone/Fax (1) 82779**]) in an attempt to centralize her prescribing. Given her recent overdose, we did not feel comfortable discharging her with any prescriptions, referring her back to her [**Hospital 12695**] clinic for suboxone management and Dr. [**Last Name (STitle) 45392**] for prescriptions of her chronic medications. No changes were made to her medications. #. Respiratory Failure: Was felt to be secondary to central respiratory depression from overdose. Patient was intubated in the ED for apneic episodes and placed on propofol for sedation. The patient was weaned off propofol and extubated the day after admission. She initially desaturated when sleeping, but improved and was stable on the hospital floor without other worrisome respiratory symptoms. # Fever: Patient had temperature to 101.0 on [**10-19**]. CXR and UA were negative. Final blood and urine cultures were pending at the time of discharge. Fever can be a side-effect of toxic levels of TCAs. The patient reported that she had been given one dose of levofloxacin for presumed sinusitis prior to admission, but she did not have signs of bacterial sinusitis and no further antibiotics were given. # Chronic Back Pain: Patient has had four different surgeries for chronic low-back pain. She complained of continuously of [**10-28**] pain in her back when asked despite having an unremarkable exam. She requested PO Morphine 15mg Q4hrs as often as possible. No other narcotics were prescribed. #. Hypothyroidism: She was continued on home regimen of Levothyroxine. #. Depression/BPD: No Amitriptyline or quetiapine was given concern for possible overdose. She showed no signs of worsening depression or mania. She will follow-up with her outpatient providers. #. Home situation: Patient was not able to leave directly to the [**Hospital1 **] shelter as she may have been barred from returning there. She will stay temporarily with him before arranging to return to [**Hospital1 **] or going to another shelter. A taxi voucher was provided on discharge. *** A copy of this discharge summary will be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45392**], patient's PCP, [**Name10 (NameIs) **] Fax# [**Telephone/Fax (1) 82779**] *** Medications on Admission: Albuterol INH Amitriptyline 150mg po qhs Clonazepam 2mg po tid Gabapentin 800mg po qid levothyroxine 100mcg daily Lidocaine patch (5%) Omeprazole 40mg daily Seroqual 50mg po bid Discharge Medications: 1. Amitriptyline 150 mg Tablet Sig: One (1) Tablet PO at bedtime. 2. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO three times a day. 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clonazepam 2 mg Tablet Sig: One (1) Tablet PO three times a day. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Diphenhydramine HCl 25 mg Capsule Sig: [**1-20**] Capsules PO twice a day as needed. 7. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO three times a day. 9. Suboxone 8-2 mg Tablet, Sublingual Sig: .5 Tablet Sublingual once a day. 10. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Transdermal once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Suboxone 8-2 mg Tablet, Sublingual Sig: One (1) Tablet Sublingual Dinner. 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Medication overdose Respiratory failure Secondary diagnoses: Hypothyroidism Bipolar disorder Discharge Condition: Stable, breathing well on room air. Discharge Instructions: You were admitted with altered mental status and not breathing enough. You had to be intubated to help you breath. We think you had trouble breathing because you were taking too much of one or several of your medications. Please only take your medications as prescribed. Your breathing has improved and you are safe to home. No changes were made to your medications. You should get your Suboxone from your [**Hospital **] clinic should you wish to continue taking this medication. You should get whatever other prescriptions you need from your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45392**], at the [**Hospital **] Hospital. Please call your doctor, Dr. [**Last Name (STitle) 45392**] if you have chest pain, difficulty breathing, fever and chills, hallucinations or seizures. Followup Instructions: You have an appointment with your primary care doctor [**First Name8 (NamePattern2) **] [**Hospital1 72815**] Hospital, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45392**], Wednesday [**11-1**] at 1:30pm. His number is [**Telephone/Fax (1) 14771**]. Completed by:[**2197-10-20**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "94.65" ]

icd9pcs

[ [ [] ] ]

9913, 9919

4525, 8469

308, 333

10076, 10114

3792, 4502

11007, 11313

3243, 3304

8697, 9890

9940, 10000

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255, 270

361, 2268

2290, 2989

3005, 3227

20,558

100,547

6628

Discharge summary

report

Admission Date: [**2154-5-2**] Discharge Date: [**2154-5-11**] Date of Birth: [**2090-9-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6169**] Chief Complaint: CC:[**CC Contact Info 25337**] Major Surgical or Invasive Procedure: Stereotactic brain biopsy History of Present Illness: HPI:Pt is a 63 yo with CAD s/p MI and stents, DM2, NASH cirrhosis, and recent diagnosis of lymphomatoid granulomatosis who presents from an OSH after GTC seizure. He was diagnosed in [**Month (only) 404**] with large B-cell lymphoma, but on further review, they have diagnosed him with probable lymphomatoid granulomatosis. He received Rituxan-CHOP, but when diagnosis changed, he was switched to Rituxan weekly only, with last dose 6 days prior to admission. He has been told that definitive treatment will require a bone marrow transplant. He has been suffering from diarrhea for 2 months and has had 10 days of an unknown med for this at home. His PET scan apparently showed disease mainly in lungs and possibly in liver. he has never had head imaging apparently. He was at home today and took his temp. He had a 103.2 fever and his wife brought him to an OSH. En route, he stopped talking and apparently started having GTC activity. They got to the ED and he either stopped briefly or continued to convulse, it is unclear. Ativan 3 mg was given with resolution. He was intubated. ? left gaze preference. CT there showed 2 cm round left temporal lobe mass with mild local edema. No shift or brainstem involvement. His temp there was 101.7. He got vanco, CTX, acyclovir, and 1 g cerebyx. He was then transferred here. Past Medical History: Large B-cell lymphoma, this has not been changed to lymphatoid granulomatosis, it is large B-cell lymphoma per Dr. [**First Name (STitle) 1557**]. iron deficiency anemia- Long standing per patient. recently treated with IV iron. Recent colonoscopy negative for bleeding source Hypertension Coronary Artery Disease s/p MI with 2 setnts placed at [**Hospital1 18**] Type II Diabetes Mellitus with retinopathy, neuropathy, nephropathy Non-Alcoholic Steatorrheic Hepatitis cirrhosis - verified by liver bx 5 years ago per pt report s/p cholecystectomy psoriasis vitiligo Social History: SH: Lives with wife. [**Name (NI) **] EtOH. No smoking. Exposed to [**Doctor Last Name 360**] [**Location (un) 2452**] in [**Country 3992**]. Family History: FH: Sister with metastatic colon CA Physical Exam: Exam:100.3, 112/50->97/48, RR=14-19, O2=99% on vent Medications received prior to exam: See above. On propofol Mental Status:Intubated and sedated. Pt is lightly sedated, and does pull against restraints at times. CN: Pupils: 3 to 2 and sluggishly reactive. Nasal Tickle: Grimaces equally and turns away briskly. Gag/Cough: Coughs on tube Corneal Reflex:Present bilaterally OCRs: Sluggish, but intact. Motor:Some spontaneous movement of all exts. Withdraws UE and LE briskly and equally to painful stimulus(nailbed pressure). Toes:Upgoing bilaterally DTRs: [**Name2 (NI) **] Tri Br Pa [**Doctor First Name **] R t t t t t L t t t t t Respiration:Pt is overbreathing ventilator. Pertinent Results: Labs/Radiology/Procedure: OSH: CBC:15/38.7\91 Chems:138/3.5/105/14/14/0.7/195 Ca=8.5 UA with neg nit, neg LE, 0-5 wbcs, 1+ bact. Coags: PTT=30, INR=1.3, PT=12.7 CT head [**5-1**]: 2 cm left medial temp lobe mass with ? vague ring of hyperdensity. Slight edema, but no shift or brainstem involvement. CXR [**5-1**]: 1. Endotracheal tube 3.3 cm above the carina. Nasogastric tube in good position. 2. Low lung volumes with bibasilar consolidations - atelectasis or pneumonia. 3. 1cm rounded opacity at the left lung base. Bilateral hilar fullness out of proportion to the vasculature. Evaluation via contrast enhanced CT is recommended. 4. Stones and surgical clips in the right upper quadrant. Correlation with patient's surgical history is requested. MRI Head [**5-2**]: 1. Left temporal lobe mass likely represents a focus of infection. Rim enhancement and edema suggests an abscess, though there is no restricted diffusion. Demyelinating process or neoplasm are also possible, though the lesion is not enhancing. 2. No other lesions within the brain parenchyma. 3. Probable developing hydrocephalus. Echocardiogram [**5-6**]: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic interatrial septum. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). False LV tendon (normal variant). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. [**Male First Name (un) **] of the mitral chordae (normal variant). No resting LVOT gradient. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No valvular pathology or pathologic flow identified. Brief Hospital Course: Mr. [**Known lastname 25338**] was admitted with seizures, fevers and a left temporal lobe mass. He was placed on Dilantin and planning for a tissue biopsy was begun. He was placed on Flagyl for concern of C. dificile. He was extubated on HD2, and subsequently transferred to the floor. He underwent radiographic studies, which may be reviewed inthe results section. He underwent a cardiac echocardiogram as part of an infectious etiology workup. On HD7, he underwent a stereotactic brain biopsy, with a preliminary diagnosis of lymphoma. With a tissue biopsy obtained, he was begun on decadron. His postoperative CT scan was unremarkable. His dilantin levels were difficult to maintain, and he was converted to Keppra. On HD7, he received 500 mg [**Hospital1 **]. The goal dose is 1500 mg [**Hospital1 **], with a wean of dilantin. He was then transferred to the medicine oncology service under the care of Dr. [**First Name (STitle) 1557**]. Mr. [**Known lastname 25338**]' staples should be removed on [**2154-5-17**]. If he is still an inpatient at that point, the Neurosurgery service would be happy to remove them. Medications on Admission: Meds(list may be old per daughters who will bring in meds as soon as possible): Immodium metoprolol 50mg daily norvasc 5mg daily lisinopril 10mg daily aspirin PRN recently d/c'd insulin glucophage HCTZ isosorbide Discharge Disposition: Home With Service Facility: ALL care VNA Discharge Diagnosis: CNS lymphoma B cell lymphoma Generalized tonic Clonic Seizures Diarrhea __________________________ Diabetes Cirrhosis Discharge Condition: good, tolerating pos, satting well on RA, ambulating without assistance Discharge Instructions: Please seek medical attention should you develop headache, nausea, vision changes, dizziness, weakness, numbness or tingling. Also seek medical attention should you develop fever, chest pain, shortness of breath, or any other concerning symptoms. Please follow up as below. Take all medications exactly as prescribed. We have stopped your aspirin, and other heart medications currently and started you on dexamethasone which you should take twice a day and keppra which you should also take 1500mg twice a day. You should finish your course of flagyl for three more days. We have also started you on lomotil for your diarrhea and pantoprazole which you should take as long as you are taking dexamethasone. Followup Instructions: Folllow as directed with Dr. [**First Name (STitle) **] [**Name (STitle) 3929**] of radiation oncology next week. his office number is ([**Telephone/Fax (1) 8082**]. You should also follow up with Dr. [**First Name (STitle) 1557**] next friday Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2154-5-17**] 12:30 Follow up on [**2158-5-17**]:00 AM with Dr. [**Last Name (STitle) **] for suture removal at [**Last Name (NamePattern1) 439**]. ([**Telephone/Fax (1) 88**]. You also have the following appointment which you should attend. Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2154-6-21**] 10:30 Please also make a follow up appointment with your opthamologist within 3 months to follow up your diabetic retinopathy

[ "787.91", "780.39", "412", "250.00", "202.80", "571.5", "414.01", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "03.31", "01.13", "96.71", "99.25" ]

icd9pcs

[ [ [] ] ]

7254, 7297

5854, 6990

344, 372

7459, 7533

3283, 5831

8293, 9198

2506, 2543

7318, 7438

7016, 7231

7557, 8270

2558, 2670

274, 306

400, 1738

2684, 3264

1760, 2330

2346, 2490

2,734

149,291

54167

Discharge summary

report

Admission Date: [**2109-4-16**] Discharge Date: [**2109-5-6**] Date of Birth: [**2044-9-8**] Sex: M Service: MEDICINE Allergies: A.C.E Inhibitors Attending:[**First Name3 (LF) 2297**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: Tracheostomy PEG Tube Cetral Line Arterial Line History of Present Illness: 64 M with CHF [**2-28**] MR, diabetes, and Asperger Syndrome found down by relative after fall without ability to rise. Brought to ED by EMS where CT head showed cerebellar bleed which has been stable on serial CT head over 10 hours. Last seen 5 days prior. While in ED had PEA arrest at 0120. Epi -> VT -> defibrillated at 200J to sinus tach. Placed on lidocaine gtt, cards consult. Emergent CTPA showed no pulmonary embolus and some mild infiltrates at bilateral bases. WBC on presentation 21 with 90% neutrophils/no bands. Lactate 3.3 and trending up to 4.4 before code, then up to 6.9 post resucitation. CXR no pneumonia. u/a no evidence of infection. No prior CP and last cath in [**2104**] showed clean coronaries. Right femoral TLC placed. Received total of 3 liters NS. Total UOP was 300 cc over 12 hrs. Given levo, flagyl, and vanco IV empirically after blood and urine cultures sent. Intubated during arrest. ABG 7.36/32/221 on AC 630, PEEP 10, f16. Lactate decreased to 3.9. Past Medical History: DM-2 HTN CHF systolic failure from mod-severe MR Bradycardia s/p PPM Pulmonary HTN Atrial Fibrillation prior GIB - (reason for not being anticoagulated) h/o Bell's Palsy in [**12-1**] with left sided facial weakness High cholesterol h/o congenital right kidney defect gerd Asperger's syndrome Social History: -lives by self and is fairly independent -no alcohol or tobacco use -has never held a full-time job due to mental disability of Asperger's syndrome Family History: -mother with few medical problems -father was an alcoholic Physical Exam: vs: Tm 98.7, bp 200/100, hr 70 v-paced, rr 16 VENT: AC 600 10 50%, observed: rr 19, Vt 650, spo2 100% ABG: 7.36/32/221 I/O: 3200/1300 x9hr uop=300 x9hr = 30cc/hr gtt: lidocaine 2mg/min, propofol gen: intubated, sedated heent: c-collar lungs: intubated, equal bilaterally, ctab. no secretions. cv: s1/s2, rrr, no MR [**First Name (Titles) 111016**] [**Last Name (Titles) **]: obese, soft, no grimace on palpation ext: no edema, varicose veins, warm and dry, dp2+ neuro: sedated. pupils 1mm equal not reactive, no blink to threat, withdrawls to pain in all extremities. Pertinent Results: Bld cul [**2109-5-1**]- [**3-2**] gram coag neg staph u cul [**2109-5-1**] - pending joint- NGTD Ucul [**2109-4-30**] NGTD cdiff (-) x 2 most recent Brief Hospital Course: 64M w/ CHF/MR, diabetes, atrial fibrillation, chronic kidney dz, and Asperger's syndrome admitted for right cerebellar/medullary infarct complicated by cardio-respiratory arrest x 2, resp failure. 1. Right cerebellar/medullary infarct: Pt initially presented to ED after fall w/ CT evidence of acute/sub-acute right cerebellar infarct. Initially planned for neuro ICU but transferred to MICU following cardiac arrest. The etiology of infarct felt most likely to be embolic. He does have known history of afib (for which had not been anti-coagulated secondary to reported GIB), had a bubble study which was negative for pfo/asd. Carotid u/s unrevealing for significant dz. However, CTA of head/neck did show evidence of thrombosis within right vertebral artery at junction of basilar artery. Furthermore, there was evidence of significant cerebral vascular dz on the left vertebral system. Initially, pt followed with serial head ct's that demonstrated no evidence of edema or hemorrhagic transformation. Blood pressure maintained with systolics in 140's. Pt started on aspirin and statin and following head CTA on [**4-18**], was initiated on heparin gtt for anticoagulation. There was discussion with neurology and MICU team regarding the risk for bleeding on heparin. The MICU team unable to find documentation of severe GIB and given the severity of cerebral vascular dz and consequences of further thrombosis, elected to anti-coagulate with iv heparin. The duration of anti-coagulation has not been established but intitial discussions with neuro indicate that indefinite anti-coagulation is preferred if clinically tolerates. His PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] may provide further insight with regards to the risk for bleeding. We started him on coumadin with no complications. Coumadin was held [**5-6**] due to elevated INR. **INR should be rechecked on [**5-7**] and coumadin restarted (at lower dose than 5mg). Coumadin should be titrated for a goal INR of [**3-1**]. Finally, CT did show evidence of both cerebellar/right medullary infarct. It has been postulated (althought not entirely clear) that difficulty in weaned vent (secondary to apnea) may be result from neurological insult. At any rate, pt has received a trach and PEG. Currently, he is responsive to commands and is able to move all extremties, athough does have weakness on right side. 2. Cardiac Arrest: First cardiac arrest in ED where pt had fell down after agitation and noted to have no pulse. Pt given epinephrine as part of PEA algorithim and then developed pulseless VT requiring defibrillation. Pt was started on amio gtt and cardiology was consulted. There was some debate as to whether amio should be continued given his first VT episode may have been in the setting of epinephrine. Later in his MICU course, pt noted to have vfib arrest in the setting of self extubation and respiratory arrest. Pt required epinephrine and defibrillation x 2. At this point, EP has recommended continued amiodarone load (400 [**Hospital1 **] x 2 weeks, beginning from [**4-19**]). He is now on amiodarone qd as per ep. Will need a formal EP study as outpatient in [**1-28**] months. 3. Respiratory Failure: Initially intubated in the setting of reported PEA arrest during ED course. Course has been notable for difficult wean off vent mostly secondary to apneic episodes. The etiolgoy of apnea not entirerly clear. He has not been overventilated. As mentioned above, there has been speculation that apnea may be related to medullary infarct interfering with resp center. Unfortunately, extent of infarct not assessed by MRI seconary to pacer. In addition, not clear that this would account for intermittent apnea. Attempts have been made to wean sedation to r/o other potential etiology of apnea. Given that patient did have another arrest following self extubation on [**4-19**] and due to slow progress of wean, ultimately had trach placed on [**4-26**]. Due to his apnea, which may be triggered by respiratory alkalosis, theophylline was started. Target levels being [**11-15**]. Since then patient has had periods of apnea lasting about 25 secs and so was placed on MMV, with a backup rate of 8. 4. Ventilator Associated PNA: Pt did develop fevers and increased sputum production on the vent several days into MICU course. Pt empirically started on VAnc and Ceftaz and sputum subsequently grew Pseuomonas sensitive to Ceftaz. Finished course of Ceftaz x 8 days for VAP. Then was found to have a line infection from picc with coag neg staph. PICC d/c'd. Started Vanco on [**5-2**] to complete 14 day course. Day [**6-9**]. Continue vancomycin for 14 days. Follow blood cultures. 5. CHF: History of CHF presumably secondary to moderate to severe mitral regurigation. F/u echo during hospital course indicated preserved systolic function with only mild MR. Pt was persistenly positive on fluid status for nearly week into course and CVP elevated at over 20. With more flexibility in blood pressure management, he has been diuresed w/ iv furosemide. Goal should likely be 500 to 1 liter negative. He has been started on low dose beta-blocker and restarted on diovan. We also resumed him spironolactone and today, converted him to standing diuretics. 6. Afib/pacer: History of afib not anticoagulated in the past secondary to gib. As mentioned above, now being anticoagulated in the setting of infarct. He has been ventricular paced during his coure. He has now been started on beta-blocker in addition to amiodarone. 7. Chronic Kidney Disease: Baseline creatinine ranges from 1.5 to 2.0. Has been stable during hospital course. 8. ?Group B strep bacteremia: One bottle of BC from [**4-16**] demonstrated group B strep. Given negative blood cultures before and after this date, most likley felt to be contaminate. However, given pacer wires, team elected to treat for 7 day course of Vanc now completed. Now on vanc again for coag neg staph from picc line that was d/c'd [**5-2**] and resited [**5-5**]. 9. Diabetes: Managed with intermittent insulin gtt and now increasing doses of NPH. He did previously use oral hypoglycemics but team was relucant to use oral-hypoglycmicis in acute illness. These could be restarted at later date. 10. Nutrition: Had PEG placed on [**4-26**]. Swallow eval not yet performed at this point as still on ventilation. 11. Access: Picc replaced RUE on [**2109-5-5**], Trach, PEG, Foley Medications on Admission: -lasix 80mg po bid -zoloft -spironolactone 50mg po qd -avandia 8mg po qd -diovan 80mg po qd -protonix 40mg po qd -stool softener -MVI -lipitor 20mg po qd -glyburide 2.5 mg po qd Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Respiratory Failure Cerebral Vascular Accident Atrial Fibrillation CHF Pneumonia Discharge Condition: Stable Discharge Instructions: Please Weigh patient every morning. Adhere to 2 gm sodium diet Fluid Restriction: 2000cc Followup Instructions: Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2109-6-13**] 3:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 544**], M.D. Date/Time:[**2109-6-21**] 9:50 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2109-9-3**] 3:00 Completed by:[**2109-5-6**]

[ "482.1", "250.00", "287.5", "V53.31", "428.20", "518.81", "424.0", "427.31", "996.62", "728.88", "585.9", "434.11", "299.80", "427.5", "401.9", "274.0", "437.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.04", "99.60", "96.6", "43.11", "99.62", "31.1" ]

icd9pcs

[ [ [] ] ]

9369, 9441

2700, 9141

284, 334

9566, 9575

2526, 2677

9713, 10123

1863, 1923

9462, 9545

9167, 9346

9599, 9690

1938, 2507

236, 246

362, 1366

1388, 1682

1698, 1847

72,725

195,674

23520

Discharge summary

report

Admission Date: [**2107-6-27**] Discharge Date: [**2107-7-2**] Date of Birth: [**2031-12-19**] Sex: M Service: MEDICINE Allergies: Heparinoids Attending:[**First Name3 (LF) 1436**] Chief Complaint: transfer from OSH for MI Major Surgical or Invasive Procedure: cardiac catheterization with no intervention History of Present Illness: Mr. [**Known lastname 60205**] is a 75 y.o man with hx of CAD with CABG [**11/2104**] (LIMA-LAD, SVG-PLV, SVG-OM), LM BMS in [**2-/2106**] transferred to the CCU from [**Hospital 4199**] Hospital for hypotension and decreased LVEF following surgery for large colon mass on [**2107-6-24**]. The patient was in his USOH until about 4 weeks prior to presentation when he started having constipation. He was admitted to OSH on [**2107-6-18**] for acutely worsening abdominal pain on the background of constipation. He underwent colonoscopy which showed intussusception and fungating cecal mass with biopsies showing invasive adenoCa. He underwent right hemicolectomy on Friday [**6-24**]. Pathology report is pending at this time. Pre-surgery he was given cardiac clearance after having a stress test that showed only inferior scarring and an ECHO with EF of 50%. He was extubated post operatively, but low SaO2 to the 80's post extubation despite NRB led to reintubation and transfer to the PACU. Per report he was extubated >1 day later. Pst-operatively, on [**6-25**] he developed hypotension requiring Levophed gtt over the weekend which was weaned off the night prior to transfer. Troponin I was noted to rise from 0.02 on [**6-24**] to 2.28 on [**6-25**], then 1.77 on [**6-25**], with down trends q 8 hrs to 1.45, 1.21, and 0.55. A TTE was read as reduced LVEF to 25%, with mid/distal anterior wall akinesis, and inferior wall akinesis/scarring. LV apex documented as akinetic as well with mild impairment of the RV iwth free wall hypokinesis. Compared to his [**6-21**] echo, the only read was mild concentric LVH, LVEF of about 54%, with inferior wall akinesis/scarring/inferolateral wall hypokinesis. He was started on aspirin 325 mg and heparin gtt on [**6-25**] following the echo results. The following day, [**6-26**] he was weaned off pressors and he was given another unit of pRBCs with good UOP. Patient also noted to be somewhat confused at OSH attributed to operative sedation. He was transferred to [**Hospital1 18**] for further management of presumed peri-operative MI. On arrival to the CCU, patient is alert and interactive. He complains of severe pain in his right leg, behind the calf and in the knee. The knee is swollen and warm, which his wife notes is relatively new but has happened before. Has numbness in lower extremities that is chronic. Denies any chest pain, SOB, nausea, vomiting, or diarrhea. Has not eaten since surgery but is passing gas. No abdominal pain. No new rashes. No headaches or visual changes. Denies any history of alcohol withdrawal seizures. He denies chest pain, SOB. On review of systems, he denies any prior history of stroke, deep venous thrombosis, pulmonary embolism, recent fevers, chills or rigors. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Reported MI (?NSTEMI) at 42 yo - CABG: [**2104**]:(LIMA-LAD, SVG-OM, SVG-RPL)c/b [**Year (4 digits) 25730**] atelectasis and pericardial effusion, which subsequently resolved - PERCUTANEOUS CORONARY INTERVENTIONS: -[**2106-2-9**]: Rotational atherectomy and bare metal stenting of the left main into the proximal LAD -[**2106-6-9**] Angiography: No significant unbypassed coronary artery disease. LAD stent widely patent. - s/dCHF (LVEF=30-45%) - HTN - Hyperlipidemia - Chronic LBP [**2-10**] spinal stenosis s/p lumbar laminectomy ([**2098**], [**2099**]) - Sciatica - Right knee osteoarthritis and associated pseudogout and chondrocalcinosis of the knee. - Arthritis in his hands - Peripheral neuropathy (?mixed large and small fiber polyneuropathy) - Colon polyps s/p polypectomy and recent colon cancer of the cecum with laporscopic R hemicolectomy ([**6-/2107**]) - Anemia -Alcohol abuse- [**1-13**] of alcohol/day with hx of neuropathy -MGUS -Presumed alcoholic cirrhosis (visualized on CT scan at OSH [**2107-6-24**]) Social History: He is married and lives with his wife in [**Name (NI) 3146**]. He is a retired salesman. Tobacco: Multiple PPD for several years. Quit approximately 33 years ago. ETOH: [**1-13**] of alcohol daily of vodka per family (patient says "3 glasses of vodka a day"). Illicit drugs: Denies Family History: His mother died at 86 of a stroke. Father died at 54 of heart problems. One sister who is no longer alive, they believe she had heart problems. A brother with CAD s/p stenting. He has one adult son who is healthy. He denies any other diseases in the family including cancers. Physical Exam: Admission Exam: GENERAL: Uncomfortable appearing. Affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVD of about 8 cm. CARDIAC: PMI located in 5th intercostal space, anterior axillarly line. Faint heart sounds. Tachycardia otherwise normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities. Mild kyphosis. Resp were unlabored, no accessory muscle use. Basilar crackles up to mid back on R, basilar crackles of lower [**1-11**] lung field on the left. No wheezes or rhonchi. ABDOMEN: Distended. Surgical scar with staples and scant erythema present in the midline. Laporascopic port sites on left and right side of abdomen without erythema. Abdomen distended with normal bowel sounds. No rebound. No organomegaly appreciated. No abdominial bruits appreciated. EXTREMITIES: 2+ edema bilaterally to mid shin. Toes with scattered eschars on frontal surface (from "scraping concrete with his toes while walking") Pain with manipulation of right leg. Right knee appears edematous with appreciated calor without rubor. Cannot manipulate knee secondary to pain. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AAOx3, although needed to be reoriented regarding year. CNII-XII intact, with reorientation during testing of EOM. [**5-14**] grip strength, biceps, triceps, wrist. Lower extremity strength difficult to assess secondary to right knee pain. Difficult moving toes bilaterally with stocking distribution of paresthesias to midshin. Cannot elicit DTR's. Positive asterixis. PULSES: Right: Carotid 2+ FDP 2+ PT 1+ Left: Carotid 2+ DP 2+ PT 1+ . Pertinent Results: Admission labs: [**2107-6-27**] 07:43PM BLOOD WBC-9.9 RBC-3.52* Hgb-11.0* Hct-32.7* MCV-93 MCH-31.1# MCHC-33.5 RDW-16.1* Plt Ct-170 [**2107-6-28**] 03:57AM BLOOD Neuts-87.8* Lymphs-8.5* Monos-3.4 Eos-0 Baso-0.3 [**2107-6-27**] 07:43PM BLOOD PT-15.0* PTT-49.4* INR(PT)-1.4* [**2107-6-27**] 07:43PM BLOOD Glucose-116* UreaN-5* Creat-0.5 Na-136 K-3.6 Cl-104 HCO3-24 AnGap-12 [**2107-6-27**] 07:43PM BLOOD ALT-9 AST-13 LD(LDH)-242 AlkPhos-54 TotBili-1.0 [**2107-6-27**] 07:43PM BLOOD CK-MB-1 cTropnT-0.19* [**2107-6-27**] 07:43PM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.6* Mg-2.0 Discharge LabS: Imaging: Ultrasound right leg [**2107-6-27**]: Limited assessment of the right posterior tibial and peroneal calf veins. Otherwise no deep venous thrombosis noted in the right lower extremity. CXR [**2107-6-27**]: FINDINGS: As compared to the previous radiograph, the patient has received a new right internal jugular vein catheter. The tip of the catheter projects over the lower SVC. There is no evidence of complications, notably no pneumothorax. An increase in density of the right lung base is likely caused by patient rotation. Moderate cardiomegaly. Sternal wires are unchanged and intact. CARDIAC CATH [**6-29**]: COMMENTS: 1. Selective native coronary angiography in this right dominant system demonstrated 3 vessel coroanry artery disease. The LMCA had a patent stent into the proximal LAD. The LAD had a 60% lesion in the mid segment. The LCX had an 80% lesion in the proximal segment, and the distal LCX was supplied by a patent SVG graft. The RCA was totally occluded. 2. Selective venous conduit angiography demonstrated patent SVG to OM and SVG to RCA grafts. 3. Selective arterial conduit angiography demonstrated a patent LIMA to LAD graft. 4. Left heart catheterization revealed a severely elevated LVEDP of 28 mmHg. There was normal systemic arterial blood pressure with a central aortic blood pressure of 101/55 mmHg. There was no gradient across the aortic valve with carefull pullback. 5. Right heart catheterization revealed severely elevated right and left sided filling pressures. The mean RA pressure was moderately elevated at 14 mmHg, and the RVEDP was severely elevated at 18 mmHg. There was moderate pulmonary hypertension with a PA pressure of 47/22 mmHg and a mean PA pressure of 32 mmHg. It was not possible to obtain a good wedge tracing, and furthur attempts at obtaining a wedge tracing were deferred given that a LVEDP had also been obtained. The cardiac output and index were normal at 5.2 L/min and 2.7 L/min/m2. The SVR was mildly reduced at 585 dyne-sec/cm5. The PVR could not be calculated due to the lack of a wedge pressure tracing. 6. Due to severely elevated filling pressures, the patient was given 80 mg IV lasix. 7. Selective renal angiography demonstrated patent bilateral renal arteries FINAL DIAGNOSIS: 1. Three vessel native coronary artery disease. 2. Patent LIMA to LAD. 3. Patent SVG to OM and SVG to RCA. 4. Severely elevated right and left sided filling pressures treated with 80 mg IV lasix. 5. Moderate pulmonary hypertension. 6. Preserved cardiac output. 7. Mildly reduced SVR. 8. Patent bilateral renal arteries. 9. Continue with medical management of CAD and CHF. . Discharge labs: [**2107-7-2**] 07:35AM BLOOD WBC-5.7 RBC-3.51* Hgb-10.5* Hct-32.5* MCV-93 MCH-29.9 MCHC-32.3 RDW-14.7 Plt Ct-246 [**2107-7-2**] 07:35AM BLOOD Glucose-87 UreaN-9 Creat-0.6 Na-139 K-3.4 Cl-103 HCO3-24 AnGap-15 [**2107-6-30**] 06:05AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.0 Brief Hospital Course: Mr. [**Known lastname 60205**] is a 75 year old man with history of coronary artery disease (CAD) with left main (LM) stent in [**2106-6-9**] and prior CABG in [**2104**] who is transferred to the CCU from [**Hospital 4199**] Hospital for concern for NSTEMI given hypotension and decreased LVEF following surgery for large colon mass. He underwent cardiac cath with no interventions, thought to have a autolysed thrombosis from heparin gtt > 48 hours before cath. # CAD: patient has significant CAD s/p CABG and recent PCI in 2/[**2106**]. Prior to surgery his EF was 45% by echo and then after the surgery he was hypotensive and developed new focal wall motion abnormalities with depressed EF to 25%, concerning for new ischemia. His Troponin peaked at OSH at 2.5 and he was transferred here for evaluation via cath of his coronaries. He was restarted on a heparin drip to cover for an acute plaque ruputure and admitted to the CCU. Cardiac cath showed chronic disease with occluded RCA, LAD 60% occluded but prior stent patent, and Left circumflex 80% occluded. We felt that the new wall motion abnormality and troponin elevation represented a true ischemic event, brought on by massive surgery, but that his prolonged heparin gtt was effective in lysing the clot prior to cath. His medical regimen was optimized to: aspirin 81 mg, clopidogrel 75 mg, lisinopril 2.5 mg daily, metoprolol succinate 50 mg daily, simvastatin 40 mg daily, furosemide 40 mg daily. # Systolic congestive heart failure: patient has history of decreased EF however his preop TTE showed EF of 50% and postop showed EF of 25% with focal wall motion abnormality concerning for ischemic heart failure due to MI perioperatively. Managed as above with beta blocker, ACEi, diuresis. Weight at discharge is 80.1 kg. # Delerium- patient became delirious in the evenings, and required haldol 0.25mg x2. He later was determined to be waxing and [**Doctor Last Name 688**], with worse confusion and hallucinations in the early morning hours. This was also exacerbated by sedating medications used for cath, etc. His mental status resolved to normal after 48 hours. # Colon cancer status post right hemicolectomy at OSH: His wound healed well and he was able to pass stool and eat during this admission. The pathology from the outside hospital was not final at time of discharge. #Liver cirrhosis: He had a CT abdomen at the OSH for staging which showed nodular liver and the intraoperative report noted a nodular, cirrhotic liver. He did have a significant drinking history. His LFTs were normal, platelets were greater than 200, and INR was 1.4. Albumin was 3.2 Social work was consulted to help with his alcohol abuse and he should have further work-up and follow-up for chronic cirrhosis. TRANSITIONAL ISSUES: - New diagnosis of cirrhosis need outpatient FU - Has f/u appt with surgeon on [**7-12**], wife has appt details. - will need appt with oncologist depending on pathology results. - Is on [**1-10**] furosemide dose from admission. Increase furosemide if pt shows signs of fluid retention. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Atenolol 25 mg PO DAILY 2. Furosemide 80 mg PO DAILY 3. Simvastatin 40 mg PO DAILY 4. Aspirin 325 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Nitroglycerin SL 0.4 mg SL PRN chest pain Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Cyanocobalamin 1000 mcg PO DAILY 3. Furosemide 40 mg PO DAILY Hold for SBP<90 4. Simvastatin 40 mg PO DAILY 5. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain do not exceed 2g in 24 hour period 6. Clopidogrel 75 mg PO DAILY 7. Lisinopril 2.5 mg PO DAILY Hold for SBP<90 8. Metoprolol Succinate XL 50 mg PO DAILY HOld for SBP<90 or HR<60 9. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 10. Nitroglycerin SL 0.4 mg SL PRN chest pain Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living Discharge Diagnosis: Non ST Elevation myocardial infarction Acute systolic congestive heart failure Hypertension Hyperlipidemia Cecum mass s/p hemicolectomy 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 had a heart attack around the time of your operation and was transferred to [**Hospital1 18**] for a cardiac catheterization. This showed that the blockages are the same and no intervention was done. You will continue on the aspirin, plavix (clopidogrel) and simvastatin to prevent the blockages from getting worse. At this time, we do not have results of the biopsy that was done at [**Hospital 4199**] hospital. The surgeon from [**Last Name (un) 4199**] should be contact[**Name (NI) **] early next week for results. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Followup Instructions: Please keep the follow up appt with your surgeon on [**2107-7-12**]. . Department: CARDIAC SERVICES When: MONDAY [**2107-7-25**] at 11:00 AM With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage **Dr. [**Last Name (STitle) **] has nothing available in the [**Location (un) **] office where you are usually seen until the end of [**Month (only) **], your doctors [**First Name (Titles) **] [**Last Name (Titles) **] [**Name5 (PTitle) **] to be seen in a months time. Please keep the above appointment unless you can call the [**Location (un) **] office and get a cancelation appt. sooner. PCP [**Name Initial (PRE) **]: Pending With:[**First Name8 (NamePattern2) 6923**] [**Name8 (MD) 6924**],MD Location: [**Hospital1 **] HEALTHCARE -[**Location (un) 2352**] Address: 1000 [**Last Name (LF) **], [**First Name3 (LF) 2352**],[**Numeric Identifier 9121**] Phone: [**Telephone/Fax (1) 1144**] **We are working on a follow up appointment with Dr. [**Last Name (STitle) 6924**] in the next week. You will be called at home with the appointment. If you have not heard within 2 business days or have questions, please call the number above. Completed by:[**2107-7-14**]

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icd9cm

[ [ [] ] ]

[ "88.53", "37.23", "88.57", "88.56" ]

icd9pcs

[ [ [] ] ]

14180, 14321

10246, 13023

297, 344

14501, 14501

6695, 6695

15364, 16707

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13685, 14157

14342, 14480

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233, 259

372, 3309

6711, 7271

14516, 14660

3332, 4360

4376, 4661

3,419

194,653

10166

Discharge summary

report

Admission Date: [**2200-8-22**] Discharge Date: [**2200-9-5**] Date of Birth: [**2130-5-25**] Sex: F Service: NEUROSURGERY Allergies: Doxil Attending:[**First Name3 (LF) 1835**] Chief Complaint: weakness Major Surgical or Invasive Procedure: s/p right parietal craniotomy for tumor resection History of Present Illness: 70F with grade II ER+/Her2neu neg infiltrating intraductal carcinoma recently on Xeloda and Zometa s/p failure of Doxil [**12-26**] hypersensitivity, with questionable medical compliance who presents to [**Hospital1 18**]. She was transferred from an OSH after 2 episodes of weakness and not being able to get off the floor. the first instance happened on the day before admission where the patient slid from a sitting position to the floor and was unable to get off the floor until her daugher got home at 4:30 in the afternoon. She said that she was unable to move her legs but was able to move her arms. reports some slight dizziness. She also reports headache for the past 2 weeks. She denies any LOC, incontinence, seizure, syncope, CP, SOB, abdominal pain, vomiting, hemoptysis, hematochezia. After help from her daughters, she was able to ambulate with the assistance of a cane. There was no change in her ambulation and she reports that since her stroke she has had some residual L-sided weakness. On the morning of admission the patient reports that she was incontient at 0300 and felt dizzy when trying to change her undergarments and fell back to the bed and went to sleep. After arising, she was sitting on the bed getting dressed and again slipped to the floor from a seated position. Again, she felt weak and was unable to get up. Prior to this she had showered, had a headache and took some aspirin and ibuprofen with mild relief. She denies any LOC, seizure, chest pain, SOB, abdominal pain, or overt blood loss. She was helped up by her daughters and was subsequently brought to an OSH ED. Her vital signs were stable, labs were remarkable for an elevated alk phos. While in the ED she was given Decadron 10 IV and a Head CT was obtained. She was then transferred to [**Hospital1 18**] for further management. Past Medical History: Oncology History: 1. [**2195-3-24**] diagnosed with grade 2 infiltrating ductal carcinoma, lymphovascular invasion present, ER positive, HER2/neu negative. 2. [**2195-4-24**] bony metastasis noted on bone scan, started on Arimidex. 3. [**2196-6-23**] tumor markers rose changed to tamoxifen. 4. [**2197-8-23**] rising tumor markers, changed to Aromasin. 5. [**2197-11-23**] changed to Faslodex because of rise in tumor markers. 6. [**2198-7-25**] increasing disease on bone scan started on Zometa and Xeloda [**2198-9-24**]. 7. [**2200-5-24**] started on Doxil & Zometa. Patient received Doxil x 3 with discontinuation during the 3rd dose [**12-26**] (back pain & dizziness), placed back on Xeloda and Zometa. Most recent tumor markers ([**2200-8-15**]) CEA 570 & CA27.29 1076. Peak levels were CEA 802 ([**2200-7-15**]) CA27.29 1216 ([**2200-5-26**]). . . . Breast Cancer [**2194**])with mets to bone HTN NIDDM Stroke [**2185**] L partial mastectomy . Social History: Denies any EtOH, tobacco, or illicit drug use. Family History: Noncontributory Physical Exam: Vitals - T:97.4 BP:166/74 HR:62 RR:14 02 sat:98% GENERAL: obese women, pleasant, jovial, laying bed, 2 daughters present SKIN: multiple sebhorrheic dermatoses on back, no other ulcerations, excoriation HEENT: AT/NC, EOMI, moist mucus membranes, no oral ulcers, left sided posterior cervical lymphadenopathy, supple [**Doctor Last Name **], no decreased ROM CARDIAC: RRR, SEM @ RUSB, S1/S2, no rubs or gallops LUNG: CTAB, no adventitious sounds ABDOMEN: obese, +BS, nondistended, nontender, no rebound/guarding M/S: 3/5 strength in RUE, [**12-29**] in LUE, [**1-26**] RLE, [**1-26**], LLE [**12-29**], moving all extremities well PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII grossly intact; Brief Hospital Course: This patient was initially seen by the oncology medicine service, and admitted under the same. At that time, her issues were as follows: 1. Brain Mass - MRI read as above. Will undergo debulking this week with subsequent radiation. - Contune decadron 4mg q6h - will start bactrim 3x/week for PCP prophylaxis as patient will be on long-term steroids - IRSS - Pre-op CXR & EKG done - Coags, UA done . 2. GYN - patient has a Foley put in overnight, and it was noted that the patient has a swollen clitoris. After inquiry, patient reports that she's had some itching over the past several months, and has tried medications, but nothing appears to have worked. She denies any difficulty voiding and hasn't noticed any discharge from her vagina or hematuria. Could this be due to chemotherapy? - Will get in touch with Dr. [**First Name (STitle) **] regarding this. - Discontinue Foley . 3. HTN - patient has a history of hypertension, but has been normotensive on the floor - Continue BB - Continue ACE - Continue CCB . 4. NIDDM - Patient will be restarted on Glyburide - IRSS - Diabetic diet . 5. FEN - IVFs at 125 cc/hr - replete lytes prn - Diabetic Diet . . The patient was seen by the Neurosurgery service and after appropriate imaging was obtained, she was scheduled for surgery. She was transfered to the [**Hospital Ward Name **] and to the neurosurgery service on [**2200-8-28**] and her surgery performed the following day. She had no major intra-operative complications after her surgery and spent the night in the recovery room. Immediately post-operatively, the patient was difficult to arouse and weak on her left side of the body. The following morning, she had a repeat CT Head which was stable from her post-op film. On this same day, POD1, the patient was admitted to the ICU for blood pressure control, neuro checks, and due to her mental status changes. She had an MRI done with a stroke protocol on this day which dod not reveal evidence of a CVA, however it did show significant cerebral edema. . On POD2, the patient remained in the ICU and her Decadron medication was increased. Her neurological exam was essentially unchanged. She had no new issues. . On [**9-1**] (POD3), the patient remained in the ICU for furthut blood pressure control and continued neuro checks. Her neurological exam was slightly improved. She had no new events. . On [**9-2**] (POD4), the patient was started on tube feeds; she was also transfered to the neuro step down unit. She was seen by PT and OT who reccomended the patient go to rehab. Her tube feed continued overnight. Over the next few days until [**9-5**], the patient's neurological exam gradually improved and she became more awake and alert. The patient did not have furthur complaints. She was seen by speech and swallow and evaluated; they reccomended a specific diet, as indicated on the patient's discharge paperwork. This patient was discharged in a stable condition. Discharge Medications: 1. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Phenytoin 100 mg/4 mL Suspension Sig: Eight (8) ml PO Q12H (every 12 hours). 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 11. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 13. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 14. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 17. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 18. Morphine Sulfate 2-4 mg IV Q4H:PRN 19. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 days: To be changed to 4mg Q12H on [**2200-9-6**]. 20. Decadron 4 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: To begin [**2200-9-8**]. 21. Decadron 4 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days: BEGIN ON [**2200-9-6**]; To be changed to 4mg Q24H on [**9-8**], [**2199**]. . Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: s/p right parietal craniotomy for tumor resection Discharge Condition: good Discharge Instructions: Please call the office or come to the emergency room for any change in mental status, new weakness, or seizure. Please call the office for any questions that you may have. Please call the office or come to the emergency room for excessive redness of your incision, drainage or fever >101.5 Followup Instructions: Pt has appointment in the brain tumor clinic on Monday [**9-8**], [**2199**] at 3pm. Please have them dc your sutures at that time. Completed by:[**2200-9-5**]

[ "198.5", "426.3", "198.3", "174.9", "198.89", "250.00", "438.89", "V45.71", "401.9", "278.00" ]

icd9cm

[ [ [] ] ]

[ "96.6", "01.59", "38.93", "02.12", "00.32", "83.32" ]

icd9pcs

[ [ [] ] ]

8810, 8889

3994, 6927

278, 329

8982, 8988

9328, 9490

3242, 3259

6950, 8787

8910, 8961

9012, 9305

3274, 3971

230, 240

357, 2185

2207, 3162

3178, 3226

29,682

104,608

13126

Discharge summary

report

Admission Date: [**2116-10-22**] Discharge Date: [**2116-11-12**] Date of Birth: [**2096-8-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Headache Major Surgical or Invasive Procedure: Tunnelled catheter placement Hemodialysis History of Present Illness: 20 F with Type I Diabetes, complicated by ESRD on HD for the last year. Recently hospitalized here 2-3 weeks ago for uncontrolled hypertension. . States that she has bifrontal headaches associated with her hypertension. This was controlled for only a few days after her discharge. Since then, she has had recurrent headaches at least daily, sometimes lasting up to all day. They have been relatively stable these past weeks. She denies associated CP, SOB. No signs of infection including fevers, chills, new rash, nausea, vomiting or diarrhea. . Was seen at endocrine clinic for her parathyroid adenoma, at which time she was referred to the ED for her elevated blood pressure to SBP > 200 and associated headache. Past Medical History: * Type I DM - since [**2098**] * ESRD on HD (MWF in [**Hospital1 789**]) * Pulmonary embolism on coumadin (diagnosed 1 month prior per patient) * Hypertension * Hyperlipidemia * Retinal detachment L eye * Bilateral cataracts Social History: The patient lives at home with her parents and younger sister. She denies any alcohol or tobacco use. Family History: No history of headaches or migraines. Father and grandparents with hypertension. Two grandparents are diabetic. Physical Exam: Physical Examination VS - 98.1 bp 160/110 HR 91 RR 18 96%RA GEN: NAD HEENT - R pupil reactive; L globe scarred; OP clr, MMM CV - RRR, no m/r/g RESP - R anterior chest tunnelled HD line c/d/i; lungs CTAB ABD - NABS, soft, NT/ND, EXT - no edema Pertinent Results: [**2116-10-22**] 03:30PM GLUCOSE-188* UREA N-39* CREAT-6.3* SODIUM-140 POTASSIUM-6.3* CHLORIDE-96 TOTAL CO2-27 ANION GAP-23* [**2116-10-22**] 09:03PM K+-5.7* . [**2116-10-22**] 03:30PM WBC-6.4 RBC-3.86* HGB-11.8* HCT-38.0# MCV-98 MCH-30.6 MCHC-31.1 RDW-18.6* NEUTS-54.5 LYMPHS-21.0 MONOS-3.3 EOS-17.6* BASOS-3.6* . [**2116-10-22**] 03:30PM PT-33.2* PTT-37.7* INR(PT)-3.6* . CXR [**10-22**]. IMPRESSION: Findings consistent with volume overload. Repeat radiography following diuresis recommended. Brief Hospital Course: In summary, Ms. [**Known lastname **] is a 20 yo female with Type I DM, ESRD on HD, h/o PE in [**8-11**] on coumadin, parathyroid adenoma, admitted for hypertensive urgency. . HTN. Patient was initially treated in the MICU on a nitroglycerin drip. Her BP improved. She was then transferred to the floor after one day. She was resumed on her home BP meds (labetolol and losartan and nifedipine). It remained unclear if hypertension was due to medication noncompliance (patient says she reliably takes all meds) versus chronic underdializing and fluid overload. She was then transferred back to the ICU for hypertensive urgency again. She required labetolol gtt on and off to control her BP. She received daily ultrafiltration and hemodialysis to regain fluid balance. She was also started on additional oral BP meds including hydralazine and minoxidil (avoided clonidine for concern over reflex hypertention if there is medication non-compliance). Once transferred back to the floor, minoxidil was uptitrated to 7.5mg daily. Hydralazine was dosed at 25mg po BID, was briefly treated with QID dosing but both patient and her mother thought this would be difficult to maintain while outpatient. Upon discharge her BP ranged from SBP 120-130s directly after dialysis to SBP 140-180 on non-dialysis days. When she did exceed SBP > 200, or DBP > 120, she was given hydralazine 5mg IV with appropriate effect. Discharged on labetolol, losartan, nifedipine, minoxidil and hydralazine. . Line infection/bacteremia. At HD on [**10-26**] she was noted to have rigors and subsequently developed a ACINETOBACTER BAUMANNII bactermia and growth from her tunnelled cath tip (after it was removed). She was treated with gentomycin until the sensitivities returned and she was switched to ciprofloxacin. A temporary line was briefly used and then a new tunneled catheter was placed once surveillance cultures returned negative. She completed a 14 day course of Cipro and then the medication was discontinued. . HA. Patient reports unilateral throbbing headache associated with photophobia and nausea. It was not clear if her headache was due to hypertension or if she was having a migraine. Throughout her course, her HA occurred nearly daily and had no clear association with her blood pressure. She was treated also with Dilaudid and morphine IV for pain which generally controlled her pain. She was started on a trial of sumatriptan for headaches which was moderately helpful, she was discharged with a limited number of this medication. Fioricet was tested and did provide moderate relief. She was discharged on a limited number of this medication. . Parathryoid adenoma. Parathyroid scan on [**2116-10-2**] showed anterior mediastinal parathyroid adenoma. Patient will need surgical removal of adenoma in future given that hypercalcemia likely contributes to both her headache and recurrent nausea. Dr. [**Last Name (STitle) 26030**] was consulted while inpatient and planned on removing her adenoma while inpatient. The day of the proposed operation, however, her blood pressure was so poorly controlled that anesthesiology thought it unsafe to proceed with surgery. She was recommended to follow-up with Dr. [**Last Name (STitle) 26030**] as an outpatient with an appropriate anesthesiology pre-operative evaluation given the severity of her hypertension. . History of PE. Patient had PE at OSH in [**8-11**] and is on Coumadin. She was continued on coumadin in the hospital with her INR within goal range of [**2-8**]. Her coumadin was briefly held while inpatient and she was transitioned to a heparin drip in preparation for her parathyroid adenomectomy. Once it became clear that her surgery could not be obtained while inpatient, she was restarted on coumadin. The day of discharge she had a therapeutic INR x 48 hours. . ESRD on HD: followed by renal consult. Continued on HD and ultrafiltration. Also treated with Sevelamer and Cinacalcet per Renal recommendations. Discharged with follow-up at prior hemodialysis facility. Also instructed INR monitoring during HD. . DM1. Long standing history on uncontrolled type 1 diabetes. She was hyperglycemic initially with her infection, but then was better controlled in the MICU. Continued on glargine [**Hospital1 **] and humalog with meals. Maintained fair control while inpatient from 100-200. Was continuously difficult to control given erratic eating patterns, poor diet compliance and refusal by patient & mother to adhere to prescribed insulin dosing at various intervals. Discharged with glargine 15u at breakfast and 12u at supper and a humalog insulin sliding scale. Also set-up with VNA services given the complexity of her medical issues. . Hyperkalemia. Intermittently hyperkalemic in the setting of ESRD. Never symptomatic. No EKG changes. Treated intermittently with kayexelate when K > 5. . Abdominal Pain - Intermittent abdominal pain described as vague and diffuse. C/w with constipation in addition to possible gastritis. Continued on PPI and an aggressive bowel regimen. Resolved with these interventions. Was discharged without abdominal pain x 48 hours. . H/O glaucoma. On multiple medications, eye drops consistent with glaucoma. Additionally on prednisone gtts of unclear reasoning. Patient insisted on continued drops during inpatient stay. On discharge was recommended to follow-up with ophthalmologist to better define course of prescribed medications. . Discharged home with moderately controlled hemodynamic stability, afebrile. VNA services set-up on discharge for family support given complexity of her medical problems. Medications on Admission: 1. B Complex-Vitamin C-Folic Acid 1 mg DAILY 2. Prednisolone Acetate 1 % Drops, One Drop Daily 3. Dorzolamide-Timolol 2-0.5 % Drops 1 Drop DAILY 4. Brimonidine 0.15 % Drops 1 Drop DAILY 5. Butalbital-Acetaminophen-Caff 50-325-40 mg One Tablet PO Q8h PRN 6. Labetalol 800 mg PO TID 7. Prochlorperazine 10 mg PO Q8h prn nausea 8. Pantoprazole 40 mg PO Q24H 9. Sevelamer 1600 mg PO TID W/MEALS 10. Warfarin 5 mg PO at bedtime Mon, Wed, Fri, Sat; 2.5 mg Tues, [**Last Name (LF) 5929**], [**First Name3 (LF) **] 11. Insulin Glargine 12 units with breakfast, 10 units at bedtime 12. Humalog sliding scale 13. Cinacalcet 90 mg PO once a day 14. Losartan 100 mg PO once a day 15. Nifedipine 30 mg PO Q8h Discharge Medications: 1. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): 1 DROP BOTH EYES DAILY . 2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily): 1 DROP BOTH EYES DAILY . 3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily): 1 DROP BOTH EYES DAILY . 4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Q MWFSAT (). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Q TUETHURSUN (). 6. Imitrex 25 mg Tablet Sig: One (1) Tablet PO once a day as needed for migraine: Please take within 2 hours of onset of headache. Disp:*30 Tablet(s)* Refills:*0* 7. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 11. Sevelamer 800 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*150 Tablet(s)* Refills:*2* 12. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 16. Butalbital-Aspirin-Caffeine 50-325-40 mg Capsule Sig: One (1) Cap PO every eight (8) hours as needed for headache. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 18. Minoxidil 2.5 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*1* 19. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Disp:*60 Tablet(s)* Refills:*1* 20. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. Disp:*60 Tablet Sustained Release(s)* Refills:*1* 21. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache for 20 doses: Do not exceed more than 3gm of Acetamenophen (Tylenol) in one day. This medication contains 325mg per tablet. Disp:*20 Tablet(s)* Refills:*0* 22. VNA port maintenance Heparin Flush Port (10 units/mL) 5 ml IV each visit with 10 ml NS followed by 5 ml of 10 Units/ml heparin (50 units heparin) each lumen, each visit. Inspect site each visit. 23. Outpatient Lab Work Please check INR at each Hemodialysis visit and forward information to Dr. [**First Name (STitle) 29653**] Z [**First Name (STitle) **] at [**Telephone/Fax (1) 40070**] so that he may adjust her coumadin dosing. 24. Lantus 100 unit/mL Solution Sig: 12-15 units Subcutaneous twice a day: Take 15 units at breakfast and 12 units at bedtime . 25. Humalog 100 unit/mL Solution Sig: As directed by insulin sliding scale units Subcutaneous four times a day. Discharge Disposition: Home With Service Facility: VNA Care [**Location (un) 511**] Discharge Diagnosis: Primary: Hypertension, Diabetes Mellitis type I Secondary: ESRD, parathyroid adenoma, hypercalcemia, hyperlipidemia, prior pulmonary embolism on Coumadin Discharge Condition: Good, moderate hemodynamic control and afebrile Discharge Instructions: You were admitted for hypertension and associated headache. Your blood pressure was controlled by increasing your medications and your headache was controlled with agressive pain relief. You additionally had an infection in your blood while you were in the hospital. You have been treated for this infection. On discharge you will have the continued VNA services. You should also have hemodialysis every Monday, Wednesday and Friday with monitoring of your INR while there. You also need to schedule a follow-up appointment with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. at ([**Telephone/Fax (1) 9011**] for removal of your parathyroid adenoma. . Please take all your medications as prescribed in the following medication sheet. There have been several modifications concerning your blood pressure medications but it is important that you take all these medications as prescribed. . If you have worsening headache, blurry vision, nausea/vomiting, shortness of breath, chest pain, or any other concerning symptoms, please call your physician or come to the emergency department. . Please keep all your outpatient appointments. Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 40069**], in 1 to 2 weeks. Please schedule an appointment by callling [**Telephone/Fax (1) 40070**]. . Or, if you prefer to have your primary care physician transferred to [**Hospital3 **], you may call [**Hospital6 733**] at [**Telephone/Fax (1) 250**] to make an appointment to establish care. . Please contact [**Name (NI) **] [**Name (NI) **], M.D. at ([**Telephone/Fax (1) 9011**] to schedule a follow-up appointment for surgical removal of your parathyroid adenoma. You will also need a preoperative anesthesiology visit prior to this operation. You should discuss this with Dr. [**Last Name (STitle) **]. . Continue to follow-up closely with your gynecologist at Women & Infant's Hospital. . Follow-up with your [**Hospital 197**] Clinic 3-5 days post-discharge for a INR check and dose adjustment.

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icd9cm

[ [ [] ] ]

[ "39.95", "38.95", "99.07" ]

icd9pcs

[ [ [] ] ]

11921, 11984

2417, 8059

324, 367

12182, 12232

1890, 2394

13443, 14361

1498, 1612

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276, 286

395, 1113

1135, 1362

1378, 1482

15,191

150,476

5866+5867

Discharge summary

report+report

Admission Date: [**2127-1-9**] Discharge Date: [**2127-1-13**] Date of Birth: [**2056-5-21**] Sex: F Service: [**Hospital Unit Name 196**] CHIEF COMPLAINT: Chest pain. HISTORY OF THE PRESENT ILLNESS: This is a 70-year-old pleasant female with a history of diabetes, coronary artery disease ([**2120**] PTCA of LAD; in [**2121**] stent to the left circumflex), hypercholesterolemia, and hypertension, who presents with 7/10 left chest pain ache that radiates to the neck and left shoulder. This pain occurred while going to bed last night. It lasted through the night, woke her up from sleep, and went away in the morning. There were no associated symptoms of nausea, vomiting, shortness of breath, or diaphoresis. She has had these chest pain episodes which come and go since [**2127-1-2**]. Her angina in the past has generally been associated with exertion and relieved with rest within a few minutes. In the past week, she noted that the pain was not relieved with rest as quickly or with sublingual nitroglycerin tablets dated back from [**2123**]. REVIEW OF SYSTEMS: No fevers, chills, sweats, abdominal pain, or dysuria. In the Emergency Department, the patient received three sublingual nitroglycerin and aspirin which made her pain-free. She also received Lopressor 5 mg IV given that her systolic pressures were in the 200s. PAST MEDICAL HISTORY: 1. Hiatal hernia. 2. Diabetes mellitus, noninsulin-dependent. 3. Coronary artery disease with a [**2120**] PTCA of the LAD; in [**2121**] stenting of the left circumflex. 4. Hypertension. 5. Hypercholesterolemia. 6. Negative ETT MIBI in [**2125-8-8**] revealing 7.5 minutes on the [**Doctor First Name **] protocol with maximal heart rate at 85% but no ECG changes or angina symptoms. SOCIAL HISTORY: The patient denied any tobacco or IV drug use. She does drink alcohol occasionally. FAMILY HISTORY: Mother had a stroke at age 62, diabetes mellitus, hypertension. Father had lung cancer. ALLERGIES: Questionable allergy to sulfa. MEDICATIONS AT HOME: 1. Vitamin E. 2. Multivitamin. 3. Metformin 1,000 mg p.o. b.i.d. 4. Lopressor 50 mg p.o. b.i.d. 5. Amaryl 4 mg p.o. q.d. 6. Aspirin 325 mg p.o. q.d. 7. Imdur 60 mg p.o. q.d. 8. Lipitor 40 mg p.o. q.d. 9. Lisinopril 10 mg p.o. q.d. 10. Caltrate 600 plus D. LABORATORY DATA UPON ADMISSION: White cell count 5.2, 59% neutrophils, 33% lymphocytes, 5% monocytes, 2% eosinophils, 1% basophils. Her sodium was 142, potassium 4, chloride 103, bicarbonate 26, BUN 17, creatinine 0.7, glucose 142, magnesium 1.8, PT 12.3, PTT 23.2, INR 1.0. CK 94 and 68, troponin less than 0.3, less than 0.3. Chest x-ray showed no signs of pneumonia or CHF. The urinalysis revealed 1 red blood cell, 20 white blood cells, few bacteria, 5 squamous epithelial cells. ECG was normal sinus rhythm at 80 with normal axis, normal interval. There were small Qs in II, III, and aVF. No STT changes noted. Poor R wave progression. HOSPITAL COURSE: 1. CORONARY ARTERY DISEASE: Given the patient's story of unstable angina, she was put on a heparin and nitroglycerin drip. She was also continued on her ACE inhibitor, statin, aspirin, and beta blocker. She went for a cardiac catheterization which revealed 95% stenosis of the mid RCA, 70% stenosis of the proximal LAD, 90% stenosis of the mid LAD, and preserved LV function. Given that she has LAD disease and diabetes, it was felt best that coronary artery bypass graft would be the best option. She will be transferred to Cardiothoracic Surgery for the CABG. 2. HYPERTENSION: Her blood pressure was running in the 160-200s. She was put on a nitroglycerin drip which kept her pressure in the 160s. After the catheterization, the nitroglycerin drip was weaned and replaced with Isordil 20 mg p.o. t.i.d. Her pressures then came back down to the 120s on the Isordil along with the Lisinopril 10 mg p.o. q.d. and the metoprolol 50 mg p.o. b.i.d. 3. DIABETES MELLITUS: Her Metformin and Amaryl was held until after the catheterization and the CABG. Her sugars are controlled with regular insulin sliding scales and remained in the low 200s during the hospital course. 4. GASTROINTESTINAL: GERD: For her GERD, she was given Protonix. 5. INFECTIOUS DISEASE: Questionable UTI. A urinalysis was repeated and she was found to have few bacteria and 0-2 white cells. Given that the patient is asymptomatic with an unimpressive urinalysis, she was not treated at this time. TRANSFER DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Hypertension. 3. Diabetes mellitus. 4. Gastroesophageal reflux disease. TRANSFER MEDICATIONS: 1. Colace. 2. Isordil 20 mg p.o. t.i.d. 3. Heparin drip. 4. Protonix 40 mg p.o. q.d. 5. Regular insulin sliding scale. 6. Lisinopril 10 mg p.o. q.d. 7. Atorvostatin 40 mg p.o. q.d. 8. Aspirin 325 mg p.o. q.d. 9. Metoprolol 50 mg p.o. b.i.d. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Transfer to Cardiothoracic Surgery. [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**] Dictated By:[**Last Name (NamePattern1) 4270**] MEDQUIST36 D: [**2127-1-12**] 00:14 T: [**2127-1-14**] 06:31 JOB#: [**Job Number 23213**] Admission Date: [**2127-1-9**] Discharge Date: [**2127-1-18**] Date of Birth: [**2056-5-21**] Sex: F Service: CARDIOTHORACIC SURGERY ADMITTING DIAGNOSIS: Coronary artery disease. DISCHARGE DIAGNOSIS: Coronary artery disease. PROCEDURES DURING ADMISSION: CABG times three; LIMA to LAD, SVG to D1, SVG to DRCA on [**2127-1-13**]. HISTORY OF THE PRESENT ILLNESS: The patient is a 65-year-old female who is status post PTCA to the LAD in the proximal mid and distal portions in 11/96 with respective residual stenosis of 25%, 10%, and 10%. Three months prior to admission, the patient had an ETT thallium which was positive for inferior-posterior reversible defect. The patient presents on [**2127-1-9**] to [**Hospital6 256**] with the complaint of chest pain radiating to her neck and left shoulder. The patient woke up from sleep with pain. She had no associated nausea, vomiting, or shortness of breath. The patient underwent a cardiac catheterization which revealed a right dominant system with a 70% stenosis of the proximal portion of the LAD of a 90% stenosis of the mid LAD as well as a 90% stenosis involving the second diagonal branch. The right coronary had a proximal 40% stenosis after the conus with serial 90% lesions in the mid RCA. The patient's ejection fraction was seen to be about 50%. HOSPITAL COURSE: The patient was beta blocked and had a preoperative evaluation. On [**2127-1-13**], she was taken to the Operating Room for a three vessel CABG. The patient tolerated the procedure well. Her postoperative course was essentially uneventful. She was extubated. She was weaned from a Neo drip. On postoperative day number one, beta blockage was begun as was diuresis. The patient tolerated this well. On postoperative day number two, her chest tubes were removed and her Neo was weaned completely to off. She was transfused for a hematocrit of 26.5. On postoperative day number three, the patient was transferred to the floor for further management as well as ambulation and rehabilitation. The patient did well. Her Lopressor was adjusted for adequate beta blockade. She was continued to be diuresed. On postoperative day number five, [**2127-1-18**], the patient was discharged home in stable condition on the following medications. DISCHARGE MEDICATIONS: 1. Lopressor 37.5 mg p.o. b.i.d. (this was adjusted given the pharmacies inability to dispense this dose to 50 mg p.o. b.i.d.). 2. Lasix 20 mg p.o. q.d. times seven days. 3. Potassium chloride 20 mEq p.o. q.d. times seven days. 4. Lipitor 10 mg p.o. q.d. 5. Amaryl 4 mg p.o. q.d. 6. Metformin 1,000 mg p.o. b.i.d. 7. Colace 100 mg p.o. b.i.d. 8. Aspirin 325 mg p.o. q.d. 9. Percocet one to two tablets p.o. q. 4-6 hours p.r.n. DIET: She was discharged home with a diabetic diet with VNA. FOLLOW-UP: She was told to follow-up with Dr. [**Last Name (STitle) 1537**] in four weeks and to follow-up with her cardiologist in approximately one week. CONDITION ON DISCHARGE: Stable. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 4985**] MEDQUIST36 D: [**2127-1-18**] 10:20 T: [**2127-1-19**] 09:22 JOB#: [**Job Number 23214**]

[ "250.00", "401.9", "V45.82", "414.01", "998.12", "411.1", "272.0", "530.81" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4911, 5406

1899, 2033

7579, 8237

5476, 6591

6609, 7556

2054, 2338

1100, 1365

174, 1080

4638, 4889

2353, 2971

5428, 5454

1387, 1779

1796, 1882

8262, 8552

28,935

140,094

8101

Discharge summary

report

Admission Date: [**2194-5-15**] Discharge Date: [**2194-5-24**] Date of Birth: [**2154-4-10**] Sex: F Service: SURGERY Allergies: Tylenol / Sulfa (Sulfonamides) / Doxycycline / Latex Attending:[**First Name3 (LF) 5547**] Chief Complaint: abdominal pain, nausea Major Surgical or Invasive Procedure: [**2194-5-15**] exploratory laparotomy, cecopexy, appendectomy History of Present Illness: Ms. [**Known lastname 28896**] is a 40 year old female with history of osteogenesis imperfecta and spinomuscular atrophy who comlaints of abdominal pain for the past day that has gradually increased in severity. She also complains of nausea, and has not passed flatus or BM recently, although she normally only has 1 bowel movement per week. Per report, a CT scan at [**Hospital3 **] revealed cecal volvulus. She was transferred to the [**Hospital1 18**] because it was thought that the ICU at [**Hospital3 **] would be poorly equipped to take care of her. Past Medical History: OI, hypotonia, chronic pain, wheelchair bound, sinusitis, ? hx DVT, migraines, osteopenia Social History: Lives with her ex-husband [**Name (NI) **], who is her caretaker and healthcare proxy. Occasionally drinks EtOH, denies tobacco. Family History: Noncontributory Physical Exam: On admission: VS: T 99.8, HR 98 BP 118/70, RR 18, O2 sat pending HEENT: NC/AT Chest: CTA B/L Heart: RRR no M/G/R Abd: Distended, hypoactive BS, soft, diffusely tender with some guarding, no rebound. Rectal exam: guaiac negative Pertinent Results: ***** [**5-15**] OPERATIVE REPORT: PREOPERATIVE DIAGNOSIS: Cecal volvulus versus closed loop small bowel obstruction. POSTOPERATIVE DIAGNOSIS: Cecal volvulus. NAME OF OPERATIONS: 1. Exploratory laparotomy 2. Reduction of cecal volvulus. 3. Cecopexy. 4. Appendectomy. ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD. ANESTHESIA: General endotracheal. INDICATIONS FOR PROCEDURE: [**Known firstname 2184**] [**Known lastname 28896**] is a 40-year-old woman with a history of muscular dystrophy and osteogenesis imperfecta who has a long chronic history of constipation. She presented to the [**Hospital3 1810**] Emergency Room with a several-day complaint of worsening diffuse abdominal pain without the passage of gas or stool for several days. She then developed nausea and emesis, and so presented to the emergency room. Upon evaluation there, she [**Hospital3 1834**] a CT scan of the abdomen that demonstrated a large dilated loop of bowel in the pelvis suspicious for either a cecal volvulus or a closed loop small bowel obstruction. Though she was nontoxic appearing with normal vital signs and a normal white blood count, she was diffusely tender with guarding and so an operation was recommended. However, there were no available ICU beds at [**Hospital3 1810**], and so the patient was offered transferred to the [**Hospital1 **] MC and she accepted. Given her significant medical comorbidities, I explained to [**Known firstname 2184**] and her healthcare proxy, Mr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12163**], that any abdominal operation carried with it a very high risk, perhaps more than 50% of mortality as well as a substantial risk of morbidity. The patient understood these risks and consented to proceed. DESCRIPTION OF PROCEDURE IN DETAIL: The patient was identified in the preoperative holding area and taken to the operating room in conjunction with her health care proxy, Mr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12163**], and she was carefully positioned on the bed with all pressure points carefully padded. The patient indicated that she was positioned comfortably and so we carefully did not move her for the remainder of the procedure. Mr. [**Name13 (STitle) 12163**] was then escorted out of the operating room. A surgical timeout procedure was performed. Intravenous Ancef was administered. The patient was sedated and a fiberoptic awake oral tracheal intubation was carried out by the anesthesia team. The patient was then placed under general anesthesia and paralyzed. An 8-French Foley catheter was carefully placed with the return of clear yellow urine. Pneumo boots were applied to both legs. A femoral arterial line was placed by the anesthesia team. Her abdomen was widely sterilely prepped and draped in the usual fashion. A midline periumbilical incision was made and the fascia was opened in the midline. The peritoneal cavity was entered sharply without incident. Intraoperative exploration showed some bland ascites. There was clearly evidence of a cecal volvulus with clockwise rotation of the cecum which was in the left mid-abdomen. The volvulus was reduced with counterclockwise rotation. The cecum was clearly viable as was the remainder of the colon and small intestine. We then systematically explored the abdomen. There was a normal stomach and duodenum. The ligament of Treitz was identified in the small bowel was run all the way to the ileocecal valve. The small bowel showed no abnormalities and was clearly viable. There was no evidence of adhesions or masses. As noted, the entire cecum, ascending, transverse and descending colon were all viable. However, the cecum in particular, but the remainder of the colon was quite distended and filled with soft solid stool. Similarly, the sigmoid colon and upper rectum were normal. Given that the cecum was clearly viable and the wall was not particularly thin or edematous, I elected to proceed with a cecopexy rather than a bowel resection in this high-risk patient. I first wished to decompress the cecum and ascending colon somewhat and elected to do this through the appendiceal orifice. Accordingly we elected to perform an open appendectomy. Adhesions from the appendix to the cecum were taken down with the cautery. The appendiceal mesentery was then divided between Schnidt clamps and ligated with 3-0 silk suture ligatures. The base of the appendix was then crushed. The appendix was excised and passed off the field. A 3-0 silk pursestring suture was placed around the base of the appendix on the cecum. A suction device was then placed through the open appendiceal stump and the gaseous distention was evacuated from the cecum and ascending colon; however, we could not completely decompress the colon as there was a large amount of formed stool throughout which was not readily amenable to removal. Accordingly, the appendiceal stump was ligated with a 3-0 silk suture ligature. It was then dunked with the 3-0 silk pursestring and an additional 3-0 silk Z stitch. The anterolateral wall of the cecum was then sutured to the right lateral abdominal wall with several 3-0 silk sutures placed through the tenia of the cecum and into the peritoneum of the right lateral abdominal wall. This positioned the cecum nicely in the right lower quadrant. There certainly was a lot of redundancy in the ascending and transverse colon, but we felt that by simply fixing the lead point the risk of recurrence should below. We elected not to place a cecostomy tube given the high morbidity and degradation and quality of life with such tubes. However, with the cecum adherent to the right lateral abdominal wall, we knew that postoperatively one could possibly be placed percutaneously if needed. Intestinal contents were then returned to their natural position. The omentum was laid over the intestinal contents. Our sponge and instrument counts reported as correct x2 by the nurse in charge. The fascia was closed with running #0 PDS sutures. Subcutaneous tissues were irrigated and the skin was closed with staples. A sterile dressing was applied. The patient tolerated the procedure well. There were no evident complications. She was transferred to the recovery room intubated, sedated and in stable condition as no ICU beds were available at this time. FLUIDS: One liter of crystalloid. BLOOD PRODUCTS: None. URINE OUTPUT: None. ESTIMATED BLOOD LOSS: Was 25 mL. Brief Hospital Course: Ms. [**Known lastname 28896**] [**Last Name (Titles) 1834**] exploratory laparotomy with cecopexy and appendectomy on [**2194-5-15**]. The procedure was uncomplicated, but she was transferred to the ICU for postoperative observation due to her multiple comorbidities. Her potassium was repleted. She did well there and was transferred to the floor on POD 2. Her postoperative course was relatively uncomplicated - chronic pain consult was called and her pain was controlled with PO dilaudid and NSAIDs, she slowly regained her physical strength, and was advanced to regular diet by POD 5. A family meeting was called to discusse options for increased level of care at home, and her caretaker was given a list of companies to call to obtain a personal care assistant. She was able to ambulate with her wheelchair by POD 6. She was passing flatus and with an aggressive bowel regimen had a large bowel movement on POD 8. She was discharged home in good condition with services, and was able to arrange for a personal care assistant to start on [**2194-5-27**]. Medications on Admission: Oxycodone 15 mg 4-5 times daily, Necon daily, buspar 30 mg [**Hospital1 **], Zometa twice a year, Albuterol INH prn, Flonase [**Hospital1 **], Colace TID, MVI, Ca, Vitamin B, vitamin C Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: Six (6) mL PO BID (2 times a day): hold for loose/watery stool. Disp:*360 mL* Refills:*2* 2. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for bladder spasm. Disp:*30 Tablet(s)* Refills:*0* 3. Levocarnitine 330 mg Tablet Sig: One (1) Tablet PO bid (). 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: 30-180 MLs PO QHS (once a day (at bedtime)). 6. Ibuprofen 200 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*100 Tablet(s)* Refills:*2* 7. Necon 0.5/35 (28) 0.5-35 mg-mcg Tablet Sig: One (1) Tablet PO once a day. 8. BuSpar 30 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for wheezing. 10. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray Nasal twice a day. Discharge Disposition: Home Discharge Diagnosis: Cecal volvulus Osteogenesis imperfecta Spinomuscular atrophy Discharge Condition: Good Tolerating regular diet Ambulating with wheelchair Pain controlled Bowel function returned Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Activity: No heavy lifting of items [**10-15**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. Diet: You may resume your regular diet. Followup Instructions: Call Dr.[**Name (NI) 12822**] office ([**Telephone/Fax (1) 7508**]) to schedule a followup appointment in [**1-1**] weeks from now. Follow up with your primary care physician [**Last Name (NamePattern4) **] [**2-2**] weeks for a postoperative visit. Completed by:[**2194-5-27**]

[ "359.1", "338.29", "756.51", "733.90", "338.18", "789.00", "560.2", "789.59" ]

icd9cm

[ [ [] ] ]

[ "46.64", "47.19", "46.82" ]

icd9pcs

[ [ [] ] ]

10366, 10372

8041, 9108

335, 400

10477, 10575

1546, 8018

11529, 11811

1264, 1281

9343, 10343

10393, 10456

9134, 9320

10599, 11506

1296, 1296

273, 297

428, 988

1310, 1527

1010, 1101

1117, 1248

11,287

177,486

47010+58966

Discharge summary

report+addendum

Admission Date: [**2107-10-22**] Discharge Date: [**2107-10-31**] Date of Birth: [**2056-5-8**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: Briefly, the patient is a 51-year-old woman with a history of atrial fibrillation, rheumatic heart disease, and status post mitral valve replacement who was transferred for [**Hospital3 934**] Hospital after being resuscitated for a pulseless ventricular fibrillation arrest that occurred during admission for shortness of breath and abdominal discomfort. In [**Month (only) 958**], the patient had a mitral valve replacement surgery with a bileaflet mechanical valve with a postoperative course significant for new onset atrial fibrillation and an ejection fraction estimated between 35% to 50% (per report). Since the time prior to admission, the patient experienced the persistence of atrial fibrillation; and, of note, had 1/6 bottles positive for coagulase-negative Staphylococcus in [**Month (only) 205**] (as per primary care physician). Prior to admission, the patient complained of a 4-day history of increased dyspnea on exertion, nausea, and vomiting. A transthoracic echocardiogram a her primary care physician's office (Dr. [**Last Name (STitle) 99683**] revealed an ejection fraction of 10%. The patient was then sent to [**Hospital3 934**] Hospital where laboratories were remarkable for a theophylline level of 29 and an INR of 4.3. The patient was also in atrial fibrillation at this time. The patient was then taken to Radiology for a right upper quadrant ultrasound for her abdominal complaints on presentation. At 2:30 p.m. on [**2107-10-22**], the technician noticed that she was blue, and the patient was in pulseless ventricular fibrillation arrest. A code was called, and the patient was cardioverted with 300 joules and loaded on 300 mg intravenously of amiodarone, intubated, and was sent to the Intensive Care Unit. The initial arterial blood gas in the Intensive Care Unit was remarkable for a pH of 7.3, a PCO2 of 32, and a PO2 of 550. This hospital course was also remarkable for an 8-beat run of nonsustained ventricular tachycardia following the ventricular fibrillation arrest, and the patient was also successfully extubated. The patient was transferred to [**Hospital1 188**]. Upon arrival to the Coronary Care Unit, the patient was in atrial fibrillation with a rapid ventricular response of approximately 120 beats per minute to 130 beats per minute. The patient was given a total of 15 mg of Lopressor intravenously with a decrease in heart rate between 100 beats per minute to 110 beats per minute with a stable blood pressure of 104/72. The patient was given 25 mg of oral Lopressor times two doses overnight with good rate control in the 90s. PAST MEDICAL HISTORY: 1. Rheumatic heart disease. 2. Status post mitral valve replacement in [**2107-4-8**]. 3. Hypertension. 4. Asthma. 5. Ulcerative colitis. 6. Atrial fibrillation. 7. Anemia. 8. Status post hysterectomy. 9. Status post appendectomy. 10. Hypercholesterolemia. 11. Chronic renal insufficiency. 12. Dilated cardiomyopathy. MEDICATIONS ON ADMISSION: (Medications a home included) 1. Lopressor 25 mg p.o. b.i.d. 2. Cardizem 120 mg p.o. b.i.d. 3. Theophylline 600 mg p.o. q.d. 4. Zyrtec 10 mg p.o. q.h.s. 5. Coumadin with alternating doses of 5 mg and 2.5 mg p.o. 6. Protonix 40 mg p.o. q.d. 7. Potassium chloride 20 mEq p.o. q.d. 8. Serevent 2 puffs b.i.d. as needed. 9. Flovent 2 puffs b.i.d. as needed. ALLERGIES: FLOXIN, 6-MERCAPTOPURINE (with reaction of nausea and vomiting and gastrointestinal intolerance). MEDICATIONS ON TRANSFER: Amiodarone drip 0.5, Protonix, vancomycin (day one), Combivent, salmeterol, and Phenergan. SOCIAL HISTORY: The patient has approximately a 15-pack-year of smoking. She reports occasional ethanol use. She denies any intravenous drug use. The patient is married. She works in the processing department. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination upon admission revealed vital signs with a temperature of 98.5, heart rate was 110, blood pressure was 104/78, respiratory was 18, oxygen saturation was 95% on 2 liters nasal cannula. Telemetry revealed atrial fibrillation. In general, the patient was resting comfortably, in no acute distress. Head, eyes, ears, nose, and throat revealed normocephalic and atraumatic. Pupils were equal, round, and reactive to light. Extraocular muscles were intact. Mucous membranes were moist. Neck was supple without lymphadenopathy. No jugular venous distention appreciated. Cardiovascular examination revealed a mechanical first heart sound, second heart sound, tachycardic, irregular rhythm. Chest examination revealed crackles at the left lower base. Good air entry. No wheezes. The abdomen was obese, soft, mild diffuse tenderness. Extremities revealed no clubbing, no cyanosis, no edema. No osseus nodes. No [**Last Name (un) 1003**] lesions. No splinter hemorrhages. Neurologically, the patient was alert and oriented times three; however, she had some memory deficits. Normal speech. Moved all extremities. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission revealed sodium was 139, potassium was 3.9, chloride was 105, bicarbonate was 20, blood urea nitrogen was 27, creatinine was 2.1, blood glucose was 157. White blood cell count was 12.1, hematocrit was 34.2, platelets were 255. PT was 28.1, INR was 5.5, PTT was 34.6. Amylase was 48, LDH was 395, AST was 21, ALT was 99, albumin was 3.4, bilirubin was 0.6. Blood cultures upon admission were negative. Laboratories from outside hospital revealed creatine kinases that were flat at 73 to 83 to 134; and troponins that remained below 0.4. RADIOLOGY/IMAGING: Echocardiogram revealed atrial fibrillation at a rate of 101, normal axis, normal intervals, flattened T waves. No ST changes. A chest x-ray was remarkable for markedly enlarged heart, prosthetic mitral valve. No signs of failure. A catheterization in [**2107-4-8**] revealed the following pressures; right atrial pressure of 20, right ventricle was 54/20, pulmonary artery pressure was 54/21, pulmonary capillary wedge pressure was 25 with a V-wave of 45, cardiac index of 3.1. Also notable for a mitral valve gradient of 12.8, mitral valve area of 1.4, ejection fraction of 45%. No regional wall motion abnormalities. Mitral regurgitation was 3+, and coronary angiography was normal. HOSPITAL COURSE BY SYSTEM: The patient was then admitted to the Coronary Care Unit for further observation, status post pulseless ventricular fibrillation arrest; awaiting implantable cardioverter-defibrillator placement. 1. CARDIOVASCULAR: (a) Rhythm/atrial fibrillation: The patient was found to be in atrial fibrillation upon admission and was on an amiodarone drip and a Lopressor 50 mg p.o. b.i.d. Rate well controlled upon admission. Initially, the patient was switched from an amiodarone drip to oral amiodarone and captopril was added at 6.25 mg p.o. t.i.d. The patient remained in atrial fibrillation with good rate control on amiodarone and Lopressor throughout the majority of the hospital stay and was successfully cardioverted in the Electrophysiology Laboratory on hospital day seven. Upon discharge, the patient's amiodarone and beta blocker were discontinued; as per Electrophysiology requisition in response to a decreased heart rate, status post cardioversion, as well as interactions with implantable cardioverter-defibrillator capturing. (b) Rhythm/ventricular fibrillation arrest: The patient with a low ejection fraction. The patient was scheduled to be awaiting implantable cardioverter-defibrillator placement throughout the majority of the hospital stay. Given a questionable history of positive blood cultures in the past, Infectious Disease was asked to consult to elucidate whether or not the patient was at risk for endocarditis and other risks associated with this history of bacteremia. After an extensive Infectious Disease consultation, the patient was cleared for implantable cardioverter-defibrillator placement. On hospital day seven, the patient received implantable cardioverter-defibrillator (as per Electrophysiology) with interrogation the following day with procedure notable for no complications and with all parameters stable upon interrogation. The patient was to follow up in the Device Clinic on [**11-3**] at 11:30 in [**Last Name (un) 469**] Seven. (c) Pump: Echocardiogram throughout the hospital course was notable for a left ventricular cavity enlargement with severe global diastolic dysfunction, moderate aortic regurgitation, a well-functioning prosthesis with mild mitral regurgitation, with an estimated ejection fraction between 10% to 20%. The patient was continued on a low-dose ACE inhibitor throughout the remainder of her hospital stay as tolerated by the patient's history of chronic renal insufficiency. (d) Valve/status post mitral valve replacement: Given the patient's questionable history of bacteremia, the patient needed to be ruled out for a possible recent history of endocarditis. Subsequent transthoracic echocardiogram and transesophageal echocardiogram to assess vegetations were negative for vegetations of abscesses. Of note, transesophageal echocardiogram was also notable for no thrombus in the left atrium, severe left ventricular dysfunction, left cavity dilation, and ventricular free wall hypokinesis. Given the patient's history of mitral valve repair, the patient remained anticoagulated throughout her hospital stay. Upon admission, the patient's Coumadin was stopped and heparin was started, with heparin being tapered upon insertion of implantable cardioverter-defibrillator. The patient was then restarted on heparin and Coumadin to achieve a therapeutic goal INR between 2.5 to 3.5 prior to discharge. (e) Coronary artery disease: The patient with no known of coronary artery disease with recent catheterization revealing no coronary artery disease. 2. PULMONARY: The patient has a history of asthma and was continued on her outpatient regimen throughout her hospital stay. Of note, the patient had one episode of acute shortness of breath with chest pain on hospital day five. The patient reported an epigastric chest pressure without radiation. No nausea, vomiting, or diaphoresis. Upon examination, vital signs were stable. The patient was saturating well on room air. The lungs were clear to auscultation bilaterally on examination. There was no jugular venous distention. No electrocardiogram changes were noted. There were also no events on telemetry, and a chest x-ray showed no evidence of congestive heart failure. A covering house officer at the time felt that these symptoms were due to ischemia given lack of electrocardiogram findings and clinical scenario, nor was it believed it was due to symptoms of fluid overload. However, given the patient's anxiety and desire for diuresis, the patient was given 20 mg of intravenous Lasix. The patient experienced no further episodes of chest pain or shortness of breath throughout her hospital stay. (3) INFECTIOUS DISEASE: The patient was continued on vancomycin upon admission as per outside hospital, and given questionable history of bacteremia in anticipation for possible implantable cardioverter-defibrillator placement. The Infectious Disease consultation service followed the patient to help elucidate the question of possible positive recent history of bacteremia. As per Infectious Disease, since positive cultures at primary care physician's office were different sensitivities and therefore likely different colonies, it was believed that this culture was most likely either a contaminant or of little clinical significance; and, thus was continued with the management planned and recommended a transesophageal echocardiogram to rule out vegetations. It was also noted that an implantable cardioverter-defibrillator was going to be placed and antibiotics should be given prior to a status post procedure. Thus, with the results were negative for vegetations, Infectious Disease felt that despite this possible questionable history of positive bacteremia, it was not clinically significant and implantable cardioverter-defibrillator could be placed without any Infectious Disease issues if dosed with vancomycin appropriately prior to and status post procedure. Of note, on hospital day five, the patient developed a phlebitis and was being treated on vancomycin, as per hospital course of bacteremia. Within three days, the patient's cellulitis was much improved and remained cleared upon pending discharge. 4. RENAL: The patient has a history of chronic renal insufficiency. Creatinine was followed throughout the [**Hospital 228**] hospital stay. 5. ENDOCRINE: The patient had an elevated glucose upon admission. The patient was written for a regular insulin sliding-scale and q.i.d. fingersticks with well-controlled blood glucose levels throughout the remainder of her hospital stay. 6. HEMATOLOGY: The patient was admitted with a supratherapeutic INR level. As above, Coumadin was held and heparin was started when INR was around 2. Once INR was around 2, the patient was restarted on heparin and continued on heparin throughout the remainder of her hospital stay. The patient was then re-dosed on Coumadin prior to discharge. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: Discharged to home. DISCHARGE DIAGNOSES: 1. Atrial fibrillation. 2. Status post pulseless ventricular fibrillation arrest. 3. Dilated cardiomyopathy. 4. Status post mitral valve replacement. 5. Asthma. 6. Chronic renal insufficiency. 7. Cellulitis. MEDICATIONS ON DISCHARGE: Unknown at the time of this dictation; will be added with an addendum to this Discharge Summary on the patient's discharge date. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. [**MD Number(1) 4992**] Dictated By:[**Last Name (NamePattern1) 7944**] MEDQUIST36 D: [**2107-10-29**] 18:34 T: [**2107-11-3**] 16:20 JOB#: [**Job Number **] Name: [**Known lastname 15963**], [**Known firstname **] Unit No: [**Numeric Identifier 15964**] Admission Date: [**2107-10-22**] Discharge Date: [**2107-11-5**] Date of Birth: [**2056-5-8**] Sex: F Service: CCU ADDENDUM: This is an addendum regarding the hospital stay from [**10-31**] to [**11-6**], the day of discharge. While awaiting therapeutic INR, she also developed some lower extremity edema which was successfully managed with diuretics. She also had episodes of atrial fibrillation on telemetry which were deemed chronic and no Amiodarone was given secondary to rate issue in the past per Electrophysiology. On the day of discharge, her INR reached 2.6, finally in the therapeutic range of 2.5 to 3.5. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Home. DISCHARGE MEDICATIONS: 1) Lopressor 50 mg p.o. b.i.d. 2) Captopril 25 mg p.o. t.i.d. 3) Lasix 20 mg p.o. q.d. 4) Coumadin 5 mg p.o.q.h.s. 5) Phenergan 10 mg p.o. q. six p.r.n. Prescriptions were given for the above medications. While at home she will also take Colazal NS 2.25 mg p.o. t.i.d. for ulcerative colitis and Salmeterol inhaler and Albuterol inhaler for asthma. DISCHARGE FOLLOW UP: Patient will go to the AICD Device Clinic next week for follow up. Phone number there is [**Telephone/Fax (1) 4004**]. Patient was given the phone number and she will call for appointment. She will also follow up with her primary cardiologist, Dr. [**First Name8 (NamePattern2) 55**] [**Last Name (NamePattern1) **] at [**Location (un) 322**]. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1095**] Dictated By:[**Last Name (NamePattern1) 15965**] MEDQUIST36 D: [**2107-11-8**] 13:58 T: [**2107-11-9**] 10:27 JOB#: [**Job Number 15966**]

[ "427.31", "593.9", "493.90", "427.41", "451.89", "V42.2", "425.4", "428.0", "790.2" ]

icd9cm

[ [ [] ] ]

[ "88.72", "37.94" ]

icd9pcs

[ [ [] ] ]

14983, 15018

13549, 13765

15041, 15408

13792, 14961

3151, 3626

6494, 13439

15420, 16074

13454, 13528

162, 2762

3652, 3744

2785, 3124

3761, 6465

29,622

151,235

12252

Discharge summary

report

Admission Date: [**2104-7-24**] Discharge Date: [**2104-7-26**] Date of Birth: [**2052-11-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 330**] Chief Complaint: Obtundation, toxic ingestion Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname 38284**] is a 51 year old man with history of cocaine abuse, prior EtOH abuse, presenting from home after his wife found him with acute mental status changes. Per wife's report, patient was acting agitated and out of the ordinary on the night prior to admission. Patient works in maintenance in 4am to 10am shift, and was per wife's report did not go to sleep at all on the night prior to admission. She reports she found him agitated, anxious and "acting differently". Patient left to work and returned more agitated, raising concerns from his wife. [**Name (NI) **] wanted to leave but she took his car keys; patient left on foot. He was found hours later in a nearby restaurant (legal seafood) with even more altered state. Patient was driven home by his wife and after not seeing any improvement, she called EMS. In the ED, patient was found to be somnolent. Temp 96.9 HR 50 BP 96/62 RR10 O2 sat 100% 4L NC. Patient admitted to taking [**3-4**] additional pills of celexa as well as inhaled cocaine. Toxicology team called and per their recommendation 1 amp of Bicarb was given. Patient bolused with NS x 7 Liters with little improvement in blood pressure. Bicarbonate was given and bradycardia acutely worsened without significant ECG changed. Patient admitted to MICU for further evaluation. On arrival, patient somnolent but arousable. At first denies any illicit substance use but with some prompting after revealing tox screen results, reports he used approx 2gm of inhaled cocaine and took 4 pill his brother gave him for anxiety. He denies having a suicidal/homicidal ideations. Past Medical History: 1. S/P appendectomy in [**2097**] 2. S/P skull fracture and seizure at age 12 in setting of hockey injury 3. Gynecomastia for three years. Attributed to low testosterone. 4. H/O cocaine use Social History: Pt is married with three kids. Works in maintenence. No tobacco use, history of prior ETOH, per his report sober x 4 years. Denies IVDU Family History: [**Name (NI) 1094**] father had a MI in his 70s. No family history of CVA or seizure disorders. Physical Exam: vitals T 96.1 BP 103/72 AR 56 RR 16 O2 sat 95% on 2L GEN: Somnolent, arousable, in no distress HEENT: 4mm pupils bilaterally, with sluggish response to light. Dry mucous membranes. CV: Regular rate, distant heart sounds, no murmurs, rubs or gallops. Lungs: Clear to auscultation bilaterally. Abd: Soft, non tender, non distended, no hepato/splenomegaly. Ext: Strong peripheral pulses, no clubbing, cyanosis or edema. Pertinent Results: WBC-7.5 RBC-4.54* Hgb-12.4* Hct-35.9* MCV-79* MCH-27.2 MCHC-34.5 RDW-14.4 Plt Ct-267 Neuts-59.0 Lymphs-29.5 Monos-4.8 Eos-6.1* Baso-0.6 Glucose-83 UreaN-8 Creat-0.9 Na-140 K-4.2 Cl-103 HCO3-28 AnGap-13 ALT-17 AST-16 TOXICOLOGY SERUM: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG URINE: bnzodzp-POS barbitr-NEG opiates-NEG cocaine-POS URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG amphetm-NEG mthdone-NEG ECG: Bradycardia with normal sinus rhytm and PAC's. Right budleoid pattern (narrow QRS with RSR'), with question of right heart strain (S wave in I, Q wave and T wave flattening on III). No ischemic ST changes. Running Strip: Bradycardia with ectopic atrial activity (wandering pacemaker?) and couplets. Resolved to baseline. Relevant Imaging: 1)Cxray ([**7-24**]): No acute cardiopulmonary abnormality. 2)CT head ([**7-24**]): No acute intracranial process. Brief Hospital Course: Mr. [**Known lastname 38284**] is a 51yo male with history of polysubstance abuse, presenting with acute mental status changes, bradycardia and hypotension refractory to fluids, in stable condition. 1)Toxic ingestion: Given patient's history of polysubstance abuse and lack of knowledge about what he took, difficult to narrow down. It appears that he did take cocaine and benzodiazepines. He also likely ingested anxiety pills, likely Celexa. On admission, there was no evidence of an acidosis. Social work was consulted and provided resources for him as an outpatient. 2)Bradycardia / Hypotension: Unclear cause. There was no evidence of QT prolongation on EKG, which would be concerning since he may have ingested Celexa. This resolved quickly within 24 hours after being admitted to the MICU. Patient was asked to stop taking Celexa until he followed up with his primary care physician. 3)Cocaine abuse: Patient has long history of cocaine use. Social work was consulted and provided outpatient resources for him. 4)Anemia: Chronic problem per [**Name (NI) **]. Suggested that he follow-up with his primary care physician. Medications on Admission: Lipitor 40mg Celexa 40mg Discharge Medications: Patient asked to stop Celexa and follow-up with his primary care physician. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Cocaine abuse Bradycardia Hypotension Anemia Discharge Condition: Stable Discharge Instructions: 1)You were admitted to the hospital after using cocaine and taking some extra Celexa. It is important that you not use cocaine again since it has many harmful effects on your body. 2)Please stop taking your Celexa. Please talk with your primary care physician as to when you should be restarted on this. 3)Please schedule a follow-up appointment with your primary care physician [**Name Initial (PRE) 176**] 1 week after being discharged from the hospital. 4)If you experience any fevers, chills, chest pain, shortness of breath, dizziness, or any other concerning symptoms, please return to the emergency room. Followup Instructions: Please schedule a follow-up appointment with your primary care physician [**Name Initial (PRE) 176**] 1 week after being discharged from the hospital.

[ "E849.0", "305.60", "780.09", "E854.0", "458.9", "970.8", "311", "285.9", "E854.3", "427.89", "780.97", "969.0" ]

icd9cm

[ [ [] ] ]

[ "94.65" ]

icd9pcs

[ [ [] ] ]

5268, 5274

3961, 5093

344, 351

5382, 5391

2924, 3802

6054, 6208

2374, 2471

5168, 5245

5295, 5361

5119, 5145

5415, 6031

2486, 2905

276, 306

3820, 3938

379, 1991

2013, 2204

2220, 2358

26,005

159,664

30411

Discharge summary

report

Admission Date: [**2125-4-4**] Discharge Date: [**2125-4-10**] Date of Birth: [**2043-11-27**] Sex: F Service: CARDIOTHORACIC Allergies: Mevacor Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain and hypotension. Major Surgical or Invasive Procedure: s/p RV perforation repair [**2125-4-4**] History of Present Illness: This 81WF was undergoing a pacemaker implant for AF and tachy/brady syndrome at MWMC when she developed acute chest pain and hypotension. An echo revealed a pericardial clot with tamponade physiology. She was transferred to [**Hospital1 18**] for surgical management. Past Medical History: AF Tachy/brady syndrome HTN Alzheimer's SIADH Anxiety s/p single chamber pacer placement [**4-4**] Pyoderma gangrensum Social History: Lives at home. Cigs: none ETOH: none Family History: Unremarkable Physical Exam: Elderly WF intubated, sedated. HEENT: NC/AT, PERLA, EOMI, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+=bilat. without bruits. Lungs: Clear CV: paced @ 60, distant heart sounds Abd: +BS, soft, nontender Ext: without C/C/E Neuro: sedated Discharge Vitals 98.4, 70 Afib, 127/58, RR 20, sat 95% Neuro alert oriented to person and place MAE r=l strength Cardiac Irregular no m/r/g Pulm CTA bilat Sternal inc healing no erythema/drainage sternum stable Abd soft, NT, ND +BS Ext warm trace edema pulses palpable Left subclavian pacer site healing no erythema/drainage with staples Pertinent Results: [**2125-4-9**] 07:25AM BLOOD WBC-9.2 RBC-3.44* Hgb-9.6* Hct-27.9* MCV-81* MCH-27.8 MCHC-34.2 RDW-14.6 Plt Ct-330 [**2125-4-4**] 03:28PM BLOOD WBC-11.9* RBC-3.76* Hgb-10.5* Hct-30.5* MCV-81* MCH-27.8 MCHC-34.3 RDW-14.6 Plt Ct-252 [**2125-4-10**] 08:00AM BLOOD PT-14.5* INR(PT)-1.3* [**2125-4-9**] 07:25AM BLOOD Plt Ct-330 [**2125-4-4**] 03:28PM BLOOD Plt Ct-252 [**2125-4-4**] 03:28PM BLOOD PT-14.4* PTT-27.2 INR(PT)-1.3* [**2125-4-9**] 07:25AM BLOOD Glucose-93 UreaN-28* Creat-0.9 Na-136 K-4.4 Cl-100 HCO3-27 AnGap-13 [**2125-4-4**] 03:28PM BLOOD UreaN-26* Creat-0.9 Cl-107 HCO3-20* [**2125-4-9**] 07:25AM BLOOD Mg-2.0 RADIOLOGY Final Report CHEST (PA & LAT) [**2125-4-9**] 4:09 PM CHEST (PA & LAT) Reason: r/o inf, eff [**Hospital 93**] MEDICAL CONDITION: 81 year old woman s/p RV repair REASON FOR THIS EXAMINATION: r/o inf, eff EXAMINATION: PA and lateral chest. INDICATION: Pleural diffusion. FINDINGS: PA and lateral views of the chest are obtained on [**2125-4-9**] and compared with the recent radiograph of [**2125-4-6**], at which time there was a small left pleural effusion. On the current examination, this left-sided pleural effusion has almost resolved with minimal blunting persisting. There is no evidence of pneumothorax. The remainder of the examination is unchanged. IMPRESSION: Decrease in size of the left pleural effusion with a minimal costophrenic angle blunting persisting on the left side. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Approved: MON [**2125-4-9**] 6:01 PM PATIENT/TEST INFORMATION: Indication: Intraop Pericardial Tamponade Drainage Status: Inpatient Date/Time: [**2125-4-4**] at 17:52 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW01-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **] MEASUREMENTS: Left Ventricle - Ejection Fraction: 55% to 65% (nl >=55%) Aorta - Valve Level: 2.7 cm (nl <= 3.6 cm) Aorta - Ascending: 3.0 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: *2.7 cm (nl <= 2.5 cm) Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec) Pericardium - Effusion Size: 2.5 cm INTERPRETATION: Findings: Limited urgent TEE exam during this emergency case LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus in the RA or RAA. 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, cavity size, and systolic function (LVEF>55%). Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Focal calcifications in ascending aorta. Mildly dilated descending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Large pericardial effusion. Effusion circumferential. No RA diastolic collapse. No RV diastolic collapse. Sgnificant, accentuated respiratory variation in mitral/tricuspid valve inflows, c/w impaired ventricular filling. 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 TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The rhythm appears to be atrial fibrillation. Results were personally reviewed with the MD caring for the patient. Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No mass or thrombus is seen in the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). 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. 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. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a large pericardial effusion. The effusion appears circumferential. No right atrial diastolic collapse is seen. No right ventricular diastolic collapse is seen. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Impression: Circumeferential moderate to large pericardial effusion with respiratory variations across the inflow valves suggestive of tamponade physiology without sustained atrial or ventricular wall collapse suggestive of early stages. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD on [**2125-4-5**] 17:47. [**Location (un) **] PHYSICIAN: Regular ventricular pacing Pacemaker rhythm - no further analysis No previous tracing available for comparison Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K. Intervals Axes Rate PR QRS QT/QTc P QRS T 60 0 160 510/510 0 -12 80 [**2125-4-9**] 10:38 am STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT [**2125-4-10**]** CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2125-4-10**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Brief Hospital Course: The patient was transferred to the OR and underwent emergency sternotomy with repair of the RV perforation on [**4-14**]. She tolerated the procedure well and was transferred to the CSRU on Propofol and Neo in stable condition. She was followed by EP and the pacer was tested and functioning well. She was extubated on the post op night and had her chest tubes d/c'd on POD#1. She was transferred to the floor on POD#1 and went into rapid AF that night. She had her Lopressor increased and was started on Diltizem. She continued to have intermittent rapid rates and eventually her rate was controlled with Lopressor and Diltiazem. She was anticoagulated with coumadin. She continued to progress and was discharged to rehab in stable condition on POD#6. Medications on Admission: Coumadin, d/c'd on [**3-29**] Norvasc 10' Xanax 0.25' Effexor 37.5' Protonix 40' Synthroid 100' Colace 100" Lopressor 12.5" MVI Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 5. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. 6. Venlafaxine 37.5 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 7. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal Q 8 HOURS PRN (). 10. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: 3mg [**4-10**] and [**4-11**] - check inr [**4-12**] for further dosing . Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab & Nursing Center - [**Location (un) 47**] Discharge Diagnosis: RV perforation s/p pacer placement AF Tachy/brady syndrome HTN Alzheimer's SIADH Anxiety Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Left arm elbow at or below shoulder level for six weeks to allow pacer site to heal - staples can be removed [**4-15**] Followup Instructions: Dr [**Last Name (STitle) 5051**] for f/u pacer call to schedule appointment - last pacer interrogation [**2125-4-10**] Dr. [**First Name (STitle) **] after discharge from rehab call to schedule appointment Dr. [**First Name (STitle) **] for 4 week please call to schedule appointment ([**Telephone/Fax (1) 170**]) PT/INR goal INR 2-2.5 for atrial fibrillation first draw [**4-12**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2125-4-10**]

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9295

Discharge summary

report

Admission Date: [**2160-10-2**] Discharge Date: [**2160-10-7**] Date of Birth: [**2102-11-18**] Sex: F Service: MEDICINE Allergies: Sulfonamides Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Transferred from outside hospital for investigation and management of large pericardial effusion. Major Surgical or Invasive Procedure: Pericardiocentesis. Pericutaneous cardiac catheterization. History of Present Illness: Mrs. [**Known lastname **] is a 57 year-old woman with obesity, squamous metaplasia of bladder (resected), fibromyalgia presenting from [**Hospital1 **] [**Location (un) 620**] with pericardial and pleural effusions for elective pericardiocentesis. Mrs. [**Known lastname **] had experienced about 2 weeks of nausea and abdominal pain. In addition her friends and family noticed that she was short of breath - she thought it was just from her pain. She saw her PCP who gave her prilosec and sent her home with the diagnosis of viral GE. However, she continued to have symptoms including fevers and chills at home, night sweats - which she attributes to menopausal symptoms, myalgias - no worse than her baseline from fibromyalgia, and diarrhea. The pain worsened on [**2160-9-30**] and vomiting appeared. The pain was paroxysmal, radiated to her back, gradually increasing in intensity with each episode and associated with early satiety. The pain worsened with lying down and radiated to her back when she took a deep breath. She then re-presented to PCP and in the office the PCP noted hypoxia to 80s on RA. The PCP was concerned and sent her to the ER at [**Hospital1 **] [**Location (un) 620**] where her initial VS were: Bp 150/80, hr 80. O2 sat 93% on 2L n.c. Several investigations were performed. EKG showed normal sinus rhythm, PR interval 154, 90 beats per minute, Q in leads II, III, and AVF, and mild ST elevation in II, III, and aVF -also seen on her old EKG from [**2160-9-29**]. CTA of the chest in [**Location (un) 620**] showed no evidence of aortic dissection or aneurysms and showed a large pericardial effusion, moderate pleural effusion with associated basilar atelectasis, and no evidence of an acute pathologic process in the abdomen or the pelvis. She was admitted to the [**Location (un) 620**] ICU. 2-D echo showed an EF of 60%-65%. "The left atrium is normal in size. The estimated right atrial pressure is [**11-18**]. Left ventricular wall thickness, cavity size, and global systolic function are normal. Right ventricular chamber size and free wall motion are normal. Aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. No mitral regurg is seen. There is a large pericardial effusion. No right ventricular diastolic collapse is seen. There is brief right atrial diastolic collapse and significant accentuated respiratory variation in mitral and tricuspid valve inflow consistent with impaired ventricular filling, and pericardial constriction cannot be excluded." Being found to have a moderate to large pericardial effusion with fibrin stranding, pulsus of 10 mmHg, right atrial collapse, along with bilateral pleural effusions. Dr. [**Last Name (STitle) **] discussed case with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and it was decided she did not need urgent tapping tonight. Therefore decision was made to transfer from [**Location (un) 620**] for management at [**Hospital1 18**], perhaps the CCU, for further evaluation. On arrival to [**Hospital1 18**] on [**2160-10-2**] she was stable with pulsus of 10. Review of Systems (+) Positive for fatigue, low-grade temperature, chills, poor p.o. intake, and chest pain; no palpitations. She has lower limb edema, some orthopnea, and no PND. Gained 10 lbs in last two weeks. Reports concentrated and small volume urine in last couple of weeks. She also has some shortness of breath with mild effort, pleuritic pain, and dry cough. She has nausea, vomiting, abdominal distention, abdominal pain, and diarrhea. She is usually constipated. She has chronic urine incontinence and lately felt decreased urine output. She has loss of energy, back pain all over her thoracic area, and no vertigo. No known infectious contacts or recent travel. (-) She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, hemoptysis, black stools or red stools. She denies exertional buttock or calf pain. No syncope or presyncope. All of the other review of systems were negative. Past Medical History: 1. Fibromyalgia. 2. Polycystic ovaries. 3. Multiple abortions. 4. Status post cholecystectomy complicated by sepsis in [**2137**]. 5. History of a 'heart-shaped uterus' per OSH record. 6. Infertility. 7. Obesity. 8. Ankle surgery. 9. IBS/constipation. 10. Stress incontinence. 11. Pre-diabetes with HbA1c of 6.2 in [**2159-3-31**]. 12. Osteoarthritis. 13. GERD - new diagnosis. 14. Chronic sinus problems. 15. Recent Achilles tendon procedure. 16. Depression. 17. Osteopenia 18. TMJ joint degenerative changes noted on head CT [**2159**] 19. Uterine fibroids on CT [**2154**] 20. Biopsy bladder neck mass [**2154**], pathology showed squamous metaplasia. Cardiac History 1. CARDIAC RISK FACTORS: No diabetes, no dyslipidemia, no hypertension 2. CARDIAC HISTORY: none. Cancer Screening -Colonoscopy in [**2157**] x 2 with poor visulization. [**2158**] repeat was clear and suggested repeat [**2168**]. -She is up-to-date for her mammogram, and Pap smear per d/c summary [**Hospital1 **] [**Location (un) 620**] [**2160-10-2**]. Social History: She lives with her husband. They have no children. She is independent in her ADL and IADLs. She works at a school. She is a teacher of theology and an assistant in administration. No history of smoking or drug abuse. She drinks alcohol occasionally. Family History: Positive for CAD. Her father had an AMI at 42 years - died in his 80s. Physical Exam: VS: T 98.3 BP 152/90 HR 90 RR 22 88% RA; 96% 4L 0/10 pain. GENERAL: In NAD; ordering dinner, watching TV; oriented x3. Mood, affect appropriate. Obese. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: No obvious JVD, but obese neck limits examination. CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Slight impression of alternating pulse intensity on lifting arm and palpating radial pulse. Pulsus with large pressure cuff of 10 mmHg. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Reduced sounds and dull percussion at bases. ABDOMEN: Soft, NTND. No HSM or tenderness. Large paramedian scar from cholecystemtomy. Abd aorta could not be examined due to adiposity. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, or xanthomas. NEURO: Alert and oriented x 3. Appropriate. Some circumlocution. Cranial nerves intact (II report; III, IV, VI full movements, PEARL; V strong; VII strong and symmetric; VIII not tested; IX not tested; shoulder shrug full strength; X & XII no dysarthria) Gait normal base, stride, arm swing, normal turn. Fisting on tandem gait and unsteady. Romberg negative. Tone normal. Power full throughout: shoulder abduction, biceps, triceps, finger extensors. Hip flexion, foot dorsiflexion, toe extension. Reflexes not tested. Sensation intact per patient report. Coordination on finger nose intact. Pertinent Results: Laboratory Data on Admission [**2160-10-2**] WBC-10.5 RBC-3.75* HGB-9.9*# HCT-31.6* MCV-84 MCH-26.5* MCHC-31.5 RDW-13.8 PLT Count-318 NEUTS-74.6* LYMPHS-21.2 MONOS-3.7 EOS-0.2 BASOS-0.3 GLUCOSE-117* UREA N-11 CREAT-0.7 SODIUM-139 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13 PT-16.0* PTT-29.6 INR(PT)-1.4* ALT(SGPT)-126* AST(SGOT)-64* LD(LDH)-231 CK(CPK)-50 ALK PHOS-180* AMYLASE-16 TOT BILI-0.6 SED RATE-68* RHEU FACT-9 CRP-240.3* [**Doctor First Name **]-NEGATIVE TSH-0.70 CK-MB-NotDone cTropnT-<0.01 Discharge and Interim Laboratory Data [**2160-10-7**] etc. WBC-8.5 RBC-4.53 Hgb-12.0 Hct-38.0 MCV-84 MCH-26.5* MCHC-31.6 RDW-13.5 Plt Ct-435 Neuts-64.5 Lymphs-29.6 Monos-3.5 Eos-2.1 Baso-0.2 Plt Ct-435 PT-14.9* PTT-28.6 INR(PT)-1.3* Glucose-141* UreaN-16 Creat-0.8 Na-141 K-4.4 Cl-99 HCO3-30 AnGap-16 ALT-44* AST-25 LD(LDH)-183 AlkPhos-160* TotBili-0.6 GGT-201* Lipase-18 Calcium-9.4 Phos-4.5 Mg-2.7* RheuFac-9 CRP-240.3* HBsAg: Negative HBs-Ab: Negative IgM-HBc: Negative HCV-Ab: Negative Smooth: Negative dsDNA: Negative HbA1c: 6.2%* ([**2159-3-31**]) Other Studies EKG Sinus tachycardia at 100bpm. Nl axis (+60) Low voltage. No electrical alternans. Pr depressions. TWF diffusely. 2D-ECHOCARDIOGRAM (At [**Location (un) 620**]) showed an EF of 60%-65%. "The left atrium is normal in size. The estimated right atrial pressure is [**11-18**]. Left ventricular wall thickness, cavity size, and global systolic function are normal. Right ventricular chamber size and free wall motion are normal. Aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurg. The mitral valve leaflets are structurally normal. No mitral regurg is seen. There is a large pericardial effusion. No right ventricular diastolic collapse is seen. There is brief right atrial diastolic collapse and significant accentuated respiratory variation in mitral and tricuspid valve inflow consistent with impaired ventricular filling, and pericardial constriction cannot be excluded. TTE [**2160-10-3**] (at [**Hospital1 18**]) Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There is a moderate sized circumferential pericardial effusion. There is an anterior fat pad. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling and elevated intrapericardial pressures. Moderate pericardial effusion with evidence of elevated intrapericardial pressures. Compared with the prior study (images reviewed) of [**2160-10-2**], the findings are probably similar (prior study was very limited). CARDIAC CATH: Right dominant coronary system HEMODYNAMICS: SITE [**First Name9 (NamePattern2) **] [**Last Name (un) **] END MEAN A Wave V Wave RV 51 23 27 PCWP 30 35 34 PA 54 30 41 PP 10 RA 17 18 18 Pericardiocentesis [**2160-10-3**] Removal of 350 ml of bloody fluid. Sent for laboratory studies that revealed no malignant cells, predominantly blood. WBC 2167* Hct,Fl 4.5* Polys 62* Lymphs 23* Monos 14* Eos 1* TotProt 5.5 Glucose 133 LDH 535 Amylase 11 Albumin 3.3 TTE [**2160-10-4**] Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion in addition to a fat pad anterior to the right ventricle. No right atrial or right ventricular diastolic collapse is seen. Compared with the prior study (images reviewed) of [**2160-10-3**], the amount of pericardial effusion remains similar over night. TTE [**2160-10-5**] Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion and a fat pad anterior to the right ventrical. No right atrial or right ventricular diastolic collapse is seen. Compared with the prior study (images reviewed) of [**2160-10-4**] the amount of pericardial effusion is slightly smaller. Abdominal Ultrasound IMPRESSION: 1. Echogenic liver consistent with diffuse fatty infiltration, although ultrasound cannot differentiate between this and more advanced forms of liver disease including fibrosis/cirrhosis. 2. No intra- or extra-hepatic bile duct dilatation in this status post cholecystectomy patient. 3. Bilateral pleural effusions. Pericardial Fluid Studies FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERICARDIAL FLUID. **FINAL REPORT [**2160-10-9**]** Fluid Culture in Bottles (Final [**2160-10-9**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S Aerobic Bottle Gram Stain (Final [**2160-10-4**]): GRAM POSITIVE COCCI IN CLUSTERS. Time Taken Not Noted Log-In Date/Time: [**2160-10-3**] 5:41 pm FLUID,OTHER Site: PERICARDIUM PERICARDIAL FLUID. **FINAL REPORT [**2160-12-8**]** GRAM STAIN (Final [**2160-10-3**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2160-10-6**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2160-10-9**]): NO GROWTH. ACID FAST SMEAR (Final [**2160-10-6**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Final [**2160-12-8**]): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Final [**2160-10-17**]): NO FUNGUS ISOLATED. [**2160-10-2**] 11:40 pm URINE Source: CVS. **FINAL REPORT [**2160-10-4**]** URINE CULTURE (Final [**2160-10-4**]): GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. Brief Hospital Course: Mrs. [**Known lastname **] is a 57 year-old woman with obesity, squamous metaplasia of bladder (resected), fibromyalgia presenting from [**Hospital1 **] [**Location (un) 620**] with pericardial and pleural effusions for elective pericardiocentesis. Brief Chronology Mrs. [**Known lastname **] was directly admitted to [**Hospital1 18**] cardiology service. She received her home pain regimen and was stable overnight. On [**2160-10-3**] she went to cath lab and underwent pericardiocentesis with placement of pericardial pig tail catheter. She was then transferred to the CCU for further monitoring. On arrival to the CCU she denied chest pain. She did note some shortness of breath. Her oxygen requirement diminished and she returned to the floor on the following day. She was stable and without any other abnormal findings. She was discharged home with follow-up arranged with Dr. [**Last Name (STitle) **] in [**Location (un) 620**]. Hospital Course by Problem Pericardial Effusion The etiology of Mrs.[**Last Name (un) 31831**] effusion remains obscure at discharge. Etiologies include hypothyroidism, CHF, cirrhosis, nephrotic syndrome, amyloidosis, rheumatoid disease, and exudate or transudate of the preceding and other etiologies. Malignant effusions are also possible. Infectious effusions include those caused by tuberculosis. Differential of etiology of effusions broad but most likely infectious vs malignancy vs rheumatologic. Positive [**Doctor First Name **] in [**Location (un) 620**] was not confirmed here and [**Doctor Last Name 1968**] and smooth muscle antibodies were not found, however this might be followed profitably. Given constitutional symptoms and fibromyalgia, a rheumatologic disorder seems likely. CRP was markedly elevated and ESR was high. More than 350 ml of serosanguinous fluid was drained. There were a large number of white cells in this drainage. Although one culture was positive, two others were not, suggesting contamination rather than septic effusion. No fungi, AFB or other organisms were found. Serial echocardiography and clinical examination revealed a diminished and stable effusion subsequently. This will be followed by Dr. [**Last Name (STitle) **]. Overall, these findings, past medical history and history of the present illness suggest a systemic inflammatory disease of unknown type. Pleural Effusions Likely same etiology as the pericardial effusion. Clinically stable with good saturation after periacrdiocentesis without thoracentesis. Transaminitis Possibly, again, related to the same syndrome that has resulted in the effusions. [**Month (only) 116**] be secondary to a viral gastroenteritis, however, may also have been the cause initially of her vomiting/nausea. This was trending down reassuringly during the admission. Hypertension Well controlled on home regimen. Pre-diabetes Patient with no diagnosis of diabetes but does have slightly elevated HgBA1c. Fibromyalgia and Pain Was continued on home pain regimen and anti-inflammatories. This diagnosis might be revisited in light of the present events. Some adjustments were made to this regimen. Urinary Tract Infection Developed during the admission. Seven day course of ciprofloxacin started on day of discharge. Medications on Admission: -BUPROPION HCL [WELLBUTRIN XL] - 300 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day -CYCLOSPORINE [RESTASIS] - 0.05 % Dropperette - 1 gtt OU twice a day -FIRST TESTOSTERONE CREAM - (Prescribed by Other Provider) - - -GABAPENTIN [NEURONTIN] - 600 mg Tablet - 1 Tablet(s) by mouth q hs Dr. [**Last Name (STitle) 31832**] for FM -HYDROCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 Tablet(s) by mouth at bedtime -IBUPROFEN - 600 mg Tablet - 1 Tablet(s) by mouth qd- [**Hospital1 **] -OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day -OXYBUTYNIN CHLORIDE [DITROPAN] - 5 mg Tablet - 1 Tablet(s) by mouth once a day -PREGABALIN [LYRICA] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 31832**]; Dose adjustment - no new Rx) - 50 mg Capsule - 1 Capsule(s) by mouth three times a day -TIZANIDINE - 2 mg Tablet - 1 Tablet(s) by mouth q hs Dr. [**Last Name (STitle) 31832**] for FM -VAGINAL MOISTURIZER - (Prescribed by Other Provider) - - Medications - OTC -CALCIUM - 500 mg Tablet - 2 Tablet(s) by mouth q d -DOCUSATE SODIUM [COLACE] - 50 mg Capsule - [**2-1**] Capsule(s) by mouth once or twice a day as needed for constipation -GUAIFENESIN - (Prescribed by Other Provider) - 400 mg Tablet - 1 Tablet(s) by mouth once a day -POLYETHYLENE GLYCOL 3350 [MIRALAX] - (OTC) - 100 % Powder - 1 by mouth once a day -RANITIDINE HCL [ZANTAC 75] - (OTC) - 75 mg Tablet - Tablet(s) by mouth Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Pregabalin 25 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 7. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO BID:PRN as needed for pain. 10. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic [**Hospital1 **] (2 times a day). 11. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. FIRST TESTOSTERONE CREAM 13. VAGINAL MOISTURIZER 14. GUAIFENESIN - (Prescribed by Other Provider) - 400 mg Tablet - 1 15. POLYETHYLENE GLYCOL 3350 [MIRALAX] - (OTC) - 100 % Powder - 1 by 16. CALCIUM - 500 mg Tablet - 2 Tablet(s) by mouth q d 17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pericardial effusion Systemic inflammatory disease, not otherwise specified Discharge Condition: Stable. Discharge Instructions: You came to the [**Location (un) 620**] with increasing shortness of breath, and were sent to [**Hospital1 18**], [**Location (un) 86**], when pericardial and pleural effusions were found as a cause. You were monitored for signs of decreased heart function given the pericardial effusion. The pericardial effusion was drained, revealing a serous fluid that was partly bloody. Since that time, the effusion has not significantly reaccumulated. A drain was placed to ensure this. During this immediate recovery period you stayed in the cardiac ICU and were transfered back to the cardiology [**Hospital1 **] when the drain was removed. Each day of your stay you produced good urine output, meaning that you lost about 1.5 L of fluid each day. This has helped to improve your shortness of breath. On top of this a diuretic was added for the last two days. You were seen by Physical Therapy and they have cleared you to return home. We would like you to follow-up closely as specified below, so that your laboratory tests can be reviewed and further steps planned. The underlying cause of these effusions will be investigated while you are an outpatient. We recommend that you return to activities as tolerated, but that it may be wise to take the remainder of this week away from work. Please take your medications as previously at home, with the addition of the antibiotic ciprofloxacin. Please follow-up with the physicians listed below. If you experience increasing shortness of breath, fever, chest pain, lightheadedness, pain upon breathing, or any other concerning symptom, please return to the hospital. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] at [**First Name9 (NamePattern2) **] [**Location (un) 620**], [**Street Address(2) 31833**]., [**Location (un) 620**], at 10:45 a.m. on Monday [**4-12**]. You can contact his office (Cardiology): [**Name (NI) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], ([**Telephone/Fax (1) 31834**].

[ "278.01", "729.1", "420.91", "511.9", "256.4", "790.4", "250.00", "423.3", "276.6", "401.9" ]

icd9cm

[ [ [] ] ]

[ "37.0", "37.21" ]

icd9pcs

[ [ [] ] ]

20449, 20455

14370, 17669

380, 440

20574, 20583

7631, 14344

22254, 22619

5975, 6047

19187, 20426

20476, 20553

17695, 19164

20607, 22231

6062, 7612

5419, 5686

243, 342

471, 4634

4656, 5399

5702, 5959

82,024

136,432

9134

Discharge summary

report

Admission Date: [**2160-12-21**] Discharge Date: [**2160-12-26**] Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2836**] Chief Complaint: Sepsis, RLQ inflammation Major Surgical or Invasive Procedure: Cardiac cath lab - History of Present Illness: [**Age over 90 **]yo F who presents to [**Location (un) 620**] appearing septic. She was having fevers at home to 102, and complains of SOB, weakness. Her BP at OSH was in the 80's and her labs were notable for an elevated troponin and d-dimer. Her CTPE was negative for PE. She was given 4L IVF, ceftriaxone and Flagyl. Her lactate was 1.9. She was given an additional gram of vanco. CT abdomen and pelvis was concerning for abscess in the RLQ near anastomosis. Of note the patient is status post R hemicolectomy for colon cancer. Past Medical History: PMH: 2 NSTEMIs, pulmonary embolism s/p Coumadin, HTN, multiple kidney stones, osteoporosis, glaucoma, T2, N1, ER positive HE2/neu breast CA Social History: lives at home. No tobacco, no ETOH, no IVDU Family History: Non-contributory Physical Exam: On Discharge: Pertinent Results: [**2160-12-21**] 02:30AM BLOOD WBC-17.1* RBC-2.96* Hgb-9.7* Hct-27.6* MCV-93 MCH-32.7* MCHC-35.0 RDW-13.9 Plt Ct-276 [**2160-12-21**] 02:30AM BLOOD Glucose-142* UreaN-25* Creat-0.6 Na-141 K-3.9 Cl-109* HCO3-24 AnGap-12 [**2160-12-21**] 02:30AM BLOOD cTropnT-0.53* Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment on [**2160-12-21**]. She was initially admitted to the ICU for hemodynamic monitoring. She was NPO/IVF and started on vanc/cipro/flagyl. She was transfused 1 unit of blood for a HCT of 27.8, which bumped appropriately to 29.8. Troponin was elevated to 0.53 upon admission, so heparin gtt was started but this was discontinued the next day per cardiology recs. BP was low initially in the ICU, with SBP in the 80s, but this responded appropriately to fluid boluses. The patient was transferred to the floor on HD2 and she was hemodynamically stable at that time. The patient was restarted on her beta [**Last Name (LF) 7005**], [**First Name3 (LF) **], and statin per cardiology and ECHO was performed on HD3, which showed new hypokinesis in the LAD distribution. From a GI perspective, CT scan showed leakage of the colonic stump/abscess and she was initially started on vanc, cipro, and flagyl, and the vanc was ultimately discontinued. Her diet was advanced to clears HD3 and subsequently to regular diet on HD 4, which the patient tolerated well without increase in abdominal pain. Her urine output was approx 20cc/hr, but she did require intermittent 250cc boluses to keep her Uop up. Foley was discontinued on HD4 and patient voided on her own. The patient was initially scheduled to go to rehab on [**2160-12-25**], but cardiology re-assessed the patient and decided that cardiac catheterization might be necessary given new changes to ECHO and the elevated troponins. The patient was taken to the cath lab on [**2160-12-25**], however after further discussion with patient and family, cardiology felt the bump in troponins was more likely from previous hypovolemia and not acute plaque rupture, so the cath was deferred. At the time, however, patient was clinically overloaded, with stable pressures, and so she recieved 10mg IV lasix twice, with good response. . At the time of discharge on HD6, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.She will continue with 10 more days of cipro and flagyl for her intraabdominal collection. Medications on Admission: Lipitor 40 mg PO HS; Lisinopril 20 mg PO OD; Omeprazole 20 mg PO OD; Metoprolol Succinate ER 50 mg PO OD; Xalatan 0.005 % Eye Drops 1 gtt OU HS; brimonidine 0.15 % eye drops TID; Xalatan 0.005 % eye drops OD; Os-Cal 500 + D -- Unknown Strength [**Hospital1 **]; One-A-Day Essential PO OD; ferrous sulfate 325 mg (65 mg Iron) PO OD; aspirin 81 mg PO OD. Discharge Medications: 1. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 9. Os-Cal 500 + D 500 mg(1,250mg) -500 unit Tablet Sig: One (1) Tablet PO once a day. 10. ferrous sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 11. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO once a day. 12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village - [**Location (un) **] Discharge Diagnosis: Sepsis and RLQ collection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-21**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Followup Instructions: Follow up with Dr. [**First Name (STitle) **] as scheduled and indicated in discharge instructions, in [**1-15**] weeks.

[ "V10.3", "733.00", "V10.05", "995.91", "560.1", "410.71", "412", "401.9", "038.9", "567.22" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5404, 5582

1444, 3839

265, 285

5651, 5651

1156, 1421

7451, 7575

1088, 1106

4249, 5381

5603, 5630

3865, 4226

5834, 6815

1121, 1121

1137, 1137

6847, 7428

201, 227

313, 847

5666, 5810

869, 1010

1026, 1072

29,538

113,364

34215+57906

Discharge summary

report+addendum

Admission Date: [**2107-4-30**] Discharge Date: [**2107-5-9**] Date of Birth: [**2051-12-21**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: frontal headaches Major Surgical or Invasive Procedure: Right-sided frontotemporal craniotomy for evacuation History of Present Illness: 55 y/o male in previously good health with a recent history of orthostatic hypotension who rose quickly from bed and fell, hitting the back of his head approximately four weeks ago. He denied loss of consciousness or headache following the event. However, over the past 2-3 weeks he has noted progressive headaches for which he has taken ibuprofren. Last night about 1800 he noted severe headaches, and his family described cognitive changes with mild confusion. He was brought to [**Hospital1 18**] ER where head CT revealed 2.7 cm right frontal subdural hematoma with 16 mm of midline shift. Neurosurgery was consulted. Past Medical History: orthostatic hypotension migraines eye surgery as a child Social History: marathon runner in good health, clinical psychiatrist in [**Location (un) 5944**], [**State 108**]. He denies tobacco or IVDU, social EtOH consumption Family History: son with glioblastoma Physical Exam: O: T: 98.9 BP: 124/78 HR: 46 R 16 O2Sats 100% Gen: WD/WN, comfortable, NAD, slightly lethargic. HEENT: Pupils: [**3-13**] bilaterally EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date (however he required prompting for the date). Recall: [**3-14**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition, but slowed responses. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-16**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: [**2107-4-30**] 10:00AM BLOOD WBC-10.2 RBC-4.30* Hgb-13.0* Hct-39.8* MCV-93 MCH-30.2 MCHC-32.7 RDW-13.7 Plt Ct-321 [**2107-4-30**] 11:00AM BLOOD PT-12.3 PTT-24.2 INR(PT)-1.0 [**2107-4-30**] 10:00AM BLOOD Glucose-129* UreaN-17 Creat-0.9 Na-148* K-4.6 Cl-109* HCO3-30 AnGap-14 [**2107-5-4**] 07:00PM BLOOD ALT-17 AST-26 AlkPhos-80 Amylase-91 TotBili-0.5 [**2107-5-4**] 07:00PM BLOOD Lipase-31 [**2107-5-1**] 03:04AM BLOOD Albumin-3.7 Calcium-8.4 Phos-4.1 Mg-1.7 [**2107-5-1**] 03:04AM BLOOD Phenyto-9.7* [**2107-5-4**] 05:09AM BLOOD Phenyto-2.4* Head CT [**4-30**]: -PRE-OP: 1. Large right acute on chronic subdural hematoma with significant mass effect, midline shift, and signs of early uncal herniation. There is also hydrocephalus and entrapment of the third ventricle. 2. Small left frontal subdural hematoma. -POST-OP: Status post right frontal craniotomy, with partial evacuation of the previously demonstrated, but now predominantly hypodense right subdural hematoma. No appreciable change in associated mass effect, with persistent leftward subfalcine herniation, early signs of right uncal herniation and probable entrapment of the foramen of [**Last Name (un) 2044**] No new sites of intracranial hemorrhage seen. No change in small left frontal subdural hematoma. Head CT [**5-2**]: 1. Interval new acute re-bleeding into previously evacuated right subdural hematoma. Amount of previously noted hypodense extra-axial fluid collection is not significantly changed. Slight interval increase in post-operative pneumocephalus. 2. Unchanged leftward subfalcine herniation and mild probable right uncal herniation. Stable enlargement of the left lateral ventricle suggestive of entrapment of the foramen of [**Last Name (un) 2044**]. Head CT [**5-3**]: 1. Status post re-evacuation of right subdural hematoma, with marked improvement, and only a small amount of residual low-attenuation fluid remaining. 2. Decreased local mass effect of the right cerebral hemisphere, decreased leftward subfalcine herniation, and decreased right uncal herniation. 3. Minimal decrease in size of left lateral ventricle. Pathology Results from OR pending Brief Hospital Course: Dr. [**Known lastname **] was evaluated in the ED by Neurosurgery. He was found to have a large subacute SDH on CT with significant mass effect, midline shift, and signs of early uncal herniation as well as hydrocephalus. He was loaded with dilantin for seizure prophylaxis and taken to the OR for a right-sided frontotemporal craniotomy for evacuation. The procedure went well and he was transfered to the ICU. His post-operative CT showed evacuation of the blood but no significant re-expansion of the brain parenchyma. This was felt to be secondary to the chronicity of his bleed. He spent a day in the ICU and was then transfered to the floor. On POD#2 however he appeared more confused and was mentating more slowly. He was therefore sent for repeat CT scan which showed new bleeding in the prior subdural space. He was therefore transfered to the step down and monitored closely. A repeat scan was done several hours later which showed persisent but not significantly larger bleeding. He was therefore taken to the OR that night for re-evacuation and lysis of adhesions. Post-operatively, he was transfered to the ICU. His post-operative CT showed marked improvement with only minimal fluid remaining and decreased mass effect. His exam improved to baseline after surgery with no focal deficits. He spent one day in the ICU and had difficulty with the foley which was removed. He was then transfered to the floor and evaluated by PT and OT. They recommended acute rehab. As Dr. [**Known lastname **] is from [**Location (un) 5944**], his family made arrangements to bring him closer to his family in [**Location 74122**], PA. He was therefore discharged with the plan to be transported to an acute rehab facility there with neurosurgery follow-up. Medications on Admission: ibuprofren prn Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*1* 2. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*20 Tablet Sustained Release(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO twice a day. 7. Senna 8.6 mg Capsule Sig: [**1-12**] Capsules PO once a day. Discharge Disposition: Extended Care Discharge Diagnosis: Subdural Hematoma Discharge Condition: Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY: • Have a 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, excessive bending • You may wash your hair only after sutures and/or staples have been removed • You may shower before this time with assistance and use of a shower cap • Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation • 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 • Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: • New onset of tremors or seizures • Any confusion or change in mental status • Any numbness, tingling, weakness in your extremities • Pain or headache that is continually increasing or not relieved by pain medication • Any signs of infection at the wound site: redness, swelling, tenderness, drainage • Fever greater than or equal to 101?????? F Followup Instructions: 1) Please have your staples removed by your neurosurgeon in [**5-21**] days and follow-up with them in 1 month with a repeat head CT Completed by:[**2107-5-9**] Name: [**Known lastname 12698**],[**Known firstname **] Unit No: [**Numeric Identifier 12699**] Admission Date: [**2107-4-30**] Discharge Date: [**2107-5-9**] Date of Birth: [**2051-12-21**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 599**] Addendum: The patient was re-evaluated by both PT and OT on [**2107-5-9**]. They felt that he had improved significantly and no longer required inpatient rehabilitation. They cleared him to go home with outpatient services: OT/PT/speech therapy. The family arranged for him to be transported to [**State 12700**] where he will have these services and he will follow-up with a neurosurgeon there. Discharge Disposition: Extended Care [**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**] Completed by:[**2107-5-9**]

[ "E884.4", "348.4", "331.4", "852.21" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

9887, 10038

4965, 6723

338, 393

7524, 7533

2794, 4942

8923, 9864

1316, 1340

6789, 7424

7483, 7503

6749, 6766

7557, 8900

1355, 1628

280, 300

421, 1049

1988, 2775

1643, 1972

1071, 1130

1146, 1300

71,220

105,141

47088

Discharge summary

report

Admission Date: [**2184-10-19**] Discharge Date: [**2184-11-2**] Service: MEDICINE Allergies: Penicillins / Sulfonamides / Tetracyclines Attending:[**First Name3 (LF) 23347**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Hemodialysis Right IJ central venous catheter placement attempt Right femoral central venous catheter placement Left IJ hemodialysis catheter removal, temporary catheter placement, and permanent catheter placement Left arm PICC placement History of Present Illness: Ms. [**Known lastname 94952**] is a [**Age over 90 **] yo female with ESRD on HD who comes in with 3 days of intermittent RUQ pain (chronic), + nausea, no vomiting. She visited her PCP, [**Name10 (NameIs) 1023**] documented a T about 100 and was concerned about abd pain on exam. He sent her to the ED where she denied current abd pain. She was noted to have a slight leukocytosis, and had a CXR showing chronic effusions but better than usual. KUB was negative. UA with epi's. During her stay, she then spiked a fever to 102 and her pressure dropped down to 80 systolic. Got .5L fluid x 2 with no improvement in her pressures. A right femoral line was placed after failure to place a right IJ. She received a dose of vanc and cipro. An abdominal CT was largely unremarkable. Of note, she was recently started on dialysis in the middle of [**Month (only) 359**] with a HD catheter placed. She was also seen 2 weeks ago for LE cellulitis in the ED. She was given a 10 day course of levofloxacin. Vitals in ED: T 102 HR 65 BP 84/36 97% on 4LNC RR 24 On the floor, she is comfortable and pleasant. She denies SOB, f/c, chest pain, cough, HA. She reports urinary frequency with incomplete voiding, but denies dysuria. Past Medical History: AFib Tachy-brady s/p PPM [**3-9**] CKD stage IV b/l ~Cr 2.2 SCC leg and neck s/p radiation [**1-9**] 4+ TR 2+ MR [**First Name (Titles) **] [**Last Name (Titles) **] HTN Hypothyroidism HTN IBS Anemia b/l Hct ~34% Diverticulosis Social History: Retired. No current alcohol or tobacco use. Dtrs very active in her care. Lives in house in [**Location (un) 10059**] with live-in aide. Family History: Noncontributory Physical Exam: vitals: T 95.4 BP 92/D P 64 R 24 98%2L gen: pleasant, NAD heent: Anicteric. OP clear. MM dry. neck: supple, no elevated jvp. L subclavian catheter c/d/i. [**Location (un) **]: CTAB cv: RRR, 2/6 SEM at LLSB abd: soft NT/ND +BS extr: 2+ LE edema. Fragile skin with some tears on R forearm. R 1st MTP with erythema and swelling although no TTP. Ostomy bag over former site of femoral line with small amt serous fluid. PICC in L antecub. neuro: Alert, oriented to [**Hospital1 18**], [**Month (only) **]. CN II-XII grossly intact. Moving all extremities. Pertinent Results: Admission Labs: [**2184-10-19**] 01:40PM BLOOD WBC-12.3*# RBC-3.09* Hgb-11.4* Hct-35.8* MCV-116* MCH-36.8* MCHC-31.8 RDW-20.2* Plt Ct-131* [**2184-10-19**] 01:40PM BLOOD Neuts-89.4* Lymphs-5.6* Monos-4.6 Eos-0.2 Baso-0.1 [**2184-10-19**] 06:50PM BLOOD PT-26.7* PTT-38.8* INR(PT)-2.7* [**2184-10-19**] 06:50PM BLOOD Glucose-108* UreaN-24* Creat-2.2* Na-144 K-3.9 Cl-100 HCO3-29 AnGap-19 [**2184-10-19**] 06:50PM BLOOD ALT-17 AST-34 AlkPhos-197* TotBili-1.2 [**2184-10-19**] 06:50PM BLOOD Lipase-25 [**2184-10-19**] 06:50PM BLOOD Albumin-3.6 Calcium-9.0 Phos-2.4* Mg-1.5* Interval Labs: [**2184-10-19**] 11:28PM BLOOD WBC-11.4* RBC-2.46* Hgb-9.0* Hct-27.9* MCV-114* MCH-36.6* MCHC-32.2 RDW-21.3* Plt Ct-113* [**2184-10-26**] 05:56AM BLOOD WBC-6.3 RBC-2.34* Hgb-8.5* Hct-26.1* MCV-112* MCH-36.2* MCHC-32.4 RDW-20.4* Plt Ct-112* [**2184-10-31**] 05:20AM BLOOD WBC-7.3 RBC-2.20* Hgb-8.1* Hct-25.2* MCV-115* MCH-36.7* MCHC-31.9 RDW-20.0* Plt Ct-184 [**2184-10-21**] 05:34AM BLOOD PT-40.2* PTT-45.3* INR(PT)-4.4* [**2184-10-25**] 04:08AM BLOOD PT-16.0* PTT-37.1* INR(PT)-1.4* [**2184-10-20**] 10:40AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.024 [**2184-10-20**] 10:40AM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-SM [**2184-10-20**] 10:40AM URINE RBC-[**10-21**]* WBC-[**10-21**]* Bacteri-MANY Yeast-NONE Epi-011/25/08 05:56AM BLOOD VitB12-1392* Folate-11.9 Discharge Labs: ****** Micro Data: [**2184-10-19**] blood cultures: 4/4 bottles positive for MRSA [**2184-10-20**] blood cultures: 2/4 bottles positive for MRSA [**2184-10-20**] catheter tip: positive for MRSA [**2184-10-20**] urine culture: GRAM POSITIVE BACTERIA. 10,000-100,000 Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. Blood cultures 11/20, [**10-21**], [**10-22**], [**10-23**], [**10-25**]: no growth Imaging: CXR [**2184-10-19**]: 1. Cardiomegaly with mild pulmonary edema and moderate-sized bilateral pleural effusions, right greater than left. 2. Interval placement of left-sided hemodialysis catheter with the tip within the right atrium. 3. Unchanged right-sided dual-chamber pacemaker. CT Abd/Pelvis [**2184-10-19**]: 1. No evidence of abcess or acute abdominal process. 2. Bilateral pleural effusion, right greater than left, measuring simple fluid attenuation. Trace pericardial effusion and small amount of abdominal / pelvic ascites. 3. Possible sludge or stone in the gallbladder without evidence of cholelithiasis. 4. Sigmoid diverticulosis without evidence of diverticulitis. Echo [**2184-10-25**]: Right atrial pressure is 10-15mmHg. LVEF>55%. Increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion c/w right ventricular pressure and volume overload. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate to severe pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. No vegetations seen. Right foot plain films ([**10-25**]): No acute fracture. Soft tissue swelling along the medial aspect of the foot centered at the first MTP joint. CXR ([**10-25**]): Moderate bilateral pleural effusion, right greater than left, continues to increase. Brief Hospital Course: 1) Septic shock: Secondary to MRSA infection of HD catheter. The catheter was removed and subsequent blood cultures were all negative. TTE showed no vegetations. She initially required levophed for hypotension and was treated with vancomycin and cefepime, but the cefepime was stopped after cultures showed MRSA in the blood. She had a temporary IJ HD line placed, which was later changed to a permanent line. A PICC was also placed for access and antibiotics. She was weaned off the levophed and transferred out of the ICU, where she remained afebrile and hemodynamically stable, with SBP improved to 110s. Due to the fluids received for resuscitation, she was significantly hypervolemic, with pleural effusions and anasarca. She was weaned off supplemental O2 and continued on HD, where some of the excess fluid was removed. The vancomycin will continue at HD for two weeks after the first negative blood culture, ie, until [**11-4**]. Her PICC was removed at discharge. 2) Gout: Painful and swollen right 1st MTP noted and podiatry was consulted. Steroids were avoided due to her recent septic shock. She responded well to a 4 day course of indomethacin. 3) Macrocytic anemia: Initial hematocrit drop in setting of IV fluid resuscitation. Patient was guaiac negative. She remained stable in the mid to upper 20s, although this was below her prior baseline. B12 and folate were normal. She was given epo at HD, and later iron was added. 4) Afib with tachy-brady: Metoprolol was held throughout the admission as the patient had no hypertension or tachycardia. Her INR was initially supratherapeutic and vitamin K was given. It later became subtherapeutic and her warfarin was restarted. 5) Post-herpetic neuralgia: Patient had intermittent pain under L breast that responded well to capsaicin cream, tylenol and warm compresses. As an outpatient, she can be evaluated for long-term therapy, such as with gabapentin or venlafaxine. 6) Abdominal pain: Noted intermittently and often not reproducible on exam. Thought to be related to IBS or constipation, or possibly fluid shifts from HD. She was kept on an aggressive bowel regimen to relieve constipation. [**Hospital 100**] Rehab to do: [ ] blood transfusion (2 u pRBCs) with hemodialysis on [**11-5**] [ ] hemodialysis [**11-5**] [ ] follow INR Medications on Admission: 1. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic [**Hospital1 **] to each eye (). 2. Citalopram 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Lactaid 3,000 unit Tablet Sig: One (1) Tablet PO QAC (). 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Polyethylene Glycol 3350 100 % Powder Sig: One (1) tablespoon powder PO once daily as directed. 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Warfarin 2.5 mg 8. Nystatin 100,000 unit/g Cream Sig: One (1) application Topical twice a day as needed for itching. 9. Metoprolol Tartrate 12.5 [**Hospital1 **] 10. Citracal + D 315-200 mg-unit Tablet two [**Hospital1 **] 11. Senna 8.6 mg qhs Discharge Medications: 1. Cyclosporine 0.05 % Dropperette Sig: One (1) Ophthalmic [**Hospital1 **] (2 times a day): to each eye. 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Polyethylene Glycol 3350 100 % Powder Sig: One (1) tablespoon PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Lactaid 3,000 unit Tablet Sig: One (1) Tablet PO before meals. 9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 11. Citracal + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO twice a day. 12. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for shoulder pain. 13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours. 18. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed. 19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 20. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous HD PROTOCOL (HD Protochol) for 1 doses: Give at HD on [**11-5**]. 21. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3 times a day). 22. Trazodone 50 mg Tablet Sig: 0.75 Tablet PO HS (at bedtime) as needed for insomnia. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Septicemia from Methicillin Resistant Staphylococcus Aureus Secondary: End stage renal disease Atrial fibrillation Irritable bowel syndrome Post-herpetic neuralgia Chronic anemia Discharge Condition: Hemodynamically stable, afebrile Discharge Instructions: You were admitted to [**Hospital1 18**] due to an infection called MRSA in your bloodstream, that initially was treated in the ICU. You received IV fluids and an antibiotic called vancomycin, which controlled this infection. We were able to remove some of your excess fluid build up with dialysis, and this will continue as an outpatient. Please take all medications as prescribed and go to all follow up appointments. We have made the following medication changes: - Increased your citalopram (Celexa) dose. - Restarted your atorvastatin (for high cholesterol) and pantoprazole (stomach acid blocker). - Stopped your metoprolol as your blood pressure and heart rate were not elevated. - You will receive a dose of vancomycin at your next dialysis session ([**11-5**]). - You have been started on tylenol, capsaicin cream for pain control - You have been started on trazodone for sleep - You have been started on simethicone for gas If you experience fevers, chills, difficulty breathing, confusion, chest pain, vomiting, diarrhea, or any other concerning symptoms, please seek medical attention or come to the ER immediately. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Followup Instructions: Please call your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 719**] to schedule a follow up appointment. Continue your dialysis Monday, Wednesday and Friday at [**Hospital 100**] Rehab. Your INR will be followed at [**Hospital 100**] Rehab. [**Name6 (MD) **] [**Last Name (NamePattern4) 23348**] MD, [**MD Number(3) 23349**]

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icd9cm

[ [ [] ] ]

[ "86.05", "38.91", "39.95", "38.95", "38.93" ]

icd9pcs

[ [ [] ] ]

11318, 11384

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49175

Discharge summary

report

Admission Date: [**2113-9-13**] Discharge Date: [**2113-9-21**] Date of Birth: [**2078-4-17**] Sex: F Service: INT MED HISTORY OF PRESENT ILLNESS: The patient is a 35 year old woman with type 1 diabetes mellitus diagnosed at age five, complicated by end stage renal disease, on peritoneal dialysis for four years, status post failed renal transplant in [**2104**], retinopathy, status post laser surgery in [**2098**], hypertension, suspected transient ischemic attack in 09/00, left below the knee amputation, multiple digit amputation, brain biopsy for naphthalene (inhaling moth balls) induced coma, who presented to the Emergency Department with a four day history of intermittent slurred speech. The patient reports moderate right frontal headache on the day of admission. This was followed by nausea and vomiting times three after taking an iron supplement. The patient was seen in clinic appointment on the morning of admission and was found to be hypertensive with a systolic blood pressure in the 200s. The patient also noted some intermittent jerking of her arms for the three days prior to admission. The patient denied any changes in her vision, focal weakness or paresthesias. In the Emergency Department, the patient had a blood pressure of 137/121 with a pulse of 96, oxygen saturation 98% in room air. The patient was treated with intravenous Labetalol in addition to Vasotec and Norvasc and transferred to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus since the age of five. 2. End stage renal disease on peritoneal dialysis times four years. The patient is status post failed renal transplant. 3. Hypertension. 4. Retinopathy, status post laser surgery in [**2098**]. 5. Suspected transient ischemic attack [**10/2112**]. The patient presented with ten minutes of left upper extremity weakness and slurred speech. 6. Multiple amputations. 7. Hypercholesterolemia. 8. Status post brain biopsy secondary to a naphthalene (inhaled moth balls) induced coma. 9. Status post parathyroidectomy. MEDICATIONS ON ADMISSION: 1. Prilosec 20 mg p.o. b.i.d. 2. Humulin 14 units subcutaneous q.a.m. 3. Nephrocaps one tablet p.o. q.d. 4. Reglan 10 mg p.o. t.i.d. 5. PhosLo one tablet p.o. b.i.d. 6. Aggrenox one tablet p.o. b.i.d. 7. K-Dur 20 meq p.o. q.d. 8. Elavil 25 mg p.o. q.h.s. 9. Restoril 45 mg p.o. p.r.n. 10. Ensure one can p.o. q.d. 11. Phenergan tablets 25 mg p.o. p.r.n. 12. Tylenol #3 2 mg p.o. b.i.d. p.r.n. back pain. 13. Regular insulin subcutaneous sliding scale. 14. Humulin NPH 10 units subcutaneous q.p.m. 15. Epogen 3800 units intravenous two times per week. 16. Vasotec 20 mg p.o. b.i.d. 17. Norvasc 5 mg p.o. q.d. 18. Labetalol 600 mg p.o. b.i.d. ALLERGIES: Compazine and Percocet. SOCIAL HISTORY: The patient lives alone and has a sister who stays with her at night. The patient finished high school and is not working. No smoking, alcohol or drug use. The patient has a history of inhaling moth balls. The patient has one daughter in DSS custody. PHYSICAL EXAMINATION: On admission, temperature 96, blood pressure 232/117, pulse 83, respiratory rate 18, oxygen saturation 98% in room air. In general, the patient is awake in no acute distress. Head, eyes, ears, nose and throat - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Cardiovascular regular rate and rhythm, normal S1 and S2. The lungs are clear to auscultation bilaterally. The abdomen is nontender, nondistended, normal bowel sounds. Neurologic - occasional white color, oriented times three, speech intermittently dysarthric, slurring words, saying wrong words, no word substitutions, appropriately responsive. No facial asymmetry, sensation intact and symmetric, tongue midline. Motor is [**6-10**] throughout. Generalized monoclonal jerks throughout examination at all four extremities and at face. No asterixis at wrists. Sensation intact throughout to light touch and temperature. Deep tendon reflexes 2+ bilateral upper extremities and lower extremities. Finger to nose intact bilaterally. Gait not tested. LABORATORY DATA: On admission, white blood count 6.4, hematocrit 35.6, platelets 331,000. Prothrombin time, partial thromboplastin time and INR within normal limits. Peritoneal fluid one white blood cell. Sodium 139, potassium 4.9, ALT 19, AST 17, total bilirubin 0.3. CPK 294 with troponin less than 0.3. Magnesium 1.5, phosphorus 6.0. Albumin 3.4. Hemoglobin A1C 6.8. Acetone negative. TSH 1.9. Dialysis fluid culture no growth. Naphthalene level from admission is pending. Magnetic resonance scan of the head - new T2-flare hyperintensity in the white matter of the right corona radiata suggestive of nonacute stroke. No acute brain infarction. Stable narrowing of the cavernous portion of the right internal carotid artery. Electroencephalogram [**2113-9-16**], mildly abnormal electroencephalogram due to the presence of slightly slow background with bursts of generalized slowing superimposed, most consistent with a mild encephalopathy of toxic, metabolic or anoxic etiology. Transcranial Doppler results from [**2113-9-14**], are pending. HOSPITAL COURSE: 1. Cardiovascular - The patient presented in clinic with hypertension. In the Emergency Department, blood pressure was 200/100s with associated slurred speech. The patient was started on the Labetalol drip, Nipride drip, and was admitted to the Medical Intensive Care Unit. The patient was taken off drips on hospital day four and started on Labetalol 700 mg p.o. t.i.d., Norvasc 7.5 mg p.o. q.d. and Vasotec 20 mg p.o. b.i.d. Of note, the patient was given Hydralazine during this admission for blood pressure control which was associated with anxiety, agitation and rapid drop in systolic blood pressure to less than 110. In addition, the patient did not tolerate alpha blockade. At the time of discharge, neurology recommended to keep the patient's MAP at 90 to 100 with gradual return to normal over the course of several months. 2. Neurology - The patient with evidence of subacute cerebrovascular accident of the right corona radiata on magnetic resonance scan. During this admission, the patient's slurred speech resolved with normal speech at the time of discharge. Electroencephalogram done did not show evidence of seizure, pattern was most consistent with a mild encephalopathy, toxic, metabolic or anoxic etiology. Transcranial Doppler was done and the results are pending. The patient is with baseline mental status at the time of discharge. Of note the patient with a history of naphthalene induced coma (inhaling moth balls). The patient's mother-in-law reported that the patient had again been sniffering moth balls prior to this admission. The patient's symptoms at presentation on this admission were similar to those which she presented with when admitted for coma secondary to naphthalene (inhaling moth balls). A naphthalene level was sent at admission and is still pending. Addiction consultation was placed. They spoke with the patient's therapist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 103150**], with whom the patient sees once a week at home for treatment of depression. 3. Renal - The patient was continued on peritoneal dialysis. The patient developed hyponatremia with low sodium at 125. The patient was placed on a 1.5 liter fluid restriction with increase in sodium to 128 at the time of discharge. 4. Hematology - The patient's Epogen was held while the patient was hypertensive. The patient's hematocrit fell to 30.4. Epogen was restarted when blood pressure was under control with hematocrit at the time of discharge being 34.0. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient discharged to home with follow-up in neurology and renal. DISCHARGE DIAGNOSES: 1. Hypertensive encephalopathy. 2. Type 1 diabetes mellitus. 3. Subacute stroke. 4. End stage renal disease on peritoneal dialysis. MEDICATIONS ON DISCHARGE: 1. Labetalol 700 mg p.o. t.i.d. 2. Vasotec 20 mg p.o. b.i.d. 3. Norvasc 7.5 mg p.o. q.d. 4. Epogen 3800 units intravenously two times per week. 5. Prilosec 20 mg p.o. b.i.d. 6. Humulin 14 units subcutaneous q.a.m. 7. Nephrocaps one tablet p.o. q.d. 8. Reglan 10 mg p.o. t.i.d. 9. PhosLo one tablet p.o. b.i.d. 10 Aggrenox one tablet p.o. b.i.d. 11. K-Dur 20 meq p.o. q.d. 12. Elavil 25 mg p.o. q.h.s. 13. Restoril 45 mg p.o. p.r.n. 14. Ensure one can p.o. q.d. 15. Phenergan tablets 25 mg p.o. p.r.n. 16. Tylenol #3 2 mg p.o. b.i.d. p.r.n. back pain. 17. Regular insulin subcutaneous sliding scale. 18. Humulin NPH 10 units subcutaneous q.p.m. 19. Bactrim Ointment q.d. to exit site daily and dressing. 20. Renagel 800 mg p.o. t.i.d. taken after meals. The patient checks fingerstick before giving insulin. [**Name6 (MD) 251**] [**Last Name (NamePattern4) 11865**], M.D. [**MD Number(1) 11866**] Dictated By:[**Last Name (NamePattern1) 1297**] MEDQUIST36 D: [**2113-9-21**] 13:45 T: [**2113-9-25**] 17:56 JOB#: [**Job Number 103151**] cc:[**Telephone/Fax (1) 103152**]

[ "362.01", "V49.75", "403.01", "250.41", "250.51", "434.91", "437.2", "272.0", "276.1" ]

icd9cm

[ [ [] ] ]

[ "54.98" ]

icd9pcs

[ [ [] ] ]

7906, 8043

8069, 9188

2107, 2794

5246, 7761

3090, 5229

165, 1482

1504, 2081

2811, 3067

7786, 7885

9,973

100,020

6876

Discharge summary

report

Admission Date: [**2142-11-30**] Discharge Date: [**2142-12-10**] Date of Birth: [**2084-5-2**] Sex: M Service: MEDICINE Allergies: Percocet / Bactrim Ds / Lisinopril Attending:[**First Name3 (LF) 898**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 25925**] is a 58 yo m w/ multiple sclerosis and seizure disorder who presented to an OSH for delusions and AMS x 2 days. At OSH, he was noted to have a Na of 124. He does have a history of hyponatremia; he had a Na of 117 in [**2-27**] but had been in the mid 130s since then. He has seen nephrology. At the OSH, he had an approx 45sec generalized tonic clonic seizure, received 1mg Ativan, and transferred to the ED at [**Hospital1 18**]. He also has a history of seizures especially in the setting of infection and hyponatremia. It is unclear if he has had seizures without an inciting event. He is currently being weaned off of Keppra and Gabapentin and is being started on Tegretol. In the ER, his VS were: 97.5; 189/105; 78; 16; 95% 3L. He was given 2L of NS. Given that he has had AMS in the setting of infection and is known to have chronic UTIs [**12-24**] indwelling suprapubic catheter and neurogenic bladder, blood and urine cultures were obtained as well as a CXR. He had a urine culture from [**11-28**] that grew pseudomonas and his CXR showed a possible infiltrate and he was treated with vancomycin and cefepime. A head CT was negative. Past Medical History: MS - since [**2119**], progressive, quadriplegic, neurogenic bladder with suprapubic catheter, restrictive PFT's History of Aspiration PNAs Esophageal Ulcer - [**12-24**] NSAIDs, [**2139**], small bowel bx negative Recurrent UTIs CHF (EF > 65% with moderate LVH in '[**39**]) HTN Legally Blind Social History: He is married 32 years and lives with his wife at home. He has three children and three grandchildren. He was a professor [**First Name (Titles) **] [**Last Name (Titles) 25949**] engineering at [**University/College 25932**], but retired on disability after the [**2128**] spring semester due to his MS. [**Name13 (STitle) **] is wheelchair-bound. He denies tobacco, alcohol, and recreational drug use. Has personal care assistant. Family History: Father had CAD and CVA. Mother has [**Name (NI) 2481**] disease. Brother has diabetes. 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 Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2142-11-29**] 10:47PM BLOOD WBC-6.4 RBC-3.99*# Hgb-11.8*# Hct-33.1* MCV-83# MCH-29.7 MCHC-35.7* RDW-15.0 Plt Ct-235# [**2142-12-10**] 05:50AM BLOOD WBC-8.8 RBC-3.54* Hgb-10.8* Hct-31.0* MCV-88 MCH-30.5 MCHC-34.7 RDW-15.3 Plt Ct-424 [**2142-12-7**] 05:50AM BLOOD PT-13.6* PTT-34.1 INR(PT)-1.2* [**2142-11-29**] 10:47PM BLOOD Glucose-102 UreaN-11 Creat-0.6 Na-126* K-4.5 Cl-88* HCO3-29 AnGap-14 [**2142-11-30**] 06:58AM BLOOD Glucose-89 UreaN-11 Creat-0.7 Na-125* K-4.6 Cl-90* HCO3-28 AnGap-12 [**2142-11-30**] 12:40PM BLOOD Na-128* [**2142-11-30**] 09:45PM BLOOD Na-127* [**2142-12-1**] 07:40AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-131* K-4.0 Cl-93* HCO3-29 AnGap-13 [**2142-12-1**] 03:00PM BLOOD Glucose-101 UreaN-16 Creat-0.8 Na-131* K-4.5 Cl-94* HCO3-30 AnGap-12 [**2142-12-2**] 05:45AM BLOOD Glucose-81 UreaN-15 Creat-0.7 Na-133 K-4.6 Cl-95* HCO3-28 AnGap-15 [**2142-12-2**] 04:10PM BLOOD Glucose-98 UreaN-15 Creat-1.0 Na-131* K-4.9 Cl-93* HCO3-27 AnGap-16 [**2142-12-3**] 06:20AM BLOOD Glucose-121* UreaN-21* Creat-1.2 Na-131* K-4.3 Cl-93* HCO3-28 AnGap-14 [**2142-12-3**] 05:40PM BLOOD Glucose-115* UreaN-25* Creat-1.3* Na-134 K-4.4 Cl-96 HCO3-27 AnGap-15 [**2142-12-4**] 07:18AM BLOOD Glucose-101 UreaN-23* Creat-0.8 Na-135 K-4.0 Cl-98 HCO3-27 AnGap-14 [**2142-12-5**] 05:30AM BLOOD Glucose-83 UreaN-21* Creat-0.7 Na-135 K-3.9 Cl-96 HCO3-26 AnGap-17 [**2142-12-6**] 05:30AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-134 K-4.2 Cl-97 HCO3-28 AnGap-13 [**2142-12-7**] 05:50AM BLOOD Glucose-102 UreaN-21* Creat-0.8 Na-137 K-4.2 Cl-97 HCO3-26 AnGap-18 [**2142-12-8**] 07:00AM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-136 K-3.9 Cl-99 HCO3-27 AnGap-14 [**2142-12-9**] 06:30AM BLOOD Glucose-96 UreaN-14 Creat-0.9 Na-140 K-4.0 Cl-101 HCO3-28 AnGap-15 [**2142-12-10**] 05:50AM BLOOD Glucose-99 UreaN-18 Creat-1.0 Na-140 K-4.5 Cl-102 HCO3-26 AnGap-17 [**2142-11-29**] 10:47PM BLOOD Osmolal-260* [**2142-11-30**] 12:40PM BLOOD Osmolal-264* [**2142-12-8**] 07:00AM BLOOD ALT-23 AST-16 LD(LDH)-213 AlkPhos-87 TotBili-0.2 [**2142-12-10**] 05:50AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.4 U/A [**11-28**]: nit +, LE +, WBC 55, RBC 6, Epi 1, bact few U/A [**11-29**]: sm bld, 100 prot/gluc; WBC [**1-24**], RBC [**1-24**], Epi [**1-24**], bact mod U/A [**12-2**]: sm LE, WBC 10, RBC 2, Epi 1, bact none U/A [**12-5**]: 30 prot, 10 ket, lg LE; WBC 99, RBC 11, Epi 1, bact few U/A [**12-6**]: 30 prot, mod LE; WBC 22, RBC 8, Epi 3, bact none U/A [**12-8**]: neg leuk CULTURES: BCx [**11-29**] x2: neg BCx [**12-2**] x2: neg UCx [**11-28**]: PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML UCx [**11-29**] pseudomonas UCx [**12-2**] yeast Ucx [**12-5**] neg Ucx [**12-6**] yeast Ucx [**12-8**] neg c.diff neg x 2 - CXR from [**12-2**]: Patchy opacity at left base again noted, but the significance in the setting of low inspiratory volumes is uncertain. - CTA from [**12-2**]: No PE. Scattered patchy ground-glass opacities may represent expiratory state with air trapping. - Renal u/s from [**12-2**]: No evidence of abscess, hydronephrosis or mass - abd xray from [**12-3**]: non-specific bowel gas pattern, stool throughout colon, no free air - abd xray from [**12-4**]: Stool- and air-filled loops of large and small bowel consistent with ileus. - Liver u/s from [**12-5**]: Hypoechoic right hepatic mass, measuring up to 4.2 cm in size - CT abd: prelim read: Arterially enhancing liver lesion cannot be fully characterized, may represent adenoma, FNH, or less likely HCC. Brief Hospital Course: 58 yo male w/ progressive multiple sclerosis was admitted for AMS and seizure after having a 45s GTC at the OSH that responded to 1mg Ativan. He had a negative head CT but was found to have a Na level of 126. He has been hyponatremic in the past and this has often caused changes in his mental status. In the ED, he was treated with 2L NS for concern of hypovolemic hyponatremia. At that time, his urine osm was 423 and serum osm was 263. He also had a CXR and there was prelim concern for pneumonia which can cause an ADH like effect (the final read was neagtive). Neurology was consulted for his AMS and seizure and they felt that his hyponatremia was likely related to recent initiation of carbamezapine for sensory illusions. Carbamezapine has a known ADH like effect and can cause hyponatremia. Following discontinuation of carbamezapine along with fluid restriction, his Na increased. After several days, the pt appeared slightly dehydrated so his fluid restriction was lifted. By time of discharge, his serum Na was 140. . In the past, his seizures have been instigated by an underlying infection. However, upon admission he was afebrile and did not have a leukocystosis. The most likely source was either pneumonia or a UTI. He has a suprapubic catheter [**12-24**] neurogenic bladder and on the day prior to admission, he had a urine sample that grew pseudomonas, a bacteria he has had in the past. He has also had several pneumonias in the past, most likely [**12-24**] frequent aspirations and his first CXR was concerning for lung infiltrate. He was treated with one dose of vancomycin and cefepime for pneumonia. Ultimately, repeat CXR and a CTA were both negative for pneumonia. . Because of his pseudomonal bacteriuria, he was started on ciprofloxacin. A urine culture drawn prior to abx inititian also grew pseudomonas. Because he was afebrile and did not have a leukocytosis and there was thought that it may actually have been colonization as opposed to infection. However, he was treated with a full course of cipro for a complicated UTI. His catheter was changed and all other cultures remained negative. . On admission, the pt was afebrile and hypertensive to 180-200. However, shortly after arriving on the floor, he had an episode of hypotension down to the 70's systolic. During this time he was mentating well, he did not have any complaints, denied chest pain, headache, and visual changes. IVFs were given, however the hypotension did not initially respond, however came up eventually prior to getting to the ICU. This labile blood pressure was most likely secondary to the patient's autonomic dysfunction secondary to his SPMS. Other considerations were infection or possible sepsis, however the patient was continued to be afebrile. Blood and urine cultures were negative. He was monitored in the ICU for 24 hours with stable swings in BP which were asymptomatic and consistent with autonomic dysfunction. Changed clonidine dosing from 0.2mg [**Hospital1 **] to 0.1mg TID. Maintained other blood pressure medications at home doses. . The next day, he was transferred out of the MICU and returned to the floor. Shortly after arrival, he developed a fever. More blood and urine cultures were sent and all were negative. Pneumonia had been ruled out and his UTI was being treated with a medication that was appropriate per sensitivities. He had a CTA which was negative for PE. However, he was started on meropenem and was treated for 2 days. He was still slightly febrile but his meropenem was discontinued for concern of drug fever. He defervesced without any further treatment. . However, his mental status continued to fluctuate despite being afebrile, no obvious source of infection, and he was eunatremic. He was occasionally aggressive and would say that he was being murdered or kidnapped. Neurology was reconsulted but did not feel that his symptoms were related to the keppra and they did not think he was having subclinical seizures. He continued to have repetitive shaking moves of his head but he was conscious and able to speak during these episodes. Also, despite the Keppra, he continued to have sensory illusions, mostly centered around the feeling of having a bowel movement (when he actually was not). . During the work up for a source of infection and source of AMS, he had a CTA which revealed a liver lesion. He had an ultrasound and a multiphase liver CT to further describe the lesion because he cannot have an MRI [**12-24**] an implanted baclofen pump. Mr [**Known lastname 25925**] and his family decided to not biopsy the lesion at this time but it was not ruled out completely for malignancy, although unlikely. During this work up he also had KUB that was concerning for ileus but he continued to have BMs so he was kept on a regular diet. . Prior to discharge, his mental status had not completely returned to baseline but he was alert and oriented x 3 and was no longer aggressive towards staff. No definite etiology was elucidated and it was hypothesized that this could be a result of the progression of his established disease. Medications on Admission: BACLOFEN 2,000 mcg/mL Kit -pump BRIMONIDINE Dosage uncertain CARVEDILOL - 25 mg Tablet [**Hospital1 **] CARBAMEZAPINE - 100mg [**Hospital1 **] CLONIDINE - 0.2 mg Tablet [**Hospital1 **] CLOTRIMAZOLE-BETAMETHASONE - 1 %-0.05 % Cream tid FENTANYL - 12 mcg/hour Patch 72 hr FUROSEMIDE - 40 mg Tablet qd IPRATROPIUM-ALBUTEROL prn LACTULOSE prn MINOCYCLINE - 100 mg Tablet [**Hospital1 **] MODAFINIL [PROVIGIL] 50 [**Hospital1 **] OMEPRAZOLE 20 [**Hospital1 **] OXYBUTYNIN CHLORIDE - 15 mg qhs SIMVASTATIN - 40 mg qd TRAVOPROST1 drop L eye once a day ACETAMINOPHEN prn ASCORBIC ACID 500 [**Hospital1 **] BISACODYL hs CALCIUM 500 mg Tid CRANBERRY 475 mg Capsule [**Hospital1 **] ERGOCALCIFEROL (VITAMIN D2)400 [**Hospital1 **] MINERAL OIL prn OMEGA-3 FATTY ACIDS [**Hospital1 **] PSYLLIUM [METAMUCIL] prn SENNA - 8.6 mg Tablet prn Discharge Medications: 1. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 6. Oxybutynin Chloride 5 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 12. Simvastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 13. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 14. Modafinil 100 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days: through [**2142-12-13**]. 16. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 18. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 19. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) inh Inhalation twice a day as needed. 20. TRAVATAN Z 0.004 % Drops Sig: One (1) Ophthalmic once a day: To Left eye. 21. Cranberry 475 mg Capsule Sig: One (1) Capsule PO twice a day. 22. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO twice a day. 23. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: One (1) Tablet PO twice a day. The patient has an allergy listed to ACE Inhibitors, and was therefore not discharged on an ACE Inhibitor. This will be communicated to PCP. Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: 1. Multiple Sclerosis 2. Urinary Tract Infection, complicated 3. Hyponatremia . Secondary: 1. Chronic Diastolic CHF Discharge Condition: Stable vital signs. Discharge Instructions: You were admitted with altered mental status and found to have low sodium and a urinary tract infection. You were started on antibiotics for your urinary tract infection (cipro) to complete a 2 week course. Your sodium corrected after adjusting your medications and reducing your water intake. . You were found to have an abnormality in your liver. You had a CT scan and the results are pending final interpretation. We have provided a phone number below so that you can schedule an appointment in [**Hospital **] clinic. It may be necessary to reimage the liver or take a biopsy of the lesion seen on CT scan. . Your medications have changed. You were switched from tegratol to keppra. Please review your most recent medication list and take only these medications, and discard any old medications not on this list. . Please return to the hospital if you develop fevers, chills, or worsening symptoms. Followup Instructions: 1. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2143-1-8**] 1:30 . 2. [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2143-1-15**] 4:00 . 3. [**Hospital **] CLINIC at [**Hospital1 18**]: ([**Telephone/Fax (1) 2233**] Completed by:[**2142-12-13**]

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Discharge summary

report

Admission Date: [**2156-12-18**] Discharge Date: [**2156-12-27**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 545**] Chief Complaint: Hypercarbia Major Surgical or Invasive Procedure: none History of Present Illness: 87 yo female with history of COPD and CHF who per her son was increasingly lethargic over the course of the week. She had URI symptoms, cough and SOB. He took her to her PCP on two days PTA and was given a Z-Pack. Still lethargic all day on the day PTA so he brought her to [**Hospital1 **] [**Location (un) 620**]. At [**Location (un) 620**], ABG 7.18 / 108 / ?. Placed on BiPap with improvement in mental status. Transferred to [**Hospital1 18**] for further work-up and eval. At the time of admission, the patient was placed on BiPap with her home settings. It was learned that there may have been a problem with the patient's home oxygen tubing. Her CXR was c/w mild CHF but the patient was not diuresed as her SBP was in the 80s (per her son, baseline usually in the 90s). Past Medical History: CHF CAD s/p MI [**3-/2156**] HTN CKD (1.1-1.7) Fe Deficiency Anemia TIA x2 Afib OSA COPD on home O2 X 2 years. Social History: Widowed. Former smoker but quite many years ago. Lives with her 2 daughters. Family History: Two daughters with muscular dystrophy. Physical Exam: T 97.3 P78 R 21 103/42 O2 Sat 100% Gen: Frail appearing. HEENT: PERRL, EOMI. Dry MM. Conjunctiva well pigmented. Neck: Supple, without adenopathy. JVP 8 cm at 45 degress. Chest: Coarse crackles at bases bilat. Cor: Normal S1, S2. II/VI holosystolic murmur. Abdomen: Soft, non-tender and non-distended. +BS, no HSM. Extremity: Warm, without edema. No CCE. Neuro: Alert and oriented to person and place. Responds to verbal stimulii and follows commands. Pertinent Results: [**2156-12-17**] 08:30PM BLOOD WBC-10.3 RBC-3.83* Hgb-10.7* Hct-34.8* MCV-91 MCH-27.9 MCHC-30.7* RDW-13.9 Plt Ct-308 [**2156-12-21**] 10:00AM BLOOD WBC-11.1* RBC-3.48* Hgb-9.6* Hct-31.4* MCV-90 MCH-27.5 MCHC-30.5* RDW-14.1 Plt Ct-292 [**2156-12-23**] 06:00AM BLOOD WBC-20.3*# RBC-3.52* Hgb-9.8* Hct-30.7* MCV-87 MCH-27.7 MCHC-31.8 RDW-14.2 Plt Ct-316 [**2156-12-27**] 06:05AM BLOOD WBC-9.0 RBC-3.32* Hgb-9.0* Hct-29.1* MCV-88 MCH-27.2 MCHC-31.0 RDW-14.2 Plt Ct-266 [**2156-12-17**] 08:30PM BLOOD PT-41.4* PTT-35.7* INR(PT)-4.5* [**2156-12-17**] 10:20PM BLOOD PT-42.0* PTT-39.5* INR(PT)-4.6* [**2156-12-20**] 05:57AM BLOOD PT-36.1* PTT-34.7 INR(PT)-3.8* [**2156-12-21**] 10:00AM BLOOD PT-19.8* PTT-29.4 INR(PT)-1.8* [**2156-12-23**] 06:00AM BLOOD PT-18.7* PTT-27.7 INR(PT)-1.8* [**2156-12-23**] 06:50PM BLOOD PT-18.9* PTT-65.5* INR(PT)-1.8* [**2156-12-24**] 06:10AM BLOOD PT-21.3* PTT-56.1* INR(PT)-2.1* [**2156-12-25**] 07:30AM BLOOD PT-25.4* PTT-76.1* INR(PT)-2.5* [**2156-12-26**] 07:45AM BLOOD PT-25.7* PTT-32.6 INR(PT)-2.5* [**2156-12-27**] 06:05AM BLOOD PT-25.0* PTT-31.5 INR(PT)-2.5* [**2156-12-17**] 08:30PM BLOOD Glucose-114* UreaN-84* Creat-2.4* Na-137 K-5.4* Cl-94* HCO3-37* AnGap-11 [**2156-12-19**] 04:19AM BLOOD Glucose-118* UreaN-106* Creat-2.9* Na-137 K-5.5* Cl-97 HCO3-32 AnGap-14 [**2156-12-20**] 05:57AM BLOOD Glucose-113* UreaN-100* Creat-2.6* Na-139 K-4.8 Cl-101 HCO3-35* AnGap-8 [**2156-12-22**] 03:50PM BLOOD Glucose-148* UreaN-81* Creat-2.1* Na-142 K-4.2 Cl-95* HCO3-42* AnGap-9 [**2156-12-23**] 06:00AM BLOOD Glucose-138* UreaN-78* Creat-2.0* Na-142 K-3.9 Cl-93* HCO3-43* AnGap-10 [**2156-12-25**] 07:30AM BLOOD Glucose-113* UreaN-60* Creat-1.8* Na-142 K-3.4 Cl-91* HCO3-44* AnGap-10 [**2156-12-26**] 07:45AM BLOOD Glucose-111* UreaN-55* Creat-1.6* Na-143 K-4.1 Cl-94* HCO3-44* AnGap-9 [**2156-12-27**] 06:05AM BLOOD Glucose-155* UreaN-54* Creat-1.7* Na-142 K-3.8 Cl-91* HCO3-46* AnGap-9 [**2156-12-17**] 08:30PM BLOOD CK(CPK)-21* [**2156-12-18**] 03:15AM BLOOD CK(CPK)-34 [**2156-12-23**] 12:50PM BLOOD CK(CPK)-16* [**2156-12-23**] 06:50PM BLOOD CK(CPK)-14* [**2156-12-24**] 06:10AM BLOOD ALT-5 AST-13 LD(LDH)-195 CK(CPK)-15* AlkPhos-65 TotBili-0.7 [**2156-12-17**] 08:30PM BLOOD CK-MB-NotDone cTropnT-0.05* [**2156-12-18**] 03:15AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2156-12-23**] 12:50PM BLOOD CK-MB-3 cTropnT-0.05* [**2156-12-23**] 06:50PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2156-12-24**] 06:10AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2156-12-17**] 08:30PM BLOOD Calcium-8.7 Phos-5.3* Mg-2.7* [**2156-12-27**] 06:05AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.1 [**2156-12-22**] 03:50PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.4 Iron-24* [**2156-12-22**] 03:50PM BLOOD calTIBC-369 Ferritn-57 TRF-284 [**2156-12-24**] 06:10AM BLOOD %HbA1c-6.0* [**2156-12-24**] 06:10AM BLOOD Triglyc-90 HDL-48 CHOL/HD-2.3 LDLcalc-42 [**2156-12-18**] 03:15AM BLOOD TSH-1.2 [**2156-12-17**] 08:30PM BLOOD Digoxin-2.0 [**2156-12-19**] 04:20PM BLOOD Digoxin-2.6* [**2156-12-20**] 05:57AM BLOOD Digoxin-2.1* [**2156-12-17**] 07:55PM BLOOD Type-ART pO2-69* pCO2-89* pH-7.24* calTCO2-40* Base XS-7 [**2156-12-17**] 11:08PM BLOOD Type-ART pO2-47* pCO2-63* pH-7.29* calTCO2-32* Base XS-1 [**2156-12-18**] 04:59AM BLOOD Type-ART Temp-37.3 pO2-31* pCO2-90* pH-7.23* calTCO2-40* Base XS-5 [**2156-12-18**] 04:01PM BLOOD Type-ART pO2-75* pCO2-84* pH-7.24* calTCO2-38* Base XS-5 [**2156-12-19**] 11:42AM BLOOD Type-ART pO2-66* pCO2-80* pH-7.29* calTCO2-40* Base XS-7 [**2156-12-18**] 04:01PM BLOOD Lactate-1.0 EKG [**12-17**]: Atrial fibrillation. Marked left axis deviation. Intraventricular conduction delay. Left bundle-branch block. Inferior Q waves - consider previous inferior myocardial infarction but may be reflecting the intraventricular conduction delay. Imaging: CXR [**12-17**]: Moderate cardiomegaly and increased interstitial markings likely representing mild CHF. Renal US [**12-19**]: 1. No evidence of hydronephrosis. 2. Renal size asymmetry with left kidney smaller and atrophic. 3. Ascites, with largest pocket in right lower quadrant. TTE [**12-20**]: The left atrium is dilated. The right atrium is markedly dilated. There is asymmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is moderate thickening of the mitral valve chordae. Mild to moderate ([**1-13**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CT Head without contrast [**12-23**]: There is no evidence of hemorrhage or recent infarction. Bilateral well-defined round areas of hypodensity near the basal ganglia may represent small areas of previous lacunar infarction/sequela of previous small vessel disease. There is periventricular white matter hypodensity consistent with chronic small vessel ischemia. There is no midline shift. Visualized portions of the paranasal sinuses are clear. MRI brain [**12-23**]: No evidence of intracranial hemorrhage, mass effect, hydrocephalus, or shift of normally midline structures. No diffusion abnormalities are identified to suggest acute ischemia. A chronic left cerebellar infarct is noted with associated encephalomalacia. T2 hyperintensity in the periventricular and deep cerebral white matter is consistent with chronic microvascular infarction. Prominence of the sulci and ventricles is consistent with moderate cerebral atrophy. MRA Brain [**12-23**]: The major tributaries of the circle of [**Location (un) 431**] are patent. Within limits of this study, there is no evidence of significant intracranial stenosis, aneurysm, or arteriovenous malformation. MRA Carotids [**12-23**]: The carotid arteries are patent bilaterally. There is at least moderate stenosis of the proximal left internal carotid artery for a segment measuring approximately 1 cm. There is mild irregularity of the right internal carotid artery but no significant stenosis is identified. The vertebral arteries are patent and unremarkable in appearance. Carotid Ultrasound [**12-24**]: Less than 40% right ICA stenosis. 60-69% left ICA stenosis. Brief Hospital Course: 87yo woman with h/o COPD and CHF admitted with lethargy and hypercarbic respiratory failure in the setting of URI and damaged biPAP tubing and CO2 to 108. Patient's symptoms began with URI syndrome and dyspnea [**12-14**]. She was given a Z-Pack by her PCP but developed lethargy and presented to [**Hospital1 **] [**Location (un) 620**] with ABG: 7.18/108/? O2. She was admitted to the MICU, where she was put on her home BiPAP with improvement in her COPD. She was also given solumedrol and her azithromycin was continued. Antihypertensives were held and she was given small boluses of IV fluids for hypotension. Digoxin was also held because of slightly elevated digoxin levels. Her INR was noted to be elevated in the setting of getting antibiotics, and her coumadin was held. There was no evidence of bleeding. # Hypercarbic respiratory failure: Patient admitted with lethargy and hypercarbia in setting of URI superimposed on COPD and damaged home BiPAP. She was diuresed for heart failure and her biPAP was repaired. She did well on her home setting of BiPAP 17/5 with target O2 90-92% as she is a chronic CO2 retainer. In addition to spiriva and advair, she did well with a prednisone taper and returned to her baseline, using 2L of oxygen by nasal cannula. # ARF on CKD: Baseline Cr 1.5-1.7. Cr on admission 2.5, increased to 2.9 after getting IV fluids, and then decreased to 1.7 with diuresis. She was felt to have prerenal renal failure in the setting of heart failure. After diuresing with IV lasix, she was sent home at her home dose of lasix. Her quinapril was held and her family was instructed not to give it to her until her primary physician recommended it again. # TIA w/ h/o prior CVA: The patient had new onset dysarthria and left facial droop [**12-23**]. Neurology was emergently consulted. Her symptoms resolved within 24 hours and there were no findings on head CT or MRI of brain to indicate acute stroke. Carotid ultrasound demonstrated moderate plaques, and the team agreed to pursue medical management. At the time of discharge, her INR was therapeutic on coumadin and she had follow-up with neurology. # CHF, diastolic, acute on chronic: The patient had evidence of diastolic heart failure on TTE performed during her admission. Given that her digoxin was supratherapeutic and that she had diastolic heart failure, the digoxin was stopped and she was instructed not to take it as an outpatient. After IV lasix for diuresis, her respiratory and renal status improved. Her metolazone was held and she was advised not to continue it for the time being. # Coagulopathy/AFib: Anticoagulated for AFib. INR 4.6 on admission in setting of antibiotics, falling nicely with holding coumadin. Once her INR had dropped, she was restarted on coumadin and advised to continue at her previous dose with close follow-up with her PCP. [**Name10 (NameIs) **] was noted to have irregular rhythm with normal rate on her exam. # Anemia, iron deficiency: Unknown baseline Hct, admitted with Hct 34.8, drifting down to a nadir of 29 and then stabilized at 31. She was noted to have guaiac positive stools in the setting of her elevated INR. Her family was advised that colonoscopy should be discussed with her PCP. # CAD: Not active Aspirin initially held in the setting of concern for GI bleed with elevated INR. At the time of discharge, she was receiving her aspirin, beta blocker and statin (lovastatin was increased to 20mg in the setting of new stroke). The ACE inhibitor was held because of renal failure as discussed above. It can be restarted by her PCP once her Cr has completely stabilized. # Chronic benzodiazepine use: The patient takes diazepam 2.5mg TID at home. This was decreased to 2mg TID during her stay. Her family was informed of the risks of continuing diazepam, particularly the risk of causing confusion or falls. They were advised to work with her primary providers to try to wean her off of the diazepam. # Code: DNR but would want to be intubated. # Comm: HCP is daughter [**Name (NI) **] [**Telephone/Fax (1) 75839**] # Dispo: Discharged home with PT and VNA. Medications on Admission: Carvedilol 6.25mg [**Hospital1 **] Digoxin 0.125mg QOD Quinapril 10mg daily Lasix 80mg two days in a row, then 120mg next day then repeat Coumadin 5mg QHS [**Doctor First Name **]-F, Sa 7.5mg--INR followed by Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] F. [**Telephone/Fax (1) 17753**] Lovastatin 10mg QHS ASA 81mg daily Colace 100mg [**Hospital1 **] Metolazone 2.5mg Qweek on Wednesdays--?did this affect her kidneys Diazepam 2.5mg TID prn anxiety Advair [**Hospital1 **]--taking once a day Spiriva inh daily Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16): Continue to take 7.5mg on Saturday but please watch your INR closely as you may only need 5mg every day. Please have your INR checked within several days following discharge. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Lasix 40 mg Tablet Sig: Two (2) Tablet PO once a day: Take 80mg for two days, then 120mg. Repeat this 3 day cycle continuously. You were given 120mg on Monday [**12-27**]. Disp:*64 Tablet(s)* Refills:*2* 9. Lovastatin 10 mg Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Hypercarbic Respiratory Failure Acute Kidney Injury Congestive Heart Failure Stroke Secondary: coronary Artery disease Atrial fibrillation Discharge Condition: Ambulating, tolerating PO diet Discharge Instructions: You were admitted with hypercarbic respiratory failure. This was felt to be secondary to a poorly functioning BiPap Machine. You were treated for heart failure and kidney failure with lasix, and your kidneys are now back to your baseline. You also suffered a ministroke. This did lot leave you with any functional deficits and the MRI showed no new brain damage. It is very important to take all medications as prescribed as well as to make and attend all follow up appointments. The following are medication changes: Your digoxin was stopped Your metolazone was stopped, and can be re-started by your primary care physician Your Warfarin will be continued at 5mg/day, but your INR needs VERY close monitoring Your lovastatin was increased to 20mg a day. Your diazepam was decreased to 2mg three times a day as needed. Please do not take your quinapril until your primary care doctor directs you to restart it. Please discuss an outpatient colonoscopy with your PCP for evaluation of hidden blood in your stool. Please return to the hospital if you become confused, develop fevers, cough, or any other concerning symptom. Followup Instructions: Please contact your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8446**], for a follow up appointment within 1-2 weeks following discharge. The phone number is [**Telephone/Fax (1) 17753**] You should be seen by neurology. You have an appointment with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] Wed [**1-20**] at 1pm. [**Hospital Ward Name 23**] building (corner of [**Location (un) **] [**Hospital1 39240**]), [**Location (un) **]. Call [**Telephone/Fax (1) 2574**] if you need to reschedule. Also, please contact your pulmonologist, Dr. [**First Name (STitle) **], to schedule a follow up appointment. Continue to follow-up with your cardiologist. Completed by:[**2157-2-5**]

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icd9cm

[ [ [] ] ]

[ "93.90", "99.04" ]

icd9pcs

[ [ [] ] ]

14143, 14192

8303, 12449

275, 281

14385, 14418

1867, 8280

15595, 16336

1335, 1375

13019, 14120

14213, 14364

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1390, 1848

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224, 237

309, 1090

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1240, 1319

30,341

174,592

30889

Discharge summary

report

Admission Date: [**2145-5-28**] Discharge Date: [**2145-6-18**] Date of Birth: [**2084-3-2**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5552**] Chief Complaint: Dehydration. Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 61 year old man with metastatic esophageal cancer to liver and lung presents from clinic with dehydration and severe mucositis. He is s/p initiation of cycle 1 of ECX (epirubicin, cisplatin, and xeloda) on [**5-20**]. Since his treatment, he has been feeling fatigued and developed a sore throat and mouth sores. He has been able to eat and drink although drinking sometimes makes him nauseated. He was prescribed magic mouthwash and did not noticed much improvement. Patietn also states that he feels confused sometims and with a slow mind. He had dairrhea in the morning with normal color, but watery stool. He denies any sick contacts or exposure to people in nursing homes, children or other infectious agents. . He had planned on coming into the outpatient treatment area for IVFs, but because he has been feeling so unwell, he presented in clinic today for evaluation. . In clinic, he was found to be orthostatic and appeared dehydrated on exam. He was noted to have oral thrush. He was given 2L NS, zofran 8 mg IV and nystatin 5 cc as well as diflucan 200 mg. he was seen by Dr. [**Last Name (STitle) **]. He is now being admitted for rehydration and treatment of his mucositis and thrush. Past Medical History: PAST ONCOLOGIC HISTORY: ====================== He initially presented in [**11/2142**] due to dysphagia and weight loss. At that time, he had a barium swallow, which showed a pinpoint narrowing of his distal esophagus. He had endoscopy and underwent dilatation of this stricture. He did not have much improvement with the dilatation and in [**Month (only) 116**] of this year underwent a second dilatation once again with no improvement. He had motility tests, which were most consistent with achalasia. In [**Month (only) **], he underwent a Botox injection to the narrowing in order to help to release it. He had a CT scan after this which showed a 1.5 cm gastrohepatic lymph node. On [**2143-8-28**] he underwent an upper endoscopy on which they saw distal esophageal narrowing. They also performed multiple biopsies of the area of narrowing. Of note, they saw some ulceration in the GE junction and a thick abnormal fold concerning for esophageal or gastric cardia cancer. The biopsy showed moderate to poorly differentiated adenocarcinoma. After this he underwent endoscopic ultrasound, however, they were unable to pass the ultrasound probe beyond the stricture. He has had a port, g-tube, and esophageal stent placed. He started treatment with 5-FU and Cisplatin on [**2143-10-10**] with concurrent radiation therapy. Radiation was completed on [**2143-11-26**]. He was admitted from [**2143-11-26**] to the [**2143-12-3**] with febrile neutropenia and dehydration. He underwent an esophagectomy on [**2144-1-20**]. Pathology from this showed a metastatic adenocarcinoma with 4/6 perigastric lymph nodes positive, and a separate foci of tumor in the adjacent adipose tissue. He completed treatment in [**2144-1-4**]. He had liver lesions noted on a CT scan [**2145-1-16**]. He had these biopsied on [**2145-1-27**] and the pathology came back as consistent with metastasis from esophageal cancer. . PAST MEDICAL HISTORY: ==================== - Esophageal cancer- moderate to poorly differentiated adenocarcinoma; Rec'd 5-FU/cisplatin with concurrent XRT in [**10-11**], now s/p minimally invasive esophagectomy [**1-10**]. - h/o atrial fibrillation - h/o S. viridans bacteremia - Sinusitis, status post surgery - Hypertension - Vocal cord paralysis Social History: He originally moved from [**Country 6171**] 17 years ago. Married, 2 children. Teaches French and Spanish. He used to smoke a pack a day, but quit 15 years ago. He used to drink a couple of glasses of wine with dinner each night, but not since diagnosis. Family History: He has a father with pancreatic cancer who died at the age of 70. Physical Exam: Vitals - T: 98.1 BP: 104/74 HR: 67 RR: 16 02 sat: 100% on RA . GENERAL: NAD, very pelasant gentleman, hoarse, very french accent SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strenght [**6-8**] in upper and lower extremities, DTRs [**6-8**], [**Name2 (NI) 73082**] 27 Pertinent Results: On Admission: [**2145-5-28**] 10:00AM WBC-2.9*# RBC-4.84 HGB-15.0 HCT-43.9 MCV-91 MCH-30.9 MCHC-34.1 RDW-13.8 [**2145-5-28**] 10:00AM PLT SMR-VERY LOW PLT COUNT-35*# [**2145-5-28**] 10:00AM GRAN CT-2240 [**2145-5-28**] 10:00AM ALT(SGPT)-100* AST(SGOT)-51* ALK PHOS-75 TOT BILI-1.4 DIR BILI-0.3 INDIR BIL-1.1 [**2145-5-28**] 10:00AM ALBUMIN-3.5 PHOSPHATE-3.5 MAGNESIUM-2.2 [**2145-5-28**] 10:00AM UREA N-36* CREAT-1.0 SODIUM-138 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13 [**2145-5-28**] 10:00AM GRAN CT-2240 Pertinent Interim/Discharge Labs [**2145-6-18**] 12:23AM BLOOD WBC-12.3* RBC-3.46* Hgb-10.7* Hct-30.5* MCV-88 MCH-31.0 MCHC-35.2* RDW-18.6* Plt Ct-228 [**2145-6-14**] 12:00AM BLOOD WBC-19.3* RBC-3.03* Hgb-9.4* Hct-28.2* MCV-93 MCH-30.9 MCHC-33.2 RDW-17.9* Plt Ct-98* [**2145-6-13**] 12:00AM BLOOD PT-15.5* INR(PT)-1.4* [**2145-6-8**] 09:36AM BLOOD PT-28.0* PTT-31.1 INR(PT)-2.8* [**2145-6-6**] 12:00AM BLOOD Gran Ct-253* [**2145-6-7**] 12:00AM BLOOD Gran Ct-704* [**2145-6-9**] 12:00AM BLOOD Gran Ct-7521 [**2145-6-18**] 12:23AM BLOOD Glucose-91 UreaN-19 Creat-0.5 Na-134 K-4.4 Cl-103 HCO3-24 AnGap-11 [**2145-6-15**] 12:00AM BLOOD ALT-27 AST-32 LD(LDH)-292* AlkPhos-160* TotBili-2.1* [**2145-6-18**] 12:23AM BLOOD Calcium-7.0* Phos-3.5 Mg-1.9 [**2145-6-15**] 12:00AM BLOOD Albumin-2.0* Calcium-6.9* Phos-3.1 Mg-1.9 CT abdomen/pelvis [**5-30**]: 1. No evidence of diverticulitis, abscess, or any acute pathology to explain LLQ pain. 2. New wedge-shaped hypodensities within the spleen, likely infarcts given relatively rapid appearance from the prior study. 3. Although incompletely assessed due to collapsed bowel, apparent wall thickening of the ascending colon which may represent bowel wall edema. No secondary signs of inflammation (ie no fat stranding). CXR [**6-3**]: As compared to the previous radiograph, there is increasing opacity at the left lung base, combined with a newly appeared blunting of the left costophrenic sinus, presumably due to effusion. The size of the cardiac silhouette is unchanged. Unchanged normal right lung, unchanged Port-A-Cath system. CT chest [**6-4**]: 1. New diffuse transverse colon wall thickening and surrounding inflammatory change consistent with colitis, only partially visualized. Further evaluation with dedicated CT enterography of the abdomen and pelvis may be obtained for further evaluation. 2. New, small left, and trace right, pleural effusions. 3. New tree-in-[**Male First Name (un) 239**] opacities in the right lower lobe with mild improvement in right upper lobe tree-in-[**Male First Name (un) 239**] opacities. These findings may be due to aspiration. TTE [**6-8**]: No vegetations seen (suboptimal-quality study). Mild mitral regurgitation. Normal global and regional biventricular systolic function. RUE U/S [**6-8**]: DVT involving the right distal brachial vein, as well as the cephalic vein. CXR [**6-9**]: Compared to [**6-3**], there is more opacification in the left lower lobe, which could be worsening atelectasis or pneumonia particularly due to recent aspiration. There has also been increase in diameter of the cardiac silhouette and the azygos vein which may indicate volume overload but there is no pulmonary edema. MICRO [**6-1**] blood cx: Strep Pneumoniae Brief Hospital Course: 1. Pneumococcal infection: While the patient was neutropenic, he was febrile once. Cultures were sent and he was started on empiric cefepime. Imaging suggested a LLL pneumonia, and blood cultures grew GPC, for which vancomycin was added. The GPC were speciated as S. pneumoniae. TTE showed no vegetations. No further blood cultures were positive, and his antibiotics were eventually narrowed to ceftriaxone alone for a 14 day course, starting at the resolution of neutropenia. For easier dosing at home, he was changed to Cefpodoxine to finish course after discharge. 2. Mucositis: Unable to tolerate PO and was resuscitated with IVF. He was started on oral lidocaine and gelclairm as well as oral fluconazole and nystatin for [**Female First Name (un) 564**]. He was later taken off the fluconazole as it elevated his transaminases and changed to micafungin. However, this was also stopped as it elevated his bilirubin. IV morphine was used for pain control and he briefly required a PCA pump. Once his neutropenia resolved, his mucositis began to improve. However, the resultant increase in secretions caused respiratory distress and hypoxia, requiring ICU transfer for frequent deep suctioning and nebulizers. This resolved rapidly and he returned to the floor. Mucositis subsequently improved. 3. Acute renal failure: Despite normal creatinine at 1.0, this essentially doubled from low baseline of 0.4-0.7 and BUN/creatinine 36. Likely in the setting of poor PO. He was agressively hydrated with IVF and creatinine improved. 4. Neutropenia: Secondary to chemotherapy. His ANC continued to trend down during admission until he became severely neutropenic. He was started on filgrastim and eventually his ANC completely recovered. 5. Thrombocytopenia: Also secondary to chemotherapy. Early in the admission, he had some hematochezia, so was transfused plts to keep his count over 30,000. 6. Right UE DVT: Found on U/S in the setting of arm swelling. He was started on enoxaparin. 7. Colitis: Early on, paient complained of LLQ pain, associated with hematochezia and then dark stools. He required 2 units RBCs for this, but endoscopy could not be done due to his neutropenia and thrombocytopenia. Stool studies were negative. CT abdomen showed some bowel edema, but no diverticulitis. A CT chest done a few days later noted some transverse colitis, although he was asymptomatic. Metronidazole was empirically started and continued for 5 days. Later on, in the setting of starting enoxaparin for DVT, he had dark guaiac positive stools. GI was consulted and felt bleeding was related to mucositis vs colitis/inflammation in setting of anticoagulation and did not feel there was indication for scope as an inpatient. His hematocrit was stable prior to discharge. 8. Esophageal cancer: On admission, he was day 9 status post chemotherapy. He received no further treatments as an inpatient, and he will follow up with his oncologist as an outpatient. 9. Nutrition: Due to poor POs, PPN was started as there was not enough access for TPN in the patient's chest port due to antibiotics and IV fluids. Once his antibiotics were weaned, TPN was initiated via his port. He also had an elevated INR that was likely nutritional, and improved with vitamin K. Medications on Admission: Emend 125mg day 1, 80mg days [**3-9**] Xeloda 2g [**Hospital1 **] (days [**2-17**]) Dexamethasone 4mg (days [**3-10**]) Magic mouthwash tid prn Lorazepam 0.5-1mg q4-6h prn Megestrol 100mg/10ml susp daily Metoclopramide 5mg tid Metoprolol 100mg [**Hospital1 **] Ondansetron 8mg q8h prn (? GI upset) Gelclair tid Oxycodone 5-10mg q4-6h prn Prochlorperazine 10mg q6-8h prn Ranitidine 150mg [**Hospital1 **] Sucralfate 1g tid Zolpidem 10mg hs prn Discharge Medications: 1. Flushes Saline flush 10cc SASH and prn heparin flush 10U/ml 5cc SASH and prn Heparin 100U/ml 5cc deaccess port 2. Lidocaine HCl 2 % Solution Sig: Fifteen (15) ML Mucous membrane TID (3 times a day) as needed. Disp:*1 bottle* Refills:*0* 3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for anxiety or nausea. 4. Megestrol 400 mg/10 mL Suspension Sig: 100mg/10ml suspension PO once a day. 5. Reglan 5 mg Tablet Sig: One (1) Tablet PO three times a day. 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 8. Oral Wound Care Products Gel in Packet Sig: One (1) ML Mucous membrane TID (3 times a day) as needed. 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 10. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea or vomit. 11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO three times a day. 12. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 13. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:*60 syringe* Refills:*0* 14. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*12 Tablet(s)* Refills:*0* 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 16. Outpatient Lab Work Please do weekly lab work and fax to [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 18971**] [**Telephone/Fax (1) 55043**] to monito while on TPN. Check CBC, BUN, Cr, electrolytes, albumin, LFTs. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary: Chemotherapy induced diarrhea and mucositis Pneumococcal bacteremia Pneumonia Deep venous thrombosis Secondary: Esophageal cancer Hypertension Discharge Condition: hemodynamically stable, afebrile, shortnes of breath and cough improved Discharge Instructions: You were admitted to [**Hospital1 18**] with dehydration, diarrhea, and inflammation of the mucous membranes (mucositis). We gave you IV fluids and started TPN, a form of nutrition given through the veins. We also treated you with antibiotics for a bloodstream infection and a pneumonia. We also started enoxaparin (Lovenox), a blood thinner, due to a blood clot found in your arm veins. Once your white blood cells recovered from your chemotherapy, your mucositis continued to improve. We changed your ranitidine to pantopraxole. Please take all medications as prescribed and go to all follow up appointments. If you experience fevers, chills, vomiting, diarrhea, abdominal pain, worsening mouth/throat pain, bloody stools, or any other concerning symptoms, please seek medical attention or come to the ER immediately. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **]. Call [**Telephone/Fax (1) 6568**] for an appointment in [**2-5**] weeks.

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icd9cm

[ [ [] ] ]

[ "99.15", "99.04" ]

icd9pcs

[ [ [] ] ]

13841, 13893

8257, 11515

284, 291

14090, 14164

4955, 4955

15034, 15163

4139, 4206

12008, 13818

13914, 14069

11541, 11985

14188, 15011

4221, 4936

232, 246

319, 1555

4969, 8234

3522, 3851

3867, 4123

7,816

188,222

10464

Discharge summary

report

Admission Date: [**2196-6-24**] Discharge Date: [**2196-6-30**] Date of Birth: [**2152-5-27**] Sex: F Service: MEDICINE Allergies: Roxicet / Prednisone Attending:[**First Name3 (LF) 2698**] Chief Complaint: Transferred for cardiac catheterization Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: This 44 year old female with a history of pancreatic endocrine cell tumor, s/p resection of the distal pancreas and spleen in [**4-22**] c/b recurrent abscesses, chronic abd pain, reflux, and IBS was admitted to [**Hospital3 **] Hospital [**6-23**] (1d pta [**Hospital1 18**]). Admitted yesterday to [**Hospital3 **] with 10/10 abd pain/vomitting. Upon arrival to their ED had a seizure (rec'd dilantin) and was intubated. CT of head showed nothing acute- but there was some demyelination. Abd CT also showed nothing acute. Trop was 2.0, Ck 200's. Ekg was read at [**Hospital3 **] to show evolving anterior MI-flipped T's anteriorly, no r waves, slight ST elev ant. Echo was read to show anterior septal and apical akinesis. OG tube was placed because the patient was vomitting coffee grounds on the day pta then againg this am at 6am.--hct is stable at 44. On transfer, the patient was intubated. Vent settings: CMV 14, 550 tv, 60% O2, rate 14, peep 5. Gas this morning on those settings: ph 7.44, co2 38.7, o2 158.6, bicarb 25.7, base excess 1.6, sat 99%. propafal gtt at 27cc/hr (60mcg/kg) wt: 71.015 kg. d5 1/2 ns at 80cc/hr (going to change to 1/2NS w/10K at 80, awaiting bag) wbc 31.8, hct 44, plt 622 chemistries: bun 6, creat 0.7, sugar 174, NA 136, k 3.4, cl 96, co2 24, ca 8.5, phos 2.5, mg 2.0 enzymes as of 6am today cpk 226, mb 13.9, ind 6.2%, trop 2.33 EEG this am at 945, no seizure activity The patient was taken to the cardiac cath lab where a tight R circ lesion was visualized and stented with a hepacoat stent. Past Medical History: BL poor functional status--sleeps most of day 4 years fevers, chronic abd pain Ovarian cyst s/p TAH/BSO Endocrine cell tumor of pancreas s/o distal pancreatectomy [**4-22**] -no chemo or xrt s/p splenectomy chronically elevated WBC to 20K Chronic pain IBS Urinary incontinence Fibromyalgia s/p inonimate stent [**2195**] Chronically elevated CEA with neg workup (mamogram, colonoscopy, CT scans) Social History: works at home with crafts history of heavy alcohol abuse 20 pack year history tobacco has 2 children Family History: brother with hypercholesterolemia, mother with [**Name2 (NI) **] cancer, breast cancer, uterine cancer, osteoporosis, emphysema. Father with heart surgery and kidney cancer Physical Exam: HR 112 BP 100/70 RR 20 99% on RA Gen: sitting up in chair, pleasant and cooperative HEENT: MMM op clear neck: no JVD Cor: tachycardic, no murmurs Pulm: CTAB no crackles Abd: soft nondistended+ BS Ext: WWP, DP 2+ bilaterally, left arm in splint and fingers edematous, no pedal edema. Neuro: CN II-XII individually tested and intact, strength 5/5 upper and lower extremities bilaterally, no disdiadokinesis Pertinent Results: [**2196-6-24**] 11:07PM GLUCOSE-158* UREA N-6 CREAT-0.6 SODIUM-137 POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-28 ANION GAP-18 [**2196-6-24**] 11:07PM CK(CPK)-221* [**2196-6-24**] 11:07PM CK-MB-5 cTropnT-0.07* [**2196-6-24**] 11:07PM WBC-30.1* RBC-4.22 HGB-13.9 HCT-40.3 MCV-96 MCH-33.0* MCHC-34.5 RDW-12.9 [**2196-6-24**] 11:07PM PLT COUNT-562* [**2196-6-24**] 04:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2196-6-24**] 01:00PM VIT B12-813 [**2196-6-24**] 01:00PM ALBUMIN-3.9 URIC ACID-1.4* CHOLEST-340* [**2196-6-24**] 01:00PM ALT(SGPT)-15 AST(SGOT)-44* LD(LDH)-577* ALK PHOS-98 AMYLASE-15 TOT BILI-0.4 DIR BILI-<0.1 [**2196-6-25**] 8:02 am CSF;SPINAL FLUID Source: LP. *FINAL REPORT [**2196-7-25**]** GRAM STAIN (Final [**2196-6-25**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2196-6-28**]): NO GROWTH. VIRAL CULTURE (Final [**2196-7-25**]): NO VIRUS ISOLATED. [**2196-6-26**] 7:05 am BLOOD CULTURE **FINAL REPORT [**2196-7-2**]** AEROBIC BOTTLE (Final [**2196-7-2**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2196-7-2**]): NO GROWTH. [**2196-6-26**] 4:29 am URINE Site: CATHETER **FINAL REPORT [**2196-6-27**]** URINE CULTURE (Final [**2196-6-27**]): NO GROWTH. CSF: ANALYSIS WBC RBC Polys Lymphs Monos Macroph [**2196-6-25**] 08:02AM 31 415* 18 64 0 18 Source: LP 1 CSF TUBE #1 CLEAR AND COLORLESS CHEMISTRY TotProt Glucose LD(LDH) [**2196-6-25**] 08:02AM 75* 117 19 Source: LP PROTEIN ELECTROPHORESIS CSF-PEP [**2196-6-25**] 08:02AM NO OLIGOCL1 Source: LP BACTERIAL MENINGITIS ANTIGEN PANEL Test In Range Out of Range Reference Range ---- -------- ------------ --------------- Bacterial Antigen Detection Panel (Bacterial Meningitis Panel) Streptococcus B Ag, LA Negative Antigen tests are an adjunct to diagnosis and are not an appropriate substitute for bacterial culture in the diagnosis of group B streptococcal colonization or infection, according to FDA safety alert. type b Negative Streptococcus pneumoniae Negative N.meningitidis Grp A/Y Negative N.meningitidis Grp C/W135 Negative Group B / E. coli K1 Negative HERPES SIMPLEX VIRUS PCR Test Result Reference Range/Units HSV DNA, PCR NOT DETECTED HSV 1 NOT DETECTED HSV 2 NOT DETECTED HIV SEROLOGY HIV Ab [**2196-6-28**] 10:00AM NEGATIVE CONSENT RECEIVED NEUROPSYCHIATRIC Phenyto 9.6* [**2196-6-28**] 03:33PM TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp Barbitr Tricycl all negative [**2196-6-24**] 04:45PM 80 (THESE UNITS) = 0.08 (% BY WEIGHT) GASTROINTESTINAL Gastrin [**2193-1-23**] 03:00PM 84 MRI: Multiple hyperintensities are visualized in the subcortical white matter of both cerebral hemispheres, predominantly involving the parietal and occipital lobes. No abnormal enhancement is seen in this region. No evidence of slow diffusion is identified in these regions. Following gadolinium, no evidence of abnormal parenchymal, vascular, or meningeal enhancement identified. There is no evidence of midline shift or hydrocephalus seen. The ventricles and extraaxial spaces are normal in size. IMPRESSION: Multiple T2 hyperintensities in the parietal occipital region including involvement of the corpus callosum without enhancement or slow diffusion. The appearances are suggestive of posterior reversible encephalopathy. Clinical correlation recommended. No abnormal enhancement is seen. EEG: This is an abnormal portable EEG due to the presence of a slow and disorganized background rhythm in the [**2-25**] Hz delta frequency range. This finding suggests deep, midline subcortical dysfunction and is consistent with a moderate encephalopathy. The patient was noted to be on Propofol at the start of the recording which is a likely culprit and, after discontinuation, there was improvement in the degree of slowing; however, the slowing did persist. Other causes for encephalopathy include infection and metabolic derangements. No lateralizing or epileptiform abnormalities were seen. ECG: Sinus tachycardia Extensive wave changes may be due to evolving anterolateral myocardial infarct. Q in V2 and small Q in leads V3-V6. CT Abdomen: 1) Thickening in left colon seen from the splenic flexure through the rectosigmoid. This is only seen where the bowel is not well distended. Findings could simply be due to underdistension, but if a true finding, differential diagnosis includes infection, including C. difficile colitis, ischemia (although all major mesenteric vessels are patent), or inflammatory processes. Correllation with C. Difficile toxin assay is reccommended. 2) Bibasilar atelectasis. 3) No evidence of intraabdominal abscess. Cardiac Cath: 1. One vessel coronary artery disease. 2. Severe diastolic ventricular dysfunction. 3. Successful stenting of the ostium of the RCA with a Bare Metal Stent. 4. Mild pulmonary artery hypertension. PORTABLE AP CHEST RADIOGRAPH: Again seen is a stent overlying the superior mediastinum. The heart size and mediastinal contours are normal. The pulmonary vasculature is normal. No pleural effusions or pneumothorax. The lung fields are clear. Soft tissue and osseous structures are normal. IMPRESSION: No pneumonia or CHF. Brief Hospital Course: Regarding her seizures/ HA, the patient was worked up for CNS infection vs mets(though outside head CT neg) vs stroke. An MRI was obtained and showed multiple T2 hyperintensities in the parietal occipital region including involvement of the corpus callosum without enhancement or slow diffusion. The appearances are suggestive of posterior reversible encephalopathy. Neurology was consulted. Intially it was though that the patient had a stroke given L sided weakness, but later in her course her neurological exam was normal and completely without deficits. A lumbar puncture was negative, except elevated protein, about 400 RBCs. A subarachnoid hemorrhage would have more red blood cells on it. She was empirically covered for meningitis with ceftaz, vanc, flagyl(? recent abd abscesses), and ampicillin for listeria. These were all discontinued on [**6-26**] per ID recs. She was continued on acyclovir for a question of HSV until her HSV PCR results returned and showed no evidence of HSV. An EEG on [**6-26**] was abnormal but at that time the patient was on propofol. A new one was obtained once she was extubated. This showed multifocal slowing, subjective of multifocal subcortical dysfunction. Vascular disease is a relatively common cause of such findings though the etiology cannot be determined by the tracing. There were no epileptiform features. The patient was initially on IV dilantin and then transitioned to oral. Her level at discharge was slightly subtherapeutic. It was decided that the level would be drawn again and followed up by her outpatient neurologist, Dr. [**Last Name (STitle) 10653**]. Ultimately, the cause of her seizures was unknown. . The patient's EKG showed PR depressions diffusely consistent with myopericarditis of unknown etiology. She had a cardiac cath and with bare-metal stent placed in the RCA. An echo down after the procedure showed EF 20% and diffuse severe akinesis with preservation of 2 cm of basal wall motion. PR depressions diffusely seemed consistent with myopericarditis of ? etiology, however, her stunned myocardium is also consistent with hypoxia secondary to her respiratory arrest with the seizure. A new cardiomyopathy work up with TSH, Fe Studies, and viral cultures was negative. After the RCA stent her enzymes were trended. Her CK was > [**2191**] which would be consistent with a seizure and was about 1000 at discharge. Aspirin and plavix were continued and the patient was started on coumadin at discharge for her LV akinesis. The patient had fevers and leukocytosis with baseline WBC in the 20's. It was unclear if this was secondary to infection vs acute stress response to seizure vs acute myocardial infarction (less likely). Per PCP notes, it was felt to be secondary to chronic infections. An LP was nonrevealing and a UA was negative. She was started empirically on antibiotics as above. At discharge, her white count was at baseline in the low 20's. The patient's nausea and vomitting was her chief complaint at the outside hospital. It may have been related to her migraines or to a CNS process however meningitis was ruled out by LP. The patient may have had an upper GI bleed since coffee grounds were reported at the outside hospital. The patient has no history of GI bleeds and cannot remember ever having hematemesis or BRBPR. She was placed on a PPI. There was no further bleeding here and it was not entirely clear that she ever really had any GI bleed. The patient was sucessfully extubated on [**6-26**]. A CXR showed mild vascular congestion but her clinical exam showed no evidence of heart failure. The patient remained tachycardic during her stay. This was thought secondary to pain v. withdrawal given h/o EtOH vs poor pump function requiring a rate related compensation for her low ejection fraction. Her fentanyl patch and percocet were restarted. At discharge, her HR was below 100. The patient's left hand swelled after infiltration of dilantin to the dorsum of hand. There was initially a concern for compartment syndrome. She was evaluated by plastics who recommended elevation and did not feel this represented compartment syndrome. At discharge, her pain and swelling were much better. The patient has a history of abdominal abscesses and a chronically high white count. The abdominal CT was unrevealing. Even so, she was initially on wide spectrum antibiotics. The white count may be accounted for by splenectomy. The patient has DM secondary to pancreatectomy. Her sugars were managed initially with Q 2 H fingersticks and Insulin sliding scale. She was well controlled at discharge. Medications on Admission: Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Tablet Sig: [**1-24**] Tablets PO Q4-6H (every 4 to 6 hours) as needed. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QAM (once a day (in the morning)). Nortriptyline HCl 50 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 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). Disp:*30 Tablet(s)* Refills:*0* 3. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:*14 Patch 24HR(s)* Refills:*0* 4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Tablet Sig: [**1-24**] Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 10. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QAM (once a day (in the morning)). 12. Diclofenac Sodium 25 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 15. Nortriptyline HCl 50 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 16. Tolterodine Tartrate 4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO QHS (once a day (at bedtime)). 17. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 19. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 20. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime): you were getting 600 mg twice per day. To reach the same level first take 200 at night, then 200 twice per day, then 300 twice per day, then 600 twice per day to avoid excessive sleepyness. 21. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:*180 Capsule(s)* Refills:*0* 22. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 23. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 24. Zantac 150 EFFERdose 150 mg Packet Sig: One (1) PO twice a day. 25. Zelnorm 6 mg Tablet Sig: One (1) Tablet PO twice a day. 26. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* 27. Outpatient Lab Work please have your INR and dilantin level drawn on [**Month/Day (2) 766**] [**7-4**]. The results should be sent to Dr. [**Last Name (STitle) 34561**] [**Telephone/Fax (1) 34562**]. Discharge Disposition: Home Discharge Diagnosis: pancreatic CA s/p TAH BSO MI and cardiomyopathy s/p stenting seizure Discharge Condition: good Discharge Instructions: Please continue home medications in addition to starting lisinopril, carvedilol, and coumadin. Call your doctor if you have fevers, increased headache, shortness of breath, chest pain, leg swelling, bleeding, or palpitations. Your INR will need to be checked on [**Telephone/Fax (1) 766**]. Have the results sent to Dr. [**Last Name (STitle) 34561**] so he can adjust your coumadin. At that time your dilantin level can also be checked and sent to Dr. [**Last Name (STitle) 10653**]. For your swollen hand, please elevate it when possible and consider applying hot packs. If it turns more swollen or red, call your doctor. Do not resume the metoclopramide as it can lower the seizure threshold. Titrate the neurontin up slowly as you did when you first started. Followup Instructions: Please see Dr. [**Last Name (STitle) 34561**] in the next 2 weeks. [**Telephone/Fax (1) 33330**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2196-8-11**] 1:00 for your heart failure. Please see Dr. [**Last Name (STitle) 10653**] [**Name (STitle) 766**] [**7-11**] at 9:30. ([**Telephone/Fax (1) 34563**].

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Discharge summary

report

Admission Date: [**2112-10-19**] Discharge Date: [**2112-10-20**] Date of Birth: [**2079-2-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4327**] Chief Complaint: Elective VT ablation Major Surgical or Invasive Procedure: VT ablation History of Present Illness: Mr. [**Known lastname **] is a 33y/o gentleman with h/o MI in [**2109**] (proximal LAD occlusion in the setting of cocaine) s/p thrombectomy and subsequent ischemic CM (EF 15-20%) and ICD placed in [**2110**], who is admitted to the CCU due to hypotension s/p VT ablation. On [**2112-10-10**] the patient was seen at [**Hospital 4199**] Hospital after experiencing an episode of palpitations followed by firing of his ICD. He was found to have had an appropriate shock for VT at 220 bpm. He was also noted to have orthostatic hypotension. Since that time, his Spironolactone has been held. He was discharged to home without further medication changes. He was then readmitted to [**Hospital1 18**] on [**2112-10-15**] after complaining of dizziness and strong palpitations while at home. Interrogation of his device at that time did not reveal any further arrhythmias. Amiodarone was initiated at 200mg daily and he is now being referred for VT ablation. Upon interview today, Mr. [**Known lastname **] reports feeling very anxious regarding the possibility of further ICD firings. He describes intermittent lightheadedness but denies any more palpitations since discharge. In addition, he denies dyspnea on exertion, orthopnea or PND. The patient was admitted today for VT ablation. The procedure revealed inducible sustained monomorphic VT with multiple morphologies. The VT induced in the baseline state caused immediate hemodynamic collapse, and he was cardioverted. One dominant VT was well tolerated hemodynamically after administration of procainamide to slow it. Activation mapping revealed the apparent site of origin on the basal areal of the anterior wall septal junction. RF energy was delivered there and at multiple nearby areas. In addition, substrate ablation was performed. He required cardioversion x 3. His ICD was reporgrammed to include ATP pacing. The patient was given 20 mg IV lasix in the EP lab because he was 3+ L positive after the procedure. Post-procedure the patient's SBPs were in the 70s-80s and he recieved a 500 cc bolus. He was transfered to the CCU for hypotension post-procedure. On arrival to the floor the patient reports that he feels tired, but otherwise has no complaints. He denies CP, SOB, palpitations, dizziness/lightheadedness. REVIEW OF SYSTEMS On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: s/p anteroseptal MI in [**2109**]/proximal LAD occlusion s/p thrombectomy (in the setting of cocaine use) c/b PEA arrest, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] -PACING/ICD: dual-chamber (A+V) ICD (St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **] model 2211-36Q) placed in [**2110**] -Ischemic dilated cardiomyopathy, LVEF 15-20% -[**1-4**]+ MR, 1+ TR -Mildly dilated aortic root 3. OTHER PAST MEDICAL HISTORY: -Anxiety Depression, h/o polysubstance abuse Social History: The patient dose not work, on disability for heart conditions. Lives with fiancee. He has 2 children and 2 step children. -Tobacco history: denies current tobacco, smoked 1ppd x 15 years, quit [**2109**] -ETOH: infrequent -Illicit drugs: denies current use, previously used cocaine, quit [**2109**] Family History: Father - alive, age 52 s/p two strokes in his early 40s. Also HTN and recently dx pancreatic CA - Mother, alive at age 51, T2DM - Brother, sisters, daughter and [**Name2 (NI) **] are well Physical Exam: Physical Exam on Admission: GENERAL: WDWN 33 y/o male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. moist mucous membranes. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. Right groin site with blood on dressing. No mass/hematoma/bruit. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: DP 1+ bilaterally, Radials 2+ bilaterally Physical Exam on Discharge: GENERAL: WDWN 33 y/o male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. moist mucous membranes. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. Crackles at right base. No wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. Right groin site with blood on dressing. No mass/hematoma/bruit. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: DP 1+ bilaterally, Radials 2+ bilaterally Pertinent Results: Labs on Admission: [**2112-10-19**] 07:15AM BLOOD WBC-6.1 RBC-4.32* Hgb-13.8* Hct-38.7* MCV-90 MCH-31.9 MCHC-35.7* RDW-12.5 Plt Ct-230 [**2112-10-19**] 07:15AM BLOOD PT-11.8 INR(PT)-1.1 [**2112-10-19**] 07:15AM BLOOD Glucose-79 Creat-1.1 Na-138 K-3.9 Cl-104 Labs on Discharge: [**2112-10-20**] 05:48AM BLOOD WBC-6.6 RBC-4.05* Hgb-12.8* Hct-36.7* MCV-91 MCH-31.5 MCHC-34.8 RDW-12.4 Plt Ct-193 [**2112-10-20**] 05:48AM BLOOD Glucose-81 UreaN-10 Creat-1.0 Na-140 K-3.9 Cl-106 HCO3-30 AnGap-8 [**2112-10-20**] 05:48AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.8 Brief Hospital Course: Mr. [**Known lastname **] is a 33y/o gentleman with h/o MI in [**2109**] (proximal LAD occlusion in the setting of cocaine) s/p thrombectomy and subsequent ischemic CM (EF 15-20%) and ICD placed in [**2110**], who is admitted to the CCU due to hypotension s/p VT ablation. # Ventricular Tachycardia: The patient has a dual chamber ICD placed in [**2110**]. Patient recently with palpitations and appropriate shock delivered for VT. Patient admited for VT ablation, EP procedure with successful substrate ablations to multiple VT morphologies. Post procedure course complicated by hypotension with SBPs to the 70s. Patient was 3+ L positive and given 20mg IV lasix in EP lab and then became hypotensive post procedure. The recieved a 500 cc bolus with some improvement. Now with SBPs in 80s on arrival to CCU. Patient asymptomatic. Baseline SBPs in high 80s-90s. The patient was monitored on telemetry without event. The patietn's BP remained stable. He was back to baseline SBPs by discharge. He was walked around the unit with stable VS and without symptoms and was discharged home. # Ischemic Cardiomyopathy: Patient with EF of 15-20% after MI in [**2109**], last ECHO in [**1-/2112**] still with EF of 15-20%. Patient appears euvolemic on exam and no current symptoms of decompensation. Home metoprolol was continued. Lisinopril was initially held secondary to hypotension, but was restarted on day of discharge. Of note the pt's spironolactone d/c about 1.5 weeks prior to admission by patient's PCP for orthostatic hypotension. BY his description his NYHA functional class is currently 2+ - he develops dyspnea and marked fatigure walking <1 block, and doing light carrying. # CAD: Pt with h/o anteroseptal MI in [**2109**]/proximal LAD occlusion s/p thrombectomy (in the setting of cocaine use) c/b PEA arrest and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**]. No current ischemic symptoms. Home ASA, metoprolol, and atorvastatin were continued. Lisinopril initially held as above. # Hyperlipidemia: Last lipid panel in [**4-/2111**] in our system, LDL 138/HDL 33. Home atorvastatin was continued. # Anxiety: Home aprazolam 0.5 mg TID/prn was continued. Transitional Issues: - Follow up with Dr. [**Last Name (STitle) **] - Follow up with Dr. [**Last Name (STitle) **] - Follow up with Dr. [**Last Name (STitle) **] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.5 mg PO TID:PRN anxiety 2. Amiodarone 200 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Lisinopril 10 mg PO DAILY Start: In am Hold for SBP <90 5. Metoprolol Succinate XL 25 mg PO DAILY Hold for HR <45 6. Aspirin 325 mg PO DAILY Start: In am Discharge Medications: 1. ALPRAZolam 0.5 mg PO TID:PRN anxiety 2. Amiodarone 200 mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. Atorvastatin 80 mg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Lisinopril 10 mg PO DAILY Hold for SBP <90 Discharge Disposition: Home Discharge Diagnosis: Elective VT ablation Ischemic dilated cardiomyopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to [**Hospital1 18**] for a VT ablation (destruction of a pathway in the heart causing abnormal rhythms). Your blood pressure was low following the procedure, so you were monitored in the CCU and had no further issues. Continue taking all of your home medications as previously weight goes up more than 3 lbs. It was a pleasure taking care of you during your hospitalization, and we wish you the best going forward. Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED When: WEDNESDAY [**2112-10-26**] at 10:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 6662**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: THURSDAY [**2112-11-3**] at 8:20 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: TUESDAY [**2112-11-15**] at 2:00 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 6738**], 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: ADULT SPECIALTIES When: MONDAY [**2112-11-21**] at 9:40 AM With: [**Name6 (MD) **] [**Name8 (MD) 10828**], MD [**Telephone/Fax (1) 21928**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Completed by:[**2112-10-21**]

[ "428.0", "424.0", "311", "412", "414.01", "428.22", "458.29", "401.9", "V45.02", "397.0", "427.1", "V15.82", "272.4", "300.00", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "37.27", "99.61", "37.34", "37.26" ]

icd9pcs

[ [ [] ] ]

9215, 9221

6259, 8443

326, 340

9318, 9318

5685, 5690

9962, 11279

4003, 4192

8974, 9192

9242, 9297

8632, 8951

9469, 9939

4207, 4221

3116, 3593

4960, 5666

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266, 288

5963, 6236

368, 3022

5704, 5944

9333, 9445

3624, 3670

3044, 3096

3686, 3987

18,996

135,244

17060

Discharge summary

report

Admission Date: [**2165-7-2**] Discharge Date: [**2165-7-7**] Date of Birth: [**2130-8-4**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Shellfish / Nafcillin / Lisinopril Attending:[**First Name3 (LF) 922**] Chief Complaint: sudden onset R sided chest/flank pain, SOB Major Surgical or Invasive Procedure: [**2165-7-4**] 1. Mediastinal re-exploration and evacuation of clot. 2. Flexible bronchoscopy. History of Present Illness: Mr. [**Known lastname 11041**] was at hemodialysis today and he was unable to get a full run d/t they said he was dry. After dialysis, he developed sharp R sided chest/flank pain, scapula pain and SOB, unrelieved w/ultram, worsen w/movement, coughing or lying flat. Pt denies dizziness or associated nausea, although he has had nausea and vomiting in the previous few days d/t constipation which is now improved. Past Medical History: mediastinal hematoma with cardiac tamponade PMH: Aortic insufficiency Aortic valve stenosis Redo, redo sternotomy/Third time aortic valve replacement with a 19-mm onyx mechanical valve, Replacement of ascending aorta and hemi arch with a 26-mm Dacron graft using deep hypothermic circulatory arrest. [**2165-6-13**] - Sternal washout and closure with removal of packs. end satge renal failure s/p left arteriovenous fistula creation s/p percutaneous fistula angioplasty [**2164-10-21**] and [**2165-2-1**] Aortic valve endocarditis with MSSA s/p bioprosthetic aortic valve replacement [**9-23**] s/p redo sternotomy, homograft redo aortic valve and aortic root replacement with reimplantation of coronary arteries ([**2161-9-29**]) MSSA bacteremia with recurrent endocarditis in [**8-25**] - On cephalexin 500 [**Hospital1 **] since for suppressive therapy endocarditis [**1-27**] following angioplasty of stenotic areteriovenous fistula congestive heart failure secondary to valve pathology H/O systolic and diastolic dysfunction, EF >55% 8/08 Bilateral subclavian vein, left IJ and left brachiocephalic thromboses s/p brachiocephalic vein stent. Hypertension chronic Low back pain Hyperlipidemia Chronic fatigue syndrome h/o Pyloric stenosis Social History: Originally from [**Male First Name (un) 1056**]. Has 3 sons. Drinks 2-3 drinks/month, continues to smoke 1ppd x10 years, no illicits. Works part-time as a teacher. Family History: mother - breast ca at 45, survivor, aunt - died of MI at 50, no other family hx of renal disease, no DM or other CA in the family Physical Exam: Pulse:110 ST Resp:30 O2 sat: 98% on 2L B/P Right: 100/58 Left: forearm fistula w/palpable thrill Height: Weight: General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs: decreased R base, scattered rhonchi Heart: RRR [x] sharp valve click Murmur none Abdomen: Soft [x] non-distended [x] significant RUQ tenderness w/palpation, no rebound, no guarding Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Grossly intact[x] Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:1+ Left:1+ Pertinent Results: [**2165-7-6**] 07:00AM BLOOD WBC-6.0 RBC-2.87* Hgb-9.0* Hct-27.3* MCV-95 MCH-31.4 MCHC-33.1 RDW-18.7* Plt Ct-182 [**2165-7-7**] 04:40AM BLOOD PT-19.5* INR(PT)-1.8* [**2165-7-6**] 07:00AM BLOOD PT-16.9* INR(PT)-1.5* [**2165-7-5**] 04:30AM BLOOD PT-15.6* INR(PT)-1.4* [**2165-7-4**] 06:34AM BLOOD PT-17.8* PTT-29.9 INR(PT)-1.6* [**2165-7-6**] 07:00AM BLOOD Glucose-82 UreaN-41* Creat-8.1*# Na-142 K-4.1 Cl-103 HCO3-30 AnGap-13 [**2165-7-5**] 04:30AM BLOOD Glucose-80 UreaN-32* Creat-5.9*# Na-142 K-4.1 Cl-105 HCO3-30 AnGap-11 1. Large right anterior mediastinal crescentic structures demonstrating hematocrit effect is consistent with a postoperative hematoma. Curvilinear material in a Y-shaped conformation abutting the most cephalad portion of the graft material is concering for extravasation although could represent surgical material). A delayed scan is recommended for further assessment if the patient is hemodynamically stable. 2. Compression of the SVC raises the possibility of SVC syndrome, which is consistent with the pronounced anasarca, new right pleural effusion (probably serosanginous in nature) and ascites. 3. No pulmonary embolus The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is low normal (LVEF 50-55%) with abnormal septal motion (post op).. Right ventricular chamber size is somewhat small with free wall hypokinesis. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis leaflets appear to move normally. There is a normal gradient. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a large (>3cm) anterior pericardial effusion with compression of the right atrium and right venticle and extensive stranding. The effusion is smaller (1cm) inferolaterally and echo filled consistent with blood, inflammation or other cellular elements. There is sustained right atrial collapse, consistent with tamponade. Brief Hospital Course: The patient was admitted on [**2165-7-2**]. Workup included chest CT and echo which revealed a large, loculated pericardial effusion resulting in compression of the SVC and RV diastolic collapse c/w tamponade physiology. Anticoagulation was reversed with FFP and Vitamin K. The patient was brought to the operating room on [**2165-7-3**] where he underwent evacuation of pericardial hematoma. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated. The patient was transferred to the telemetry floor for further recovery. Chest tubes were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home with VNA services in good condition with appropriate follow up instructions. He will resume hemodialysis at his regular center on Tuesday [**2165-7-9**]. The [**Hospital 191**] [**Hospital 2786**] clinic will resume management of INR/coumadin dosing. Medications on Admission: aspirin 81mg by mouth daily colace 100mg by mouth twice daily lisinopril 20mg by mouth daily nephrocaps 1 daily protonix 40mg daily nicotine patch 14mg/24 hours daily sevelamer 2400 mg by mouth 3 times/day lactulose 10grams by mouth 3 times daily coumadin for INR goal 2.0-2.5 tramadol 50mg by mout every 4 hours as needed for pain lopressor 75 mg by mouth 3 times a day Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*200 Tablet(s)* Refills:*2* 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. 9. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*14 Patch 24 hr(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: dose to change for goal INR 1.8-2.5, coumadin clinic to manage. Disp:*30 Tablet(s)* Refills:*2* 13. Outpatient Lab Work serial PT/INR dx: mechanical aortic valve goal INR 1.8-2.5 Results to [**Company 191**] coumadin clinic phone [**Telephone/Fax (1) 2173**] 14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Disp:*qs ML(s)* Refills:*0* 15. TEDS knee high compression stockings wear 8-12 hours/day take off prior to bed Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: mediastinal hematoma with cardiac tamponade PMH: Aortic insufficiency Aortic valve stenosis Redo, redo sternotomy/Third time aortic valve replacement with a 19-mm onyx mechanical valve, Replacement of ascending aorta and hemi arch with a 26-mm Dacron graft using deep hypothermic circulatory arrest. [**2165-6-13**] - Sternal washout and closure with removal of packs. end satge renal failure s/p left arteriovenous fistula creation s/p percutaneous fistula angioplasty [**2164-10-21**] and [**2165-2-1**] Aortic valve endocarditis with MSSA s/p bioprosthetic aortic valve replacement [**9-23**] s/p redo sternotomy, homograft redo aortic valve and aortic root replacement with reimplantation of coronary arteries ([**2161-9-29**]) MSSA bacteremia with recurrent endocarditis in [**8-25**] - On cephalexin 500 [**Hospital1 **] since for suppressive therapy endocarditis [**1-27**] following angioplasty of stenotic areteriovenous fistula congestive heart failure secondary to valve pathology H/O systolic and diastolic dysfunction, EF >55% 8/08 Bilateral subclavian vein, left IJ and left brachiocephalic thromboses s/p brachiocephalic vein stent. Hypertension chronic Low back pain Hyperlipidemia Chronic fatigue syndrome h/o Pyloric stenosis Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 1+ LLE Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 2) Please NO lotions, cream, powder, or ointments to incisions 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) No driving for approximately one month until follow up with surgeon 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] *Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2165-7-11**] 10:00 Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2165-8-2**] 10:00 Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2165-8-6**] 2:00 Please call to schedule appointments with: Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-19**] weeks ([**Telephone/Fax (1) 250**]) [**1-19**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication=Mechanical valve Goal INR 1.8-2.5 First draw on [**2165-7-8**] Results to [**Company 191**] Anticoagulation Management services phone #[**Telephone/Fax (1) 2173**] Completed by:[**2165-7-7**]

[ "423.3", "428.0", "285.21", "998.12", "428.42", "V43.3", "585.6", "403.91", "E878.1" ]

icd9cm

[ [ [] ] ]

[ "39.95", "34.03" ]

icd9pcs

[ [ [] ] ]

9006, 9064

5340, 6765

355, 452

10354, 10583

3192, 5317

11439, 12483

2363, 2495

7188, 8983

9085, 10333

6791, 7165

10607, 11416

2510, 3173

272, 317

480, 895

917, 2165

2181, 2347

61,296

188,877

35225

Discharge summary

report

Admission Date: [**2154-9-12**] Discharge Date: [**2154-9-23**] Date of Birth: [**2110-3-3**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: [**9-13**] left inguinal lymph node biopsy [**9-20**] left thoracentesis [**9-21**] right thoracentesis History of Present Illness: 44F transferred from [**Hospital1 **] [**Location (un) 620**] with AMS x1 month and general malaise. In [**Month (only) 205**], she developed L hip pain which was initially treated with PT and improved. During PT, she developed constant low back pain in the setting of being adjusted by PT. She was started on narcotics and Valium. In the context of these new medications, she developed AMS with confusion, difficulty following conversations, short term memory difficulties, slurred speech over the course of the last 2-3 weeks. These meds were stopped but she continued to have AMS and weakness. Also endorses 20lb unintentional weight loss in last month. Lethargic with decreaed exercise tolerance and DOE x 2 weeks. 2 episodes of vomiting last weekend, none since. Non-bloody, non-bilious. No diarrhea, +constipation x 2 weeks. No HA/F/C/night sweats/dizziness/LH/palps/sick contacts. Nonproductive [**Name2 (NI) **], worse with drinking water, x 1 week. No dysuria or frequency, endorses decreased UOP x 1 week. She presented to her PCP yesterday who noted supraclavicular and inguinal LAD and referred her to [**Hospital1 **] [**Location (un) 620**]. On exam at [**Hospital1 **] [**Location (un) 620**] she had b/l supraclavicular LAD and LLQ mass. NCHCT showed no masses. She was hypotensive to 90s systolic (no known h/o low BPs). Labs showed hypercalcemia to 17.1 in a hemolyzed specimen and [**Last Name (un) **] at OSH. Foley was placed, she was given Lasix, 4L NS and started empirically on heparin gtt given persistent tachycardia, possible malignancy, and inability to obtain CTA. She was also given Azithromycin and Ceftriaxone at OSH given concern for PNA vs LLL mass on CXR. She was transferred to [**Hospital1 18**] [**Location (un) 86**] for further workup. . In the [**Hospital1 18**] ED, inital vitals were 101.1 120 92/57 28 94% 2L. Exam notable for woman appearing older than her stated age, LLE weakness, supraclavicular LAD, LLQ mass, AAO x3. Labs notable for WBC 8.1 with 80%N, 2 bands, 6%L, 11%M. Also notable for Hct 25.1, INR 1.3, BUN/Cr 72/2.4, K 3.2, HCO3 20, albumin 2.6, calcium 14.1, lactate 2.1, UA with trace leuks, few bacteria. Blood and urine culture were sent. MR L/T spine was performed without contrast given [**Last Name (un) **] and so poor study, showed possible central canal mass and bulky mediastinal and retroperitoneal LAD. Spine was consulted and requested CT Torso. BPs remained stable in the 90s-100s systolic throughout so no CVL was placed. She was initially continued on heparin gtt then stopped and given Tylenol suppository. VS at transfer: 108 101/61 23 98% 2L NC. . Upon arrival to the [**Hospital Unit Name 153**], she complains of extreme thirst. Family at bedside report dysarthria and confusion improved from recently. Denies fevers or chills. . Past Medical History: h/o palpitations h/o HELLP syndrome in setting of pregnancy Seasonal Allergies Social History: Lives in [**Hospital1 6930**] with husband and 13yo twins. Recently laid off from work. - Tobacco: Denies - Alcohol: [**12-23**] glasses wine/week - Illicits: Denies Family History: Mother with [**Name (NI) **] [**Name (NI) **] diagnosed [**2151**], on prednisone. MGM diagnosed with breast CA at 52yo. No other known malignancies. Physical Exam: ADMISSION PHYSICAL EXAM: Tmax: 37.2 ??????C (98.9 ??????F) Tcurrent: 37.2 ??????C (98.9 ??????F) HR: 104 (104 - 108) bpm BP: 111/63(74) {92/47(58) - 111/65(74)} mmHg RR: 20 (16 - 30) insp/min SpO2: 98% Heart rhythm: ST (Sinus Tachycardia General: Appears older than stated age, intermittently dysarthric, oriented, no acute distress HEENT: PERRL, Sclera anicteric, MM very dry, oropharynx clear Neck: supple, JVP not elevated, b/l supraclavicular LAD, 3cm Lungs: Diminished BS at L base and dullness to percussion, no wheezes, rales, ronchi CV: Regular rhythm, fast, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, Palpable LLQ mass extending almost to midline GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Oriented to person, place, time, POTUS. Able to recite days of week, months of year backwards though slow with months. Strength 5-/5 in b/l deltoids, otherwise [**4-25**] throughout. CN II-XII grossly intact and symmetric. Sensation intact to light touch. . DISCHARGE PHYSICAL EXAM: . Pertinent Results: ADMISSION LABS: [**2154-9-12**] 02:54AM BLOOD WBC-8.1 RBC-3.30* Hgb-8.5* Hct-25.1* MCV-76* MCH-25.9* MCHC-34.1 RDW-15.0 Plt Ct-304 [**2154-9-15**] 12:00AM BLOOD WBC-10.2 RBC-3.42* Hgb-9.2* Hct-26.6* MCV-78* MCH-27.0 MCHC-34.8 RDW-14.7 Plt Ct-319 [**2154-9-12**] 02:54AM BLOOD Neuts-80* Bands-2 Lymphs-6* Monos-11 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2154-9-15**] 12:00AM BLOOD PT-15.1* PTT-21.8* INR(PT)-1.3* [**2154-9-12**] 02:54AM BLOOD Glucose-89 UreaN-72* Creat-2.4* Na-137 K-3.2* Cl-104 HCO3-20* AnGap-16 [**2154-9-15**] 12:00AM BLOOD Glucose-180* UreaN-29* Creat-0.8 Na-140 K-3.3 Cl-97 HCO3-32 AnGap-14 [**2154-9-12**] 02:54AM BLOOD ALT-20 AST-27 LD(LDH)-188 AlkPhos-38 TotBili-0.3 [**2154-9-15**] 12:00AM BLOOD LD(LDH)-251* TotBili-0.3 [**2154-9-14**] 01:08AM BLOOD ALT-20 AST-30 LD(LDH)-222 AlkPhos-30* TotBili-0.3 [**2154-9-15**] 12:00AM BLOOD Calcium-8.4 Phos-2.1* Mg-1.2* UricAcd-0.1* [**2154-9-12**] 02:54AM BLOOD Albumin-2.6* Calcium-14.1* Phos-3.7 Mg-1.9 UricAcd-15.5* [**2154-9-12**] 02:00PM BLOOD calTIBC-181* Hapto-321* Ferritn-1107* TRF-139* [**2154-9-14**] 04:54PM BLOOD Hapto-392* [**2154-9-12**] 02:00PM BLOOD Osmolal-311* [**2154-9-12**] 02:00PM BLOOD PEP-NO SPECIFI IgG-670* IgA-97 IgM-272* [**2154-9-12**] 02:00PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE [**2154-9-12**] 02:00PM BLOOD PTH-7* . IMAGING: MR L SPINE W/O CONTRAST Study Date of [**2154-9-12**] 5:23 AM IMPRESSION: 1. Extensive mediastinal and retroperitoneal lymphadenopathy. 2. Bilateral pleural effusions. 3. Within the limitations of a non-contrast study, no evidence of epidural abscess or intraspinal mass seen. . CT TORSO W/O CONTRAST Study Date of [**2154-9-12**] 9:09 AM IMPRESSION: Massive mediastinal, mesenteric, retroperitoneal, and intrapelvic lymphadenopathy, resulting in moderate obstruction of the left collecting system and likely compression of the left sciatic nerve. . BILAT LOWER EXT VEINS Study Date of [**2154-9-12**] 1:35 PM IMPRESSION: 1. No evidence of bilateral lower extremity deep venous thrombus within the visualized portions. 2. Dampening of the Doppler waveforms of the left common femoral vein and augmentation indicative of more central occlusion/stenosis, in the setting of known massive retroperitoneal adenopathy as demonstrated on CT. 3. Left groin lymphadenopathy as better characterized on concurrent CT from [**2154-9-12**]. . ECHO: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. No pulmonary hypertension or clinically-significant valvular disease seen. Bilateral pleural effusions. . [**9-14**] CT HEAD: There is no acute intracranial hemorrhage, edema, mass effect, or major vascular territorial infarct. [**Doctor Last Name **]-white matter differentiation is preserved. The ventricles and sulci are normal in size. The imaged paranasal sinuses and mastoid air cells are clear. No suspicious lytic or sclerotic bone lesions are seen. IMPRESSION: No evidence of an acute intracranial process. MRI would be more sensitive for detecting intracranial malignancy, if clinically warranted. . [**9-19**] CT CHEST: 1. Increased bilateral pleural effusions with complete collapse of the left lower lobe and near complete collapse of the right lower lobe. 2. Overall decrease in mediastinal and retroperitoneal lymphadenopathy compared to the CT torso performed one week prior. . PATHOLOGY: FISH evaluation for a BCL6 rearrangement was performed on nuclei with the LSI BCL6 Dual Color, Break Apart Probe ([**Doctor Last Name 7594**] Molecular) at 3q27 and is interpreted as ABNORMAL. Rearrangement was observed in 185/200 nuclei, which exceeds the range of a normal hybridization pattern (up to 3% rearrangement) established for this probe in our laboratory. A BCL6 rearrangement is a typical cytogenetic aberration in a subset of B-cell lineage non-Hodgkin's lymphoma with large cell histology and follicular center cell origin. FISH evaluation for a MYC rearrangement was performed on nuclei with the LSI MYC Dual Color Break Apart Rearrangement Probe ([**Doctor Last Name 7594**] Molecular) at 8q24 and is interpreted as NORMAL. No rearrangement was observed in 198/200 nuclei, which is within the normal range established for this probe in the Cytogenetics Laboratory at [**Hospital1 18**]. Up to 4% of cells in normal samples can show apparent MYC rearrangement using this probe set. A normal MYC FISH finding can result from absence of a MYC rearrangement, from an atypical MYC rearrangement, or from an insufficient number of neoplastic cells in the specimen. FISH evaluation for an IGH-BCL2 rearrangement was performed on nuclei with the Vysis LSI IGH/BCL2 Dual Color, Dual Fusion Translocation Probe ([**Doctor Last Name 7594**] Molecular) for IGH at 14q32 and BCL2 at 18q21 and is interpreted as NORMAL. No dual rearrangement was observed in 200/200 nuclei, which is within the normal range (up to 1% rearrangement) for this probe in our laboratory. A normal finding can result from absence of an IGH-BCL2 rearrangement, from a variant IGH-BCL2 rearrangement, or from an insufficient number of neoplastic cells in the specimen. Brief Hospital Course: Ms. [**Known lastname 80377**] is a 44 year old female who presents with general malaise, weight loss, low back pain, hypercalcemia and bulky lymphadenopathy with concern for malignancy. She was found to have large cell lymphoma and underwent the first cycle of [**Hospital1 **]. She was also found to have large bilateral pleural effusions and had these drained and sent for flow cytometry. . # Large cell lymphoma: She was suspected to have lymphoma based upon clinical presentation and she underwent a left inguinal lymph node dissection which confirmed large cell lymphoma. She also had a bone marrow biopsy which showed she did not have involvement of the bone marrow by lymphoma. CT scans of the torso showed "massive" lymphadenopathy in the mediastinum and abdomen. This improved after her [**Hospital1 **] treatment. She tolerated the first round of [**Hospital1 **] extremely well without side effects. . # Bilateral pleural effusions: Upon admission, patient had a 4L supplemental O2 requirement. Her extremity dopplers were all negative for DVT and a CTA did not have evidence of a pulmonary embolus. Her echocardiogram showed a normal ejection fraction. After three days of aggressive diuresis (net negative 6-7L) she was able to maintain her saturations at >95% on room air. However, a repeat CT at that time showed that her bilateral effusions were larger. She underwent thoracenteses of each side separately, with removal of 1L each. The pleural fluid showed ********** . # AV nodal re-entrant tachycardia (AVNRT): Patient with intermittent episodes of narrow complex, regular tachycardia to 200s which self-resolve in less than 1 minute. She has a history of this and has had a prior workup including Holter monitor. Cardiology consult was called and they felt this was a non malignant event, probably not related to lymphoma. They did not feel further imaging would be helpful and recommended that we reinforce training for valsalva maneuvers to break the rhythm. . # Hypercalcemia: Upon presentation, she was hypercalcemic, which was most likely reflective of underlying malignant process. She did have an elevated parathyroid hormone related peptide level. Calcium improved with IVF, intermittent IV lasix, and calcitonin. . # Fevers: Upon admission, she had intermittent temperatures with spike to 102 for the first two days of hospitalization. She was treated with 7 days of ceftriaxone and 5 days of azithromycin, although her CT chest showed clear lung parenchyma with large bilateral effusions. Later in the hospitalization, on day 1 of filgrastim administration after [**Hospital1 **], she spiked a fever to 100.4 2 hours after filgrastim. This resolved without treatment and blood cultures were negative. . # Acute kidney insufficiency: This was multifactorial including contributions from tumor lysis syndrome, hypercalcemia, hypovolemia, and lymphadenopathy causing obstruction. She did have a hydroureter on imaging, but this resolved with lymphoma therapy. She was fluid resusitated and her creatinine improved to 0.6 upon discharge. . # Extremity Edema: She presented with upper extremity edema, R > L with a negative doppler for DVT. Also, she had left lower extremity swelling (doppler negative) after her inguinal lymph node dissection. . TRANSITIONAL ISSUES: - Please make sure that she stays on schedule for her chemotherapy cycles in the future. She will come to 7F for rituximab on Thursday and then she should be admitted for further cycles of dose-adjusted [**Hospital1 **] due to pleural involvement of lymphoma - Please set-up for her to have a port placed before her next cycle of [**Hospital1 **], this can be done when she returns on Thursday for rituximab - Please assess the need for ongoing DVT/PE prophylaxis with lovenox due to hypercoagulability of cancer Medications on Admission: [**Doctor First Name **] PRN Flonase PRN Colace PRN Ibuprofen 800mg TID PRN (never more) Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 3. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for heartburn, indigestion. Disp:*30 ML(s)* Refills:*0* 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) pkt PO DAILY (Daily) as needed for Constipation. Disp:*30 pkt* Refills:*0* 6. Cepacol Sore Throat 15-3.6 mg Lozenge Sig: One (1) lozenge Mucous membrane three times a day as needed for dry throat. Disp:*30 lozenge* Refills:*0* 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. Disp:*30 Tablet(s)* Refills:*0* 8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea/vomiting. Disp:*30 Tablet(s)* Refills:*0* 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 10. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-23**] Sprays Nasal TID (3 times a day) as needed for nasal discomfort/runny nose. Disp:*3 bottles* Refills:*0* 11. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for nausea/anxiety/insomnia. Disp:*30 Tablet(s)* Refills:*0* 12. filgrastim 300 mcg/mL Solution Sig: One (1) injection Injection Q24H (every 24 hours): Until [**9-29**]. Disp:*10 injection* Refills:*5* 13. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*0* 14. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day. Disp:*30 Capsule, Extended Release(s)* Refills:*0* 15. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray Nasal once a day: each nostril. 16. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO once a day. 17. Outpatient Lab Work Please draw CBC twice per week starting [**2154-9-23**]. Fax results to Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 80378**] Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: PRIMARY DIAGNOSIS: Large B-cell lymphoma Hypercalcemia Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname 80377**], . You were admitted to the hospital because you were having weight loss and lower back pain. You were found to have lymphoma by a biopsy of your lymph nodes in the groin. You were treated with the first cycle of a chemotherapy regimen called [**Hospital1 **]. You will have many cycles of this therapy. . You also had a new need for oxygen in order to maintain your blood oxygenation. We gave you a diuretic called furosemide (lasix) which pulled extra fluid from your lungs. Also, you underwent a procedure to drain fluid around your lungs--called thoracentesis. . The swelling in your arms and legs is improving as well. This is more likely due to enlarged lymph nodes from the lymphoma which makes it difficult to drain fluid. . The following changes were made to your medications: YOU SHOULD START TAKING THE FOLLOWING MEDICATIONS: - Filgrastim until [**9-29**] - For constipation you can take senna and docusate every day - If you are still constipated, you can add on polyethylene glycol and bisacodyl once daily - For nausea you can take prochlorperazine - For anxiety, take lorazepam - For upset stomach, take milk of magnesia - You should take ranitidine everyday to prevent upset stomach and heartburn - pain medications - You should take potassium pills once daily with food . It is also important that you keep all of the follow-up appointments listed below. . It was a pleasure taking care of you in the hospital! Followup Instructions: Please return to 7 [**Hospital Ward Name 1826**] on Thursday [**9-26**] for Rituximab therapy. The address is below. Department: BMT/ONCOLOGY UNIT When: THURSDAY [**2154-9-26**] at 9:00 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 You should call your primary care doctor, Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 17753**], to make a follow-up appointment with him when it is conveinent for you. He has access to the records of your cancer treatment here.

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Discharge summary

report

Admission Date: [**2193-5-29**] Discharge Date: [**2193-6-5**] Date of Birth: [**2106-4-7**] Sex: M Service: MEDICINE Allergies: aspirin Attending:[**First Name3 (LF) 348**] Chief Complaint: Fever, weakness Major Surgical or Invasive Procedure: Leg ulcer debridement History of Present Illness: History of Present Illness: 87M w/PMH myelodysplastic d/o, ESRD on HD who presented from [**Hospital3 2558**] Skilled Nursing Facility with fevers and weakness for 3-4 days. The patient reports he had a fall approximately 4 days ago hitting his chest and left leg, however he cannot remember if hit his head. This episode occurred in the setting of him bending over to pick up his pants, and he did not experience dizziness or vertigo. He received dialysis [**5-28**] in [**Location (un) **] as scheduled, and was rescheduled to get an additional session of UF [**5-29**] for extra fluid removal. His blood pressures after dialysis [**5-28**] was 110/56 his baseline after dialysis. He was brought to the ED from [**Location (un) **] over concern of his increased weakness and fever, in the setting of need for follow-up hemodialysis. He states he has been feeling generally weak but denies chills, chest pain, cough, dysuria, headache shortness of breath, or difficulty with bowel or bladder. In the ED, initial VS were: T 100.8 HR 98 BP 128/56 RR 20-24 O2 98% RA. He was found to be moderately unresponsive, had decreased lung sounds bilaterally, and had 4 cm x 3 cm ulcer over his left shin. Labs were significant for WBC 73, Hct 27.8, trop 0.2, proBNP > [**Numeric Identifier **], LDH 456, Cr 3.7, uric acid 6.4, and lactate 3.1. CXR showed cardiomegaly and interstitial opacities suspicious for congestive heart failure vs multifocal pneumonia. He was given 1L, vanc 1g, cefepime 1g, levofloxacin 750mg, and hydrocortisone 100mg. A head CT and pelvic radiograph was unremarkable. He was admitted for possible emergent hemodialysis, and evidence of pneumonia/sepsis. Past Medical History: ESRD: unknown etiology, since [**3-26**] Elevated WBC count Polycythemia [**Doctor First Name **] AS CHF HTN HL Dysphagia Hypothyroidism Social History: Previously smoked 2ppd for 30 years, quit in [**2155**]. No EtoH or drug use. Used to live with son at home prior to last d/c from [**Hospital1 2025**] when they sent him to [**Hospital3 2558**] rehab. Family History: non-contributory Physical Exam: General: elderly man, moderately responsive, oriented HEENT: Missing teeth, sclera anicteric, MMM, oropharynx clear, PERRL Neck: supple, JVP elevated, no LAD CV: regular, tachycardic, S1 + S2, 4/6 systolic murmur at left upper sternal border Lungs: bilateral rales 1/2 up the back, poor respiratory effort. Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: foley, no obvious lesions Ext: Prominent pulsating left arm bilateral 2+ lower extremity swelling, 4 cm x 3 cm ulcer over left shin with a small amount of purulent/membranous exudate. Neuro: CNII-XII grossly intact, moves all four extremities, grossly normal sensation, 1+ reflexes bilaterally, gait deferred. DISCHARGE EXAM: Vitals: 99 BP 130/64 HR 96 RR 18 96% RA General: frail elderly man, alert HEENT: Missing teeth, sclera anicteric, MMM, oropharynx clear, blood in right nares with packing strips CV: RRR S1 + S2, 4/6 systolic murmur most prominent LUSB Lungs: bilateral basilar rales, no wheezes or rhonchi present otherwise. Abdomen: soft, non tender. non-distended, bowel sounds present, Ext: Palpable thrill, turbulent flow audible. 2+ pitting edema to mid shin with bronzing bilaterally, recently debrided 7.5 x 3.2 cm x 0.4 cm depth ulceration on the L shin. Neuro: moves all four extremities, grossly normal sensation. Scrotum: diffuse ecchymosis (nontender) over scrotum and penis (Stable) Pertinent Results: ADMISSION LABS [**2193-5-29**] 12:40PM PT-13.6* PTT-35.4 INR(PT)-1.3* [**2193-5-29**] 10:30AM GLUCOSE-67* UREA N-33* CREAT-3.7* SODIUM-137 POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-26 ANION GAP-19 [**2193-5-29**] 10:30AM estGFR-Using this [**2193-5-29**] 10:30AM ALT(SGPT)-28 AST(SGOT)-34 LD(LDH)-456* CK(CPK)-67 ALK PHOS-85 TOT BILI-0.4 [**2193-5-29**] 10:30AM CK-MB-2 cTropnT-0.20* proBNP-GREATER TH [**2193-5-29**] 10:30AM ALBUMIN-3.8 URIC ACID-6.4 [**2193-5-29**] 10:30AM WBC-73.9*# RBC-2.32* HGB-8.5* HCT-27.8* MCV-120* MCH-36.8* MCHC-30.6* RDW-21.8* [**2193-5-29**] 10:30AM NEUTS-94.4* LYMPHS-2.4* MONOS-2.9 EOS-0.2 BASOS-0.1 [**2193-5-29**] 10:30AM I-HOS-AVAILABLE [**2193-5-29**] 10:30AM PLT COUNT-149* [**2193-5-29**] 10:27AM LACTATE-3.1* RELEVANT LABS: [**2193-5-29**] 10:30AM BLOOD CK-MB-2 cTropnT-0.20* proBNP-GREATER TH [**2193-5-30**] 05:29AM BLOOD CK-MB-13* MB Indx-9.4* cTropnT-0.62* proBNP-GREATER TH [**2193-6-1**] 05:55PM BLOOD CK-MB-3 cTropnT-1.35* [**2193-6-3**] 07:00AM BLOOD CK-MB-2 cTropnT-2.17* [**2193-6-4**] 01:20PM BLOOD CK-MB-2 cTropnT-2.57* DISCHARGE LABS: [**2193-6-5**] 07:30AM BLOOD WBC-25.4* RBC-2.25* Hgb-8.2* Hct-25.9* MCV-115* MCH-36.3* MCHC-31.5 RDW-23.0* Plt Ct-74* [**2193-6-5**] 07:30AM BLOOD Glucose-45* UreaN-38* Creat-3.2*# Na-143 K-4.6 Cl-102 HCO3-30 AnGap-16 [**2193-6-5**] 07:30AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.8 IMAGING: CT Head [**2193-5-29**]: There is no evidence of hemorrhage, edema, mass effect, or territorial infarction. The ventricles and sulci are prominent, consistent with the patient's age. The basal cisterns are patent and [**Doctor Last Name 352**]-white matter differentiation is preserved. Periventricular white matter hypodensities are most consistent with chronic small vessel ischemic disease. There is no fracture. The right posterior mastoid is underpneumatized and contains some fluid. The visualized paranasal sinuses and middle ear cavities are clear. IMPRESSION: No evidence of acute intracranial process. Findings suggestive of chronic small vessel ischemic disease. Probably chronic inflammatory change in the right posterior mastoid. HIP UNILAT MIN 2 VIEWS LEFT Study Date of [**2193-5-29**] 10:38 AM IMPRESSION: No evidence for fracture or dislocation. CT C-SPINE W/O CONTRAST Study Date of [**2193-5-29**] 10:40 AM IMPRESSION: 1. No evidence of fracture dislocation involving the cervical spine. 2. Moderate multilevel degenerative changes with spinal canal stenosis, worst at C6-7. 3. Thickening of apical interlobular septae, suggesting congestive heart failure. DUPLEX DOP ABD/PEL LIMITED Study Date of [**2193-6-1**] 4:16 PM IMPRESSION: 1. Normal testicular echotexture and vascularity. 2. Multiple epididymal calcifications, which may reflect sequela of prior infection or inflammation. [**2193-6-5**] Radiology ART EXT (REST ONLY) READ PENDING MICROBIOLOGY: [**2193-5-29**] 10:20 am BLOOD CULTURE x2 **FINAL REPORT [**2193-6-4**]** NO GROWTH [**2193-5-29**] 6:05 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2193-6-1**]** MRSA SCREEN (Final [**2193-6-1**]): No MRSA isolated. [**2193-6-2**] 2:32 pm URINE Source: CVS. **FINAL REPORT [**2193-6-3**]** URINE CULTURE (Final [**2193-6-3**]): <10,000 organisms/ml. [**2193-6-2**] 02:32PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2193-6-2**] 02:32PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 Brief Hospital Course: # Summary: 87 yo M w/ PMH myelodysplastic d/o, CHF, ESRD on HD, HTN, HLD, aortic stenosis who presents with fever and weakness for 3-4 days, admitted for multifocal pneumonia. # Sepsis / pneumonia: The patient presented with elevated WBC 73.9 (94.4% pmns), fever (T 100.8), tachypnea (RR 24), and CXR that showed interstitial opacities concerning for multifocal pneumonia vs CHF exacerbation. Other significant labs include lactate 3.1. He had mild hemodynamic instability (hypotension 90s-100s/40s-60s) without evidence of new end-organ dysfunction. He was started on a 8-day course of vancomycin and cefepime (starting [**2193-5-29**]) and was transitioned to vancomycin and ceftazidime, for which he completed a 7 day course. Blood cultures taken at the time of admission showed NGTD. At the time of discharge, his WBC was much improved, and he was afebrile. . # CHF / fluid overload: He has a history of CHF, aortic stenosis, ESRD on HD, all of which contribute to interstitial opacities seen on CXR. proBNP tremendously elevated > 70,000. He was treated with hemodialysis [**2193-5-30**], which removed 3L of fluid and another liter on [**2193-5-31**]. He was kept on 2L nasal cannula. He was resticted to a low sodium, low fluid diet, and his home antihypertensives were held. At the time of discharge, he was re-started on metoprolol. #Troponinemia: Patient chronically has elevated troponin (0.6 is baseline) but had elevation to 2.17. Cardiology consulted who felt it was related to demand ischemia. He was then given dialysis and repeat troponin was drawn with CK-MB. EKG showed LVH, mildly increased from EKG [**2192-10-18**]. His cardiac enzymes were likely chronically elevated due to his ESRD, or from demand ischemia given his fluid overload; cardiology was consulted, and agreed with this assessment. He did not have chest pain, new shortness of breath, and remained hemodynamically stable. # LLE ulcer: He presented with a chronic-appearing 3x4cm ulcer in the left lower extremity that had been previously debrided. Given the mild membranous exudate, there may have been a superimposed cellulitis. He was treated with IV vancomycin and ceftazidime for a total of 7 days, albeit for a MFP, and not cellulitis. On the day prior to discharge, he was evaluated by wound care, who noted a much larger area skin that required debridement; this was performed by vascular surgery, with a plan for repeat evaluation in the clinic by Dr. [**Last Name (STitle) **] at [**Hospital1 18**] in a week's time; he was sent out with a week's worth of Augmentin for his wound. # ESRD: He has end stage renal disease and regularly receives HD via the L arm graft T/Th/Sat. At the time of admission, his Cr was 3.7, unchanged from baseline in [**2192-12-19**]. He was treated with HD on his normal schedule (T, Th, Sat), and continued on his home nephrocaps. # Leukocytosis: his WBC on admission was 73.9, and improved with antibiotics. He has a known history of myelodysplastic syndrome, and his leukocytosis is likely a combination of his mds and superimposed sepsis. Other pertinent labs on admission included uric acid 6.4 and LDH 456 elevated. His Hct 27.8 (baseline 21-29) and Plt 21.8 (19-26) are low but at his baseline since [**2191**]. Heme-onc was curbsided, and thought this was mostly likely infectious etiology, and recommended getting a peripheral smear. After consulting with heme-onc, they did not feel like his smear was alarming, and thought it was part of his MDS pathology. His outpatient hematologist was informed. . # HTN: His home antihypertensives amlodipine and metoprolol were held initially, and he was restarted on metoprolol on [**2193-5-31**]. . # Hypothyroidism: he was continuned on his home levothyroxine. . # HLD: he was continued on his home atorvostatin. . FOLLOW UP ISSUES . 1. Please obtain a repeat CXR to ensure that the patient's CHF has resolved. Please check his weight and evaluate his fluid status. . 2. Please check his WBC to ensure that his leukocytosis has resolved. 3. Please re-evaluate his CHF/anti-HTN medications as an outpatient. 4. Please follow-up final results of ABI (preliminarily normal upon discharge). 5. Please follow-up wound eval in [**Hospital **] clinic Medications on Admission: - amlodipine 5 mg Po daily on dialysis days - amlodipine 10 mg po daily on non dialysis days - atorvostatin 80 mg po daily at bedtime - nephrocaps 1 tab po daily - finasteride 5 mg po daily - levothyroxine 75 mcg po daily - methylphenidate 5 mg po daily - metoprolol succinate 25 mg po daily - mirtazapine 7.5 mg po daily qhs - tylenol prn - calcium carbonate 1 tab [**Hospital1 **] - cholecalciferol (vitamin d3) 400 unit po daily - sennosides [**Hospital1 **] Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN pain, fever 2. Atorvastatin 80 mg PO DAILY 3. Calcium Carbonate 500 mg PO BID 4. Finasteride 5 mg PO DAILY 5. Levothyroxine Sodium 75 mcg PO DAILY 6. MethylPHENIDATE (Ritalin) 5 mg PO QAM 7. Mirtazapine 7.5 mg PO HS 8. Nephrocaps 1 CAP PO DAILY 9. Senna 1 TAB PO BID:PRN constipation 10. Vitamin D 400 UNIT PO DAILY 11. Amlodipine 5 mg PO DAILY ON DIALYSIS DAYS 12. Amlodipine 10 mg PO DAILY ON NON-DIALYSIS DAYS 13. Metoprolol Succinate XL 25 mg PO DAILY 14. Amoxicillin-Clavulanic Acid 500 mg PO Q24H Duration: 7 Days Please administer at 8 PM Daily RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by mouth Daily Disp #*7 Capsule Refills:*0 Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: Multi-focal pneumonia, Possible Cellulitis Secondary Diagnosis: End stage renal disease, congestive heart failure, Troponinemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure to treat you at [**Hospital1 18**] for your pneumonia. You had an infection of the lung which we treated with antibiotics. You also have a leg wound which we debrided, and are treating with antibiotics. While you were here, you were found to have increase in your cardiac markers. Our cardiologists evaluated you, and think that this is because of your heart failure; we do not think that you had had a heart attack. Also, while you were here, your wound on your left shin was evaluated; we saw that there were areas of dead tissue, which the surgeons removed. You should plan on seeing your wound care team in a week's time for further evaluation. Followup Instructions: Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Name: [**Last Name (LF) **],[**First Name3 (LF) 177**] A. Location: [**Hospital 99830**] MEDICAL GROUP Address: [**Last Name (un) 12264**], [**Location (un) **],[**Numeric Identifier 10614**] Phone: [**Telephone/Fax (1) 99831**] Department: VASCULAR SURGERY When: THURSDAY [**2193-6-20**] at 10:00 AM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: HEMODIALYSIS When: THURSDAY [**2193-6-6**] at 7:30 AM Department: INFUSION/PHERESIS UNIT When: FRIDAY [**2193-6-7**] at 8:15 AM [**Telephone/Fax (1) 14067**] Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: OSTOMY/[**Hospital **] CLINIC When: TUESDAY [**2193-6-11**] at 9:30 AM With: WOUND/OSTOMY NURSE [**Telephone/Fax (1) 23664**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2193-6-5**]

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icd9cm

[ [ [] ] ]

[ "39.95", "86.28" ]

icd9pcs

[ [ [] ] ]

12893, 12963

7437, 11668

281, 305

13155, 13155

3897, 4986

14063, 15382

2403, 2421

12180, 12870

12984, 12984

11694, 12157

13335, 14040

5002, 7414

2436, 3180

3196, 3878

226, 243

361, 2006

13068, 13134

13003, 13047

13170, 13311

2028, 2167

2183, 2387

19,460

184,271

54598

Discharge summary

report

Admission Date: [**2134-3-22**] Discharge Date: [**2134-3-30**] Date of Birth: [**2075-2-20**] Sex: F Service: MEDICINE Allergies: Motrin Attending:[**First Name3 (LF) 348**] Chief Complaint: CC: Weakness Major Surgical or Invasive Procedure: Placement of Hemodialysis Catheter Hemodialysis History of Present Illness: MICU Admission HPI - History limited secondary to patient's agitation. Obtained in conjunction with [**First Name3 (LF) **] translator and husband, and from report of renal fellow. . 59 y.o. female with past medical history siginifcant for schizoaffective disorder with multiple suicide attempts via drug overdose who presents with a chief complaint of weakness. Patient specifically reports generalized fatigue and weakness, preventing her from performing ADLs and even going to the bathroom to urinate/have BM. She denies fevers/chills, sick contacts or UTI symptoms. Patient unable to cooperate with further ROS. Her continued weakness prompted her to come to the ED. She specifically denied suicidal ingestion and states that she took the lithium in accordance with her prescription. . In the ED, patient was found to have acute renal failure with a creatinine of 4.6 (elevated from baseline of 2.4-2.6) and a Lithium level of 3.0. EKG was unchanged from prior. She received IVF and renal was notified for emergent HD. . In MICU, pt underwent dialysis [**3-22**]. Lithium level improved from 3.0->1.2, but increased to 1.4 over the course of [**3-23**]. Creatinine improved from 4.6->2.2 after HD x 1. Pt was seen by toxicology who recommend close monitoring of lytes (q6h) and renal who recomend close monitoring of lithium levels (q4h). Past Medical History: DM type 2 Schizoaffective Disorder Chronic Renal Insufficiency Hypercholesterolemia Anemia Osteoarthritis History of Tb TAG-BSO secondary to endometrial CA . PSYCHIATRIC HISTORY copied from [**Date Range **]: -Multiple psychiatric admits and last hospitalized @ [**Hospital1 18**] [**2134-2-12**] through [**2134-2-18**]. -First hospitalized @ age 16 for suicidal ideation in the [**Location (un) 3156**] -[**11-22**] had ECT x 1 but refused further treatments -Past suicide attempts by stabbing and overdosing. Social History: Denies hx of illicit drugs/IVDU/ETOH. Pt born in [**Location (un) 3156**]. Diagnosed with schizophrenia at age 16. Married and lives with husband in [**Name (NI) 583**], who also has schizophrenia Family History: Mother has anxiety and father has dementia and behavioral problems. [**Name (NI) 6419**] are psychiatric patients of Dr [**Last Name (STitle) 111674**]. Physical Exam: Admission Exam: Vitals: T- 98.5, BP - 109/53, HR - 64, RR - 30, O2 - 98% on RA General: Awake, alert, acutely agitated, uncooperative, labile affect HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous, dentures in place, dry mucous membranes Neck: Supple, No LAD Chest/CV: S1, S2, no m/r/g appreciated, but difficult to auscultate given agitation and screaming Lungs: CTAB Abd: Soft, NT, ND, + BS Ext: No c/c/e Neuro: Uncooperative Skin: No rashes Pertinent Results: STUDIES: CT HEAD : . . . LABS: [**2134-3-22**] 03:00AM BLOOD WBC-8.6 RBC-3.27* Hgb-10.5* Hct-31.5* MCV-96 MCH-32.0 MCHC-33.3 RDW-13.4 Plt Ct-232 [**2134-3-22**] 01:00PM BLOOD WBC-7.7 RBC-3.64* Hgb-11.4* Hct-35.7* MCV-98 MCH-31.3 MCHC-32.0 RDW-13.5 Plt Ct-301 [**2134-3-24**] 01:40PM BLOOD WBC-7.7 RBC-3.15* Hgb-10.1* Hct-30.4* MCV-97 MCH-32.0 MCHC-33.1 RDW-13.4 Plt Ct-220 [**2134-3-25**] 05:50AM BLOOD WBC-8.1 RBC-3.13* Hgb-10.1* Hct-30.2* MCV-97 MCH-32.3* MCHC-33.5 RDW-13.4 Plt Ct-218 [**2134-3-26**] 07:25AM BLOOD WBC-10.0 RBC-3.26* Hgb-10.4* Hct-30.7* MCV-94 MCH-32.1* MCHC-34.1 RDW-13.3 Plt Ct-219 [**2134-3-28**] 06:10AM BLOOD WBC-9.8 RBC-3.28* Hgb-10.7* Hct-31.7* MCV-96 MCH-32.5* MCHC-33.7 RDW-13.7 Plt Ct-209 [**2134-3-22**] 03:00AM BLOOD Glucose-154* UreaN-15 Creat-1.3*# Na-143 K-3.4 Cl-106 HCO3-31 AnGap-9 [**2134-3-22**] 01:00PM BLOOD Glucose-102 UreaN-74* Creat-4.7*# Na-138 K-6.3* Cl-112* HCO3-18* AnGap-14 [**2134-3-22**] 04:15PM BLOOD UreaN-73* Creat-4.6* Na-141 K-4.8 Cl-114* HCO3-18* AnGap-14 [**2134-3-24**] 12:35AM BLOOD Glucose-124* UreaN-19 Creat-2.3* Na-142 K-4.1 Cl-109* HCO3-26 AnGap-11 [**2134-3-25**] 05:50AM BLOOD Glucose-104 UreaN-16 Creat-2.4* Na-146* K-4.0 Cl-114* HCO3-24 AnGap-12 [**2134-3-25**] 05:51PM BLOOD Glucose-149* UreaN-16 Creat-2.5* Na-142 K-4.0 Cl-112* HCO3-21* AnGap-13 [**2134-3-26**] 07:25AM BLOOD Glucose-142* UreaN-17 Creat-2.7* Na-144 K-4.0 Cl-113* HCO3-22 AnGap-13 [**2134-3-27**] 06:22AM BLOOD Glucose-95 UreaN-20 Creat-2.6* Na-145 K-4.6 Cl-112* HCO3-21* AnGap-17 [**2134-3-28**] 06:10AM BLOOD Glucose-183* UreaN-28* Creat-2.7* Na-142 K-4.1 Cl-109* HCO3-21* AnGap-16 [**2134-3-22**] 01:00PM BLOOD ALT-10 AST-25 LD(LDH)-498* AlkPhos-156* TotBili-0.2 [**2134-3-27**] 06:22AM BLOOD ALT-16 AST-17 AlkPhos-170* TotBili-0.3 [**2134-3-24**] 06:35AM BLOOD Lipase-72* [**2134-3-25**] 05:50AM BLOOD Lipase-65* [**2134-3-22**] 01:00PM BLOOD cTropnT-<0.01 [**2134-3-22**] 03:00AM BLOOD Calcium-8.5 Phos-1.3*# Mg-1.7 [**2134-3-25**] 05:51PM BLOOD Calcium-10.5* Phos-3.1 Mg-2.2 [**2134-3-26**] 07:25AM BLOOD Calcium-10.3* Phos-3.8 Mg-2.4 [**2134-3-27**] 06:22AM BLOOD Albumin-4.0 Calcium-10.2 Phos-4.5 Mg-2.3 [**2134-3-28**] 06:10AM BLOOD Calcium-9.9 Phos-4.3 Mg-2.3 [**2134-3-24**] 01:40PM BLOOD Osmolal-309 [**2134-3-22**] 01:00PM BLOOD TSH-3.4 [**2134-3-27**] 06:22AM BLOOD PTH-198* [**2134-3-22**] 03:00AM BLOOD Lithium-0.8 [**2134-3-22**] 01:00PM BLOOD Lithium-3.0*# [**2134-3-23**] 08:49AM BLOOD Lithium-1.2# [**2134-3-23**] 11:59AM BLOOD Lithium-1.3 [**2134-3-23**] 05:04PM BLOOD Lithium-1.4 [**2134-3-24**] 06:35AM BLOOD Lithium-1.3 [**2134-3-25**] 05:50AM BLOOD Lithium-1.2 [**2134-3-25**] 05:51PM BLOOD Lithium-1.1 [**2134-3-28**] 06:10AM BLOOD Lithium-0.8 [**2134-3-22**] 06:00PM BLOOD Lactate-0.7 [**2134-3-27**] 07:57AM BLOOD freeCa-1.29 Brief Hospital Course: MICU Course: . Ms. [**Known lastname 22741**] was evaluated emergently by toxicology and renal services in the ED, was emergently dialyzed for a toxic lithium level, and was admitted to the ICU. . # Lithium Intoxication: Lithium level was 3.0 on admission and underwent emergent dialysis. After dialysis the level was 0.8, however repeat level on the day she was transferred to the floor was 1.3, reflecting redistribution of protein-bound lithium. She denies intentional overdose and states she took the Lithium as prescribed; intoxication was likely secondary to decreased excretion in the setting of acute on chronic renal failure. EKGs were notable for prolonged QTc. . On the medical floor, the patient's lithium level continued to trend downward to 0.8 on [**2134-3-28**]. Discussion with her psychiatrist revealed that she had been started on lithium recently for mood instability. Her symptoms of confusion, delerium, and weakness resolved as her lithium level improved. On [**2134-3-30**], she was felt to be at her baseline per her mother and [**Name (NI) 595**] translator who has worked with her extensively before. . # Acute on Chronic Renal Insufficiency: Creatine on admission was 4.6 with baseline of 2.4-2.6. Renal US shows no obstruction and there were no urine eosinophils. Urine electrolytes ordered, without creatinine, but patient had already received IVF prior. Her enalapril was held secondary to her renal disease; restarting should be considered as an outpatient. . On the medical service pt's creatinine trended back towards baseline and was 2.6 on [**2134-3-27**]. Her vitamin D level was transiently heled [**1-22**] concern for hypercalcemia (10.5). PTH level was mildly elevated, which was felt to be [**1-22**] lithium toxicity. Calcium improved without intervention. Mild rise in creatinine were felt [**1-22**] poor po intake for which pt was gently rehydrated. She was started on both [**Month/Day (2) 7222**] and [**Month/Day (2) **] for her renal disease and was discharged with close follow up from her renal doctor. . . # delerium/weakness: pt presented with weakness and confusion felt [**1-22**] lithium toxicity, a known cause of neuromuscular weakness. In the MICU, patient unable to cooperate with physical exam to further explore neurological symptoms.her neurologic exam markedly improved over the course of her admission to the medical floor. she was initially uncooperative with exam, but moving all extremities compared with admission. . Neuro exam on [**3-27**] suggested hyperelexia, slurring of speech, and slight L LE weakness, which were resolved completely on [**3-28**]. CT head negative for bleed, per discussion [**3-27**] with pt's mother and translator pt's mental status and speech were back to baseline. she is ambulating without obvious deficits. . . # psych: pt with h/o schizoaffective disorder, with multiple admission to DEAC4 psych [**Hospital1 **] where she is well known. her delerium was felt to be resolving over course of her admission. . pt is followed by Dr. [**Last Name (STitle) 111670**] @ [**Hospital3 **] ([**Telephone/Fax (1) 111676**]), who apparently started pt on lithium ~1wk prior to admission, 300mg po BID with plan to increase to TID after 1 week. after admission to micu all psych meds were held (lithium, lamictal, amytriptyline, seroquel), and pt was crying continuosly, which apparently occurs when psych meds are missed. . pt was evaluated by psychiatry this admission, and her seroquel was restarted and titrated up to 300 mg po TID. her lamictal and amitryptyline are being held. ativan 1mg po tid prn were used for agitation. a 1:1 sitter was used. . . # anemia: pt remained at her baseline of 33-35, she was continued on iron replacement. . . # cardiac: pt has a h/o HTN, hypercholesterolemia, ? CAD, but negative stress MIBI in [**2130**] (EF 66%). she denies chest pain, sob, palpitation. she was continued on her home regimen of ASA, statin. her ACE-I was initially held [**1-22**] ARF. EKG demonstrated prolonged QTc on admission. serial EKG's were examined given ?QTc but were unremarkable over the course of her admission to the medical floor (QTc 460s). . . #DM2: appears to be diet controlled at home, FSBS well controlled during this admission. FSBS were followed and HISS maintained. . . # COMM: mother mya [**Known lastname **], [**Telephone/Fax (1) 111677**], cell [**Telephone/Fax (1) 111678**] Medications on Admission: Lithium (dose unknown, but taken TID) Lamotrigine 100 mg TID Amitriptyline 50 mg QHS Aspirin 81 mg QD Senna 8.6 mg [**Hospital1 **] Enalapril Maleate 5 mg QD Ergocalciferol (Vitamin D2) 50,000 unit Capsule 3x/week Ferrous Sulfate 325 mg QD Lorazepam 1 mg TID PRN Quetiapine 300 mg TID Pantoprazole 40 mg QD Atorvastatin 10 mg QHS Amitriptyline 25 mg QD Bisacodyl 10 mg PRN Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation. 5. Quetiapine 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*12 Tablet(s)* Refills:*0* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. [**Hospital1 **] 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. [**Hospital1 7222**] 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: primary: lithium toxicity acute renal failure / chronic renal insufficiency schizoaffective disorder Discharge Condition: Stable, at baseline mental status Discharge Instructions: You were admitted to the hospital with weakness and confusion and found to have lithium toxicity. You underwent hemodialysis and your lithium level is now sub-therapeutic. . Two different medications have been started for your kidney problems, [**Name (NI) **] and [**Name (NI) **]; you have close follow up with your renal doctor (see below). . You should NOT take your lithium, Lamictal, or amitriptyline unless instructed to do so by your psychiatrist. . If you develop further weakness or confusion, please seek medical attention immediately. Followup Instructions: you should have a repeat CT scan of your head to follow up on cysts seen during this admission. you should speak with your PCP about when and how to arrange this repeat CT scan. . You need to have your calcium level checked on [**4-1**] this week (Thursday); a prescription has been provided for you. . Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 111679**], M.D. Phone [**Telephone/Fax (1) 111675**] Date/Time: [**2134-4-2**] (Friday) at 2:45PM . Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2134-4-8**] 11:00 . Provider: [**Name10 (NameIs) 1947**] CLINIC (SB) Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2134-6-7**] 1:00

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icd9cm

[ [ [] ] ]

[ "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

11631, 11637

5927, 10359

279, 328

11782, 11818

3112, 5904

12413, 13157

2471, 2626

10783, 11608

11658, 11761

10386, 10760

11842, 12390

2641, 3093

227, 241

356, 1704

1726, 2239

2255, 2455

10,635

173,428

50074

Discharge summary

report

Admission Date: [**2126-7-8**] Discharge Date: [**2126-7-13**] Date of Birth: [**2068-11-10**] Sex: F Service: MEDICINE Allergies: Azmacort / Clindamycin / Versed / Fentanyl / Morphine / Optiray 300 / Ceftriaxone / Clarithromycin Attending:[**First Name3 (LF) 9240**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: 57 y/o f with h/o dyemyelinating syndrome, restrictive lung defect [FVC 52%], asthma and recurrent aspiration pneumonias requiring intubations in past who presented to ED on [**7-8**] with hypoxia and transferred to [**Hospital Unit Name 153**] for respiratory distress. . Patient presented with increased cough, feeling unwell and SOB x 2-3d. She complained of SOB at rest, which is not usual for her. SHe claimed that her sputum is yellowish with no blood. DEnies fever/chills, did claim that her friend was [**Name2 (NI) **] with "pneumonia". SHe claimed that she had been using increasing frequency of albuterol at home. SHe went for her scheduled pulmonary clinic on day of admission and was found to be hypoxemic 82-85% on RA. She was unable to effectively cough up secretions. Patient was placed on 6L with sats in mid-90s. CT scan on [**7-8**] shows resolution of the total collapse of the right middle lobe and mucoid impaction of [**Month/Year (2) 25730**], and [**Month/Year (2) 25730**] consolidation. . In ED, initial VS were T 99.2 P79 BP154/66 R14-16 1005 NRB. Patient received solumedrol 125mg x1 and combivent. guiac negative in ED. She was placed on continuos nebs with improvement in O2 sat. However, she would desat to 80s when that was discontinued. Repeat CTA show interval development of mild RML collapse, no PE/aortic dissection. . Patient was admitted to the [**Hospital Unit Name 153**] and was started on steroids, nebs, chest PT and was initiated on levofloxacin and tiotropium. Patient also noted to have persistently low BP, though close to baseline, though thought the be [**1-17**] sedation. Patient remained stable with improving oxygenation and was transferred to the floor on [**7-11**]. Patient currently reports feeling well, and her breathing is much improved. She is requesting Ativan for muscle spasms, but otherwise is without complaints. Past Medical History: 1. Chronic demyelinating disease with unclear etiology, probably secondary to parainfectious encephalomyelitis. The disease was diagnosed in [**2111**] when she presented with left lower extremity weakness following colonoscopy. There was significant disease progression between [**2111**] and [**2115**] and the patient became wheelchair-bound. She received several evaluations by neurologists including Dr. [**First Name (STitle) **] [**Name (STitle) 10442**] and Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 29138**] in the early [**2109**]. MRI report from [**2111**] showed signs of demyelination. She later underwent a sural nerve biopsy that was negative. She was evaluated by [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 2523**] of neuro-ophthalmology who found some abnormalities including arcuate defect and RAPD suggesting possible optic nerve defect os at least,( possibly also od given reduced acuity and colour acuity). Felt that it could be due to MS. VEPs were negative. Eventually, her condition was felt to be due to parainfectious encephalitis. Her symptoms have waxed and waned overtime. She currently walks with Canadian crutches and is no longer wheelchair bound. She suffers from a hypotonic bladder requirings self catheterizations and aspiration requiring a J tube. Her last neurology evaluation was by Dr. [**Last Name (STitle) 8760**] on [**2125-2-23**]. Unfortunately, this evaluation could not be completed. Ms. [**Known lastname 104543**] did not return to complete the evaluation. . 2. Oropharyngeal dysphagia: Abbreviated history. in [**2114**] had study showing mild to moderate oropharyngeal swallowing disturbance and trace aspiration. This progressed in [**2115**]. She had a G tube placed in [**5-/2116**] by Dr. [**First Name8 (NamePattern2) 11312**] [**Last Name (NamePattern1) 9779**] due to poor po intake at the Greenery. The PEG was changed to a button in 7/[**2115**]. In [**2124**], she had some time without the tube, but lost 15 pounds. In [**11/2125**] PEG changed by Dr. [**Last Name (STitle) 349**]. It was changed again by Dr. [**First Name (STitle) 572**] in [**2126-2-13**]. She has also had J tubes in the past, but did not tolerate them. She also declined to stay home that was necessitated by the slow infusion speed of a J tube. She has had fistulas compromising her abdomen as well due to the feeding tubes. She is followed now by Dr. [**First Name (STitle) 572**]. She easts minimal po for quality of life reasons. . 3. Decreased memory. . 4. Obstructive/restrictive lung disease, for which she has had multiple hospitalizations, requiring stress dose of steroids. She had open lung bx in [**2112**] that was negative. Work up for aspergillosis negative as well. PFTs done in [**8-/2124**] showed reduced FVC, IC, ERV with low normal TLC and normal FRC suggestive of restrictive neuromuscular process. She was formerly followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and has seen Dr. [**Last Name (STitle) 575**] as an inpatient and will be seeing him as an outpatient. He has recommended repeat sleep study for her. In the meantime, receiving asthma inhaler regimen. . 5. Left Renal artery Thrombus: Dx in [**2123**] when wbc elevated and abdominal pain. Was on coumadin, c/b right femoral bleed in [**2123**]. Risk felt to be too excessive and warfarin d/c’d. Maintained on ASA and folic acid for hyperhomocysteinemia. Exact cause of clot not clear. protein C, lupus anticoagulant, and antithrombin III were all normal. Seen in hematology [**12-20**]. . 6. Possible adrenal insufficiency: unlikely chronic problem. Possible due to recurrent steroid use. Seeing Dr. [**Last Name (STitle) **] for evaluation. . 7. s/p appendectomy . 8. s/p ccy: Dr. [**Last Name (STitle) 2896**]. S/p ex lap for unexplained abd pain. . 9. PUD: had sscp. Endoscopy in [**6-/2123**] with gastritis and few shallow pre pyloric ulcers. H pylori negative. . 10. Dilated panc ducts seen on RUQ U/S and CTA. ERCP by Dr. [**Last Name (STitle) **] in 9/[**2122**]. s/p sphincterotomy. . 11. Osteoporosis: dx [**2121**]. T score hip and spine about –3.4. IV pamidronate, changing to IV Boniva soon. . 12. Hypothyroidism . 13. pulmonary nodules. [**2122**]. Stable over time. . 14. Hypotension: likely due to autonomic neuropathy. On florinef. . 15. Hypercholesterolemia . 16. Left Breast papilloma: had nipple discharge. Excised by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**11/2119**] c/b infection treated with keflex. . 17. Muscle Spams: intermittent. Come at with suggestion. Psychogenic component. . 18. Right IJ thrombus: after line placement there. Resolved in [**2113**]. . 19. Acquired IgG deficiency, diagnosed in [**2111**] at [**Hospital1 336**]. The patient received IgG treatment in the past from [**2109**] to [**2113**]. No improvement in asthma symptoms, so it was d/c’d. . 20. Colonic polyps. Hyperplastic in [**2111**]. Others since. Due colonoscopy in [**2128**]. . 21. Urethral carbuncle: s/p incision and removal Dr. [**Last Name (STitle) 986**] 2/[**2114**]. 22. Sensorineural hearing loss: on audiogram [**2123**]. Told to get bilateral hearing aides. Getting second opinion MEEI. . 23. Klebsiella urosepsis: [**2123**]. . 24. Periorbital cellulitis in [**2117**]. . 25. Depression/anxiety: declining treatment now . Social History: Lives: with husband Family: married with 2 children Employment: social work Smokes: 1 ppd x 20 years. Quit [**2110**] Health Care Proxy: husband Family History: ctwin sister: healthy. Her mother and another sister died secondary to breast cancer. Another sister died secondary to brain cancer. Her father died secondary to [**Year (4 digits) 499**] cancer. One brother died secondary to heart attack. Physical Exam: VS 98 98/52 100 91%3L Gen: [**Last Name (un) **] female lying in bed NAD HEENT: PERRL, EOMI, Op clear, no LAD CVS: S1 S2 RRR no m/r/r Chest: rhonchorous breath soundes, wheezes and scattered crackles Abd: soft, +PEG, no tenderness ext: trace edema neuro: A&Ox3, increased UE muscle tone, [**3-20**] BLE Pertinent Results: [**2126-7-11**] 07:42AM BLOOD WBC-10.2 RBC-3.64* Hgb-11.9* Hct-37.9 MCV-104* MCH-32.8* MCHC-31.5 RDW-13.8 Plt Ct-342 [**2126-7-10**] 04:04AM BLOOD WBC-16.5*# RBC-3.80* Hgb-12.4 Hct-38.4 MCV-101* MCH-32.6* MCHC-32.2 RDW-13.9 Plt Ct-329 [**2126-7-10**] 04:04AM BLOOD Neuts-83.2* Bands-0 Lymphs-11.4* Monos-3.6 Eos-1.5 Baso-0.2 [**2126-7-11**] 07:42AM BLOOD Plt Ct-342 [**2126-7-8**] 05:05PM BLOOD PT-11.7 PTT-26.0 INR(PT)-1.0 [**2126-7-11**] 07:42AM BLOOD Glucose-91 UreaN-14 Creat-0.6 Na-147* K-4.2 Cl-109* HCO3-33* AnGap-9 [**2126-7-10**] 04:04AM BLOOD Glucose-118* UreaN-13 Creat-0.7 Na-142 K-3.8 Cl-110* HCO3-28 AnGap-8 [**2126-7-11**] 07:42AM BLOOD Calcium-9.4 Phos-2.9 Mg-2.1 .. CTA chest: 1. Interval development of mild right middle lobe collapse and left lower lobe atelectasis. 2. No evidence of pulmonary embolism or aortic dissection. .. CT chest without: 1. Resolution of collapse of right middle lobe and mucoid impaction of left lower lobe subsegmental bronchi. 2. Mild emphysema. 3. Stable 3-mm nodule in the left lower lobe since [**2123-11-15**], consistent with a benign etiology. No further followup for this nodule is necessary. .. Brief Hospital Course: SSESSMENT AND PLAN: 57 F with a dyemyelinating NM syndrome, restrictive lung disease and asthma, aspiration pna, presenting with respiratory distress and hypoxia to the 80s on RA. Found to have multilobar PNA, now with improved oxygenation on levofloxacin. . # Hypoxic Respiratory distress: COPD exacerbation/PNA Treated with levofloxacin and prednisone for a onw week taper to be done at home. Also treated with albuterol/atrovent nebs. Initial CTA showed no PE but RML collapse, repeat CT showed resolution of collapse. Improved clinically and was discharged on 2L home O2. . # Hypotension: -Resolved s/p IVF, now at baseline . # NMD: Had episode of severe spasm on [**7-9**] and mild episode [**7-10**]. - Continue muscle relaxants/benzos per outpatient regimen. . # Anxiety: Stable - Continue outpatient medications, carefully watching her respiratory status. . # Hypothyroidism: Presumed stable. In [**1-21**], TSH of 0.15. - Continue synthroid . # FEN: - Continue tube feeds and restart oral diet - Follow and replete lytes prn, recheck Na in am to ensure pt does not become hypernatremic . # Prophylaxis: PPI (outpt), SC heparin, bowel regimen . # Access: 1 PIV . # Code Status: Full . Medications on Admission: Outpatient Meds: cCURRENT MEDICATIONS: Levoxyl 50 mcg daily aspirin 325 mg daily calcium supplement 1 tablet daily Tums 4 to 5 tablets daily vitamin D 800 units. daily vitamin B 1200 IU daily Baclofen 20 mg po tid Klonopin 2 mg po tid BuSpar 10 mg po tid [**Date Range 102130**] 8 mg po tid Oxazepam 30 mg po qhs in the hospital Lipitor Ativan 2 mg po tid Protonix 40 mg po daily folic acid daily potassium supplement Advair 500/50 one puff [**Hospital1 **] Albuterol nebs prn Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Tizanidine 2 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 10. Oxazepam 15 mg Capsule Sig: [**12-17**] Capsules PO HS (at bedtime) as needed. 11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 16. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q1-2H () as needed. 17. Prednisone 10 mg Tablet Sig: Per taper Tablet PO once a day: Please take 4 tabs daily for 2 days, then 3 tabs daily for 2 days, then 2 tabs daily for 2 days, then 1 tab daily for 2 days, then stop. Disp:*20 Tablet(s)* Refills:*0* 18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 21. Oxygen Please continue oxygen via nasal cannula at 2L continuous until you follow up with your PCP. Discharge Disposition: Home Discharge Diagnosis: Aspiration Pneumonia Discharge Condition: stable, on 2L O2 Discharge Instructions: Please continue your regular medications. Please follow up with your PCP in the next 1-2 weeks. Please continue your home tube feeds. Please also continue your antibiotic and steroid taper. Please use 2L continuos home O2 until you follow up with your PCP. Followup Instructions: 1. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2126-7-29**] 11:30

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icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

13362, 13368

9653, 10852

363, 370

13433, 13452

8473, 9630

13757, 13884

7891, 8135

11379, 13339

13389, 13412

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13476, 13734

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320, 325

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398, 2284

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163,847

52937

Discharge summary

report

Admission Date: [**2101-1-26**] Discharge Date: [**2101-1-30**] Date of Birth: [**2026-2-5**] Sex: M Service: MEDICINE Allergies: Shellfish / Norvasc / Univasc Attending:[**First Name3 (LF) 425**] Chief Complaint: "Popping sensation in head" Major Surgical or Invasive Procedure: [**2101-1-27**] - Ventricular tachycardia ablation History of Present Illness: The patient is a 74 year old male with a history of coronary artery disease ([**2085**] LCX occlusion s/p PTCA), infarct-related cardiomyopathy with LVEF 35-40% and monomorphic VT s/p dual chamber [**Company 1543**] ICD implantation in [**2096**] for primary prevention who presents to the Emergency Department with intermittent episodes of "popping sensation in his head." He was in his normal state of health until this past Friday morning when he was in the car and he suddenly developed a sensation of flushing in his ears followed by a jolt in his head, which lasted seconds. This sensation has repeated itself approximately ten times since Friday. He has never had this sensation before. He denies palpitations, chest pain, syncope, pre-syncopal symptoms. He reports some dyspnea on exertion over the past several weeks, which he attributes to upper respiratory tract infection. He denies orthopnea, weight gain, lower extremity edema. His ICD was last interrogated on [**12-29**], since last clinic visit in [**Month (only) 956**] there were no sustained arrhythymias, 6 NSVT. The VT detection is between 150 and 188, fast VT detection is between 188 and 250 while the VF detection is greater than 250 beats per minute. The VT therapy equals anti-tachy pacing followed by 5 shocks between 20 and 35 joules, fast VT therapy equals anti-tachy pacing followed by 5 shocks between 20 and 35 joules, whereas the VF therapy equals anti-tachy pacing during charging followed by 6 shocks between 24 and 25 joules His device is programmed to treat rates greater than 150 bpm inthe VT zone, rates greater than 188 bpm in the VF zone. The brady portion of his device is in the MVP mode AAI/DDD lower rate 55 bpm. The mode switch feature is ON for atrial rates greater than 171 bpm. In the ED, initial vitals were: 97.4 72 147/86 16 98%. Initial EKG showed sinus rhythm, rate 57, normal axis with old inferior and high lateral TWI with several PVC of right bundle, superior axis morphology. During evaluation, he developed similar symptoms and on telemetry had NSVT at a rate in the low 200s lasting up to ten seconds. Cardiology interrogated ICD, which revealed 255 episodes of fast VT (>188BPM) since last interrogated, 244 pace terminated episodes (ATP), 11 shock terminated episodes (20J then 30J if refractory). CBC, Chemistry, troponin unremarkable. CXR showed AICD in place with no acute process. He was started on amiodarone 150mg bolus and drip without improvement in NSVT. He was then started on lidocaine drip with improvement in NSVT and now with infrequent PVC. On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - PERCUTANEOUS CORONARY INTERVENTIONS: [**2085**] PTCA LCX - PACING/ICD: [**Company 1543**] Virtuoso dual-chamber ICD placed [**Month (only) **] [**2096**] for primary prevention after Holter monitor showed frequent PVC and NSVT, referred for EP study (MADIT I criteria). Device last interrogated [**2100-12-29**] -> device programmed to treat rates greater than 150 bpm inthe VT zone, rates greater than 188 bpm in the VF zone. Thebrady portion of his device is in the MVP mode AAI/DDD lower rate55 bpm. The mode switch feature is ON for atrial rates greater than 171 bpm. 3. OTHER PAST MEDICAL HISTORY: - Coronary artery disease s/p inferior MI in [**2079**] and recurrent inferior MI in [**2085**] s/p PTCA to LCX - Infarct-related cardiomyopathy with LVEF 35-40% - Obstructive Sleep Apnea, not on CPAP - Knee OA s/p surgery for meniscal tear - Abdominal Aortic Aneurysm s/p repair Social History: - Works in Sales - Lives w/ Wife in [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **] - Tobacco history: Former smoker - ETOH: infrequent (once per month) - Illicit drugs: Denies Family History: - Mother: Died from MI in early 60s - Father: Unknown Physical Exam: Admission exam: VS: BP:127/75 HR: 67 RR: 16 O2: 95% 2LNC GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: No JVD. Supple CARDIAC: PMI located in 5th intercostal space, midclavicular line. regular rhythm, S1, S2, no murmur appreciated, distant heart sounds LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Discharge exam: Unchanged from above. Pertinent Results: Admission labs: [**2101-1-25**] 11:10PM BLOOD WBC-7.9 RBC-4.97 Hgb-16.1 Hct-47.5 MCV-96 MCH-32.4* MCHC-33.9 RDW-13.2 Plt Ct-143* [**2101-1-26**] 06:18AM BLOOD PT-11.4 PTT-27.1 INR(PT)-1.1 [**2101-1-25**] 11:10PM BLOOD Glucose-116* UreaN-20 Creat-1.0 Na-136 K-3.8 Cl-103 HCO3-26 AnGap-11 [**2101-1-26**] 06:18AM BLOOD CK(CPK)-192 [**2101-1-25**] 11:10PM BLOOD cTropnT-<0.01 [**2101-1-25**] 11:10PM BLOOD Calcium-9.7 Phos-3.4 Mg-2.1 [**2101-1-25**] 11:10PM BLOOD TSH-2.5 Imaging: -TTE ([**2101-1-26**]) - The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is severe regional left ventricular hypokinesis with akinesis of the inferior and inferolateral walls, apical inferior wall and apex (LVEF = 25-30%). The inferior septum is hypokinetic. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). Significant aortic stenosis is present (not quantified). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, anteriorly directed jet of moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. Compared to the findings of the prior study of [**2096-1-26**], left ventricular systolic function has deteriorated. IMPRESSION: Severe left ventricular systolic dysfunction with overall EF of 25-30% and wall motion abnormalities as described above. Moderate MR, trace TR and AI. Aortic stenosis is present. However, the severity cannot be reliably estimated given depressed systolic function. -CXR ([**2101-1-26**]) - No acute chest pathology; there is no radiographic evidence for pulmonary edema. -KUB ([**2101-1-27**]) - 1. Prominent air-filled mildly dilated loops of small bowel are most consistent with an ileus, although a partial or early small-bowel obstruction cannot be excluded. 2. Marked gastric distention. -CXR ([**2101-1-27**]) - NGT ends in the fundus of a moderately to severely distended stomach. There is no free subdiaphragmatic gas. The transverse colon is at least moderately dilated. Lung volumes are low exaggerating heart size, probably top normal. No pneumothorax or pleural effusion. Transvenous right atrial and right ventricular pacer defibrillator leads are in standard placements respectively. -KUB ([**2101-1-28**]) - 1. NG tube in proper position within the stomach. 2. Interval decrease in gastric distention and dilation of small bowel loops. -KUB ([**2101-1-29**]) - The NG tube tip is coiled at the level of the gastroesophageal junction and should be further advanced. The stomach bubble has slightly decreased since the prior study. There is no definitive evidence of free air. There is no evidence of bowel dilatation. Brief Hospital Course: 74 year old male with a history of coronary artery disease s/p inferior myocardial infarction, infarct-related cardiomyopathy with LVEF 25-30% and [**Company 1543**] ICD implantation in [**2096**] for primary prevention who presents to the emergency department with non-specific symptoms found to have intermittent monomorphic ventricular tachycardia with appropriate ICD shock. . # Ventricular tachycardia - After ICD interrogation, it was found that he had many episodes of NSVT, some of which required antitachycardia pacing and eventually shocks. He was initially started on a lidocaine drip in an attempt to suppress the VT. This was stopped after less than 24 hours because of nausea and some vomiting which may have been caused by the lidocaine. He subsequently underwent a VT ablation. They were unable to induct any VT during the procedure but a substrate ablation was performed in the area of scar from his prior MI. He did not have any more VT after the procedure, only frequent PVCs with groups up to 3 beats at a time (which had also been noted from prior to admission on his ICD/pacer interrogation). Antiarrhythmics were held after the procedure, he was only continued on metoprolol. He will be anticoagulated for 3 months after the ablation because of the elevated risk for stroke. He was started on warfarin at discharghe. For bridging, he was initially on a heparin gtt which was transitioned to Lovenox 100mg sc q12h, which he will continue until his INR is therapeutic. . # Nausea/vomiting - At presentation, he had some mild nausea, some of which was attributed to the lidocaine drip which was started at admission. However, after the VT ablation, for which he had general anesthesia, his nausea was significantly worse. He had projectile bilious vomiting and a KIB showed significant gastric dilation. This was presumed to be a post-anesthesia ileus, he had a similar reaction after his AAA repair which required decompression with an NGT. An NGT was placed again this admission and his symptoms improved. His abdominal exam remained benign with no tenderness to palpation. The tube was removed after 48 hours when his KUB showed resolving gastric dilation. He was able to tolerate PO intake prior to discharge. . # CAD - He did not have any complaints of chest pain and his cardiac enzymes were negative. He was continued on aspirin and his beta blocker was changed from atenolol to metoprolol. . # Hyperlipidemia - Continued on home dose of atorvastatin . #Code status this admission - FULL CODE . #Transitional issues - Will continue on Lovenox 100mg sc q12h until INR is therapeutic - Started on coumadin with subtherapeutic INR at discharge, will have INR checked on Tuesday [**2101-2-1**] - Atenolol was changed to metoprolol during this admission - Should follow-up with the device clinic after discharge, will need to call for the appointment as he was discharged on a weekend. Will see Dr. [**First Name (STitle) **] as an outpatient. Medications on Admission: - atenolol 50 mg a day - aspirin 81 mg a day - atorvastatin 40 mg a day - Seroquel 25 mg at night - vitamin D - ibuprofen p.r.n. Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. [**First Name (STitle) **]:*30 Tablet(s)* Refills:*0* 4. enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg Subcutaneous Q12HOURS (): Continue until your INR is [**3-18**] and then continue only the Coumadin - as outlined by your primary care physician. [**Name Initial (NameIs) **]:*20 doses* Refills:*0* 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. [**Name Initial (NameIs) **]:*30 Tablet Extended Release 24 hr(s)* Refills:*0* 6. quetiapine 25 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 7. cholecalciferol (vitamin D3) Oral 8. Outpatient Lab Work Please check INR given patient's need for anticoagulation. Check on Tuesday, [**2101-2-1**]. . FAX RESULTS TO PCP: [**Name10 (NameIs) **],[**Name8 (MD) 2946**] MD [**Telephone/Fax (1) 7922**] Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary diagnosis: 1. Ventricular tachycardia status-post ablation procedure . Secondary diagnoses: 1. Coronary artery disease 2. Ischemic cardiomyopathy (EF=25-30%) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 14696**], . It was a pleasure taking care of you during your admission to [**Hospital1 18**]. You were admitted to the Cardiac Care Unit because you were found to have frequent episodes of ventricular tachycardia (VT) which was causing your ICD to discharge. You had a VT ablation and did not have any further episodes of VT afterwards. After receiving general anesthesia, you had nausea and projectile vomiting which required placement of a nasogastric tube, which has subsequently been removed. Your symptoms improved and the tube was removed prior to discharge. . You were started on Warfarin for anticoagulation after your ablation procedure. You will also continue to take Lovenox injections every 12 hours until your INR (a test of how thin your blood is) is between [**3-18**]. You should have your INR checked on Tuesday. You can take the attached prescription to any phlebotomy laboratory and have the results faxed to your PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 7922**]. . * As discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], your cardiology attending this admission, you are okay to perform some lifting after a resting period (resume mild lifting less than 5-lbs on Tuesday, [**2-1**]). You are able to travel and continue driving, in discussion with Dr. [**Last Name (STitle) **]. * . * If your ICD device fires ONCE, and you feel well following this, you may resume your normal activities and call your outpatient Cardiologist with 1-2 days. . * If your ICD device first MULTIPLE TIMES or your FEEL UNWELL following this, then proceed to the emergency room. . The following CHANGES have been made to your medications: . START: Metoprolol succinate XL 50 mg by mouth daily START: Lovenox 100 mg subcutaneous every 12-hours until your INR is between [**3-18**]. Your doctor will tell you when to stop this medication. START: Warfarin 5 mg by mouth daily . The following medications were DISCONTINUED this admission: DISCONTINUE: Atenolol Followup Instructions: We will email Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] regarding an appointment for next week. Her office will call regarding scheduling. . Department: [**State **]When: WEDNESDAY [**2101-2-2**] at 2:00 PM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking . Department: CARDIAC SERVICES When: TUESDAY [**2101-3-29**] at 9:30 AM With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**] Building: None None Campus: AT HOME SERVICE Best Parking: None . Department: CARDIAC SERVICES When: WEDNESDAY [**2101-5-18**] at 10:00 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "37.34", "37.26", "37.27" ]

icd9pcs

[ [ [] ] ]

13028, 13079

8782, 11763

316, 369

13289, 13289

5716, 5716

15498, 16437

4731, 4788

11942, 13005

13100, 13100

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4514, 4715

21,431

176,691

51314+51315+51316

Discharge summary

report+report+report

Admission Date: [**2139-12-1**] Discharge Date: [**2139-12-4**] Date of Birth: [**2083-6-22**] Sex: M Service: MICU HISTORY OF THE PRESENT ILLNESS: The patient is a 56-year-old man with brittle diabetes, end-stage renal disease of transplanted kidney, long medical history, who presents from an outside hospital with DKA. Most of the history was obtained by the patient's wife by phone as the patient was very confused upon arrival. She reports an acute disorientation on the morning of admission with a glucose [**Location (un) 1131**] of "unreadable" on the machine. Neither she nor the patient have a clear idea about the precipitant of the hyperglycemia. The wife reports increased lethargy, increased sleep, and decreased p.o. intake over the last one to two days. She said "he didn't feel well", but could not pinpoint any specifics. The patient denied nausea, vomiting, fevers, chills, shortness of breath, chest pain, pain, diarrhea, or dysuria. The patient does make urine, approximately four bathroom trips per day with a decent amount of output. His last hemodialysis was on [**2139-11-29**] per the patient. He reports being compliant with his insulin and Accu-Cheks. When the patient arrived at [**Hospital 487**] Hospital, his glucose [**Location (un) 1131**] was 868 with an anion gap of 15. His initial arterial blood gas was 7.22/55.9/145 on 2 liters nasal cannula. Upon arrival to the [**Hospital1 18**] the patient was confused but was able to answer most questions. PAST MEDICAL HISTORY: PCP is [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **]. 1. Insulin-dependent diabetes times 28 years secondary to alcohol-induced pancreatitis. 2. Severe peripheral vascular disease with toe amputations. 3. End-stage renal disease of transplanted kidney. 4. Transplant of kidney in [**2133**]. 5. Right tibia-fibula fracture, status post ORIF complicated by wound infection, osteomyelitis in [**2139-8-24**]. 6. Per notes, renal failure is secondary to pyelonephritis in [**2137**]. 7. Neuropathy. 8. Back pain. 9. Anemia. 10. DVT of right upper extremity. 11. History of MRSA in [**2136-9-23**]. 12. GERD. 13. Depression. 14. Penile prosthesis. 15. Malabsorption. 16. Vocal cord polyps. 17. Questionable seizures with hypoglycemia. ADMISSION MEDICATIONS: 1. Folate and multiple vitamin. 2. Wellbutrin 100 t.i.d. 3. Protonix 40 q.d. 4. Neurontin 300 q.d. 5. Clorhexadine 50 t.i.d. 6. Aspirin 81 q.d. 7. Pancreatic enzymes. 8. Calcium carbonate 500 t.i.d. 9. Amlodipine 5 mg b.i.d. 10. Insulin regimen 22 units of NPH in the a.m., 8 units q.h.s. with Humalog sliding scale throughout the day. 11. Colace 100 mg b.i.d. 12. Clonidine 0.3 b.i.d. 13. Hydralazine 75 q.i.d. 14. Lovenox 40 q.d. 15. Prednisone 5 mg q.d. 16. Celexa 20 mg q.d. 17. Metoprolol 100 mg b.i.d. 18. Oxycontin 40 mg b.i.d. 19. Atorvostatin 10 mg q.d. 20. Calcitriol 0.5 mg q.d. ALLERGIES: Codeine, Prograf, Phenergan, Haldol. SOCIAL HISTORY: The patient lives with wife, remote alcohol, and tobacco history. No IV drug use. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.7, blood pressure 160/91, pulse 69, respirations 12, oxygen saturation 100% on 2 liters. Glucose 150. I&O 250 out at the outside hospital. No urine output here. General: The patient was a lethargic man looking older than age. HEENT: Dysconjugate gaze, mucous membranes dry. The oropharynx was clear. Neck: There were distended neck veins, supple. Cardiovascular: Regular rate and rhythm, distant heart sounds, no murmurs, rubs, or gallops. Pulmonary: Bilaterally clear to auscultation. Abdomen: Two well-healed scars, normoactive bowel sounds. No hepatosplenomegaly. Transplanted kidney in the left lower quadrant. Extremities: Amputated toes on left foot, scaly dry skin. The patient has a fixator on his right leg. Neurologic: Alert and oriented times two, lethargic but cooperative. LABORATORY/RADIOLOGIC DATA: Upon admission, the white blood cell count was 9.8, hematocrit 36.9, platelets 220,000. Coagulation studies were normal. Chemistries: Sodium 144, potassium 4.2, chloride 111, bicarbonate 22, BUN 41, creatinine 6.2, glucose 81 with an anion gap of 11. The liver function tests were normal. Calcium 7.1, magnesium 1.9, phosphorus 5.9. Blood cultures were pending. Chest x-ray was clear. Blood gas was 7.32/36/140 on 2 liters nasal cannula. EKG showed normal sinus rate of 64, old T wave inversions in V1 through V3, no ST changes, biphasic Ts. HOSPITAL COURSE: 1. DIABETIC KETOACIDOSIS: The patient's sugars were well controlled by the time he arrived at the [**Hospital1 18**]. His anion gap had closed. The patient's insulin drip was discontinued soon after arrival and he was covered with NPH as well as a Humalog sliding scale during admission. The [**Last Name (un) **] Consult Service followed the patient and adjusted his Humalog sliding scale. The patient's precipitant of his DKA is unclear but is thought to be likely noncompliance with insulin regimen. Blood cultures and urine cultures were obtained and were negative at the time of this discharge summary. The patient was also ruled out for a myocardial infarction. Other likely precipitants could have been a viral syndrome since the patient had been fatigued with decreased p.o. intake on days before admission. A hemoglobin A1C level was checked and is pending at the time of this discharge. 2. END-STAGE RENAL DISEASE: The patient was initiated on hemodialysis to continue his three day a week dialysis regimen. The Renal Service followed the patient and he had dialysis on [**2139-12-3**] without incident. The patient's Calcitriol was continued along with his calcium carbonate and prednisone for his transplanted kidney. 3. CORONARY ARTERY DISEASE: The patient was continued on his aspirin, metoprolol, and Atorvostatin. The patient ruled out for a myocardial infarction by enzymes and EKG. 4. HYPERTENSION: The patient has resistant hypertension and was admitted on a four drug regimen. The patient was restarted on his metoprolol, hydralazine, clonidine, and amlodipine during admission. Dose adjustments were made upon discharge as the patient's blood pressure did lower with dialysis. 5. NUTRITION: The patient was maintained on a diabetic diet and was continued on his folate and multivitamin. Pancrease and Viokase were continued for his pancreatic insufficiency. 6. DEPRESSION: The patient was continued on his Citalopram and Bupropion. The patient is a full code and was evaluated by physical therapy. Physical therapy evaluation is pending at the time of this dictation. The patient is expected to be discharged to home with VNA along with nursing at hemodialysis. DISCHARGE DIAGNOSIS: 1. DKA. 2. Insulin-dependent diabetes mellitus. 3. Severe peripheral vascular disease with toe amputations. 4. End-stage renal disease of transplanted kidney. 5. Status post transplant of kidney in [**2133**]. 6. Right tibia-fibula fracture. 7. Neuropathy. 8. Chronic back pain. 9. Anemia. 10. Gastroesophageal reflux disease. 11. Depression. DISCHARGE MEDICATIONS: 1. The same as the medications upon admission with the exception of Clonidine 0.3 mg b.i.d. 2. Amlodipine 5 mg q.d. 3. Calcium carbonate 1,000 mg t.i.d. 4. Insulin regimen recommended upon discharge is a standing dose of Glargine 12 units q.h.s. and Humalog coverage at meals as determined by [**Last Name (un) **]. The patient's sliding scale of Humalog should be glucose 0-50, Humalog dose 0; glucose 51-100, receive 2 units of Humalog at breakfast, lunch, and dinner, and 0 at bedtime; glucose 101-150, receive 4 units of Humalog at breakfast, lunch, and dinner with 0 units at bedtime; glucose 151-200, the patient should receive 6 units of Humalog at breakfast, lunch, and dinner, and 0 units at bedtime; glucose 201-250, the patient should receive 7 units at breakfast, lunch, and dinner, and 2 units at bedtime; glucose 251-300, the patient should receive 8 units of Humalog at breakfast, lunch, and dinner, and 3 units at bedtime; glucose 301-350, the patient should receive 10 units of Humalog at breakfast, lunch, and dinner, and 4 units at bedtime. Glucose readings 351-400, the patient should receive 12 units of Humalog at breakfast, lunch, and dinner, and 6 units at bedtime; glucose greater than 400, the patient should receive 1,400 units of Humalog at breakfast, lunch, and dinner, and 8 units at bedtime. The patient should take juice or Dextrose if his glucose is less than 60. OUTPATIENT FOLLOW-UP: 1. The patient will follow-up at [**Last Name (un) **] with Dr. [**First Name (STitle) 3636**] on [**2139-12-15**] at 2:30 p.m., phone number [**Telephone/Fax (1) 2384**]. 2. The patient will also be seen at the [**Hospital 191**] clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Nurse Practitioner, on [**2139-12-9**] at 11:20. DISCHARGE STATUS: Stable. DISCHARGE CONDITION: To home with VNA. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**] Dictated By:[**Last Name (NamePattern1) 9244**] MEDQUIST36 D: [**2139-12-3**] 03:03 T: [**2139-12-6**] 09:03 JOB#: [**Job Number 106444**] Admission Date: [**2139-12-1**] Discharge Date: [**2139-12-10**] Date of Birth: [**2083-6-22**] Sex: M Service: Medicine, [**Hospital1 **] Firm HISTORY OF PRESENT ILLNESS: This is a 56-year-old gentleman with multiple medical problems including hypertension, diabetes, and pancreatic insufficiency who presented as a transfer from an outside hospital Emergency Department with an episode of diabetic ketoacidosis. The patient was recently discharged from the [**Hospital1 **] less than one month ago for the same diagnosis. He was doing well at home until a few days ago when he developed increasing fatigue and decreased oral intake. On the day of admission, the patient's wife noted a change in his mental status and said his sugar "off the chart." He was seen at an outside hospital Emergency Department where his blood sugar was found to be in the 800s. He was given 10 units of subcutaneous insulin and then started on a drip. His initial blood gas was 7.22/55/145. His anion gap was 13. On arrival to [**Hospital1 69**] the patient was oriented and answering questions. He denied any recent fevers, chills, urinary tract symptoms, or upper respiratory tract symptoms. He had no chest pain, shortness of breath, abdominal pain, nausea, vomiting, or diarrhea. He does make urine but had noted some decrease in his urine output over the past several days. PAST MEDICAL HISTORY: 1. Peripheral vascular disease with claudication; status post amputation of his left toes, status post amputation of his right fifth toe. 2. Type 1 diabetes secondary to ethanol pancreatitis (on insulin for some 20 years). 3. End-stage renal disease; status post failed renal transplant in [**2133**], now back on hemodialysis. 4. Right tibia/fibula fracture; status post open reduction/internal fixation in [**2139-8-24**]. Course complicated by a wound infection and osteomyelitis; currently with an external fixator. 5. Hypertension. 6. Neuropathy. 7. Anemia. 8. History of right upper extremity deep venous thrombosis. 9. History of methicillin-resistant Staphylococcus aureus. 10. Gastroesophageal reflux disease. 11. Depression. 12. Penile prosthesis. 13. History of pancreatitis with current pancreatic insufficiency and history of pseudocyst. 14. Seizure disorder secondary to hypoglycemic episodes. ALLERGIES: Allergies were noted to CODEINE, PROGRAF, PHENERGAN, and HALDOL. MEDICATIONS ON ADMISSION: SOCIAL HISTORY: This gentleman lives with his wife and daughter. [**Name (NI) **] indulges in occasional beer, but he quit tobacco use several years ago. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on presentation to the Emergency Department revealed the patient's temperature was 97.7 degrees Fahrenheit, his blood pressure was 168/91, his heart rate was 69, his respiratory rate was 12, and his oxygen saturation was 100% on 2 liters via nasal cannula. In general, he was a thin, clinically ill-appearing, gentleman. The pupils were equal, round, and reactive to light with a dysconjugate gaze. He had dry mucous membranes. The neck was supple with a flat jugular venous pulsation. Heart was regular in rate and rhythm. Normal first heart sounds and second heart sounds. No murmurs. The lungs were clear to auscultation bilaterally. He had a soft, nontender, and nondistended abdomen with no hepatosplenomegaly. He had no peripheral extremity edema. External fixator was noted on the right lower extremity with no erythema or pus at external fixator sites. He was status post left toe amputations and right fifth toe amputation. His skin showed no rashes. He had no costovertebral angle tenderness and a nontender spine. His neurologic examination was nonfocal. PERTINENT LABORATORY VALUES ON PRESENTATION: Complete blood count revealed the patient's white blood cell count was 4, his hematocrit was 36.9, and his platelet count was 220. Differential revealed 69% polys, 25% lymphocytes, no bands, and 5% monocytes. Chemistry-7 revealed his sodium was 144, potassium was 4.2, chloride was 111, bicarbonate was 22, blood urea nitrogen was 41, creatinine was 6.2, and blood glucose was 81. His anion gap was 11 at the time of his admission to [**Hospital1 **]. First arterial blood gas done here was 7.32/36/140. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed normal sinus with a rate of 64, with old T wave inversions at V1 through V3, and no ST changes. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit with a diagnosis of diabetic ketoacidosis of unknown precipitant. His anion gap was noted to be improving on an insulin drip. He was initially treated with an insulin drip, and his glucose had normalized by the time he had arrived at the [**Hospital1 **]. He was shortly changed over in the Medical Intensive Care Unit to an NPH and regular insulin sliding-scale schedule. His home medications for hypertension were continued in order to control his systolic blood pressure. The Renal team was notified of his arrival so that dialysis could be arranged as an inpatient. He was placed on telemetry as a rule out myocardial infarction to rule out a cardiac pathology as a source of his diabetic ketoacidosis. He was continued on his beta blocker and given aspirin. He was maintained on Protonix for his gastroesophageal reflux disease and was continued on his pancreatic enzymes replacement strategy. A left internal jugular line was placed in the Unit for access. By the end of hospital day two, the patient's sugars had been stable and he was transferred from the Medical Intensive Care Unit to the floor for further management. Initially, the plan was to discharge once his diabetic ketoacidosis had resolved. However, the patient continued to have episodes of waxing and [**Doctor Last Name 688**] mental status of unclear etiology. The source of his diabetic ketoacidosis was initially not clear. He had negative blood cultures, negative urinalysis and urine cultures. He had recent normal folate and B12. His acute myocardial infarction was negative times three, ruling out a myocardial infarction or cardiac source of diabetic ketoacidosis. The most likely scenario for his sugar of 800 was noncompliance with his medication regimen in the absence of any obvious source of infection or cardiac pathology. On the floor, the patient continued to have episodes of waxing and [**Doctor Last Name 688**] mental status. He remained oriented to person, but he would often believe that it was [**2131**] and that the president was [**First Name8 (NamePattern2) 892**] [**Last Name (NamePattern1) 1806**]. He would become confused; especially late in the evening, and he would try to climb out of bed with rails up. The patient likely had some underlying degree of dementia, but the waxing and [**Doctor Last Name 688**] course seemed more consistent with a delirium; the most likely cause of which was thought to be either metabolic related to his sudden enlarged shift in glucose and/or polypharmacy. Psychiatry was called to evaluate the patient on [**12-5**]. The patient was agitated and insisting on leaving but was unable to verbalize the medical risks of discharge. He would not follow verbal redirection and attempted to leave despite the presence of security personnel. Therefore, for the patient's safety, he was put on mechanical restraints at that time. He was given a one-to-one sitter as well as some Ativan for sedation. Celexa and Wellbutrin were discontinued. It was agreed that the OxyContin might be contributing to his clouded mental status, and he was slowly weaned down to a lower dose. He was changed over to as needed Trilafon. There was initial concern that this might have a cross-reactive reaction given his agitation he experiences with Phenergan, but no cross-reactivity occurred during the patient's stay here. His QTc was elevated by electrocardiogram, and it was something we were following daily. It was over 500 for several days, which is why both haloperidol and Geodon were recommended as not wise. The patient improved over the last few days of his stay, and although he has not reached his baseline, he no longer requires mechanical or chemical restraint. The Endocrine Service, [**Last Name (un) **] Service as well as the Renal Service continued to follow the patient while he was on the floor contributing to recommendations for his care related to his diabetes and renal disease. The patient care team met with Mr. [**Known firstname **] [**Known lastname 63715**] and his wife to discuss disposition. It was felt by the wife as well as by the care team that he would benefit from a rehabilitation stay given some mild remaining confusion as well as difficulty maintaining insulin regimens at home. The concern was that he would have a recurrence of his diabetic ketoacidosis shortly after returning home if he was not taking his insulin properly. The patient declined, and was discharged to home. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: Discharge status was to home. DISCHARGE DIAGNOSES: 1. Diabetes mellitus. 2. Diabetic ketoacidosis. 3. Mental status changes with delirium; now resolved. 4. End-stage renal disease (on hemodialysis). MEDICATIONS ON DISCHARGE: 1. OxyContin sustained release 20 mg in the morning and 10 mg in the evening (hold for sedation). 2. Nephrocaps one tablet by mouth every day. 3. Amlodipine 5 mg by mouth every day. 4. Metoprolol 50 mg by mouth twice per day. 5. Clonidine 0.1 mg by mouth twice per day. 6. Perphenazine 2 mg by mouth twice per day as needed (for agitation). 7. Calcium carbonate 1000 mg by mouth three times per day (with meals plus two tablets at hour of sleep). 8. Atorvastatin 10 mg by mouth once per day. 9. Prednisone 5 mg by mouth once per day. 10. Docusate 100 mg by mouth twice per day. 11. Pancrease two tablets by mouth three times per day (with meals). 12. Viokase one tablet by mouth three times per day (with meals). 13. Aspirin 81 mg by mouth once per day. 14. Chlorhexidine gluconate 15 mg by mouth three times per day as needed. 15. Pantoprazole 40 mg by mouth q.24h. 16. Multivitamin one tablet by mouth once per day. 17. Folic acid 1 mg by mouth once per day. 18. Glargine insulin 12 units at bedtime with a sliding-scale. 19. Recommendation for 3 units of Humalog with snacks in between meals in order to control spikes with snacking. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1302**], M.D. Dictated By:[**Last Name (NamePattern1) 10454**] MEDQUIST36 D: [**2139-12-10**] 14:38 T: [**2139-12-10**] 17:06 JOB#: [**Job Number 106445**] Admission Date: [**2139-12-1**] Discharge Date: [**2139-12-10**] Date of Birth: [**2083-6-22**] Sex: M Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 56 year old gentleman with multiple medical problems including Type 1 diabetes secondary to ethyl alcohol pancreatitis, end stage renal disease, status post failed renal transplant in [**2133**] on hemodialysis, right tibia- fibula fracture, status post open reduction and internal fixation complicated by wound infection and osteomyelitis requiring Aciphex who was transferred from an outside hospital Emergency Department with a diagnosis of diabetic ketoacidosis and hypertension. The patient was recently discharged from [**Hospital6 1760**] less than one month ago for an episode of diabetes ketoacidosis. He was doing well at home until a few days ago when he developed increasing fatigue, increasing lethargy, and decreased p.o. intake. On the day of admission, the patient's wife noted a change in his mental status and mentioned that his sugar was off the chart. He was seen in an outside hospital at which time he was noted to be hypertensive and treated with Nitropaste and Lopressor. His blood sugar was noted to be in the 800s for which he was given 10 units of subcutaneous insulin and was started on an insulin GTT. Initial arterial blood gases at the outside hospital was pH of 7.22, pCO2 55, pO2 145. On arrival to the [**Hospital6 256**] the patient was noted to be agitated but was answering questions. He denied any recent fevers or chills, urinary symptoms or cough and congestion. He noticed no chest pain, palpitations, shortness of breath, abdominal pain, nausea, vomiting or diarrhea. He does make urine, but noticed decreased urine output over the last several days. PAST MEDICAL HISTORY: 1. Peripheral vascular disease with claudication status post amputation of left toes, status post amputation of right fifth toe. 2. Diabetes Type 1, secondary to ethyl alcohol pancreatitis on insulin for some 20 years. 3. End stage renal disease, status post renal transplant in [**2133**], transplant failed within one year and the patient is back on hemodialysis. 4. Right tibia-fibula fracture, status post open reduction and internal fixation in [**2139-8-24**] complicated by wound infection and osteomyelitis currently with an external fixation device. 5. Hypertension. 6. Neuropathy. 7. Back pain. 8. Anemia. 9. History of right upper extremity deep vein thrombosis. 10. History of Methicillin-sensitive resistant Staphylococcus aureus. 11. Gastroesophageal reflux disease. 12. Depression. 13. Penile prosthesis. 14. History of pancreatitis including pancreatic insufficiency, status post pseudocyst development. 15. Sleep disorder. 16. Seizure disorder, likely secondary to hypoglycemia. SOCIAL HISTORY: This gentleman lives with his wife and daughter. [**Name (NI) **] indulges in an occasional beer but quit tobacco several years ago. PHYSICAL EXAMINATION: Initial physical examination revealed vitals on presentation to the Emergency Department with temperature of 97.7, blood pressure 168/91, heartrate 69, respiratory rate 12 and 100% on 2 liters of nasal cannula. He was a thin older gentleman, clinically ill-appearing. Pupils were equal, round and reactive to light, with dysconjugate gaze noted. His mucous membranes were dry. His neck was supple with a flat jugulovenous pressure and no lymphadenopathy. He was regular rate and rhythm, normal S1 and S2, with no murmurs. His lungs were clear to auscultation bilaterally without crackles or wheezes. His abdomen was nontender, nondistended with no rebound tenderness. He had no lower extremity edema. He had an external fixation device on his right lower extremity. The left toes are noted to be amputated as well as the right fifth toe. Skin showed no rash. He had no costovertebral angle tenderness and a nontender spine. His neurological examination was nonfocal. LABORATORY DATA: Laboratory data on initial presentation showed complete blood count with a white count of 4, hematocrit of 36.9, and platelet count of 220. Differential was 69 polys, 25 lymphocytes, 0 bands, 5 monocytes. Chem-7 showed a sodium of 144, potassium 4.2, chloride 111, carbon dioxide 22, BUN 41, creatinine 6.2, and sugar of 81. Arterial blood gases was 7.32/36/140. Electrocardiogram performed showed a normal sinus rhythm at a rate of 64 with T wave inversions in leads V1 to V3 noted to be old, and no ST changes. HOSPITAL COURSE: Mr. [**Known lastname 63715**] was admitted to the Medical Intensive Care Unit with a diagnosis of diabetic ketoacidosis of unknown precipitant. The left internal jugular line was placed for access. He was initially maintained on an insulin GTT in order to control his sugars. His gap quickly closed based on comparing laboratory data from the outside hospital. His home medicines for hypertension were continued to attempt to control his pressure. Renal team was contact[**Name (NI) **] in order to arrange for in-house dialysis while he was a patient. He was initially placed on Telemetry in order to rule out myocardial infarction as a cause of his diabetic ketoacidosis. He was continued on a proton pump inhibitors for his gastroesophageal reflux disease as well as pancreatic replacement enzymes. Blood cultures were taken in order to rule out infection as a precipitant of this episode of diabetic ketoacidosis. By later in the first day of the hospitalization, the patient was discontinued off of the insulin drip and started on his schedule of NPH and sliding scale regular insulin. The patient was clinically improved but the precipitating diabetic ketoacidosis was still unidentified. Laboratory data thus far have been unhelpful in determining cause and noncompliance with insulin regimen was suspected as a major precipitant. The [**Last Name (un) **] fellow consulted on this admission and continued to leave daily rx while he was an inpatient to try to optimize his insulin regimen. It was ultimately decided that it would be best to switch him to an [**Doctor Last Name 360**] such as Glargine which provides more constant basal control of insulin production. The patient was clinically improved and was transferred to the floor on the evening of [**12-3**], on hospital day #2. Initially the plan was to discharge the patient once the episode of diabetic ketoacidosis had resolved. However, the patient developed waxing and [**Doctor Last Name 688**] mental status while on the floor causing concern to the care team. He was followed by Endocrine Team to try to control his sugar swings and also was followed by psychiatry in order to optimize his medication regimen controlling agitation without contributing to it through poly-pharmacy. The patient likely has some degree of underlying dementia, but while on the floor would developed confusion and agitation especially late at night. This lead the team to believe that he would be unsafe to discharge to home until we had tracked down the source. The patient was put on a one-to-one at times when he seemed particularly prone to fall and on two occasions required the use of restraints in bed in order to prevent him from harming himself. Initially Psychiatry recommended a one-to-one, use of Ativan for sedation, Zyprexa Zydis and tapering the Celexa and Wellbutrin. They were concerned as well as the Medicine Team was concerned that narcotic use may be clouding his mental status and it was decided to attempt to taper his Oxycontin. His QTC on serial electrocardiogram remained above 500 causing concerns for use of certain antipsychotics for agitation suppression such as Haloperidol or Geodon. Daily electrocardiograms were taken in order to monitor this. The Zyprexa was ultimately discontinued as there were concerns that it might exacerbate his hypoglycemic episodes. He was started on prn b.i.d. Trilafon in order to attempt to control symptoms of agitation. A possible cross reactivity to an allergy to Phenergan was noted, the reaction to Phenergan being agitation. Given the constraints in terms of prescribing other medicines it was attempted that we would try the doses of Trilafon and see if he had adverse reactions. The patient did receive Trilafon while on the floor and never experienced adverse effects. The most likely contributors to his waxing and [**Doctor Last Name 688**] mental status on those first few days on the floor are poly-pharmacy and metabolic derangement. He had a recent Folate and B12 one month ago that were normal. He had a negative urinalysis and urine culture. He had negative blood cultures. He had an RPR that was negative. He had no headache, meningismus, cough, abdominal pain, or urinary symptoms. He had had a recent head computerized tomography scan that was negative. There was no medical illness we could discover that was contributing to these shifts in consciousness. Over the next several days, the patient's mental status began to clear as medications were taken off of his list and as the Oxycontin was tapered. Over the last two days of his stay in the hospital, he was much clearer in his thinking and although occasionally confused, never became agitated or required chemical or physical restraint. We suggested a rehabilitation stay - he would only go to [**Hospital1 **] (but was not accepted), so he was discharged to home. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Home. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (NamePattern1) 106446**] MEDQUIST36 D: [**2139-12-10**] 14:13 T: [**2139-12-10**] 15:57 JOB#: [**Job Number 106447**]

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Discharge summary

report

Admission Date: [**2185-8-14**] Discharge Date: [**2185-9-23**] Date of Birth: [**2136-11-16**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p scooter crash Major Surgical or Invasive Procedure: 1. Anterior cervical decompression and diskectomy at C4-5, C5-6 and C6-7. 2. Anterior fusion, C4 to 7. 3. Anterior instrumentation C4-7. 4. Structural allograft. 5. Closed reduction of nasal fractures 6. Open tracheostomy. 7. Central line placement History of Present Illness: This is 48 year-old male who fell off his moped while intoxicated and not wearing a helmet. +LOC and amnesia of events of injury. The patient was transported to [**Hospital6 33**] where he was found to have nondisplaced fracture through the body of C3 and fracture of the posterior element of C4 as well as fractures of the nasal bones and right frontal sinus bones but no intracranial hemorrhage. He was transferred by ambulance to [**Hospital1 18**]. Past Medical History: Depression NIDDM (diet/exercise-controlled) h/o DVT Social History: Alcohol Tobacco Family History: Noncontibutory; no FHx of neurologic disease Physical Exam: On arrival: Afebrile P85 BP139/76 R20 95%O2 Gen: Awake and alert, intoxicated. No acute distress. HEENT: Normocephalic. Large complex right supraorbital laceration with exposed, fractured bone in wound bed. Superficial laceration over bridge of nose and over upper lip. PERRL, EOEMI, vision grossly intact. No midface instability or step-offs. Dentition in place, no oral lacs. No nasal septal hematoma. TMs clear. Neck: + collar. trachea midline Chest: Atraumatic. Equal breath sounds bilaterally CV: Regular rate and rhythm, S1S2. Abd: Soft, nontender. FAST negative for free fluid/pericardial effusion. Back: Nontender, no stepoffs. Atraumatic. Pelvis/Rectal: Pelvis stable. Rectal exam with normal tone, no blood. Ext: MAE, motor/sensory exam grossly normal. Well-perfused. Pertinent Results: [**2185-8-14**] 07:53AM GLUCOSE-165* UREA N-10 CREAT-0.6 SODIUM-137 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15 [**2185-8-14**] 07:53AM ALT(SGPT)-17 AST(SGOT)-29 ALK PHOS-62 AMYLASE-38 TOT BILI-0.6 [**2185-8-14**] 07:53AM CALCIUM-8.5 PHOSPHATE-2.7 MAGNESIUM-1.7 [**2185-8-14**] 07:53AM WBC-14.7* RBC-3.50* HGB-11.8* HCT-34.6* MCV-99* MCH-33.6* MCHC-34.0 RDW-13.1 [**2185-8-14**] 07:53AM NEUTS-91.2* LYMPHS-6.5* MONOS-2.2 EOS-0 BASOS-0 [**2185-8-14**] 07:53AM MACROCYT-1+ [**2185-8-14**] 07:53AM PLT COUNT-147* [**2185-8-13**] 11:12PM PO2-48* PCO2-46* PH-7.34* TOTAL CO2-26 BASE XS--1 COMMENTS-GREEN TOP [**2185-8-13**] 11:12PM GLUCOSE-189* LACTATE-2.6* NA+-141 K+-4.3 CL--103 [**2185-8-13**] 11:12PM HGB-12.4* calcHCT-37 O2 SAT-80 CARBOXYHB-1 MET HGB-1 [**2185-8-13**] 11:12PM freeCa-1.05* [**2185-8-13**] 11:05PM UREA N-16 CREAT-0.8 [**2185-8-13**] 11:05PM AMYLASE-53 [**2185-8-13**] 11:05PM ASA-NEG ETHANOL-154* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2185-8-13**] 11:05PM WBC-17.3* RBC-3.73* HGB-12.9* HCT-37.0* MCV-99* MCH-34.5* MCHC-34.8 RDW-13.0 [**2185-8-13**] 11:05PM PLT COUNT-191 [**2185-8-13**] 11:05PM PT-12.0 PTT-22.7 INR(PT)-1.0 [**2185-8-13**] 11:05PM FIBRINOGE-219 CT RECONSTRUCTION [**2185-8-13**] 11:50 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: fx? [**Hospital 93**] MEDICAL CONDITION: 48 year old man s/p scooter accident, no helmet REASON FOR THIS EXAMINATION: fx? CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Status post scooter accident without a helmet. Outside hospital cervical spine CT suggested that the C3 vertebral body and C4 posterior elements are fractured. COMPARISON: No comparison studies in PACS. TECHNIQUE: Axial multidetector CT images of the cervical spine were obtained. Sagittal and coronal reconstructions were performed. FINDINGS: There is a fracture of the spinous process of C4 which extends to the right lamina. There are prominent nutrient foramina within the body of C3. No definite C3 fracture is identified. There is swelling in the prevertebral soft tissues, concerning for traumatic injury. There is spondylosis and disc space narrowing at C5/6. There is a 9 x 6 mm focus of dependent soft tissue in the trachea, which may represent secretions versus a polypoid lesion. IMPRESSION: 1. C4 spinous process fracture extending into the right lamina. No definite C3 fracture. 2. Prevertebral soft tissue swelling. Further evaluation by MRI may be helpful. 3. Dependent secretions versus polypoid lesion in the trachea. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2185-8-13**] 11:47 PM CT SINUS/MANDIBLE/MAXILLOFACIA; CT RECONSTRUCTION Reason: r/o fx [**Hospital 93**] MEDICAL CONDITION: 48 year old man with fall from moped onto head/face without helmet REASON FOR THIS EXAMINATION: r/o fx CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Status post scooter accident without a helmet. Outside Hospital CT suggests facial fractures. COMPARISON: No previous studies in PACS. TECHNIQUE: Axial multidetector CT images of the facial bones were obtained without intravenous contrast. Sagittal and coronal reformatted images were obtained. FINDINGS: There is a comminuted fracture of the anterior wall of the right frontal sinus, with a free fragment that is depressed into the sinus. The posterior wall of the sinus is intact. There is fluid and mucosal thickening within the sinus. There is a laceration overlying the fracture. Multiple nasal bone fractures are present bilaterally, with angulation of the distal fracture fragments to the left. There is mucosal thickening and probably also fluid in the ethmoid air cells bilaterally. Mild mucosal thickening is present in the maxillary and sphenoid sinuses. IMPRESSION: 1. Fracture of the anterior wall of the right frontal sinus with a depressed free fragment. 2. Multiple nasal bone fractures. MR L SPINE SCAN [**2185-8-16**] 8:32 AM MR L SPINE SCAN Reason: acute changes in the L-spine [**Hospital 93**] MEDICAL CONDITION: 48 year old man s/p trauma with weakness involving the right ankle REASON FOR THIS EXAMINATION: acute changes in the L-spine CLINICAL INFORMATION: Status post trauma with right ankle weakness. MRI OF THE LUMBAR SPINE. FINDINGS: There is a right-sided focal disc protrusion at L5-S1 with slight displacement of the right S1 nerve root sleeve. There is no evidence of canal or foraminal stenosis. There is no evidence of abnormal signal to suggest the presence of an acute vertebral body fracture or ligamentous injury. IMPRESSION: Right-sided disc herniation at L5-S1 with features as discussed above. MR HEAD W & W/O CONTRAST [**2185-8-19**] 4:40 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Reason: with DWI and gadolinium, eval for evidence of brain injury Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 48 year old man with recent onset seizure, ?hypoxic brain injury REASON FOR THIS EXAMINATION: with DWI and gadolinium, eval for evidence of brain injury MRI OF THE BRAIN. CLINICAL INFORMATION: Patient with question of brain injury, for further evaluation. TECHNIQUE: T1 sagittal and axial and FLAIR, T2, susceptibility and diffusion axial images of the brain were obtained before gadolinium. T1 sagittal, axial and coronal images were obtained following the administration of gadolinium. Correlation was made with the head CT examination of [**2185-8-18**]. FINDINGS: The diffusion images demonstrate no evidence of slow diffusion. The ventricles and extraaxial spaces are normal in size. There is no evidence of midline shift, mass effect, or hydrocephalus seen. No evidence of acute or chronic blood products is seen within the brain. Extensive soft-tissue changes are seen in the paranasal sinuses, which could be related to intubation. The basal cisterns are patent. There is no evidence of tonsillar herniation. The vascular flow voids are maintained. Following gadolinium administration, no evidence of abnormal parenchymal, vascular or meningeal enhancement identified. Mild soft-tissue swelling is seen in the right parietal scalp region. IMPRESSION: No significant intracranial abnormalities detected on the MRI of the brain with and without gadolinium. Soft-tissue changes in the paranasal sinuses and mastoid air cells could be related to intubation. No abnormal enhancement seen. OBJECT: BEDSIDE EEG FROM [**8-28**] TO [**8-29**] TO [**8-30**] [**2184**]. 48-YR-OLD MAN WITH S/P SEIZURES. REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] FINDINGS: The recording begins at 7:[**9-23**]. The background rhythm is low voltage and supressed with intermittent fast activity and low voltage bursts of generalized slowing. Through the record there are several brief runs with rhythmic, moderate voltage 2 Hz delta frequency slowing [**Hospital1 **]-frontal predominance with occasional sharp features, lasting 5-30 seconds. In addition there are, bursts of generalized sharp slow wave discharges seen. CARDIAC MONITOR: Normal sinus rhythm with a rate of 96 bpm. IMPRESSION: This is an abnormal discontinued 48 hour bedside telemetry from [**8-28**] to [**8-30**] and shows a severe encephalopathy consistent with medication induced suppressive coma. There are brief episodes of rhythmic, generalized [**Hospital1 **]-frontal predominent delta frequency slowing with sharp features, these findings are consistent with brief electrographic seizures. Regarding the previous EEG recording, these brief seizures seem to be less pronounced and more brief. Also the seizures in the previous recording seem to correlate with discontinued Propofol. CHEST (PORTABLE AP) [**2185-9-20**] 11:36 AM CHEST (PORTABLE AP) Reason: interval change? consolidation? [**Hospital 93**] MEDICAL CONDITION: 48 year old man s/p scooter crash, tracheostomy, anoxic brain inj, frequent suctioning, acute breathing change this morning REASON FOR THIS EXAMINATION: interval change? consolidation? INDICATION: Status post motor vehicle collision, frequent suctioning, acute respiratory change. COMPARISON: Chest x-ray from [**2185-9-19**]. SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: Again seen is left lower lobe consolidation with air bronchograms as well as an associated elevation of the left hemidiaphragm, suggestive of atelectasis. A tracheostomy tube is in place. The cardiac and mediastinal contours are unchanged within normal limits. The right lung is clear. IMPRESSION: Persistent left lower lobe atelectasis with associated left hemidiaphragm elevation. These findings were discussed with Dr. [**Last Name (STitle) **] at the time of dictation. Brief Hospital Course: On arrival, the patient was hemodynamically stable and complained of face and neck pain but no numbness, tingling, or back pain. His initial evaluation confirmed the cervical spine and facial fractures. Antibiotics were given for the facial fractures and laceration and the Plastic Surgery service saw the patient in the ED. The Spine Surgery service was also consulted; a repeat neurologic exam revealed a right foot drop. The patient was admitted to the floor on the Trauma Surgery service. 1) C-spine fracture: The patient was kept in a hard cervical collar until HD 2, when the patient was taken to the OR for an anterior cervical decompression and diskectomy at C4-5, C5-6 and C6-7 and an anterior fusion with instrumentation at C4 to 7. Please see the operative note for details. Postoperatively he was moving all extremities with intact sensation and full strength other than the foot drop. He was observed in the PACU and then transferred to the floor. Physical and Occupational therapies consulted and have recommended acute rehabilitation after discharge from hospital. 2) Nasal fracture: The patient underwent closed reduction on [**2185-8-16**] (at the same time as the spine surgery). Please see the operative note for details. 3) Hypoxic brain injury: The night after surgery the patient began coughing and having difficulty breathing. A Code Blue was called; patient vitals were noted as BP 109/70, HR 52, O2 50-60%. Per the anesthesia note, there were two unsuccessful attempts at direct laryngoscopy. An LMA was placed, and using fiber optic scope, an ETT was passed. The patient was transferred to the TICU and was sedated on propofol. After the propofol was discontinued, the patient began having seizure-like jerking of his extremities. Neurology was consulted and an EEG was obtained, which was read as consistent with status epilepticus. The patient was loaded on dilantin; phenobarbitol and depakote were also started when dilantin alone failed to control the movements. Repeated EEGs showed decreased seizures, which was confirmed by physical exam. The patient regained alertness slowly in the ICU and then on the floor and was able to respond to questions by nodding his head. He was observed to have episodes of extremity shaking but while conscious; these were felt to be a postural tremor and not seizures. His seizure medications were slowly decreased in dosage with daily monitoring of drug levels. On [**9-8**] the patient was noted to have some brief, self-resolving tonic-clonic seizures. He was reloaded on dilantin, as that day's level was low (previous level had been in therapeutic range) and was transferred from the floor to the step-down unit. Patient seen and evaluated by Behavioral Neurology for his brain injury. 4) Tracheostomy: Given the patient's respiratory distress on the floor and difficult intubation, he underwent an open tracheostomy on [**8-23**]. He requires intermittent suctioning because of mucous plugging. He is on scheduled nebulizer treatments as well. 5) Diabetes: He has a history of NIDDM and has been followed closely by [**Last Name (un) **] Diabetes Center during his hospitalization. He is currently on Humalog sliding scale and Lantus qhs. Medications on Admission: Paxil Xanax no diabetes medications Discharge Medications: 1. Colace 150 mg/15 mL Liquid Sig: Thirty (30) ML PO twice a day: Give via G-tube. 2. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-26**] Drops Ophthalmic PRN (as needed). 4. Senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a day): Give via G-tube. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed: give via G-tube. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Give via G-tube. 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Give via G-tube. 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): Hold for HR less than 60 and SBP less than 110 mm Hg. 11. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 16. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1) PO Q8H (every 8 hours). 17. Phenytoin 50 mg Tablet, Chewable Sig: 6.5 Tablet, Chewables PO TID (3 times a day): Name brand only DIlantin, OK by Pharmacy to crush. 18. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 19. Phenobarbital 20 mg/5 mL Elixir Sig: One (1) PO Q12H (every 12 hours). 20. Lantus 100 unit/mL Solution Sig: Thirty Six (36) units Subcutaneous at bedtime: . 21. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous every six (6) hours: Per Sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: s/p Scooter crash C4 spinous process fracture Right frontal sinus fracture Multiple nasal bone fractures Right foot drop Discharge Condition: Stable Discharge Instructions: Follow up in Trauma Clinic after discharge from hospital. Followup Instructions: Follow up in Trauma Clinic in one month, call [**Telephone/Fax (1) 6439**] for an appointment. Completed by:[**2185-9-23**]

[ "736.79", "305.00", "873.43", "799.1", "997.3", "806.00", "802.0", "345.3", "250.00", "E819.2", "438.82", "801.52", "348.1" ]

icd9cm

[ [ [] ] ]

[ "31.1", "86.59", "81.63", "43.11", "96.6", "21.71", "81.02", "03.53" ]

icd9pcs

[ [ [] ] ]

16144, 16214

10832, 14052

332, 582

16379, 16388

2048, 3394

16494, 16620

1189, 1235

14138, 16121

9957, 10081

16235, 16358

14078, 14115

16412, 16471

1250, 2029

275, 294

10110, 10809

610, 1065

1087, 1140

1156, 1173

18,188

104,587

18658

Discharge summary

report

Admission Date: [**2124-10-10**] Discharge Date: [**2124-10-14**] Date of Birth: [**2085-2-11**] Sex: F Service: HISTORY OF PRESENT ILLNESS: Patient is a 39-year-old state trooper, who was diagnosed with squamous cell carcinoma of the left neck, which was resected. She did well for approximately a year and about nine months started developing progressive sensory symptoms over the left neck and jaw. Initially started with some numbness over the left earlobe above the surgical site followed by burning sensation in the jaw. She then noticed when she brushed her hair behind her ear, it felt raw. Pain that went down the neck to the chest and shoulder area. For the past month, these symptoms have been relatively stable without progression. On direct questioning, she and her husband, who is here with her cooberates some difficulty with short-term memory which has worsened in the past year or so. A MRI scan of the head shows a third ventricle hyperintense lesion in T1 weighted images, which does not enhance causing mild-to-moderate increased size in the lateral ventricles. There is no significant transependymal fluid noted on T2 weighted images, and the cerebellar tonsils are a little bit low lying, but just at the level of the foramen magnum. The fourth ventricle was normal in size and the corporis callosum is thin throughout relatively uniformly. PHYSICAL EXAMINATION: On physical exam, she is awake, alert, and fully oriented. Speech is normal and fluent. Cranial nerves are normal. Strength is normal throughout. Gait is normal. Sensory examination reveals some decreased touch sensation over the left neck posterior to the ear and the occipital areas as well as along the neck to the upper part of the anterior chest. Left neck neuropathic symptoms concerning for a perineural invasion. On MRI scan of the head, the third ventricles tumor is an incidental finding. Dr. [**First Name (STitle) **] felt that this was most likely a colloid cyst, and the patient was given an option for VP shunt and watching colloid cyst or drainage. Patient opted for resection of the colloid cyst. Patient underwent transcallosal resection of the third ventricle colloid cyst without intraoperative complication. Postoperatively, the patient was monitored in the ICU without complication. Postoperatively, she was monitored in the Surgical ICU. There were no intraoperative complications. Postoperatively, patient was alert, awake, oriented, following commands. Motor strength is [**5-15**] in all muscle groups. Face is symmetric. Pupils are equal, round, and reactive to light. EOMs were full. Tongue was midline, good language skills. Patient had ventricular drain in place that was level 10 meters about the tragus draining 45 cc to 10 cc over postoperative day #2. Head CT was performed on [**2124-10-11**]. CT scan showed no hemorrhages, showed good size of ventricles with decompression of the ventricles. The vent drain was removed on [**2124-10-13**], and the patient after having it clamped which showed no evidence of hydrocephalus, the patient was transferred to the regular floor on [**2124-10-13**]. She remained neurologically stable. The patient was discharged home on [**2124-10-14**] for followup with staple removal on postoperative day #10 and follow up in the Brain [**Hospital 341**] Clinic in two weeks. MEDICATIONS AT TIME OF DISCHARGE: 1. Nicotine patch once a day. 2. Percocet 1-2 tablets p.o. q.4h. prn for pain. 3. Dilantin 100 mg p.o. t.i.d. for seven days and then discontinue. CONDITION ON DISCHARGE: Stable at the time of discharge. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2124-12-20**] 11:18 T: [**2124-12-22**] 11:01 JOB#: [**Job Number 51200**]

[ "355.9", "496", "V10.82", "305.1", "742.4", "331.4" ]

icd9cm

[ [ [] ] ]

[ "01.59", "02.2" ]

icd9pcs

[ [ [] ] ]

1412, 3560

158, 1389

3585, 3898

26,141

138,781

21853

Discharge summary

report

Admission Date: [**2119-9-24**] Discharge Date: [**2119-10-2**] Date of Birth: [**2051-7-29**] Sex: M Service: MED Allergies: Ace Inhibitors / Niferex / Metoclopramide / Angiotensin Receptor Antagonist Attending:[**First Name3 (LF) 10223**] Chief Complaint: Angioedema Major Surgical or Invasive Procedure: Intubation/extubation History of Present Illness: 68 yo male with history of CAD s/p CABG, CRI and HTN presents from OSH with angioedema of tongue. Pt noticed angioedema at 7:30 pm on [**9-23**]. He had no trouble breathing but noted dysarthria and drooling, as well as the sensation that he could not keep his tongue in his mouth. He had no recently prescribed meds, but had restarted lisinopril 2.5mg in [**4-11**] per his PCP. (Of note, per his home pharmacy, he only filled the prescription on [**2119-9-16**], but per the [**Hospital1 2025**] pharmacy, he filled the prescription both in [**2119-6-8**], as well as in [**2119-1-8**]. The patient cannot supply more history.) He also started terazosin [**6-11**]. The patient had also taken one sip of cough medicine the night before the event. He denies new foods, shellfish, or berries. On specific questioning, the patient reported a new cough for 2 days prior to the episode. * The patient was originally taken to [**Hospital 4199**] hospital, where his initial O2 sat was 95%RA. He was started on empiric steroids (solumedrol and decadron), benadryl, zantac, epi 0.3 sc, and transferred to [**Hospital1 18**] later in the evening. * On arrival at the [**Hospital1 18**], the patient felt that the swelling was slightly increased. O2 sat was 97-98%2L and he had no stridor. ENT performed a scope and noted some swelling of soft palate without vocal cord swelling. Re-scope 30 minutes later showed bilateral edema of false vocal cord. An elective intubation for airway protection was performed in the ER (early AM [**9-24**]). * The angioedema was considered to be due to a lisinopril allergy. Over a 3-day MICU stay, the patient was treated with solumedrol, benadryl, and famotidine IV. He was seen by the allergy and renal teams. His acute on chronic renal failure was considered secondary to a brief episode of hypotension (unclear whether this occurred at OSH or in transit), while his underlying CRF was considered secondary both to HTN and due to atheroemboli after his CABG (there was a rapid increase in Cr after CABG). His Cr on arrival was 4.9; this rose to 5.8 on [**9-24**], then fell. The sequelae of his renal failure were treated as follows: The patient's hyperkalemia was treated with kayexelate. His metabolic acidosis was treated with bicitra 30cc [**Hospital1 **]. His hyperphosphatemia was treated with Renagel. It was noted that the patient had previously been on Epo. The patient's HTN was also a problem, and he was treated with metoprolol 100 [**Hospital1 **], then with labetolol and nitrate drips. On [**2119-9-27**], the pateitn was noted to be tachycardic in the setting of T 100.1, on steroids. CXR showed early infiltrate/aspiration PNA, and sputum sample showed GNR. Ucx from [**2119-9-15**] likely d/t contamination. * On [**9-26**], the patient was extubtated. On [**2119-9-27**], he was transferred from the ICU to the floor. Past Medical History: 1. CAD, s/p MI [**2108**]. S/p cath [**2108**] (angioplasty of circ). Second cardiac cath revealed stenosis of OM. PTCA done of the OM lesion. Maintained on medical therapy. - S/p CABG x 6 [**3-12**] [**Hospital1 2025**] (cath showed 3vd: severely diseased RCA, severely diseased PDA, 80% LAD, severely diseased D1, 70% LFCX lesion, severely stenosed OM1). CABG: SVG to D1, SVG to circ marginal, SVG to RV marginal, SVG to PDA, LIMA to second diag, LIMA to LAD. - EF [**2-9**] 67%, mild LVH, trace MR, no WMA 2. Anemia. Started [**2-9**] on Epo and Iron. 3. CRI. 2.7-3.4 [**2119-2-9**], was 3.9 [**2119-8-9**]. 4. TCC, unclear. 5. Colonic polyps 6. Gastritis 7. Hematuria 8. Hyperlipidemia 9. HTN 10.BPH 11.Tubular adenoma 12.UTI 13.DJD 14.+PPD 15.S/p appendecomy 16.S/p lumbar surgery Physical Exam: On admission to [**Hospital1 18**] ER: 84 160/85 22 97%RA A+Ox3, extremely dysarthric RRR, no M/R/G Lungs clear, no stridor Abd mildly obese, soft, nontender, nondistended, +BS No LE edema No visible rashes Tongue extremely swollen, protruding slightly past lips. No lip swelling. * On transfer to the floor: A+Ox3, still with some dysarthria and swollen tongue. Patient with mild SOB - breathing heavily at rest, using accessory muscles. No lymphadenopathy EOMI, PERRL, MMM, no lesions or o/p erythema seen RRR, no murmurs, JVP 6cm Abd soft, mildly distended, NT, hypoactive BS Extr no edema Neuro grossly intact Pertinent Results: [**2119-9-27**] 06:07AM BLOOD WBC-14.6* RBC-3.82* Hgb-10.8* Hct-31.5* MCV-82 MCH-28.1 MCHC-34.1 RDW-15.5 Plt Ct-217 [**2119-9-27**] 06:07AM BLOOD Plt Ct-217 * [**2119-9-27**] 12:44AM BLOOD UreaN-60* Creat-3.3* Na-141 K-3.3 Cl-109* HCO3-18* AnGap-17 [**2119-9-27**] 06:07AM BLOOD Glucose-200* UreaN-61* Creat-3.3* Na-141 K-4.1 Cl-110* HCO3-18* AnGap-17 [**2119-9-27**] 04:50PM BLOOD K-4.0 * [**2119-9-27**] 12:44AM BLOOD CK(CPK)-129 [**2119-9-27**] 12:44AM BLOOD CK-MB-3 cTropnT-<0.01 [**2119-9-27**] 04:50PM BLOOD Phos-3.8 Mg-2.1 [**2119-9-27**] 06:07AM BLOOD Calcium-8.2* Phos-4.1 Mg-2.0 [**2119-9-27**] 12:44AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.1 * [**2119-9-25**] 04:01PM BLOOD calTIBC-243* Ferritn-150 TRF-187* Brief Hospital Course: A/P: 68yo M with PMH significant for CAD s/p MI '[**08**] and CABG [**3-12**], HTN, and CRF, transferred [**2119-9-27**] from the MICU, after presentation on [**9-23**] with angioedema likely d/t lisinopril allergy, s/p intubation for airway protection and extubation [**2119-9-26**]. * 1. Resolving angioedema. Was on solumedrol 80mg IV q8, benadryl, and famotidine IV in ICU. - [**9-27**]: Changed solumedrol 80mg IV q8 to prenisone 80mg po taper over 8 days. - Continued famotidine and benadryl IV initially on the floor, then d/c'ed these [**9-29**]. - C4 and C1 inhibitor function, CH50, serum tryptase - pending at the time of discharge. - Counseled the patient against using ACEI or [**Last Name (un) 11823**]. - F/u appt made with allergy and with PCP. . 2. HTN. Was on nitro and labetalol drips in unit until noon [**9-27**]. - Metoprolol 100po tid, amlodipine 10po qd, isosorbide dinitrate 20mg po tid. - Added hydral 50mg po q6 on transfer to floor; increased it on [**9-29**] to 50po q6, and on [**9-30**] to 75po q6. Increased it on [**10-1**] to 100po q6 and pt had low BP's and felt dizzy --> Back to 75mg po q6. - 40mg lasix [**Hospital1 **] * 3. ID. Pt with mild SOB. CXR showed possible PNA. Endotracheal sputum from [**9-25**] showed GNR and GPC in pairs, which was confirmed to be H. flu. - PNA: Initially treated empirically with vanc (renal dose 1mg q48h) and zosyn (2.25mg IV q8h). When culture data became available, vanc was d/c'ed. The patient was changed from zosyn to augmentin po. - BACTEREMIA: Low grade temps (high 100.1) on [**2119-9-27**]. Bcx showed GPC in pairs, chains, and clusters in [**1-9**] bottles. Culture data showed Group B strep. The patient was maintained on augmentin for coverage of GBS bacteremia as well. - Two sets of surveillance cultures were negative afterwards. - The patient was kept in the hospital an extra day as the WBC increased to 21, but the patient remained well-appearing and afebrile. * 4. CRF/ARF. Pt has had progressive renal failure, with creatinine increasing from 2.2 in [**2-9**] to 3.9 (baseline on admission, from [**2119-8-9**] at [**Hospital1 2025**]). Rapidly progressing renal failure from [**2-9**] to [**8-12**] after CABG likely due to ateroemboli with underlying renovascular disease/HTN nephrosclerosis. Additional ARF on this admission, to a peak of Cr 5.8 was likely secondary to a transient episode of hypotenion with decreased renal perfusion. Negative for urine eo's. Foley was d/c'ed on [**9-27**] with nl U/O. - Metabolic acidosis, likely secondary to renal failure. The patient was initially placed on bicitra 30cc [**Hospital1 **]; this was d/c'ed on [**9-29**]. - Pt was given lasix 40 po bid in ICU, which was increased on transfer to floor 60mg po bid, as was positive net 3L. With achievement of more euvolemic status, pt was then switched back to lasix 40 [**Hospital1 **]. - Had been on renagel 1600 qd in unit; d/c'ed [**9-29**]. - Hyperkalemia - resolved. On pt's last day of admission, K was repleted. * 5. Steroid-induced hyperglycemia - On RISS, poorly controlled in ICU (190's). Scale increased on transfer to floor. - Pt not d/c'ed on [**9-29**] d/t poor glucose control; glipizide lowest dose begun on [**9-29**], with better but not great control of sugars. BS remained in low 200's. * 6. Anemia. Hct stable, on famotidine. ACD by labs. Black stool x 1 on [**9-27**], by pt's report. Guiac negative on exam. No further reports; hct stable. Transfusion goal was for hct < 27. * 7. CAD - Continued lipitor, aspirin, beta blocker. Enzymes were cycled in ICU; patient was ruled out for MI. * 8. Hypoparathyroidism - PTH 243 at OSH, had been on calcitriol. - Can consider restarting this as an outpatient. * 9. GERD - H2 blocker * 10. BPH - Continued terazosin. 11. PPX- H2 blocker, SQ heparin, bowel regimen * 12. Contact info - HCP - Unknown (married in past but lives alone now, no contact info available for wife in [**Male First Name (un) 1056**]). Per [**Hospital1 2025**] records, emergency contact is [**Name (NI) 8369**] [**Name (NI) 57331**]. [**Telephone/Fax (1) 57332**] (disconected). Does have a son in [**Male First Name (un) 1056**]. . PCP= [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 2025**]/[**Location (un) **]. Nephrologist is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 2025**]/[**Location (un) **]. Cardiologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Hospital1 2025**]) [**Telephone/Fax (1) 57333**] ([**E-mail address 57334**]). * 13. Access - PIV * 14. FC Medications on Admission: MEDS ([**2119-6-22**]): Norvasc 10 QD Ecotrin 325 HCTZ 25 Isordil 40 QID Lipitor 40 Metopriolol 150 [**Hospital1 **] Plavix 75 (per PCP; will have to confirm with cardiologist [**Hospital1 2025**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) Nexium 40 Norvasc 10 Renegel 400 TID Terazosin 5 (apparently started [**6-11**]) Zestril 2.5 Acetaminophen 1000 q4 PRN. * PCP and cardiologist [**Name (NI) 653**] to figure out recent meds. Records a bit convoluted. Apparently he has received meds from 3 different pharmacies ([**Doctor Last Name **] [**Location (un) **] [**Telephone/Fax (1) 57335**]; [**Hospital1 2025**] outpatient [**Telephone/Fax (1) 57336**]; [**Hospital1 2025**] [**Location (un) **] [**Telephone/Fax (1) 57337**]). Discharge Medications: 1. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 2. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO twice a day. 4. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 5. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 6. Terazosin HCl 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Amoxicillin-Pot Clavulanate 250-125 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 8. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Prednisone 10 mg Tablet Sig: Saturday: Take 5 pills at bedtime. Sunday: Take 4 pills at bedtime. Monday: Take 3 pills at bedtime. Tuesday: Take 2 pills at bedtime. Wednesday: Take 1 pill at bedtime. Tablet PO As directed. for 5 days. Disp:*15 Tablet(s)* Refills:*0* 13. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Severe allergic reaction, likely secondary to lisinopril. Pneumonia (H. influenza) Bacteremia (GBS) Discharge Condition: Good Discharge Instructions: Please call 911 immediately if you experience any recurrence of drooling, tongue swelling, or difficulty breathing. * NEVER take ACE Inhibitors such as: lisinopril (zestril), captopril, lisinopril (zestril), quinapril, ramipril Never take any angiotensin receptor blockers ([**Last Name (un) 11823**]) such as: losartan (cozaar), valsartan (diovan), candesartan (atacond), irebesartan (avapro), telmisartan. You have an ALLERGY to these medications. Please go to the nearest pharmacy as soon as possible to get a medicalert bracelet, warning of these allergies. Also, DO NOT take robitussin until you have spoken with an allergist. * STOP taking your hydroclorathiazide (HCTZ). Lasix (Furosemide) will be in place of this. * NEW MEDICATIONS: 1) Predinsone for 5 days (decreasing amounts as directed) 2) Glipizide for 5 days 3) Lasix (Furosemide), instead of HCTZ 4) Augmentin for 10 days 5) Hydralazine Please address any difficulties swallowing or breathing with your primary care physician. Followup Instructions: You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 2025**]/[**Location (un) **] on Thursday, [**10-5**], at 4pm. * [**Telephone/Fax (2) 28339**]Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 1723**] Date/Time:[**2119-10-17**] 8:15

[ "790.7", "482.2", "276.7", "584.9", "272.0", "V45.81", "995.1", "403.91", "276.2", "E942.6" ]

icd9cm

[ [ [] ] ]

[ "96.04", "33.22", "96.71" ]

icd9pcs

[ [ [] ] ]

12252, 12258

5465, 10060

343, 366

12402, 12408

4727, 5442

13454, 13844

10864, 12229

12279, 12381

10086, 10841

12432, 13431

4092, 4708

293, 305

394, 3264

3286, 4077

32,733

191,244

50422+50423

Discharge summary

report+report

Admission Date: [**2148-8-4**] Discharge Date: [**2148-8-8**] Date of Birth: [**2106-11-23**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 603**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 41 yo F with PMH of IDDM, HTN, asthma who presents wtih 2 weeks of cough. She reports that her daughter was [**Name2 (NI) **] several wks ago with a cold and she started feeling [**Name2 (NI) **] with rhinnorhea and cough about 3 weeks ago. Over the last two weeks things have become worse. The cough is productive with green to yellow sputum. She has some dizziness and lightheadedness, poor food intake but trying to drink fluids and nausea but no vomiting. She endorses orthopnea and LLE swelling and pain for 2 weeks. Denies chest pain, palpitations. Her temperature at home was 99.6, +chills. She was avoiding coming to the doctor and she was taking albuterol nebulizer treatments every 3-4 hours at home but things were not getting better. . In the ED, vital signs initially were T 100.6 but rose to 101.3, HR 109, BP 156/82, O2sat 96% on 4L NC. Urine hCG was negative. She had a CXR which showed bilateral infiltrates. Ddimer was mildly elevated and U/S LLE was negative for clot. CTA chest was done which was negative for PE but showed LAD. She was given levofloxacin 750mg x1, several albuterol treatments, benadryl and tylenol. . On arrival to floors, she feels a little bit better. Still has some SOB but the chest tightness is improved. No n/v. No currently fevers or chills. +cough. No diarrhea or constipation. No dysuria or hematuria. No leg or arm pains. Pt states at basseline, she cooks and cleans at home, takes care of her 4 children and can walk 50 ft but gets SOB walking up 1 flight of stairs. Past Medical History: 1. DM: diagnosed 8 years ago, managed with nightly Lantus, Glucophage 2. Asthma: Never intubated but multiple hospitalizations 3. Obesity 4. HTN 5. Diastolic CHF: Echo [**7-5**] EF>60% 6. s/p Cesearean section [**7-5**] 7. h/o preeclampsia [**2146**] 8. ?sleep apnea no sleep study to date. Social History: 4 children ages 19, 16, 9 and 2. All but the 9 year old live with her. Smoked [**1-31**] ppd until 3 wks ago when she quit. No EtOH or other drug use. Family History: Mother- died of "blood clot" at age 42, also with asthma. Father- Died from DM complications at age 65, also with HTN. Cousin- with breast CA [**Name (NI) 12408**] DM [**Name (NI) 8765**] HTN Physical Exam: On arrival to floors: vitals: Tc 98.7 Tm 99.2 BP 142/86 P 95 R 22 O2 sat 91% on RA Gen- NAD, Comfortable in bed on nasal cannula HEENT- MMM, nl oropharynx Neck- No LAD CV- tachycardic, regular, no murmur appreciated Lungs- Decreased breath sounds at bases, occassional expiratory wheezes throughout Abd- + BS, Soft, NTND, obese Ext- no pitting edema, cyanosis. 2+DP bilaterally Pertinent Results: [**2148-8-4**] 02:30PM GLUCOSE-272* UREA N-7 CREAT-0.7 SODIUM-135 POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-30 ANION GAP-14 [**2148-8-4**] 02:30PM WBC-18.4*# RBC-4.62 HGB-11.0* HCT-38.6 MCV-84 MCH-23.9*# MCHC-28.6*# RDW-16.6* [**2148-8-4**] 02:30PM D-DIMER-526* CXR [**2148-8-4**] Pulmonary infiltrates at the lung bases (L>R), most likely representing infection. Atelectasis felt less likely. CTA [**2148-8-4**]: 1. No central or segmental pulmonary embolism, subsegmental PE cannot be excluded due to inadequate opacification of the distal pulmoanry artery branches. No aortic dissection. 2. Multifocal air space disease (multilobar pneumonia) with enlarged mediastinal lymph nodes, likely reactive. These warrant followup with a chest CT in three months after acute presentation subsides to ensure clearance. Also clinical correlation is advised to exclude Sarcoidosis for the adenopathy. CXR [**2148-8-7**]: As compared to the previous radiograph, the pre-described opacities that correspond to pneumonia are slowly resolving. There is no evidence of reactive pleural effusion. The size of the cardiac silhouette is unchanged. Brief Hospital Course: A/P: 41 yo F with PMH of asthma, DM2, diastolic CHF who presented with 2 week of worsening SOB on [**2148-8-4**]. . 1. SOB:Admission sputum culture w/ extensive contamination. Blood cultures negative at the time of discharge. CXR on admission with evidence of infiltrates at both base. Follow up CXR on [**8-7**] showed slowing resolving pneumonia. F/U Sputum culture [**8-7**]/ showed oropharyngeal contamination and no PCP. [**Name10 (NameIs) **] on ATC Albuterol and Ipratropium nebs here. Pt started on Levofloxacin and discharged with 2 days Rx to complete a 7 day course. After discussion with PCP, [**Name10 (NameIs) **] started on Advair in the hospital and discharged on the same. Pt was put on Prednisone here and recieved 3 doses at 60mg/day, 2 at 40mg/day and was discharged on 20 mg DAILY for 2 days. During her stay, the pt reported feeling well with baseline SOB on [**2148-8-7**] however pt remained hypoxic after exercise. On the day of discharge, pt had O2 Sat 94% on RA at rest which went to 85% with exercise. Thus, pt was discharged on home O2 to titrate O2 Sat to 88%. On day prior to discharge, pt's peak flow was 210. She reported her baseline was 250. Of note, a CTA chest on admission showed significant LAD which was recommended to be followed up with rpt CT in 3 months. 2. Tachycardia: Was seen on admission likely secondary to numerous albuterol nebs. Resolved on day 2 of hospitalization. . 3. DM2: Pt's diabetes was difficult to control on this hospitalization likely due to steroids with blood sugars from 90's to 400's. Pt was discharged on Lantus 25units DAILY (up from 20 units daily) and a new Humalog sliding scale as well as her prior dose of Metformin. . 4. Tobacco abuse: Pt was repeatedly encouraged to remain smoke-free during and after her hospital stay especially in light of her new home oxygen therapy. . Medications on Admission: Medications: -Metformin 1000mg [**Hospital1 **] -HCTZ 25mg daily -lantus 20 units at bedtime -combivent [**Hospital1 **] -proair (albuterol IH) -albuterol nebs prn Discharge Medications: 1. Home Oxygen 2L by NC 2L by NC continuously please titrate for O2 Sat >88% 2. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous at bedtime. 5. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 2 days: Take on [**8-9**] and [**8-10**]. Disp:*6 Tablet(s)* Refills:*0* 6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days: Take on [**8-9**] and [**8-10**] then stop. Disp:*2 Tablet(s)* Refills:*0* 7. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 9. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) treatment Inhalation Q4H (every 4 hours) as needed. 11. Insulin Lispro 100 unit/mL Solution Sig: One (1) injection Subcutaneous three times a day: Please inject according to sliding scale. Disp:*2 cc* Refills:*2* 12. syringes Please dispense 1 box syringes. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: Pneumonia Secondary Diagnoses: Asthma Exacerbation DM type II HTN CHF Discharge Condition: Good Discharge Instructions: You were admitted for pneumonia and an asthma exacerbation. You were treated here with 5 days of antibiotics. You are being sent home on 2 more days of antibiotics for a 7 day course as well as 2 more days of prednisone. You are also being sent home on oxygen until your lungs recover. We restarted you on the inhaled steroid Advair here after consultation with your primary care doctor. YOU MUST NOT SMOKE ANYMORE PARTICULARLY WHILE ON OXYGEN. Please return to the Emergency Room or call your docotr if you have increasing shortness of breath, chest pain, increasing cough, fever, chills, increased wheezing or any other worrisome symptoms. Followup Instructions: Dr. [**Last Name (STitle) **] at [**Hospital1 3578**] Monday [**8-12**] at 1p Completed by:[**2148-8-8**] Admission Date: [**2148-8-9**] Discharge Date: [**2148-8-11**] Date of Birth: [**2106-11-23**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 12077**] Chief Complaint: SOB, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 41 yo F with PMH of IDDM, HTN, asthma who presents with SOB. The patient states she developed right-sided pleuritic pain yesterday at time of discharge from the hospital after being treated for PNA and mild asthma flare. This pain got progressively worse over the night until it was [**11-8**] sharp chest pain. She was unable to sleep and became very short of breath due to the pain. She states she received minimal relief from her nebulizer and woke her daughter up at 4 am to take her to the ED. Patient states she has taken none of her medications since discharge because of this back pain. Patient did no lifting at home that strained her back. Patient states this pain in unlike the pain she got with shingles. . In the ED VS temp 96.4 hr 115 bp 140-180/60-77 rr 30-40 o2sat 74% RA by nursing notes and 99%/FM. ABG 7.39/60/116. PEFR 150 (baseline 250). Patient was given combivent *3, solumedrol 125 mg iv *1, mag 2 gm iv, levofloxacin 750 mg iv *1, and then started on a continuous albuterol nebulizer and sent to the MICU. . ROS: The patient denies any fevers or chills, nausea, vomiting. She continues to endorse a productive cough. No chest pain, + SOB. No urinary urgency, or dysuria. . Past Medical History: 1. DM: diagnosed 8 years ago, managed with nightly Lantus, Glucophage 2. Asthma: Never intubated but multiple hospitalizations 3. Obesity 4. HTN 5. Diastolic CHF: Echo [**7-5**] EF>60% 6. s/p Cesearean section [**7-5**] 7. h/o preeclampsia [**2146**] 8. ?sleep apnea no sleep study to date. Social History: 4 children ages 19, 16, 9 and 2. All but the 9 year old live with her. Smoked [**1-31**] ppd until 3 wks ago when she quit. No EtOH or other drug use. Family History: Mother- died of "blood clot" at age 42, also with asthma. Father- Died from DM complications at age 65, also with HTN. Cousin- with breast CA [**Name (NI) 12408**] DM [**Name (NI) 8765**] HTN Physical Exam: PE: Temp:97.6 BP 141/72, HR 103, RR: 25, O2 sat 90% 4LNC Gen: in mild distress HEENT: EOMI, neck supple, no JVD CV: tachy rate, regular rhythm, no m/r/g Pulm: poor airmovement throughout. minimal air movement right lower lung field, decreased tactile fremitus, no egophony. mild end espiratory wheezing. inspiratory halt due to pain when asked to take a deep breath Back: tender to palpation and light touch right side mid-back in dermatome distribution, no rash/lesions, no CVA tenderness Abd: obese, soft, non tender, normoactive bowel sounds Ext: no c/c/e, 2+ DP, no calf tenderness, bilateral legs equal in size Pertinent Results: chem-7: [**2148-8-8**] 05:20AM BLOOD Glucose-166* UreaN-13 Creat-0.6 Na-136 K-4.4 Cl-94* HCO3-36* AnGap-10 [**2148-8-9**] 06:10AM BLOOD Glucose-320* UreaN-12 Creat-0.7 Na-136 K-5.1 Cl-91* HCO3-34* AnGap-16. . cbc: [**2148-8-8**] 05:20AM BLOOD WBC-9.2 RBC-4.22 Hgb-10.2* Hct-34.9* MCV-83 MCH-24.1* MCHC-29.1* RDW-15.7* Plt Ct-587* [**2148-8-9**] 06:10AM BLOOD WBC-11.2* RBC-4.96 Hgb-12.1 Hct-41.1 MCV-83 MCH-24.3* MCHC-29.4* RDW-15.6* Plt Ct-647* [**2148-8-9**] 02:29PM BLOOD WBC-8.1 RBC-4.72 Hgb-11.3* Hct-39.3 MCV-83 MCH-24.0* MCHC-28.9* RDW-16.4* Plt Ct-633* [**2148-8-9**] 06:10AM BLOOD Neuts-69.5 Lymphs-22.7 Monos-6.5 Eos-1.0 Baso-0.3 [**2148-8-9**] 02:29PM BLOOD Neuts-84.2* Lymphs-13.3* Monos-1.5* Eos-0.4 Baso-0.6 . Cardiac enzymes: [**2148-8-9**] 06:10AM BLOOD CK(CPK)-216* [**2148-8-9**] 02:29PM BLOOD CK(CPK)-103 [**2148-8-9**] 09:21PM BLOOD CK(CPK)-87 [**2148-8-9**] 06:10AM BLOOD CK-MB-8 cTropnT-<0.01 proBNP-420* [**2148-8-9**] 02:29PM BLOOD CK-MB-6 cTropnT-<0.01 [**2148-8-9**] 09:21PM BLOOD CK-MB-NotDone cTropnT-<0.01 . Blood gases [**2148-8-9**] 07:37AM BLOOD Type-ART pO2-116* pCO2-60* pH-7.39 calTCO2-38* Base XS-9 . Lactate [**2148-8-9**] 06:19AM BLOOD Lactate-1.8 . Imaging: CXR: [**2148-8-9**]: stable enlarged pulmonary vasculature. unable to visualize left costophrenic angle due to technique. mild blunting of right costophrenic angle. Overall no significant change from prior [**2148-8-7**]. . CTA [**2148-8-9**]: IMPRESSION: 1. No pulmonary embolus or acute aortic abnormalities. 2. Overall, improvement in multifocal pneumonia. Decreased consolidation at the bases, but new foci in the right middle lobe. Interval decrease in size of hilar lymphadenopathy. . . ECHO [**2146**]: LVH, LVEF>55%, 1+ MR, 1+ AR, 2+ TR, mod pulm htn, and grade II diastolic dysfunction . ECG [**2148-8-9**]: rate 102, sinus, left axis deviation, LVH and RVH, markedly biphasic p-waves in V1-V3, suggesting left atrial enlargement, upsloaping ST/T segments V2-V4 similar morphology to prior, but with ST elevation 1mm, may represent early repol. . Brief Hospital Course: A/P: 41 yo F with PMH of IDDM, HTN, asthma who presents new onset *24 SOB in the setting of right-sided chest pain. . # SOB: Broad differential: Pt. was admitted to CCU for fear of PE, given history and [**Doctor Last Name **] of 6. CTA showed no evidence of pulmonary embolism. Patient was started emperically on heparin until CTA returned negative for PE, then it was stopped. MI was ruled out w/ three sets of negative enzymes (TropT < 0.02 x3). Also concerned with lateral ST elevations although upsloping, reassuring as similar in shape to prior, Also possible that this represents the begining of shingles outbreak or dermatomal pain from disc disease given patient's skin sensitivity and dermatomal distribution of pain. Patient has hx of R-sided zoster in the past, though she said it felt nothing like this. BNP was 420, unlikely CHF. Wegner's unlikely given no protein in urine. Patient with no new fevers, chills, cough improving to suggest worsening of infection. The pain decreased and she was transfered to a medicine floor where her pain was easily controlled w/ ibuprofen and she was weaned off oxygen. Pt. was set up for sleep study w/ respiratory but did not tolerate CPAP. . # Leukocytosis with normal diff: may be stress response to solumedrol depending on when labs were drawn, no left shift, no new fevers. U/A shows no bacteria, glucose in blood, no ketones. WBC 8.1 on day of d/c. . #Tachycardia: Pt had sinus tachycardia to the 120s that was unresponsive to fluid boluses (500 ml NS x2). BPs stable and in the 140s/70s. Pt has been documented w/ tachycardias ranging from 90 - 120 HR as an outpatient since [**2140**]. Denies CP or palpitations. Given obesity, CAD risk factors, and prolonged inactivity, likely patient is deconditioned. She was monitored on telemetry o/n and was asymptomatic. . # DM: restarted lantus and HISS as patient presented with high blood glucose in the setting of taking none of her home medications. . # Asthma: Did not appear to be significantly contributing to SOB, was kept on home meds . # HTN: cont HCTZ, bp poorly controlled on admission SBPs140-180s. Given patient is a diabetic would benefit from ACEi, she was started on 5mg lisinopril and her SBPs came down to the 120s on day of D/C. . # Diastolic CHF: Echo [**7-5**] EF>60%: She had no pleural effusions or leg swelling to suggest this was causing her SOB. BNP was <500 . # ? Sleep apnea: Pt. did not tolerate autoset CPAP. . Medications on Admission: Medications: (on discharge) 1. Home Oxygen 2L NC continuously please titrate for O2 Sat >88% 2. Metformin 1,000 mg [**Hospital1 **] 3. Hydrochlorothiazide 25 mg daily 4. Lantus 25 units QHS 5. Levofloxacin 750 mg daily for 2 more days [**8-9**], [**8-10**] Disp:*6 Tablet(s)* Refills:*0* 6. Prednisone 20 mg daily for 2 more days [**8-9**], [**8-10**] 7. Combivent 18-103 mcg [**Hospital1 **] INH 8. Fluticasone-Salmeterol 250-50 mcg [**Hospital1 **] INH 9. ProAir HFA 90 mcg/Actuation HFA Aerosol Q4H:PRN 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Q4HR PRN 11. Insulin Lispro 100 unit/mL at meals per sliding scale Discharge Medications: 1. Insulin Lispro 100 unit/mL Solution Sig: One (1) injection Subcutaneous three times a day: Please inject according to sliding scale 2 cc 2. 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation Q4 hours PRN as needed for shortness of breath. 3. Combivent Inhalation 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. Disp:*1 disk* Refills:*2* 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25) Units Subcutaneous at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary Back pain undetermined cause Secondary DM Glucophage Asthma Obesity HTN Diastolic CHF: Echo [**7-5**] EF>60% Discharge Condition: Stable Discharge Instructions: You have been diagnosed with back pain, we could not determine what caused it, we do not think that it is shingles. We added lisinopril 5mg to your high blood pressure medications. We stopped your prednisone and levofloxacin. We increased the dose of your advair to 500-50mcg twice a day. Please take all of your medications exactley as prescribed. Please continue your sliding scale insulin as you were taking before admission. If you experience any chest pain, shortness of breath, fever, chills, blood sugar greater than 400, confusion or any other concerning symptoms please call your doctor immediately or return to the emergency department. Followup Instructions: Please call [**First Name8 (NamePattern2) **] [**Doctor Last Name **] for an appointment within one week. Please call ([**Telephone/Fax (1) 9525**] for a sleep study or set this up through Dr. [**Last Name (STitle) **]. Completed by:[**2148-8-11**]

[ "401.9", "493.92", "486", "428.0", "428.32", "250.00", "327.23", "724.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

17408, 17414

13481, 15934

8816, 8822

17576, 17585

11401, 12126

18283, 18535

10556, 10749

16630, 17385

17435, 17555

15960, 16607

17609, 18260

10764, 11382

7654, 7695

12143, 13458

8761, 8778

8850, 10055

7623, 7633

10077, 10369

10385, 10540

52,452

127,542

54471

Discharge summary

report

Admission Date: [**2120-4-15**] Discharge Date: [**2120-4-24**] Date of Birth: [**2070-2-21**] Sex: F Service: MEDICINE Allergies: Flagyl / Serax Attending:[**First Name3 (LF) 1928**] Chief Complaint: respiratory distress, SOB Major Surgical or Invasive Procedure: intubation, mechanical ventilation bronchoscopy w/ BAL IJ placement History of Present Illness: Ms. [**Known lastname 48497**] is a 50 y/o F w/ Crohn's dz, anxiety, hx opiod abuse, bipolar depression w/ hx ECT and multiple suicide attempts, fibromyalgia, OSA (nonadherent w/ BiPAP) admitted from ED w/ PNA. Of note, she was discharged yesterday [**4-14**] after admission from falling off her bicycle due attributed to dizziness from recently starting Geodon. She had a CXR on [**4-13**] which showed mild pulmonary edema but no evidence of PNA. She reportedly presented to the ED today with back pain and difficulty breathing after having laid in bed all day. Per ED note, she had been having shortness of breath x1-2 days, with no associated chest pain, nausea or vomiting. She was BIBA EMS to ED w/ SaO2 100% on NRB. When NRB removed, she desaturated to 68% on RA. NC was attempted and since pt was satting 90% on 6L, NRB was replaced. In the ED, CXR was concerning for B/L PNA. she was given Vanco/Levo and Zosyn to cover for hospital acquired PNA, given recent hospitalization. In the ED VS: T 99.0 HR 102 BP 107/63 RR 18 SaO2 100% NRB initially, 77% on 2 L NC, 86% on 4L, 92% on 6L, 100% on NRB. Just prior to [**Hospital Unit Name 153**] transfer, pt was intubated for increased work of breathing/ respiratory fatigue. Past Medical History: 1. Chronic low back pain s/p MVC and L4-L5 discectomy in [**2108**]. 2. Chronic abdominal pain 3. Crohn's disease with h/o anal fistula 4. Depression with h/o ECT, psych admissions and multiple suicide attempts 5. S/p TAH-BSO for endometriosis 6. Ductal ectasia 7. H/o opioid abuse 8. Multinodular goiter 9. Cervical spondylosis with muscle contraction headaches 10. Fibromyalgia 11. Obstructive sleep apnea - doesn't use her BiPAP 12. Anxiety Social History: Lives with parents. 1ppd tobacco for 30 years. No EtOH or drugs. Retired postal worker. Family History: Sister died age 59 of colon CA. Brother with ?Crohn's. Sister with IBD. Physical Exam: Physical Exam on Admission to ICU VS: T 100.4 HR 104 BP 114/71 100% on ventilator settings GEN: intubated, sedated caucasian F appearing older than stated age, initially agitated but now in NAD HEENT: PERRLA, 5-->3 cm B/L, large pupils b/l CV: tachycardic, regular rhythm, nl S1, S2 no appreciable murmur LUNGS: coarse ventilated BS anteriorly B/L, B/L wet crackles ABD: +BS soft ND, cannot assess tenderness EXT: no edema B/L LE, 2+ distal pulses B/L NEURO: intubated, sedated, not responsive to voice (responsive to RN's sternal rub). Pertinent Results: [**Age over 90 **] |100| 5 ------------< 91 4.1 |27 | 0.6 LDH: 443 proBNP: 3862 MCV: 82 10.1 12.3 >------< 371 30.0 N:87.4 L:9.2 M:2.5 E:0.6 Bas:0.3 PT: 13.4 PTT: 27.7 INR: 1.1 IMAGING: CXR PA & LAT [**4-15**]- Increased bilateral left mid to lower lung > right mid to lower lung opacities with suggestion of air bronchograms, particularly on the left, worrisome for worsened infectious process/bilat pnas. rec clin [**Last Name (un) **]. superimposed mild edema not excluded TTE [**2120-4-16**]- The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a very small pericardial effusion. CT CHEST [**2120-4-17**]- Massive respiratory motion artifacts limit the interpretability of the study. The main findings are diffuse bilateral confluent pulmonary opacities. The opacities show a clear gradient of severity from the dependent towards the non-dependent lung regions, with predominant ground-glass and reticular opacities in the non-dependent and consolidations in the dependent lung regions. There are mild bilateral pleural effusions with maximum diameters of 1.3 cm on the left. Minimal paraseptal emphysema at the apex of the right upper lobe. Moderate mediastinal lymph node enlargement, the largest lymph node is located in left paratracheal location and measures 20 mm in diameter. No cardiac enlargement. No pericardial effusion. Nasogastric tube in situ. No evidence of abdominal abnormalities. Status post intubation, right central venous access line and gastric tube are in place. No evidence of coronary calcifications. No evidence of destructive bone lesions. IMPRESSION: The described CT findings are consistent with ARDS. Small right apical paraseptal emphysema. Mild mediastinal lymphadenopathy. No pneumothorax. Discharge labs: CBC: 6.3 > 9.1/27 < 500 Chem: 139| 101 | 12 < 91 4.3| 27 | 0.7 [**Doctor First Name **] positive 1:160 ANCA negative Sclerodermal Ab negative Brief Hospital Course: Ms. [**Known lastname 48497**] is a 50 year-old female who was admitted for worsening respiratory distress, consistent with ARDS. ICU Course: [**2120-4-15**]- [**2120-4-22**] 1. ARDS- Ms. [**Known lastname 48497**] arrived to the ICU from the ED intubated and sedated for increased work of breathing. She had initially arrived on NRB, but desatted to 68% on RA. Initially, the thought was pt had worsening B/L PNA, so she was treated for HAP in the ED w/ Vancomycin, Zosyn and Levofloxacin. In the ICU, TTE was done on [**4-16**] to evaluate potential component of heart failure that could contribute to pulmonary edema- TTE revealed normal biventricular function. She had CT chest done on [**4-17**] which was consistent with ARDS. Pt underwent bronchoscopy and had bronchoalveolar lavage which was unrevealing for any infectious etiology. The reason for her ARDS remains largely unclear. [**Name2 (NI) 1092**] surgery was consulted in the ICU to evaluate pt for possible VATS-mediated vs. open lung biopsy to help determine etiology of her respiratory failure, but at the time it was thought to be too risky to perform on this intubated pt. Due to prolonged sedation w/ propofol and concern for elevated triglycerides, Ms. [**Known lastname 48497**] was transitioned to sedation with ketamine after extensive discussion with pharmacy, with midazolam and zyprexa for agitation, which the patient tolerated well. (She did not tolerate sedation with versed/ fentanyl likely due to history of opiod abuse and multiple psychiatric medications). Ms. [**Known lastname 111476**] respiratory status continued to improve in the ICU; she was weaned from sedation and ventilator settings and eventually extubated on [**4-21**] with diuresis with lasix. Her BNP on admission was > 3000 and after diuresis was < 200. An 8 day course of Vancomycin/Zosyn and Levofloxacin was completed on [**4-22**] to cover for hospital-acquired pneumonia although she had negative cultures from her bronchoscopy. [**Doctor First Name **] was sent to evaluate for potential autoimmune process to explain her respiratory compromise and returned positive at 1:160 in diffuse pattern. Scleroderma antibodies and other autoimmune labs were pending at time of transfer out of ICU and will need to be followed. Pt will need outpatient pulmonology follow-up for further evaluate this once all her labs return. On the floor, she was continued on PO lasix (10mg every other day) and her supplemental O2 was weaned to 2-2.5L. She was discharged on home O2. 2. Anxiety/Bipolar d/o - patient's psychiatric medications were held during ICU course as pt was intubated and unable to take PO medications. Psychiatry evaluated pt in ICU who thought it was safe to hold psychiatric medications while intubated. On transfer to the floor, she was restarted on her home medications (pregabalin, duloxetine, and klonipin) 3. CROHN'S DISEASE- Mesalamine was held from [**Date range (1) 62159**] and restarted on [**4-22**] once pt was extubated and able to take PO medications. 4. ANEMIA - Hct on discharge was 27. She did not have recorded guaiacs on discharge, but she denied BRBPR or melena. She had no abdominal pain or diarrhea during her hospitalization. She will need serial Hct checks after discharge with her PMD to follow this issue. All other medical issues were stable and no changes in medications were made. Medications on Admission: 1. Pantoprazole 40mg daily 2. Mesalamine 2400mg [**Hospital1 **] 3. Pregabalin 225mg [**Hospital1 **] 4. Buprenoprhine-Naloxone 8-2mg 3 tabs daily 5. Duloxetine 120mg daily 6. Clonazepam 1mg QID (geodon, abilify and prozac d/c'd per recent d/c summary) Discharge Medications: 1. Pregabalin 75 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 2. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Six (6) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Four (4) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Lasix 20 mg Tablet Sig: [**12-2**] Tablet PO every other day. Disp:*30 Tablet(s)* Refills:*0* 5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*15 Tablet(s)* Refills:*0* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. oxygen therapy Home oxygen @ 2LPM continuous via nasal cannula, conserving device for portability Discharge Disposition: Home With Service Facility: Greater [**Location (un) 1468**] VNA Discharge Diagnosis: ARDS (Acute respiratory distress syndrome) Anxiety h/o Bipolar d/o Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with difficulty breathing. You were intubated in the ED and taken to the ICU. There, you were started on antibiotics for a pneumonia and you were found to have fluid in your lungs. You were given a medication to remove the fluid. Your oxygen level improved and you were taken off the ventilator and transferred to the floor. Your oxygen level is still improving, but you will need to continue using home oxygen for now. Medication changes: 1. Lasix was added to help remove fluid from your lungs Followup Instructions: Primary Care Doctor Appointment With: [**Last Name (LF) **], [**Name6 (MD) **] [**Name8 (MD) **] MD When: TUESDAY, [**5-7**], 1:45PM Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL GROUP Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 133**] *We are working on an appointment for you to see Dr. [**Last Name (STitle) **] in Pulmonary. The office will contact you with an appointment. If you have not heard from them, please call ([**Telephone/Fax (1) 3554**].

[ "724.2", "428.22", "486", "458.9", "327.23", "304.01", "790.01", "296.80", "555.9", "518.81", "241.1", "428.0", "721.0", "789.00", "300.00", "729.1" ]

icd9cm

[ [ [] ] ]

[ "38.91", "93.90", "96.04", "33.24", "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

9710, 9777

5215, 8602

301, 370

9889, 9889

2867, 5026

10599, 11157

2219, 2292

8906, 9687

9798, 9868

8628, 8883

10040, 10499

5042, 5192

2307, 2848

10519, 10576

236, 263

398, 1630

9904, 10016

1652, 2097

2113, 2203

15,843

192,396

54371

Discharge summary

report

Admission Date: [**2102-8-31**] Discharge Date: [**2102-9-1**] Service: MEDICINE Allergies: Shellfish Attending:[**First Name3 (LF) 2704**] Chief Complaint: Admission to CCU fpr monitoring s/p elective Stent to L ICA Major Surgical or Invasive Procedure: S/P L ICA stent History of Present Illness: HPI: 85 yo M with h/o CAD s/p CABG, s/p stent to SVG -> ramus, PTCA of prox. RCA, CHF (EF 25-30% in [**10-3**]), s/p BiV ICD [**1-3**], CVA, recent stent of R ICA in [**7-4**] for TIA who presents for elective stents to L ICA. During procedure, pt required neosynephrine to keep SBP >100. Neo was weanted at end of case. Pt reports no CP, no SOB, no changes in vision, no numbness or tingling. He does complain of bladder fullness. Past Medical History: Hypercholesterolemia, CABG in [**2083**], PTCA in [**2095**], [**2098**] to RCA and SVG. ICD placement [**1-3**]. ICA stents R ([**7-4**]) and L (this admission). Social History: The pt. lives alone, son lives down the street and is with him most of the time. He uses a walker at baseline. Has used alcohol and tobacco in the remote past, none now. Family History: 57 yo son with CAD Brother with DM. Physical Exam: PE: T 97 BP 90/61 HR 62 RR 14 Wt 105kg 100% O2 RA HEENT: R pupil scar, MMM, No exudates Neck: 8cm JVD, Nl thyroid Lung: Bilat crackles, L>R CV: RRR S1, Loud S2, crescendo/decrescendo murmur heard best at apex. Abd: RUQ tenderness, Soft, NABS Pulses: 1+ DP/PT, 2+ radial, no bruits. Pertinent Results: [**2102-8-31**] 05:45PM GLUCOSE-179* UREA N-16 CREAT-1.3* SODIUM-142 POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-28 ANION GAP-15 [**2102-8-31**] 05:45PM CK(CPK)-48 [**2102-8-31**] 05:45PM CK-MB-NotDone [**2102-8-31**] 05:45PM CALCIUM-9.3 PHOSPHATE-3.8 MAGNESIUM-2.1 [**2102-8-31**] 05:45PM WBC-4.0 RBC-4.36* HGB-14.4 HCT-42.7 MCV-98 MCH-33.1* MCHC-33.8 RDW-13.4 [**2102-8-31**] 05:45PM PLT COUNT-171 . Data: . Echo [**10-3**] The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the basal half of the inferior and inferolateral walls, distal septum and apex. The remaining walls are mildly hypokinetic. No masses or thrombi are seen in the left ventricle (does not exclude due to suboptimal apical image quality). The aortic root is moderately dilated. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-1**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. No definite cardiac source of embolism identified.Compared with the prior study (tape reviewed) of [**2101-5-31**], septal motion is less vigorous and the distal septum and apical dysfunction are now apparent c/w interim ischemia. Based on [**2093**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . Brief Hospital Course: 83 year old M with a history of CAD, TIA s/p R ICA stent in [**7-4**] now s/p L ICA stent [**8-31**] . 1. S/P L ICA stent today. Doing well except for hypotention. Will continue neo to keep SBP >100. Will cont. neuro changes. Hold antihypertension. Cont. ASA plavix, lipitor. -[**9-1**] Pt did very well overnight with no events. He will be discharged today on ASA, plavix, lipitor. HCT stable at 38. No chest pain and groin looks good. Will follow up with VNA nursing and Dr. [**Last Name (STitle) 12167**] next week. . 2. CHF. Follow I/O's. Will restart lasix in am depending on Creat. Watch pulm status. . 3. FEN. Heart Healthy Diet. No IVFs. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*5* 2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*20 Tablet(s)* Refills:*5* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 4. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*5* 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*1 bottle* Refills:*5* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*5* 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*5* 8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*5* 9. 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:*5* 10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 caps* Refills:*5* Discharge Disposition: Home With Service Facility: VNA of [**Location (un) 86**] Discharge Diagnosis: CAD s/p L ICA stent Discharge Condition: Stable Discharge Instructions: You should follow up with Dr. [**First Name (STitle) **] in 2 months You should re-start your high blood pressure medicines tomorrow (Lasix and Metoprolol XL). Continue to take your other medications as you did before this hospitalization, including aspirin and plavix. You must take the aspirin and plavix to prevent your stents from clotting. Followup Instructions: Follow up with Dr.[**Name (NI) 11325**] office on Tuesday, [**2102-9-5**] for a blood pressure check, call [**0-0-**].

[ "V45.02", "V70.7", "414.00", "428.0", "433.10", "414.8", "272.0", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "00.61", "00.63", "88.41" ]

icd9pcs

[ [ [] ] ]

5014, 5074

3221, 3882

276, 294

5137, 5146

1505, 3198

5539, 5660

1150, 1187

3905, 4991

5095, 5116

5170, 5516

1202, 1486

177, 238

322, 759

781, 945

961, 1134

59,004

166,336

4784

Discharge summary

report

Admission Date: [**2103-2-19**] Discharge Date: [**2103-3-8**] Date of Birth: [**2025-8-1**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5569**] Chief Complaint: Jaundice Major Surgical or Invasive Procedure: pigtail in biloma PTC placement in right anterior and right posterior duct PTC placement in left hepatic duct picc placed History of Present Illness: 77M with history of gastric adenoCA s/p Billroth II gastrectomy. Patient just returned from [**Location (un) **]. Patient presented to physician in [**Name9 (PRE) **] on [**12-13**] with abdominal pain and underwent cholecystectomy in [**Location (un) **] for gallstones. According to the family, some kind of biliary drain was placed in the post-op setting. The patient then represented approximately 1 month later with jaundice. The supposed PTC drain was not working. He was admitted to the ICU septic and placed on multiple antibiotics. He was in acute renal failure and was started on hemodialysis. Patient returns now from [**Location (un) **] now with jaundice and mild abdominal discomfort, worse in the epigastric region. +chills at home but no fever. +nausea, -vomiting but poor appetite. On presentation to our ED tbili is elevated and CT w/o contrast now shows ? of pancreatic mass. . Past Medical History: Hypertension Hypercholesterolemia GERD Knee surgery Bilroth II gastrectomy Social History: He smoked half a pack a day for several years and quit smoking 11 years ago. He drinks socially. Denies other drug use. Family History: His father died of unknown causes at age 53 and his mother died at age 45 of unknown causes. Physical Exam: 99.8 94 153/85 20 100%RA Gen: NAD HEENT: +icterus, some temporal wasting Lymph: no adenopathy in neck/axilla/groin chest: CTAB CV: RRR, -MRG Abd: soft, PTC w bilious fluid, mild epigastric tenderness, ND, no masses palpated Ext: +jaundice, -edema . Labs: 1.7 > 21.6 < 279 Lactate:1.1 142 114 21 --------------< 86 3.3 19 1.4 AST: 70 ALT: 38 AP: 191 Tbili: 12.8 PT: 14.1 PTT: 33.2 INR: 1.2 . Imaging: CT abdomen w/o contrast: Prior partial gastrectomy with gastrojejunostomy. External-internal biliary drain with tip lying in 3rd portion of duodenum. Multiple subcapsular collections that are resolving hematomas vs infection. Hypoattenuating lesion in segment VI of the liver - ? additional collection or bile [**Doctor Last Name **]. Fullness of pancreatic head, an underlying mass cannot be excluded. Associated right intrahepatic biliary ductal dilatation. . Pertinent Results: [**2103-3-8**] 06:25AM BLOOD WBC-7.5 RBC-3.07*# Hgb-9.8*# Hct-28.6* MCV-93 MCH-31.9 MCHC-34.3 RDW-18.4* Plt Ct-300 [**2103-3-6**] 12:44PM BLOOD PT-14.5* PTT-32.7 INR(PT)-1.3* [**2103-3-8**] 06:25AM BLOOD Glucose-90 UreaN-19 Creat-1.6* Na-135 K-3.5 Cl-101 HCO3-25 AnGap-13 [**2103-2-19**] 03:35PM BLOOD ALT-44* AST-68* LD(LDH)-286* AlkPhos-205* TotBili-13.7* DirBili-9.2* IndBili-4.5 [**2103-2-23**] 05:15AM BLOOD ALT-46* AST-95* AlkPhos-156* TotBili-14.7* DirBili-12.3* IndBili-2.4 [**2103-3-8**] 06:25AM BLOOD ALT-57* AST-111* AlkPhos-166* TotBili-10.5* [**2103-3-6**] 04:26AM BLOOD Lipase-211* [**2103-3-8**] 06:25AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.2 Brief Hospital Course: He was admitted to SICU on the surgery service under Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. An ABD CT on [**2-19**] demonstrated Fullness of the pancreatic head, with atrophy of the pancreatic body and tail and an abrupt cutoff of the pancreatic duct. Findings were concerning for an underlying pancreatic mass. A biliary drain was present, with moderate right intrahepatic biliary ductal dilatation. Multiple subcapsular and intraparenchymal collections within the liver which were heterogeneous and complex, concerning for infected bilomas. Tiny bilateral pleural effusions were also noted. On [**2-21**], a CTA was done to better evaluate the pancreas. There was no evidence of pancreatic head mass. Multiple perihepatic and intrahepatic fluid collections, with most of the intrahepatic collections communicating with the biliary ducts, especially in the right lobe were noted. Findings were most compatible with cholangitis leading to abscess formation. There was increased soft tissue surrounding the hepatic arteries and soft tissue enhancing material in the proximal hepatic duct at the bifurcation concerning for underlying neoplasm. On [**2-23**], an 8 French internal-external PTBD catheter was placed in the right posterior ductal system and a 12 French internal-external PTBD catheter was replaced in the right anterior ductal system. A 10 French locking pigtail drain was placed within perihepatic fluid collection Bilirubin trended down to 8.7 from 14. Pseudomonas grew from the bile on [**2-20**] and blood cultures from [**2-22**]. He was maintained on Ceftaz/Cipro and flagyl. ID was consulted and followed closely. A cardiac echo was done to r/o vegetations. There were no vegetations. On [**2-26**], a left picc picc line was placed with tip of the line projecting over the mid SVC. Left arm became swollen with concern for DVT. LENIS were done and were negative for DVT. On [**2-27**],a biopsy of the right biliary ductal mass was performed with pathology demonstrating poorly differentiated carcinoma. His family was informed of these findings. The right anterior PTC was changed due to occlusion. Repeat abd CT was done on [**2-28**] to assess for resolution of the collection. This demonstrated resolution of intrahepatic biliary ductal dilatation in the right lobe of the liver. The pigtail catheter had drained a subcapsular fluid collection posteriorly to segment VI/VIII. Lateral and medial oblong hepatic subcapsular fluid collections were noted to abutt the inferior right lower lobe. There was a stable loculated enhancing collection in the gallbladder fossa. The bilateral pleural effusions were increased to moderate size. On [**3-3**], a chest CT was done to evaluate for metastatic disease. Findings were as follows: Bronchial wall thickening and interstitial thickening in the right upper lobe consistent with airways disease. Granulomatous infection, such as tuberculosis cannot be excluded. 2. Small bilateral pleural effusions and bibasilar atelectasis, decreased. 3. No findings suggestive of metastatic disease in the thorax, as questioned. On [**3-2**], ID recommended changing Ceftaz to Zosyn. This was done to cover Enterococcus (vanco sensitive) noted in bile on [**2-23**]. On [**3-5**], a Left PTC was placed with downsizing of the right-sided anterior PTBD, with an 8 French drain left in place. Cholangiogram showed a focal area of reduction of caliber at the origin of the left biliary duct without signs of obstruction in the left biliary tree. On [**2-6**], there was some bloody drainage in the new left PTC bag. Hct was stable. On [**3-7**], hematocrit trended down to 23.6 from 24.7. Two units of PRBC were transfused with hct increasing to 28.6 on [**3-8**]. On [**3-7**], ID recommended switching antibiotics to an oral regimen. Zosyn was stopped and Augmentin was added. Cipro and fluconazole were continued. Carotid studies were done in the event of possible surgery. Results were as follows: Wall thickening involving both common carotid arteries and extending into the ICA and ECA. The peak systolic velocities bilaterally were normal as are the ICA/CCA ratios. There was normal antegrade flow involving both vertebral arteries Initially, Nutrition felt that he would benefit by TPN or tube feeds. These were not started. He was given nutritional supplements and tolerated these well without nausea or vomiting. Physical therapy worked with him noting decondition and need for a walker. Rehab was recommended. Rehab screened him and a bed became available on [**3-7**]. The plan is for him to go to rehab with the existing drains on indefinite antibiotic regimen with outpatient follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Of note, the patient had not been informed of pathology findings per patient's family request given their concern for his response. This will be discussed when he follow up with Dr. [**Last Name (STitle) **]. As such, oncology did not meet with him as an inpatient. This will be set up in follow up with Dr. [**Last Name (STitle) **]. Medications on Admission: Aspirin 81 mg daily, Metoprolol succinate 25 mg daily, Simvastatin 10 mg daily. Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): duration indeterminate while drains remain in place. 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): duration indeterminate while drains remain in place. 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. 9. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 10. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 11. Morphine Sulfate 1-2 mg IV Q6H:PRN pain [**Month (only) 116**] want to premedicate prior to moving him or bathing him 12. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Hepatic abscesses h/o gastric ca Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Out of Bed with assistance to chair or wheelchair with walker Discharge Instructions: Please call Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 673**] if any of the warning signs are experienced. Empty and record drain outputs. Bring a record of drain outputs to next office appointment with Dr. [**Last Name (STitle) **] [**Name (STitle) **] will be going to [**Hospital **] Rehab Followup Instructions: please schedule a follow up appointment with Dr. [**Last Name (STitle) **] next week [**Telephone/Fax (1) 673**] [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**] RN coordinator for Dr. [**Last Name (STitle) **] can be called with questions [**Telephone/Fax (1) 17195**] Completed by:[**2103-3-8**]

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icd9cm

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48946

Discharge summary

report

Admission Date: [**2113-9-28**] Discharge Date: [**2113-10-12**] Date of Birth: [**2033-11-17**] Sex: F Service: MEDICINE Allergies: Lisinopril / Verapamil / Beta-Adrenergic Agents Attending:[**First Name3 (LF) 8104**] Chief Complaint: Fall Major Surgical or Invasive Procedure: Intubation with NG tube Femoral line PICC line ([**10-2**]) History of Present Illness: 79F w h/o DM, CAD and ESRD on HD presenting to [**Hospital1 18**] [**2113-9-28**] after a fall. The patient was in her usual state of health until the morning of [**9-28**] when she fell as she was about to go down the stairs in her house. The pt reported feeling dizzy and falling on her side. She lost consciousness and was woken up by her sister who called the hospital. There was no CP/SOB, palpitation. No loss of continence or confusion. . Vitals in the ED were T 96.7 BP 210/82 HR 50 RR18 99%RA. Head CT showed 8mm subdural hematoma in right parietal lobe and likely a small R frontal parenchymal hemorrhage. No cervical trauma. Pt was seen by neurosurgery and sent to floor for further conservative management and hemodialysis. . Past Medical History: Diabetes (last HgbA1c 01/08=6.7) Hypertension Peripheral vascular disease Lower extremity edema/venous insufficiency Arthritis Lumbar disc disease Coronary Artery Disease Chronic kidney disease on HD, previously via left UE fistula but that was infected [**6-25**] at an area of repaired aneurysm so no via tunnelled HD cath Pulmonary hypertension Toxic Multinodular Goiter Anemia- low iron and EPO s/p Breast biopsy s/p Hysterectomy, s/p excision of a left ear mass s/p right toe amputation of digits one, two, three, four, five Echo [**8-21**] - 2+TR, 1+MR, LAE/[**Last Name (un) **], severe pulm HTN, EF60%) ESRD on HD (T,Th,Sa) Social History: Lives on [**Location (un) **], sister on [**Location (un) 453**], not married, denies tobacco/etoh or illicit drugs Family History: Diabetes Physical Exam: T 96.2 HR 88 BP 146/59 RR 25 Sat 99% on 6L face mask Gen: Somnolent, relatively unresponsive. HEENT:NC/AT, PERRL minimally (2.5->2), sclera anicteric, MM dry Neck: supple, no LAD, JVP flat LUNG: Coarse rhonchi throughout with decreased BS at B bases, no wheezes or rales. CV: RRR S1, S2, [**3-23**] holosystolic murmur at L USB, no rubs/gallops ABD: Soft, NT, ND, +BS, hepatosplenomegally or masses EXT: No edema, RLE without toes. NEURO: Does not respond to voice or noxious stimuli; DTR's 2+ biceps, triceps, brachioradialis, patellar B. Pertinent Results: STUDIES: CT head non-con ([**9-28**]): In the extra-axial space overlying the right lateral parietal cortex, there is a hyperdense focus measuring 8 mm in thickness, corresponding to an acute subdural hemorrhage. In the superior right frontal cortex is a 4-mm focus of hyperdensity, which likely reflects an acute intraparenchymal hemorrhage. There are no other foci of hemorrhage. There is no edema or midline shift associated with either focus of hemorrhage. There is no evidence of infarction. The ventricles and sulci are prominent, consistent with age-related involution. Periventricular white matter hypodensities are consistent with chronic microvascular ischemia. The basilar cisterns are patent and the [**Doctor Last Name 352**]-white differentiation is preserved. Soft tissues are unremarkable without scalp hematoma. There is no fracture. Paranasal sinuses demonstrate mucosal thickening of the nasal cavity and left maxillary sinus, and there is soft tissue density material nearly filling the right maxillary sinus. The mastoid air cells are well aerated. The maxillary sinus walls are diffusely thickened and increased in density. this may be a consequence of chronic inflammation, but given his history of renal failure, this may also reflect renal osteodystrophy. . IMPRESSION: 1. Acute right subdural hematoma overlying the right lateral parietal cortex measuring 8 mm. 2. 4-mm focus of hyperdensity in the right superior frontal cortex, likely indicating parenchymal hemorrhage. 3. No fracture or scalp hematoma. . . Neurophysiology Report EEG Study Date of [**2113-9-29**] IMPRESSION: Abnormal routine EEG due to the slow background with occasional suppressive bursts. These findings suggest a widespread encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. Hypoxia is another possible explanation. Nevertheless, there were no areas of prominent focal slowing although encephalopathies can obscure focal findings. There were no clearly epileptiform features. . . CT-HEAD [**2113-9-30**] FINDINGS: There has been no interval change in right parieto-occipital subdural hematoma, again measuring 7 mm at its deepest, and again extending around the occipital cortex posteriorly. The intraparenchymal focus of bleeding in the right frontal cortex is unchanged. There are no new areas of bleeding. There is no shift of normally midline structures or herniation. Ventricles and sulci are again prominent, consistent with age-related involution. Periventricular white matter hypodensities are consistent withchronic small vessel ischemia. Basilar cisterns and [**Doctor Last Name 352**]-white differentiation are patent, and there is no evidence of infarction. There is no fracture. The paranasal sinuses again demonstrate mucosal thickening in the maxillary sinuses. . IMPRESSION: No interval change in right parieto-occipital subdural hematoma and right frontal intraparenchymal hemorrhage. No new hemorrhage, and no midline shift or herniation . MRI AND MRA OF THE BRAIN AND MRA OF THE NECK WITHOUT CONTRAST DATED [**2113-9-30**]. FINDINGS: The study is compared with the recent NECT of the head, dated [**2113-9-29**]; there is no previous MR examination on record. The known extensive, but relatively thin acute subdural hematoma overlying the right cerebral convexity and tentorium is, overall, unchanged, with a similar degree of mass effect and slight flattening of the subjacent gyri. There is no significant shift of the normally-midline structures or evidence of herniation. There are scattered foci of subarachnoid hemorrhage, particularly in right frontal sulci and right frontovertex, as on the serial CTs; no true hemorrhagic parenchymal contusion is identified. There is multifocal confluent and punctate FLAIR- hyperintensity in bihemispheric subcortical and periventricular, as well as central pontine white matter, representing chronic microvascular infarction, related to the patient's numerous chronic medical illnesses. However, apart from the susceptibility artifact originating from the extra-axial hemorrhage, there is no evidence of restricted diffusion to indicate acute infarction. There is also no white matter abnormality to specifically suggest the presence of posterior reversible encephalopathy syndrome. The major intracranial vascular flow-voids, including those of the dural venous sinuses, are preserved (see MRA, below). Incidentally noted are mild-moderate chronic inflammatory changes in the paranasal sinuses with bilateral maxillary mucus- retention cysts. . There is normal flow-related enhancement in the included intracranial portions of both internal carotid and proximal middle and anterior cerebral arteries, with normal symmetric arborization of MCA branches and no flow-limiting stenosis. There is normal flow-related enhancement in distal vertebral arteries with dominant left and hypoplastic right vessel, as well as the basilar artery, which is markedly tortuous, and bilateral superior cerebellar and posterior cerebral arteries, with no flow-limiting stenosis. Anterior and left posterior communicating vessels are demonstrated, and there is no aneurysm larger than 3 mm in diameter. . The axial 2D time-of-flight sequence is somewhat limited; however, there is normal flow-signal in bilateral common and proximal internal and external carotid arteries, which are grossly normal in caliber and contour, with no flow-limiting stenosis. There is normal flow- signal in the cervical vertebral arteries with markedly dominant left and hypoplastic right vessel, as on the cranial MRA, with no discrete flow- limiting stenosis seen. . IMPRESSION: 1. Stable extensive but thin subdural hematoma layering over the right cerebral convexity and that portion of the tentorium, with no significant change in the degree of mass effect or shift of the midline structures. 2. Likely post-traumatic small subarachnoid hemorrhage at the right frontovertex, with no new hemorrhage seen. 3. No evidence of acute infarction and no specific finding to suggest PRES. 4. Unremarkable cranial and limited cervical MRA, with no flow-limiting stenosis. . LUMBAR SPINAL PUNCTURE Study Date of [**2113-10-1**] 11:21 AM INDICATION: 79 y/o female with end stage renal disease, hypertension, fever, mental status changes. HISTORY: Multiple attempts for lumbar puncture on the floor by the referring clinician were unsuccessful. Patient is referred for fluoro-guided lumbar puncture. Informed consent was obtained after explaining the risks, indications, and alternative management. . The patient was brought to the fluoroscopic suite and placed on the fluoroscopic table in prone position. Access to the lumbar subarachnoid space was obtained with a 22 gauge spinal needle under local anesthesia using 1% lidocaine and with aseptic precautions. Approximately 10 cc of CSF was collected. The patient tolerated the procedure well without any complications. Patient was sent to the floor with postprocedure orders. Access was obtained at the L3/4 level. The attending physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] was present throughout the entire procedure. . IMPRESSION: Successful fluoro-guided lumbar puncture. The samples were sentfor routine laboratory analysis as requested by the referring physician. . FLUORO GUID PLCT CENTRAL LINE Study Date of [**2113-10-2**] 12:26 PM IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French double lumen midline placement via the right brachial venous approach. Final internal length is 26 cm, with the tip positioned in right subclavian vein. The line is ready to use. . CHEST (PORTABLE AP) Study Date of [**2113-10-3**] 2:57 AM FINDINGS: In comparison with the study of [**10-2**], the tip of the endotracheal tube remains about 2.3 cm above the carina. Increasing bibasilar atelectatic changes. The upper zones are clear. Nasogastric tube again extends to the stomach and the right double-lumen CVP catheter again terminates in the right atrium. The catheter beneath the right shoulder that projects just over the outer aspect of the lung is of unclear etiology. . CHEST (PORTABLE AP) Study Date of [**2113-10-4**] 3:16 AM REASON FOR EXAMINATION: Followup of a patient with pneumonia after IMPRESSION: No significant appreciable change compared to the prior study. . . [**2113-10-5**] TTE: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . IMPRESSION: No vegetations or clinically-significant regurgitant valvular disease seen (reasonable-quality study). Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. In presence of high clinical suspicion, absence of vegetations on transthoracic echocardiogram does not exclude endocarditis. . Compared with the report of the prior study (images unavailable for review) of [**2111-7-1**], the findings appear similar. . . [**2113-10-8**] HEAD CT: FINDINGS: Right parieto-occipital subdural hematoma measuring 6 mm in greatest dimension is not appreciably changed in size since prior study. Focus of right frontal intraparenchymal hemorrhage is not well appreciated on current study. Subarachnoid vs. parenchymal hemorrhage within the right temporoparietal region (2:15) demonstrates little change from [**9-30**]. Prominent ventricles and sulci bilaterally are consistent with age-related parenchymal atrophy. Periventricular white matter confluent hypoattenuation is also noted and unchanged, consistent with chronic microvascular infarction. There is worsening of right maxillary sinus disease with near complete opacification on current study. The left maxillary sinus, ethmoid air cells, and sphenoid sinuses appear clear. Cerumen impaction presumed in the external auditory canals bilaterally. . IMPRESSION: 1. No significant change in intracranial hemorrhage since prior study. 2. Worsening right maxillary sinus disease with near complete opacification. . . . . MICROBIOLOGY: [**2113-10-2**] 10:30 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2113-10-8**]** GRAM STAIN (Final [**2113-10-3**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2113-10-8**]): OROPHARYNGEAL FLORA ABSENT. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. FURTHER WORK-UP PER DR [**Last Name (STitle) **] ([**Numeric Identifier **]). STAPH AUREUS COAG +. HEAVY GROWTH. PENICILLIN SENSITIVITY AVAILABLE ON REQUEST. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. ENTEROBACTER CLOACAE. SPARSE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. 5TH TYPE. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 102783**] ([**2113-10-3**]). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | PSEUDOMONAS AERUGINOSA | | ENTEROBACTER CLOACAE | | | KLEBSIELLA PNEUM | | | | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 2 S CIPROFLOXACIN--------- <=0.25 S <=0.25 S <=0.25 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S <=1 S <=1 S <=1 S LEVOFLOXACIN---------- 0.25 S MEROPENEM------------- <=0.25 S <=0.25 S <=0.25 S OXACILLIN------------- 0.5 S PIPERACILLIN---------- <=4 S <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S <=1 S . . . [**2113-10-3**] 11:44 am Mini-BAL Site: NOT SPECIFIED **FINAL REPORT [**2113-10-9**]** GRAM STAIN (Final [**2113-10-3**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2113-10-8**]): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. FURTHER WORK-UP PER DR [**Last Name (STitle) **] ([**Numeric Identifier 102784**]). STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 102785**] ([**2113-10-2**]). KLEBSIELLA PNEUMONIAE. ~4000/ML. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. PSEUDOMONAS AERUGINOSA. ~4000/ML. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. sensitivity testing performed by Microscan. KLEBSIELLA PNEUMONIAE. ~[**2105**]/ML. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. PSEUDOMONAS AERUGINOSA. ~1000/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | PSEUDOMONAS AERUGINOSA | | KLEBSIELLA PNEUMONIAE | | | PSEUDOMONAS AERU | | | | AMPICILLIN/SULBACTAM-- 4 S 4 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S S <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=2 S <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 2 S 2 S CIPROFLOXACIN---------<=0.25 S <=0.5 S <=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S <=1 S <=1 S MEROPENEM-------------<=0.25 S S <=0.25 S <=0.25 S PIPERACILLIN---------- <=8 S <=4 S PIPERACILLIN/TAZO----- <=4 S <=8 S <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S . . [**2113-10-4**] 11:18 am BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2113-10-6**]** GRAM STAIN (Final [**2113-10-4**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2113-10-6**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. ~1000/ML. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 102785**] ([**2113-10-2**]). . . [**2113-10-5**] 9:49 am BLOOD CULTURE Source: Line-[**Month/Day/Year 2286**] line. **FINAL REPORT [**2113-10-11**]** Blood Culture, Routine (Final [**2113-10-11**]): NO GROWTH . . [**2113-10-5**] 9:51 pm STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT [**2113-10-6**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2113-10-6**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . [**2113-10-1**] 10:51 am CSF;SPINAL FLUID Source: LP. **FINAL REPORT [**2113-10-7**]** GRAM STAIN (Final [**2113-10-1**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2113-10-7**]): NO GROWTH. . . . LABS AT ADMISSION: [**2113-9-28**] 06:45AM PLT SMR-NORMAL PLT COUNT-162 [**2113-9-28**] 06:45AM NEUTS-68.6 LYMPHS-21.0 MONOS-6.4 EOS-3.6 BASOS-0.4 [**2113-9-28**] 06:45AM WBC-5.1 RBC-4.65# HGB-12.7# HCT-42.0# MCV-90 MCH-27.2 MCHC-30.2* RDW-17.1* [**2113-9-28**] 06:45AM CK-MB-3 [**2113-9-28**] 06:45AM cTropnT-0.23* [**2113-9-28**] 06:45AM CK(CPK)-127 [**2113-9-28**] 06:45AM estGFR-Using this [**2113-9-28**] 06:45AM GLUCOSE-70 UREA N-53* CREAT-7.8*# SODIUM-140 POTASSIUM-9.2* CHLORIDE-103 TOTAL CO2-23 ANION GAP-23* [**2113-9-28**] 09:30AM PT-13.1 PTT-25.2 INR(PT)-1.1 [**2113-9-28**] 09:43AM freeCa-1.20 [**2113-9-28**] 09:43AM GLUCOSE-50* NA+-141 K+-8.3* CL--99* TCO2-27 [**2113-9-28**] 09:43AM PH-7.28* [**2113-9-28**] 12:41PM freeCa-1.29 [**2113-9-28**] 12:41PM GLUCOSE-58* NA+-144 K+-4.8 CL--103 TCO2-27 [**2113-9-28**] 12:41PM PH-7.35 [**2113-9-28**] 06:40PM PT-12.9 PTT-53.8* INR(PT)-1.1 [**2113-9-28**] 06:40PM PLT COUNT-173 [**2113-9-28**] 06:40PM WBC-7.3 RBC-4.28 HGB-12.0 HCT-37.1 MCV-87 MCH-28.1 MCHC-32.3 RDW-17.6* [**2113-9-28**] 06:40PM ALBUMIN-4.4 CALCIUM-10.2 PHOSPHATE-3.0 MAGNESIUM-1.8 [**2113-9-28**] 06:40PM CK-MB-NotDone cTropnT-0.31* [**2113-9-28**] 06:40PM ALT(SGPT)-11 AST(SGOT)-16 LD(LDH)-225 CK(CPK)-47 ALK PHOS-113 TOT BILI-0.4 [**2113-9-28**] 06:40PM GLUCOSE-125* UREA N-28* CREAT-5.2*# SODIUM-138 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-27 ANION GAP-17 [**2113-9-28**] 09:35PM PT-13.3 PTT-31.7 INR(PT)-1.1 [**2113-9-28**] 09:35PM PLT COUNT-159 [**2113-9-28**] 09:35PM WBC-7.5 RBC-4.54 HGB-12.2 HCT-40.4 MCV-89 MCH-26.9* MCHC-30.2* RDW-17.1* [**2113-9-28**] 09:35PM PHENYTOIN-5.9* [**2113-9-28**] 09:35PM T4-8.6 FREE T4-1.5 [**2113-9-28**] 09:35PM TSH-0.031* [**2113-9-28**] 09:35PM ALBUMIN-4.0 CALCIUM-10.1 PHOSPHATE-4.0 MAGNESIUM-1.8 [**2113-9-28**] 09:35PM cTropnT-0.29* [**2113-9-28**] 09:35PM GLUCOSE-126* UREA N-30* CREAT-5.6* SODIUM-138 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-27 ANION GAP-17 . LABS AT DISCHARGE: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2113-10-12**] 08:30AM 7.0 3.61* 10.0* 32.3* 90 27.6 30.9* 18.7* 324 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2113-10-12**] 08:30AM 123* 35* 6.6*# 140 4.0 97 31 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2113-10-12**] 08:30AM 9.2 6.0* 2.0 TSH [**2113-9-29**] 12:37PM <0.02* . Brief Hospital Course: 79 F admitted to [**Hospital1 18**] [**2113-9-28**] after a fall, found to have SDH and IPH, which were managed conservatively by neurosurgery. On [**9-29**] she developed acute mental status changes, and witnessed seizure, resulting in transfer to ICU and subsequent intubation for further imaging, and LP. Her ICU course was c/b failure to wean, and she was tx for ?aspiration PNA. She was subsequently returned to the medical floor on [**10-5**]. Her mental status gradually improved, and she was discharged to rehab on [**10-12**]. . # altered mental status - likely due initially to subdural hematoma and intraparenchymal bleed. Etiology of SDH/IPH likely [**2-18**] fall, though not clear whether they preceded and may have caused fall. She was evaluated by neurosurgery in ED and managed conservatively. . Per neurology notes, on admission on [**9-28**] pt was oriented x2 and cooperative with exam. On [**9-29**], she became more somnolent and oriented x1. She had a CT of her head which was negative for interval progression of hemorrhage, mass effect, midline shift. . After returning the medical floor from Head CT, her BP was noted to be 189/84 with stable mental status, however she then was noted to have oxygen desaturation to the 80's. At that time she had a witnessed 30-second generalized tonic-clonic seizure. It resolved spontaneously, but she was given 2 mg IV Ativan. She had received no sedating medication other than 2 mg Ativan [**9-28**]. She was noted to have had a fever of 100.6. . SBP became elevated to 210. She had a witnessed aspiration in this setting. In short order she was given supplemental oxygen, hydralazine 20mg iv and ativan 2mg iv (as described above). Her BP droped to 160-170 systolic. She was noted to be unresponsive after tonic-clonic activity, without stereo-typed movement, with coarse breath sounds. Neurosurgery and her medical attending were made aware of the events and she was transferred to the Medical ICU for further management. Subsequent EEG showed no NCSE. . Per Neurology her exam was described as follows: She opens her eyes to loud voice but requires frequent physical stimulation to keep them open; she produces only unintelligible sounds but no speech. Her pupils are small but equal and reactive (2 -> 1 bilaterally); her face appears symmetric; She moved all extremities spontaneously antigravity except her left UE, which she withdraws antigravity from pain; She has symmetric but diminished reflexes in her LEs and normal reflexes in the RUE, and possibly hyperreflexic in the L UE; she has flexor plantar responses (no TFL contraction on right as her toes have been amputated on that side). . On arrival to the MICU, she was re-loaded with dilantin (she had received 1000 mg after SDH, but PHT level subtherapeutic at that point so re-loaded with additional 800 mg). She remained only minimally arousable. . Given difficulty with peripheral IV placement, a right femoral CVL was placed under USN guidance for urgent administration of phenytoin. . the etiology of her mental status changes was ultimatley attributed to SDH/IPH with a superimposed toxic-metabolic component. LP was not c/w infection. EEG without seizure activity. MRI without evidence of infarction and MRA shows no stenosis. Pt's mental status improved gradually over the remainder of her ICU and subsequent medical floor course. Repeat head CT on [**10-8**] showed stable SDH/IPH. On [**10-11**], she was evaluated in the presence of his sister [**Doctor First Name **], with whom she was A&Ox3, interacting appropriately, asking to go home, though still sluggish in her responses. . She was continued on dilatin with goal level between [**11-6**] after correcting for her albumin. She should avoid sedating medications. She will require neurology follow-up in [**2-19**] months. An appointment was made for her. After discussion with neurosurgery, she should have a follow-up CT of her head within 1 months of her discharge, on the day of a follow-up appointment with Dr. [**First Name (STitle) **]. . . # pneumonia - pt s/p witnessed aspiration event in the setting of tonic clonic seizure. He was started on vancomycin, zosyn, and cipro floxacin on [**9-29**] empirically for aspiration PNA. Mini-BAL and BAL were performed and revealed MSSA (>100K), multiple species of klebsiella and psuedomonas (<10K, not felt to be pathogenic). . pt had difficulty weaning from ventilator felt likely [**2-18**] PNA, requiring pressure support [**11-1**], PEEP 5. Pt was extubated [**10-4**]. She was transferred to the medical floor on [**10-5**]. Based on the above sensitivities, her abx were narrowed to nafcillin and cipro for completion of an 8 day course on [**10-10**]. Her O2 requirement was weaned down to room air on [**10-10**]. the patient removed her nasogastric tube on [**10-8**]. . given her ongoing mental status changes, she was maintained on aspiration precautions. . . # nutrition - NG tube was placed at the time of intubation. after extubation, pt removed her NGT on [**10-8**]. she was re-evaluated by the speech & swallow service who recommended aspiration precautions, and a cardiac/Heart healthy diet with consistency: Ground; Thin liquids, Supplement: Ensure Plus breakfast, lunch, dinner 1:1 supervision with all meals, upright with meals. . . # hypertension - Temporally related to hemorrhage, though unclear if preceeded or followed hemorrhage. Relatively significant increase from her documented baseline of 130-150. Elevated pulse pressure may be [**2-18**] decreased compliance in light of DM and PVD. SBP goals were 120-160 upon discharge from ICU given SDH and concern for HTN as possible cause of seizure. . Pt not previously on BP medications. She was started on oral labetalol which was titrated up to 200mg po twice daily, which per renal, was held if SBP<130. . # Toxic Mulitinodular Goiter: TSH <0.02 which is usual; FT4 1.5. Pt restarted on methimazole on [**10-1**]. She will need to have her TSH reassessed in [**3-21**] weeks by her primary care physicians. . . # Diabetes: Pt with elevated BS around 200s Her sliding scale was titrated up, and she was started on lantus 10U. Her FSs varied between 70 and 200 on this regimen. . . # ESRD: on HD, on Tu/Thurs/Sat, followed by the renal service. She continued [**Date Range 2286**] without difficulty. She was continued on cinacalcet. She was started on sevalemer per renal recommendations. She received [**Date Range 2286**] on [**2113-10-12**]. . . # CAD - pt initially had aspirin held given SDH, however this was restarted after discussion with neurology, along with atorvastatin. Pt w/ no CP no EKG changes on admission. She was noted to have a single bradycardic episode on [**2113-10-5**] during [**Date Range 2286**] and rectal tube placement, which resolved spontaneously, likely vagal event. She was otherwise continued on labetalol as above. . . # Peripheral vascular disease - pt continued on home regimen of aspirin. She had palpable distal pulses. . # Arthritis - pt treated symptomatically with tylenol prn. . # anemia - hct 42 on admission, likely hemoconcentrated, gradual decline to 32-34. no active bleeding during this hospitalization. no transfusions required. stool guaic were unremarkable. LDH was 169, not suggestive of hemolysis. she has been on iron and EPO in past, which can be resumed per her primary care physicians. and nephrologist. . # loose stools - pt notes loose stool on [**10-11**], her standing colace and senna were discontinued. stool cultures were negative for cdiff on [**10-11**]. . # PPX: pneumoboots, bowel regimen, SSI, Ranitidine, Heparin SQ (SQ heparin confirmed OK with neurosurgery). . # Access: right tunnelled IJ HD cath, Midline placed R arm. Midline removed prior to discharge. . # Code: full, confirmed with sister. . # Contact: [**First Name8 (NamePattern2) **] [**Name (NI) **] SISTER/hcp [**Telephone/Fax (1) 102786**] CELL [**Telephone/Fax (1) 102787**] . # Dispo: Pt is being discharged to [**First Name4 (NamePattern1) 41920**] [**Last Name (NamePattern1) **]. She will require follow-up with neurosurgery in 1 months time from discharge, with CT of Head on the day of her appointment. She will require follow-up with neurology in [**2-19**] months. She should continue phenytoin until she is evaluated by her neurologist. Medications on Admission: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Methimazole 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Nateglinide 60 mg Tablet Sig: One (1) Tablet PO TIDAC (3 times a day (before meals)). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Methimazole 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 6. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Phenytoin 125 mg/5 mL Suspension Sig: One (1) PO Q8H (every 8 hours) as needed for seizure. 8. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for HTN. 9. Acetaminophen 160 mg/5 mL Solution Sig: [**1-18**] PO Q6H (every 6 hours) as needed for pain. 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): DVT prophylaxis. 11. INSULIN please take insulin according to attached sliding scale. 10 units of glargine QAM, and humalog according to attached sliding scale. 12. Lantus 100 unit/mL Solution Sig: One (1) Subcutaneous once a day: take as instructed per attached sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Primary: -Sub-dural hematoma/intraparenchymal brain bleed -Aspiration pneumonia -Seizure secondary to brain bleed . Secondary: -Diabetes (last HgbA1c 01/08=6.7) -Hypertension -Peripheral vascular disease -Arthritis -Lumbar disc disease -Coronary Artery Disease -Chronic kidney disease on hemodialysis -Pulmonary hypertension -Toxic Multinodular Goiter -Anemia- low iron and EPO -status post breast biopsy -status post Hysterectomy, -status post excision of a left ear mass -status post right toe amputation of digits one, two, three, four, and five Discharge Condition: Afebrile, all vital signs stable, improving mental status (conversive) Discharge Instructions: You were admitted after a fall and loss of consciousness. A CT scan of your head detected a small area of bleeding in your brain. You were started on a medication to prevent seizures, called Dilantin. . Unfortunately, you did have a seizure, likely because of the small brain bleed, and you were transferred to the intensive care unit for closer monitoring. You ultimately required intubation for a breif period of time given your altered mental status. . While in the ICU, you were found to have a pneumonia, likely due aspiration during your seizure. You were treated for 8 days with multiple antibiotics for the pneumonia, and you made a good recovery and were extubated on [**10-4**]. . You were transferred back to the regular medical floor, where your mental status gradually improved although you remained slightly groggy, likely because of your recent head injury and pneumonia. . You were switched to a diet of soft foods and thin liquids with nutritional supplements, with strict aspiration precautions. . You were evaluated by physical therapy, and discharged to a rehab facility for physical therapy and further recovery. . You continued to received hemodialysis according to your usual schedule. . 2)We have made the following changes to your medications: -We started dilantin to help prevent seizures due to the small bleed in your brain. Please continue to take Dilantin as directed, and discuss this medication with your neurologist at your follow-up appointment. -We started labetalol for high blood pressure. Please continue this medication, and discuss management of your blood pressure with your primary doctor at your follow-up appointment. -We started Sevelamer, which was recommended by the kidney doctors [**First Name (Titles) **] [**Last Name (Titles) 102788**] your phosphate levels. Please take this three times a day with meals as directed. Discuss this medication with your renal doctors [**First Name (Titles) **] [**Last Name (Titles) 2286**]. -Please take all your medications as directed. . 3)Please call your doctor or go to an emergency room if you have fever, chills, chest pain, shortness of breath, loss of consciousness, confusion, changes in your vision, severe headache, nausea and vomiting, or any other symptoms that are concerning to you. . 4)Please keep your follow-up appointments as listed below. Followup Instructions: Please follow-up with your transplant doctor regarding your AV fisulta: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2113-10-13**] 2:40 . Please follow-up with your neurologist within 2-3 months regarding your head injury, an appointment has been made for you: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 2928**] Date/Time:[**2113-11-24**] 9:00 . Please go to your scheduled mammography appointment: Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2113-12-1**] 9:40 . You will need to follow-up in the [**Hospital 102789**] clinic in 1 months time. you will need to have a CT scan of your head prior to that appointment on the same day. an appointment has been made for you in the neurosurgery clinic on [**2113-11-9**] at 1:30 PM. You will receive phone call regarding what time on [**2113-11-9**] you should go to [**Date Range **] for your head CT prior to your appointment. If you have any questions or concerns, or have not heard what time you should [**Last Name (un) 5511**] [**Last Name (un) **] prior to [**2113-11-8**], please call ([**Telephone/Fax (1) 88**]. . . Please schedule a routine follow-up appointment with your primary care physician within the next 4-6 weeks regarding the above multiple medical issues. . Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2113-11-9**] 1:30

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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315, 376

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1641

Discharge summary

report

Admission Date: [**2146-4-14**] Discharge Date: [**2146-4-19**] Date of Birth: [**2074-10-23**] Sex: M Service: [**Location (un) 259**] CHIEF COMPLAINT: Hypotension. HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old man with a past medical history as noted below, who presented to the Emergency Department with complaints of several weeks of progressive weakness and fatigue. On the morning of admission, the patient states that he developed mild "slow vertigo" that was worse when sitting up. The patient states that he had a similar episode one month prior to admission that was attributed to dehydration from diarrhea; the patient was hospitalized from [**3-18**] through [**2146-3-22**] for this problem. [**Name (NI) **] has also noted slurred speech for about three weeks prior to admission, which his family attributes to cyclobenzaprine and Percocet use. He otherwise, denied fever, chills, headache, tinnitus, hearing loss, visual changes, chest pain, shortness of breath, or sensory loss. In the Emergency Department, the patient received hydrocortisone 100 mg IV, 1 gram of Vancomycin IV, ceftriaxone, Flagyl, and 2 liters of normal saline IV. PAST MEDICAL HISTORY: 1. Rheumatoid arthritis. 2. Coronary artery disease status post five vessel CABG in [**2128**]. 3. Congestive heart failure with an ejection fraction of 20% and moderate mitral regurgitation. 4. Ischemic stroke in [**2141**]. 5. Left carotid endarterectomy in [**2142-8-29**]. 6. Diverticulitis. 7. Colovesicular fistula. 8. Bilateral knee replacements. 9. Left inguinal herniorrhaphy. 10. Asbestosis. 11. Staphylococcal osteomyelitis in [**2140-12-29**]. 12. Left hip replacement. 13. Cavitary pulmonary aspergilloma. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Prednisone 6 mg po q day. 2. Aspirin 81 mg po q day. 3. Alendronate 70 mg po q Monday. 4. Ipratropium two puffs qid. 5. Lisinopril 10 mg po q day. 6. Atorvastatin 20 mg po q day. 7. Furosemide 20 mg po q day. 8. Levofloxacin 250 mg po q day. 9. Ranitidine 150 mg po q day. 10. Voriconazole 200 mg po bid. 11. Metoprolol 25 mg po bid. 12. Cyclobenzaprine 10 mg po q day. 13. Acetaminophen 650 mg po q4-6h prn. 14. Percocet. SOCIAL HISTORY: The patient has a 100 pack year smoking history, but he quit smoking cigarettes five years prior to admission. He denies any history of alcohol abuse. He worked in the Navy, which is where he had asbestos exposure. He walks with assistance at home, and he is on 2 liters of oxygen by nasal cannula at home. His daughter is actively involved in his medical care. FAMILY HISTORY: [**Name (NI) **] mother died of bone cancer. His father died of lung cancer. PHYSICAL EXAMINATION: On initial physical examination, the patient's temperature was 96.6, heart rate 80, blood pressure 96/56, respiratory rate 24, and oxygen saturation 100% on 1.5 liters of oxygen by nasal cannula. The patient was a thin, elderly, cachectic gentleman in no acute distress. His sclerae were clear bilaterally, pupils were 4 mm and equally reactive to light bilaterally, his oropharynx was dry, and he had no jugular venous distention. He had no wheezes, he had empty breath sounds over the right upper lung fields, and had bibasilar crackles. He had no rhonchi. His heart was a regular, rate, and rhythm, there were normal S1, S2 heart sounds. There was a 1-2/6 early systolic ejection murmur heard best at the right upper sternal border, no S3, S4 heart sounds, and evidence of a prior CABG scar. His abdomen was soft, nontender, nondistended, there were normoactive bowel sounds. He had no hepatosplenomegaly. There was no rebound or guarding, and he had a lower abdominal scar. There was no lower extremity edema. He had palpable dorsalis pedal pulses bilaterally, and evidence of chronic rheumatoid arthritis deformations of his hands bilaterally. He was alert and oriented times three, had occasional slurred speech, cranial nerves II through XII were intact, strength was [**5-2**] throughout, he had no focal sensory deficits, and his deep tendon reflexes were 1+ throughout. On initial laboratory evaluation, the patient's white count was 8.6 (with a differential of 83% neutrophils, 2% bands, 5% lymphocytes, and 9% monocytes), hematocrit of 29.9, and platelets of 203,000. Initial serum chemistries demonstrated a sodium of 130, potassium 5.5, chloride 101, bicarbonate 18, BUN 61, creatinine 2.3 (baseline creatinine is 1.3-1.5), and glucose of 108, his calcium is 8.8, magnesium 2.3, and phosphate 4.3. His INR was 1.1 and his PTT was 24.3, ALT was 8, AST 24, amylase 33, total bilirubin 0.4, and his albumin was 3.2. His initial urinalysis demonstrated a specific gravity of 1.020 and was otherwise negative. Of note, the patient's initial CK was 60, but his initial troponin-I was 10. His initial electrocardiogram demonstrated normal sinus rhythm at 80 beats per minute, intraventricular conduction delay, normal axis, minimal ST segment depressions in leads V4 through V6; his ST segment changes were slightly different compared with an electrocardiogram dated [**2146-3-18**]. On initial chest radiograph, he had persistent chronic changes, no evidence of failure, and no acute cardiopulmonary process. HOSPITAL COURSE BY SYSTEMS: 1. Cardiovascular: After the initial troponin value of 10, the patient subsequently had troponin values of 15 and then 9. Given his elevated troponins in the setting of hypotension on admission, the patient was felt to have had a recent NSTEMI in the setting of low effective circulating volume. In the absence of recent or active chest pain or anginal symptoms, and given the patient's acute renal failure, it was thought that this myocardial infarction most likely occurred within seven days prior to admission. Because he appeared to have a low effective circulating volume on admission, the patient was aggressive rehydrated with intravenous fluids with a subsequent good response in his blood pressure. In order to evaluate whether or not the patient had any new clinically significant ischemic changes resulting from his NSTEMI, a transthoracic echocardiogram was performed on hospital day two. This study demonstrated that the left atrium is mildly dilated, the left ventricular wall thicknesses are normal. The left ventricular cavity size is normal, there is severe global left ventricular hypokinesis. The right ventricular cavity is markedly dilated. There is severe global right ventricular free wall hypokinesis, the aortic root is moderately dilated, and there were no significant valvular abnormalities noted. Overall, compared with the report of a prior transthoracic echocardiogram done on [**2142-6-27**], no major changes were found on this transthoracic echocardiogram. In order to further evaluate the patient's NSTEMI, he had a small P-MIBI on the day prior to discharge. During this study, he had no angina or ischemic electrocardiogram changes. The nuclear portion of this study demonstrated a moderate, fixed defect in the inferior myocardial wall, enlarged left and right ventricles, and global hypokinesis with a left ventricular ejection fraction of 18%. When compared to the prior study of [**2142-8-27**], there was significant interval deterioration. In terms of the patient's hypotension on admission, by hospital day two, his standing metoprolol dose was restarted. On hospital day three, his ACEI was reinstituted, and on the day prior to discharge, he was restarted on his standing furosemide dose for his significant congestive heart failure. 2. Renal: The patient's renal function improved dramatically following aggressive fluid resuscitation. On the day prior to discharge, his serum creatinine was 1.0; on the day of discharge it was 1.2 following the reinitiation of therapy with furosemide. 3. Endocrine: Given the patient's presentation with relative hyponatremia, hyperkalemia, and hypotension, there was consideration given to the possibility of adrenal insufficiency, especially given the patient's prolonged steroid use. Of note, his prednisone dose had reportedly recently been changed from 7 mg daily to 6 mg daily. During the first day of his hospitalization, the patient received stress dosed steroids; he was changed to his standing prednisone dose of 6 mg daily on hospital day two. On hospital day three, a random morning cortisol level was checked; this level subsequently returned at 7.6. In talking with the Endocrine Department, it was felt that this level was difficult to interpret in the face of the patient's chronic prednisone therapy. In order to further evaluate for the possibility of adrenal insufficiency, a cortisol level was drawn prior to the administration of the patient's morning prednisone dose on the morning of discharge. However, the patient was no longer orthostatic at the time of discharge, and Dr. [**Last Name (STitle) 1266**] will follow up on the results of this cortisol level on an outpatient basis. 4. Infectious Diseases: As noted above, the patient had MSSA osteomyelitis in late [**2139**] and early [**2140**]. At that time, the osteomyelitis was found to including the patient's left hip, which was subsequently replaced. According to OMR notes, it seemed possible that the patient may have had an occult source of infection at the time that his left hip was replaced. Because of this possibility, the decision was made in conjunction with the Department of Infectious Diseases at that time, to continue the patient on life-long antimicrobial therapy with levofloxacin. His levofloxacin was therefore continued during this hospitalization. In addition, the patient was recently noted to have a cavitary pulmonary aspergilloma, for which he is continuing to receive long-term therapy with voriconazole. Of note, the patient's white blood cell count was mildly elevated at 11.6 on the date of discharge; Dr. [**Last Name (STitle) 1266**] will also follow this level on an outpatient basis. 5. Hematology: The patient's hematocrit trended down over the first three days of his hospitalization, such that his hematocrit was 25.3 on hospital day three. Given his extensive history of coronary disease, the patient was therefore transfused 2 units of packed red blood cells on hospital day three. His hematocrit subsequently increased to a level of 34; it was 32.3 on the date of discharge. Iron studies obtained prior to these transfusions were most consistent with a picture of anemia of chronic disease, although the patient's iron level was normal at 89. 6. Neurology: By hospital day four, the patient began complaining of a severe right sided, periauricular headache. The etiology of this headache was unclear, but the patient did have a negative head CT scan at the time of admission. This headache was treated supportively, and on the day of discharge, the patient found that certain movements were able to alleviate the headache. 7. Gastrointestinal: The patient's alkaline phosphatase level was found to be elevated in the absence of any nausea, vomiting, or abdominal pain. This level will continue to be followed on an outpatient basis. Also of note, the patient had a bedside swallowing evaluation during this hospitalization, during which the Department of Speech Pathology felt that the patient could continue with his current diet. DISCHARGE CONDITION: Stable. DISCHARGE PLACEMENT: Home with services. DISCHARGE DIAGNOSES: 1. Hypotension. 2. Non-ST elevation myocardial infarction. 3. Systolic congestive heart failure. 4. Headache. 5. Hypovolemia. Please see the past medical history list for the remainder of the [**Hospital 228**] medical problems. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q day. 2. Alendronate 70 mg po q Monday. 3. Ipratropium two puffs qid. 4. Levofloxacin 250 mg po q day. 5. Ranitidine 150 mg po bid. 6. Voriconazole 200 mg po bid. 7. Atorvastatin 10 mg po q day. 8. Metoprolol 25 mg po bid. 9. Celicoxib 200 mg po bid. 10. Furosemide 20 mg po q day. 11. Prednisone 6 mg po q day. 12. Lisinopril 10 mg po q day. 13. Acetaminophen 325-650 mg po q4-6h prn pain. DISCHARGE INSTRUCTIONS: The patient was instructed to call Dr. [**Last Name (STitle) 1266**] on the day following discharge to arrange for a follow-up appointment with him by [**Last Name (LF) 2974**], [**2146-4-29**]. He was also instructed to maintain all previously arranged medical appointments. [**Known firstname **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**] Dictated By:[**Name8 (MD) 2507**] MEDQUIST36 D: [**2146-4-19**] 18:47 T: [**2146-4-22**] 06:40 JOB#: [**Job Number 9510**]

[ "276.1", "276.7", "276.5", "410.71", "458.8", "428.0", "117.3", "584.9", "428.20" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11404, 11456

2637, 2716

11477, 11708

11731, 12145

1810, 2237

12170, 12693

5304, 11382

2739, 5276

171, 185

214, 1188

1210, 1784

2254, 2620

50,141

161,474

5017

Discharge summary

report

Admission Date: [**2165-6-14**] Discharge Date: [**2165-6-20**] Date of Birth: [**2118-7-30**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine / Dilaudid (PF) / Ciprofloxacin / IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 1505**] Chief Complaint: occasional palpitation Major Surgical or Invasive Procedure: Mitral Valve Repair (#28mm CE Physio Ring) [**2165-6-14**] History of Present Illness: 46 year old man with a history of HTN, Hepatitis C (Child A), ESRD on hemodialysis (s/p failed kidney transplant) and prior large pericardial effusion without tamponade s/p pericardiocentesis in [**2160**]. For the past years he has developed mitral regurgitation as well as aortic regurgitation and tricuspid regurgitation thought to be secondary to a high-output state from a prior AV fistula. He is recently s/p EPS in [**2164-12-30**] for palpitations where typical tricuspid isthmus dependent atrial flutter as well as left atrial tachycardia was induced. The atrial flutter was successfully ablated. Since that time the patient has undergone stress testing which revealed a fixed defect in the RCA territory (unchanged from last year). In addition, he underwent repeat transthoracic echo. This revealed 2+ AI, 4+ MR, 2+ TR and severe pulmonary hypertension. His valve disease was noticeably worse as compared to last years echocardiogram. He subsequently underwent a TEE which also showed severe MR, moderate AI with low normal systolic function, dilated LV and mild global hypokinesis with worse involvement of the inferior wall. In terms of symptoms, he used to have severe palpitations prior to his ablation, but now completely resolved. In addition, he has had some exertional upper abdominal pressure without radiation that would resolve within a few minutes with rest, but has not had that recently. He denies chest discomfort, shortness of breath, PND or orthopnea currently. Given the severity of his disease, he was been referred for surgical management. He underwent a cardiac catheterization in [**Month (only) 116**] which showed clean coronaries. Past Medical History: Mitral Regurgitation PMH: - Atrial flutter s/p ablation [**1-10**] - Left atrial tachycardia - Hypertension - Dyslipidemia - Pericardial effusion without tamponade status post drainage in [**2160**] - Hepatitis C - Congenital single kidney - ESRD on HD s/p transplant in [**2156**] which subsequently failed in [**2160**] - Anemia - Depression - GERD - Chronic left knee pain - Right facial fracture in [**2156**] (after a car accident) - Possible sleep apnea (needs to have study) Past Surgical History: - s/p Kidney transplant (cadaveric) [**2156**] Social History: Lives with: Wife in [**Location (un) 686**] Contact: [**Name (NI) 20752**] [**Name (NI) **] (wife): [**Telephone/Fax (1) 20753**] Occupation: Previously worked as a janitor at the Museum of Science, but is not currently working Cigarettes: Smoked no [] yes [X] last cigarette [**2156**] Hx: 1ppd x 15yrs Other Tobacco use: ETOH: < 1 drink/week [X] [**2-5**] drinks/week [] >8 drinks/week [] Illicit drug use: Prior history of cocaine use, but has not used any in over 9 years. Family History: No known family history of kidney disease, early MI, arrhythmia, cardiomyopathy, diabetes, hypertension, or hyperlipidemia. # Father -- died of emphysema # Mother -- died of abdominal malignancy # Siblings -- healthy Physical Exam: Pulse: 55 Resp: 18 B/P Right: - (fistula) Left: 172/92 99% RA Height: 72" Weight: 155lbs General: NAD AAOx3 Skin: Dry [X] intact [x] HEENT:NCAT, PERRLA, sclera anicteric, OP benign, teeth in good repair. Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [X] Irregular [] Murmur [x] grade III/VI systolic Abdomen: Soft [x] non-distended [x] non-tender [x] RLQ abdominal scar from prior kidney transplant Extremities: Warm [x], well-perfused [x] No Edema Right AV fistula + bruit and thrill Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: none Left: none Discharge Exam: VS: T 98.4 HR: 60-70's SR BP: 130-140/80 Sats: 98% RA FSBS 111-173 WT: 74.5 kg General: 46 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Card: RRR Resp: Clear breath sounds throughout GI: benign Extr: warm no edema Incision: sternal clean, dry intact. no erythema, no click Neuro: awake, alert oriented Pertinent Results: Intra-op TEE [**2165-6-14**]: Conclusions PREBYPASS No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen.Mild to moderate ([**12-31**]+) mitral regurgitation is seen. After induction of general anesthesia.. With steep Trendelenberg, phenylephrine infusion to increase systolic BP to 150 mm Hg the MR increased to 3+. The mitral valve leaflets are mildly thickened. POSTBYPASS Biventricular systolic function remains normal. There is a ring prosthesis in the mitral position. No MR [**First Name (Titles) **] [**Last Name (Titles) 20755**]d. The remaining study is unchanged from prebypass. CXR [**2165-6-19**]: PA & Lateral Right lung is clear. Left lower lobe atelectasis is improving. Small bilateral pleural effusions are stable. Cardiomediastinal silhouette has a normal post-operative appearance. Air in the pericardium and mediastinum seen on the lateral view at level of the xiphoid is not an uncommon post-operative finding this early. [**2165-6-20**]: WBC-8.1 RBC-3.02* Hgb-9.3* Hct-28.2* MCV-93 MCH-30.7 MCHC-32.8 RDW-16.2* Plt Ct-216 [**2165-6-14**] WBC-20.1*# RBC-3.92* Hgb-11.9* Hct-37.1* MCV-95 MCH-30.4 MCHC-32.2 RDW-15.0 Plt Ct-260 [**2165-6-20**] Glucose-129* UreaN-75* Creat-11.3*# Na-133 K-4.3 Cl-92* HCO3-23 [**2165-6-14**] UreaN-37* Creat-8.6*# Na-137 K-4.6 Cl-101 HCO3-22 [**2165-6-20**] Calcium-8.0* Phos-6.0* Mg-2.9* [**2165-6-14**] MRSA SCREEN (Final [**2165-6-16**]): No MRSA isolated. Brief Hospital Course: The patient was brought to the Operating Room on [**2165-6-14**] where the patient underwent Mitral Valve Repair with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Renal followed and Hemodialysis was resumed. He had a brief episode of AFib. He is followed by Dr. [**Last Name (STitle) **], who recommended titrating Lopressor. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were removed without complication. Lisinopril was restarted for hypertension. Renal followed the patient throughout his course and hemodialysis was continued. The patient was evaluated by the physical therapy service for assistance with strength and mobility. They deemed him safe for home. By the time of discharge on POD6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged on [**2165-6-20**] to home with [**Hospital 119**] Homecare in good condition. He will follow-up as an outpatient. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Aspirin 325 mg PO DAILY 2. Amlodipine 5 mg PO DAILY 3. Atorvastatin 10 mg PO DAILY 4. Nephrocaps 1 CAP PO DAILY 5. BuPROPion 150 mg PO BID 6. Cinacalcet 30 mg PO DAILY 7. CloniDINE 0.3 mg PO HS 8. Lisinopril 40 mg PO DAILY 9. Metoprolol Tartrate 50 mg PO BID 10. Omeprazole 20 mg PO DAILY 11. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO PRN pain 12. Renagel *NF* 800 mg Other three times a day with meals Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO DAILY 3. Cinacalcet 30 mg PO DAILY 4. Lisinopril 40 mg PO DAILY hold for SBP<95 and notify HO if held 5. Nephrocaps 1 CAP PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Acetaminophen 650 mg PO Q4H:PRN PAIN 8. Docusate Sodium 100 mg PO BID 9. Sodium Chloride Nasal [**12-31**] SPRY NU QID:PRN congestion 10. BuPROPion 150 mg PO BID 11. Renagel *NF* 800 mg Other three times a day with meals 12. Metoprolol Tartrate 25 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. [**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg twice a day Disp #*60 Tablet Refills:*3 13. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX *Oxecta 5 mg every six (6) hours Disp #*50 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Mitral Regurgitation PMH: - Atrial flutter s/p ablation [**1-10**] - Left atrial tachycardia - Hypertension - Dyslipidemia - Pericardial effusion without tamponade status post drainage in [**2160**] - Hepatitis C - Congenital single kidney - ESRD on HD s/p transplant in [**2156**] which subsequently failed in [**2160**] - Anemia - Depression - GERD - Chronic left knee pain - Right facial fracture in [**2156**] (after a car accident) - Possible sleep apnea (needs to have study) Past Surgical History: - s/p Kidney transplant (cadaveric) [**2156**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with [**Year (4 digits) 5059**] when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] [**2165-6-25**] at 10:30a [**Month/Day/Year **] Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2165-7-24**] at 1:15p Cardiology: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2165-6-21**] 3:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11899**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2165-6-27**] 1:00 Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13985**] [**Telephone/Fax (1) 13987**] in [**4-4**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2165-6-20**]

[ "276.7", "403.91", "285.21", "585.6", "V15.82", "396.3", "753.0", "997.1", "416.8", "427.31", "285.1" ]

icd9cm

[ [ [] ] ]

[ "35.33", "39.95", "39.61" ]

icd9pcs

[ [ [] ] ]

9420, 9478

6647, 8088

373, 434

10074, 10230

4603, 6624

11037, 11970

3218, 3436

8644, 9397

9499, 9981

8114, 8621

10254, 11014

10004, 10053

3451, 4224

4240, 4584

310, 335

462, 2130

2152, 2634

2722, 3202

50,837

139,993

34196

Discharge summary

report

Admission Date: [**2106-3-3**] Discharge Date: [**2106-3-4**] Date of Birth: [**2048-10-11**] Sex: M Service: MEDICINE Allergies: Accupril / Naprosyn / Quinapril Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: egd History of Present Illness: Mr. [**Name14 (STitle) 32153**] is a 57M with a PMH of advanced metastatic pancreatic cancer, s/p gastric and biliary bypass [**5-/2105**], chemo, xrt, and s/p recent palliative small bowel bypass procedure for an SBO in 1/[**2105**]. This morning the patient reports sudden vomiting of ~500cc of bright red blood with some dark clot about an hour after waking up. He denies having had nausea, abdominal pain, lightheadness, syncope, shortness or breath or chest pain. . He was taken to [**Hospital6 33**], where he had a hematocrit of 31, which is his baseline. He recieved two liters of NS, one unit of pRBCs, IV pantoprazole, and was transferred to [**Hospital1 18**]. . In the ED, his presenting vitals were BP=117/53, HR=77, RR=16, O2sat=96%RA. He refused an NGT. Both GI and surgery were made aware of his admission. One Peripheral IV was placed in addition to his existing portacath. . He currently complains only of low energy and mild abdominal discomfort, both present for the past month. He has had no recurrent hematemesis. He reports that he was guiac negative in the ED and denies any melena or blood per rectum. Of note he reports taking about 6 ibuprofen over the past week for shoulder pain. . Of note he has had one similar episode of hematemesis in [**12/2105**] 5 days after his small bowel bypass procedure. Past Medical History: # Pancreatic cancer, status-post Double bypass (Roux-en-Y choledochojejunostomy and gastro-enterostomy) # Diabetes Mellitus (DM) type 2 on insulin # Chronic pancreatitis # OA knees # Gastroesophageal reflux disease (GERD) # "hole in heart" at age 8. # Status-post tonsillectomy # Status-post shoulder surgery # Hydrocele? s/p drainage # Status-post Vasectomy # Status-post Cholecystectomy. Oncologic history: Mr. [**Name14 (STitle) 32153**] is a 56-year-old gentleman with a history of diabetes who originally presented on [**2105-5-14**] with a chief complaint of jaundice, weight loss, erratic blood glucose measurements, early satiety, increasing foul smelling flatulence, variations in his stool and GERD symptoms. He then underwent an ERCP with stent placement at [**Hospital1 18**] on [**2105-5-15**] and was noted to have a stricture in the distal bile duct as well as a tortuous pancreatic duct and calcification in the pancreatic head. His jaundice resolved after ERCP and he felt generally well for three weeks after the procedure. However, after returning from his vacation around [**2105-6-8**], he began to experience gradually worsening upper abdominal pain and fevers and was treated for cholangitis. He was transferred to [**Hospital1 18**] on [**2105-6-16**], and successfully underwent an ERCP showing a single 15 mm long stricture in the distal third of the common bile duct. Brushings were obtained but were negative for malignancy. He recovered well from his ERCP with a fall in total bilirubin. EUS and needle biopsy showed an ill-defined mass in the head of the pancreas and surgery was consulted for the possibility of a local procedure, which was planned for [**2105-6-22**]. The patient underwent surgery on [**2105-6-22**], but due to the operative findings of tumor invasion of the SMV and SMA, the procedure was converted to a palliative bypass with Roux-en-Y choledochojejunostomy/gastroenterostomy and cholecystectomy due to the locally advanced nature of the disease. Three core biopsies were obtained of the pancreatic mass with the pathology revealing chronic pancreatitis with atypical glands suspicious for adenocarcinoma. This surgery was complicated by wound infection with gram-positive cocci in pairs and chains on culture. The wound was reopened at the bedside and he was restarted on Zosyn. A VAC dressing was placed to help with wound healing. He was discharged home with a wound VAC. Since then the patient has completed clinical trial 07-299, where he was randomized to the TNFerade plus SOC arm which consists of five local injections of TNFerade biologic via EUS approach combined with continuous infusion of 5-FU Monday through Friday along with radiation. Week 6 consisted of 5-FU and radiation therapy only. The clinical trial ended in early [**2105-9-30**], and following this the patient began chemotherapy with gemcitabine on [**2106-10-28**], as standard of care. Treatment with gemcitabine has been complicated by neutropenia and abdominal pain and fever due to a closed loop bowel obstruction secondary to tumor, for which the patient underwent an ex-lap with by-pass of a dilated pancreaticobiliary drainage limb on [**2106-1-18**]. Social History: Patient lives at with his wife and children. No alcohol, tobacco, or illicit drug use. Family History: Mother: melanoma, DM, breast cancer. Father and uncle: abdominal aneurysm. Physical Exam: VITAL SIGNS: T=99.9 BP=129/56 HR=76 RR=15 O2=96% . . PHYSICAL EXAM GENERAL: Appears pale and fatigued but in no acute distress. HEENT: Normocephalic, atraumatic. Pale conjunctiva. No scleral icterus. PERRLA/EOMI. Moist mucous membranes with sublingual pooling. OP clear. No lymphadenopathy. No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP= 7cm LUNGS: CTAB, good air movement biaterally. ABDOMEN: + bowel sounds. Nondistended. Mild tenderness to deep palpation on the R, otherwise non tender. No guarding or rebound. No hepatosplenomegaly. Liver span 7cm. EXTREMITIES: Trace bilateral pitting edema. Good capillary refill and skin turgor. No calf pain. 2+ dorsalis pedis/ posterior tibial pulses. SKIN: Pale. No rashes/lesions, ecchymoses. Portacath in place, clean, dry, no erythema. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. ++ Reflexes, equal BL. Normal coordination. No tremor or asterixis. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2106-3-3**] 09:51PM HCT-26.5* [**2106-3-3**] 05:30PM LACTATE-1.2 [**2106-3-3**] 04:57PM GLUCOSE-113* UREA N-11 CREAT-0.7 SODIUM-136 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-29 ANION GAP-10 [**2106-3-3**] 04:57PM ALT(SGPT)-40 AST(SGOT)-73* LD(LDH)-127 ALK PHOS-637* TOT BILI-2.3* DIR BILI-1.6* INDIR BIL-0.7 [**2106-3-3**] 04:57PM ALBUMIN-2.6* CALCIUM-7.7* PHOSPHATE-3.5 MAGNESIUM-1.9 [**2106-3-3**] 04:57PM WBC-7.3 RBC-3.24* HGB-9.2* HCT-27.6* MCV-85 MCH-28.3 MCHC-33.2 RDW-14.6 [**2106-3-3**] 04:57PM NEUTS-88.5* LYMPHS-5.6* MONOS-5.5 EOS-0.4 BASOS-0.1 [**2106-3-3**] 04:57PM PLT COUNT-250 [**2106-3-3**] 04:57PM PT-15.9* PTT-23.0 INR(PT)-1.4* [**2106-3-3**] 02:58PM COMMENTS-GREEN TOP [**2106-3-3**] 02:58PM LACTATE-1.0 [**2106-3-3**] 02:58PM HGB-10.0* calcHCT-30 [**2106-3-3**] 02:50PM GLUCOSE-110* UREA N-11 CREAT-0.7 SODIUM-136 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-29 ANION GAP-10 [**2106-3-3**] 02:50PM estGFR-Using this [**2106-3-3**] 02:50PM WBC-7.5# RBC-3.30* HGB-9.4* HCT-27.9* MCV-85 MCH-28.5 MCHC-33.8 RDW-14.0 [**2106-3-3**] 02:50PM NEUTS-89.9* LYMPHS-5.0* MONOS-4.6 EOS-0.3 BASOS-0.2 [**2106-3-3**] 02:50PM PLT COUNT-295# [**2106-3-3**] 02:50PM PT-16.1* PTT-22.5 INR(PT)-1.4* . EGD [**3-4**]: not official read: gastritis, no active bleed Brief Hospital Course: Mr. [**Known lastname 61610**] is a 57yo with metastatic pancreatic cancer admitted with one episode of ~500cc hematemeis. He has remained hemodynaically stable with no signs of ongoing bleeding. . 1. Hematemesis - resolved spontaneously, thought [**2-1**] to tumor locally invasive into the upper GI tract leading to bleed or gasritis [**2-1**] nsaids. Patient showed no signs of bleeding while inpt, hct remained stable, started on protonix gtt, then transitioned to PO protonix. EGD performed by GI, signs of gastritis and radiation enteritis, no signs of active bleed. Discharged with protonix and zofran. Gastroenterology recommendations, given increasing biliary [**Last Name (LF) **], [**First Name3 (LF) **] benefit from palliative stent placement. Should have laboratory checks within next week for further evaluation. . 2. Abnormal liver function tests - Elevated INR. Elevated bilirubin, alk phos, ALT, and AST. These are consistent with poor synthetic function and liver injury. This is likely secondary to known invasion of tumor into his liver. Given ongoing bleeding correction of coagulopathy is warranted. Was given vitamkin K po. Outpt oncologist and pcp f/u needed for lab checks, if indicated with GOC. . 3. Pancreatic Cancer - Patient has metastatic pancreatic cancer. Dr. [**Last Name (STitle) **] [**Name (STitle) 78772**] pt while inpatient, with tentative plan for no additional chemotherapy. . 4. Pain - Chronic abdominal pain secondary to tumor. -Morhpine SR 15mg [**Hospital1 **] -Morphine 15-30mg PO q4h PRN -Odansetron 8mg PO q8h PRN -Prochlorperazine 5-10 mg PO/IV q6h PRN . 5. Insulin dependent diabetes - continued on lantus half dose and iss. . 6. Code status DNR/DNI, transitioning to home hospice, as per pt wishes. Hospice arranged by case management. . EMERGENCY CONTACT: [**Name (NI) **] [**Name (NI) **] is primary HCP ph [**Telephone/Fax (1) 78773**], wife is secondary [**Telephone/Fax (1) 78774**] (cell), [**Telephone/Fax (1) 78775**] (home). Medications on Admission: AMYLASE-LIPASE-PROTEASE 249 mg (33,200 unit-[**Unit Number **],000 unit-[**Unit Number **],500 unit) Capsule [**4-5**] Capsule with meals INSULIN GLARGINE 12 units at bedtime INSULIN LISPRO Sliding scale MS-CONTIN 15mg [**Hospital1 **] MS-IR 15-30mg q4H prn ONDANSETRON 8 mg q8H prn PANTOPRAZOLE 40 mg daily PROCHLORPERAZINE 10mg q6H prn DOCUSATE SODIUM 100mg [**Hospital1 **] Discharge Medications: 1. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*45 * Refills:*2* 4. Morphine 10 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed. 5. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*1* 6. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 8. Lantus 100 unit/mL Cartridge Sig: 12u Subcutaneous at bedtime: as per regular routine. 9. lispro Sig: sliding scale with meals as needed for high glucose: as per regular routine, sliding scale. 10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. lancets for glucose checks please provide quantity sufficient for 1 month Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: 1. ugib - unknown source 2. gastritis . Secondary: 1. Metastatic unresectable pancreatic cancer -Dx in [**5-/2105**] -s/p aborpted whipple converted to palliative Roux-en-Y hepaticojejunostomy, gastroenterostomy, cholecystectomy in [**2104**] -s/p cyberknife radiation -on a clinical trial for TNFerade plus standard of care (gemcitabine/5FU), last [**12/2105**] -Recently admitted in [**12/2105**] with a closed loop SBO secondary to tumor metastatic to omentum, s/p pallative small bowel bypass procedure, discharged on [**2106-1-26**]. Had self limited hematemesis on post op day 5, not worked up. -Currently in the process of discussing hospice with or without second line chemotherapy with capcitabine and oxaliplatin. -Oncologist: Dr. [**Last Name (STitle) **] [**Name (STitle) **]: Dr. [**Last Name (STitle) 28529**] 2. Insulin-dependent diabetes for 10 years. 3. GERD. 4. Osteoarthritis s/p shoulder surgery years ago 5. Hypercholesterolemia. 6. PFO 7. s/p tonsillectomy Discharge Condition: Patient discharged to home in stable condition, ambulating, tolerating po feeds. Discharge Instructions: Patient was admitted for upper GIB, which was stable throughout his hospital course; EGD did not show active signs of bleed and his blood counts were stable. Patient is advised to seek medical attention if he acquires chest pain, sob, nausea, vomiting, or any other concern that is out of the ordinary for him. Patient is advised to keep all of his outpatient appointments. Followup Instructions: Please keep you outpt f-u with your ongologist and pcp. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "250.00", "157.9", "272.0", "535.50", "530.81", "569.84", "578.9", "790.6" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.13" ]

icd9pcs

[ [ [] ] ]

11266, 11317

7531, 9528

310, 315

12352, 12435

6219, 7508

12857, 13052

5010, 5086

9956, 11243

11338, 12331

9554, 9933

12459, 12834

5101, 6200

259, 272

343, 1675

1697, 4889

4905, 4994

31,602

116,145

33543

Discharge summary

report

Admission Date: [**2125-4-11**] Discharge Date: [**2125-4-25**] Date of Birth: [**2107-1-20**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2836**] Chief Complaint: Foreign Body ingestion (bra underwire) Major Surgical or Invasive Procedure: Exploratory laparotomy with gastrotomy and jejunotomy to extract a braw underwire. History of Present Illness: Patient is a 18 yo female with a history of multiple hospitalizations for suicidal ideation as well as self injury and anger with unstable affect. She states that on Tuesday, [**4-10**] she was feeling depressed and felt like she wanted to die due to her feelings about wanting to leave the residental program. She states that it is her "trigger place" because the other girls there hate her for an unknown reason. She reports that she swallowed an underwire of a bra. She reports that shortly there after she started having abdominal pain and was transported to a local ED. In the ED the pateint reports that they were unable to visualize the underwire and she was transfered to [**Hospital3 44097**] for suicidal ideation. However she reports that yesterday [**4-11**] while at [**Hospital3 44097**] she started throwing up, and was transfered to [**Hospital **] hospital. At that time the wire was visualized but GI there was unable to remove the wire and the patient was transfered to [**Hospital1 18**] for further evaluation. Past Medical History: bipolar, SI, PTSD, ADHD Social History: She reports that in [**2124**] she was raped and becoming acutly suicidal and attempted to jump infront of a train. Patient reports she heard two voices continuously for 2 years, one telling her bad things from the past, the other telling her to kill herself, that stopped when she was 17. She states that she was hospitalized at that time at [**Doctor First Name 1191**] and then moved to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Academy where she has been for the last 8 months. She reports a history of swallowing F.O's including a straw and a marker cap. Born in [**Hospital1 189**]. She states that her mother was a prositute and her father was killed in jail. She reports being in [**Doctor Last Name **] care from age [**5-14**] then adopted at age 7. She states that she moved to independent living at 17 and now [**Doctor Last Name **] in a residential program. She states that she has 5 siblings. She adds that she has been molested by many adults in her past. Family History: Family psych hx; bipolar disorder, alcoholism, and cocaine abuse in mother, now [**Name2 (NI) 7758**]. Physical Exam: 98.9, 71, 104/60, 18, 100% RA Gen: A+O x3, minimal distress CV; RRR Chest: CTA bilat. Abd: +BS, minimal epigastric tenderness, no peritoneal signs, no guarding. Rectal: guaiac negative, no masses Pertinent Results: [**2125-4-12**] 10:15AM BLOOD WBC-18.3*# RBC-3.87* Hgb-11.2* Hct-33.4* MCV-86 MCH-28.8 MCHC-33.5 RDW-13.5 Plt Ct-293 [**2125-4-13**] 09:20AM BLOOD WBC-9.2 [**2125-4-15**] 10:35AM BLOOD Glucose-102 UreaN-7 Creat-0.7 Na-139 K-4.8 Cl-104 HCO3-25 AnGap-15 [**2125-4-12**] 10:15AM BLOOD ALT-14 AST-24 AlkPhos-57 Amylase-42 TotBili-0.3 [**2125-4-12**] 10:15AM BLOOD Lipase-16 [**2125-4-15**] 10:35AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9 [**2125-4-12**] 10:15AM BLOOD TSH-0.49 . ABDOMEN (SUPINE & ERECT) PORT [**2125-4-11**] 9:50 PM SUPINE AND ERECT ABDOMINAL FILMS: A endoscopic snare is seen with its tip in the duodenum around a 5-cm linear foreign body in the mid abdomen. There is no free air under the diaphragm. The bowel gas pattern is non- obstructive. IMPRESSION: Non-obstructive bowel gas pattern with snare and foreign body visualized in the mid abdomen. . CHEST (PORTABLE AP) [**2125-4-11**] 9:49 PM CLINICAL INDICATION: 18-year-old female with known foreign body in the duodenum, s/p attempted extraction with snare in place; evaluate for free air. COMPARISON: None. AP CHEST: An endoscopic snare is noted with its tip in the mid-abdomen in the expected location of the 4th portion of the duodenum. The snare tip abuts the linear metallic foreign body. There is no free air under the diaphragm. The lungs are clear. The cardiomediastinal silhouette is unremarkable. IMPRESSION: 1. No evidence of free air. 2. Snare tip/foreign body in the expection region of the 4th portion of the duodenum. Brief Hospital Course: This is a 18 year old female with a foreign body ingestion and unsuccessful removal at an OSH. She went to the OR on [**2125-4-12**] for an Exploratory laparotomy with gastrotomy and jejunotomy to extract a bra underwire. She did well post-operatively from the surgery. She was NPO with IVF and a NGT. The NGT was removed on POD 3. She was started on sips on POD 4. She was tolerating a regular diet on POD 5. Her abdomen was C/D/I with staples in place. The staples will be removed at her follow-up appointment. Pain: She was on a PCA for pain control. Her pain was well controlled. Once tolerating a regular diet, she was ordered for PO pain meds. She had no pain at time of discharge. Psych: She was followed by psych and there are detailed notes in OMR. She was restarted on all her home meds once tolerating a diet. Social work was involved for placement issues. Medications on Admission: topomax 100', trazadone 100', Abilify 10'', Zantac 150'', MVI, Effexor 300', Nalterxone 50', Lamictal 50 qam, 100qhs, Vistaril 50 prn, Trazadone 50' Discharge Medications: 1. Topiramate 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Four (4) Capsule, Sust. Release 24 hr PO DAILY (Daily). 5. Lamotrigine 100 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). 6. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 10. Vistaril 50 mg Capsule Sig: One (1) Capsule PO every [**7-15**] hours as needed. Discharge Disposition: Extended Care Facility: [**Hospital 1680**] [**Hospital **] Hospital Discharge Diagnosis: Foreign body ingestion Suicidal ideation Discharge Condition: Good Tolerating a diet. Pain well controlled Discharge Instructions: Please call your doctor or return to the ER for any of the following: * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily * No heavy lifting (>[**11-21**] lbs) for 6 weeks. * Monitor your incision for signs of infection * You may shower and wash. No tub baths or swimming. Keep your incision clean and dry. Followup Instructions: Please follow-up with Dr [**First Name (STitle) **] next week for staple removal. Wednesday, [**4-25**] at 9:30am. Clinic is at [**Hospital1 18**], [**Location (un) **]., [**Hospital Ward Name 23**] [**Location (un) 470**]. Completed by:[**2125-4-18**]

[ "V62.84", "314.01", "296.89", "936", "E849.7", "E958.8", "935.2", "309.81" ]

icd9cm

[ [ [] ] ]

[ "96.07", "43.0", "45.02" ]

icd9pcs

[ [ [] ] ]

6360, 6431

4439, 5313

354, 439

6515, 6561

2916, 4416

7992, 8246

2580, 2685

5513, 6337

6452, 6494

5340, 5490

6585, 7969

2700, 2897

275, 315

467, 1502

1524, 1549

1565, 2564

67,104

116,413

38257+38258

Discharge summary

report+report

Admission Date: [**2134-8-20**] Discharge Date: [**2134-9-8**] Date of Birth: [**2053-12-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2009**] Chief Complaint: Nausea and vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 80 yo Armenian-speaking F with a history of multiple myeloma, hypertension, and [**First Name3 (LF) 2320**], who was discharged two days prior from [**Hospital1 18**] after being admitted for constipation, now with nausea and vomiting. . She was admitted here from [**Date range (1) 85266**] for constipation, thought to be due to chronic narcotic use (fentanyl patches, dilaudid pca, tramadol, and oxycodone in recent past) for her multiple myeloma pain. She was started on an aggressive bowel regimen and oral naloxone. Of note, she was admitted to [**Hospital1 2177**] for similar symptoms from [**Date range (1) 33692**]. . Since being discharged to rehab two days ago, she has had persistent nausea and vomiting. According to her grandson, she has attempted to drink juices and Ensure, and has vomited it all soon after drinking. Last night there was some brown clots in the vomit. She has not had a BM since being discharged. She denies abdominal pain or feeling bloated. . In the ED her vitals were 98.4, 136/80, 90, 18, 98%RA. She received Zofran for nausea. An NG tube was placed with 700cc of bilious output. She was guaiac negative. A CT was done, and she was started on heparin gtt for a R common femoral vein DVT. . On ROS, she endorses weakness in her LE bilaterally. She denies fevers, chills, night sweats, recent weight changes, rinorrhea, confusion, chest pain, SOB, urinary retention or dysuria, rash or joint pain. Past Medical History: 1. Kappa light chain multiple myeloma. Diagnosed approximately one and a half years ago, and has been treated with velcade/bortezomib and dexamethasone. She has significant pain and is on chronic narcotics. Oncologist: Dr. [**Last Name (STitle) 85264**] at [**Hospital6 **], phone [**Telephone/Fax (1) 63775**]. 2. Hypertension 3. HLD 4. [**Telephone/Fax (1) 2320**] 5. Cataracts 6. Arthritis 7. Recent oral candidiasis Social History: Lives with daughter and grandson. She does not smoke, drink or use illicit drugs. Family History: Both parents were ~age [**Age over 90 **] years when they died and were healthy. Her sister has Type II DM. Also a family history of cataracts. Physical Exam: ADMISSION: VS 97.2 122/64 100 18 100/2LNC Gen: Fatigued-appearing, speaks quietly with grandson [**Name (NI) 4459**]: NC/AT, NGT to wall suction w/ dark brown fluid draining Neck: Supple, no LAD CV: Tachy w/ regular rhythm, nl S1/S2 Pulm: Auscultated anteriorly, CTAB Abd: Soft, nontender, nondistended, striae present, hypoactive BS Ext: Warm, 2+ pitting edema to mid-calf Pertinent Results: Chemistries: - [**2134-8-20**] 02:10AM GLUCOSE-115* UREA N-12 CREAT-1.3* SODIUM-142 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-29 ANION GAP-12 LACTATE-1.5 - [**2134-8-27**] 07:12AM BLOOD Glucose-102* UreaN-11 Creat-1.1 Na-137 K-4.1 Cl-104 HCO3-24 AnGap-13 - [**2134-8-31**] 09:20AM BLOOD TSH-3.4 Hematology: - [**2134-8-20**] 02:10AM WBC-10.0 (NEUTS-78.9* LYMPHS-15.8* MONOS-3.8 EOS-1.1 BASOS-0.3) RBC-3.71* HGB-10.2* HCT-32.7* MCV-88 MCH-27.5 MCHC-31.2 RDW-17.6* PLT COUNT-201 - [**2134-8-27**] 07:12AM BLOOD WBC-6.0 RBC-3.43* Hgb-9.5* Hct-30.9* MCV-90 MCH-27.7 MCHC-30.8* RDW-17.3* Plt Ct-303 Coagulation Studies: - [**2134-8-20**] 02:10AM PT-11.4 PTT-25.6 INR(PT)-0.9 [**2134-8-16**] CT Abdomen without IV contrast: IMPRESSION: 1. Diffuse gaseous distension and borderline dilation of small bowel without evidence of obstruction. Findings could represent ileus secondary to narcotic use. 2. Subtle nodularity and bronchial wall thickening in the RLL suggestive of aspiration. 3. Bilateral femoral head lucencies may represent multiple myeloma lesions. Correlate with prior imaging if available. 4. Cholelithiasis. [**2134-8-20**] CT Abdomen with IV contrast: 1. Left pelvic sidewall mass extending through the left obturator foramen is concerning for plasmocytoma. 2. Clot in the right common femoral vein. The thrombus does not extend into the iliac vein. The distal extent of this thrombus is not visualized however. 3. Gallstone within the gallbladder, but no evidence for cholecystitis. [**2134-8-24**] KUB: Slight progression of diffuse gaseous distention of small bowel with increasingly collapsed colon distally, suggestive of ileus versus early or partial small-bowel obstruction. No free air. [**2134-8-26**] Upper Extremity CT: 1. Large destructive lesion in the left humeral head extending into the diaphysis of the humerus as well as large external soft tissue component as described above. Numerous additional lesions with and without soft tissue component, including incompletely imaged lesions in the cervical spine. Findings are consistent with stated history of multiple myeloma. 2. Small left pleural effusion. [**2134-8-30**] CXR: No evidence of pneumonia. Small left pleural effusion and erosion of the right humeral head. [**2134-8-30**] Echo: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate global left ventricular hypokinesis (LVEF = 35-40 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. Brief Hospital Course: Ms. [**Known lastname 85265**] was admitted to the floor with n/v on [**2134-8-20**]; an NGT suctioned ~1000cc bilious fluid in the ED. #Nausea and Vomiting: The abdominal CT revealed no mechanical obstruction; her ileus was presumed to be due to the high dose of narcotics she was on for her bone pain. On the floor, the patient's NGT remained in for 24 hours, with minimal residuals. Her PO fluid intake were minimal initially, thought to be due to remaining ileus. Her hospital course was marked by increasing nausea/vomiting when her narcotics were provided, and a KUB on hospital day 4 revealed an ileus consistent with medications. When she ultimately transitioned to standing tylenol for her pain, her PO remained poor. Because of malnutrition, her family maintained a strong interest in having her start TPN. They were counseled about the challenges of TPN, including the lack of an end point, but wanted to have it started. A double lumen PICC was placed on [**9-4**] and TPN was started. TPN will continue and should be adjusted based on daily chem 10s by nutrition. #DVT: On admission CT scan she was found to have a R common femoral vein DVT. She was started on heparin gtt. Discussion of an IVC filter was postponed until after this hospitalization. On [**2134-8-22**] there was difficulty obtaining blood draws and monitoring her PTT. She was transitioned to lovenox. Her lovenox was held on [**9-3**] and [**9-4**] out of concern for a LGIB (? LGIB versus bleeding hemorroid), but was restarted on [**9-5**]. Hct 26 on discharge and stable. #Pain Control: On admission she had a 100mcg/hr fentanyl patch on her arm dated [**2134-8-17**]. In an attempt to decrease her potential for narcotic-related ileus, the patch was not replaced; she was placed on oxycodone for pain. On [**2134-8-22**], the patient (through her family) reported a significant increase in her joints where she is known to have lytic lesions. A 50mcg/hr fentanyl patch was placed. However, her ileus persisted, and she was transitioned to standing tylenol with ultram for breakthrough (which she had been on before) with good response. . Given her continued nausea and poor PO intake, a KUB was done and revealed an ileus. Her fentanyl patch and oxycodone were again discontinued; she was left on standing tylenol. Ultram was written for breakthrough pain, but she did not require it. Rad-onc and heme-onc were consulted for palliative radiation and chemotherapy, in an effort to wean her off pain meds. A CT of her shoulder revealed significant lytic lesions, and rad-onc felt it was amenable to XRT as an outpatient (started [**9-2**]). The family reported on [**9-3**] that they would like to hold the XRT while she starts getting the TPN and will resume as an outpatient. . #Multiple myeloma: The abdominal/pelvic CT revealed a mass concerning for a plasmacytoma. Her outpatient oncologist at [**Hospital1 2177**] reported that this was an amyloidoma, and has been known since her diagnosis 1.5 years ago. No further workup on this mass was done. The patient's family expressed an interest in having a second opinion by [**Hospital1 18**] oncologists and her oncology care transferred to [**Hospital1 18**]. An appointment was made to be seen as an outpatient by Dr. [**Last Name (STitle) **] in [**Hospital1 18**] oncology, but her new medical problems during this hospitalization prompted involvement of the inpatient heme-onc consult service. Their advice was solicited to help establish goals of care. A family meeting was held on [**9-6**] with oncology, after they had time to review her [**Hospital1 2177**] records. It was felt that she currently is not a good candidate for more aggressive chemotherapy given her clinical status and ongoing medical issues. The family decided they will consider a outpatient opinion once she spends time at rehab to regain strength. Palliative care was also involved in the discussions with the family and the family is not ready at this time to begin a palliative approach. The patient would also like to be aggressive at this time. The plan on discharge was to continue TPN to improve the patients nutritional status/strength and the family would like time to see how she progresses and get ongoing further treatment options. #Hypertension: On admission her BP was 122/64 and she was continued on her home medications of metoprolol, amlodipine and lasix. Her lasix and amlodipine was held on [**8-21**] after a BP of 99/38 and poor PO intake. Her metoprolol was continued given her a.fibb and the dose was adjusted to keep her BP stable and HR under control. She was discharged on 12.5mg PO q6. #[**Month/Year (2) 2320**]: She was hypoglycemic on the floor initially, requiring dextrose 50% and glucagon per hypoglycemia protocol. Subsequent AM glucose were 90-115, and her finger sticks were d/c'ed. They were restarted on [**9-3**] because of starting TPN. She was subsequently started on Lantus 6U qhs with ISS. This should be adjusted based on daily fingersticks with sliding scale. #Anemia: At the time of her [**2134-8-18**] discharge her Hct was 34.4, thought to be due to her chronic disease. When she arrived on this admission it was 32.7, and trended down to 27.8 one day after being admitted. There was a question of heme-positive residuals from her NGT, but this could not be verified. Her Hct rebounded and stablized in the low 30s, before dropping to 24.8 on [**9-2**]. Because she was on lovenox and noted to have dark maroon stools, it was suspected that she had a LGIB. Her lovenox was held. Her hct then stabilized and her bleeding was thought to be due to her hemorrhoid. She was transfused 1U on [**9-3**], with appropriate increase in her hct. Her Hct susbequently remained stable around 26-28. #Wound care: Noted on admission to have a clean wound on coccyx. Subsequently noted to have ecchymotic perianal tissue, described as 2 small open areas at 3 and 7 o'clock, also 0.2 cm pink ulcer on large external hemorrhoid. Wound care was consulted. Recommended gentle foam cleaner and dry patting. On hospital day 11 she wound care noted significant blistering in the skin folds of her breast and groin, as well as an ulcerous periurethral lesion. Through a translator, these were neither painful nor pruritic. Dermatology was consulted, and recommended nystatin and zinc oxide for suspected contact vs irritant dermatitis. Derm did not suspect HSV for her periurethral lesion. . #Afib: Was tachycardic on [**8-30**], thought to be due to dehydration in the setting of poor PO intake. She remained asymptomatic, denying chest pain or shortness of breath. Telemetry suggested that she was in afib with RVR. Her metoprolol was increased to 25mg TID. The next day her HR was intermittently in the 160s. An EKG revealed no ischemic changes or R heart strain. A CXR revealed no focal consolidation. She was given IVF and her metoprolol was increased to 37.5mg TID. Her HR decreased to 80s and 90s. An echo showed moderate LV hypokinesis (LVEF = 35-40%), increased LV filling pressure (PCWP>18mmHg), and no evidence of R ventricular strain or wall motion abnormalities. Rate control was obtained with metoprolol 12.5mg PO QID. This should be adjusted as needed. . #ACS/Demand Ischemia: Elevated troponins x 2. No EKG changes suggestive of MI; elevated enzymes thought to be due to new-onset afib. Cardiology was consulted, recommended medical management. ASA and statin were started, as she was already on lovenox and metoprolol at the time. The ASA and lovenox were held on [**9-3**] and [**9-4**] out of concern for a LGIB (? LGIB versus bleeding hemorroid), but restarted on [**9-5**]. Lisinopril was started given low EF. . #hyponatremia- Pt noted to have Na 126 and remained stable; initially thought to be hypovolemic hyponatremia but did not respond to IVF. Pt had urine lytes which showed an SIADH picture. Pt was not taking in much PO; and given diffuse anasarca trial of Lasix was done (20mg IV on [**9-6**]) which she responded to well. She should continue to get Lasix as needed. Her Na on discharge was 128. . #Decreased urinary output: On [**9-2**] she was noted to have decreased urine output, thought to be due to decreased intravascular volume in the setting of poor PO intake. A foley was placed (rather than having to repeatedly straight cath her given her periurethral lesion), and she had adequate UOP following IVF. #Arthritis: Stable. Her pain was addressed with the standing tylenol described above. #Social: Several conversations were held with the family (most often the grandson) about their goals for her long term care. He stated that they remain optimistic for her, and would like to pursue rehab for physical therapy and further outpatient oncology opinions relative to future treatment. Medications on Admission: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 3. Nystatin 500,000 unit Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 8. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 9. Insulin Glargine 100 unit/mL Solution Subcutaneous 10. Lantus 100 unit/mL Cartridge Sig: 15 units Subcutaneous at bedtime. 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 12. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 13. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 20. Prochlorperazine Maleate 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for nausea/vomiting. 21. Fentanyl 100 mcg/hr Patch 72 hr Sig: [**2-13**] Patch 72 hrs Transdermal Q48H (every 48 hours). 22. Naloxone 1 mg/mL Syringe Sig: One (1) 3mg Injection TID (3 times a day): Please give 3mg PO TID. . 23. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation: hold for >2 BM daily. 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:*112 Tablet(s)* Refills:*0* 7. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea, before meals. Disp:*42 Tablet, Rapid Dissolve(s)* Refills:*0* 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID:PRN as needed for constipation. 10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 11. 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. 12. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 17. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO every six (6) hours. 19. Insulin Glargine 100 unit/mL Cartridge Sig: 6 units Subcutaneous at bedtime. 20. Insulin Regular Human 100 unit/mL Cartridge Sig: Sliding scale Injection once a day: Please see sliding scale per attached. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Primary: N/V secondary to narcotic-related ileus, R common femoral DVT, perianal wound Secondary: Multiple myeloma, HTN, diabetes II, anemia Discharge Condition: Ms. [**Known lastname 85265**] is being discharged from the hospital in stable condition, at normal mental status (per her family) and in a wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 85265**], You were admitted to the hospital with concern for your nausea and vomiting. After an evaluation consisting of a history, physical exam, imaging and blood tests, it was suspected that it was due to your high levels of pain medications. These can cause your stomach and digest food slowly. The CT scan showed no physical obstruction. We decreased the doses of your pain medications, and it appeared that your nausea and vomiting improved. You should continue to try to take the Boost shakes and eat whatever you can tolerate. The CT of your abdomen also showed a blood clot in your right leg. We are treating this with the appropriate blood-thinning medication called Lovenox. You should continue to take this until you follow-up with your outpatient doctor. During your hospitalization your heart rate was noted to be in an irregular rhythm called atrial fibrillation. Your Metoprolol was changed to help control the heart rate. You were also found to have a silent heart attack, which may have been due to the demand on your heart from the fast heart rate. You were seen by the cardiology team and started on new medications to help manage this. You were also not eating very well during your hospitalization and the decision was made with your family to begin nutrition through an IV, called TPN. You will continue TPN until you get your strength back and your nausea improves enough for you to eat by mouth. Medications that were changed during this admission are: 1. STARTED Acetaminophen (Tylenol) 325mg, you can take this every 8 hours as needed for pain. 3. STARTED Zofran 4mg PO - This is another medication for your nausea. You should take this before your meals as needed. 4. STARTED Lovenox injections - This is a medication for the blood clot in your leg. 5. STOPPED Amlodipine 6. STOPPED Oxycodone 7. STOPPED Fentanyl Patch 8. STOPPED Furosemide 9. CHANGED Metoprolol to 12.5 mg four times/day 10. STARTED Simvastatin 80mg daily 11. Started aspirin 325mg daily 12. Started Miconazole powder for a rash 13. Started Tramadol 50mg as needed for pain 14. CHANGED Lantus to 6units every evening 15. Stopped Compazine Followup Instructions: We understand that you would like to transfer your oncology care from [**Hospital6 **] to our hospital. Once you complete your stay at rehab and make a decision regarding further desire for chemo or radiation, please call [**Hospital1 18**] for an appointment in oncology. You will be seen by the oncologist at the rehab which you are going. Admission Date: [**2134-9-9**] Discharge Date: [**2134-10-30**] Date of Birth: [**2053-12-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3556**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: [**Location (un) 260**] IVC filter placement History of Present Illness: Ms. [**Known lastname 85265**] is a 80 yo Armenian-speaking F with a history of multiple myeloma, [**Known lastname 2320**], and multiple recent admissions to [**Hospital1 18**] for constipation, nausea, and vomiting, recently started on anticoagulation for DVT, who presents from [**Hospital3 **] one day after discharge with a large dark stool and concern for GI bleed. History was obtained from pt grandson [**Name (NI) 382**]. . Of note, she was recently admitted to [**Hospital1 18**] from [**8-6**] - [**8-12**] and again from [**8-16**] - [**8-18**] for constipation in the setting of chronic narcotic use (fentanyl patches, dilaudid pca, tramadol, and oxycodone in recent past) for her multiple myeloma pain. She was then readmitted [**2134-8-20**] and discharged [**2134-9-6**] for an ileus which improved when narcotics were stopped. During this admission she was also found to have a R common femoral vein DVT and was started on heparin gtt. This was transitioned to lovenox, which was held [**9-3**] and [**9-4**] for dark maroon stool and a Hct drop (29.6 --> 24.8) with concern for lower GI bleed. At the time she was transfused 1 unit of RBCs and her Hct stabilized and it was then thought that she had had a bleeding hemorroid. Her lovenox was restarted on [**9-5**] and her Hct was stable at 26 on discharge. She was also started on full dose aspirin per cardiology who evaluated her for NSTEMI in the setting of a fib with RVR during her hospitalization. She was discharged to [**Hospital1 **] and the following day (day of presentation) she was noted to have a large dark stool. Per grandson pt has no history of previous GI bleed other than the recent hospitalization. She has continued to have nausea and emesis every few days. Two nights ago there was some brown clots in the vomit. She denies abdominal pain or diarrhea. Her last BM was 2 days ago. . In the ED, initial vs were: BP 110/60 HR 60 RR 14 Sats 96% RA. on exam she was found to be lethargic. Communication was with grandson. GI was consulted and the patient was found to have maroon stools that were guaiac +. NG lavage caused epistaxis and revelaed initial bright red blood which cleared with 250 cc. A second lavage a little while later again revealed blood tinge. A third lavage yt eh GI fellow was clear. She went into a fib with RVR with no ST changes but T wave flattening during the NG lavage. Hct was 26.7 then repeat 23.3. Pt was given protonix 80 mg and then started on gtt. A peripheral 18 guage was placed and she has the PICC from rehab. She was also given Ciprofloxacin for UTI. . Just prior to transfer to the ICU the patient became hypotensive to the 80s and a small amount of bright red blood ber rectum was noted on the rectal thermometer. . Of note, the patient's Multiple Myeloma - which was diagnosed a year and a half ago - was recently thought to be unamenable to chemotherapy by oncology given the pt multiple medical issues including poor PO intake and anasarca. She was discharged to rehab on TPN per request by her family who after many goals of care discussions decided that they wanted to pursue aggressive supportive care with the hope of eventually starting chemotherapy. Past Medical History: 1. Kappa light chain multiple myeloma. Diagnosed approximately one and a half years ago, and has been treated with velcade/bortezomib and dexamethasone. She has significant pain and is on chronic narcotics. Oncologist: Dr. [**Last Name (STitle) 85264**] at [**Hospital6 **], phone [**Telephone/Fax (1) 63775**]. 2. Hypertension 3. HLD 4. [**Telephone/Fax (1) 2320**] 5. Cataracts 6. Arthritis 7. Recent oral candidiasis Social History: Lives with daughter and grandson. She does not smoke, drink or use illicit drugs. Family History: Both parents were ~age [**Age over 90 **] years when they died and were healthy. Her sister has Type II DM. Also a family history of cataracts. Physical Exam: Vitals: T: BP: 97/45 P: 103 R: 18 O2 100% General: Lethargic, oriented x 3, no acute distress [**Age over 90 4459**]: pale conjunctiva, MMM, oropharynx unable to assess due to limited ability to open mouth, NGT in place Neck: supple, JVP not elevated, no LAD Lungs: Clear to bibasilar rhales, no wheezes or rhonchi CV: Irregular Regular rhythm, no murmurs Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: anasarcic, warm, 1+ pulses Pertinent Results: [**2134-9-8**] 07:50AM BLOOD WBC-8.6 RBC-2.92* Hgb-8.5* Hct-26.7* MCV-92 MCH-28.9 MCHC-31.6 RDW-18.4* Plt Ct-275 [**2134-9-9**] 12:42AM BLOOD Neuts-75.2* Lymphs-18.2 Monos-5.4 Eos-1.1 Baso-0.1 [**2134-9-9**] 02:50AM BLOOD PT-11.7 PTT-30.8 INR(PT)-1.0 [**2134-9-14**] 07:55PM BLOOD Fibrino-558* [**2134-9-8**] 07:50AM BLOOD Glucose-138* UreaN-27* Creat-0.9 Na-128* K-4.2 Cl-97 HCO3-25 AnGap-10 [**2134-9-13**] 11:17PM BLOOD CK(CPK)-29 [**2134-9-13**] 11:17PM BLOOD CK-MB-7 cTropnT-0.28* [**2134-9-8**] 07:50AM BLOOD Calcium-6.7* Phos-2.6* Mg-2.2 [**9-15**] EEG: This is an abnormal VEEG-telemetry due to the presence of a moderately slow background rhythm. This record is consistent with a mild encephalopathy, secondary to possible infectious, metabolic, or medication-related effects. The superimposed beta frequency rhythm throughout much of the record is likely due to medication effect, most likely benzodiazepine or barbiturates. There are no focal abnormalities or electrographic seizures recorded [**9-30**] MR [**Name13 (STitle) 430**]: . No acute infarction, hemorrhage or specific evidence of anoxic brain injury. 2. The CSF within the cerebral extra-axial spaces and cortical sulci is FLAIR-hyperintense and slightly T1-hyperintense without subjacent brain parenchymal abnormality, while the intraventricular CSF signal appears normal. While such a pattern may be seen with supplemental oxygen administration, this is usually seen at high FIO2, reaching 100% and review of this patient's OMR confirms that her FIO2 has been consistently at 40, last measured this morning. Given the patient's progressive renal insufficiency, with serum creatinine rising from 1.2 to 2.3, this most likely represents retained gadolinium administered for the [**9-26**] MR study. This phenomenon may produce a pattern of relatively abnormal sulcal CSF. Abnormal protein or cells in the CSF is a less likely consideration, which would have to be excluded by lumbar puncture, if feasible. 3. Erosion of the dens surrounded by thickened T1-hypointense tissue which demonstrated contrast enhancement, previously. This is not significantly changed compared with the prior study. No evidence of abnormal alignment at the craniocervical junction or atlantoaxial articulation. Given the history, this most likely relates to underlying multiple myloma this is concerning for plasmacytoma 4. Stable left maxillary sinus and bilateral mastoid air cell mucosal thickening and fluid. Brief Hospital Course: In summary, Mrs. [**Known lastname 85265**], [**First Name3 (LF) **] 80 y/o woman w/ multiple myleoma, was admitted on [**2134-9-9**] for BRBPR, had two PEA arrests, developed sepsis, and hypotensive despite pressors, and after a lengthy ICU course, passed away on [**2134-10-30**]. Futher details provided below. Mrs. [**Known lastname 85265**] was an 80 yo Armenian speaking woman with history of multiple myeloma and recent hospitalizations for constipation/ileus complicated by DVT and NSTEMI, on lovenox and full dose aspirin who presented with BRBPR. On arrival to the medicine floor, she was breathing 26 times per minute and satting 98% on 2L NC. Her telemetry was showing an Afib rhythm with a HR in the low 100s. She was awake and responsive to questions with nods and mouthing words but could not clearly vocalize. She was also profoundly weak in both upper and lower extermities with poor hand grip and poor hand coordination. . ## PEA arrest s/p cooling protocol c/b subclinical seizures: Her PEA arrest was attributed to macroaspiration on [**9-14**], with a question of family feeding patient despite NPO status. Her warming complicated by subclincal seizures noted on EEG which improved on anti-epeleptic medication. Her neurologic status remained poor but was close to baseline while in the hospital according to her family. She was followed by neurology until [**9-23**] when it was recommended that IV Keppra be continued and further EEG monitoring or imaging was not required. On [**9-24**], she again developed PEA arrest with degeneration into asystole [**3-16**] again secondary to aspiration. Code blue was called and she required CPR and defibrillation to restore a palpable pulse. She was then transfered to the MICU. Following this second PEA arrest, she was persistently unresponsive and unable to follow commands, though brainstem reflexes were intact. Neurology was consulted. Serial EEGs captured at least two short bursts (less than 10 seconds of) electrographic seizures over an extremely low voltage burst suppression pattern -- a record signifying an extremely poor neurological prognosis in the setting of cardiopulmonary arrest. Her Keppra dose was increased, after which no seizures were captured on serial EEGs. An MRI showed no acute infarction, hemorrhage or specific evidence of anoxic brain injury, but was not stroke protocol due to renail failure. Somatosensory evoked potentials demonstrated some delay, but ultimately transmission of each potential. Given the patient's failure to regain neurological function, the patient's family was advised that she had an extremely poor prognosis for regaining any further neurological function. Palliative care and social work followed. Pt was trached and PEGed. Her neurological function remained poor and she did not regain any more function. Pt was put on Keppra for seizure proph. # Bacteremia - The patient started spiking fevers through vancomycin and zosyn. Blood cultures came back positive for VRE. She was started on linezolid, then switched to dapotmycin because of its lower fluid requirement. . ## Hypotension: The patient was hypotensive s/p second PEA arrest requiring norepinephrine and fluid boluses secondary to tension pneumothorax, aspiration, and Afib with RVR. Norepinephrne was later weaned with placement of a chest tube and rate control. Later in her course, the patient again developed a pressor requirement and was placed on phenylephrine, likely due to sepsis. Positive blood culture from [**10-12**] grew VRE and pt was transitioned to linezolid, then daptomycin as above. Attempted to wean off of pressors but continued to require neo. Neo requirements continued to increase in the setting of fever and increased WOB. By [**10-21**] Neo requirement was 3.5. . ## Acute Kindey Injury: The patient suffered acute kidney injury following her second PEA. Labs were consistent with ATN. Nephrology was consulted and declined to offer CVVH given the patient's poor overall prognosis. Cr continued to increase to 4.0 and continued to hover around this value. . ## Pneumothorax: s/p PEA arrest the patient was hypotensive on norepi, breath sounds diminished on R. CXR showed tension PTX on R, subcutaneous air on L and pneumomediatinum. A chest tube was placed emergently with decompression of the thorax. The chest tube was later removed and repeat chest x-ray showed resolution of the pneumothorax. . ## VAP/LLL collapse: She developed a LLL consolidation on CXR, but has been afebrile and without change in WBC count. Her lung exam was unremarkable. She improved on treatment with reduced work of breathing and reduced oxygen requirement as she was satting 98% on room air. An 8 day course of Vanc/Zosyn was started in the MICU and continued on the floor. In addition, she received respiratory therapy to provide cough assistance therapy and bronchodilators. Pt completed her treatment. . ## Acute on chronic CHF: She was diuresed in the ICU with lasix bolus and drip. Unclear how much she put out from MICU documentation, but has been off lasix x 1 day. EF 35-40% on TTE from [**8-31**]. Now on minimal oxygen. Repeat CXR demonstrated improved airspace disease with stable or slightly worsening pleural effusions. Her beta blocker was continued. . ## Afib with RVR: There was difficulty controlling her heart rate in the setting of poor po intake, infection, electrolyte abnormalities. Electrolytes were checked regularly and repleted. She was rate controlled on beta-blockers. Prior to hospitalization the patient had been anticoagulated on coumadin for a recent DVT. Her anticoagulation was held given her recent GI bleed. Amiodarone was started with relative success. Pt did not cardiovert but HR 100-120. . ## Recent GIB: Family refusing endoscopy for LGIB. She received 1 unit PRBC while in the ICU and she has had a stable Hct in the low 30s. Her Hct on the floor was 32.1. After the patient's second PEA arrrest she did have guaiac negative stools and a slowly falling hematocrit that did require intermittent blood transfusions. . ## Nutrition: Given multiple aspirations causing significant morbidity she was kept NPO while on the medicone flood. A bedside swallow study recommened a video swallow study which revealed gross aspiration. Family was considering a Dobhoff tube. On [**9-24**] she had a presumed aspiration event that resulted in another PEA arrest becoming asystole requiring CPR and defibrillation. In the MICU she received TPN and transitioned to TF after PEG placement. . ## Myeloma: Per Hemo/Onc, no further care is offered for the patient's multiple myeloma. . ## DM: ISS while in house . ## Urinary Tract Infection: Grew pansensitive Ecoli earlier during admission. Completed 7 day course of quinolone. No bacteremia noted. She later was started on ceftriaxone for urinarlysis c/w UTI; however, this was discontinued after urine cultures were negative. Finally, she was treated with fluconazole for persistent yeast in her urine despite frequent Foley replacement. A bladder ultrasound was negative for fungal ball. . # Hyponatremia: Thought to be secondary to SIADH in setting of MM. Diuresis and free water restriction were held in setting of GI bleed, Na was followed. She was eunatremic on arrival to the medicine floor. . # Goals of care: Several conversations were held with the family (most often the grandson [**Last Name (un) **] during her hospitalization about their goals for her long term care which were to provide aggressive supportive care with TPN and rehab with hopes to pursue further outpatient oncology opinions relative to future treatment. Family requested trach and PEG. Pt remains DNR. Medications on Admission: 1. Multivitamin PO DAILY 2. Citalopram 20 mg Tablet PO DAILY (Daily) 3. Prednisolone Acetate 1 % Drops, One Drop Ophthalmic [**Hospital1 **] 4. Polyethylene Glycol 3350 17 gram/dose Powder Q day PRN 5. Bisacodyl 10 mg Suppository QHS PRN 6. Acetaminophen 650 mg PO Q6H 7. Ondansetron 4 mg PO Q8H PRN 8. Senna 8.6 mg PO BID PRN 9. Docusate Sodium 100 mg PO BID:PRN as needed for constipation. 10. Trazodone 25 mg PO HS (at bedtime) as needed for insomnia. 11. Enoxaparin 80 mg/0.8 mL SQ Q12H (every 12 hours). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) PO BID 13. Aspirin 325 mg Tablet PO DAILY 14. Simvastatin 80 mg PO DAILY 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] 16. Tramadol 50 mg Q 6 PRN 17. Metoprolol Tartrate 25 mg Tablet PO every six (6) hours. 18. Insulin Glargine 6 units Q HS 19. Insulin Regular per Sliding scale Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: primary: septic shock, PEA arrest, gastrointestinal bleed secondary: multiple myeloma, diabetes mellitus type 2, chronic systolic congestive heart failure, deep venous thrombosis, urinary tract infection Discharge Condition: Deceased Discharge Instructions: - Followup Instructions: - [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

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icd9cm

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icd9pcs

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30422

Discharge summary

report

Admission Date: [**2158-4-20**] Discharge Date: [**2158-5-1**] Date of Birth: [**2083-9-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: melena Major Surgical or Invasive Procedure: PEG tube revision [**2158-5-1**] Left IJ CVL [**2158-4-24**] - removed Intubation [**2158-4-24**] - extubated [**2158-4-28**] Biliary stent placement [**2158-4-24**] s/p IR embolization of right hepatic artery [**2158-4-23**] EGD [**2158-4-23**] History of Present Illness: This is a 74 YOM with significant medical history of cholangiocarcinoma, severe pneumonia, aspiration requiring PEG tube, and anemia who presents from rehab after episode of melena.He has been at rehab for several days and doing well with PT. His respiratory status was back to baseline. Today he had a sudden on set of lower abdominal pain, [**7-7**], sharp without radiation. Patient states that it lasted ~30m and ended when he passed out from the pain. No pain sense that time. Had melena per rehab report, patient states he knows he had BM around the time of the pain but did not see it. In the ED, initial vitals were T97.1 HR 105 BP 104/49 RR20 93% on 2L. He was given IV pantoprazole, 2L of NS and 2 units of pRBCs. Remained normotensive and tachycardic. Lavage done via PEG tube with no return of blood or coffe ground material. Attempted NG lavage but unable to pass tube. ROS (+)cough with white sputum. (-)Headache, chest pain, SOB, hemoptysis, nausea, emesis Past Medical History: -Recent admit for pneumonia/empyema (strep milleri), still on vancomycin and Zosyn until [**2158-4-24**]. Discharged to rehab [**2158-4-10**]. -Recurrent aspirations, now npo with PEG tube -PEG tube compilcated by melena -Anemia (baseline HCT 26) -Alcohol abuse -Liver mass, biopsy consistent with cholangeocarcinoma -[**2158-3-24**] c scope: Polyp in the ascending colon (polypectomy). Otherwise normal colonoscopy to cecum . -[**2158-3-30**] EGD: Normal esophagus.Dobhoff in place, past the second portion of the duodenum. As the scope was retrieved, the dobhoff was removed accidently. There was no evidence of active bleeding seen in the stomach or small intestine. Normal duodenum. . - COPD, emphysema on home O2 at 4 liters nasal cannula. . -Splenectomy [**12-30**] trauma >30 years ago. Social History: Retired from the Special Forces. He traveled while he was in the services, to [**Country 3992**], [**Country **], and [**Country 10181**]. He startedsmoking at the age of 10, he smoked 2 packs per day until he quit 4 years ago. He has over 120-pack-year history. He drank alcohol approximately [**1-30**] beverages a day prior to his hospitalization, in the past had drank more than that.No alcohol in more than 30 days. Family History: NC Physical Exam: Vitals: T:97.3 BP:112/50 P:102 R:12 SaO2:96% on 4L General: Awake, alert, cachetic man HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMdry, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Crackles at bases Cardiac: Distant heart sounds. RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds. Liver enlarged. PEG c/d/i. Extremities: No edema, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: No deficits to light touch throughout Pertinent Results: _ _ _ _ _ ________________________________________________________________ CXR at admission There is improved aeration in the right lower lung. Linear opacities persist, likely in part atelectasis versus resolving airspace disease. There is a persistent right pleural effusion blunting the right costophrenic angle which may have slightly decreased in size as well. There is no volume overload. No discrete visceral pleural line is seen to suggest pneumothorax. The left lung is hyperexpanded but otherwise unremarkable. There is a minimal tortuosity to an atherosclerotic aorta. The cardiac silhouette is within normal limits for size. A tube of indeterminate origin or etiology is seen overlying the included abdomen. There is a high attenuation focus projecting within the lateral right upper lung which is clearly extrapulmonary when compared to prior studies. This is likely within the axillary soft tissues. . CXR [**2158-4-24**] Severe pulmonary edema is new. Consolidation at the right lung base is partially obscured but probably unchanged. Heart size normal. Pulmonary artery dilatation reflecting pulmonary hypertension due to longstanding chronic lung disease, unchanged. ET tube in standard placement. No pneumothorax. . CT Abd/Pelvis [**2158-4-23**] CT OF THE ABDOMEN WITH IV CONTRAST: Degree of consolidation in both lower lobes appears to have progressed slightly. There are superimposed interstitial densities compatible with fibrosis at the lung bases. There is an unchanged rim-enhancing pleural fluid collection in the right lung base. There is new filling of the prior lumen of the common bile duct and intrahepatic ducts with high-density material which has the Hounsfield units (60-70) of acute blood clot. The gallbladder is abnormal in appearance with heterogeneous areas of high density, also likely indicating hematoma/blood clot. In some images (series 2, image 35), there is a suggestion that there is hemorrhage both in the lumen and in the gallbladder wall. There is worsening intrahepatic biliary ductal dilatation. There is redemonstration of the large mass in the junctions of segments VII and VIII which is not changed in size or appearance. Located anteriorly and just slightly inferior to the largest portion of the lesion, there is a new 6-mm tubular collection of arterial phase contrast seen adjacent to a branching vessel from the right hepatic artery (which is replaced, arising from the SMA). On reconstructed images, this appears to be more tubular in shape. No delay-phase images were acquired. There is also a heterogeneous area of slightly increased attenuation in the liver parenchyma near the porta hepatis. The portal vein is small but remains patent, along with the SMV and likely splenic vein. A gastrojejunostomy tube is present. There is mild dilatation of the pancreatic duct measuring up to 4 mm. The common bile duct is massively dilated, measuring up to 2.6 cm. At a similar level on [**4-6**], the duct measured 13 mm. There is no ascites. Multiple splenules are present. The adrenal glands, kidneys, and bowel loops are unremarkable. . CT OF THE PELVIS WITH IV CONTRAST: Scattered air-fluid levels are present in the colon. There is no colonic wall thickening. There is no free fluid in the pelvis or blood in the pelvis. . [**2158-4-24**] ERCP - FINDINGS: Ten fluoroscopic images obtained during ERCP procedure were submitted to be evaluated by Radiology. No radiologist was present during the procedure. The scout image demonstrates surgical clips in the right upper quadrant. Cannulation and opacification of the biliary duct is noted. There is marked dilation of the CBD with a large filling defect may represent blood. There is partial opacification of the pancreatic duct with borderline diffuse dilatation. A double pigtail biliary stent was placed. IMPRESSION: Successful ERCP with placement of a double pigtail biliary stent. . [**4-23**] Hepatic artery embolization - 1. Selective and superselective arteriograms through the superior mesenteric artery and the replaced right hepatic artery showed the suspected pseudoaneurysm coming off a cranial branch of the right hepatic artery, without active extravasation of contrast. 2. Successful flow-directed embolization of the branches supplying the pseudoaneurysm with multiple straight coils and Gelfoam slurry, until stasis was achieved. 3. Follow-up angiogram demonstrates good angiographic results with stasis at the level of the branches supplying the pseudoaneurysm and no more opacification of the pseudoaneurysm. . [**2158-5-1**] PEG placement - IMPRESSION: Successful replacement of percutaneous gastrojejunostomy tube. The tube is now ready for use. Brief Hospital Course: 74yo M with biliary carcinoma a/w melena who later than developed UGIB complicated by respiratory failure. # UGIB: Pt admitted on [**2158-4-20**] for evaluation of melena. Since HCT remained stable and felt to be slow bleed, scope deferred. However, on Sunday [**2158-4-23**], at 7:30 am vomitted up ~250 cc of bright red blood and had abrupt onset of abdominal pain. Called GI for urgent endoscopy, and surgery for evaluation of abdominal pain. Pt was also intubated for respiratory distress and airway protection for hematemasis. Patient was found on chemistries to have developed new billiary obstruction. Endoscopy showed blood coming from ampulla. Collective decision among all involved services to get CTA of abdomen to evaluate further. CT showed large bleed in the billiary system. Pt was transfused a total of 4 units of blood and 4 units of FFP. IR was called, and patient went for embolization. HCT remained stable after transfusion and embolization of the right hepatic artery. For biliary obstruction from blood clot, ERCP done the following day, [**2158-4-24**] to remove clot and pig tail stent placed. During that procedure, the existing PEG tube was removed due to visual obstruction. The stent resulted in resolution of obstruction. He was fluid resuscitated and was briefly on levophed gtt for a day. Since [**2158-4-26**], patient has been hemodynamically stable with stable Hct and no further evidence of bleeding. No signs of obstruction at this time. Total bilirubin is now down to 1.8 from a peak of 21, continues to improve. Recommend checking later this week to ensure improvement. PEG tube was replaced on [**2158-5-1**] prior to discharge. Patient was receiving tube feeds through NGT prior to replacement of PEG tube. Discharge Hct stable at 27, continue to trend to ensure stability. # Respiratory failure: Pt has a baseline O2 requirement of 4L when he was initially admitted to the MICU. Pt then later developed respiratory distress/failure which was multifactorial in cause with COPD/SIRS/[**Doctor Last Name **]/ARDS, recent aspiration PNA and aspiration of hematemasis. Pt was intubated for respiratory distress/failure on [**4-23**]. He was continued on vanc and Zosyn until [**4-30**] for aspiration pneumonia. Pt was extubated successfully on [**2158-4-28**] and weaned O2 to 5L via nasal cannula. He remains stable from this standpoint and is no longer on any IV antibiotics. His WBC is still slightly elevated but stable and he has remained afebrile. #ID - patient was continued on vancomycin and zosyn for his aspiration PNA and ?cholangitis until [**2158-4-30**]. He has remained afebrile. WBC continues to be elevated between 14-16, would recheck later this week to ensure stability. Blood cx and other cx have remained negative to date. # Biliary adenocarcinoma: Pt has biliary adenocarinoma with a liver lesion and a ? of pulmonary nodule. Pt was previously followed by Dr. [**First Name (STitle) 1058**] and Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] was made aware of pt's admission. He will need to undergo CT PET in the near future to further evaluate any metastasis. If pt has metastatic disease, pt has a poor prognosis. He has a follow-up appointment with Dr. [**Last Name (STitle) **] next week. # Hypotension - During active bleed and intubation. SIRS vs sepsis. Also was on a lot of PEEP. Started on levophed [**4-25**] which was weaned quickly with fluid resuscitation. Pt was continued on vanc and zosyn empirically as there was a concern for cholangitis in the setting of biliary obstruction and respiratory failure thought to be [**12-30**] [**Doctor Last Name **]/ARDS. He improved quickly and was weaned off levophed on [**2158-4-26**]. He has not required any further pressors or fluid boluses. He is off antibiotics as well as specified above. He has remained afebrile, but with an elevated WBC which remains stable. Stable abdominal exam as well. # COPD - Continue spiriva, advair and nebs prn. # Aspiration - Tube feeding through PEG tube. However, tip of G-J had to be cut off during ERCP for visualization and had to be replaced by IR on [**5-1**]. In the interim, pt was tube fed via OJ and NGT. #Prophylaxis : PPI, pneumoboots, bowel regimen while having hematemasis. SC heparin was later added once hct has been stable given his cancer. #FEN: Tube feeding as above. #Access: PICC, placed [**2158-3-7**] - will keep in place as patient has poor access in the event he needs access at rehab. Further decision about whether to keep PICC in place will be made by the rehab facility. #Code Status: DNR but DO intubate after discussion with patient and wife. Medications on Admission: Acetaminophen 325 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO Q4-6H prn Heparin (Porcine) 5,000 unit tid Docusate Sodium 100 mg PO BID Bisacodyl 10 mg Suppository prn Senna 8.6 mg Tablet prn Ferrous Sulfate 325 (65) mg daily Tiotropium Bromide 18 mcg daily Thiamine HCl 100 mg Tablet PO DAILY Folic Acid 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). Albuterol Sulfate 0.083 % neb q4h prn Ipratropium Bromide 0.02 % neb q6h prn Sertraline 50 mg Tablet PO DAILY Fluticasone-Salmeterol 250-50 mcg/Dose Inhalation [**Hospital1 **] Lansoprazole 30 mg Tablet PO BID Piperacillin-Tazobactam 4.5 g Q8H Vancomycin 1,000 mg twice a day Morphine 2 mg/mL Syringe [**Hospital1 **]: Two (2) mg (every 4 hours) prn Discharge Disposition: Extended Care Facility: [**Hospital 169**] Center Discharge Diagnosis: Primary - Biliary adenocarcinoma s/p upper GIB s/p respiratory failure recent pneumonia Secondary - -Recent admit for pneumonia/empyema (strep milleri), still on vancomycin and Zosyn until [**2158-4-24**]. Discharged to rehab [**2158-4-10**]. -Recurrent aspirations, now npo with PEG tube -PEG tube compilcated by melena -Anemia (baseline HCT 26) -Alcohol abuse -Liver mass, biopsy consistent with cholangeocarcinoma - COPD, emphysema on home O2 at 4 liters nasal cannula. -Splenectomy [**12-30**] trauma >30 years ago. Discharge Condition: Stable on 5 L/NC, hemodynamically stable Discharge Instructions: -continue with all medications as prescribed -please keep all appointments as listed below -continue physical therapy, chest therapy as needed -patient is a DNR, but intubation OK -discharge Hct stable at 27, WBC slightly elevated at 16 but stable, total bilirubin 1.8 (has been decreasing rapidly from a peak of 21) -please check CBC, chemistries, LFTs later this week to ensure improvement or stability Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2158-5-10**] 1:30 Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2158-5-10**] 1:30 Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2158-6-1**] 8:30 Completed by:[**2158-5-1**]

[ "507.0", "V12.72", "305.00", "276.52", "458.9", "496", "197.7", "155.1", "V44.1", "578.1", "518.81", "578.0", "576.2", "442.84" ]

icd9cm

[ [ [] ] ]

[ "96.72", "97.02", "99.07", "99.04", "96.6", "51.87", "38.93", "38.91", "45.13", "39.79", "96.04" ]

icd9pcs

[ [ [] ] ]

13799, 13851

8340, 13022

320, 568

14416, 14459

3630, 8317

14913, 15310

2845, 2849

13872, 14395

13048, 13776

14483, 14890

3467, 3611

2864, 3371

274, 282

596, 1572

3386, 3450

1594, 2390

2406, 2829

7,488

174,857

14574+14575+56551

Discharge summary

report+report+addendum

Admission Date: [**2144-6-26**] Discharge Date: [**2144-6-29**] Date of Birth: Sex: Service: HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old male with bipolar disorder admitted to [**Hospital 10073**] Hospital for psychotic depression on [**6-3**]. The patient also reported being suicidal at that time. On [**6-25**] at 11:40 p.m., the patient requested Ambien 10 mg in addition to his usual 10 mg. Around 12:30 a.m., the patient fell out of bed with continued snoring. His heart rate was 120-140 with variable respiratory rate. The patient seemed to be short of breath. Oxygen was given, and the ambulance was called. In the Emergency Department, the patient's heart rate was 130, blood pressure 150/74, respirations was agonal. He had decreased oxygen saturation, and fingerstick was 125. Arterial blood gas was with a pH of 7.15, pCO2 of 75, pO2 45 on room air. The patient was intubated. He had an upper GI lavage which showed no evidence of toxins. Also, the patient had food in his stomach. The patient was obtunded and unresponsive. He received Clindamycin and Ceftriaxone. PAST MEDICAL HISTORY: 1. Bipolar disorder. 2. Question of history of coronary artery disease. SOCIAL HISTORY: The patient is unemployed and homeless. He lives with his parents. His house burned down about six weeks ago. No alcohol or drug abuse. ALLERGIES: NO KNOWN DRUG ALLERGIES.. MEDICATIONS ON ADMISSION: Topamax 100 mg p.o. q.h.s., Zyprexa 10 mg p.o. q.h.s., Effexor XR 150 mg p.o. b.i.d., Prozac 40 mg p.o. q.d., Nexium 40 mg p.o. q.d., Ambien 10 mg p.o. q.h.s., ................. 40 mg p.o. t.i.d., Clozaril 350 mg p.o. q.h.s. PHYSICAL EXAMINATION: Vital signs: The patient was afebrile, heart rate 106, blood pressure 110/52. He was on assist control at 750 with a respiratory rate of 14, FI02 100%, PEEP 5. The patient had good oxygen saturation on these settings. General: He was a responsive, obese white male, intubated, cool, and not sweating. HEENT: Sclerae clear. Oropharynx moist. Pupils 2 mm and reactive bilaterally. Neck: Obese. Chest: Clear to auscultation bilaterally. No crackles. No wheezes. Cardiovascular: Faint tachycardia. No S1 and S2. No murmurs. Abdomen: Positive bowel sounds. Soft and nontender. Extremities: No lower extremity edema. Fair dorsalis pedis pulses bilaterally. No cyanosis. Neurological: Unable to assess secondary to his intubation. LABORATORY DATA: On admission white count was 11.4, hematocrit 40.4, platelet count 244, neutrophils 66, lymphocytes 0.6, monocytes 4, eosinophils 4; PTT 24.8, INR 1.2; sodium 141, potassium 4.4, chloride 112, bicarb 22, BUN 17, creatinine 1.2, glucose 171; serum for Aspirin, alcohol, .............., Benzodiazepines, barbiturates, tricyclics were negative. Electrocardiogram showed sinus tachycardia at 115, normal axis, normal intervals, no ST-T changes. Chest x-ray showed small lung volumes, ETT at the carina and the right bronchus which was subsequently .................. HOSPITAL COURSE: The patient was admitted to the MICU initially intubated. He was continued on Zyprexa and Haldol p.r.n.. The patient had a head CT which did not demonstrate bleed, edema, or mass affect. He woke up shortly after transfer to MICU. He was violently agitated. He was started on Propofol. The patient was shortly extubated. He did well from a respiratory point of view; however, he has been fatigued. The patient's psychiatric symptoms have been followed by the Psychiatry Service. He has been placed on Haldol p.r.n. and Olanzapine 10 mg p.o. q.h.s. This is being followed by the Psychiatry Service. The patient will be likely discharged to [**Hospital 42339**] Hospital on [**2144-6-29**]. DISCHARGE MEDICATIONS: Tylenol 325-650 mg p.o. q.4-6 hours p.r.n., Protonix 40 mg p.o. q.24 hours, Heparin 5000 U subcue q.12 hours, Haldol 5-25 mg IV q.4 hours p.r.n., Olanzapine 10 mg p.o. q.h.s., Colace 100 mg p.o. b.i.d., Dulcolax 10 mg p.o. p.r. q.d. p.r.n. DISPOSITION: The patient will be discharged back to Bournwood and will receive an outpatient sleep study for evaluation of obstructive sleep apnea. CONDITION ON DISCHARGE: The patient is being discharged in stable condition. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 5476**] MEDQUIST36 D: [**2144-6-29**] 10:12 T: [**2144-6-29**] 10:16 JOB#: [**Job Number 42989**] Admission Date: [**2144-6-26**] Discharge Date: [**2118-3-14**] Date of Birth: [**2112-10-15**] Sex: M Service: ADDENDUM: Please note that the patient should not be given further Ambien, as this is probably what lead to his hospitalization. Also, his antipsychotic regimen should be restarted gradually, as over aggressive antipsychotic treatment is probably related to his admission at least in part. The patient's medication regimen will be adjusted by the psychiatric service before his discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**] Dictated By:[**Last Name (NamePattern1) 5476**] MEDQUIST36 D: [**2144-6-29**] 10:25 T: [**2144-6-29**] 10:43 JOB#: [**Job Number 42990**] Name: [**Known lastname 7780**], [**Known firstname **] Unit No: [**Numeric Identifier 7781**] Admission Date: Discharge Date:[**2144-7-3**] Date of Birth: Sex: M Service: ADDENDUM: This discharge addendum will cover the [**Hospital 1325**] hospital course from his prior discharge summary until his ultimate discharge. The patient had a sleep study on the evening of [**2144-7-1**] which demonstrated obstructive sleep apnea and his CPAP was titrated to 9 cm of water. The sleep consult fellow felt that the patient's psychiatric disease may be secondary to his REM sleep behavioral disorder. The patient was interviewed by psychiatry consult on [**7-2**] and stated that he had thoughts of killing his parents. The patient therefore was determined to be appropriate for discharge to a psychiatric facility which is currently being arranged. The patient's discharge medications include all of those on the previous discharge summary with the exception of Zyprexa which has been discontinued. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] M.D.12-929 Dictated By:[**Last Name (NamePattern1) 6341**] MEDQUIST36 D: [**2144-7-2**] 16:43 T: [**2144-7-2**] 16:23 JOB#: [**Job Number 7813**]

[ "967.8", "E852.8", "780.57", "518.81", "296.7", "458.2", "276.2" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

3783, 4174

1457, 1683

3059, 3759

1706, 3041

152, 1135

1158, 1234

1251, 1430

4199, 6618

23,680

169,980

47369

Discharge summary

report

Admission Date: [**2179-6-5**] Discharge Date: [**2179-6-21**] Date of Birth: [**2111-4-12**] Sex: M Service: MEDICINE Allergies: Heparin Flush Attending:[**First Name3 (LF) 5608**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: Thoracentesis [**6-15**] History of Present Illness: 67 yo male with CAD s/p CABG, CHF EF 20%, HTN, DM2, h/o UTI, h/o CoNS bacteremia, ? HIT, s/p trach/peg ([**5-3**]) presents as transfer from [**Hospital 8**] hospital with shock. Patient was recently discharged from [**Hospital 8**] hospital on [**5-25**] with flash pulmonary edema and was discharge to [**Hospital3 **]. He represented to [**Hospital1 8**] on [**6-3**] with signs of hypovolemic shock. On the evening prior to admission, patient had an episode of flash pulmonary edema and was given 80 mg IV lasix, with perihilar infiltrates on Xray which resolved after diuresis. The following day he was found to be lethargic and was found to he hypotensive to 66/42. H was given 250 cc of fluid and transferred to the [**Hospital1 8**] ED with a BP 80s/40s prior to transfer. . At [**Hospital1 8**], patient was noted to be febrile to 103.2 on [**6-4**]. He was felt at the time to have sepsis [**1-26**] to pneumonia with sputum growing GNR and pseudomonas. He was treated with [**Last Name (un) **]/Cipro/Vanco adjust to renal function. He was treated with levophed and dopamine for MAPs 65. Cr was noted to be 1.9 from a baseline of 1.1 which was felt to be [**1-26**] contraction in the setting of diuresis and hypotension. Total I/Os for LOS was 1.89/590. Patient was also noted to develop LLE edema. Plan was for patient to have LENI performed, but this was not done prior to transfer. INR on admission was noted to be 2, but trended down to 1.6. Plan was for patient to be started on lepeirudin, but this was not initiated prior to transfer. In regards to DM, home dose of lantus 20 U were continued. . In the ICU, patient is on mechanical ventilation through a trach. He appears comfortable at this time. . Review of sytems: Limited due to patient on mechanical ventilation. Past Medical History: CAD s/p CABGx3 [**2168**] - h/o VF arrest [**6-30**] s/p ICD placement; required explantation for MRSA pocket infection with reimplantation [**10-31**], s/p lead removal [**4-2**] - mechanical [**Last Name (LF) 1291**], [**First Name3 (LF) **]. [**Male First Name (un) 1525**], [**2168**] - ascending aorta repair c graft [**4-/2169**] - CHF (EF 20% per TTE [**2178-8-19**]) - high grade CoNS bacteremia in [**2-2**] c/b high grade CoNS, VRE bactermia while on vancomycin [**3-2**], s/p 4 weeks daptomycin and explantation of ICD leads - pseudomonas UTI [**6-2**] s/p cefepime x 14 days, now pseudomonas UTI [**8-2**] s/p meropenem x 14 days - R lateral foot ulcer s/p debridement s/p zosyn x 14 days - DM2 c/b neuropathy, nephropathy, L BKA - Hep C (dx [**4-2**], 2.38 million IU/ml. Seen by Hepatology, [**2178-7-30**] note emphasizes deferring IFN/ribavirin tx for now given infections, etc.) - HTN - HLP - PVD s/p L BKA [**7-27**] - hypothyroidism - h/o opiate dependence, ?benzo dependence - acute on chronic SDH, [**8-30**] - h/o R scapula fx - h/o MRSA elbow bursitis, [**5-1**] - h/o closed bimalleolar fx s/p repair, removal of hardware [**6-26**] - ischemic bowel s/p small bowel resection and anastomosis on [**2178-12-17**] - S/p trach/peg [**5-3**] Social History: Lives in [**Location (un) **], though has been in rehab for much of the past few months. Former cab driver. Social history is significant for the current tobacco use of 40 pack years. There is no history of alcohol abuse or recreational drug use. Lives with common-law wife of 35 years who is a home health aid. . Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: General: Trach, on ventilation, arouses to verbal and mechanical stimulation, and follows commands HEENT: Sclera anicteric, MMM, + thrush Neck: supple, JVP elevated to pinna, no LAD Lungs: quietlung sounds, crackles bilateral bases, no wheeze or rhonchi CV: Regular rate and rhythm, loud mechanical click at aortic region, 3/6 SEM, normal S1 + S2, Abdomen: PEG inplace, with mild erythema surrounding the site, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: + foley with yellow urine Ext: left BKA, with 2+ edema LEFT greater than right, no erythema appreciate, 2 stage III ulcers on sacral region Pertinent Results: [**2179-6-5**] 05:00PM Admission labs WBC-9.7# RBC-3.75* Hgb-10.5* Hct-33.7* MCV-90 MCH-28.1 MCHC-31.3 RDW-17.0* Plt Ct-249 Neuts-74.3* Lymphs-19.6 Monos-4.0 Eos-1.8 Baso-0.3 PT-19.8* PTT-40.2* INR(PT)-1.8* Glucose-320* UreaN-62* Creat-1.9* Na-136 K-4.1 Cl-98 HCO3-30 AnGap-12 ALT-30 AST-66* LD(LDH)-272* AlkPhos-100 TotBili-0.9 Albumin-2.6* Calcium-7.8* Phos-4.1 Mg-3.2* MIX Temp-37.1 PEEP-12 FiO2-100 pO2-40* pCO2-50* pH-7.39 calTCO2-31* Base XS-3 AADO2-642 REQ O2-100 Intubat-INTUBATED Lactate-1.3 [**Hospital3 **] [**2179-6-10**] 03:54AM BLOOD WBC-6.8 RBC-3.23* Hgb-9.2* Hct-28.7* MCV-89 MCH-28.6 MCHC-32.2 RDW-17.8* Plt Ct-261 [**2179-6-16**] 02:54AM BLOOD WBC-6.3 RBC-3.07* Hgb-8.9* Hct-27.2* MCV-89 MCH-29.0 MCHC-32.6 RDW-17.2* Plt Ct-218 [**2179-6-16**] 02:54AM BLOOD Neuts-72.8* Lymphs-16.6* Monos-5.8 Eos-4.5* Baso-0.3 [**2179-6-16**] 03:51PM BLOOD PT-37.2* PTT-71.6* INR(PT)-3.9* [**2179-6-12**] 04:42AM BLOOD Glucose-176* UreaN-28* Creat-0.9 Na-133 K-3.6 Cl-93* HCO3-33* AnGap-11 [**2179-6-13**] 03:52PM BLOOD UreaN-29* Creat-0.8 Na-130* K-3.7 Cl-88* HCO3-33* AnGap-13 [**2179-6-16**] 03:51PM BLOOD Glucose-207* UreaN-27* Creat-0.9 Na-129* K-3.9 Cl-90* HCO3-33* AnGap-10 [**2179-6-7**] 02:40AM BLOOD proBNP-9834* [**2179-6-14**] 05:48AM BLOOD Type-ART pO2-112* pCO2-50* pH-7.48* calTCO2-38* Base XS-12 Discharge Labs COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2179-6-21**] 05:37 6.9 3.34* 9.7* 28.8* 86 29.1 33.8 16.8* 235 Source: Line-picc DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2179-6-19**] 05:10 68.2 21.0 7.1 3.2 0.5 Source: Line-picc BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2179-6-21**] 05:37 235 Source: Line-picc [**2179-6-21**] 05:37 43.7* 53.2* 4.7* Glucose UreaN Creat Na K Cl HCO3 AnGap [**2179-6-21**] 05:37 861 36* 1.3* 127* 4.1 88* 32 11 . Micro: Blood cx no growth Urine cx no growth Urine legionella negative and C diff and stool studies negative x 2 [**6-5**] Sputum: RESPIRATORY CULTURE (Final [**2179-6-10**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. RARE GROWTH. OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 4 S MEROPENEM------------- 4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S Pleural fluid cytology negative for malignant cells Pleural fluid: GRAM STAIN (Final [**2179-6-15**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): ACID FAST SMEAR (Final [**2179-6-16**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): Reports: [**6-6**] LENIS:negative for DVT [**6-7**] TTE:Well seated aortic valve mechanical prosthesis. Moderate mitral regurgitation. Symmetric left ventricular hypertrophy with severe global hypokinesis. Compared with the prior study (images reviewed) of [**2179-1-18**], the left ventricular cavity is slightly smaller and the estimated PA systolic pressure is lower. The other findings are similar. CXR: CT A/P: IMPRESSION: 1. Increase in bilateral pleural effusions since CT of [**1-17**], with increased bilateral consolidation and atelectasis. A rounded density involving the right middle lobe may represent rounded atelectasis, consolidation, or a combination of both. Confirmation of resolution after treatment is recommended. 2. Increased presacral and perirectal stranding with rectal tube in place. The findings may indicate proctitis. Clinical correlation recommended. 3. Hyperdense material in the nondistended gallbladder, may represent sludge, excreted contrast, or tiny stones. Brief Hospital Course: 67 yo male with CAD s/p CABG, CHF EF 20%, HTN, DM2, h/o UTI, h/o CoNS bacteremia, antibody positive-HIT, s/p trach/peg ([**5-3**]) who presented as a transfer from [**Hospital 8**] hospital with septic and cardiogenic shock. . #. Shock: Met SIRS criteria by fever, tachycardia, and relative leukocytosis and required pressors for several days, treated initially with levophed and then dobutamine with concern for cardiogenic component. Most likely source was Pseudomonas pneumonia which was sensitive to ciprofloxacin. Other blood cx, urine cxa nd C diff negative. He was initially treated with broad coverage abx which was narrowed to cipro for 15 day course for Pseudomonas VAP as below. Also felt to be in cardiogenic shock and he was diuresed aggressively on lasix drip. Repeat TTE with EF 25%. Diuresis as below for CHF. BP normal over >72 hours off pressors with diuresis. #. Mechanical [**Hospital 1291**]: Patient on warfarin with INR goal 2.5-3.5. Arrived with subtherapeutic INR. We were unable to bridge with heparin given ? HIT so bridged with argatroban with therapeutic INR on [**6-17**]. INR will need to be closely monitoried and he may need increased coumadin dose since now will be off cipro and will have lowering of INR once discontinued. Will need to restart argatroban if INR<2.5. Coumadin dose stable at 5mg daily, decreased to 2 mg daily and was on hold the day of discharge given uptrending INR (while on 2.5mg daily), which was 4.7 at discharge. Will need close monitoring since medications being adjusted and will be off cipro. . #. VAP: Psuedomonas on sputum cx associated with leukocytosis and sepsis with infiltrate so treated for 15 day course ciprofloxacin, last day [**6-18**]. # Chronic respiratory Failure: Was maintained on full vent support with intermittent trials of PSV as tolerated but tended to tire at night. NIFs low at lowest -`17 but slowly improved, -mid 30s and was tolerating trach mask most of day for several days prior to discharge, asking to be placed back on AC at night for fatigue. Tolerated PMV and passed swallow eval for soft solids while PMV in place. Was planning for discharge to [**Hospital1 **] on [**6-18**] but had an episode of mucous plugging that required bagged ventilation. A bronchoscopy was performed which was unremarkable, and event was felt to be due to a mucous plug. Patient remained stable from a respiratory prespective over the next 3 days. . # Cuff leak: Noted by respiratory with Vt loss during ventilation. IP consulted and he had tracheostomy tube exchange over an exchange catheter [**6-10**] to a Portex 9.0 mm inner diameter, 12.3 mm outer diameter, cuffed tracheostomy tube, nonfenestrated with inner cannula. . # CHF; EF 20% with evidence of volume overload on CXR. Diuresed aggressively on lasix drip then lasix and metolazone. Continued amiodarone at decreased frequency two times per week per cardiology recommendations. Addition of captopril and lisinopril limited by hypotension in MICU when pt concurrently being aggressively diuresed. Plan is for patient to continue to have torsemide daily to goal even I/Os. His weight on discharge is 104 kg, down from 119 kg on admission. He reponds to Lasix 60-80 mg IV, but was held for Na 150 and Cr up to 1.3 on discharge. We advise continuing torsemide 40mg 1-2 times diaily for goal even I/Os, until Na worsens or cr increases above 1.2. Patient has been considered a candidate for ICD again in the future and is followed by a cardiologist at [**Hospital1 18**] with whom he should follow up within the next 3-4 weeks. . # HTN: hold antihypertensives for now. Would restart captopril if BP allows. . # DM2: Was on insulin drip initially for glucose control but transitioned to lantus at increased dose and HISS. . #. R pleural effusion: Had [**Female First Name (un) 576**] [**6-15**] 1.5L which was consistent with exudate by protein criteria. Cytology negative and final cx will need follow up. Patient will need CT follow up as below. . # R sided mass vs effusion: Had pleural based infiltrate on CXR post-[**Female First Name (un) 576**] so CT obtained which was more consistent with effusion and likely atelectasis and lung collapse. Should have imaging to eval for recurrent effusion based on symptomatology and a repeat CT chest in [**12-26**] months to evaluate for interval change to follow a lung nodule and rule out enlarging mass. # Abdominal pain: Pt c/o relatively chronic abd pain [**Name (NI) 25714**] which worsened during hosp course and was not related to PEG. C diff negative. Had loose stool on stool softeners but no frank diarrhea and guaiac negative. CT A/P with PO contrast obtaiend with ? proctitis. Rectal tube d/c'd prior to discharge as could be contributing factor. Continued on oxycodone. [**Month (only) 116**] consider long acting narcotic while taking po diet with PMV in place. . # Hyponatremia: Developed worsneing hyponatremia during hospital course felt to be secondary to med effect from over diuresis. . # Asymmetric edema: LENIs negative. Likely CHF since improved with diuresis. . # Thrush: treated with Nystatin . # Acute renal failure: likely ATN in the setting of sepsis in addition to poor forward flow from CHF since improved with diuresis. BUN and Cr normalized with diuresis, and slightly elevated with diuresis to 36 and 1.3 respectively at discharge likely [**1-26**] overdiuresis. . # Right lung nodule: Need follow up CT chest to document stability in 3 months time. . # FEN: TFs until maintaining adequate PO, diet as instructed when PMV in place; No IVF with fluid restriction # Prophylaxis: coumadin, ppi # Access: PICC # Communication: [**Name (NI) **] [**Name (NI) 6955**] (girlfriend, hcp) [**Telephone/Fax (1) 100257**], [**Telephone/Fax (1) 100258**] # Code: Full (discussed with HCP) Medications on Admission: Amiodarone 200 mg po MWThF Acetaminophen 325-650 mg Q6H PRN Neurontin 300 TID Aspirin 81 mg daily atrovent neb Q2 prn Cepacol lozenge prn Coumadin 2.5 mg ? (unknown) Dulcolax 10 mg pr prn Lantus 25 U [**Hospital1 **] Atorvastatin 40 mg daily Lisinopril 2.5 mg daily Aldactone 25 mg daily Carvedilol 3.125 daily Prevacid 15 mg [**Hospital1 **] PRN - tylenol 650 prn, albuterol Q1H prn, colace 100 po BID prn, oxycodone 10 Q4H, senna 2 tabs po QHS, ativan 2mg IV QH Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Five (5) ML Mucous membrane [**Hospital1 **] (2 times a day). 2. Polyvinyl Alcohol 1.4 % Drops [**Hospital1 **]: 1-2 Drops Ophthalmic Q6H (every 6 hours). 3. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 5. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3 times a day). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]: Eight (8) Puff Inhalation q2h as needed for dyspnea. 8. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID (3 times a day). 9. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [**Last Name (STitle) **]: 15-30 MLs PO QID (4 times a day) as needed for GI upset. 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 12. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) ml PO Q4H (every 4 hours) as needed for pain. 13. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO 2X/WEEK (MO,TH). 14. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Forty (40) units Subcutaneous twice a day. 15. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 mg PO Q3H (every 3 hours) as needed for pain. 16. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**12-26**] Drops Ophthalmic Q6H (every 6 hours) as needed for dry eyes. 17. Insulin Regular Human Subcutaneous 18. Guaifenesin 100 mg/5 mL Syrup [**Month/Day (2) **]: Fifteen (15) ML PO Q6H (every 6 hours) as needed for cough. 19. Warfarin 2 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day: hold or titrate dose down for INR > 3.5 (goal INR 2.5-3.5). 20. Torsemide 20 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO once a day: Goal even I/0. Will likely need to increase to [**Hospital1 **] dosing if/when patient running positive or weight trending up. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis: Shock, multifactorial related to sepsis from VAP and cardiogenic shock Secondary Diagnosis: Acute on chronic systolic CHF, EF 25% Mechanical Aortic Valve Replacement Antibody positive Heparin Induced Thrombocytopenia Abdominal pain Discharge Condition: On trach mask during the day, tolerating PMV; back on AC at night as needed for SOB. Afebrile. BP 130/50 O2 sats 100% on trach mask fiO2 40% Discharge Instructions: You were admitted to the ICU with low blood pressure related to pneumonia and decreased heart function. You were treated with antibiotics for your infection and lasix for your heart failure. You were also treated with argatroban for your mechanical valve while we were waiting for your coumadin level to be therapeutic. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow up with Dr [**Last Name (STitle) **] in [**1-27**] weeks. Call his office for an appointment ([**Telephone/Fax (1) 2037**] Follow up CT Chest (1-2 months) to follow up possible right sided pulmonary nodule to document stability

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icd9cm

[ [ [] ] ]

[ "38.91", "97.23", "96.6", "34.91", "96.72", "33.21", "38.93" ]

icd9pcs

[ [ [] ] ]

17344, 17415

8639, 14432

285, 312

17710, 17853

4579, 7362

18312, 18558

3767, 3882

14947, 17321

17436, 17436

14458, 14924

17877, 18289

3897, 4560

7618, 8616

7491, 7584

234, 247

2078, 2130

340, 2060

17547, 17689

17455, 17526

7444, 7458

2152, 3418

3434, 3751

7394, 7408

19,116

117,565

21921

Discharge summary

report

Admission Date: [**2183-10-3**] Discharge Date: [**2183-10-10**] Date of Birth: [**2108-2-14**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: A 75-year-old gentleman who had been worked up for back surgery. As part of the workup, patient had a history of angina and underwent cardiac catheterization. Cardiac catheterization showed significant left main disease and three vessel coronary artery disease. Patient was transferred from [**Hospital6 **] to [**Hospital1 1444**] for further evaluation and treatment. PAST MEDICAL HISTORY: Sleep apnea for which he uses a CPAP machine at night. Coronary artery disease status post myocardial infarction in [**2152**]. Benign prostatic hypertrophy. GERD. Hypertension. Spinal stenosis. Status post left shoulder surgery. Status post melanoma removal from his back. Status post fusion of his lumbar vertebrae. Status post bilateral total knee replacements. Status post right shoulder replacement. SOCIAL HISTORY: Patient has a 50-pack-year tobacco history, quit smoking in [**2166**]. He admits to drinking [**2-18**] alcoholic drinks per day. ALLERGIES: Rifampin. Sulfa. Ancef. PREOPERATIVE MEDICATIONS: 1. Lisinopril 10 mg by mouth every day. 2. Aspirin 81 mg by mouth every day. 3. Pravachol 20 mg by mouth every day. 4. Mobic 7.5 mg by mouth every day. 5. Nitro paste 1" every six hours. 6. Mirapex 0.5 mg by mouth every day. 7. Flomax 0.4 mg by mouth every day. 8. Protonix 40 mg by mouth every day. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**]. Upon evaluation of his catheterization films and evaluation of the patient, it was determined patient had ongoing angina. An intra-aortic balloon pump, which was placed, did not result in resolution of angina. Patient was taken urgently to the operating room with Dr. [**Last Name (STitle) **] on [**10-3**] for a CABG x2, LIMA to LAD, and saphenous vein graft to OM, total cardiopulmonary bypass time 42 minutes, cross-clamp time 32 minutes. Patient was transferred to the Intensive Care Unit in stable condition. Patient's intraoperative transesophageal echocardiogram showed an ejection fraction of greater than 55 percent. Patient had his intra-aortic balloon pump removed on postoperative day number one. He remained intubated on postoperative day number one due to episode of rapid atrial fibrillation to the 140s, which required multiple attempts at cardioversion and treatment with amiodarone. Patient had hypotension associated with the event. Patient had moderate amount of agitation while he was off sedation. Patient was started on Precedex. Patient was weaned and extubated from mechanical ventilation on postoperative day number two. Patient converted into sinus rhythm spontaneously. Prior to extubation, patient continued to required Levophed to maintain adequate systolic blood pressure. The Levophed was weaned to off and on postoperative day number three, the patient was transferred from the Intensive Care Unit to the regular part of the hospital. Patient had been begun on Ativan due to his history of EtOH intake and agitation and aggressive behavior. Patient was transfused 1 unit of packed red blood cells on postoperative day number three. Patient's chest tubes and pacing wires were removed without incident. Patient began ambulating with Physical Therapy, and it was decided that the patient should be anticoagulated due to his multiple episodes of postoperative atrial fibrillation. Patient was started on Heparin drip and given Coumadin. By postoperative day number six, patient had cleared level 5 with Physical Therapy. His INR had reached therapeutic level and he was cleared for discharge home. On postoperative day seven, he was discharged to home in stable condition. CONDITION ON DISCHARGE: Temperature 99, pulse 62 in sinus rhythm, blood pressure 119/59, respiratory rate 15, room air oxygen saturation 93 percent. Patient's weight on [**10-10**] is 81 kg, preoperatively, the patient weighed 79 kg. Neurologically: He is awake, alert, anxious, and oriented x3 and nonfocal. Heart is regular rate and rhythm without rub or murmur. Patient's last episode of atrial fibrillation was greater than 48 hours ago. Respiratory: Breath sounds are clear and decreased at the left base. Chest x-ray on [**10-10**] showed bilateral atelectasis, no significant effusion or consolidation, no pneumothorax. Abdomen has positive bowel sounds, soft, nontender, nondistended. Extremities had 1 plus edema in the left lower extremity, which is the site of the vein harvest. Trace edema in the right lower extremity and left lower extremity Steri-Strips are intact. There is no erythema or drainage. Sternum: Steri-Strips are intact. There is no erythema or drainage. The sternum is stable. Potassium 4.2, BUN 23, creatinine 1.1. [**Name (NI) **] PT is 19.4, INR is 2.4. DISCHARGE CONDITION: The patient is to be discharged to home in stable condition. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg by mouth twice a day. 2. Colace 100 mg by mouth twice a day. 3. Enteric coated aspirin 81 mg by mouth every day. 4. Protonix 40 mg by mouth every day. 5. Pravastatin 20 mg by mouth every day. 6. Flomax 0.4 mg by mouth every day. 7. Mirapex 0.5 mg by mouth every day. 8. Amiodarone 200 mg by mouth every day. 9. Lorazepam 0.5 mg by mouth every evening as needed. 10. Ibuprofen 600 mg by mouth every six hours. 11. Tylenol with codeine number three 1-2 tablets by mouth every four to six hours as needed. 12. Lasix 40 mg by mouth every day x7 days. 13. Potassium chloride 20 mEq by mouth every day x7 days. 14. Coumadin. The patient is to receive 2.5 mg of Coumadin on [**9-5**], and [**10-12**]. He is to have his PT/INR checked by the visiting nurse on [**10-3**] with results called to his cardiologist, Dr.[**Name (NI) 33126**] office. Dr. [**Name (NI) 33126**] office is to adjust his Coumadin for a goal INR of [**2-17**].5. DISCHARGE DIAGNOSES: Coronary artery disease. Status post coronary artery bypass graft. Postoperative atrial fibrillation. Benign prostatic hypertrophy. Hypertension. Sleep apnea. Spinal stenosis. DISCHARGE CONDITION: The patient is to be discharged to home in stable condition. FOLLOW-UP INSTRUCTIONS: He is to followup with Dr. [**Last Name (STitle) 9751**] by phone number [**10-13**] for his INR results and Coumadin dosing. He is to followup with Dr. [**Last Name (STitle) 9751**] in the office on [**10-23**] at 2 p.m. Follow up with Dr. [**Last Name (STitle) **] in [**2-18**] weeks. He is to followup with Dr. [**Last Name (STitle) **] in [**3-20**] weeks. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern4) 8524**] MEDQUIST36 D: [**2183-10-10**] 19:28:35 T: [**2183-10-11**] 05:30:21 Job#: [**Job Number **]

[ "285.9", "307.9", "427.32", "305.00", "458.29", "411.1", "414.01", "997.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.62", "36.15", "39.61", "88.72", "36.11", "37.61", "94.62", "97.44", "99.04" ]

icd9pcs

[ [ [] ] ]

6224, 6286

6019, 6202

4999, 5997

1513, 3788

1193, 1495

166, 539

6311, 6913

562, 978

995, 1167

3813, 4892

7,842

171,847

18779

Discharge summary

report

Admission Date: [**2101-9-2**] Discharge Date: [**2101-9-22**] Date of Birth: [**2030-11-15**] Sex: M Service: Medicine Intensive Care Unit-Green HISTORY OF PRESENT ILLNESS: This is a 70 year old male with a history of coronary artery disease, status post myocardial infarction, status post motor vehicle accident on [**9-2**] with knee and wrist pain. The patient denied any loss of consciousness. The patient was found to have left distal radial and proximal fibular fractures and was recommended nonsurgical management by Orthopedics and Plastic Services. The patient was to be discharged on [**9-3**], however, that evening he underwent an acute desaturation to 84% on his nasal cannulas which then increased to 93% on a nonrebreather mask. The patient had a temperature of 100.4 orally, coarse rhonchi and the blood pressure was stable. An arterial blood gases was done which showed 7.33/47/59. There were no changes on the electrocardiogram. The patient stopped intravenous fluids and got 10 mg of intravenous Lasix times three and put out 500 cc of urine output. The patient was transferred to the Post Anesthesia Care Unit and went into atrial fibrillation which he has a history of proximal atrial fibrillation in the rates of 120 to 130s and the blood pressure remained normotensive. He was started on a Nitro drip, Morphine Sulfate, Lopressor and white blood cell count then went up to 17.2. The patient then became hypoxic on 100% nonrebreather and was intubated in the Trauma Surgery Intensive Care Unit and then transferred to the Medicine Intensive Care Unit. The patient got a chest computerized tomography scan which was consistent with a pneumonia and no pulmonary embolism. He was started on Propofol for intubation at that time and his systolic blood pressure decreased in the 70s. His temperature was 101 and with a white blood cell count of 17.2 there was concern that the patient was in septic [**Last Name (LF) **], [**First Name3 (LF) **] he was started on a Neo-Synephrine drip at 3 mcg/kg/min. The patient was swanned with a central venous pressure of 12, pulmonary artery pressure of 30/15 and pulmonary capillary wedge pressure of 15/16. PAST MEDICAL HISTORY: 1. Cerebrovascular accident, right-sided with a left hemiparesis and contracture of his left side; 2. Status post myocardial infarction; 3. Hypertension; 4. Paroxysmal atrial fibrillation. MEDICATIONS ON ADMISSION: Outpatient medications include Aspirin and Zoloft. ALLERGIES: No known drug allergies. SOCIAL HISTORY: One beer per day, positive tobacco despite being in a wheelchair and a left-sided hemiparesis the patient lived alone. The patient's guardian is [**Name (NI) 501**], his daughter and he has two other sisters, [**Name (NI) **] and [**Name (NI) **] who also live here in the [**Location (un) 86**] area. PHYSICAL EXAMINATION: In general sedated in no distress. Lungs were clear to auscultation bilaterally, occasional wheeze. Cardiovascular, regular rate, no murmur, rub or gallop. Abdomen was soft, nontender, nondistended, normal bowel sounds. Extremities, no cyanosis, clubbing or edema. Warm, 1+ pulses. Neurological, sedated, left-sided contracted. LABORATORY DATA: White blood cell count 11.7, hematocrit 33.2, platelets 153, INR 1.3, sodium 137, potassium 4.0, chloride 102, bicarbonate 22, BUN 20, creatinine 1.4, glucose 120, anion gap 14. Fibrinogen 488, troponin less than .001 times three. Creatinine kinase 238, 212, 173, amylase 55, lactate 2.4. Arterial blood gases was 7.37/42/122 on AC, title volume 500, respiratory rate 14, FIO2 of 1.00 and 5 positive end-expiratory pressure. Electrocardiogram showed normal sinus rhythm at 76 beats/minute, 0.5 to [**Street Address(2) 4793**] depressions in V2 through V5 which improved. Computerized tomographic angiography of chest showed no pulmonary embolism, bilateral lower lobe consolidation with air bronchograms, associated collapse. Chest x-ray, bilateral basilar opacities, endotracheal tube, Swan in good position. HOSPITAL COURSE: 1. Respiratory distress - This was most likely caused initially by aspiration pneumonia, believed to have occurred while they were clearing his neck post trauma as he had to lay flat on his back for prolonged periods of time. This became complicated by most likely a ventilatory associated pneumonia because he grew out on [**2101-9-7**] from his bronchial lavage and sputum samples Methicillin resistant Staphylococcus aureus that was Vancomycin sensitive. The respiratory failure was also considered to be worse from the over-fluid resuscitation, elitism congestive heart failure. The patient completed a 14 day course of each Vancomycin, Levofloxacin and Flagyl. The patient's blood cultures remained negative for no growth to date while in the hospital. The patient was intubated on [**9-3**] and was extubated on [**2101-9-15**]. For most of his intubation, the patient was on pressor support and tolerated this well. 2. Septic [**Year (4 digits) **]. The patient was considered to be in septic [**Year (4 digits) **] on admission to the Medicine Intensive Care Unit as felt by his high white blood cell count, fever to 102, low systemic blood pressure and a high cardiac output with a low SVR. The patient was initially on Levophed but after receiving several boluses of fluid the Levophed was discontinued. However, the fluid resuscitation lead to congestive heart failure and the patient needed diuresis after that time. 3. Congestive heart failure, coronary artery disease - The patient ruled out for a myocardial infarction but appeared to be in heart failure. An echocardiogram off of pressors showed an ejection fraction of 40%, while on pressors the ejection fraction was approximately 55%. The patient was placed on Lopressor to control his tachycardia and Lisinopril for afterload reduction. The patient also restarted his Aspirin. 4. Acute renal failure - Initially the patient had an increase in his creatinine from his baseline of 0.6 up to 1.4. The patient's creatinine responded to fluid boluses and the acute renal failure was deemed to be secondary to prerenal hypovolemia in the setting of septic [**Year (4 digits) **]. 5. Gastrointestinal - The computerized tomography scan of the abdomen showed a question of an enlarged gallbladder. There was a question of acalculus cholecystitis versus common bile duct stone since there was an elevation in the total bilirubin and direct bilirubin. This was evaluated by HIDA scan and there was not deemed to be any obstruction. Over time, the bilirubin trended back towards normal. After discussions with the trauma surgeons it was felt no intervention needed to be performed. The patient was initially covered with Ampicillin for enterococcus and was discontinued once it was felt the gallbladder was not associated with his fevers or sepsis picture. A percutaneous endoscopic gastrostomy tube was placed, after extubation the patient was unable to tolerate swallowing and it was felt a high aspiration risk after speech and swallow evaluation. A percutaneous endoscopic gastrostomy tube was placed on [**9-21**] so that the patient could continue to receive tube feeds for nutrition. 6. Alcohol withdrawal - There was a concern that the patient was undergoing alcohol withdrawal with a history of minimal alcohol use. The patient was placed on a CIWA assessment scale and now was tachycardiac and hypertensive at times. It was not felt that he was undergoing alcohol withdrawal per the scale. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: To a skilled nursing facility for continued suctioning and chest and physical therapy to increase his strength. DISCHARGE DIAGNOSIS: 1. Pneumonia: aspiration and ventilator associated 2. Respiratory failure 3. Congestive heart failure 4. Hypotension 5. Percutaneous endoscopic gastrostomy tube placement 6. Alcohol withdrawal 7. Acute renal failure 8. Elevated bilirubin and transaminitis 9. Methicillin-sensitive resistant Staphylococcus aureus pneumonia 10. Aspiration pneumonia 11. Adult respiratory distress syndrome 12. Thrombocytopenia 13. Anemia 14. Left upper extremity fractures DISCHARGE MEDICATIONS 1. Docusate Sodium 100 mg orally b.i.d. 2. Folic acid 1 mg orally q.d. 3. Thiamine 100 mg orally q.d. 4. Miconazole powder one application t.p. h.s. 5. Aspirin q.d. 6. Heparin 5000 units q. 8 hours 7. Venlafaxine 75 mg orally b.i.d. 8. Sucralfate 1 gm orally q.i.d. 9. Gabapentin 600 mg orally q. 8 hours 10. Metoprolol 50 mg orally b.i.d. 11. Haloperidol 0.5 mg intravenously b.i.d. as needed for delirium with agitation 12. Ipratropium bromide metered dose inhaler 2 puffs inhaled q.i.d. as needed 13. Lisinopril 5 mg orally q.d. 14. Reglan 10 mg orally q.i.d. 30 minutes before meals and at bedtime. FOLLOW UP: The patient will follow up with the physicians at his skilled nursing facility and his primary care physician as needed. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Doctor Last Name 51429**] MEDQUIST36 D: [**2101-9-21**] 08:04 T: [**2101-9-21**] 08:19 JOB#: [**Job Number 51430**]

[ "428.0", "518.81", "995.92", "785.52", "038.9", "427.31", "507.0", "482.41", "813.42" ]

icd9cm

[ [ [] ] ]

[ "43.11", "33.24", "99.15", "38.93", "96.72", "89.64", "96.04", "96.6" ]

icd9pcs

[ [ [] ] ]

7743, 8843

2446, 2536

4066, 7558

8855, 9227

2880, 4048

196, 2203

2226, 2419

2553, 2857

7583, 7722

13,628

115,231

51863

Discharge summary

report

Admission Date: [**2124-1-11**] Discharge Date: [**2124-1-14**] Date of Birth: [**2049-2-1**] Sex: M Service: SURGERY Allergies: Ambien Attending:[**First Name3 (LF) 371**] Chief Complaint: rectal bleeding and rectal pain Major Surgical or Invasive Procedure: none History of Present Illness: CC:[**CC Contact Info 107401**] HPI: This is a 74M with a history of a rectosigmoid polyp resection and subsequent rectal bleeding with multiple sigmoidoscopies c/b perforation requiring a Hartmann procedure [**2123-10-25**]. He came back to the clinic today to discuss reversing his colostomy but was found to have new bright red rectal bleeding since this past Thursday. The bleeding soaks four 4x4 gauzes per day. The patient denies any dizziness or LOC associated with the bleeding. He does report rectal pain and a feeling of rectal fullness that has been present since his surgery in [**Month (only) **]. He also complains of new pain to the left of the ostomy. He denies F/C/N/V. The ostomy is functioning well. Of note, the patient has a mechanical AV and MV for which he is on coumadin. His INR today was 2.9. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: # Mechanical MVR/AVR ([**2098**]) [**1-12**] rheumatic fever # Atrial fibrillation s/p AV node ablation, biventricular pacer ([**2115**]) on anticoagulation # Biventricular pacer . 3. OTHER PAST MEDICAL HISTORY: # COPD # Asthma # GERD # Osteoarthritis # Bilateral total knee replacements [**1-12**] OA # Gout # Hypothyroidism [**1-12**] amiodarone # Chronic Kidney Disease Stage II, baseline cr 1.6 # anemia # Melanoma # obesity # ETOH use # insomnia # hemorrhoids # h/o cellulitis # h/o MRSA PNA # osteopenia # # s/p Cholecystectomy # s/p Appendectomy Social History: Social Hx: Lives with wife. Family History: # Mother d 85: Asthma # Father d 99 [**10-21**]: PAD, HTN # Siblings (5B, 2S): HTN, unknown, rheumatic fever Physical Exam: PE: upon admission [**2124-1-11**] 97.1 69 132/70 20 98%RA Gen NAD, AAOx3, mentating well CV RRR, audible clicks Pulm CTAB, no w/r/r Abd soft, obese, TTP to L of ostomy and inferior to ostomy, no G/R, no hernias noted, incisions healing well but area of panniculitis inferior to ostomy, minimal erythema; ostomy retracted but functioning - brown stool and air in bag Ext wwp, 2+ edema bilaterally in LE DRE: stricture ~4cm from anal verge, BRB; on anoscopy, clots can be seen but no identifiable source of bleeding Pertinent Results: [**2124-1-14**] 06:00AM BLOOD WBC-8.3 RBC-3.44* Hgb-9.5* Hct-29.5* MCV-86 MCH-27.7 MCHC-32.3 RDW-17.3* Plt Ct-154 [**2124-1-13**] 03:30PM BLOOD WBC-7.5 RBC-3.47* Hgb-9.6* Hct-29.4* MCV-85 MCH-27.6 MCHC-32.6 RDW-17.2* Plt Ct-151 [**2124-1-13**] 01:52AM BLOOD WBC-7.5 RBC-3.34* Hgb-9.6* Hct-28.4* MCV-85 MCH-28.7 MCHC-33.8 RDW-17.8* Plt Ct-156 [**2124-1-12**] 11:10AM BLOOD Hct-30.5* [**2124-1-11**] 09:59PM BLOOD Hct-26.5* [**2124-1-14**] 06:00AM BLOOD Plt Ct-154 [**2124-1-13**] 03:30PM BLOOD Plt Ct-151 [**2124-1-13**] 03:30PM BLOOD PT-24.0* PTT-30.5 INR(PT)-2.3* [**2124-1-13**] 01:52AM BLOOD Plt Ct-156 [**2124-1-13**] 01:52AM BLOOD PT-30.0* PTT-33.7 INR(PT)-3.0* [**2124-1-12**] 04:18AM BLOOD PT-34.8* PTT-35.5* INR(PT)-3.6* [**2124-1-14**] 06:00AM BLOOD Glucose-101* UreaN-17 Creat-0.8 Na-138 K-3.7 Cl-104 HCO3-26 AnGap-12 [**2124-1-13**] 03:30PM BLOOD Glucose-131* UreaN-16 Creat-0.8 Na-137 K-3.6 Cl-102 HCO3-25 AnGap-14 [**2124-1-14**] 06:00AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.8 [**2124-1-13**] 03:30PM BLOOD Calcium-8.9 Phos-2.4* Mg-1.9 [**2124-1-11**]: Cat scan of abdomen and pelvis: IMPRESSION: 1. No evidence of leak of the Hartmann pouch or pelvic fluid collection. 2. Filling defects along the lower rectum/anus. This may represent hemorrhoids, hemorrhage, or other intraluminal lesions. Please correlate clinically. 3. Small fat-containing ventral hernia/abdominal wall defect. [**2124-1-12**]: EKG: Ventricular paced rhythm. Underlying atrial rhythm is uncertain, probably atrial fibrillation. Since the previous tracing of [**2123-10-8**] no significant change. Brief Hospital Course: 74 year old gentleman who presented to the Acute Care clinic with rectal bleeding. Upon admission he was made NPO, had intravenous fluids started and had imaging study done. He was monitored in the intensive care unit where he had serial hematocrits. The GI service was consulted. A cat scan of his abdomen did show a possible soft tissue mass within the rectum. He was taken to the operating room on [**1-13**] where he had a rectal examination and sigmoidoscopy under anesthesia. He tolerated the procedure well without evidence of bleeding. He is preparing for discharge home with VNA services. His vital signs are stable. He is tolerating a regular diet and has been ambulating. He is not having any active bleeding from his rectum. His hematocrit is stable at 29.5. He has resumed his pre-hospital medications including his coumadin. He has been evaluated by physical therapy for recommendations for his deconditioning. He has also been seen by the ostomy nurse. His last INR is 2.3. He will follow-up with his primary care provider for monitoring of his INR. Medications on Admission: [**Last Name (un) 1724**]: 1. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: 1 tab on [**Last Name (un) 766**] and Friday, 1.5 tabs on all other days. 2. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 3. enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO twice a day. 4. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 7. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for gout. 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 9. ciclopirox 0.77 % Gel Sig: One (1) application to abdomen folds Topical twice a day. 10. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 11. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 12. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-12**] Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 13. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation four times a day as needed for shortness of breath or wheezing. 14. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. orphenadrine citrate 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day as needed for back pain. 16. sildenafil 50 mg Tablet Sig: One (1) Tablet PO once as needed for sexual activity. 17. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 18. trazodone 50 mg Tablet Sig: [**12-12**] to 1 Tablet PO at bedtime as needed for insomnia. 19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for diarrhea. 20. sodium chloride 0.65 % Aerosol, Spray Sig: Three (3) Spray Nasal TID (3 times a day). 21. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 22. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: hold for diarrhea. 23. nitrofurantoin Discharge Medications: 1. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for wheeze. 5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for wheeze. 6. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)) as needed for gout. 7. warfarin 5 mg Tablet Sig: 1.5 Tablets PO 5X/WEEK ([**Doctor First Name **],TU,WE,TH,SA). 8. warfarin 5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,FR). 9. levothyroxine 50 mcg Capsule Sig: One (1) Capsule PO once a day. 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. nitrofurantoin (macrocryst25%) 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 5 days. Disp:*10 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Rectal bleeding, stricture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with rectal bleeding. You were monitored in the intensive care unit. During your stay, you had a blood transfusion. Your vital signs and hematocrit are normal and you are now preparing for discharge home with VNA services. Please follow these instructions upon discharge: Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2124-1-25**] 12:50 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2124-1-26**] 9:00 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2124-1-26**] 10:00

[ "715.90", "403.90", "530.81", "V43.3", "585.2", "274.9", "E942.0", "V43.65", "493.20", "569.3", "272.4", "569.2", "V44.3", "733.90", "569.42", "244.3", "427.31" ]

icd9cm

[ [ [] ] ]

[ "48.23" ]

icd9pcs

[ [ [] ] ]

8694, 8765

4153, 5229

296, 303

8836, 8836

2535, 4128

9321, 9682

1870, 1980

7550, 8671

8786, 8815

5255, 7527

8987, 9281

1995, 2516

1253, 1435

225, 258

9298, 9298

331, 1159

8851, 8963

1466, 1808

1181, 1233

1824, 1854

46,484

178,936

47517

Discharge summary

report

Admission Date: [**2107-7-20**] Discharge Date: [**2107-7-25**] Date of Birth: [**2045-2-20**] Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim Attending:[**First Name3 (LF) 689**] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: 62 y/o F with a history of chronic progressive multiple sclerosis, hypertension, anorexia nervosa, recently diagnosed with Clostridium difficile diarrhea, represents due to a worsening leukocytosis, anasarca, abdominal distension, and profuse diarrhea. Per her husband she was started on ciprofloxacin in mid- [**Month (only) 205**] and 4-5 days later started to have profuse watery diarrhea for which her urologist, Dr. [**Last Name (STitle) **], provided her with imodium. The next day ([**7-11**]), she was taken to [**Hospital3 **] because of the diarrhea and dehydration. She was found to have moderately low blood pressures. She was given fluids and diagnosed with c.diff. The day after admission, she had a BP of 76/51 and was transferred to the ICU. Of note during her hospitalization her weight went from 83 lbs to 132 lbs and she became anasarcic. Her treatment consisted of IV flagyl and PO vanco initially. Her IV flagyl was stopped upon discharge from [**Hospital3 **]. Her plan was to complete 14 d course of PO vanco. At rehab, she was started on dual therapy IV vanco and flagyl. She always denied fevers, chills, nausea, vomitting. She would have intermittent abdominal pain. On [**7-18**] She was discharged to [**Hospital1 13696**] rehab where she was started on TPN. At rehab she was noted to have an increased WBC count from 15 (on discharge from [**Hospital **]) to 29. She also had an increasingly tender abdomen so she was sent to [**Hospital1 18**] ER for further eval. . In the ED, initial vs were: T 100.1, P 80, BP 118/76, R 19, O2 sat 95% on 4L. She was persistently tachycardic in 110s-120s while in the ED; did not decrease with IVFs. Patient was given Flagyl IV 500 mg x1, Vanco 500 mg IV x1, zofran x1 and 1.5L NS IVFs. . On the floor, she is feeling well. She noted shortness of breath earlier in the day, but it has since resolved. She has no cough, fevers, chills. No nausea, vomitting. She does not eat well, although has been trying to drink ensure. She denies headaches, dizziness. Past Medical History: Multiple sclerosis (diagnosed in [**2086**], chronic progressive for 20 y, wheel chair bound and has a paraplegia at baseline) Depression Anorexia nervosa HTN Osteoporosis Social History: Worked in CPA firm, no longer working but accompanied husband to work, wheelchair bound; used to drink socially, no tobacco or drug history; has 2 children with grandchildren Family History: Mother-colorectal ca [**Name (NI) 100464**] hemorrhage Physical Exam: Vitals: T: 96.8, BP: 118/59, P: 109, R: 28, O2: 93% on 4L 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 breath sounds [**1-25**] up lung fields on back, no crackles or wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, distended, bowel sounds present but mildly hypoactive, no rebound tenderness or guarding, no organomegaly GU: foley Rectal: poor tone, soft nonbleeding external hemorrhoid Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+ pitting edema wiht pink, blotchy rash bilaterally Pertinent Results: labs- [**2107-7-20**] 02:30PM BLOOD WBC-25.5*# RBC-2.77*# Hgb-8.0*# Hct-26.4*# MCV-95 MCH-28.7 MCHC-30.1* RDW-15.4 Plt Ct-490* [**2107-7-25**] 04:54AM BLOOD WBC-21.4* RBC-3.26* Hgb-9.2* Hct-29.6* MCV-91 MCH-28.1 MCHC-30.9* RDW-16.5* Plt Ct-280 [**2107-7-20**] 02:30PM BLOOD Neuts-84* Bands-4 Lymphs-7* Monos-3 Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2107-7-20**] 02:30PM BLOOD Hypochr-3+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-1+ Spheroc-OCCASIONAL [**2107-7-21**] 04:01AM BLOOD PT-11.4 PTT-24.9 INR(PT)-0.9 [**2107-7-20**] 02:30PM BLOOD Glucose-774* UreaN-17 Creat-0.5 Na-129* K-5.5* Cl-91* HCO3-30 AnGap-14 [**2107-7-20**] 03:20PM BLOOD Glucose-132* UreaN-17 Creat-0.3* Na-135 K-3.9 Cl-100 HCO3-29 AnGap-10 [**2107-7-25**] 04:54AM BLOOD Glucose-106* UreaN-16 Creat-0.4 Na-138 K-4.4 Cl-103 HCO3-30 AnGap-9 [**2107-7-20**] 02:30PM BLOOD ALT-24 AST-23 AlkPhos-77 [**2107-7-22**] 06:36AM BLOOD ALT-27 AST-30 LD(LDH)-242 CK(CPK)-47 AlkPhos-102 TotBili-0.1 [**2107-7-20**] 10:50PM BLOOD calTIBC-150* Ferritn-147 TRF-115* [**2107-7-25**] 04:54AM BLOOD Triglyc-123 [**2107-7-20**] 10:50PM BLOOD TSH-6.2* [**2107-7-21**] 04:01AM BLOOD Free T4-0.94 [**2107-7-20**] 02:48PM BLOOD Lactate-1.4 [**2107-7-21**] 08:59PM BLOOD Lactate-0.8 [**2107-7-21**] 01:01AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-NEG [**2107-7-21**] 01:01AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.022 [**2107-7-24**] 12:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2107-7-21**] 4:25 am STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT [**2107-7-23**]** FECAL CULTURE (Final [**2107-7-22**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2107-7-23**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2107-7-21**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT Abd/pelvis [**7-20**] with contrast IMPRESSION: 1. Abnormal hyperenhancement and wall thickening of the left hemicolon, consistent with patient's history of colitis. Large amount of ascites. No evidence of perforation. 2. Bilateral pleural effusions with compressive lower lobe atelectasis. Echo [**7-21**] The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Hyperdynamic left ventricular systolic function. Large left pleural effusion. Left upper ext ultrasound IMPRESSION: No evidence of DVT. Brief Hospital Course: 62 y/o F with hx of MS, HTN, and anorexia who was recently diagnosed with c.diff colitis and admittted with recurrent diffuse watery diarrhea. . # C.diff Colitis: The patient has hx of c.diff colitis form outside hospital. Upon admission, she continued to have voluminous diarrhea output requiring rectal tube placement. The patient was also intravascularly volume depleted secondary to decreased PO intake and increased diarrhea output. She initially had borderline hypotension and tachycardia to 120s, and received IVF as well as PRBC transfustion to replete volume. The patient was noted to have leukocyctosis, likely from inadequate treatment of severe infection, which trened down to 21 at discharge. CT scan was consistent with colitis, no dilation, abscess or perforation. The patient was initially on IV flagyl and PO vanco later changed to PO flagyl and PO vanco. She was maintained on bowel rest in the MICU with TPN for nutrition until diarrhea decreased, and now is briging with TPN back to a regular diet. Her diarrhea stopped on [**2107-7-23**], and she will need a 14 day course of these abx from this date (end date [**2107-8-6**]) and then a [**Doctor Last Name 2949**] of the vancomycin. Taper will be 125 mg vancomycin PO BID for 7 days, followed by 125 mg PO daily for 7 days, followed by 125 mg every other day for 2 weeks. . . # Anasarca: She initially developed anasarca secondary to aggressive rehydration in the setting of hypoalbuminemia with her initial c. diff infection. During this hospital course this improved with Lasix 10mg IV x 2 during her stay. She has a poor nutritional status which likely causes her anasarca. She was continued on TPN as above. UA was negative for protein, to rule out nephrotic syndrome. Echo was checked to rule out heart failure, ef was normal. . # Anemia - patient has new anemia from baseline. Hct of about 25 on admission, up to 29 at discharge. Likely from slow blood loss due to colitis. Was given 1 unit of RBCs during admission. Hct then remained stable. . # Tachycardia / relative hypotension: as discussed above, secondary to volume depletion from diarrhea. Not febrile, lactate normal. Do not think she has septic shock. Improved to low 100s at dishcarge. . # L arm swelling: L arm slightly more swollen than R arm, is the same arm where PICC was placed. No erythema, intact pulses. US of left arm showed no DVT. . #. lower extremity pain: The patient began complaining of bilateral pain at back of thigh and knees on [**7-22**]. Due to high risk for DVT in setting of immobility, bilateraly LENI's were done and were negative for DVT. Pain improved with Tylenol and repositioning. . # MS: stable, unchanging symptoms. Neuro consulted in the ED, followed pt. She was continued on her Oxybutinin and Impramine at home doses. Provigil was held due to tachycardia and should be restarted as out pt when appropriate. . # HTN: SBPs stable in 100s, holding antihypertensives for now. Valsartan and quinapril should be restarted as outpatient when appropriate. . # Anorexia: long standing issue (for >20 years). Was restarted on TPN prior to admission. Continued on TPN during her hospital course. Changed to cycled TPN during nights only to encourge appetite. Meals were supplemented with Ensure. . The patient was discharged to [**Hospital **] [**Hospital **] rehab on [**2107-7-25**]. Medications on Admission: Alendronate-Vitamin D3 70 mg-2,800 units weekly Ergocalciferol (Vitamin D2) 50,000 unit Capsule monthly Econazole 1 % Cream [**Hospital1 **] Imipramine 100 mg qHS Modafinil 100 mg daily Oxybutynin SR 5 mg Tab daily Quinapril 40 mg daily Valsartan 160 mg daily Guar Gum [Benefiber] 1 g tab daily One-A-Day Womens Formula daily Potassium Chewable 20 mg tabs, 0.5 tabs daily Nexium EC 40 mg daily Phos-NaK 280mg-160mg-250mg packets, 1 pack daily Mag-[**Doctor Last Name **] 200mg-200mg/5ml, 10ml q6hrs Tums 500 mg tabs, 2 tabs [**Hospital1 **] Florastor 250 mg [**Hospital1 **] Ativan 0.5 mg PO q4hrs PRN Tobramycin 0.3% Oph Soln 2 gtt each eye daily Regular (Novolin) Insulin SC SQ Hep tid TPN . Vanco 250 mg IV q6hrs - started at [**Hospital1 1872**] Flagyl 500 mg IV q8hr - started at [**Hospital1 1872**] Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 11 days: Last day [**8-6**] at this dose, then taper as directed. 3. Imipramine HCl 25 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous ASDIR (AS DIRECTED). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 days: last day of course [**8-6**]. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Alendronate-Vitamin D3 70-2,800 mg-unit Tablet Sig: One (1) Tablet PO once a week. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 14. Benefiber (Guar Gum) 1 gram Tablet Sig: One (1) Tablet PO once a day. 15. Tobramycin Sulfate 0.3 % Drops Sig: Two (2) drops Ophthalmic once a day. 16. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 17. Tums 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO twice a day. 18. Florastor 250 mg Capsule Sig: One (1) Capsule PO twice a day. 19. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. 20. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous PRN line flush. 21. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous PRN line flush. 22. Saline flush Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] Discharge Diagnosis: C. dif infection anasarca primary: C. dif infection . secondary: multiple sclerosis anorexia nervosa Discharge Condition: The patient was discharged in good condition, afebrile, with stable vital signs. Discharge Instructions: You were admitted to the hospital with diarrhea and were found to have a recurrence of C dif infection. You were treated with antibiotics and your symptoms should continue to improve. You will need to continue these antibiotics for several weeks. . You also received supplemental nutrition through your IV. You will continue to receive this at rehab, but you should start to eat more on your own. . The following changes were made to your home medications: --> You will take Flagyl and vancomycin as directed until [**8-6**]. You will then take decreasing doses of vancomycin as directed for the next several weeks. . --> You will not take Provigil, quinapril or Valsartan unless directed by physician. . Please seek medical attention if you experience fever, cough, shortness of breath, abdominal pain, diarrhea, or any new symptoms. Followup Instructions: You should follow-up with your primary care physician after you leave [**Hospital **] [**Hospital **] rehab.

[ "340", "285.9", "782.3", "401.9", "307.1", "008.45" ]

icd9cm

[ [ [] ] ]

[ "99.15" ]

icd9pcs

[ [ [] ] ]

13173, 13219

6936, 10293

290, 297

13365, 13448

3533, 6913

14331, 14443

2752, 2809

11150, 13150

13240, 13344

10319, 11127

13472, 13911

2824, 3514

13929, 14308

242, 252

325, 2348

2370, 2544

2560, 2736

80,785

146,144

38937

Discharge summary

report

Admission Date: [**2113-3-1**] Discharge Date: [**2113-3-6**] Date of Birth: [**2063-11-7**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Attending Info 65513**] Chief Complaint: 15cm complex pelvic mass Major Surgical or Invasive Procedure: 1. TAH/BSO 2. Omentectomy 3. Cholecystectomy 4. SBR with primary reanastomosis 5. Umbilical herniorraphy History of Present Illness: Ms. [**Known lastname 70938**] is a 49-year-old premenopausal G2P2 with a history of morbid obesity, HTN, hyperlipidemia, & a recently discovered 15cm complex pelvic mass s/p TAH/BSO complicated by colon resection for Meckel's diverticulum & cholecystectomy. She was in her usual state of health until last week when she woke with lower abdominal pain mostly in the left lower quadrant. As she was having urinary frequency, this was thought to be secondary to urinary tract infection. She was treated empirically with antibiotics; however, her pain continued and was soon accompanied by nausea and vomiting. She presented to the emergency room where she was again evaluated and placed on another antibiotic. She then presented to her gynecologist's office where an exam was performed and the patient was sent for lab work and a CT scan. The CT scan showed a 15 x 13 x 13 cm solid cystic mass in the pelvis, appearing to arise from the ovary and concerning for an ovarian malignancy. There was no evidence of bowel obstruction or urinary obstruction. A small amount of ascites was noted. Upper abdominal structures appeared unremarkable. The patient also had some lab work performed. This showed a CA-125 of 957. Her chemistries and LFTs were within normal limits. Hematocrit was 31 and she had an elevated white count of 18. Urine pregnancy test was negative. Past Medical History: Morbid obesity Hypertension Hyperlipidemia Glucose intolerance Adjustment disorder Hypocalcemia Foot arthritis s/p Caesarian section x 2 Social History: Denies smoking, alcohol, or drug abuse. She works in housekeeping at the [**Location (un) **] of [**Location (un) 511**]. Family History: Noncontributory for ovarian, colon, or uterine cancer. A paternal aunt had breast cancer. 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, no clubbing, cyanosis or edema Pertinent Results: [**2113-3-1**] 11:53PM GLUCOSE-122* UREA N-11 CREAT-0.7 SODIUM-141 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-27 ANION GAP-14 [**2113-3-1**] 11:53PM ALT(SGPT)-33 AST(SGOT)-53* ALK PHOS-64 TOT BILI-0.2 [**2113-3-1**] 11:53PM CALCIUM-7.8* PHOSPHATE-4.4# MAGNESIUM-2.4 [**2113-3-1**] 11:53PM WBC-17.1* RBC-3.85* HGB-8.7* HCT-29.2* MCV-76* MCH-22.6* MCHC-29.9* RDW-18.1* [**2113-3-1**] 11:53PM PLT COUNT-545* [**2113-3-1**] 11:00PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.017 [**2113-3-1**] 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2113-3-1**] 05:23PM TYPE-ART PO2-231* PCO2-33* PH-7.55* TOTAL CO2-30 BASE XS-7 INTUBATED-INTUBATED VENT-CONTROLLED [**2113-3-6**] 05:55AM BLOOD WBC-7.9 RBC-3.40* Hgb-7.5* Hct-25.7* MCV-75* MCH-22.0* MCHC-29.2* RDW-17.9* Plt Ct-546* [**2113-3-5**] 05:25AM BLOOD WBC-8.0 RBC-3.53* Hgb-7.7* Hct-26.8* MCV-76* MCH-21.9* MCHC-28.8* RDW-18.0* Plt Ct-475* [**2113-3-4**] 06:50AM BLOOD WBC-10.7 RBC-3.36* Hgb-7.3* Hct-25.7* MCV-77* MCH-21.8* MCHC-28.5* RDW-17.7* Plt Ct-454* [**2113-3-3**] 06:05AM BLOOD WBC-12.8* RBC-3.56* Hgb-7.8* Hct-27.2* MCV-76* MCH-22.0* MCHC-28.9* RDW-18.3* Plt Ct-542* [**2113-3-2**] 05:36AM BLOOD WBC-14.9* RBC-3.74* Hgb-8.2* Hct-28.5* MCV-76* MCH-21.8* MCHC-28.6* RDW-17.8* Plt Ct-523* [**2113-3-1**] 11:53PM BLOOD WBC-17.1* RBC-3.85* Hgb-8.7* Hct-29.2* MCV-76* MCH-22.6* MCHC-29.9* RDW-18.1* Plt Ct-545* [**2113-3-6**] 05:55AM BLOOD Glucose-98 UreaN-5* Creat-0.4 Na-143 K-4.0 Cl-105 HCO3-29 AnGap-13 [**2113-3-5**] 05:25AM BLOOD Glucose-101* UreaN-4* Creat-0.4 Na-142 K-4.1 Cl-106 HCO3-29 AnGap-11 [**2113-3-4**] 06:50AM BLOOD Glucose-107* UreaN-5* Creat-0.5 Na-141 K-4.0 Cl-107 HCO3-26 AnGap-12 [**2113-3-3**] 06:05AM BLOOD Glucose-125* UreaN-9 Creat-0.5 Na-140 K-4.1 Cl-105 HCO3-27 AnGap-12 [**2113-3-2**] 05:36AM BLOOD Glucose-112* UreaN-10 Creat-0.6 Na-143 K-4.5 Cl-106 HCO3-30 AnGap-12 [**2113-3-1**] 11:53PM BLOOD Glucose-122* UreaN-11 Creat-0.7 Na-141 K-4.5 Cl-105 HCO3-27 AnGap-14 [**2113-3-3**] 06:05AM BLOOD ALT-32 AST-48* [**2113-3-2**] 05:36AM BLOOD ALT-34 AST-74* LD(LDH)-267* AlkPhos-65 TotBili-0.2 [**2113-3-6**] 05:55AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.0 [**2113-3-5**] 05:25AM BLOOD Calcium-7.8* Phos-3.5 Mg-2.1 [**2113-3-4**] 06:50AM BLOOD Calcium-7.7* Phos-3.2 Mg-2.1 [**2113-3-3**] 06:05AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.5 [**2113-3-2**] 05:36AM BLOOD Albumin-2.8* Calcium-7.9* Phos-3.9 Mg-2.4 [**2113-3-1**] 05:23PM BLOOD Type-ART pO2-231* pCO2-33* pH-7.55* calTCO2-30 Base XS-7 Intubat-INTUBATED Vent-CONTROLLED Brief Hospital Course: The patient is a 49-year-old G2P2 with morbid obesity, HTN, hyperlipidemia, who underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, small bowel resection for a Meckel's diverticulum and cholecystectomy on [**2113-3-1**] for 15cm complex pelvic mass. Please see operative reports for full details. Immediately post-op, the patient had mild tachycardia to the low 100s and a low grade fever of 99.9. She was admitted to the [**Hospital Unit Name 153**] postoperatively for concerning SIRS. Her vital was stable and within normal range throughout the [**Hospital Unit Name 153**] course. She was therefore transferred to the floor on post-operative day 1. She received 24hours of prophylactic Zosyn per general surgery's recommendation. General surgery followed the patient during her hospital course and gave recommendations regarding advancement of her diet. The patient urine cultures and blood cultures drawn on POD 1. Her urine culture was negative, and her blood culture had no growth to date at time of discharge. The patient's pain was initially controlled with an Epidural and Dilaudid PCA. Her epidural was removed on [**2113-3-4**]. Her Foley catheter was also removed at this time. She voided spontaneously. The patient diet was advanced to clears. The patient had a bowel movement and was passing gas by [**3-5**]. At this time her diet was advanced to regular. Her Dilaudid PCA was discontinued, and her pain was well controlled with oral pain medication. On [**3-5**], the patient was noted to have some erythema on the superior aspect of her incision. It was mildly tender to palpation. There was no drainage. The patient remained afebrile with a normal WBC count. The patient was started on Keflex for presumed skin cellulitis. She was discharged with this medication to complete a full 10 day course. The patient was ambulating well and tolerating a regular diet by the time of her discharge. The patient was kept on an insulin sliding scale with regular glucose checks during her hospital stay. She has no known history of diabetes but likely has some element of glucose intolerance. She will need diabetes testing as an outpatient by her PCP. The patient was discharged to home on post-operative day #5 in good condition. Medications on Admission: Vicodin 2 pills q6H:PRN pain Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: do not exceed 4g tylenol in 24hours. Disp:*45 Tablet(s)* Refills:*0* 2. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 9 days. Disp:*24 Capsule(s)* Refills:*0* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*2* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Hemorrhagic ovarian cyst 2. Ovarian torsion 3. Meckel's diverticulum 4. Cholelithiasis Discharge Condition: stable Discharge Instructions: You underwent a laparotomy, small bowel resection including Meckel's diverticulum, with primary anastomosis, open cholecystectomy, removal of pelvic mass, left salpingo-oophorectomy, right salpingo-oophorectomy, total abdominal hysterectomy, infracolic omentectomy, umbilical herniorrhaphy. Your surgery was uncomplicated. Plaese keep all of your follow up appointments as outlined below. Please take all of your medications as perscribed. Followup Instructions: Provider: [**Name10 (NameIs) 35354**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2113-3-13**] 2:00 PM Dr. [**Last Name (STitle) **], ([**Telephone/Fax (1) 2047**], [**2113-3-17**] 2pm, [**Hospital Ward Name 23**] [**Location (un) 470**] [**Name6 (MD) 35354**] [**Name8 (MD) **] MD [**MD Number(2) 65515**]

[ "272.4", "682.2", "E878.6", "401.9", "620.5", "620.2", "789.59", "751.0", "278.01", "553.1", "998.59", "574.00" ]

icd9cm

[ [ [] ] ]

[ "45.62", "65.61", "68.49", "53.49", "51.22", "54.4" ]

icd9pcs

[ [ [] ] ]

8285, 8291

5384, 7674

350, 457

8425, 8434

2768, 5361

8927, 9297

2175, 2267

7753, 8262

8312, 8404

7700, 7730

8458, 8904

2282, 2749

286, 312

485, 1859

1881, 2019

2035, 2159

29,722

122,835

10617

Discharge summary

report

Admission Date: [**2180-10-6**] Discharge Date: [**2180-10-14**] Date of Birth: [**2114-5-16**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Levaquin / Erythromycin Base / Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 2745**] Chief Complaint: Cough, abdominal distention Major Surgical or Invasive Procedure: PICC line placement and removal History of Present Illness: 66yo woman with IDDM, CAD, CHF (EF 30%), CKD stage III, and 2 recent admissions to [**Hospital1 18**] presents with c/o cough, abdominal distention, and facial swelling. . History provided by patient and her husband, who is her primary caregiver. . Over the last 3-4 days, patient has had a minimally productive cough. One day ago, she developed facial swelling, and today felt that her belly was bloated. Her urine output has declined over the last few days. Of note, she was discharged from rehab 1 week ago. She states she is compliant with her diet. Her dry weight is 189 pounds. +Poor appetitite, + nausea. Cough is associated with back pain/tightness. Denies fevers, chills, chest pain, abdominal pain, diarrhea, or constipation. . Of note, patient has 2 recent admissions to [**Hospital1 18**]. In [**Month (only) 216**], she was admitted with RLE cellulitis and treated with vanc/cefepime. In [**Month (only) **], she was readmitted with mental status change. Of note, she had a waxing/[**Doctor Last Name 688**] mental status during both admissions with extensive work-up. Her poor mental status was felt to be a mixture of post-ictal state following subtle seizures and hepatic encephalopathy. She was started on keppra as well as lactulose. . In the ED: VS 98.3 110 107/79 16 96% RA. She had a CXR, RUQ ultrasound and was sent to the floor. Past Medical History: 1. Type I Diabetes Mellitus--+nephropathy, no A1C available 2. Coronary Artery Disease 3. Congestive Heart Failure--EF 30%, 2+ TR, mod PA HTN per echo in [**2180-7-19**] 4. CKD stage III with baseline Cr 1.3-1.9 5. Hyperlipidemia 6. Gastritis 7. Venous Stasis 8. Allergic Rhinitis 9. Osteomyelitis 10. RLE wound--after trauma, s/p graft 11. Cirrhosis--thought to be due to NASH; on lactulose, ursodiol and rifamixin in the past . ALLERGIES (reports reaction to everything is itch) Penicillins Sulfa (Sulfonamides) Levaquin Erythromycin Base IV Contrast--difficulty breathing Iodine Containing Social History: - Lives with husband, who is primary caregiver. [**Name (NI) **] help with ADLs. Quit smoking in [**2154**]. h/o alcohol abuse. - Son lives next door; he and his wife also help with her care. - Has daily VNA. - Can walk up four steps with assistance. Family History: non-contributory Physical Exam: VS: 97.2 91/69 (rechecked to be 110/70) 124 26 96% RA Sitting on edge of bed next to husband, slumped over, not making eye contact or communicative, but answering questions appropriately, wants to go home. Constantly scratching at her thighs and back Multiple scabs/excoriations over chest, back, abdomen, arms. Right pupil larger than left (chronic per patient), both reactive Mucous membranes moist; White plaques on soft palate, tongue, and ?buccal mucosa (though patient minimal effort with opening mouth) Neck supple, no thyroid enlargement S1, S2, distant, regular Lungs clear b/l but with poor inspiratory effort so difficult to assess bases Abdomen obese, BS present, soft, mild diffuse tenderness, no guarding or rebound Ext: dressings on lower extremities on legs and feet b/l Pertinent Results: Labs on admission: [**2180-10-6**] 01:00PM PT-32.6* PTT-41.2* INR(PT)-3.5* [**2180-10-6**] 01:00PM PLT COUNT-275# [**2180-10-6**] 01:00PM NEUTS-82.2* LYMPHS-10.1* MONOS-5.5 EOS-2.0 BASOS-0.2 [**2180-10-6**] 01:00PM WBC-11.1*# RBC-4.60 HGB-12.7 HCT-40.0 MCV-87 MCH-27.6 MCHC-31.8# RDW-22.0* [**2180-10-6**] 01:00PM FREE T4-1.5 [**2180-10-6**] 01:00PM TSH-3.6 [**2180-10-6**] 01:00PM ALBUMIN-3.3* [**2180-10-6**] 01:00PM CK-MB-NotDone cTropnT-0.04* proBNP-6573* [**2180-10-6**] 01:00PM LIPASE-27 [**2180-10-6**] 01:00PM ALT(SGPT)-23 AST(SGOT)-40 CK(CPK)-26 ALK PHOS-409* AMYLASE-40 TOT BILI-1.9* [**2180-10-6**] 01:00PM estGFR-Using this [**2180-10-6**] 01:00PM GLUCOSE-120* UREA N-60* CREAT-1.8* SODIUM-133 POTASSIUM-3.9 CHLORIDE-89* TOTAL CO2-31 ANION GAP-17 [**2180-10-6**] 01:08PM LACTATE-3.0* [**2180-10-6**] 01:08PM COMMENTS-GREEN . Labs on Discharge: [**2180-10-14**] 05:23AM BLOOD WBC-8.3 RBC-4.28 Hgb-11.9* Hct-39.2 MCV-92 MCH-27.8 MCHC-30.4* RDW-21.6* Plt Ct-239 [**2180-10-14**] 05:23AM BLOOD Plt Ct-239 [**2180-10-14**] 05:23AM BLOOD PT-23.8* INR(PT)-2.4* [**2180-10-14**] 05:23AM BLOOD Glucose-85 UreaN-63* Creat-1.6* Na-142 K-3.5 Cl-100 HCO3-35* AnGap-11 [**2180-10-12**] 11:40AM BLOOD ALT-24 AST-34 LD(LDH)-276* AlkPhos-338* TotBili-1.4 [**2180-10-7**] 07:22AM BLOOD GGT-184* [**2180-10-14**] 05:23AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.5 [**2180-10-7**] 07:22AM BLOOD %HbA1c-6.9* [**2180-10-6**] 01:00PM BLOOD TSH-3.6 [**2180-10-6**] 01:00PM BLOOD Free T4-1.5 [**2180-10-8**] 05:45AM BLOOD Cortsol-15.9 . EKG: Sinus tachycardia, low voltage, T wave flattening in I, aVL and V6 that is stable as compared with prior. . CXR [**10-6**]: 1. CHF with small bilateral pleural effusions. 2. Findings involving the medial right lung base, suggestive of pneumonic consolidation with associated collapse. . Liver Ultrasound [**10-6**]: 1. No intrahepatic ductal dilatation or hepatic venous abnormalities to indicate Budd- Chiari. 2. No evidence of cholelithiasis. Gallbladder wall thickening and edema likely related to third spacing of fluid in a patient with known underlying cirrhosis and possible cardiac dysfunction. . Video swallow study: IMPRESSION: Mild oropharyngeal dysphasia with tongue weakness, premature spillage, swallow initiation delay, and incomplete laryngeal valve closure resulting in penetration with thin and nectar thick liquids and aspiration with mixed consistency. For details of the swallowing evaluation, please refer to the speech pathology report on CareWeb. . EEG: IMPRESSION: Markedly abnormal EEG due to the frequent bursts of generalized delta slowing and background slowing and focal bursts of delta slowing particularly in the right posterior quadrant. The first two abnormalities signify a widespread encephalopathy affecting both cortical and subcortical structures. Medications and metabolic disturbances are among the most common causes. The focal abnormality suggests a focal subcortical dysfunction in the right hemisphere (and possibly bilaterally). Vascular disease is one possible cause, but the tracing cannot specify the etiology. There were no clearly epileptiform features. . Brief Hospital Course: She was admitted to the medical floor, and monitored. Over the day, she was given IVF bolus on HD#1. On HD#2 given rising WBC and CXR that showed a possible pna she was placed on Cefepime/Vanco given history of pseudomonas LE infxn and recent rehab stay. She had a RUQ U/S that showed dilated GB wall but no frank cholecystitis was noted. This was likely secondary to her ongoing cirrhosis. On eve of HD#2 (10.20) she triggered for low BP to 80/55 although was asymptomatic at the time. She was given an extra 500cc of NS and her BP responded appropriately. . She again triggered for low BP of 77/43, was given 750cc NS and transferred to the MICU for concern of sepsis in the setting of hypotension. On arrival, she denied any lightheadedness/dizziness, presyncope, CP, SOB, abd pain, N/V. Stated that she was taking POs and was not excessively thirsty. . While in the MICU, the patient responded well to fluid boluses and did not require pressors. Patient was not febrile at any point and leukocytosis continued to decline. . Hypotension improved on transfer to MICU, and continued to improve with fluid. She was transfered back to the medicine floor and maintained systolic blood pressures in the 130s. Likely hypovolemic hypotension (Una <10, ARF) from dehydration [**1-21**] poor PO prior to admission. Sepsis appeared unlikely given no clinical source of infxn except for possible PNA and leukocytosis which also improved. UA negative. Blood cultures x2 had no growth. The patient was started back on Bumex and carvedilol prior to discharge. She had high UOP with bumex so zaroxylyn was held and can be restarted as an outpatient. Patient was continued on antibiotics for her presumed pneumonia, with her last dose on the day of discharge (7 days total course). . The patient's diabetes was managed while she was here with lantus and insulin sliding scale. She was found to have morning hypoglycemia, and her evening lantus was decreased prior to discharge to improve morning sugars. She was continued on her aspirin and carvedilol for her coronary artery disease as above. She was also continued on Keppra for her seizure activity. An EEG was performed while admitted as per her outpatient Neurologist, and the report was forwarded for further work up. . While the patient was admitted, she was followed by vascular surgery for her RLE wound. Dressings were changed weekly and the patient had follow up for further evaluation as an outpatient upon discharge. Her feet were at baseline dusky, but with palpable pulses. Color improved with elevation. . The patient had a history of aspiration. A video swallowing study was completed. the patient was placed on aspiration precautions, and she should have soft solids and thin liquids with no mixed consistencies. Pills should be placed whole and in puree, and she should drink with her chin to her chest to avoid aspiration. Medications on Admission: Nephplex 1mg daily Zaroxylin 10mg QAM, give before bumex Bumex 6mg daily Sarna lotion 0.5% TID prn itch Carvedilol 3.125mg daily Lantus 28 units SC QHS Lispro 4 units Lunch and dinner Prilosec 20mg po daily Fluocinonide 0.05% cream [**Hospital1 **] PRN rash Travoprost 0.004% one drop OU MWF before bed Warfarin 2mg QHS Eucerin cream to arms and legs daily Keppra 500mg po bid Doxepin 10mg QHS PRN pruritis Klorcon 40mEq daily ASA 81mg daily Nystatin ointment topically [**Hospital1 **] Lactulose 30ml po BID Discharge Medications: 1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for patient request. Disp:*1 bottle* Refills:*0* 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Bumetanide 2 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic MWF (Monday-Wednesday-Friday). 6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 7. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID PRN () as needed for itching. Disp:*30 Tablet(s)* Refills:*0* 8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16). 9. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*0* 10. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Klor-Con 20 mEq Packet Sig: Two (2) packets PO once a day. 14. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for itching. 15. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 16. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous at bedtime. Disp:*30 days* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: Pneumonia Secondary Diagnoses: Diabetes, Congestive heart failure, acute on chronic renal failure, Cirrhosis of the liver, venous stasis, right lower extremity wound Discharge Condition: Stable Discharge Instructions: You were admitted with cough and abdominal distention and were found to have a pneumonia. You developed low blood pressures and were treated with intravenous antibiotics and fluids. It was found that you often aspirate when you eat. It is very strongly recommended that you eat a diet of soft solids and thin liquids without mixed consistencies. Also, your pills should be placed in puree whole. When you drink, place your chin to your chest and take small sips. Alternate between bites and sips as well. 1. Please take all medications as prescribed. 2. Please attend all follow-up appointments as listed below. 3. Please call your doctor or return to the hospital if you develop any shortness of breath, chest pain, diarrhea, increased cough, dizziness or headaches or any other symptoms that concern you. Followup Instructions: It is very important that you keep the following follow up appointments. In addition, it is very important that you follow up with your primary care provider to discuss your medical problems. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2180-10-19**] 2:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2180-10-26**] 11:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2180-11-1**] 1:15 You must have your INR checked on Monday by VNA and have this faxed to Dr. [**Last Name (STitle) **] who is following your coumadin levels until you have your primary care doctor visit at [**Company 191**].

[ "486", "585.3", "459.81", "428.0", "V58.67", "276.51", "250.60", "345.90", "357.2", "414.01", "272.4", "571.5", "458.9", "584.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11710, 11768

6756, 9647

384, 418

11997, 12006

3571, 3576

12866, 13729

2721, 2739

10206, 11687

11789, 11789

9673, 10183

12030, 12843

2754, 3552

11839, 11976

317, 346

4455, 6733

446, 1821

11808, 11818

3590, 4436

1843, 2437

2453, 2705

52,261

154,647

34567

Discharge summary

report

Admission Date: [**2148-4-4**] Discharge Date: [**2148-4-7**] Date of Birth: [**2117-5-5**] Sex: M Service: MEDICINE Allergies: Penicillins / Depakote / Tegretol Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: unresponsive Major Surgical or Invasive Procedure: Intubated on ventilator starting [**4-4**] Bronchoscopy with BAL on [**4-5**] History of Present Illness: 30 y/o with h/o schizophrenia, HTN, HL, Etoh abuse presents to the ED for suspected intoxication. Pt was found to be intoxication when reporting to his day program this afternoon. He appeared normal at his group home this am. Per the facility the patient has been less responsive and more psycotic over the last 2-3 weeks. No other symptoms noted by the group home. Per the pt's mother he has been complaining of SOB, cough, and rhinitis for a few weeks. No reported F/C/S, CP, Abd pain. Diarrhea x 1. No dysuria. Per the mother pt was less responsive over the last 3 weeks but improving with the addition of lamictal. He has occasional HA but no recent exacerbation. . The Mother confirms that Mr [**Name (NI) 79357**] regularly drinks a pint of whiskey 3x weekly. He has a h/o withdraw but no DTS. Occasional Marajuana use, however no h/o of other illict use. The group home confirms he does not have access to medications himself. . In the ED, initial vs were: T97.6 P89 BP134/78 R14 O2 sat 99. On arrival the pt was arousable with sternal rub and admitted to Etoh use but not illicts. He then became more somulent and vomitted non-bloody emesis x 1. He has oxygen desaturation to the high 70s low 80s. ABG showed a pCO2 of 96 and the pt was intubated. Patient was given 2mg of narcan without improvement, as well as zofran 2mg. He received fentanyl, versed, rocuronium, and propofol gtt with intubation. VS prior to transfer 112, 122/83, 33, 97% on AC 500, 22, 100%, 5. . On the floor, pt is intubated and sedated. With discontinuation of the propofol pt is aggitated but unresponsive. Past Medical History: schizophrenia depression bipolar constipation HTN clozaril induced DM Vit D defieciency Hyperlipidemia sleep apnea has CPAP but non-compliant. Etoh abuse Social History: Drinks 3 of 7 days a week, pint of whiskey. Has been drinking for years. No DT but h/o alcohol withdraw. Active smoker. Lives in group home. h/o MJ use but no other illicits. Works within group home cleaning. independent in ADL. Family History: Unknown Physical Exam: Vitals: T:98.7 BP:122/78 P:92 R:21 O2: 100% on AC General: intubated, sedated. unresponsive to painful stimuli HEENT: Sclera erythematous, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds diminished, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema skin: no rash Pertinent Results: [**2148-4-4**] 02:45PM ASA-NEG ETHANOL-236* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2148-4-4**] 02:45PM GLUCOSE-109* UREA N-9 CREAT-1.0 SODIUM-138 POTASSIUM-5.6* CHLORIDE-96 TOTAL CO2-31 ANION GAP-17 [**2148-4-4**] 04:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2148-4-4**] 04:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2148-4-4**] 04:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2148-4-4**] 05:25PM WBC-10.2 HGB-14.2 HCT-46.7 [**2148-4-4**] 05:25PM NEUTS-73.8* LYMPHS-22.4 MONOS-2.7 EOS-0.5 BASOS-0.6 [**2148-4-4**] 05:25PM PLT COUNT-224 [**2148-4-4**] 05:25PM OSMOLAL-346* [**2148-4-4**] 05:25PM ALBUMIN-4.6 [**2148-4-4**] 05:25PM CK-MB-3 cTropnT-<0.01 [**2148-4-4**] 05:25PM LIPASE-47 [**2148-4-4**] 05:25PM ALT(SGPT)-28 AST(SGOT)-17 LD(LDH)-155 CK(CPK)-275 ALK PHOS-90 AMYLASE-54 TOT BILI-0.1 [**2148-4-4**] 05:25PM GLUCOSE-176* UREA N-8 CREAT-0.9 SODIUM-139 POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-34* ANION GAP-13 [**2148-4-4**] 05:31PM HGB-15.6 calcHCT-47 [**2148-4-4**] 05:31PM K+-4.9 [**2148-4-4**] 05:37PM K+-4.5 [**2148-4-4**] 05:37PM PO2-136* PCO2-96* PH-7.18* TOTAL CO2-38* BASE XS-4 COMMENTS-O2 DELIVER [**2148-4-4**] 09:34PM LACTATE-6.8* [**2148-4-4**] 09:34PM TYPE-ART O2-100 PO2-162* PCO2-49* PH-7.35 TOTAL CO2-28 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED . [**4-4**] CT head: IMPRESSIONS: 1. No acute intracranial hemorrhage or other acute process seen. 2. Small 4th ventricle and low lying cerebellar tonsils noted; MRI may be performed to assess for possible Chiari malformation or other posterior fossa abnormality. Increased intracranial pressure is not suspected. . [**4-4**] CXR: IMPRESSION: 1. Endotracheal tube is now in good position, 2.9 cm above the carina. 2. Stable bilateral lower lobe opacities, left greater than right. . [**4-5**] CT chest: IMPRESSION: Near complete bilateral lower lobe collapse likely due to acute mucoid impaction. . [**2148-4-7**] 04:01AM BLOOD WBC-7.6 RBC-4.95 Hgb-13.3* Hct-41.5 MCV-84 MCH-26.9* MCHC-32.1 RDW-15.9* Plt Ct-186 [**2148-4-5**] 05:27AM BLOOD Neuts-57.9 Lymphs-35.5 Monos-5.9 Eos-0.6 Baso-0.1 [**2148-4-7**] 04:01AM BLOOD Glucose-122* UreaN-7 Creat-0.8 Na-145 K-4.0 Cl-106 HCO3-31 AnGap-12 [**2148-4-7**] 04:01AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.9 Brief Hospital Course: This is a 30 year old male with PMH of schizophrenia and EtOH abuse intubated for somnolence and hypercapnia. . # Somnolence/Alcohol intoxication: Felt to be most likely secondary to alcohol and benzodiazepine intoxication. His toxin screen was otherwise negative and he did not respond to narcan. Head CT scan was negative for an acute process. His mental status quickly cleared and a lumbar puncture was deffered. . # Respiratory failure: Hypoxic and hypercarpic respiratory failure in the ED. Hypercarbic respiratory failure most likely secondary to respiratory depression from alcohol and benzodiazepines. Hypoxia likely from aspiration pneumonitis. Patient was successfully extubated after 2 days. He was treated broadly with antibiotics initially but then was narrowed down to levofloxacin and then stopped as he had no fever, leukocytosis and sputum cultures were negative. --He should follow up with [**Hospital **] clinic to ensure resolution and for PFTs . # Acid Base: His original ABG on admission showed acute respiratory acidosis with underlying metabolic alkalosis. An elevated lactate also suggested metabolic acidosis despite the lack of an AG at presentation. Respiratory acidosis likely from underlying PNA and sleep apnea. Metabolic alkalosis likely from vomitting. Lactic acidosis from combination of etoh use, metformin, and underlying infection. No known liver dz and LFTS normal. . # Etoh abuse: He does not have a history of seizure with withdrawal, but is reportedly tremulous without EtOH. He was given IV thiamine, folate, and started on a CIWA scale when he was extubated. He did not require any benzodiazepines and was not tremulous . # HTN: He was continued on his home metoprolol and amlopdipine. . # Pscyh: His home Lamictal, Wellbutrin, Abilify, clozapine, and Celexa were all continued. . #. DM: His metformin was held given his lactic acidosis. He was maintained on an insulin sliding scale. metformin was restarted on discharge . #. Code: Confirmed full code . #. Communication: With patient, Mother [**Name (NI) 9527**] [**Name (NI) 79357**] is legal guardian and HCP [**Telephone/Fax (1) 79358**], Group home: [**Telephone/Fax (1) 79359**] Medications on Admission: Aripiprazole 20mg qam aspirin 81mg daily acamprosate 666mg TID celexa 20mg PO daily clozapine 500mg QHS colace 100mg [**Hospital1 **] metformin 500mg PO BID metoprolol tartrate 50mg PO BID HCTZ 12.5 mg daily amlodipine 5mg PO daily -- not on PCP list omeprazole 20mg PO daily simvastatin 20mg PO daily bupropion SR 200mg qam -- not on PCP list lamotrigine 200mg PO qhs --- not on PCP list Vit [**Name Initial (PRE) **] 1000 IU daily salicylic acid-lactic acid duofilm [**Hospital1 **] prn warts Discharge Medications: 1. Aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Acamprosate 333 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 4. Clozapine 100 mg Tablet Sig: Five (5) Tablet PO HS (at bedtime). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 7. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: intoxication, aspiration penumonitis, collapse of right and left lower lung lobes Secondary: alcohol abuse, schizophrenia, obstructive sleep apnea, diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because you stopped breathing. This was because of the amount of alcohol that you drank. You inhaled contents from your stomach which irritated your lungs and caused them to collapse. You needed to have a tube placed in your throat to help you breath. Please stop drinking alcohol. Followup Instructions: Please call your primary care physician and make an appointment in the coming week to review your hospitalization and make sure you are getting better. Please call ([**Telephone/Fax (1) 513**] and make an appointment with one of the pulmonologists (lung doctors). [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "518.81", "507.0", "401.9", "303.01", "295.90", "276.4", "518.0", "250.00", "296.80", "780.09" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

9200, 9206

5484, 7676

311, 390

9426, 9426

3045, 4525

9903, 10307

2450, 2459

8221, 9177

9227, 9405

7702, 8198

9577, 9880

2474, 3026

259, 273

418, 2011

4534, 5461

9441, 9553

2033, 2188

2204, 2434

32,548

150,756

33606

Discharge summary

report

Admission Date: [**2163-4-1**] Discharge Date: [**2163-4-16**] Date of Birth: [**2107-7-11**] Sex: M Service: SURGERY Allergies: Codeine / Percocet / Dilaudid / Penicillins / Morphine Attending:[**First Name3 (LF) 668**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2163-4-1**]: ex-lap, small bowel resection History of Present Illness: Per Dr [**First Name (STitle) **] OP Note: Mr. [**Known lastname 2202**] is a 55-year-old gentleman who is currently listed on the liver transplant list at [**Hospital 50878**] who presents with a 7-day history of abdominal pain. The outside CT scan from [**Hospital3 **] reveals pneumatosis and free air. The patient was recently admitted to [**Hospital 4415**] Hospital with acute superior mesenteric venous thrombosis. Based on the [**Hospital 228**] medical findings, he was taken to the operating room after receiving appropriate IV resuscitation of crystalloid and colloid to correct an INR of 5.6 due to Coumadin. Past Medical History: ETOH cirrhosis Gastric ulcer Restless leg syndrome Social History: Currently on liver transplant list at [**Hospital1 336**] Family History: N/C Physical Exam: Post Op VS: 97.9, 71, 124/60, 20, 99%AC Gen: Intubated,sedated Card: S1S2, RRR Lungs: intubated, decreased bases Abd: Soft, non-distended, JP with sero-sang output dressing with ser-sang drainage Extr: No C/C/E Pertinent Results: On Admission: [**2163-4-1**] WBC-20.0* RBC-4.68 Hgb-16.5 Hct-46.7 MCV-100* MCH-35.2* MCHC-35.3* RDW-14.1 Plt Ct-202 Neuts-91.0* Bands-0 Lymphs-4.0* Monos-4.6 Eos-0 Baso-0.2 PT-49.2* PTT-44.1* INR(PT)-5.6* Glucose-112* UreaN-38* Creat-1.1 Na-126* K-4.7 Cl-90* HCO3-19* AnGap-22* ALT-35 AST-42* AlkPhos-101 Amylase-19 TotBili-4.4* DirBili-1.5* IndBili-2.9 Lipase-12 Albumin-2.6* Calcium-8.7 Phos-4.7* Mg-1.9 Iron-64 Cholest-83 calTIBC-182* Ferritn-571* TRF-140* Brief Hospital Course: Patient taken to surgery by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] due to findings on outside CT scan for corcern for perforated small bowel. During surgery the peritoneal cavity, had approximately 3 liters of bile stained ascites and extensive fibrinous exudate throughout the peritoneal cavity. The liver was grossly cirrhotic and there were extensive abdominal and retroperitoneal varices and collaterals. A small area in the mid jejunum was found that had evidence of necrosis and obvious perforation on the mesenteric side of the small bowel. A side-to-side jejunojejunostomy was performed. Please see the operative [**Last Name (un) **] for further surgical detail. He was transferred to the SICU still intubated. On POD 1 he was extubated. By [**4-4**], the patient was transferred to the floor. Neuro: Due to reactions to various pain medications he was placed on a Fentanyl PCA, with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications (Percocet), which he tolerated well. CV: The patient's vital signs were routinely monitored, and his antihypertensive regimen was adjusted accordingly. The patient was started on his home dose of propranolol and Imdur once tolerating clears on [**4-4**] as he was mildly tachycardic to 105 bpm, and his blood pressures were stable. On [**4-12**], the Imdur and HCTZ were discontinued as his blood pressures were not elevated. Pulmonary: The patient was stable initially from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout this hospitalization. On the patient acutely developed shortness of breath and increasing oxygen requirement. A CT of the chest with PE protocol was performed, which was negative for a PE. The patient was able to be weaned off the oxygen with no further issues. GI/GU/FEN: Post operatively, the patient was made NPO with IVF; he received albumin replacement as needed, and adjusted according to albumin serum levels and JP drain outputs. The patient's diet was advanced when appropriate (clears on [**4-4**] to a regular diet on [**4-6**]), which was tolerated well. The patient's intake and output were closely monitored, and IVF were adjusted when necessary. The patient's electrolytes were routinely followed during this hospitalization. On [**4-7**], the patient began receiveing albumin repletion for his JP output; he was not discharged home with the albumin. The same day, a CT was performed revealing a fluid collection for which the patient had IR drainage and pigtail placement. Cultures were followed, and his antibiotic regimen was adjusted accordingly. On [**4-12**], the patient had a follow up CT, and his drain was upsized from an 8 French to a 10 French drain. On [**4-15**], an additional CT revealed a new collection which was drained, and the existing pigtail drain was removed. On [**4-9**], the patient's wound was opened as there was some subcutaneous fluid collecting; he received wet to dry dressing changes. A Vac was subsequently placed, and the wound was debrided when changed on [**4-13**]. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Vanco, Cipro and Flagyl were started postoperatively for empiric coverage. Cultures from the IR drainage were followed, and his antibiotic regimen was adjusted accordingly to linezolid, meropenem and fluconazole. On [**4-13**], the patient's CVL was removed. The patinet had a PICC placed for prolonged antiobiotic dosing; he was discharged on ertapenem in lieu of meropenem for ease of dosing. Endocrine: The patient's blood sugar was monitored throughout this stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required during this stay. He received FFP prior to procedures with good result Other: A physical therapy consult was obtained for evaluation and treatment throughout the patient's stay. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: imdur 30', omeprazole 20', propanolol 20"', spironolactone/HCTZ 25/25', quinine 324' Discharge Medications: 1. Fluconazole in Saline(Iso-osm) 400 mg/200 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 4 weeks. Disp:*2800 mg* Refills:*8* 2. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*4* 3. Ertapenem 1 gram Recon Soln Sig: One (1) gm Intravenous once a day. Disp:*7 gm* Refills:*4* 4. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): [**Month (only) 116**] take Prilosec or generic. 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 7. Spironolactone 25 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 9. 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. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 2436**] Home Care Discharge Diagnosis: end stage liver disease cirrhosis perforated viscus, s/p ex-lap and ileal rxn [**4-1**], abdominal collection drainage Discharge Condition: good Discharge Instructions: Incision Care: Keep clean and dry. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. -Continue VAC care per VNA -Record all drain outputs, and continue stripping drains frequently throughout the day -Please continue drain care as instructed, continue measuring drain amounts, and bring these with you to your follow up appointment. . Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([**11-9**] lbs) until your follow up appointment. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] on Monday at 3:30. Please call his office to confirm at ([**Telephone/Fax (1) 3618**]

[ "789.59", "998.13", "456.8", "V49.83", "567.21", "571.2", "333.94", "569.83" ]

icd9cm

[ [ [] ] ]

[ "54.12", "38.93", "54.91", "45.62", "45.91" ]

icd9pcs

[ [ [] ] ]

7785, 7846

1931, 6390

327, 374

8010, 8016

1447, 1447

9948, 10090

1190, 1195

6526, 7762

7867, 7988

6416, 6503

8040, 8040

8056, 9924

1210, 1428

273, 289

402, 1025

1461, 1908

1047, 1099

1115, 1174