ChanBeDu/relevant_section_length · Datasets at Hugging Face

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47789

Discharge summary

report

Admission Date: [**2189-12-21**] Discharge Date: [**2189-12-26**] Date of Birth: [**2137-2-8**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1505**] Chief Complaint: DOE/CP Major Surgical or Invasive Procedure: CABGx3, LIMA-->LAD, SVG-->OM, SVG-->PLB CPB 81min, cross clamp time 66min History of Present Illness: 52 year old male with HTN and hyperlipidemia, + Stress test [**6-16**], EF 45-50%. He underwent PCI with Cypher stents to his dLAD, mCx, and angioplasty of OM1 on [**2189-7-3**]. He then began experiencing chest pain and dyspnea on exertion at the beginning of [**11-16**] while climbing stairs, radiating down his right arm and up his shoulder, resolved with rest. He underwent cardiac catheterization revealing severe 3vd for which he was referred to cardiac surgery for cardiac revascularization. Past Medical History: HTN, hypercholesteremia, CAD, s/p PCI (cypher stent x3) Social History: tobacco 1PPDx17yrs Family History: father had MI late 60's Physical Exam: 52y/o male NAD BP 116/66 P 64 R 16 SpO2 98% T 98.2 HEENT NCAT O/P clear, sclera anicteric, neck supple Chest CTA, resp unlab, RRR no m/r/g ABD s/nt/nd/bs+ EXT no c/c/e No varicosities Brief Hospital Course: Mr. [**Known lastname 22130**] was admitted to the [**Hospital1 18**] on [**2189-12-21**] for further management of his chest pain and dyspnea. He was taken to the catheterization lab where he was found to have no significant left main coronary artery disease, 60% stenosed left anterior descending, and two discrete 60% stenoses of the Left circumflex artery, 90% stenosis of jailed OM, Right coronary artery diffuse stenosis of 70%left ventricular ejection fraction of 45%. Given the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. He was worked-up in the usual preoperative manner to include hematology consultation for evaluation of vonWillebrand's disease. His work up was negative for the presence of vonWillebrands On [**2189-12-21**], Mr. [**Known lastname 22130**] was taken to the operating room. CABG was performed, LIMA to LAD, and SVG to OM, SVG to PLB. He was on Cardiopulmonary bypass for 81 minutes and cross clamped for 66 minutes. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day (POD) one, he awoke neurologically intact and was extubated. On POD 2 his pressors were weaned and he was transferred to the cardiac stepdown unit. Beta blockade and aspirin were resumed. He was gently diuresed towards his preoperative weight. On POD 2 his chest tubes and epicardial pacing wires were removed on . The physical therapy service was consulted to assist with her postoperative strength and mobility. His oxygen saturations improved to 98% on room air. On POD 3 his hematocrit was 22.2 for which he was transfused one unit PRBC's without complication. His stools were guiac negative. He was cleared by Physical therapy and considered safe for discharge to home. On POD 4 his hematocrit remained stable at 23.4% and he was discharged home on oral iron and vitamin C. He will follow up with his PCP, [**Name10 (NameIs) 2085**], and Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Nadolol 40 qday Lisinopril 10 qday ECASA 81mq qday Lipitor 10mg qday Plavix 75mg qday Verapamil 120mg qday Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Coronary artery disease HTN Hyperlipidemia Discharge Condition: good Discharge Instructions: Shower, wash incisions with mild soap and water and pat dry. No lotions, creams or powders to incisions. Call with fever >101.0, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **], in four weeks [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) **], in [**12-14**] weeks [**Telephone/Fax (1) 30748**] Dr. [**Last Name (STitle) **] in [**12-14**] weeks [**Telephone/Fax (1) 4022**] Completed by:[**2189-12-26**]

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Discharge summary

report

Admission Date: [**2185-10-28**] Discharge Date: [**2185-11-30**] Date of Birth: [**2111-4-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: VATS with decortication of left lung Cardiac catheterization s/p DES and BMS stent placement Chest tube placement s/p removal JP drain placement s/p removal evacuation of L hemothorax History of Present Illness: Mr. [**Known lastname 53917**] is a 74 year-old male with a history of CAD status post 2-vessel CABG in [**2182**], status post porcine AVR for aortic stenosis, ischemic cardiomyopathy with EF 30-35% on last echo, chronic atrial fibrillation now off Coumadin following a GI bleed, and a history of bilateral fibrothoraces status post right thoracotomy and total lung decortication, with persistent left fibrothorax, who presents with increased dyspnea on exertion. Of note, he is scheduled for left-sided decortication on [**11-4**]. He was also recently admitted at [**Hospital3 4107**] for pneumonia, treated with antibiotics. Shortly thereafter, he was admitted with an upper GI bleed, at which time his Coumadin was discontinued ([**2185-9-17**]). An EGD was performed. . Since his last discharge in [**Month (only) **], he notes that he has been experiencing worsening dyspnea on exertion. He was placed on home oxygen about one month ago, titrated from 2L/min to 3L/min over the past week. He reports no dyspnea at rest, and claims that he can only go up/down 3 stairs versus 1 flight 6 weeks ago. He denies orthopnea, and reports stable use of 1 pillow. He also denies PND. + LE edema since discharge, now improved versus a few weeks ago. He reports a mild non-productive chronic cough. No chest pain. No fever or chills. He saw Dr. [**Last Name (STitle) 4469**] on [**10-26**], who increased his Lasix from 20 [**Hospital1 **] to 40 [**Hospital1 **], but he only took one dose prior to presentation. . In ED, T 98.6, HR 86, BP 100/58, RR 22, Sat 98% on 3L NC. A CXR showed possible mild interstitial edema and a known left-sided effusion. A CT chest was subsequently obtained, negative for PE or dissection, but remarkable for a large stable left-sided effusion. He was seen by thoracic surgery, who recommended admission to medicine, with an impression of CHF. Past Medical History: 1. CAD status post MI [**2167**], s/p PTCA [**2167**], s/p 2-vessel CABG in [**12/2182**], with LIMA to LAd, SVG to OM1. Pre-CABG cath with distal 50% LMCA stenosis, proximal LAD 80% stenosis with diffuse mild mid vessel plaquing, distal LAD wrapped around the apex. OM1 40% stenosis at origin and 40% stenosis proximally. LCx had a 70% stenosis after OM1, 80% stenosis before LPL and LPDA and 80% stenosis between LPL and LPDA. RCA proximal 90%. 2. CHF, last echo [**2-/2184**] with EF 30-35%, 1+ AR, 2+ MR. 3. Aortic stenosis status post porcine AVR [**91**]/[**2182**]. 4. Hypertension 5. Hypercholesterolemia 6. Chronic atrial fibrillation, Coumadin D/C'd [**2185-9-17**] [**2-3**] GI bleed. 7. Bilateral fibrothoraces and history of recurrent pleural effusions. Approximately 6 months after CABG/AVR, developed right hemothorax, 6 unit bleed, and thoracentesis for over 3000 cc. Effusion reaccumulated on right, tapped again, complicated by bleeding. Status post right right thoracoscopy with evacuation of pleural clot and small thoracotomy with total decortication of the right lung. Pleural biopsies benign, fluid cytology benign. Has left fibrothorax, which has been followed, but recently plan was to proceed with left-sided decortication. 8. Thrombocytopenia. He reportedly had a BM biopsy (done by Dr. [**First Name (STitle) 4223**], but this report is unavailable. Treated with Prednisone without improvement. Baseline platelets 75-100K. 9. Status post admission for UGI bleed [**9-/2185**], Coumadin D/C'd. Social History: Extensive smoking history, 1 pack a day since age 18, quit in [**2167**]. Mild asbestos exposure while removing a boiler. He worked in the shipyards for 1 year as a carpenter. He lives with his wife. They have 4 children; his daughter is a nurse. Family History: Non contributory Physical Exam: VITALS: T 97.1, BP 125/68, HR 95, RR 20, Sat 94% on 4L. GEN: Obese gentleman, in NAD. HEENT: Anicteric. NECK: Evaluation of JVP limited by body habitus. RESP: Decreased air entry over left hemithorax. Right chest clear to auscultation, with few basilar crackles. Dullness to percussion along entire left hemithorax except for apices. CVS: Irregularly irregular, III/VI SEM heard best at LLSB. GI: Obese abdomen, soft, non-tender. EXT: Trace-1+ bilateral lower extremity edema, dry skin, unable to palpate pulses at DPs bilaterally. Legs/feet are warm. Pertinent Results: [**2185-10-28**] 03:30PM CK(CPK)-40 [**2185-10-28**] 03:30PM CK-MB-NotDone cTropnT-0.01 [**2185-10-28**] 03:30PM IRON-28* [**2185-10-28**] 03:30PM calTIBC-384 FERRITIN-58 TRF-295 [**2185-10-28**] 09:35AM GLUCOSE-95 UREA N-21* CREAT-1.0 SODIUM-143 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-31 ANION GAP-12 [**2185-10-28**] 09:35AM CK(CPK)-35* [**2185-10-28**] 09:35AM CK-MB-NotDone cTropnT-0.02* [**2185-10-28**] 09:35AM MAGNESIUM-2.0 [**2185-10-28**] 09:35AM WBC-4.1 RBC-2.70* HGB-8.7* HCT-25.6* MCV-95 MCH-32.1* MCHC-33.9 RDW-19.1* [**2185-10-28**] 09:35AM PLT SMR-LOW PLT COUNT-106* LPLT-1+ [**2185-10-28**] 09:35AM RET AUT-2.4 [**2185-10-27**] 09:10PM GLUCOSE-99 UREA N-21* CREAT-1.1 SODIUM-138 POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-29 ANION GAP-14 [**2185-10-27**] 09:10PM CK(CPK)-44 [**2185-10-27**] 09:10PM CK-MB-NotDone cTropnT-<0.01 proBNP-7914* [**2185-10-27**] 09:10PM WBC-6.2 RBC-2.87* HGB-9.3* HCT-27.6* MCV-96 MCH-32.3* MCHC-33.6 RDW-19.1* [**2185-10-27**] 09:10PM NEUTS-73* BANDS-3 LYMPHS-10* MONOS-11 EOS-2 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2185-10-27**] 09:10PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ SCHISTOCY-1+ PAPPENHEI-OCCASIONAL [**2185-10-27**] 09:10PM PLT SMR-LOW PLT COUNT-114* [**2185-10-27**] 09:10PM PT-15.0* PTT-31.1 INR(PT)-1.3* . CXR: IMPRESSION: Stable large left pleural effusion with adjacent atelectasis. Question mild superimposed edema versus technique. . ECHO [**10-28**]: Conclusions: The left atrium is markedly dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis. 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. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2184-2-19**], left ventricular systolic function appears similar (was underestimated on prior report). Tricuspid regurgitation is now more prominent. Mitral regurgitation is similar. . CTA Chest: [**10-28**] CT CHEST WITHOUT AND WITH IV CONTRAST: There are multiple mediastinal lymph nodes, some of which are pathologically enlarged, including a prevascular node measuring 12 mm in shortest diameter seen on series 3, image 39, previously 8 mm in diameter. There are enlarged pretracheal nodes that today measure 8 and 9 mm respectively seen on series 3, image 31, previously 6 and 7 mm respectively. There is no hilar or mediastinal lymphadenopathy. There are a few areas of subpleural linear nodular thickening likely representing residual pleural fluid. There is no appreciable effusion on the right, significantly improved compared to prior study. There is a small-to-moderate sized left-sided pleural effusion similar in size tracking laterally and anteriorly along the pleura with associated atelectasis of the left lower lobe. Bilateral pleural calcifications are noted. Limited views of the upper abdomen demonstrate no significant abnormalities aside from extensive calcifications of the celiac axis, splenic artery, and superior mesenteric artery and aorta. Marked aortic and coronary calcifications are again noted alongwith an artificial aortic valve. There are no focal nodular densities or areas of new consolidation. CTA CHEST: There are no filling defects within the pulmonary arterial vasculature. There is no evidence of pulmonary embolism. There are marked aortic calcifications with no evidence of dissection or aneurysmal dilatation. BONE WINDOWS: There are no suspicious lytic or sclerotic bony lesions. IMPRESSION: 1. No evidence of pulmonary embolism or aortic dissection. 2. Worsening mediastinal lymphadenopathy. 3. Stable-appearing left pleural effusion. 4. Improved right pleural effusion compared to [**2184-2-19**] CT chest. 5. Bilateral calcified pleural plaques consistent with prior asbestos exposure. . [**10-31**]: Persantine MIBI No perfusion defects noted; gated portion not completed due to AF. . [**10-31**]: Stress test TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 69 SYMPTOMS: NONE INTERPRETATION: 74 yo man (h/o AVR and CABG in [**2182**]) was referred for a CAD evaluation prior to surgery. The patient was administered 0.142 mg/kg/min of persantine over 4 minutes. No chest, back, neck or arm discomforts were reported during the procedure. No significant ST segment changes were noted from baseline. The rhythm was atrial fibrillation with occasional VPDs noted during the procedure. The hemodynamic response to the persantine infusion was appropriate. Three min post-MIBI, the patient was administered 125 mg aminophylline IV. IMPRESSION: No anginal symptoms or ECG changes from baseline. Nuclear report sent separately. . [**10-31**] CXR PA AND LATERAL CHEST: Compared to [**2185-10-27**] and CTA chest of [**2185-10-28**]. There has been no significant interval change in the moderate-to-large left-sided pleural effusion. Median sternotomy wires midline and intact. No definite effusion on the right. There is probable underlying volume overload/CHF, which also appears not significantly changed. Cardiac prosthetic valve and coronary artery calcification noted. Extensive degenerative change of the thoracic spine without evidence of acute compression fractures. Bilateral calcified pleural plaques are better visualized on the prior chest CT. IMPRESSION: No significant interval change in the large left pleural effusion with associated atelectasis. . [**11-10**] chest CT: IMPRESSION: 1. Large complex left pleural effusion with multiple high attenuation areas consistent with blood/hemorrhage. The effusion is multiloculated and contains multiple small hydropneumothoraces. 2. Chest wall edema and hematoma, presumably due to recent intervention. 3. Left lung is mostly atelectatic with only small aerated portions. Airway narrowing is likely extrinsic as the airways were normal in appearance on recent preprocedure CTA. 4. Interstitial pulmonary edema. 5. Mixed response of lymphadenopathy with increasing left hilar and subcarinal nodes but slight improvement in other mediastinal nodes. 6. Apparent minimal increase in 2 mm diameter peripheral right upper lobe nodule, for which three to six month followup CT is recommended to exclude a small focus of neoplasm. . [**11-11**] ccath: COMMENTS: 1) Resting hemodynamics on the ventilator revealed severely elevated right and left sided filling pressures with severe pulmonary hypertension and borderline low cardiac output on pressor support (neosynephrine) while tachycardic. 2) Pulmonary angiogram revealed no evidence of R or L main pulmonary embolism with normal blush to the right lung parenchyma and a known compressed left lung (large left pleural effusion). 3) Coronary angiography revealed a normal left main, an occluded proximal LAD with a widely patent LIMA to the mid LAD and mild distal LAD disease, a 90% proximal dominant CX lesion with OM1 occluded and OM1 filled via a widely patent vein graft, and the nondominant RCA with a 90% calcified proximal lesion. 4) Successful PTCA and stenting was performed of the proximal CX lesion with a 3.0x15 mm Vision bare metal stent which was postdilated to 3.5 mm with a NC balloon. Final angiography revealed 0% residual stenosis, no dissection, and TIMI 3 flow. (see PTCA comments) 5) Unsuccessful PTCA was performed of the proximal RCA with a 1.5 mm and 2.0 mm balloon due to suboptimal guide support from the anterior origin 80% proximal lesion essentially unchanged, no dissection, and normal flow. Further intervention was not attempted as the vessel was small, nondominant and did not appear to be the culpril lesion. (see PTCA comments) FINAL DIAGNOSIS: 1. Three vessel coronary artery disease with 2 patent grafts. 2. Severe proximal CX and RCA stenosis. 3. Successful stenting of the proximal CX with a bare metal stent. 4. Unsuccessful PTCA of the proximal RCA due to unfavorable PCI characteristics. 5. Severely elevated right and left sided filling pressures. 6. Borderline low cardiac output. 7. No evidence of pulmonary embolus on pulmonary angiogram. . [**11-18**] echo: Conclusions: The right atrium is moderately dilated. The interatrial septum is aneurysmal. A small secundum atrial septal defect is present, with R to left shunt. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the septum. The right ventricular cavity is moderately dilated. There is moderate global right ventricular free wall hypokinesis. There are simple atheroma in the ascending aorta, the aortic arch, and the descending thoracic aorta. A bioprosthetic aortic valve prosthesis is present. The aortic prosthesis leaflets appear to move normally. The transaortic gradient is normal for this prosthesis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. Brief Hospital Course: This is a 74 year-old male with CAD status post 2-vessel CABG, s/p porcine AVR, chronic AF off anticoagulation, ischemic cardiomyopathy and persistent left fibrothorax s/p R decortication who presented with increasing DOE and oxygen requirement. During his hospitalization, the patient was diuresed and then underwent a decortication of his L lung. He subsequently developed a L hemothorax. He was taken back to the OR to evacuate the hemothorax and became hypotensive after induction of anesthesia with propafol. An echo showed RV failure and the patient was taken to the cath lab for presumed PE. A pulmonary angiogram was negative for PE. However, visualization of the coronary arteries showed a 90% ostial stenosis of L Cx and a tight calcific stenosis of the small, non-dominant RCA which underwent POBA. Although the POBA to the RCA lesion was unsuccessful, the L Cx lesion was successfully stented with a BMS. The patient was then started on ASA and plavix and extubated the day after his cath. He then underwent a VATS for evacuation of his L hemothorax on [**11-18**] and was successfully extubated on [**11-19**]. Two chest tubes an a JP drain were placed. Following this procedure, his 02 requirement was 2L NC from 3L NC with improvement in lung sounds. . 1. Dyspnea: His dyspnea was thought to be multifactorial in origin, as he was known to have a left fibrothorax, mild interstitial pulmonary edema. He also has known hx of CAD s/p 2V CABG, and worsening tricuspid regurge, evidence of pulmonary hypertension on echo. CTA was negative for PE. He also had a chronically low Hct, which may be contributing to his dyspnea. He was diuresed aggressively with a goal of 1-2L/day, and was putting out to 40mg Lasix IV. His creatinine and potassium were monitored closely given aggressive diuresis, and were stable during his hospital course. On admission, oxygen requirement was 4L (he was satting mid 90s), and was weaned down to 2L with diuresis. The patient underwent decortication of the left fibrothorax with thoracic surgery on [**11-4**]. After surgery, the patient was found to have increasing respiratory distress and 02 requirement. He was found to have a L hemothorax and was taken to back to the OR for a L VATS with evacuation of the L sided hematoma. The evacuation of the hematoma was postponed due to the developement of hypotension during induction of anesthesia as described above. He eventually underwent evacuation of his L hemothorax on [**11-18**]. Two chest tubes and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] drain were placed for continued drainage. Prior to discharge, the chest tubes were pulled as the patient was no longer dyspneic and sating well. He was initially diuresed with PRN IV lasix doses, then transitioned to qd PO lasix 80mg three days prior to discharge, and to 80mg PO bid the day of discharge. This regimen will have to followed at rehab with alterations as needed for maximal fluid balance, given pt was on an increased dose prior to admit. . 2. CAD s/p CABG: EKG on admission did not show any changes and biomarkers remained stable. Cardiology was consulted for help with management. His lisinopril was increased to 5mg po qd, carvedilol was discontinued per their recommendations and diltiazem was started for rate control. pMIBI for risk stratification prior to surgery made ischemia unlikely as a contributor to his dyspnea. As stated above the pt was taken to cath after becoming hypotensive in the OR prior to a scheduled VATS for evacuation of the L hemothorax. They found a 90% ostial stenosis of L Cx wich was stented with a BMS. He also had an unsuccessful POBA to the proximal RCA. 3. Pump: Hemodynamics during ccath showed CWP 25, RA 27, PA 83/42/61, suggesting BiV failure. CKs were remained flat indicating no acute coronary syndrome. His PA HTN appeared to be longstanding as evidenced on prior echos and was likely related to chronic lung compromise secondary to hemothorax and fibrothorax. The patient was transiently on Dopa post cath for his BiV failure but this was successfully weaned off. An echo done post cath showed an EF 45-50%. He was maintained on ACEI and metoprolol for their cardioprotective effects. . 4. Post OR hypotension: Although it was initially thought that the patient had a large PE while in the OR for evacuation of his L hemothorax, pulmonary angiography found no evidence for this. A 90% ostial stenosis of L Cx was stented, but CKs were flat. Therefore, the hypotensive episode was attributed to a propafol induced drop in pre-load, and subseuqent ischemia in the tight LCx and RCA lesions. DDX for the hypotension also included adrenal insufficiency given his h/o prednisone use. Therefore, the patient was started on stress dose steroids x 5 days. He was then transitioned to PO prednisone (last dose 11/19). Post cath, the patient was maintained on ASA, plavix, lipitor, ACEI and metoprolol. . 5. Chronic atrial fibrillation: Pt has history of GI bleed, and thus all anticoagulation was discontinued. He was rate controlled, with HR in 70s-80s, with diltiazem titration as blood pressure tolerated. Dilt was discontinued prior to arrival to the CCU s/p hypotensive episode in the OR. In the CCU the patient was rate controlled with digoxin and metoprolol. Given the patient's h/o bleeding (GIB and hemothorax) he was not started on heparin or coumadin. The digoxin was eventually weaned off as his EF 45-50%. He was discharged on metoprolol 12.5 [**Hospital1 **]. . 6. Left sided fibrothorax and pleural effusion: The patient underwent a L sided decortication on [**11-4**] with subsequent development of a L hemothorax. His L hemothorax was evacuated on [**11-8**] with placement of two chest tubes and a JP drain. Surgery was following the patient and pulled all drains prior to discharge. . 7. Mediastinal lymphadenopathy: The patient was found to have pathologically enlarged lymph nodes and a BM biopsy concerning for MDS. This will need to be followed up as an outpatient. . 8. Bicytopenia: Anemia and thrombocytopenia. The patient's low Hct was in the setting of multiple procedures and s/p L hemothorax. It was therefore attributed to blood loss. MDS is a also on the differential. He reportedly had a BM biopsy as an out-patient, bm bx results from OSH concerning for MDS. He also had been on prednisone for his TCP with little effect. During this hospitalization, the patient was transfused on one occasion and received FFP prior to his operations. His hct and platelets were monitored closely and repleted as needed. Three days prior to discharge, pt's hematocrit showed a slow downward trend, which over the next two days prompted administration of 2uPRBCs. He was found to be guiac positive but without evidence of visible blood or melanotic stools. Patient recommended to have a repeat hematocrit check 3 days after discharge to assess need for additional transfusions. . 9. Coagulopathy: The patient had an elevated INR throughout his entire admission. This was thought to be due to poor PO intake. He was given Vit K to keep his INR<1.4. He was also encourage to increase his PO intake. Patient should have his vit K intake maximized as an outpt and his coags should be followed given his high levels despite anticoagulation as an inpatient. . 10. ARF: The patient had a baseline Cr 0.9 which increased to 1.2 post cath. This was thought to be due to hypoperfusion from cardiogenic shock in the setting of anemia and the contrast dye load. The patient's renal failure resolved with post cath hydration and remained stable during the rest of his hospitalization. Medications on Admission: Lasix 40 mg PO BID (increased on [**10-26**]) Coreg 6.25 mg PO BID Zoloft 50 mg PO QD Thiamine 100 mg QD Folic acid 1 mg daily Nexium 40 mg daily Lisinopril 2.5 mg daily Colace 100 mg [**Hospital1 **] Crestor 10 mg daily Coumadin stopped [**2185-9-17**] Discharge Medications: 1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze, sob. 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 14. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**5-11**] MLs PO Q6H (every 6 hours) as needed for cough. 15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 17. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 18. Morphine 4 mg/mL Syringe Sig: 2-4 mg Injection Q4H (every 4 hours) as needed. 19. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 20. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 21. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 22. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Furosemide 80 mg Tablet Sig: One (1) Tablet [**Hospital1 **]. Discharge Disposition: Extended Care Facility: [**Hospital1 685**] at [**Doctor Last Name **] hospital Discharge Diagnosis: Primary Diagnosis: Non ST elevation MI Hemothorax Hematuria Mild ARF Transient Hypotension . Secondary Diagnosis: CHF AS s/p AVR HTN Hypercholesterolemia Chronic Atrial fibrillation Thrombocytopenia Discharge Condition: Stable to be discharged to rehab. Discharge Instructions: Please take all medications as prescribed. If you acquire chest pain or shortness of breath that is out of the ordinary for you, please call 911 or come to the emergency department. ***Instructions for rehab: 1. Lasix dose upon DC was 80mg PO qd - please assess daily for adjustment need, maintaining output goals of ~1L or more if needed. 2. Please follow coags, given chronic INR elevation despite no anticoagulation medications. 3. Please check pt's hematocrit within 3-5 days to ensure stabilization, given his need for transfusions as an inpt and guaic (+) stools. Further investigation into his bleeding, possible GI source, may be merited. Please address this issue. Followup Instructions: 1. Please check pt's hct, pt, inr within 3-5 days of discharge. . 2. Please follow up with your primary care doctor 1 week after discharge from the rehab hospital. . 3. Please follow up with your thoracic surgeon, Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**], in 1 to 2 weeks after your discharge from the rehab hospital. Dr.[**Name (NI) 1816**] phone number is [**Telephone/Fax (1) 170**]. . 4. Please also have a hematocrit checked 3 days following discharge from the hospital. While you were in the hospital your hematocrit had been slowly falling. Please check a hematocrit in 3 days to assess if hematocrit has stabilized. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "410.71", "998.12", "518.0", "599.7", "428.0", "286.7", "934.1", "285.1", "414.8", "511.8", "519.19", "427.31", "276.52", "414.01", "584.5", "V45.81", "E912", "238.75", "V42.2", "458.29", "263.9", "416.8", "785.51", "785.6", "518.82", "515" ]

icd9cm

[ [ [] ] ]

[ "99.05", "37.23", "36.06", "88.56", "34.51", "00.66", "00.17", "88.72", "88.43", "96.6", "00.45", "00.41", "33.24", "99.07", "88.57", "99.04", "96.71" ]

icd9pcs

[ [ [] ] ]

24471, 24553

14565, 22189

337, 523

24796, 24832

4856, 13160

25559, 26353

4251, 4269

22493, 24448

24574, 24574

22215, 22470

13177, 14542

24856, 25536

4284, 4837

278, 299

551, 2423

24688, 24775

24593, 24667

2445, 3970

3986, 4235

11,335

171,028

2221

Discharge summary

report

Admission Date: [**2173-2-22**] Discharge Date: [**2173-2-26**] Date of Birth: [**2133-6-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: chest pain, vomiting Major Surgical or Invasive Procedure: cardiac catheterization with stent placement History of Present Illness: 39F with DMI x 9 years, HTN, no known CAD, presented to [**Hospital1 **] [**Location (un) 620**] ED with few episodes nausea and vomiting, and subsequent chest and left arm tightness. She noticed her blood glucose was very high and not responding to insulin for the past 24 hours. She began feeling nauseous and started vomiting early this afternoon. At around 2pm, she developed chest tightness, radiating to her L arm. She was brought in by ambulance to [**Hospital1 **] [**Location (un) 620**] and was found to be in DKA (HCO3 12, AG 20) and was started on an insulin gtt. Her EKG at 4:50pm showed large STE in V4-V6 with smaller STE in V2-3, I, and aVL. She received ASA 325mg, Plavix 600mg, heparin, and integrilin. She was then transferred to [**Hospital1 18**] for emergent cath. . Cath revealed an ulcerated plaque in the prox-mid LAD with distal emboli. She got a bare metal stent to her mid-LAD lesion. Hemodynamics revealed normal R and L filling pressures and a CI of 3.2. EKG postcath had persistent large STE in V4-5, smaller STE in V6, I, II, and aVL. She was admitted to the CCU for further monitoring. . Upon arrival to the CCU, her FS was 230s and she was continued on insulin gtt. She complained of an ache in her L arm. She denied chest pain/tightness, SOB, N/V, lightheadedness. Vitals were stable and EKG showed further improvement in her STEs. Her L arm achiness resolved with SL NTG x 2. Past Medical History: - DM, type I: dx 9y ago, on insulin pump, no known complications, states HgA1C has been 8.4 x 1y, followed at [**Last Name (un) **] - HTN: reports SPBs in high 130s, on quinapril - Major depressive disorder: on bupropion and Trileptal - Cervical disc herniation: C5-6, moderate spinal stenosis, stable - vitamin B12 deficiency: monthly injections Social History: married, 2 children, works at [**Company 2267**], exercises daily, denies tobacco and drugs Family History: no heart disease or DM Physical Exam: vitals- T 97.0, HR 80, BP 154/83, RR 14, O2sat 100% 2LNC General- young woman lying flat in bed, NAD, flat affect HEENT- sclerae anicteric, moist MM, OP clear Neck- no JVD, no carotid bruits Lungs- CTAB anteriorly Heart- RRR, 2/6 SEM heard throughout Abd- soft, NT, ND, NABS Ext- no LE edema, DP/PT pulses 2+ b/l Pertinent Results: OSH ECG: NSR at 86, 6-8 mm STE in V4-6, 1 mm STE in V2-3/I/L/II, TWI V1 ECG p cath: NSR at 76, 4 mm STE in V5-6, <1mm STE I/L/II, TWI V1 ECG in CCU: NSR at 85, persistent 1 mm STEs V4-6. ECG at discharge: persistent 1 mm STEs V4-6. . Cath: 50% ulcerated prox-LAD with distal thrombus, LV apical segment occluded; no RCA disease. S/p bare metal stent to prox-LAD. . Echo ([**2173-2-23**]): LA is normal in size. LV wall thicknesses normal. LV cavity size normal. Mild regional LV systolic dysfunction. There is probable mild regional LV systolic dysfunction with a small area of focal septal apical hypokinesis. Tissue velocity imaging demonstrates an E/e' <8 suggesting normal LV filling pressure. RV chamber size and free wall motion are normal. (There is an area of outpouching in the distal RV wall (just proximal to the apex) without any definite associated wall motion abnormality; this may represent a normal variant.) The aortic root is mildly dilated. 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. Estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . Echo ([**2173-2-25**]): unchanged compared with prior study [**2173-2-23**] except focal dyskinesis involving the very distal apex is now present. . Chest X Ray: no acute process . Glucose: initially in 200s but trended down. . Bicarbonate: initially 14 with anion gap but corrected to normal within 12 hours on insulin drip. . Peak CK 1063; peak tropT 2.24. Brief Hospital Course: A/P: 39F with diabetes mellitus type 1 x 9 years and mild HTN who presented to [**Hospital3 628**] with nausea, vomiting, and chest discomfort, found to be in diabetic ketoacidosis and to have large lateral ST elevations on ECG. Brought emergently to [**Hospital1 18**] cath lab s/p stent to mid-LAD. STEMI with peak CK 1063. . # CAD: admitted with an ST elevation myocardial infarction, s/p bare metal stent to mid-LAD. Risk factors include suboptimally managed DM1 x 9 years (HbA1c in mid-8% range), mild HTN, mild hyperlipidemia with (LDL 108, TG ~90, HDL ~70 in [**10-26**]). No tobacco, no family Hx early MI. Peak CK 1063. Echo on [**2173-2-23**] revealed preserved ejection fraction and no anterior wall dyskinesis. ST elevations slowly improved post-cath but persisted even at discharge. Repeat echo on [**2173-2-25**] revealed small area of dyskinesis at distal apex, which likely accounts for patient's persistent ST changes. Initially with occasional PVCs on telemetry, likely from reperfusion. Patient was started and continued on ASA, Plavix, atorvastatin, and beta blocker (metoprolol then atenolol). Pt was on Integrilin x 18h peri-cath. Patient's [**Year (4 digits) 3782**] ACE-I (quinapril) was increased to 10 daily. Plan outpatient follow-up with Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] (since patient lives in [**Location 620**]). . # Diabetic Ketoacidosis: pt initially with FS glucose in 300-400 range at [**Location (un) 620**], with low bicarbonate, and anion gap, all consistent with DKA. Pt was continued on an insulin drip which was slowly weaned as her glucose and bicarbonate improved. Pt was also supported with IV fluids and potassium repletion as needed. Pt was then transitioned to her insulin pump. [**Last Name (un) **] was consulted (because she is followed at [**Last Name (un) **] as an outpatient). Precipitant of pt's DKA was likely her acute myocardial infarction. Basic infectious work-up was normal, including chest x-ray and urinalysis. No other localizing symptoms. Plan close [**First Name9 (NamePattern2) 3782**] [**Last Name (un) **] follow-up. . # HTN: ACE-I and beta blocker were titrated to good BP control. . # History of depression: clinically stable. Continued on outpatient Wellbutrin and trileptal. . # FEN: Maintained on a cardiac, diabetic diet. Electrolytes were repleted as needed. . # Prophylaxis: pt was maintained on SC heparin for DVT prophylaxis and was eating well so was not on PPI. . # Code status: FULL CODE. Medications on Admission: Insulin (Novalog, pump) Quinapril 5mg qd Wellbutrin 150mg [**Hospital1 **] Trileptal 300mg qd vitamin B12 IM qmonth Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed): Take 1 tab for chest pain every 15 minutes x 3. After the 3rd tab, seek medical attention immediately. Disp:*qs Tablet, Sublingual(s)* Refills:*2* 5. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Insulin pump: using as directed by [**Last Name (un) **] doctor. Discharge Disposition: Home Discharge Diagnosis: ST elevation MI Diabetic ketoacidosis Hypertension Discharge Condition: good Discharge Instructions: Please take all of your medications as prescribed. If you experience chest pain, shortness of breath, vomiting, or other concerning symptoms, please call your doctor or go to the ER. Followup Instructions: 1) Cardiology: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], [**2173-3-31**] at 9:45am, 148 Chestnut, ([**Telephone/Fax (1) 11814**]. 2) Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 11815**] ([**2173**], to schedule a follow up within the next 1-2 weeks. If you are looking for a new PCP who is located closer to you, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4390**] ([**Telephone/Fax (1) 11816**] works in [**Location (un) 620**]. 3) [**Last Name (un) **]: Please call Dr. [**Last Name (STitle) 10088**] [**Telephone/Fax (1) 11817**] to schedule a follow-up appointment. Completed by:[**2173-2-26**]

[ "266.2", "786.52", "401.9", "296.20", "V45.85", "307.50", "410.11", "V70.7", "250.11", "414.01" ]

icd9cm

[ [ [] ] ]

[ "99.20", "00.40", "37.23", "88.56", "00.66", "36.06", "00.45" ]

icd9pcs

[ [ [] ] ]

8005, 8011

4333, 6846

335, 381

8106, 8113

2704, 2895

8345, 9079

2332, 2356

7012, 7982

8032, 8085

6872, 6989

8137, 8322

2371, 2685

2909, 4310

275, 297

409, 1836

1858, 2206

2222, 2316

29,600

132,773

29054

Discharge summary

report

Admission Date: [**2170-7-12**] Discharge Date: [**2170-7-18**] Date of Birth: [**2117-1-8**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Atorvastatin / Protamine Attending:[**First Name3 (LF) 165**] Chief Complaint: Transfer from OSH for cath SOB, Chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization [**2170-7-12**] off-pump CABGx2 (LIMA>LAD, SVG>Diag) [**2170-7-13**] History of Present Illness: 53 y/o M with T2DM, hyperlipidemia, hypertension and known CAD, s/p 3 x 18mm Cypher stent to D1 and 2.5 x 18 mm Cypher stent to OM1 in 7/[**2168**]. He also is status post shoulder surgery recently complicated by a DVT in the right lower leg (3/[**2170**]). He was transferred here to [**Hospital1 18**] on [**2170-5-15**] after being admitted to [**Hospital1 **] [**Location (un) 620**] for chest pain and dyspnea. He ruled out for a MI but underwent cardiac catheterization where he was found to have 95% lesion in the D2, 60% mid LAD lesion, 60% prox LAD, and a 45% proximal RCA. He subsequently underwent successful, complicated Cullotte stenting of the LAD and D2. It was suggested that because it was such a complicated stenting that a relook in [**3-27**] months would not be unreasonable. He was admitted to [**Hospital1 **] [**Location (un) 620**] on [**2170-7-9**] with complaints of shortness of breath and chest pain for three days. He also reported vomiting in the am on occasion. He reports being symptom free for ~3 months after prior cath, has been having [**8-2**] crushing chest pain with walking [**1-24**] block (could walk 3.5 miles previously) associated with SOB. Has also been having pain now with rest. Subsides in 15 minutes without intervention. + PND, + chronic LE swelling, no orthopnea. At [**Hospital1 **] Neeham he had an ultrasound of his leg but recurrent DVT was not seen. He ruled out for a MI. He underwent echocardiogram which demonstrated an EF of 55-60%, a mildly dilated LA, normal sized LV with nl function, normal valves. He had one episode of CP 2 days prior to transfer treated successfully with 1Sl NTG. He is transferred to [**Hospital1 18**] transferred for a relook cardiac catheterization. This patient is noted by his nurse to be intermittently incontinent for no apparent reason. He is legally blind and lives alone. Apparently on discharge in [**2170-4-24**] he was extremely resistent to having even one visit by a visiting nurse. He will need to be transitioned to coumadin and may benefit from social service referral to encourage home service involvement. Past Medical History: CAD S/P MI in [**2167**] S/P DES to OM2, and D1 in [**2168**] Diabetes Diabetic retinopthy (legally blind) Diabetic neuropathy HTN Hyperlipidemia Sleep apnea Appendectomy S/P rotator cuff surgery [**2170-4-12**] Right leg DVT Severe left ventricular diastolic heart failure Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse, drinks 1-2 beers per week. Pt lives alone has home health aide. Walks with walking cane. Family History: There is no family history of premature coronary artery disease or sudden death. Diabetes mellitus in family. Physical Exam: VS 235lbs 118/72 61 98% RA Gen: Obese man in NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Legally blind, conjunctiva injected, face flushed Neck: Supple, thick neck, unable to appreciate neck veins. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Distant heart sounds. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Obese. Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: Trace non-pitting ankle edema. Right groin site c/d/i, no bruit, no hematoma. Left foot cool. Decreased sensation b/l. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Tatoo left forearm. Pulses: Right: DP 1+ PT dopplerable Left: DP dopplerable PT dopplerable Pertinent Results: [**2170-7-18**] 05:23AM BLOOD Hct-24.0* [**2170-7-17**] 10:51AM BLOOD Hct-22.1* [**2170-7-17**] 05:35AM BLOOD WBC-13.8* RBC-2.53* Hgb-8.0* Hct-23.2* MCV-92 MCH-31.7 MCHC-34.6 RDW-15.1 Plt Ct-303 [**2170-7-16**] 01:44AM BLOOD WBC-17.3* RBC-2.92* Hgb-9.0* Hct-27.2* MCV-93 MCH-30.7 MCHC-32.9 RDW-15.2 Plt Ct-245 [**2170-7-18**] 05:23AM BLOOD PT-13.4 INR(PT)-1.2* [**2170-7-17**] 10:51AM BLOOD PT-12.8 INR(PT)-1.1 [**2170-7-14**] 02:43AM BLOOD PT-14.1* PTT-26.8 INR(PT)-1.2* [**2170-7-18**] 05:23AM BLOOD K-4.9 [**2170-7-17**] 05:35AM BLOOD K-4.7 [**2170-7-16**] 01:44AM BLOOD Glucose-257* UreaN-28* Creat-1.1 Na-135 K-5.2* Cl-100 HCO3-28 AnGap-12 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 69993**] (Complete) Done [**2170-7-13**] at 10:54:44 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2117-1-8**] Age (years): 53 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Chest pain. Coronary artery disease. Hypertension. ICD-9 Codes: 786.51, 440.0 Test Information Date/Time: [**2170-7-13**] at 10:54 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW4-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Findings LEFT ATRIUM: Normal LA size. No spontaneous echo contrast is seen in the LAA. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Normal LV cavity size. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mildly thickened mitral valve leaflets. No mass or vegetation on mitral valve. Mild mitral annular calcification. No MS. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Suboptimal image quality. Results were personally reviewed with the MD caring for the patient. Conclusions Off_Pump CABG:1. The left atrium is normal in size. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 7. The mitral valve appears structurally normal with trivial mitral regurgitation. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Physiologic mitral regurgitation is seen (within normal limits). Dr. [**Last Name (STitle) **] was notified in person of the results. 8. Transient RWMA seen with LAD, OM occlusion with acceptable bp, SvO2, and CO throughout. Radiology Report CHEST (PA & LAT) Study Date of [**2170-7-17**] 9:12 AM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2170-7-17**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 69994**] Reason: re-eval left apical ptx [**Hospital 93**] MEDICAL CONDITION: 53 year old man with REASON FOR THIS EXAMINATION: re-eval left apical ptx Final Report CLINICAL HISTORY: 53-year-old male with left apical pneumothorax. AP & lateral chest radiograph compared to [**2170-7-16**] shows small left apical pneumothorax minimally decreased in size compared to prior exam. The remainder of the exam is essentially unchanged. Again seen is stable moderate cardiomegaly and normal postoperative widening of the mediastinum which is decreased in size compared to the immediate postoperative radiographs. Small left pleural effusion and retrocardiac atelectasis is stable. Tip of a right internal jugular central venous line overlies the distal SVC. Note is made of normal retrosternal fluid collection with tiny locule of air, unchanged. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: TUE [**2170-7-17**] 10:37 PM Brief Hospital Course: Cath here with near occlusion of stents. Csurg was consulted and he underwent preoperative workup. He was taken to the operating room on [**7-13**] where he underwent a CABG x 3. He was transferred to the ICU in stable condition. Postoperatively he was noted to have an allergic reaction, with total baody rash and hypotension which was treated with benadryl and pepcid IV, and resolved. Unsure of cause but platelets had just completed and protamine infusing when reaction noted, blood bank notified and worked up for platelet reaction. Anesthesia has recommended outpatient allergy/skin testing to potentially confirm protamine reaction. Additional left chest tube was placed for a large left pleural effusion. He was extubated on POD #1. He was transferred to the floor on POD #2. Chest tubes and wires were pulled per protocol. Post pull chest xray showed a small left apical pneumothorax which remained stable on subsequent chest xray. He was restarted on coumadin with a lovenox bridge for history of DVT. His vein harvest leg became tender and he was started on a 10 day course of doxycycline. He should have an ACE wrap on his left leg from foot to groin. Plavix was dc'd given that he was on coumadin and aspirin. He was ready for discharge to rehab on POD #5. Medications on Admission: Oxycontin SR 10 mg PO Q6H PRN pain Novalog SS Neurontin 300 mg PO BID Lasix 80 mg PO daily Colace Plavix 75 mg PO daily Lisinopril 40 mg PO daily Coumadin 6 mg PO daily ASA 325 mg PO daily Coreg 12.5 mg PO BID Zetia 10 mg PO daily 70/30 Insulin Metformin 1000mg [**Hospital1 **] Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg Subcutaneous Q12H (every 12 hours): please check INR daily, discontinue lovenox when INR 2.0 or greater. 8. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 10 days. Capsule(s) 9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Travatan 0.004 % Drops Sig: One (1) gtt Ophthalmic daily (). 11. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: Fifty (50) units Subcutaneous with breakfast. 16. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: Fifty (50) units Subcutaneous with dinner. 17. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. 18. Insulin Lispro 100 unit/mL Solution Sig: sliding scale units Subcutaneous four times a day. 19. Coumadin 6 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. Discharge Disposition: Extended Care Facility: [**Location (un) **] health care center Discharge Diagnosis: CAD s/p CABG PMH: Chronic diastolic heart failure, HTN, Hyperlipidemia CAD S/P MI in [**2167**] S/P DES to OM2, and D1 in [**2168**], Diabetes, Diabetic retinopthy (legally blind), Diabetic neuropathy, Sleep apnea, Right leg DVT PSH: Appendectomy [**8-/2169**], S/P rotator cuff surgery [**2170-4-12**], RLE vein stripping 15 yrs ago, umbilical hernia repair Discharge Condition: Good. Discharge Instructions: You may have had an allergic reaction to a medication called protamine. Please follow up with your primary care doctor for further testing. Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) 30197**] [**Telephone/Fax (1) 19980**] 2 weeks Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 4105**] 2 weeks Dr. [**First Name (STitle) **] 4 weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2170-7-18**]

[ "V58.61", "V14.0", "780.57", "518.0", "693.0", "512.1", "250.50", "427.89", "412", "511.9", "401.9", "458.29", "369.4", "414.01", "411.1", "428.0", "V12.51", "428.32", "E934.5", "272.4", "250.60", "357.2", "362.01", "999.8" ]

icd9cm

[ [ [] ] ]

[ "36.15", "88.56", "34.04", "99.05", "88.72", "36.11", "37.22" ]

icd9pcs

[ [ [] ] ]

13542, 13608

10215, 11488

346, 441

14011, 14019

4268, 9104

14472, 14773

3172, 3283

11818, 13519

9144, 9165

13629, 13990

11514, 11795

14043, 14449

3298, 4249

264, 308

9197, 10192

469, 2584

2606, 2942

2958, 3156

52,245

158,845

37942+37943

Discharge summary

report+report

Admission Date: [**2156-8-13**] Discharge Date: [**2156-8-16**] Date of Birth: [**2091-9-2**] Sex: M Service: MEDICINE Allergies: Iodine / Shellfish Derived Attending:[**First Name3 (LF) 1990**] Chief Complaint: Melena Major Surgical or Invasive Procedure: ERCP - [**2156-8-11**] History of Present Illness: Mr. [**Known lastname 30380**] is a 64 year old male with a history of choledocholithiasis s/p ERCP with stone removal [**2156-8-9**] and laparascopic cholecystectomy [**2156-8-11**] who presents from home with melena and two episodes of syncope. He was discharged from the hospital one day prior to this presentation and at that time was feeling well. He awoke at 4 AM and went to the bathroom and had an episode of black diarrhea. He noted that he felt lightheaded, dizzy and was having some cold sweats. He went back to bed and woke again a few hours later at approximately 7 AM and had a second episode of melena. When he went to stand up he again felt dizzy and syncopized. His wife heard him fall and found him with his head on the ground face down. He was not unconscious and when he tried to stand he fell again. His wife called EMS who initially brought him to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] emergency room. . On arrival to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] his initial vitals were T: 96.9 BP: 88/66 HR: 75 O2: 95% on RA. He was noted to be pale and diaphoretic. He had two 18 g peripheral IVs placed and received one unit of PRBCs and two liters of normal saline. Hematocrit on arrival was 28.4 (from 33 on [**8-11**]). BUN was 28 with a creatinine of 1.0. He was transferred here as this was where his recent ERCP was performed. In the ED, initial vs were: T: 98.1 BP: 116/78 P: 68 R: 20 O2: 97% on RA. In the emergency room he had a CT of the c-spine which was negative for fracture and a CT of the head which was negative for hemorrhage. . The patient was taken immediately from the emergency room to the ERCP suite. Prior to the procedure he received one dose of ampicillin 2 gram IV, and gentamicin 60 mg IV x 1. He underwent ERCP which showed no active bleeding at the site of previous sphincterotomy. [**Hospital1 **]-CAP was performed to the site of sphincterotomy. His blood pressure was stable in the 100s to 120s systolic throughout the procedure. He was transferred to the [**Hospital Unit Name 153**] post-procedure for further care. . On arrival to the ICU he has no complaints. He reports feeling groggy from the procedure but otherwise his lightheadedness, dizziness, chest pain, difficulty breathing, nausea, vomiting, abdominal pain, constipation, leg pain or swelling. He denies fevers or chills but has felt diaphoretic today. No further bowel movements since transfer. He does not otherwise have a history of gastrointestinal bleeding or easy bruising. All other review of systems negative in detail. Past Medical History: Choledocholithiasis s/p ERCP with sphincterotomy [**2156-8-9**] s/p laparoscopic cholecystectomy [**2156-8-11**] Double hernia repair s/p knee replacement Arthritis Hypercholestolemia Social History: Sales clerk at a paint store. No smoking, social alcohol, no illicits. Family History: Father had cancer, unknown type. History of hypertension and stomach problems. Physical Exam: Physical Exam on admission to ICU: Vitals: T: 98.1 BP: 107/79 HR: 74 RR: 20 O2: 97% on 2L 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, laparoscopic cholecystecomy sites well healing without signs of infection GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: CBC [**2156-8-14**] 07:51AM BLOOD Hct-28.7* [**2156-8-14**] 02:00AM BLOOD WBC-12.0* RBC-2.94* Hgb-9.9* Hct-28.1* MCV-96 MCH-33.5* MCHC-35.1* RDW-14.8 Plt Ct-242 [**2156-8-13**] 07:22PM BLOOD Hct-29.1* [**2156-8-13**] 05:15PM BLOOD Hct-31.3* [**2156-8-13**] 12:20PM BLOOD WBC-11.6* RBC-3.37* Hgb-10.4* Hct-31.3* MCV-93 MCH-30.8 MCHC-33.1 RDW-14.0 Plt Ct-288 Coags [**2156-8-14**] 02:00AM BLOOD PT-13.3 PTT-22.7 INR(PT)-1.1 [**2156-8-13**] 12:20PM BLOOD PT-12.9 PTT-20.7* INR(PT)-1.1 Chemistry [**2156-8-14**] 02:00AM BLOOD Glucose-94 UreaN-28* Creat-0.8 Na-141 K-3.9 Cl-109* HCO3-23 AnGap-13 [**2156-8-13**] 12:20PM BLOOD Glucose-115* UreaN-30* Creat-0.7 Na-141 K-4.5 Cl-111* HCO3-21* AnGap-14 LFTs [**2156-8-13**] 12:20PM BLOOD ALT-52* AST-29 AlkPhos-172* Amylase-27 TotBili-1.0 CT Head ([**8-13**]) FINDINGS: There is no evidence of intracranial hemorrhage, mass effect, or [**Doctor Last Name 352**]-white matter differentiation abnormality. Bilateral periventricular white matter hypodensities especially within bilateral frontal lobes are likely related to chronic microvascular ischemic changes. The ventricles and extra-axial spaces are grossly unremarkable and appropriate for age. There is no depressed skull fracture. There are mucosal retention cysts within the right maxillary sinus. There is right-sided [**Doctor Last Name 13856**] bullosa. There is mild right nasal septal deviation with right-sided sparing. The visualized mastoid air cells are clear. The visualized globes are unremarkable. IMPRESSION: No acute intracranial abnormality. CT C-Spine ([**8-13**]) FINDINGS: There is no fracture. The prevertebral soft tissue is normal. There is grade 1 anterolisthesis of C3 upon C4 with mild posterior disc bulge causing mild narrowing of the spinal canal at this level. There is disc space narrowing and posterior disc osteophyte formation at C5-C6 causing mild spinal canal stenosis. There is facet joint hypertrophy and uncovertebral spurring causing mild-moderate right neural foraminal narrowing at C3- C4 and also facet joint hypertrophy and uncovertebral spurring causing mild-moderate right neural foraminal narrowing at C5-C6. Vertebral body heights are maintained. IMPRESSION: No fracture of the cervical spine. Mild grade I anterolisthesis of C3 upon C4. While this finding may be degenerative in etiology, an MRI is recommended for evaluation of ligamentous and spinal cord injury. Multilevel degenerative changes with mild-moderate central canal narrowing and right neural foraminal narrowing at C3-C4 and C5-C6. ERCP ([**8-13**]) - Evidence of a previous sphincterotomy was noted in the major papilla. There was a small amount of biliary sludge on the papilla which was cleared. No fresh or old blood seen. There was bile coming out of the bile duct. Cannulation of the biliary duct was successful and deep with a balloon catheter over the existing guidewire. Contrast medium was injected resulting in complete opacification. The common bile duct, common hepatic duct, right and left hepatic ducts were filled with contrast and well visualized. The course and caliber of the structures are normal with no evidence of extrinsic compression, no ductal abnormalities, and no filling defects A balloon sweep was performed which did not show any blood or stones. Since he may have bleed from the site of his sphinterotomy, [**Hospital1 **]-CAP electrocautery was applied successfully at the apex of the previous sphinterotomy site. Brief Hospital Course: 64 year old man with PMH of choledocholithiasis s/p ERCP on [**2156-8-9**] with sphincterotomy and extraction of 3 stones followed by laparoscopic cholecystectomy on [**2156-8-11**] who presented with one day of melena and syncope x 2. He underwent repeat ERCP but no active bleeding was seen from the sphincterotomy site. He was admitted to the ICU but otherwise he had no further lightheartedness or dizziness. He had no chest pain, difficulty breathing, nausea, vomiting, or abdominal pain. He did not have a history of gastrointestinal bleeding but had pre-cancerours polyp on the most recent colonoscopy. The most likely etiology of bleeding was the site of previous sphincterotomy although the repeat ERCP was without active bleeding. Formal upper endoscopy not performed during this exam but no gross blood was noted in the stomach. Hematocrit was followed in the ICU and on the medical floor; HCT remained stable and he was treated conservatively. He was discharged to home with follow up with GI in a week; he was prescribed an iron supplement at the recommendation of the GI team. Medications on Admission: Aspirin 81 mg (on hold) Saw Pallmetto daily Multivitamin Fish Oil [**Hospital1 **] Vitamin D Vitamin E Garlic Selenium Percocet PRN Discharge Medications: medications above resumed. The following prescribed: 1. Niferex 60 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stools. Disp:*60 Capsule(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Blood loss anemia Gastrointestinal bleeding from sphincterotomy Discharge Condition: No bleeding. AF and VSS. Ambulatory. Tolerating PO intake. Discharge Instructions: Please report to your doctor if you develop recurrent bleeding. Please take iron supplements with laxatives and [**Location (un) 2452**] juice. Do not take any aspirin. Discuss with your primary doctor when you can resume taking this safely. You may resume your other home medications. We have prescribed only the three medications described below to add to your regimen. Followup Instructions: LITTLE,[**Doctor Last Name **] C. [**Telephone/Fax (1) 84800**] [**Doctor First Name **] [**Doctor Last Name **] (GI/[**Hospital **] clinic) - within one week. Call for appointment at: ([**Telephone/Fax (1) 31331**] Admission Date: [**2156-8-17**] Discharge Date: [**2156-8-22**] Date of Birth: [**2091-9-2**] Sex: M Service: MEDICINE Allergies: Iodine / Shellfish Derived Attending:[**First Name3 (LF) 1990**] Chief Complaint: Black stools Major Surgical or Invasive Procedure: None History of Present Illness: Time of encounter: 11:20pm 64yo male with history of recent ERCP with stone retrieval complicated by presumed bleeding at sphincterotomy site and laparascopic cholecystectomy on [**8-11**] was admitted from the ED with recurrent black stools. Patient has had a complicated two weeks with the following events: - [**2156-8-9**] ERCP with stone retrieval and sphincterotomy - [**2156-8-11**] Laparoscopic Cholecystectomy - [**2156-8-13**] returned with melena and syncope, taken to ERCP immediately. No immediate source of bleeding seen, although BiCap performed at site of sphincterotomy. Patient was discharged from [**Hospital1 18**] on [**2156-8-16**]. Then on this day of admission, patient felt "[**Doctor Last Name **]" in the middle of his abdomen and shortly thereafter had small black stools surrounded by bright red blood. He was taken to an OSH ED and was then transferred to [**Hospital1 18**] for further evaluation. Upon arrival to the ED, temp 98.6, HR 76, BP 112/71, RR 16, and pulse ox 98% on room air. His exam and labs were generally unremarkable. ERCP was contact[**Name (NI) **] in the [**Name (NI) **] and recommended EGD and colonoscopy tomorrow. He received pantoprazole 40mg IV x 1. Review of systems: (+) Per HPI. black stools (-) Denies pain, fever, chills, night sweats, weight loss, headache, sinus tenderness, rhinorrhea, congestion, cough, shortness of breath, chest pain or tightness, palpitations, nausea, vomiting, constipation, abdominal pain, change in bladder habits, dysuria, arthralgias, or myalgias. Past Medical History: 1. Choledocholithiasis s/p ERCP with sphincterotomy [**2156-8-9**] 2. s/p laparoscopic cholecystectomy [**2156-8-11**] 3. Double hernia repair 4. s/p knee replacement 5. Arthritis 6. Hypercholesterolemia Social History: Home: Lives with wife Occupation: [**Name2 (NI) 19205**] clerk at a paint store. Tobacco: Denies EtOH: Social Drugs: Denies Family History: Father - died with cancer of unknown type Mother - 87yo - hypertension Physical Exam: T 98.7 / BP 122/60 / HR 76 / RR 16 / Pulse ox 98% RA Gen: no acute distress, lying comfortably in bed, speaking clearly HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM. well-healing lap ccy scars EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength throughout. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2156-8-16**] - Discharge labs WBC 8.8 / Hct 26.8 / Plt 297 [**2156-8-17**] - 4:48pm Na 138 / K 4.7 / Cl 104 / CO2 26 / BUN 16 / Cr .9 / BG 94 WBC 8.3 / Hct 29.1 / Plt 372 N 59 / L 33 / M 5 / E 3 / B 1 INR 1.1 / PTT 23.1 OSH LABS: [**2156-8-17**] Na 137 / K 4 / Cl 102 / CO2 25 / BUN 14 / Cr 1.1 /BG 100 Ca 9 / TP 6.4 / Alb 3 / TB .7 / Alk Phos 122 / AST 23 / ALT 32 / Lipase 60 WBC 8.2 / Hct 29.5 / Plt 321 N 54 / L 33 / M 9.4 / E 3 / B 1 STUDIES: ECG [**2156-8-17**] - sinus rhythm at ~75bpm, normal axis, no acute ST changes ERCP [**2156-8-13**] 1. Evidence of a previous sphincterotomy was noted in the major papilla. 2. There was a small amount of biliary sludge on the papilla which was cleared. No fresh or old blood seen. There was bile coming out of the bile duct. 3. Cannulation of the biliary duct was successful and deep with a balloon catheter over the existing guidewire. Contrast medium was injected resulting in complete opacification. 4. The common bile duct, common hepatic duct, right and left hepatic ducts were filled with contrast and well visualized. The course and caliber of the structures are normal with no evidence of extrinsic compression, no ductal abnormalities, and no filling defects 5. A balloon sweep was performed which did not show any blood or stones. Since he may have bleed from the site of his sphinterotomy, [**Hospital1 **]-CAP electrocautery was applied successfully at the apex of the previous sphinterotomy site. . Colonoscopy ([**8-19**]) Impression: Diverticulosis of the sigmoid colon and descending colon Normal mucosa in the whole colon Otherwise normal colonoscopy to cecum . EGD ([**8-19**]) Mucosa: Normal mucosa was noted in the whole duodenum. The ampulla was examined with a duodenoscope. This was located next to a diverticulum and showed changes of previous sphincterotomy. No fresh or old blood was noted. No ulcers were noted. Impression: Normal EGD to third part of the duodenum Brief Hospital Course: #GIB: Patient underwent EGD and Colonoscopy for further evaluation of potential source of GIB. Both were unremarkable (reports above). Colonoscopy did note finding of moderate diverticulosis. Patient also underwent upper GI series with SBFT to rule out potential pathology, including stricture of the mid small bowel, which was also unrevealing. It was felt the noted melanotic stool prior to this admission was most likely secondary to antecedent, resolving post-procedure GIB. He will follow-up with the GI service with consideration for a capsule study to rule out potential small bowel sources of bleed (i.e. AVM). The patient was continued on a proton-pump inhibitor 40mg po qd. Iron studies were sent and were within normal limits. The patient's hematocrit remained stable during the course of admission (Hct of 29 on admission and 31.5 on discharge). He remained hemodynamically stable during this hospitalization. He has follow-up appointment scheduled with Dr. [**First Name (STitle) **] [**Name (STitle) **] two weeks following discharge. Patient was instructed to return to the ED/Hospital if he noted recurrence of melanotic, blood-streaked stool. . The patient was advised to continue to hold ASA pending further evaluation of GIB. Given history of hypercholesterolemia, we have deferred repeat lipid chemistries to the out-patient setting. The risk-benfit ratio of ASA as primary prevention, in the setting of known GIB, will be dictated by long-term CAD risk (ACC/AHA threshold is >10% over 10 years or USPSTF >3% over 5 years). If ASA is resumed, risk of recurrent upper GIB is substantially attenuated in the setting of concurrent PPI. Of note, there remains no categorical evidence of upper GIB (EGD was unremarkable). On discharge, patient remained on daily PPI without ASA. Decisions re: further management are being deferred to primary GI and PCP pending further evaluation. Medications on Admission: 1. Niferex 60 mg PO daily 2. Colace 100 mg PO bid 3. Pantoprazole 40 mg PO daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Gastrointestinal Bleed Secondary Diagnoses: Hypercholesterolemia Discharge Condition: Stable Discharge Instructions: You were admitted to the [**Hospital 18**] hospital for further evaluation of melanotic/black stool. You recieved a Colonoscopy and upper endoscopy to visualize your large and small bowel. These were normal and found no evidence of bleeding. You also had another procedure to evaluate your bowel (small bowel follow through) which was also normal. Your red blood cell count was stable during your admission. It was felt that the black stool you mentioned was likely related to the bleeding episode you experienced the week prior to this admission. . No new medications were started during this admission. Please continue to hold your home Aspirin until you see Dr. [**Last Name (STitle) **] in clinic (see appointment below). . If you experience recurrent dark/black stool, bloody stool, worsening diarhea, abdominal pain, dizziness, chest palpitations, chest pain, shortness of breath, or any symptom that concerns you please contact your primary care physician or return to the hospital. Followup Instructions: Please follow-up with your primary care physician. [**Name10 (NameIs) **] have an appointment with Dr. [**Last Name (STitle) **] [**8-27**] at 3:15PM. You have an appointment scheduled with the GI/ERCP service (Dr. [**First Name (STitle) 1948**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]) on [**2156-9-3**] at 4:10PM. His office phone number is [**Telephone/Fax (1) 463**].

[ "285.1", "E878.8", "272.0", "578.1", "998.11", "V12.72", "780.2", "562.10", "V45.89", "576.8", "716.90" ]

icd9cm

[ [ [] ] ]

[ "45.23", "51.85", "87.54", "45.13" ]

icd9pcs

[ [ [] ] ]

17140, 17146

14962, 16859

10364, 10371

17274, 17283

12991, 14939

18321, 18720

12328, 12401

16992, 17117

17167, 17167

16885, 16967

17307, 18298

12416, 12972

17230, 17253

11629, 11943

10312, 10326

10399, 11610

17186, 17209

11965, 12171

12187, 12312

1,995

144,420

7250

Discharge summary

report

Admission Date: [**2151-10-13**] Discharge Date: [**2151-10-19**] Date of Birth: [**2078-5-30**] Sex: F Service: SURGERY Allergies: Glucophage / Morphine / Codeine Attending:[**First Name3 (LF) 1234**] Chief Complaint: [**First Name3 (LF) **] claudication Major Surgical or Invasive Procedure: Femoral / popliteal PTFE graft with distal PTFE to Posterior Tibial Bypass vein graft History of Present Illness: Pt c/o several weeks duration of worsening pain with walking progressing to claudication. Came to hospital for evaluation and surgical correction of [**First Name3 (LF) **] vascualr disease. Past Medical History: DMII Hypercholesterolemia Pancytopenia (unclear etiology, has appointment with Dr.[**Last Name (STitle) **] [**1-21**]). HTN CEA X 2 (bilaterally) Social History: >20 years heavy alcohol, quit [**2128**]. 40 pack year tobacco, quit 8 years ago lives with daughter Family History: Non-contributory Physical Exam: HEENT: Left swollen parotid gland c/w parotitis. carotid pulses +2 b/l, no bruits. Surgical scar on L neck c/w hx of L CEA. Otherwise normal exam CV: RRR no MRG RESP: some mild crackles on LLLF, otherwise CTA b/l no RRW ABD: soft, NT, ND no masses, +BS, no aortic pulsation palpable, no bruits EXT: RLE +2 edema, palpable pulses Fem, [**Doctor Last Name **], DP, dopplerable PT [**Name (NI) **]: +2 edema, surgical scar c/w recent BPG. Staples intact, serous drainage from wound. Palpable femoral and popliteal pulses, dopplerable DP, palpable PT. Pertinent Results: [**2151-10-19**] 07:03AM BLOOD WBC-5.8 RBC-3.23* Hgb-10.1* Hct-29.9* MCV-92 MCH-31.3 MCHC-33.9 RDW-18.8* Plt Ct-61* [**2151-10-19**] 07:03AM BLOOD Plt Ct-61* [**2151-10-19**] 07:03AM BLOOD Glucose-95 UreaN-37* Creat-1.1 Na-138 K-3.8 Cl-107 HCO3-22 AnGap-13 [**2151-10-15**] 01:30PM BLOOD ALT-25 AST-54* AlkPhos-61 Amylase-79 TotBili-2.4* [**2151-10-19**] 07:03AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.4* Brief Hospital Course: Pt admitted [**10-13**] for scheduled operative intervention, bypass of [**Month/Year (2) **] stenosis. PTFE graft from L Femoral to L AK Popliteal, with L vein graft from distal PTFE to posterior tibial artery. Pt did well post operatively, but on POD 1 developed swollen L parotid gland. CTA showed evidence c/w Parotitis, which she was placed on Unasyn for three days and then changed over to Augmentin to be continued for a total of 2 weeks. Her post operative course was c/b serous drainage from wound at medial thigh on POD 4, and dressing changes were performed accordingly. Otherwise she did well, and graft was assessed to be functioning well. Pt cleared for dischage to a rehab facility for further rehabilitation and teaching. Discharge Medications: 1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4-6H (every 4 to 6 hours) as needed. 9. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days. Tablet(s) 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital1 4860**] - [**Location (un) 4310**] Discharge Diagnosis: Peripheral Vascular Disease with [**Location (un) **] stenosis Discharge Condition: stable Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**2-19**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Dr. [**Last Name (STitle) **] 1 - 2 weeks call for appointment [**Telephone/Fax (1) 1241**]

[ "440.24", "401.9", "527.2", "577.1", "V58.67", "707.19", "250.60", "303.93", "571.2", "357.2", "305.1", "287.5" ]

icd9cm

[ [ [] ] ]

[ "99.07", "38.93", "39.29", "99.04", "38.91" ]

icd9pcs

[ [ [] ] ]

3612, 3686

1998, 2743

330, 418

3793, 3802

1575, 1975

6646, 6741

945, 963

2766, 3589

3707, 3772

3826, 6213

6239, 6623

978, 1556

254, 292

446, 639

661, 810

826, 929

4,640

111,911

14785

Discharge summary

report

Admission Date: [**2175-10-7**] Discharge Date: [**2175-10-9**] Date of Birth: [**2141-6-17**] Sex: F Service: MEDICINE Allergies: tramadol Attending:[**First Name3 (LF) 338**] Chief Complaint: Nausea, vomiting, hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Name13 (STitle) 6129**] is a 34 year old woman with DM type 1 and Hashimoto's thyroiditis who presented to the ED with nausea, vomiting, and hyperglycemia concerning for DKA. She took tramadol the night before admission for R shoulder pain and has been nauseous and vomiting since that time. She has been unable to take anything by mouth. Since then she has noted a high blood sugars over the past 24 hours. She uses an insulin pump and has been taking her insulin and bolusing frequently, but finger stick blood glucose remained in the high 300s to low 400s, so she became concerned that that she was in DKA. She has been in DKA a few times in the past and was worried that she would be unable to keep up with her fluid requirements given her nausea and vomiting, so she came into the ED. She attributes the nausea to the tramadol. She denies recent illness, fevers, diarrhea, [**Name13 (STitle) **], shortness of breath, chest pain, abdominal pain, rashes, dysuria, URI symptoms, or sick contacts. In the ED, initial vital signs were: T 97 HR 102 BP 116/75 RR 20 O2 sat 98% RA, pain 10. On admission, finger stick blood glucose was 349. Labs were notable for serum glucose of 383, urinalysis with 1000 glucose and 150 ketones. Lactate was 2.1. Lytes were notable for potassium of 5.1, bicarb of 14 and AG of 20. White count of 11.0 with a left shift. She was given lorazepam 2 mg x 2, Zofran 4 mg x 1, 2.5 L NS with potassium, and 8 units IV insulin and gtt at 5 units per hr (since 8pm). For access, she has two 18 gauge peripheral IVs. On arrival to the MICU, vital signs were T 98.4 HR 103 BP 99/43 RR 20 O2 100% . She was comfortable, noting that her nausea and vomiting had resolved and she was feeling much better. She clearly reported the history above and denied any additional symptoms. Finger stick blood glucose was 228 on arrival to the [**Hospital Unit Name 153**]. Review of systems: (+) Per HPI, also notes right shoulder pain. (-) Denies fever, recent weight loss or gain. Denies vision changes, headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, [**Hospital Unit Name **], or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Diabetes, type 1 (on insulin pump) - Hashimoto's thyroiditis Social History: Lives with husband, two children, and dog and works as a stay at home mom. She denies tobacco or illicit drugs. Endorses rare alcohol. Family History: Father died from adrenal failure, also had hypertension. Mother alive and healthy. No family history of diabetes or heart disease. Physical Exam: Admission Physical Exam: Vitals: T 98.4 HR 103 BP 99/43 RR 20 O2 100% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic ejection murmur loudest at the base, no rubs or gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: Admission labs: [**2175-10-7**] 06:00PM BLOOD WBC-11.0 RBC-4.44 Hgb-14.8 Hct-45.1 MCV-102* MCH-33.3* MCHC-32.7 RDW-11.9 Plt Ct-450* [**2175-10-7**] 06:00PM BLOOD Neuts-91.6* Lymphs-7.2* Monos-0.6* Eos-0.2 Baso-0.3 [**2175-10-7**] 06:00PM BLOOD Glucose-383* UreaN-28* Creat-0.9 Na-136 K-5.1 Cl-102 HCO3-14* AnGap-25 [**2175-10-7**] 06:00PM BLOOD Calcium-9.8 Phos-5.2* Mg-2.1 [**2175-10-8**] 12:28AM BLOOD Type-[**Last Name (un) **] pO2-194* pCO2-28* pH-7.27* calTCO2-13* Base XS--12 Comment-GREEN TOP [**2175-10-7**] 06:15PM BLOOD Lactate-2.1* Micro: None Studies: [**2175-10-7**] CXR: The heart size is normal. The mediastinal and hilar contours are unremarkable. Lungs are clear and the pulmonary vascularity isnormal. No pleural effusion or pneumothorax is present. No acute osseous abnormalities are detected. IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: 34 year old woman with DM type 1 and Hashimoto's thyroiditis who presented to the ED with nausea, vomiting, and hyperglycemia concerning for DKA, admitted to the [**Hospital Unit Name 153**] for insulin drip. # DKA: Patient with type 1 diabetes diagnosed in [**2163**]. She follows with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**] at [**Last Name (un) **] and has very good glucose control at baseline (reports A1c in the 5 range). She was felt to be in DKA given persistently high FSBG readings at home, nausea, vomiting, electrolytes demonstrating an anion gap of 20, and urinalysis with glucose and ketones in the urine on arrival to the ED. VBG was notable for pH 7.27 and CO2 28. The etiology of her DKA is likely secondary to nausea, vomiting, and resulting hypovolemia from adverse reaction to tramadol that she had taken for shoulder pain. Unlikely infectious given that she is afebrile without any localizing symptoms, no dysuria, clean urinalysis (other than glucose and ketones), no rashes, no recent illness or sick contacts, no [**Name2 (NI) **] and clear chest x-ray. Serum glucose on arrival ranged from 350 - 400. She was started on an insulin drip at 5 units per hour and was bolused 3 L NS in the ED. As her serum glucose fell below 200, she was transitioned to D5 water with prn boluses of NS. Lytes were measured q2 hours until gap resolved the following morning and D5 was discontinued. Potassium remained within the range of 4.5 to 5.0 with repletion. She was seen by [**Last Name (un) **], who recommended restarting her home insulin pump at 0.7 units per hour basal with i:[**Doctor Last Name **] 1:15, CF 40, and target of 120. She remained hyperglycemic on these settings, [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommended increasing her basal rate to 0.9 units/hr, i:[**Doctor Last Name **] to 1:12 and CF to 35. She was scheduled for a follow up appointment with [**Last Name (un) **]. # Right rotator cuff pain: Patient has rotator cuff injury for which she is seeing ortho. She has outpatient cortisone injection scheduled for early [**Month (only) 359**]. She was prescribed tramadol (which she had never taken) for pain refractory to ibuprofen, and developed nausea and vomiting which likely precipitated DKA (above). She was continued on ibuprofen, started on acetaminophen standing, and instructed on physical therapy exercises to help with pain and range of motion. She has ortho follow up already scheduled for early [**Month (only) 359**]. # Hashimotos thyroiditis: She is euthyroid on exam and was continued on her home dose of levothyroxine 50 mcg PO daily. # Insomnia: Patient recently started taking Zoloft for insomnia. She denies symptoms of depression. # FEN: IVF, replete electrolytes, insulin drip # Prophylaxis: SQH, pneumoboots # Contact: [**Name (NI) 4906**] [**Telephone/Fax (1) 43474**] # Code: Full (confirmed) # Transitional issues: - Patient will need close PCP/endocrine follow up given DKA - Basal settings for insulin pump changed in consultation with [**Last Name (un) **]: 0.9 units/hr, i:[**Doctor Last Name **] to 1:12 and CF to 35 -- this should be discussed with [**Last Name (un) **] provider at follow up appointment Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Ibuprofen 800 mg PO Q8H:PRN pain 3. Sertraline 50 mg PO DAILY 4. Insulin Pump SC (Self Administering Medication)Insulin Aspart (Novolog) (non-formulary) Target glucose: 80-180 Discharge Medications: 1. Ibuprofen 800 mg PO Q8H:PRN pain 2. Insulin Pump SC (Self Administering Medication)Insulin Aspart (Novolog) (non-formulary) Basal rate minimum: 0.7 units/hr Target glucose: 80-180 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Sertraline 50 mg PO DAILY 5. Acetaminophen 1000 mg PO Q8H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Diabetic ketoacidosis Secondary Diagnoses: - Diabetes type 1 - Hashimotos thyroiditis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Last Name (Titles) 6129**], You came into the ED because of nausea, vomiting, hyperglycemia, and were found to be in diabetic ketoacidosis (DKA). You were admitted to the ICU because you were required an insulin drip. You were also given several liters of fluid and your blood sugars came back down to normal. We monitored you overnight and your symptoms resolved and your sugars were controlled with your home insulin pump. You were also complaining of shoulder pain from your right rotator cuff and you are scheduled for follow up with ortho to have a cortisone injection. You should not take tramadol any longer due to the adverse reaction of nausea and vomiting which may have caused you to go into DKA. It was a pleasure taking care of you at the [**Hospital1 18**]! Followup Instructions: You have the following appoinments scheduled following discharge: Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**], NP Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3402**] Appt: Thursday, [**10-12**] at 10:30am NOTE: This appointment is with a member of Dr [**Last Name (STitle) 43475**] team as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular provider. Department: ORTHOPEDICS When: MONDAY [**2175-10-23**] at 10:00 AM 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: SPINE CENTER When: MONDAY [**2175-10-23**] at 10:20 AM With: [**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], NP [**Telephone/Fax (1) 8603**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: MONDAY [**2175-11-13**] at 3:45 PM With: [**Name6 (MD) **] [**Name8 (MD) 10918**], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage NOTE: Dr [**Last Name (STitle) **] is a resident and your new physician in [**Name9 (PRE) 191**]. Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43476**] over sees this doctor and both will be involved in your care. For insurance purposes, Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Doctor Last Name **] will be listed as your PCP in your record. Completed by:[**2175-10-9**]

[ "250.13", "726.10", "276.51", "245.2", "780.52", "V58.67", "V45.85" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8656, 8662

4726, 7649

300, 306

8814, 8814

3828, 3828

9778, 11720

2950, 3082

8337, 8633

8683, 8683

7995, 8314

8965, 9755

3122, 3809

8748, 8793

2247, 2694

229, 262

334, 2228

3844, 4703

8702, 8727

8829, 8941

7672, 7969

2716, 2780

2796, 2934

16,123

109,827

25912

Discharge summary

report

Admission Date: [**2137-2-26**] Discharge Date: [**2137-3-9**] Date of Birth: [**2101-5-15**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: relatively asymptomatic Major Surgical or Invasive Procedure: [**2137-2-26**] Bentall Procedure utilizing [**Street Address(2) 64443**]. [**Male First Name (un) 923**] mechanical aortic valve and 34 millimeter Ascending Aortic Tube Graft. History of Present Illness: 35 yo male with connective tissue disorder, most likely Marfan syndrome. Found to have bicuspid AV and dilated aorta. Referred for aortic root replacement by Dr. [**Last Name (STitle) 1290**]. Past Medical History: MVP myopia scoliosis incomplete RBBB s/p appy [**2111**] Social History: lives with wife and 2 year old daughter patent attorney never used tobacco social ETOH Family History: positive for sudden cardiac death of great uncle (30's) and cousin ( 40's) Physical Exam: 6'4" 170 # HR 60 RR 18 right 111/70 left 107/59 tall, thin in NAD skin,HEENt unremarkable neck supple with full ROM, no bruits CTAB RRR with holosystolic murmur at left sternal border extrems warm and well-perfused, no edema or varicosities neurop grossly intct 2+ bil. fem, 1+ bil. DP/PT pulses Pertinent Results: [**2137-3-9**] 04:50AM BLOOD PT-20.9* INR(PT)-2.0* [**2137-3-9**] 04:50AM BLOOD Plt Ct-535* [**2137-3-7**] 05:40AM BLOOD Glucose-97 UreaN-14 Creat-0.9 Na-134 K-5.2* Cl-99 HCO3-25 AnGap-15 [**2137-3-9**] 04:50AM BLOOD UreaN-13 Creat-1.0 K-4.5 Brief Hospital Course: Admitted on [**2-26**] and underwent Bentall procedure with Dr. [**Last Name (STitle) 1290**] ( St. [**Male First Name (un) 923**] 31mm mech. valve/ graft composite 34mm).Transferred to the CSRU in stable condition on amicar and propofol drips. Vent wean on POD #1 on insulin, nitroglycerin and propofol drips. Swan removed on POD #2 and lasix /lopressor started. Transferred to the floor on POD #3. Chest tubes removed.Had an episode of hypoxia the next night with confusion. Neuro exam nonfocal. This cleared and he began to work on increasing his activity level. Pacing wires removed without incident. Heparin drip continued until INR therapeutic. Lopressor changed to his home dose of betaxolol, and this was titrated up. He experienced some confusion periodically at night , but was able to reorient himself. When INR was 2.0 on POD #9, heparin was stopped. Thoracentesis performed for left pleural effusion on POD #10 and repeat CXR cleared him for discharge to home on POD #11. Medications on Admission: betaxolol 20 mg daily ( pt. unsure of dose) occuvite daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Check INR [**3-11**] with results called to Dr. [**Last Name (STitle) **]. Goal INR 2.0-3.0 Disp:*30 Tablet(s)* Refills:*0* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Betaxolol 10 mg Tablet Sig: Three (3) Tablet PO QD (). Disp:*90 Tablet(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. Disp:*14 Packet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Connective Tissue Disorder - most likely Marfan Syndrome, Biscuspid aortic valve and ascending aortic aneurysm - s/p Bentall procedure, Postop Pleural Effusion - s/p thoracentesis, mitral valve prolapse, myopia, scoliosis, incomplete RBBB, s/p appendectomy Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in [**4-10**] weeks, please call office for appt. Dr. [**Location (un) 57220**] on [**2137-3-11**] @ 10 AM for followup appt and PT/INR check. Dr. [**First Name (STitle) **] in [**2-8**] weeks, please call office for appt Completed by:[**2137-3-29**]

[ "424.0", "367.1", "441.2", "427.89", "V58.61", "511.8", "746.4" ]

icd9cm

[ [ [] ] ]

[ "99.06", "34.91", "38.45", "99.05", "39.61", "35.22", "99.07", "99.04", "36.99" ]

icd9pcs

[ [ [] ] ]

3821, 3879

1625, 2611

344, 523

4180, 4187

1359, 1602

4505, 4792

946, 1022

2720, 3798

3900, 4159

2637, 2697

4211, 4482

1037, 1340

281, 306

551, 745

767, 825

841, 930

5,060

163,954

24298

Discharge summary

report

Admission Date: [**2180-12-30**] Discharge Date: [**2180-12-31**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Intoxication Major Surgical or Invasive Procedure: None History of Present Illness: 36 year old homeless man with h/o polysubstance abuse and frequent admissions who signed out AMA yesterday morning after two admissions over the past 4 days for alcohol intoxication. At the most recent admission, the patient required intubation for altered mental status. . He was BIBA after found to be ataxic and intoxicated. BAL 279 and urine tox positive for benzos and cocaine. In the ED, received multiple doses of valium, ativan, haldol and a banana bag. He repeatedly wanted to leave the ED to return to the street to drink but had reportedly endorsed SI overnight to staff. Psychiatry was consulted who eventually determined no active SI and cleared the patient for discharge. However, at that time he was reportedly ataxic and actively withdrawing with hallucinations (hearing "echos" and complained of his skin crawling). Therefore, Psych recommended inpatient admission for EtOH withdrawal. SW was consulted re: possible section 35 (mandated court ordered detox) but stated that it would be difficult to obtain over the weekend and was non-emergent. he was then transferred to the ICU for further management of his withdrawal. . Currently he states that he is quite unhappy. He states that past attempts at detox have been unsuccessful. He states that no sooner does he get released that he returns to the streets and begins to drink again. He feels that his situation is hopeless. Though he states that he is not actively suicidal, he does feel like he would not mind is he just died. Patient states that he does not want to go to rehab because he cannot handle having to deal with so many people [**3-10**] to his social phobia. Cimialry, he states that he does not derive any benefit from AA. Patient states that he is willing to try detox here and is willing to talk to social work and case management to see what other options exist. Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Drinks regularly, 1/2-1 gallon of vodka per day. Uses heroin and benzodiazepines occasionally. Homeless, living in the [**Location (un) **] area. no IVDU since [**2167**]. no cigarrettes in >10 years. Family History: Father with depression and alcoholism. Mother died of DM complications Physical Exam: On admission: Vitals: T 97.3 HR 94 BP 143/94 RR 17 SaO2 99% Gen: Disheveled male HEENT: PERRL, anicteric, MMM Neck: No JVD Chest: CTAB CV: RRR, normal s1/s2, no m/r/g Abd: Soft, NT/ND, normoactive bowel sounds Ext: No c/c/e, reports fracture of left 4th adn 5th digits Skin: No rash Neuro: Alert and oriented, +tremulousness bilaterally, 2+ DTR's, moves all 4 extremities, follows commands, denies hallucinations Pertinent Results: [**2180-12-30**] 08:35AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [**2180-12-29**] 08:37AM ALT(SGPT)-44* AST(SGOT)-71* ALK PHOS-96 AMYLASE-99 TOT BILI-0.7 [**2180-12-29**] 08:37AM LIPASE-46 [**2180-12-29**] 08:37AM CALCIUM-7.6* PHOSPHATE-2.3* MAGNESIUM-1.5* [**2180-12-29**] 08:37AM TRIGLYCER-47 [**2180-12-30**] 03:25AM WBC-9.7# RBC-4.40* HGB-12.9* HCT-37.4* MCV-85 MCH-29.4 MCHC-34.6 RDW-17.6* [**2180-12-30**] 03:25AM NEUTS-71.4* LYMPHS-21.9 MONOS-3.4 EOS-2.9 BASOS-0.4 [**2180-12-30**] 08:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2180-12-30**] 03:25AM GLUCOSE-85 UREA N-9 CREAT-0.8 SODIUM-139 POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-22 ANION GAP-20 [**2180-12-30**] 08:35AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG . CXR - IMPRESSION: No signs for acute cardiopulmonary process. Brief Hospital Course: 36M h/o polysubstance abuse and frequent admissions for EtOH intoxication presents with EtOH withdrawal. . # Alcohol withdrawal: Has history of DTs and withdrawal seizures. Current signs of mild withdrawal but actively hallucinating in ED. Had lengthy discussion with patient about different treatment and dispo options that might exists. patient does not want to return to [**Location (un) 1475**] expresses desire to withdraw from alcohol on night of admission. The following morning the patient states that he would like to leave AMA. Team continued to offer continued care but patient stated that he could not handle being indoors any longer and that he would like to leave - Valium prn CIWA>10 - MVI, folate, thiamine - Aggressively replete lytes - Trend LFTs . # Psych: No current [**Last Name (LF) **], [**First Name3 (LF) **] continue to monitor. - Psych and social work following - Discuss section 12 vs. section 35 - decided not to pursue either option at this time . # PPx: Heparin sc tid # FEN: Regular # Access: PIV # Code: FULL # Communication: Patient # Dispo: patient left AMA Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Facility: Homeless Discharge Diagnosis: Alcohol Intoxication and subsequent Withdrawal Cocaine Use Discharge Condition: Trmulous, in withdrawal. Not fit for discharge. Patient left AMA. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "305.52", "305.60", "291.81", "303.01", "V60.0", "305.90", "070.30", "070.70" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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294, 300

5480, 5686

3194, 4148

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5398, 5459

5293, 5299

2759, 2759

242, 256

328, 2181

2773, 3175

2203, 2436

2452, 2656

16,992

134,503

47324+59001

Discharge summary

report+addendum

Admission Date: [**2115-1-10**] Discharge Date: [**2115-1-19**] Date of Birth: [**2038-10-25**] Sex: M Service: MEDICINE Allergies: Penicillins / Amiodarone Attending:[**First Name3 (LF) 898**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: ICD interrogation on [**1-7**] History of Present Illness: The patient is a 76 male with PMH signficant for CAD s/p MIx2, VF arrest, CHF (EF 20%) s/p BiV ICD, Afib on warfarin and mexiletine, CKD p/w progressively increasing productive cough and lethargy x5 days. Patient denies fevers/chills, runny nose/sore throat, SOB/chest pain, palpitations. He also reported decreased POs since discharge from rehab on [**1-2**] after girdlestone procedure, but denied abdominal pain, nausea/vomiting. The patient was referred to the ED by his PCP on the day of admission given his symptoms, and was initially sent to [**Hospital 1281**] Hospital (closest to home in [**Location (un) 1456**]). . Of note, he had had a 4lb weight gain immediately following d/c from rehab, his dose of lasix was increased to 30mg PO x1 day (since being back on 10mg/day) and is now 4lbs down from rehab d/c weight. . In the ED at the OSH a CXR was performed which reportedly showed a pneumonia per [**Hospital1 18**] ED call in. He received 500mg PO levofloxacin and was transferred to [**Hospital1 18**] ED for further care given this is his primary hospital. . Upon transfer to our ED, initial vitals were T 99.1 HR 98 BP 102/69 RR 20 O2 sat 100% 2L NC. He received 1g IV ceftriaxone and 500mg azithromycin. His BPs were consistently 90s-low 100s while in the ED, and in the setting of probable pneumonia, he is being admitted to the ICU for further monitoring and care. . ROS: +30lb weight loss over 6 months. Denies fevers/chills. No dysuria/hematuria. No blood in stool, dark tarry stool. No rashes, no joint pain. Past Medical History: # CV --CAD --MI ([**2094**], [**2101**]): VF arrest/coma/neurologic sequelae, ICD placement --Pacemaker/ICD: First placed in [**2101**], BiV in [**2110**], currently has [**Company 1543**] InSync model 7272 BiVentricular ICD abdominally implant, epicardial LV and LA leads. RV is Transvene and there is a stand-alone SCV coil. Abandoned RV/RA leads located in right pectoral region. --CM: Ischemic, EF 10-20%, NYHA class III heart failure --Mod-severe MR [**First Name (Titles) **] [**Last Name (Titles) **] --Atrial fibrillation on warfarin, mexiletine --HTN --Hypercholesterolemia . # Renal --Chronic Kidney Disease per OMR, however GFR appears consistently normal in labs --Nephrolithiasis . # Heme --Anemia --SVC thrombosis . # GI --GI bleed [**2-14**] --Pharyngeal dysphagia [**2-9**] structural abnormalities Social History: # Personal: Lives in [**Location (un) 100183**] with wife. [**Name (NI) 2760**] to cardiac rehab 2 x weekly and walks with a walker. No in-home health services. # Professional: Retired banker # Substance use: Never smoked nor used recreational drugs. Past remote drinking. Family History: - CAD: sister - prostate CA: father Physical Exam: VS: Temp: 97.5 BP: 112/71 HR: 92-115 RR: 19-28 O2sat 99% 3L GEN: Cachectic HEENT: PERRL, EOMI, anicteric, mildly dry MM, white plaques on roof of mouth able to scrape off, tongue with white plaques however unable to scrape NECK: No supraclavicular or cervical lymphadenopathy, jvd 6cm, no carotid bruits, no thyromegaly or thyroid nodules RESP: Rhonchorus right lung base, o/w clear without significant rales/wheezes CV: Irregular, systolic murmur heard greatest LUSB ABD: Cachectic, +b/s, soft, nt, no masses or hepatosplenomegaly, ICD box in abdominal wall EXT: no c/c/e, cool, Right with 2+DP, 1+PT, [**Name (NI) 2325**] 2+PT, 1+DP SKIN: no rashes/no jaundice NEURO: AAOx3, flat affect. CN II-XII intact grossly. 4-5/5 strength throughout (symmetric, however generalized mild weakness). No sensory deficits to light touch appreciated. 2+DTRs-patellar and biceps Pertinent Results: [**2115-1-10**] 05:28PM WBC-14.7*# RBC-3.68* HGB-11.5* HCT-34.8* MCV-94 MCH-31.3 MCHC-33.1 RDW-14.2 [**2115-1-10**] 05:28PM PLT SMR-NORMAL PLT COUNT-194 [**2115-1-10**] 05:28PM NEUTS-86.9* BANDS-0 LYMPHS-6.6* MONOS-6.0 EOS-0.3 BASOS-0.2 [**2115-1-10**] 05:28PM GLUCOSE-91 UREA N-16 CREAT-1.0 SODIUM-134 POTASSIUM-5.0 CHLORIDE-96 TOTAL CO2-30 ANION GAP-13 [**2115-1-11**] 02:47AM BLOOD Digoxin-0.8* [**2115-1-11**] 02:47AM BLOOD calTIBC-186* VitB12-515 Folate-13.4 Ferritn-275 TRF-143* Iron-15* [**2115-1-11**] 02:47AM BLOOD Ret Aut-1.0* [**2115-1-11**] 02:47AM BLOOD PT-18.9* PTT-33.1 INR(PT)-1.7* [**2115-1-14**] 06:15AM BLOOD WBC-6.5 RBC-3.41* Hgb-10.4* Hct-31.8* MCV-93 MCH-30.6 MCHC-32.8 RDW-14.2 Plt Ct-219 [**2115-1-14**] 06:15AM BLOOD Neuts-64.5 Lymphs-13.5* Monos-6.3 Eos-15.2* Baso-0.4 [**2115-1-15**] 05:50AM BLOOD Neuts-70 Bands-0 Lymphs-7* Monos-11 Eos-12* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2115-1-16**] 05:40AM BLOOD WBC-7.5 RBC-4.01* Hgb-12.2* Hct-37.8* MCV-94 MCH-30.5 MCHC-32.3 RDW-14.3 Plt Ct-275 [**2115-1-17**] 06:10AM BLOOD PT-35.3* PTT-38.7* INR(PT)-3.7* [**2115-1-17**] 06:10AM BLOOD Glucose-109* UreaN-19 Creat-1.0 Na-135 K-4.5 Cl-97 HCO3-29 AnGap-14 [**2115-1-17**] 06:52PM BLOOD Lactate-1.1 [**2115-1-17**] 07:45PM BLOOD CK(CPK)-32* cTropnT-<0.01 [**2115-1-18**] 01:15AM BLOOD CK(CPK)-27* cTropnT-<0.01 [**2115-1-18**] 09:45AM BLOOD CK(CPK)-26* cTropnT-<0.01 [**2115-1-18**] 01:15AM BLOOD Triglyc-68 HDL-30 CHOL/HD-3.5 LDLcalc-61 [**2115-1-19**] 11:30AM BLOOD WBC-7.5 RBC-3.64* Hgb-11.2* Hct-35.2* MCV-97 MCH-30.9 MCHC-31.9 RDW-15.7* Plt Ct-377 [**2115-1-19**] 11:30AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-136 K-4.8 Cl-99 HCO3-27 AnGap-15 . [**1-10**] EKG: Atrial fibrillation with moderate ventricular response. Underlying ventricularly paced rhythm. There are occasional [**Month/Day (4) **] spikes which are non-conducted. Occasional ventricular premature beats are also noted. Low QRS voltage in the limb leads. Compared to the previous tracing of [**2114-11-22**] atrial fibrillation with occasional ventricular paced rhythm persists. However, ventricular premature beats are new. Clinical correlation is suggested. . LABS: [**1-10**] - Bl. Cx - negative [**1-12**] - [**Last Name (un) **] Cx. - negative . CXR. [**2115-1-10**] 1. New retrocardiac opacity consistent with atelectasis. 2. Opacity within the right lung base which has been noticed to be present on several previous radiographs. Recommend repeat radiographs with nipple markers in both neutral frontal and 10 degree oblique views to assess weather this represents overlying soft tissue (favored) rather than a developing pneumonia. . [**2115-1-17**] Abdomen XR: IMPRESSION: Status post abdominal AICD placement with stable position of [**Month/Day/Year **] leads. . [**2115-1-17**] CXR AP port: The heart size is moderately enlarged, slightly increased in size compared to the previous study. There is significant increase in bilateral perihilar opacities and bronchial wall thickening continuing towards the lower lungs with bilateral increase in currently moderate-to-small pleural effusion, finding consistent with pulmonary edema. . [**2115-1-17**] CT head without contrast: IMPRESSION: No acute hemorrhage or infarct. . [**2115-1-18**] CT head without contrast: IMPRESSION: No acute hemorrhage or infarct. Brief Hospital Course: The patient is a 76 year-old male with CAD s/p MI x 2, VF arrest, CHF with EF 20-25% in [**9-15**] s/p ICD placement, A. fib, and CKD admitted with pneumonia. He was initially treated with Levaquin at an OSH ED and transferred here to [**Hospital1 18**], where he had a short MICU course for concern of hypotension. The patient was found to have baseline low blood pressure in the 90s-100s systolic. His MICU course was complicated by low urine output that responded to IVF. Patient was treated with ceftriaxone and azithromycin with improvement of WBC and cough. Remainder of hospital course is by problem: . # Pneumonia: Admission CXR showed a RLL opacity, possibly chronic, consisted with soft tissue v. infiltrate as well as a retrocardiac opacity representing atelectasis v. infiltrate. The patient had a productive cough and leukocytosis concerning for pneumonia, especially in setting of questionable aspiration given previous history. The patient completed a 7 day course of cefpodoxime and 5 days of azithromycin with improvement in cough/SOB and resolution of leukocytosis. The patient had evidence of a rising peripheral eosinophilia while on antibiotics (possibly due to cephalosporins) without evidence of any rash or end-organ effects. . # Failure to thrive. The patient presented with history of signficant weight loss, which is ikely multifactorial with elements of depression, dysphagia, and end-stage CHF contributing. (Dysphagia is chronic dysphagia due to a structural problem with neg EGD in [**3-15**]. S&S evaluated patient in [**11-15**] and on this admission; however, patient requests a regular diet and is informed of risk of aspiration.) Nutritional consult was obtained, who recommended ensure plus tid and possibly tube feeding ultimately if the patient continues to loose weight. . # Oliguria: The patient had evidence of low urine output during admission (lowest UOP about 300cc/day), which was fluid-responsive. PVR showed no evidence of obstruction. Gentle NS boluses were given when necessary, but were generally avoided given degree of CHF. Lisinopril was uptitrated to 5mg daily to decrease afterload and improve forward flow. . # Congestive heart failure, diastolic, EF 20-25%: The patient was given IVF as necessary, as above, but generally maintained BP 100-120 SBP. He continued to remain mildly volume depleted/ euvolemic so home dose of lasix was stopped. The patient was continued on carvedilol, lisinopril, and digoxin with no acute issues. . # Rhythm: Patient has underlying atrial fibrillation with BiV ICD placed in [**2110**] with almost 100% V pacing. The patient had one episode of VT on telemetry (asymptomatic) for which the patient was evaluated by EP. His ICD was interrogated and was reprogrammed to fire @ 80bpm. Carvedilol was uptitrated per their recommendations, and this was well-tolerated. ICD was also interrogated on [**1-16**] for brief pauses (<2 seconds) and was found to be sensing noise from coughing given abdominal placement. The patient was discharged on mexiletine and carvedilol dose of 12.5mg [**Hospital1 **] with improvement in HR control. Coumadin was continued throughout admission. . # CVA: On [**1-17**] the patient developed symptoms of dysarthria and left lower facial droop. There were no other neurological complaints or other deficits on exam. The patient was oriented and appropriate throughout. VSS throughout. Cardiac enzymes were negative x 3 with no EKG changes concerning for ischemia (but difficult to interpret given V-pacing). [**1-17**] INR was elevated at 3.7, but serial head CTs ([**1-17**] and [**1-18**]) were negative for IC bleed. Etiology of stroke was unclear, but unlikely due to IC bleed given lack of CT findings, and unlikely to be cardio-embolic given supratherapeutic INR. The patient clinically improved overnight with increased strength in affected regions. Fasting lipid panel was checked, as shown above. The patient was continued on medical management. . # Hyperlipidemia: The patient was continued on outpatient statin. . # Anemia: Baseline hct appears to be predominantly 33-35, with hct during admission within baseline. Iron studies were felt to be consistent with iron-deficiency anemia, and the patient was started on supplementation. Stools were guaiac negative while inhouse. . # F/E/N: The patient was continued on a regular diet with ensure plus supplementation with meals. Speech and swallow eval suggests thin liquids and soft consistency solids and to continue crushing pills. . # Code Status: Full, discussed with patient and wife . # Communication: Patient and wife [**Name (NI) 7346**] [**Name (NI) **] [**Telephone/Fax (1) 100184**] (h), [**Telephone/Fax (1) 100185**] (c) . The patient was discharged to NH in stable condition, afebrile, VSS, neurologically stable. He had follow-up arranged with primary care, cardiology, and device clinic. Medications on Admission: Medications: 1. Carvedilol 3.125 mg PO bid 2. Coumadin 6mg daily 3. Digoxin 125 mcg PO MWF 4. Digoxin 62.5 mcg PO T/TH/SAT/SUN 5. Simvastatin 80 mg PO daily 6. Omeprazole 40 mg PO daily 7. Mexiletine 150 mg tid (6am, 2pm, 10pm) 8. [**Telephone/Fax (1) **] 81 mg PO daily 9. MVI 1 PO daily 10. Buproprion 75 mg [**Hospital1 **] 11. Furosemide 10 mg daily 12. Lisinopril 2.5 mg 1 PO daily . Allergies: Penicillins->rash Amiodarone->"ICD fires" per wife Discharge Medications: 1. Carvedilol 12.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 2. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO QTUESDAY, THURSDAY, SATURDAY (). 3. Digoxin 125 mcg Tablet [**Hospital1 **]: 0.5 Tablet PO QSUNDAY, MONDAY, WEDNESDAY, FRIDAY (). 4. Simvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Mexiletine 150 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID AT 6AM, 2PM, 10PM (). 7. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 8. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 9. Bupropion 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]: One (1) Inhalation every 6-8 hours as needed for shortness of breath or wheezing. 11. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 12. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily) as needed for constipation. 13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 14. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. Warfarin 2 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY16 (Once Daily at 16). 16. Lisinopril 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**] Discharge Diagnosis: primary: pneumonia, failure to thrive secondary: coronary artery disease, cardiomyopathy, ICD placement, atrial fibrillation, hypertension, hypercholesterolemia Discharge Condition: good, afebrile, VSS, ambulating with assistance, neurologically stable Discharge Instructions: You were admitted with a pneumonia and weakness/ volume depletion. You completed a course of antibiotics to treat this. You were also given IV fluids for hydration. During your hospitalization you had clinical evidence of a small stroke. A CT scan of the head was negative for evidence of bleeding. Weakness showed signs of significant improvement by discharge. . During your hospitalization the dose of your carvedilol and lisinopril were increased and your lasix was stopped. Please continue to take all of your medications as prescribed on the updated list provided. Please attend all of your follow-up appointments. . If you experience any fevers > 101, chills, increased dizziness, shortness of breath, worsening cough, chest pain, weakness or any other concerning symptoms, please contact your primary care doctor or go to the emergency room for further evaluation. Followup Instructions: Please have your INR checked daily with your coumadin dose titrated accordingly at your nursing facility until in the therapeutic range. . Please follow-up with your primary care doctor, Dr. [**Last Name (STitle) **], on [**2115-1-29**] at 12:00pm, Phone:[**Telephone/Fax (1) 1144**] . Please follow up in DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2115-2-18**] 10:00 . Please follow up with DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2115-2-18**] 10:30 Name: [**Known lastname 520**],[**Known firstname **] E Unit No: [**Numeric Identifier 16108**] Admission Date: [**2115-1-10**] Discharge Date: [**2115-1-19**] Date of Birth: [**2038-10-25**] Sex: M Service: MEDICINE Allergies: Penicillins / Amiodarone Attending:[**First Name3 (LF) 211**] Addendum: The patient was empirically treated for aspiration pneumonia during his hospital course with improvement in respiratory status. Discharge Disposition: Extended Care Facility: [**Location (un) 12573**] Nursing & Rehabilitation Center - [**Location (un) 4534**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**] Completed by:[**2115-2-28**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2118-8-27**] Discharge Date: [**2118-9-5**] Date of Birth: [**2057-3-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Myocardial Infarction, Cardiac Arrest Major Surgical or Invasive Procedure: Cardiac Catheterization Endotracheal intubation (done at another hospital) and extubation History of Present Illness: The patient is a 61 yo man with h/o DM, CAD s/p stents to D1 and LCx, who presented from [**Hospital3 4107**] as a Code STEMI. The patient was reportedly in his normal state of health until noon on [**8-27**], when he was lifting furniture and developed chest pain. He reportedly had associated diaphoresis and lightheadedness. An hour and a half later, the patient drove himself to [**Hospital1 **], where he continued to have substernal chest pain. On arrival to the ED, the patient was noted to be ashen but conversant and AAO x3. His initial VS were BP 130/77, P 51, R 14, O2 97% on RA, Wt 233 lbs. On transfer to the ED stretcher, the patient went into VFib arrest. He was coded for 54 minutes, during which time he was intubated and received 12 mg Epinepherine, 5 mg of Atropine, and was started on Lidocaine and Dopamine gtts. Cooling protocol was initiated, and he was then transferred to [**Hospital1 18**] as code STEMI for cardiac catheterization. In the cath lab, the patient was found to have a total occlusion of the mid-RCA. He underwent successful primary PCI and had a BMS placed in his RCA. He was weaned off the pressors, and heparin and integrilin were discontinued as the patient continued to have substantial bleeding from his nares. The patient was intubated and sedated upon arrival to the CCU and was thus unable to answer ROS. Past Medical History: Dyslipidemia Hypertension Percutaneous Coronary Interventions: - [**5-/2115**] at [**Hospital6 33**], PCI of LCx - [**6-/2115**] at [**Hospital1 112**], DES to the LAD Social History: Single and unmarried per [**Hospital1 112**] file, works as an accountant and employment benefits manager. Lives alone, has girlfriend that travels often. Family in [**Location (un) **], CT and on west coast. Family History: Per [**Hospital1 112**], family history of CAD, but details are unknown. Physical Exam: VS: BP 111/78, HR 83, RR 19 O2 sat 99% on CMV with TV 600, FiO2 100%, RR 25, PEEP 5 GENERAL: Middle aged man, intubated and sedated, in NAD. HEENT: Pupils minimally reactive bilaterally. NGT in place, draining frank blood. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVD of 13 cm CARDIAC: Distant heart sounds, obscured by ventilator. RR, no r/m/g appreciated. LUNGS: Diffuse coars breath sounds bilaterally. Ventilated. No crackles or wheezes appreciated. ABDOMEN: Hypoactive BS, non-distended. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 1+ edema bilaterally. Femoral venous lines in place bilaterally. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distant radial pulses bilaterally. Pertinent Results: Admission Labs: WBC 20.8 Hgb 13.2 Hct 38.7 Plt 293 Pt 14.7 PTT 38.4 INR 1.3 Na 139 K 3.3 Cl 106 HCO3 15 BUN 16 Crt 1.4 Gluc 102 AST 415 ALT 288 LDH 952 CK 3402 AlkPhos 81 Tot Bili 0.7 Other Labs: Cholest 94 Triglyc 85 HDL 30 LDLcalc 47 Microbiology: [**2118-8-30**] Sputum: GRAM STAIN (Final [**2118-8-30**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES PERFORMED PER DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Numeric Identifier 82934**]). GRAM NEGATIVE ROD(S). RARE GROWTH. Blood Cx: No growth to date Urine Cx: Group B streptococcus >100,000 organisms Imaging/Studies: CXR [**2118-8-31**]: Portable upright chest radiograph is compared to [**2118-8-30**]. There has been interval removal of endotracheal and nasogastric tubes. The lung volumes are low. The cardiomediastinal silhouette is probably unchanged. However, there is new fullness in the hilar regions bilaterally and increase in interstitial markings suggesting new pulmonary edema above what would be expected for extubation. Small bilateral pleural effusions are also evident. There is no pneumothorax. Retrocardiac density, likely atelectasis, is unchanged. . ECHO [**2118-8-29**]: 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%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a fat pad. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No definite valvular pathology or pathologic flow identified. Dilated aortic root. . Cardiac Cath [**2118-8-27**]: 1. Selective coronary angiography of this right-domimant system revealed single-vessel coronary artery disease. The LMCA had no significant stenoses. The LAD had mild diffuse disease and patent stents in the first diagonal with moderate diffuse restenosis. The LCX had patent proximal stent and a large OM2 branch with mild diffuse disease. The RCA had an acute mid-vessel total occlusion 2. Resting hemodynamics demonstrated elevated biventricular filling pressures and RA / PCWP pressures suggestive of right ventricular infarction, with depressed cardiac output. 3. Successful manual aspiration thrombectomy and placement of a 3.5x18mm Vision bare-metal stent were performed in the mid-RCA. Final angiography showed TIMI 3 flow, no apparent dissection, and no residual stenosis. (See PTCA comments.) 4. Post PCI bleeding was observed in the left nares, resolved with manual pressure and cessation of integrilin. Brief Hospital Course: The patient is a 61 yo man with h/o CAD s/p DES to the LAD and D1, and hyperlipidemia, who presented from [**Hospital3 **] s/p cardiac arrest with STEMI and is now s/p BMS to the RCA. # Right Ventricular Myocardial Infarct: The patient presented with chest pain and subsequently lost consciousness at [**Hospital1 **]. He was found to have STe in II, III, AVF, and after one hour of resuscitiation, subsequent cardiac catheterization demonstrated a fresh thrombus in the mid-RCA. He was on Dopamine briefly prior to cardiac catheterization. He underwent cooling protocol with Fentanyl/Versed for sedation and Vecuronium for paralytics for 18 hours. He was then rewarmed and weaned off sedation without complication. He was started on aspirin 325mg daily, Plavix 75mg daily, Lipitor 80mg daily, and metoprolol 25mg [**Hospital1 **]. Heparin and integrilin were held due to nose bleeding post-cath. He had episodes of hypotension over the 24-48 hours after cath, and was aggressively given IV fluids to maintain blood pressure. HIs BP and HR were stable at discharge on current meds. #. Respiratory Distress: The patient was intubated at [**Hospital1 **] in the setting of cardiac arrest. After cardiac cath, extubation was slightly delayed due to concern for ventilator-associated pneumonia and increased secretions. He was started on Vancomycin/Cefepime, and later switched to Levofloxacin. He was extubated without complication and his respiratory status improved daily. He was given ipratropium nebulizers and was diuresed with Lasix prn for fluid overload and pulmonary edema. # Neurologic Status - Patient was intubated and sedated on arrival to our hospital. His neurologic status continually improved throughout his hospitalization. At discharge, his short term memory was intact but he retains a memory deficit surrounding his cardiac arrest and the week before his arrest. He also has slight difficulty with balance while ambulating. On day of discharge, he was deemed to be safe to d/c home by PT and will get PT and OT at home. He will f/u with Dr. [**First Name (STitle) 437**] from neurology here and may be referred to Dr. [**First Name (STitle) **]. # Acute Systolic Congestive Heart Failure: The patient had an acute RV infarct and his hemodynamics in the cath lab demonstrated increased biventricular filling pressures. A TTE after cath showed an LVEF>55% and no wall motion abnormalities. He appears euolemic at discharge with no O2 requirement or evidence of fluid overload. He will be discharged on an ACE and a beta blocker. # Nose bleed: The patient had a persistent nosebleed in the setting of traumatic NGT placement and integrilin/heparin gtts. The bleeding stopped with Afrin nasal spray and the patient's Hct has remained stable. # Rhythm: The patient presented in VFib arrest and then had a junctional rhythm. He converted to normal sinus rhythm shortly after his cardiac arrest, and remained in sinus rhythm throughout his hospital stay. # Thrombocytopenia: Patient had thrombocytopenia approximately 5 days after being started on SC heparin for DVT prophylaxis. His platelets dropped from 293 on admission to 116 on day 5 of heparin. There was concern for HIT so heparin was stopped and a heparin antibody was pending at time of d/c. This should be followed/up as an outpt. His HCT was stable but low at 27, likely [**3-14**] phlebotomy and extreme illness. # Obstructive Sleep Apnea: Patient with some apneic episodes while sleeping. This may be related to a previous condition, or may be a result of brain injury after his cardiac arrest. Patient may benefit from a sleep study as an outpatient. Medications on Admission: Atenolol 50 mg daily Lipitor 80 mg daily ASA 325 mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Do not stop until specifically instructed by your doctor. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*11* 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2* 6. Outpatient Lab Work: Please check CBC in 1 week. Call results to Dr.[**Name (NI) 82935**] office at [**Telephone/Fax (1) 4475**]. Discharge Disposition: Home With Service Facility: MASONIC PARTNERS [**Name (NI) **] [**Last Name (NamePattern4) 82936**] Discharge Diagnosis: ST Elevation Myocardial Infarction of the right ventricle Acute Systolic Congestive Heart Failure due to Myocardial Infarct and Cardiac arrest, now ejection fraction 60% and heart failure resolved Epistaxis Memory Deficits after cardiac arrest Multilobar Pneumonia Thrombocytopenia Discharge Condition: Stable, oriented, and afebrile Discharge Instructions: You had a heart attack and you developed cardiac arrest. You were transferred from [**Hospital3 **] to [**Hospital3 **] and you had a bare metal stent placed in your right coronary artery. You did have a heart attack and needed to be on a breathing machine with medicine to support your blood pressure. You have recovered well and now have only small memory defecits because of the cardiac arrest. We expect your memory will return to normal in time. We have set up an appointment for you to see your neurologist after you leave the hospital. Medication changes: 1. Stop taking Atenolol 2. Continue taking Atorvastatin (Lipitor) 80mg by mouth daily and Aspirin 325 mg by mouth daily 3. Start Metoprolol 25 mg by mouth twice daily: to protect your heart from another heart attack 4. Start Lisinopril 5mg by mouth daily: to help your heart recover from the heart attack. 5. Clopodigrel (Plavix) 75 mg daily: to keep the stent from clotting off. Do not stop taking this medicine or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **] tells you to. . Please call Dr. [**Last Name (STitle) 39288**] or Dr. [**Last Name (STitle) **] if you have any further chest pain, trouble breathing, fevers, increasing coughing, fatigue, unusual swelling or any other concerning symptoms. You should not drive until Dr. [**Last Name (STitle) **] tells you it is OK. You may go up and down stairs, take short walks, go shopping but no strenuous exercise until after you see Dr. [**Last Name (STitle) **]. Your platelet level dropped suddenly and then recovered. We sent an anti-platelet antibody to see if it is positive. It is still pending today and should be followed-up with Dr. [**Last Name (STitle) **]. . Please weigh yourself every day and call Dr. [**Last Name (STitle) 39288**] if your weight increases more than 3 pounds in 1 day or 6 pounds in 3 days. Please follow a low sodium diet. Followup Instructions: Primary Care: [**Last Name (LF) **],[**First Name3 (LF) 251**] T. Phone: [**Telephone/Fax (1) 4475**] Date/time: Monday [**9-12**] at 10:30am . Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/Time: [**2118-10-3**] 3:20 [**Hospital Ward Name 23**] [**Location (un) 436**], [**Hospital Ward Name 516**], [**Hospital1 18**], [**Location (un) **], [**Location (un) 86**]. . Neurology: Phone: [**Telephone/Fax (1) 2928**] Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] and [**First Name4 (NamePattern1) 2431**] [**Last Name (NamePattern1) **]. Date/Time: [**10-31**] at 10:00 am [**Hospital Ward Name 23**] [**Location (un) **], [**Hospital Ward Name 5074**], [**Hospital1 18**], [**Location (un) **], [**Location (un) 86**]. Office may call you with an earlier appt.

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icd9cm

[ [ [] ] ]

[ "36.06", "00.45", "37.22", "88.56", "00.40", "96.71", "00.66", "99.20" ]

icd9pcs

[ [ [] ] ]

11426, 11527

6837, 10496

359, 451

11852, 11885

3198, 3198

13863, 14729

2283, 2357

10604, 11403

11548, 11831

10522, 10581

11909, 12452

2372, 3179

3905, 6814

12472, 13840

282, 321

479, 1844

3214, 3384

1866, 2039

2055, 2267

3396, 3864

8,137

173,919

25568

Discharge summary

report

Admission Date: [**2154-8-27**] Discharge Date: [**2154-9-6**] Date of Birth: [**2090-5-30**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Severe left main coronary artery lesion - transferred for coronary artery bypass grafting Major Surgical or Invasive Procedure: [**2154-9-2**] Three vessel coronary artery bypass grafting utlizing the left internal mammary artery to left anterior descending; saphenous vein graft to obtuse marginal and saphenous vein graft to posterior descending artery. [**2154-8-29**] Stenting of left internal carotid artery History of Present Illness: Mrs. [**Known lastname **] is a 64 year old female with multiple cardiac risk factors. She has a history of a positive stress test. During an evaluation for her peripheral vascular disease with claudication, she underwent cardiac catheterization. This was notable for an 80% ostial left main lesion with a totally occluded right coronary artery and 70% stenosis of the circumflex. Ventriculogram revealed an LVEF of 52% without mitral regurgitation. Her aortic root was normal. Based on the above results, she was transferred to the [**Hospital1 18**] for surgical coronary revascularization. Past Medical History: Coronary artery disease, Carotid artery stenosis, Hypertension, Hypercholesterolemia, Diabetes mellitus, Peripheral Vascular Disease, Hypothyroidism Social History: 50-100 pack year history of tobacco. She denies excessive ETOH. She is married and lives with her husband. They have one son. Denies IVDA. Family History: Denies premature coronary disease. Mother died of MI at age 80. Father died of brain tumor. Physical Exam: Temp 98.5, BP 120/48, Pulse 50-60, Resp 18 with 96% room air saturations. General: Well developed female in no acute distress HEENT: Oropharynx benign Neck: Supple, no JVD, ?soft left bruit noted Lungs: clear bilaterally Heart: regular rate and rhythm, normal s1s2, no murmur or rub Abdomen: benign Extremities: warm, no edema or cyanosis Pulses: 1+ distal pulses Neuro: alert and oriented, cranial nerves grossly intact, good strength in all extremities, no focal deficits noted PVRs: Right ABI 0.81(DP) 0.92(PT) / Left ABI 0.62(DP) 0.74(PT) PVR with exercise: Right ABI 0.47(PT) / Left ABI 0.28(PT) Pertinent Results: [**2154-9-6**] 05:45AM BLOOD WBC-9.4 RBC-3.25* Hgb-9.3* Hct-27.2* MCV-84 MCH-28.6 MCHC-34.2 RDW-14.9 Plt Ct-229 [**2154-9-6**] 05:45AM BLOOD Glucose-99 UreaN-11 Creat-0.9 Na-144 K-4.5 Cl-107 HCO3-29 AnGap-13 [**2154-9-6**] 05:45AM BLOOD Mg-1.7 [**2154-8-28**] Carotid Duplex Ultrasound 1. Moderate stenosis of the right internal carotid artery between 40 to 59%. 2. Severe stenosis of the left internal carotid artery between 80 and 99%. [**2154-9-2**] ECHO The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal half of the inferolateral wall. The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. The ascending aorta and aortic arch are mildly dilated. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no pericardial effusion. [**2154-9-2**] CXR Status post median sternotomy and post-CABG. The left chest tube has been removed. The mediastinal and hilar contours are stable. There is a left basilar atelectasis and tiny bilateral effusions. No areas of consolidations are seen. There is no pneumothorax. [**2154-9-2**] EKG Sinus rhythm Low limb leads QRS voltage - is nonspecific Consider left anterior fascicular block Late precordial QRS transition - is nonspecific Since previous tracing of [**2154-8-25**], borderline left axis deviation present and ST-T wave changes decreased Brief Hospital Course: Mrs. [**Known lastname **] was admitted and underwent further preoperative evaluation. She remained pain free on medical therapy. A carotid ultrasound on [**8-28**] was notable for moderate stenosis of the right internal carotid artery(between 40 to 59%) and severe stenosis of the left internal carotid artery(between 80 and 99%). The vascular and neurology services were subsequently consulted. Given her perioperative risk of stroke and that she was not a carotid endarterectomy candidate at the time, it was decided to proceed with endovascular revascularization prior to coronary bypass grfating. On [**8-29**], successful stenting of the left internal carotid artery was performed. Plavix therapy was therefore initiated. There were no complications and she remained neurologically intact. The rest of her preoperative course was unremarkable. On[**9-2**], Dr. [**Last Name (STitle) 1290**] performed three vessel coronary artery bypass grafting utilizing the left internal mammary artery to left anterior descending artery with saphenous vein grafts to obtuse marginal and posterior descending artery. Her operative course was uneventful and she was brought to the CSRU for further invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. She weaned from intravenous therapy without complication. She maintained stable hemodynamics and transferred to the SDU on postoperative day one. Low dose beta blockade was resumed. She remained in a normal sinus rhythm. All chest tubes and pacing wires were removed without complication. She was diuresed toward her preoperative weight as her oral diabetic agents were resumed. Over several days, she made clinical improvements and made steady progress with physical therapy. By discharge, her oxygen saturations on room air were 98%. She was medically cleared for discharge on postoperative day four. She will need to remain on Aspirin and Plavix for at least nine months. Mrs. [**Known lastname **] will follow-up with Dr. [**Last Name (Prefixes) **], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Lipitor 20 qd, Aspirin 325 qd, Effexor 37.5 [**Hospital1 **], Metformin 1000 [**Hospital1 **], Actos 10 qd, HCTZ 12.5 qd, Lisinopril 40 qd, Synthroid 150 mcg qd, Glyburide 2.5 qd Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*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:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Venlafaxine 75 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Coronary artery disease - status post coronary artery bypass grafting, Carotid artery stenosis - status post stenting of left internal carotid artery, Hypertension, Hypercholesterolemia, Diabetes mellitus, Peripheral Vascular Disease, Hypothyroidism Discharge Condition: Good, stable. Discharge Instructions: 1)Patient may shower. No creams, lotions or ointments to incisions. 2)No driving for at least one month 3)No lifting more than 10lbs for at least 10-12 weeks. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in 4 weeks Local PCP and cardiologist in 2 weeks - call for appt Completed by:[**2154-10-1**]

[ "272.0", "244.9", "443.9", "414.01", "V15.82", "401.9", "433.10", "250.00" ]

icd9cm

[ [ [] ] ]

[ "36.15", "00.63", "39.61", "00.61", "36.12", "88.41", "89.60" ]

icd9pcs

[ [ [] ] ]

7968, 7974

4072, 6192

410, 697

8268, 8283

2394, 4049

8490, 8620

1663, 1756

6421, 7945

7995, 8247

6218, 6398

8307, 8467

1771, 2375

281, 372

725, 1319

1341, 1491

1507, 1647

2,548

100,535

52747

Discharge summary

report

Admission Date: [**2110-5-5**] Discharge Date: [**2110-5-7**] Service: MEDICINE Allergies: Naproxen Attending:[**First Name3 (LF) 398**] Chief Complaint: Melena Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: 81F CAD s/p "silent MI", here w/ melena after course of NSAIDs. USOH until three days prior to admission, developed melena, weakness, gnawing discomfort in epigastrium, no CP, SOB. Guaiac pos in PCP office and sent to ED. Found to have decrease in Hct to 31.5 from baseline ~37. Given IV protonix and brought to unit for EGD, which revealed gastritis, shallow ulcer, but no active bleeding. Recommended IV PPI [**Hospital1 **], [**Hospital1 **] Hct while in house, NPO overnight, then f/u scope in two months while on PPI. Past Medical History: HTN Hyperlipidemia CAD s/p "silent MI" Osteoarthritis Social History: Occasional alcohol. Does not smoke. Independent ADLs. Family History: NC Physical Exam: VS 67 118/45 16 98%2L GENERAL: NAD sleepy after scope HEENT: EOMI, OMMM NECK: Supple, no LAD CARDIOVASCULAR: S1, S2, reg, I/VI systolic, no RG LUNGS: CTAB ABDOMEN: Soft, NT, ND, active bowel sounds. EXTREMITIES: Warm, no CCE NEURO: sleepy, but arousable Pertinent Results: [**2110-5-5**] 11:57PM HCT-25.8* [**2110-5-5**] 07:15PM HCT-27.7* [**2110-5-5**] 04:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2110-5-5**] 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR [**2110-5-5**] 04:50PM URINE RBC-0 WBC-[**2-2**] BACTERIA-MOD YEAST-NONE EPI-[**5-10**] [**2110-5-5**] 02:15PM GLUCOSE-106* UREA N-15 CREAT-0.8 SODIUM-140 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14 [**2110-5-5**] 02:15PM CALCIUM-9.9 PHOSPHATE-3.7 MAGNESIUM-2.2 [**2110-5-5**] 02:15PM WBC-6.6 RBC-3.30* HGB-11.2* HCT-31.5* MCV-96 MCH-34.0* MCHC-35.6* RDW-13.5 [**2110-5-5**] 02:15PM NEUTS-64.9 LYMPHS-28.4 MONOS-4.8 EOS-1.6 BASOS-0.3 [**2110-5-5**] 02:15PM MACROCYT-1+ [**2110-5-5**] 02:15PM PLT COUNT-269 [**2110-5-5**] 02:15PM PT-11.6 PTT-21.3* INR(PT)-1.0 EGD: Small hiatal hernia Ulcer in the stomach body and antrum Erythema, friability, congestion and erosion in the antrum and stomach body compatible with erosive gastritis Erythema, friability and congestion in the proximal bulb Brief Hospital Course: 81F with erosive gastritis likely [**1-2**] NSAIDS. * Gastritis: Noted to have shallow nonbleeding ulcers by EGD, continued on PPI [**Hospital1 **]. Initially found to have continued Hct drop overnight, and as such was kept in ICU for further observation. Transfused two units, and bumped appropriately. No further episodes of melena, and tolerated PO diet with no difficulty. Counseled to avoid NSAIDs, however, allowed to continue taking ASA for presumed secondary prevention of CAD. * CAD: N tachycardia or demand ischemia noted during this admission. * FEN: NPO initially, then soft diet in AM following scope. Discharged to home following observation and transfusion. To return in [**5-8**] weeks for followup endoscopy. Medications on Admission: Atenolol 12.5 Lipitor 80 Lisinopril 10 ASA 325 Ibuprofen Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Atenolol Oral 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Gastritis Melena Blood loss anemia Discharge Condition: Patient had stable hct at discharge. No further bleeding or melena. Discharge Instructions: Please take your medications as prescribed. Please do not take any ibuprofen (Advil or Motrin). You may still take tylenol for pain. . Please call your doctor or return to the ER if you have chest pain, shortness of breath, dizziness, black stools or bloody stools, blood when you vomit or have other concerning symptoms. Followup Instructions: You should follow-up to have an endoscopy in 6 weeks. . You should follow-up with your primary care doctor, Dr. [**Last Name (STitle) **] [**Name (STitle) 1728**], in [**12-2**] weeks. His phone number is [**Telephone/Fax (1) 904**].

[ "535.41", "414.01", "272.4", "285.1", "E935.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

3684, 3690

2389, 3125

220, 248

3768, 3838

1263, 2366

4209, 4445

969, 973

3233, 3661

3711, 3747

3151, 3210

3862, 4186

988, 1244

174, 182

276, 802

824, 880

896, 953

2,258

160,971

10711

Discharge summary

report

Admission Date: [**2131-7-2**] Discharge Date: [**2131-7-6**] Date of Birth: [**2073-7-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Acute onset SOB Major Surgical or Invasive Procedure: -Intubation -Abdominal aorta & visceral artery imaging, selective renal angiography-->PTA/Stent x1 celiac artery, PTA/stent x1 Right Renal artery. History of Present Illness: 57 M c CAD s/p CABG, PCI, PVD s/p atherectomy to R SFA, dm2, bilateral RAS, copd p/w sudden onset SOB to OSH. The patient developed acute respiratory distress rather suddenly while on a car trip with his family. EMS was called and found pt in car in resp distress. He was taken to [**Hospital1 10478**] where he arrived 1620 on [**7-2**] vs: [**Telephone/Fax (3) 35066**]8 77 RA. He was promptly intubated. CXR showed CHF. He was given morphine, labetalol IV 20, nebs, solumedrol 125 IV, ceftriaxone 1 gm, d-dimer was 1800(nl is 400). He received 200 lasix IC as well and put out well. There were non-specific small ST elevations II, III, aVF that resolved with improved bp control. tnI was 0.06 9nl 0.03, CK 315. BNP was 1870. ABG was 7.10/73/88. Past Medical History: - CAD - RCA stenting [**2123**]. CABG [**12-19**], LIMA-LAD, SVG-RPL-RPDA, SVG-D1, L radial artery-OM. Cath in [**4-18**] showing SVG-RPL-RPDA occluded and SVG to D1 occlusion. SVG-D1 stented. mid RCA stented. Repeat cath in [**4-18**] showed acute stent thrombus in SVG-D1; restented. Cath [**5-19**] showed total occlusion of SVG-D1. Radial-OM stented at this time complicated distal edge dissection. Cath [**4-20**]: 90% distal RCA tx c [**Month/Year (2) **], 50% L main, severe LAD c diffuse mid and proximal disease but filling distally from LIMA, diffuse moderate LCX c proximal OM occlusion. OM filling via radial graft which has 70% mid vessel lesion. 90% stenosis in the distal stent just before the bifurcation. Grafts on last cath: LIMA-LAD 80% proximal stenosis; stenting of ostium [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 35065**]-OM 90% instent stenosis; stenting of ostial ISR arterial graft . - PVD - [**1-20**] - directional atherectomy to R SFA. MRI/MRA [**4-21**] showing mild-moderate stenosis of celiac artery. Stenosis ostium L renal artery, atherosclerotic disease of infrarenal abdominal aorta + b/l common iliacs. - Type II DM on insulin; neuropathy - HTN - Hyperlipidemia - COPD - GERD - hx Lyme disease - hx Pericarditis [**2099**] - b/l knee surgery Social History: SH: married, 1 ppd tobacco * 40 years, denies ETOH, truck driver on disability Family History: FH: father with CVA at 66, mother with DM, ESRD, sister with DM Physical Exam: VS: Temp: 100.4 BP: 119/73 HR: 95 RR: 19 O2sat: 99 RA general: intubated, sedated HEENT: PERLLA, no jvd lungs: clear anteriorly, no wheezes. heart: RR, S1 and S2 wnl, no m/r/g abdomen: nd, +b/s, soft, nt/nd extremities: no cyanosis, clubbing or edema Pertinent Results: ECHO Study Date of [**2131-7-3**] Ejection Fraction: 35% to 40% (nl >=55%) Conclusions: The study is suboptimal due to inability to properly position the patient. The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is moderately depressed, with global hypokinesis (probably slightly worse in the inferolateral wall). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderatel global left ventricular hypokinesis. Compared with the prior study (images reviewed) of [**2131-5-19**], the overall left ventricular systolic function has deteriorated slightly. Brief Hospital Course: 57 M c CAD s/p CABG, PCI, PVD s/p atherectomy to R SFA, DM2, Renal Artery Stenosis, COPD p/w sudden-onset SOB to OSH. Underwent angiography & stenting of Right Renal Artery & celiac artery [**2131-7-4**]. SBP improving since stenting. . ## Resp failure: Pt intubated upon admission for hypoxic respiratory failure. His acute respiratory decompensation was due to CHF exacerbation in the setting of hypertensive urgency with renal artery stenosis. PE was considered as a possible cause of the acute respiratory decompensation given the history; however, the pt's rapid improvement with diuresis argued against this. Lower extremity non-invasives were performed here & were negative for DVT. Pt was sucessfuly extubated on [**7-3**]. COPD & bronchitis may have contributed to pt's respiratory failure as well. There was no evidence of PNA on CXR, though pt initially febrile with leukocytosis. Pt reported having a cough for one week prior to this event (his whole family has similiar sx's). We treated him for a presumed bronchitis with 5 days of azithromycin. The pt was weaned off O2 and tolerated room air. . ## Cardiac: #Ischemia: significant CAD history. Pt did not have ACS, despite subtle ST elevations. Enzymes CK: 312-->255 MB: 11-->14 MB: 3.5-->5.4 Trop-*T*: 0.05-->0.04. He was treated with aspirin, [**Month/Year (2) **], Statin and beta-blocker. Discussed with pt the importance of smoking cessation. . #Pump: EF 35-40%, w/ slight decrease in LV systolic funx since last echo, BNP 1870, CXR showed CHF. Oxygenation improved with diuresis. Prior to renal artery stenting, pt required Nitro gtt and multiple anti-hypertensive to try to control his SBP. Following RRA stenting, pt was weaned off Nitro drip & BP normalized, though still on multiple anti-hypertensive medications. The day prior to discharge the pt's SBP ranged from 110's to 130's on the following regimen: Toprol XL 200mg daily, HCTZ 25mg daily, amlodipine 10mg daily, Imdur 120mg daily, and hydralazine 25mg QID. His regimen was re-adjusted on the morning of discharge: the hydralazine was discontinued and lasix 20mg daily (his previous dose) was started. Of note, the Imdur dose was maximized given the pt's history of apparent stable angina. He was given two diuretics because of his apparent tendency to become volume overloaded. Initiation of an ACEi was considered, particularly given the pt's h/o CHF & diabetes; however, given the number of changes made to the pt's anti-hypertensive regimen prior to discharge we refrained from this. Once the pt has been stabilized on his new regimen as an outpt, he will likely benefit from an ACEi. #Valves: no know dz #Rhythm: No abnormalities . ## Vascular Dz: The pt had been previously found to have renal artery stenosis (although prior to admission it was thought to be bilateral). He also described a history of weight loss and poor appetite, which was consistent with mesenteric ischemia. Upon angiography of the aorta, the viscera, and the renal arteries, the pt was found to have only uni-lateral RAS (90%) & celiac artery stenosis (70%). These lesions were stented with good residuals & flow post-stent placement. He had an uncomplicated recovery from the procedure. . ## ARF: Pt was in renal failure on admission with Cr=1.7. Post-diuresis, the pt's Cr trended down to 1.1 (his baseline). Hence, it was thought that his acute renal failure was pre-renal, resulting from poor forward flow & poor perfusion in the setting of CHF exacerbation. . ## Fever/leukocytosi: Pt had likely had bronchitis. No clear infiltrate on CXR. He was given ceftriaxone x1 was given at OSH. Lung sounds course & (+) non-productive cough. WBC on admission in the 20's; however, it was thought that the pt was likely intra-vascularly dry & hemoconcentrated (Hct was 49, as well). WBC trended down to 11. He completed a course of azithromycin. Was not febrile except at time of admission. Cough was improving during hospitalization. . ## COPD: no PFTs available. No steroids were given, as it was thought that his copd was playing a major role in his picture. He recieved albuterol & tiatropium inhalers . ## Hct drop: Pt's initial HCT of 49 was thought to be falsely elevated due to hemoconcentration. As his volume status improved, his HCT acutely dropped to 32. There was no evidence of bleeding & he was asymptomatic. Repeat HCTs were stable & on day of discharge pt's HCT rebounded to 40--no transfusions given. . ## DM2: pt treated with RISS. ## Proph: pt received sub-cutaneous heparin and PPI ## Code: full ## Social: pt seen by social work--SOCIAL WORK: Pt referred to SW to support pt/family coping. SW met with pt and wife. Wife articulated stress of trying to manage heremployment while attending to pt in hosp. Couple were forced to sell their home in past in order to pay for [**Hospital **] medical expenses. Wife now concerned their rented home is poorly accessible for pt as there are many stairs to enter, pt unable to manage as he gets very SOB. SW providing support to wife, offered resources re: seach tools for accessible housing. Wife prefers to remain in [**Location (un) 3320**] as their youngest son (of 5 children) is still in high school. Social worker will continue to follow to support pt/family coping. Medications on Admission: [**Location (un) **] 325 qd [**Location (un) **] 75 qd Toprol XL 50 qd Duragesic Patch 50 q72hr Vicodin PRN Zantac Lasix 20 qd amlodipine 10 qd atorvastatin 80' ranitidine 150" Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*6* 6. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 8. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 10. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*6* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 12. Vicodin Oral Discharge Disposition: Home Discharge Diagnosis: Primary Dx: Hypoxic Respiratory Failure Hypertensive Urgency Renal Artery Stenosis Congestive Heart Failure Mesenteric Ischemia (celiac artery stenosis) Acute Renal Failure Bronchitis . Secondary Dx: Coronary artery disease LE Neuropathy Type II Diabetes Hypertension Hyperlipidemia Chronic Obstructive Pulmonary Disease Gastroesophageal reflux disease Discharge Condition: Stable Discharge Instructions: -Please take your aspirin and [**Location (un) **] every day. Do not stop taking these medications unless Dr. [**Last Name (STitle) 7047**] instructs you to do so. Stopping these medications could result in blockage of your stents (possibly leading to a heart attack, kidney or intestinal death). -If you experience shortness of breath, chest pain/pressure, fever, acute abdominal pain or significant drop in your urine output please contact your doctor or go the ER. Followup Instructions: -Please see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 30224**] [**Name (STitle) **] in his office on [**Name (STitle) 766**] [**7-9**] at 11:15am. (Bring a list of your new medications with you to the appointment.) -Please go to the laboratory at Dr. [**Last Name (STitle) 35067**] office on Friday [**7-13**] to have your blood drawn. -Please go to Dr.[**Name (NI) 9654**] office in [**Hospital1 1474**] on Tuesday, [**7-17**] at 10:30am for a blood pressure check. -Please see Dr. [**Last Name (STitle) 7047**] in his office for a follow-up appointment on Friday [**7-27**] at 1:45pm. -Please make an appointment with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **], the interventional cardiologist who put the stents in your renal & celiac arteries. The appointment should be scheduled for 6 weeks after your hospital discharge. Phone # ([**Telephone/Fax (1) 7236**].

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icd9cm

[ [ [] ] ]

[ "00.41", "88.45", "96.71", "88.47", "39.90", "00.46", "96.04", "39.50", "88.42" ]

icd9pcs

[ [ [] ] ]

10802, 10808

4057, 9339

329, 478

11206, 11215

3083, 4034

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2719, 2786

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2801, 3064

274, 291

506, 1257

1280, 2606

2622, 2703

57,805

158,741

39790

Discharge summary

report

Admission Date: [**2199-7-22**] Discharge Date: [**2199-7-27**] Date of Birth: [**2130-1-23**] Sex: M Service: OME The patient was on the biologic service. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old male with metastatic renal cell carcinoma admitted today to begin cycle 1 week 2 high-dose IL-2 therapy. His oncologic history began in [**2197-8-10**] when a torso CT performed due to dyspnea was noted to have large right renal mass and multiple lung nodules. On [**2197-9-12**] he underwent right nephrectomy revealing renal cell carcinoma, clear cell type 6 cm, stage PT3AN0. He was followed with scans every 4 months with stable pulmonary nodules noted. PET CT on [**2199-3-11**] showed multiple pulmonary nodules and mildly prominent mesenteric nodes. On [**2199-3-5**], he underwent left lower lobe wedge resection with pathology from an 8 mm nodule consistent with metastatic renal cell carcinoma noted. Followup torso CT [**2199-6-10**] revealed stable lung nodules but a new pancreatic mass. Treatment options were discussed and high-dose IL-2 therapy was recommended. He passed eligibility testing and began cycle 1 week 1 high-dose IL-2 on [**2199-7-1**] receiving 11 of 14 doses. His course was complicated by mild toxic encephalopathy and acute renal failure. He is now recovered. He is being admitted for cycle 1 week 2 high-dose IL-2 therapy. PAST MEDICAL HISTORY: Kidney cancer as above, anxiety, hypercholesterolemia, right knee surgery, hypertension. ALLERGIES: Previously reported myalgia secondary to statins, now tolerating low-dose simvastatin. SOCIAL HISTORY: He lives in [**Location 49880**] with his wife. [**Name (NI) **] has 3 adult daughters and 8 grandchildren. He previously ran a garage with significant exposure to asbestos, more recently sold kitchen cabinets. A 15-pack per year smoking history but 20 years ago. Social EtOH. No illicit drugs. MEDICATIONS: 1. Celexa 20 mg per oral daily. 2. Fish oil 1000 mg per oral daily. 3. Aspirin 81 mg per oral daily. 4. Amlodipine 2.5 mg per oral daily. 5. Simvastatin 5 mg per oral daily. 6. Niacin 125 mg per oral daily. 7. Lorazepam 1 mg as needed. 8. Atarax 10 mg as needed pruritus. 9. Omeprazole 20 mg daily as needed for indigestion. 10.Multivit 1 tablet daily. FAMILY HISTORY: Noncontributory for kidney cancer. PHYSICAL EXAMINATION: GENERAL: Well-appearing male in no acute distress. Performance status 1. VITAL SIGNS: 97.9, 92, 20, 112/64, O2 sat 98% on room air. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Moist oral mucosa without lesions. NECK: Supple. LYMPH NODES: No cervical, supraclavicular or bilateral axillary lymphadenopathy. HEART: Regular rate and rhythm. S1, S2. CHEST: Clear bilaterally. ABDOMEN: Rounded, soft, nontender. EXTREMITIES: No edema. SKIN: Intact. NEUROLOGIC EXAM: Nonfocal. ADMISSION LABS: WBC 5.7, hemoglobin 14.3, hematocrit 41.6, platelet count 453,000. INR 1.1. BUN 18, creatinine 1.6. Sodium 138, potassium 4.9, chloride 106, CO2 of 22. ALT 36, AST 26. CK 30. Albumin 4.1. HOSPITAL COURSE: The patient was admitted to begin therapy and underwent central line placement. His admission weight was 97 kg and he received Interleukin-2, 600,000 international units per kilo equaling 49.7 million units based on adjusted ideal body weight. During this week he received 8 of 14 doses with dosing stopped early due to development of shock. On treatment day number 4, he was noted to be become hypotensive to systolic blood pressure of mid 80s without response to fluid boluses. He was initiated on dopamine blood pressure support. Hypotension was treated with capillary leak syndrome from IL-2 therapy. While on dopamine, he was noted to go into rapid atrial fibrillation with a heart rate between 160 and 180. He was transitioned off dopamine and changed to Neo-Synephrine but had a persistent rapid ventricular response and persistent hypotension noted. He was felt to require transfer to the ICU to provide further blood pressure support and rate slowing agents. He transferred to the ICU and was initially treated with diltiazem without response and persistent hypotension. He was subsequently placed on amiodarone with improvement in his heart rate and eventual conversion to normal sinus rhythm. He was slowly weaned off Neo-Synephrine and transferred back to the floor on [**2199-7-26**]. IL-2 therapy was held at that time and blood pressure remained stable throughout the rest of his hospitalization. Other side effects during this week included chills, nausea, vomiting, and diarrhea which resolved at the time of discharge. During this week he developed acute renal failure with a peak creatinine of 4.4 with associated oliguria. Metabolic acidosis was noted with a minimum bicarb of 12 and improved with bicarb repletion up to 19. He had no transaminitis, myocarditis, or coagulopathy noted. He developed hyperbilirubinemia with a peak bilirubin of 3.3, improved to 3.2 at the time of discharge. He was anemic without need for packed red blood cell transfusion. He developed thrombocytopenia with a platelet count low 75,000 without evidence of bleeding. By [**2199-7-27**], he had recovered for side effects to allow for discharge to home. CONDITION ON DISCHARGE: Alert, oriented and ambulatory. DISCHARGE STATUS: To home with his wife. DISCHARGE DIAGNOSES: Metastatic renal cell carcinoma status post cycle 1 week 2 __________ therapy complicated by shock, atrial fibrillation and acute renal failure. DISCHARGE MEDICATIONS: 1. Acetaminophen 325 to 650 mg q.i.d. as needed for pain. 2. Sarna lotion topically q.i.d. as needed for pruritus. 3. Cephalexin 500 mg twice a day times 5 days. 4. Citalopram 20 mg per oral daily. 5. Lomotil 1-2 tabs q.i.d. as needed for loose stools. 6. Lasix 20 mg per oral times 5 days or until you reach pre- treatment weight. 7. Hydroxyzine 50 mg q.i.d. as needed for pruritus. 8. Imodium 2-4 mg q.i.d. as needed for diarrhea. 9. Lorazepam 0.5-1 mg 3 times daily as needed for nausea and vomiting. 10.Prochlorperazine 10 mg q.i.d. as needed for nausea and vomiting. 11.Eucerin cream topically. FOLLOWUP: The patient will return to clinic in 4 weeks after CT scans to assess disease response. I have reviewed the discharge summary as dictated by [**First Name8 (NamePattern2) 622**] [**Last Name (NamePattern1) 17265**] and agree with the course and disposition as noted. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 66804**] Dictated By:[**Last Name (NamePattern1) 18853**] MEDQUIST36 D: [**2199-8-13**] 19:43:42 T: [**2199-8-13**] 22:35:26 Job#: [**Job Number 87611**] cc:[**Numeric Identifier 87612**]

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icd9cm

[ [ [] ] ]

[ "00.15", "89.44", "38.93" ]

icd9pcs

[ [ [] ] ]

2320, 2356

5410, 5556

5579, 6776

3111, 5287

2379, 2853

207, 1405

2899, 3093

2871, 2882

1428, 1618

1635, 2303

5312, 5388

82,462

130,552

36754

Discharge summary

report

Admission Date: [**2140-7-16**] Discharge Date: [**2140-8-1**] Date of Birth: [**2071-6-9**] Sex: F Service: NEUROSURGERY Allergies: Scopolamine / Darvon / Amoxicillin / Penicillins / Fentanyl / Midazolam / Oxycodone / Cipro / Cephalosporins Attending:[**First Name3 (LF) 78**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: [**2140-7-16**] Diagnostic Cerebral Angiogram [**2140-7-30**] PEG History of Present Illness: 69yo F who fell off her back deck today and hit her head. Unsure whether she lost consciousness. Initially did well until she started vomiting 3-4x. Convinced by family to go to the hospital. CT obtained at OSH c/w SDH and SAH. Per report, normal neuro exam at outside hospital. Currently only complains of occipital headache. Past Medical History: hypothyroid, hyperlipidemia, HTN, osteoperosis, hysterectomy, a bladder surgery, mucous cyst excision of her left finger Social History: Lives with husband in [**Name (NI) **], MA. Spends 2 days per week at the Arboretum leading groups, 2 days at physical therapy. Has master's degree in preschool education. Family History: NC Physical Exam: On admission: GCS 15 O: T: 98.2 BP: 98/89 HR: 80 R: 14 O2Sats: 96% Gen: WD/WN, lethargic, NAD. HEENT: Pupils: 4->2, symmetric EOMs: intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 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 finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Globally [**1-23**], except L LE: ?neglect Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Normal bilaterally Toes upgoing bilaterally Upon discharge: Gen: WD/WN, lethargic, NAD. HEENT: Pupils: 4->2, symmetric EOMs: intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, somewhat fluctuating verbal responsiveness. Orientation: U/A Language: Largely non verbal, occasional one word answers Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light 5 to3 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: moves left upper spontaneously, withdraws right upper to nox. withdraws bilaterl lower extremities to stim. Sensation: Withdraws to noxious stimulation bilaterally Reflexes: B T Br Pa Ac Normal bilaterally Pertinent Results: CT HEAD W/O CONTRAST [**2140-7-16**] 1. Short-interval increase in subarachnoid blood in the interhemispheric fissure, with subarachoid blood also again noted in the parafalcine sulci and basal cisterns. The pattern of hemorrhage is highly concerning for a ruptured anterior communicating artery aneurysm, and the short-interval increase in hemorrhage indicates ongoing bleeding. An urgent head CTA or conventional angiogram is recommended. 2. Stable parafalcine and paratentorial subarachnoid hemorrhage. 3. Stable intraventricular hemorrhage. Stable ventricular enlargement, which could be secondary to cerebral atrophy. However, an element of communicating hydrocephalus cannot be excluded, and close follow-up is recommended. CTA HEAD W&W/O C & RECONS [**2140-7-16**] Technically limited head CTA. While no intracranial aneurysm is identified, the pattern of subarachnoid hemorrhage remains suspicious for an aneurysm in the region of the anterior communicating artery. Since a small aneurysm may be obscured or compress subarachnoid hemorrhage, a conventional cerebral angiogram should be considered [**2140-7-16**] Angiogram: negative for any aneurysm or vascular malformation [**2140-7-17**] CT Head: IMPRESSION: Minimal progression of interhemispheric hematoma along with a small subdural hematoma along the falx. [**2140-7-18**] CTA Head: IMPRESSION: 1. No changes seen in interhemispheric hemorrhage or subdural hemorrhage seen along the tentorium. 2. No new areas of hemorrhage seen. No aneurysm is seen. No mass effect or change in size of ventricles. 3. Right fetal PCA observed. [**2140-7-19**] Renal Ultrasound: IMPRESSION: 0.7 cm hyperechoic lesion consistent with an angiomyolipoma within the lower pole of the left kidney. Six-month followup is suggested to confirm expected stability. [**2140-7-19**] EEG: IMPRESSION: This telemetry captured a single pushbutton activation, without clear change on the EEG or with video evidence of a seizure. The EEG showed a slow and mildly disorganized background throughout with intermittent delta slowing in a generalized distribution. It did not change much over the course of the recording. Occasionally, there was some additional delta slowing in the right hemisphere, but this was brief, infrequent, and not reliably indicative of an additional problem. There were no epileptiform features, electrographic seizures, or other signs of seizure. [**2140-7-20**] CTA Head: IMPRESSION 1. No change in the caliber, contour or character of well-opacified principal vessels of the circle of [**Location (un) 431**] and their major branches to suggest cerebral vasospasm. 2. No change in the anterior interhemispheric fissural and other subarachnoid hemorrhage, with no new focus of hemorrhage. 3. No evidence of acute infarct. 4. Junction between the A1 and A2 segments of the left ACA and the ACom vessel is bulbous, as before, but there is no discrete aneurysm at this site or elsewhere in the circle of [**Location (un) 431**]. [**2140-7-20**] EEG: IMPRESSION: This telemetry captured no pushbutton activations. The background remained disorganized and mildly slow throughout, with some additional bursts of generalized slowing or even 1 second episodes of suppression. It indicated a widespread encephalopathy. Medications and metabolic disturbances are among the most common causes. There were no prominent focal abnormalities. There were some sharp features but no evidence of ongoing seizures. [**2140-7-22**] CT HEAD WITHOUT CONTRAST There is no new hemorrhage seen or evidence of infarct. The degree of interhemispheric and right frontal subarachnoid hemorrhage is reduced. Subdural hematoma along the falx is essentially unchanged. Hemorrhage within the dependent portion of the ventricles are unchanged. There is no shift of normally midline structures or mass effect. There is no evidence of herniation. There is stable mild ventriculomegaly with no evidence of hydrocephalus. IMPRESSION: 1. No change in interhemispheric fissural subarachnoid hemorrhage. 2. Slight decrease in amount of subarachnoid hemorrhage seen in the frontal lobe and subdural hematoma. 3. No clinically significant changes since prior study. [**2140-7-23**] Head CT: There is no significant interval change in the hemorrhage within the anterior interhemispheric fissure, intraventricular blood, and subarachnoid hemorrhage. There is a lesion in the genu of the corpus callosum which demonstrates restricted diffusion. This could represent a focus of artifact from hemorrhage in the anterior interhemispheric fissure. Ventricular prominence is unchanged. No large territorial infarction is seen. Intracranial flow voids are maintained. Fluid in the left lateral recess of the sphenoid sinus is noted. There is mild venous hyperemia on the post-gadolinium images. IMPRESSION: Overall extent of intracranial hemorrhage is unchanged compared to the prior study. No large territorial infarction. Stable ventricular prominence. [**2140-7-24**]: CHEST Xray FINDINGS: Compared to the prior study, there is no significant interval change. There is no new infiltrate. [**2140-7-24**] Brain MRI: There is no significant interval change in the hemorrhage within the anterior interhemispheric fissure, intraventricular blood, and subarachnoid hemorrhage. There is a lesion in the genu of the corpus callosum which demonstrates restricted diffusion. This could represent a focus of artifact from hemorrhage in the anterior interhemispheric fissure. Ventricular prominence is unchanged. No large territorial infarction is seen. Intracranial flow voids are maintained. Fluid in the left lateral recess of the sphenoid sinus is noted. There is mild venous hyperemia on the post-gadolinium images. IMPRESSION: Overall extent of intracranial hemorrhage is unchanged compared to the prior study. No large territorial infarction. Stable ventricular prominence. Neurophysiology Report EEG Study Date of [**2140-7-24**] IMPRESSION: This telemetry captured no pushbutton activations. It continued to show an encephalopathic background with occasional sharp features, more on the right, but with no definitely epileptiform abnormalities. It also showed very infrequent additional slowing in the right temporal region. Background frequencies were a bit higher than they were two to three days ago but not much changed from the previous day. There were no electrographic seizures. Neurophysiology Report EEG Study Date of [**2140-7-25**] IMPRESSION: This telemetry captured no pushbutton activations. The recording showed a mild encephalopathy throughout. There were no prominent focal features, and there were no overtly epileptiform abnormalities or electrographic seizures. BILAT LOWER EXT VEINS Study Date of [**2140-7-26**] 2:55 PM IMPRESSION: No evidence of deep vein thrombosis in either leg. Neurophysiology Report EEG Study Date of [**2140-7-26**] FINDINGS: CONTINUOUS EEG: Began at 6:41 on the morning of [**7-26**] and showed a low voltage theta background in most areas. There were also bursts of generalized, frontally predominant slowing in the delta range. That afternoon, the background appeared more regular, with the theta to alpha frequency more prominent posteriorly, but still a bit slow on the average. There was more muscle artifact and eye movement artifact. This remained the case through the end of the recording at 16:27 that afternoon. SPIKE DETECTION PROGRAMS: Showed no significant sharp waves. There were no epileptiform features. There was some muscle artifact. SEIZURE DETECTION PROGRAMS: There were two events in this file. They show the same regular theta activity described earlier. There were no electrographic seizures. PUSHBUTTON ACTIVATIONS: There were none. SLEEP: No normal waking or sleeping patterns were evident. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: This telemetry captured no pushbutton activations. The background showed the same mild to moderate encephalopathy throughout. The widespread distribution of the regular theta frequencies suggested medication effect. There were no prominent focal abnormalities. There were no epileptiform features. Brief Hospital Course: 69 y/o F presents to s/p fall off her back deck with positive LOC. She was convinced by her family to go to OSH where a head CT was done which revealed a SDH and SAH. She was transferred to [**Hospital1 18**] for further neurosurgical evaluation. On examination at OSH, patient reported occipital headache, but was otherwise nonfocal. When evaluated in [**Hospital1 18**] ED, patient was seen to have R pronator drift and R ptosis as well as lethargic. Due to the appearance and location of hemorrhage, a CTA was done to evaluate for aneurysm or AVM. CTA was negative, a formal angiogram was done. Angiogram was also negative. On [**7-17**], exam remained the same. Her NA levels were decreasing, she was started on salt tabs and NA level improved. A repeat head CT was done which showed improvement of the hemorrhage and stable ventricle size. On [**7-18**] she was noted to be somewhat more lethargic. Labs Repeat CTA was unchanged and negative for aneurysm. TCD was limited due to poor windowing and could not evaluate MCA, ACA, or PCA; there was no evidence of vasospasm in the vessels seen. Repeat TCD on [**7-19**] showed normal flow in bilateral MCA's. She continued to be lethargic with somewhat fluctuating mental status. UA and culture were positive for E. coli UTI and she was started on Ceftriaxone. Other labs including TSH, B12, and Depakote level were normal. EEG showed diffuse slowing without evidence for epileptiform activity. On [**7-20**] a repeat Head CTA was negative for vasospasm. There was concern as her exam had differed as she was less interactive and she was not moving her LUE. Hypertonic Saline 3% was started at 20 cc/hr and her SBP was pushed 160-180. The next day on [**7-21**] her exam was slightly improved as she gave "no/yes" answers. On [**7-22**] her exam once again varied and a repeat Head CT was stable. She stablized on exam but mental status was not improving. Neurology was consulted on [**7-23**] and recommended labs, LP, EEG, and MRI brain. She was started on acyclovir empirically while awaiting CSF HSV PCR; this was stopped on [**2140-7-28**] after PCR came back negative. Labs revealed normal BMG, elevated LFT's, normal ammonia, negative UA. She developed a leukocytosis and was treated for C. diff. Sodium normalized on 3% saline and she was transitioned to salt tabs TID. EEG again showed diffuse slowing with no epileptiform activity. MRI was unremarkable, demonstrating stable intracranial hemorrhage and ventricular prominence. She was seen by speech and swallow. Serial PO trials were performed but she was unable to maintain adequate PO intake to meet her nutritional needs. After discussion with her family a PEG tube was placed on [**2140-7-29**]. On [**7-29**], The patient continues to be lethargic and non-verbal. The serum sodium level is low but stable at 131. She continues on Sodium Chloride Tablets 3grams po TID. The patient's serum magnesium level was low at 1.5 and she was given magnesium for repleation. The patient's diet is NPO for a PEG tube placement today. She did well and was tolerating tube feeds without residual. Her stomach was noted to be mildly tender and distended on [**2140-8-1**] so a KUB was obtained. This demonstrated air in her large and small bowel concernig for colonic ilieus, but She was noted to have positive bowel sounds on exam. Her flexi seal was discontinued. A small amount of air was also noted under her diaphragm, but this is an expected finding given her recent PEG placement. Her hyponatremia improved with a NA of 143 on [**8-1**]. NaCl was decreased to one gram three times a day. Her Sodium should be checked daily for the next 2 to three days. Medications on Admission: Depakote ER Effexor XR Synthroid simvastatin Fosamax Plus D quinapril hydrochlorothiazide glucosamine-chond-msm-vit C-Mn aspirin 81 vitamin E Fish Oil Imitrex [**Doctor First Name **] Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): hold for diarrhea. 2. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for headache. 4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day): hold for diarrhea. 6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 8. venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 9. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 10. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 14. valproic acid (as sodium salt) 250 mg/5 mL Syrup Sig: Ten (10) ml PO Q12H (every 12 hours). 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. amantadine 50 mg/5 mL Syrup Sig: Ten (10) ml PO BID (2 times a day). 17. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 19. Ondansetron 4 mg IV Q8H:PRN nausea 20. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 21. 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. 22. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 23. 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. 24. Fosphenytoin 200 mg PE IV Q12H 25. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H d/c after last dose on [**8-7**] Discharge Disposition: Extended Care Facility: [**Hospital 38**] [**Hospital 731**] Rehabilitation and Nursing Center - [**Location (un) 38**] Discharge Diagnosis: Anterior falciform SDH/SAH Cerebral edema Confusion Fevers UTI C. Diff colitis protien/calorie malnutrition SIADH Herpes Zoster / Opthalmic involvement Dysphagia Abulia Discharge Condition: Mental Status: Clear and coherent. Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? You may safely resume taking your Aspirin. ?????? CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in ____4___weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. You had a renal ultrasound as part of your work up here in the ICU for blood in your urine, you will need to have a follow up ultrasound in 6 months. Please follow up with your PCP and have order your follow up study. Completed by:[**2140-8-1**]

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icd9cm

[ [ [] ] ]

[ "38.93", "38.91", "96.6", "43.11", "03.31", "88.41" ]

icd9pcs

[ [ [] ] ]

17809, 17931

11625, 15297

379, 447

18144, 18144

3435, 4639

19228, 19814

1158, 1162

15543, 17786

17952, 18123

15323, 15520

18356, 19205

1177, 1177

330, 341

2402, 2609

475, 809

2777, 3416

4648, 7648

7657, 11602

1191, 1468

18194, 18332

831, 953

969, 1142

9,413

176,956

1802

Discharge summary

report

Admission Date: [**2187-9-19**] Discharge Date: [**2187-9-24**] Date of Birth: [**2132-5-5**] Sex: M Service: SURGERY Allergies: Sulfonamides / Dapsone / Keflex Attending:[**First Name3 (LF) 1481**] Chief Complaint: s/p Motor cycle crash; left sided rib pain Major Surgical or Invasive Procedure: None History of Present Illness: 55 year old male driver; helmeted; s/p motorcycle crash on [**9-5**] with splenic lac, treated and released for this at [**Hospital1 18**], who presented to [**Hospital1 18**] on [**2187-9-19**] after being trasferred from area hospital with decreased Hct from 41 to 30, new splenic hematoma as well as free fluid. Pt. denies LUQ pain but reports [**Month (only) **] BM's (last 2 days). +flatus, no n/v, no sob, no fevers/chills. Past Medical History: HIV (+) HTN PVD Hayfever Social History: quit smoking-- 20pack/yr hx occ marijuana no EtOH Family History: non-contributory Physical Exam: Exam on arrival to ED: 99.8 93 154/85 16 99%RA Gen: A&Ox3, NAD Pulm: decreased BS at L base, otherwise CTAB CVS: RRR, no murmors Abd: Decreased BS, soft, NT/ND GU: guiac negative, firm stool non-impacted Ext: C/C/E Pertinent Results: [**2187-9-19**] 06:15PM BLOOD WBC-9.6 RBC-3.19*# Hgb-10.3*# Hct-29.7*# MCV-93 MCH-32.3* MCHC-34.7 RDW-14.0 Plt Ct-429 [**2187-9-23**] 07:15AM BLOOD Hct-28.4* [**2187-9-19**] 06:15PM PT-14.0* PTT-24.1 INR(PT)-1.3 [**2187-9-19**] 06:15PM PLT COUNT-429 [**2187-9-19**] 06:15PM NEUTS-76.2* LYMPHS-15.2* MONOS-6.6 EOS-1.4 BASOS-0.6 [**2187-9-19**] 06:15PM WBC-9.6 RBC-3.19*# HGB-10.3*# HCT-29.7*# MCV-93 MCH-32.3* MCHC-34.7 RDW-14.0 [**2187-9-19**] 06:15PM GLUCOSE-105 UREA N-16 CREAT-0.9 SODIUM-134 POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-28 ANION GAP-13 [**2187-9-19**] 10:48PM HCT-27.2* [**2187-9-21**] Hematocrit 29.2* [**2187-9-22**] Hematocrit 29.6* [**2187-9-23**] Hematocrit 28.4* Brief Hospital Course: Upon arrival to the emergency department as a transfer from [**Hospital1 **] [**Name (NI) 620**], pt. was evaluated by the emergency department and trauma surgery staff. The pt was found to have a hematocrit in the high 20's and was placed on telemetry, bedrest, NPO and admitted to the trauma SICU for monitoring. The pt. was stable on bedrest, NPO and IVF for three days while being monitored in the [**Last Name (LF) 10115**], [**First Name3 (LF) **] the pt. was transferred to the floor where he continued to be monitored. After another uneventful day, the pt.'s diet was advaced, and pt. advanced slowly with his mobility. By HD#5, Mr. [**Known lastname 10116**] had a benign abdominal exam, no complaints, and was walking around the floor. He was evaluated and cleared by physical therapy as safe to go home, and his hematocrits were stable. He was discharged home on HD #6, with a scheduled follow-up CT scan on [**10-8**] and follow up in Trauma Clinic on [**10-9**]. Medications on Admission: 1. Indinavir 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*3 Capsule(s)* Refills:*2* 2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Medications: 1. Indinavir 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*3 Capsule(s)* Refills:*2* 2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Oxycodone 5 mg Tablet Sig: 1-4 Tablets PO every four (4) hours as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: splenic laceration re-bleeding episode left-sided rib fractures Discharge Condition: Good Discharge Instructions: -Take your medications as perscribed -If you have severe abdominal pain, faintness or feeling as if you are going to pass out, dizziness, unexplained fast heart rate you need to proceed immediately to the nearest emergency room and inform them that you may be bleeding internally -You perscibed medications include narcotic pain medication. This medication will impair your judgement and motor skills. Do not drive a car or operated heavy machinery while taking this medication. Also, please do not partake in any activity that requires fine motor skills to complete when taking this medication as it may hinder your ability to complete the activity safely. Followup Instructions: Please follow in trauma clinic on [**10-9**]: call to schedule a time [**Telephone/Fax (1) 6439**] You have a CT scan of abdomen/pelvis scheduled on [**2187-10-8**]: please call [**Telephone/Fax (1) 11**] to schedule a time. Provider: [**Name10 (NameIs) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2788**] INTERNAL MEDICINE Date/Time:[**2187-11-21**] 3:30

[ "V08", "401.9", "511.9", "V54.19", "443.9", "865.01", "E819.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4374, 4380

1914, 2895

333, 340

4488, 4495

1198, 1891

5202, 5617

930, 948

3381, 4351

4401, 4467

2921, 3358

4519, 5179

963, 1179

251, 295

368, 799

821, 847

863, 914

1,041

159,277

27633

Discharge summary

report

Admission Date: [**2174-6-9**] Discharge Date: [**2174-6-17**] Date of Birth: [**2116-3-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: Cardiac arrest due to ventricular fibrillation Major Surgical or Invasive Procedure: Cardiac catheterization Stent to left circumflex History of Present Illness: 58 year old male with unknown PMH p/w witnessed cardiac arrest in the field. He was in [**Hospital1 778**], by report CPR was started by retired nurses within seconds. EMS arrived in 3 minutes and ALS was initiated. Initial rhythm VF, pt shocked x9, given 300 amio, then another 150. atropine 1 mg, epi 3 mg, had regular rhythm at 15 minutes by EMS strips, return of spontaneous circulation at 20 minutes by report. Arrived at ED at [**Hospital1 18**] at 25 minutes with vitals p 90 bp 112/p rr 16 sats 100% after being intubated on arrival. ECG showed afib with Qs V1,2 ST depressions V2-V5 with question of small St elevations I, II. emergency head CT, CT of C-spine were negative. He was taken for urgent cath, found to have 80% LAD lesion, and total occlusion to LCx which was treated with Cypher x2. He was admitted to CCU for further mgmt and for cooling therapy. Past Medical History: R hip arthroplasty x2 Social History: Works as teacher in [**Location 9583**]. Divorced. No tobacco. [**5-2**] beers/day. No drugs Family History: Noncontributory Physical Exam: Gen: Intubated, sedated HEENT: Pupils sluggish but reactive Heart: RR, nS1, S2, no appreciable murmurs Lungs: Coarse, no crackles Abd: soft, NT, ND +BS Ext: 2+ DP, radial pulses bilaterally Neuro: Moving arms spontaneously but not reacting to anything, legs rigid, extended at knees, plantar flexed at ankles Pertinent Results: [**2174-6-9**] 03:07PM WBC-7.9 Hct-42.7 Plt Ct-266 [**2174-6-9**] 07:44PM WBC-18.9 Hct-40.3 Plt Ct-148 [**2174-6-12**] 06:08AM WBC-14.7 Hct-27.8 Plt Ct-235 [**2174-6-9**] 03:07PM PT-12.4 PTT-34.8 INR(PT)-1.1 [**2174-6-9**] 07:44PM Glucose-211 UreaN-15 Creat-1.0 Na-139 K-4.1 Cl-106 HCO3-20 [**2174-6-12**] 06:08AM Glucose-119 UreaN-17 Creat-0.6 Na-139 K-3.9 Cl-108 HCO3-21 [**2174-6-9**] 07:44PM CK-2985 CK-MB-137 MB Indx-4.6 cTropnT-1.66 [**2174-6-11**] 12:11AM cTropnT-2.21 [**2174-6-11**] 06:14AM CK-4320 CK-MB- >500 cTropnT-2.32 [**2174-6-12**] 06:08AM CK-3160 CK-MB-118 MB Indx-3.7 cTropnT-2.06 [**2174-6-9**] 03:13PM Lactate-10.2-->1.7-->1.0 [**2174-6-14**] 03:31AM BLOOD WBC-9.8 RBC-3.36* Hgb-10.7* Hct-29.2* MCV-87 MCH-31.7 MCHC-36.5* RDW-15.0 Plt Ct-236 [**2174-6-14**] 03:31AM BLOOD Neuts-80.1* Lymphs-14.1* Monos-5.2 Eos-0.6 Baso-0.1 [**2174-6-14**] 03:31AM BLOOD Plt Ct-236 [**2174-6-14**] 03:31AM BLOOD Glucose-103 UreaN-10 Creat-0.7 Na-141 K-3.2* Cl-108 HCO3-26 AnGap-10 [**2174-6-14**] 03:31AM BLOOD TotBili-1.4 DirBili-0.5* IndBili-0.9 [**2174-6-14**] 11:00AM BLOOD ALT-75* AST-121* AlkPhos-39 TotBili-1.1 [**2174-6-14**] 03:31AM BLOOD Calcium-8.5 Phos-2.2* Mg-1.7 [**2174-6-15**] 06:50AM BLOOD WBC-7.4 RBC-3.31* Hgb-10.3* Hct-29.1* MCV-88 MCH-31.1 MCHC-35.3* RDW-14.6 Plt Ct-295 [**2174-6-15**] 06:50AM BLOOD Plt Ct-295 [**2174-6-15**] 06:50AM BLOOD PT-12.2 PTT-30.3 INR(PT)-1.0 [**2174-6-15**] 06:50AM BLOOD Glucose-92 UreaN-12 Creat-0.7 Na-141 K-3.5 Cl-107 HCO3-26 AnGap-12 [**2174-6-16**] 11:38AM BLOOD WBC-8.5 RBC-3.09* Hgb-9.8* Hct-27.1* MCV-88 MCH-31.7 MCHC-36.2* RDW-14.3 Plt Ct-342 [**2174-6-16**] 11:38AM BLOOD Plt Ct-342 [**2174-6-16**] 11:38AM BLOOD K-3.7 Cardaic catheterization: Selective coronary angiography revealed a right dominant system with patent LMCA and proximal LAD. Mid LAD had a long 80% lesion. D1 had a 70% stenosis. LCX was proximally totally occluded. RCA was free of angiographically apparent disease. Left ventriculography was deferred. Hemodynamic assessment showed normal left and right sided filling pressures and low normal cardiac index. Successful stenting of the LCX with 3.5x28mm Cypher and a 3.0x8mm Cypher (post dilated to 3.5mm). Occluded right iliac vessel. ECHO ([**2174-6-13**]):Mild regional left ventricular systolic dysfunction c/w CAD. Possible regional right ventricular free wall hypokinesis. Mild mitral regurgitation. EF 55% CXR([**2174-6-13**]): New mild to moderate heart failure. Resolv opacity in the right upper lobe. Brief Hospital Course: 58 year old male w/ unknown PMH s/p vfib arrest. Cath revealed LCx complete occlusion, which was stented. #Cardiac: Had acute MI, with cypher stent placed in the left circumflex artery. He was continued on aspirin, plavix, atorvastatin, and metoprolol. Echo showed EF of 55%. s/p VF arrest, had atrial fibrillation in the ED. Got amio loaded in field. Was in sinus later and amio discontinued. Pt remained hemodynamically stable following revascularization, without chest pain or further arrhythmias. He will need to follow up with Dr. [**Last Name (STitle) 911**] within the month. . #Neuro: Suffered anoxic brain injury as it took 20 minutes before heart revived after the vfib arrest. Upon arrival at [**Hospital1 18**], pt underwent head & neck CT, which were unremarkable. Neuro was consulted. Pt started on cooling protocol. Following cooling protocol, pt was weaned off sedatives, and slowly began showing signs of increasing neurologic function. Following cessation of paralytics, pt was able to move all extremities without deficits; he was seen by PT and OT who both felt that he would benefit from a rehab stay. He required soft, ground diet initially, though was transitioned to full PO after further evaluation by speech & swallow. The degree of anoxic brain injury sustained is unclear, though MRI was unrevealing for significant anoxic damage (see report). The pt is pleasant & is oriented to self. However, he is not oriented to place or time, indicating some cognitive deficits. ## Respiratory failure: Patient intubated in setting of code, but extubated within 48 hours, without further respiratory problems. ## Pneumonia: Had leukocytosis on admission thought to be secondary to stress response; however, his leukocytosis persisted and his CXR revealed a RUL infiltrate, thought to be aspiration. He was initially started on levaquin and flagyl, but later changed to vancomycin and zosyn given that he had been on a ventilator (to cover nosocomial pathogens). His infiltrates resolved on chest x-ray and he completed a 7 day course of antibiotics in house. His oxygen saturation was consistently > 97% on RA. ## EtOH: Pt reportedly drinks 6-12 beers/day. He required about 20 mg of valium on the 4th-5th days of hospitalization, however subsequently has not required any more doses, without any signs of withdrawal. ## FEN: He was seen by speech and swallow who cleared him for a PO diet with ground solids and thin liquids (cardiac heart healthy). He should continue on this diet for now, but should have a repeat speech and swallow evaluation at rehab at some point, as he may be able to have his diet advanced in the near future. ## Social: From SOCIAL WORK--Pt has reported HX of EtOH abuse. SW met briefly with pt and 2 sisters, then alone with sisters with pt's permission while he had a PT eval. Pt presented as anxious and expressed wish to return home in near future. [**Name (NI) 1094**] sisters, [**Name (NI) **] and [**Name (NI) **], talked about their ambivalence about taking control while pt was confused, as pt has compartmentalized his life in past, so they were not familiar with his friends, and had limited knowledge of his ex-wife and family. Sisters expressed concern pt has hx of heavy EtOH abuse since adolescence. They state pt's mother expressed concern about his drinking when she was alive and pt lived with her. Sisters have found large quantities of beer in his house and car since his hospitalization. They note pt is a much loved high school teacher and coach, and they have been surprised by the magnitude of public support for him in his small town. Sisters do not believe pt has ever had a DUI or legal consequences for drinking, nor blackouts, missed work or any previous attempts at sobriety. [**Name (NI) 1094**] sister's articulate being committed to supporting pt's needs in community though one lives in OH. Sisters report pt was fully independent with all [**Name (NI) 5669**] PTA, exercised regularly (swimming), gave up running due to past hip replacements. Family note significant improvement in pt's mental status, but are aware of ST memory deficits. Medications on Admission: None Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for cad. 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for stent. 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Coronery artery disease Secondary: Anoxic brain injury Pneumonia Alcoholism Atrial fibrillation, now in sinus Discharge Condition: Stable Discharge Instructions: Please take all medications as prescribed. If you have chest pian, shortness of breath, dizziness, fever, chills, abdominal pain please call the physician on call. Please continue to take Aspirin and Plavix daily without fail. Do not discontinue them unless told otherwise by your cardiologist. We are starting you on new medications like lisinopril, atenolol, aspirin, plavix, multivitamins, atorvastatin. Please see the attched sheet for instructions regarding these medications. Followup Instructions: Please call Dr[**Name (NI) 5786**] office ([**Telephone/Fax (1) 67508**]) to ask about your appointment with him. Please make a follow up appointment with your PCP Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 67509**]) within one to two weeks. You have an appointment scheduled with Neurologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 67510**]) on [**2174-8-8**] at 11 am. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD, PHD[**MD Number(3) **]:[**Telephone/Fax (1) 8645**] Date/Time:[**2174-8-8**] 11:00

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icd9cm

[ [ [] ] ]

[ "37.23", "00.46", "88.56", "96.71", "36.07", "00.66", "00.40" ]

icd9pcs

[ [ [] ] ]

9251, 9330

4419, 8568

369, 420

9484, 9493

1854, 4396

10026, 10600

1492, 1509

8623, 9228

9351, 9463

8594, 8600

9517, 10003

1524, 1835

283, 331

448, 1321

1343, 1366

1382, 1476

18,323

181,666

17479

Discharge summary

report

Admission Date: [**2113-6-28**] Discharge Date: [**2113-7-1**] Date of Birth: [**2067-7-20**] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Toradol / Compazine / Remicade Attending:[**First Name3 (LF) 2160**] Chief Complaint: Short of breath, stridor Major Surgical or Invasive Procedure: Intubation History of Present Illness: This is a 45 year old female with history of Asthma and Crohn's intermittently on steroids who was admitted to the ICU on [**2113-6-28**] with dyspnea, stridor, and wheezing requiring intubation. Past Medical History: 1. Asthma 2. Crohn's disease s/p ileo-cecal resection with ileo-sigmoid anastomosis, revision with ileostomy s/p multiple SBOs 3. Portacath Social History: Disabled, lives with partner, non-[**Name2 (NI) 1818**], no EtOH, no IVDU or other drugs Family History: mother with colitis, father died of lung and bone cancer Physical Exam: VS: Temp 97.7, Pulse 136, BP 143/74, RR 28, 100% on NRB Gen: alert, oriented, cooperative female in obvious respiratory distress with wheezing audible from across the room. HEENT: MMM, OP clear (no enlargement of tonsils or neck swelling), PERRL Neck: no lymphadenopathy or swelling, stridor on exam Lungs: decreased breath sounds throughout, stridor audible CV: RRR, nl S1S2, no murmers Abd: soft, non-tender, non-distended, positive BS Ext: no edema Neuro: alert and oriented X2, patient urgently intubated so remainder of exam deferred. Pertinent Results: [**2113-7-1**] 06:24AM BLOOD WBC-11.1* RBC-3.37* Hgb-11.0* Hct-31.6* MCV-94 MCH-32.6* MCHC-34.8 RDW-14.2 Plt Ct-215 [**2113-6-28**] 01:00PM BLOOD WBC-21.1*# RBC-3.83* Hgb-12.2 Hct-34.6* MCV-90 MCH-31.7 MCHC-35.1* RDW-14.8 Plt Ct-288 [**2113-7-1**] 06:24AM BLOOD Plt Ct-215 [**2113-6-28**] 01:00PM BLOOD PT-13.4* PTT-118.8* INR(PT)-1.2* [**2113-6-29**] 03:56AM BLOOD ESR-46* [**2113-7-1**] 06:24AM BLOOD Glucose-115* UreaN-18 Creat-0.6 Na-138 K-2.9* Cl-105 HCO3-27 AnGap-9 [**2113-6-28**] 01:00PM BLOOD Glucose-118* UreaN-10 Creat-0.7 Na-139 K-3.3 Cl-104 HCO3-22 AnGap-16 [**2113-6-29**] 03:56AM BLOOD ALT-27 AST-27 LD(LDH)-190 AlkPhos-59 Amylase-48 TotBili-0.2 [**2113-6-29**] 03:56AM BLOOD Lipase-16 [**2113-6-28**] 01:00PM BLOOD CK-MB-3 [**2113-7-1**] 06:24AM BLOOD Calcium-8.6 Phos-1.8* Mg-2.4 [**2113-6-29**] 03:56AM BLOOD Albumin-3.6 Calcium-7.5* Phos-1.4*# Mg-2.2 Iron-30 [**2113-6-29**] 03:56AM BLOOD calTIBC-311 VitB12-444 Ferritn-30 TRF-239 [**2113-6-29**] 03:56AM BLOOD CRP-1.1 [**2113-6-29**] 11:05AM BLOOD Ethanol-NEG Acetmnp-NEG [**2113-6-28**] 11:50PM BLOOD Type-MIX pO2-30* pCO2-51* pH-7.27* calTCO2-24 Base XS--4 Intubat-INTUBATED [**2113-6-28**] 08:32PM BLOOD Type-ART pO2-174* pCO2-40 pH-7.30* calTCO2-20* Base XS--5 [**2113-6-28**] 02:04PM BLOOD Type-ART pO2-73* pCO2-37 pH-7.41 calTCO2-24 Base XS-0 Intubat-NOT INTUBA [**2113-6-28**] 11:50PM BLOOD Lactate-5.0* [**2113-6-28**] 08:32PM BLOOD Lactate-6.7* [**2113-6-28**] 09:58PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.022 [**2113-6-28**] 09:58PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2113-6-28**] 09:58PM URINE RBC-5* WBC-0 Bacteri-OCC Yeast-NONE Epi-0 [**2113-6-29**] 11:05AM URINE Hours-RANDOM [**2113-6-29**] 11:05AM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-POS [**2113-6-28**] 9:58 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2113-6-29**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. RESPIRATORY CULTURE (Preliminary): HEAVY GROWTH OROPHARYNGEAL FLORA. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2113-6-28**] 9:58 pm URINE Source: Catheter. **FINAL REPORT [**2113-6-29**]** URINE CULTURE (Final [**2113-6-29**]): NO GROWTH. CHEST, ONE VIEW: Comparison with chest radiograph, [**2113-6-28**]. New small left pleural effusion and left lingular atelectasis. Right lung appears clear. Endotracheal tube, nasogastric tube, and left subclavian line are unchanged. No pneumothorax. Osseous structures are unchanged. IMPRESSION: New small left pleural effusion and left lingular atelectasis. CT NECK W/CONTRAST (EG:PAROTID Reason: evaluate for airway abnormalities, causes of swelling, in pa [**Hospital 93**] MEDICAL CONDITION: 45 year old woman with history of Asthma, Crohn's presenting with respiratory distress found to have severe stridor now s/p intubation. REASON FOR THIS EXAMINATION: evaluate for airway abnormalities, causes of swelling, in patient with severe stridor CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 45-year-old woman with a history of asthma and Crohn's disease. Now with stridor and intubated. COMPARISON: None. TECHNIQUE: Contrast-enhanced CT of the neck. FINDINGS: Note is made of an endotracheal tube, nasogastric tube, and a left subclavian central venous catheter. The soft tissues of the neck appear unremarkable. There is no drainable fluid collection, pathologically enlarged lymph nodes, or other mass. The airway demonstrates no significant narrowing, although the study is limited by the presence of the endotracheal tube. The vocal cords do not appear markedly swollen. The lung apices demonstrate minimal scarring. The paranasal sinuses demonstrate mucosal thickening in multiple ethmoid air cells as well as the right maxillary sinus, likely related at least in part to the intubation. IMPRESSION: No extrinsic mass or fluid collection in the neck. Portable AP chest radiograph was compared to [**2113-6-28**] obtained at 13:14 p.m. The ET tube tip terminates 2.5 cm above the carina. The left subclavian line tip terminates in mid SVC. The NG tube tip passes below the diaphragm most likely terminating into the stomach. The heart size and mediastinal contours are unremarkable and the lungs are essentially clear with no sizeable pleural effusion identified. PORTABLE UPRIGHT CHEST, 1:14 p.m., [**6-28**] INDICATION: Respiratory distress. Evaluate for pneumonia. FINDINGS: No prior comparisons. The heart is not enlarged. No CHF. The left subclavian Port-A-Cath tip is at the level of the brachiocephalic/SVC confluence. No definite pulmonary infiltrates or sizable effusions. There is the suggestion of some prominence/indistinctness of the markings at the right lung base medially, which may just be due to overlying soft tissues, but if there is a clinical suspicion of early pneumonia, then followup PA and lateral views may be helpful to further evaluate this. No other suspicious areas for pneumonia. There is a tiny roughly 5-mm nodule density projecting just lateral to the cardiac apex, which is indeterminate for confluence of markings versus a small nodule/granuloma or possibly a bone island. Attention to this on followup studies, or comparison with prior old films or reports recommended. Brief Hospital Course: Acute Respiratory failure - intubation for airway protection. Etiology thought to be vocal cord dysfunction given that stridor stopped abruptly after intubation, no wheezing aon exam and very low peak airway pressures were noted. Neck CT showed no pathology to account for stridor. On discussion with the ICU attending, Dr [**Last Name (STitle) 2168**] - vocal cords were normal in apprearance. She was treated with empiric coverage with Levofloxacin for a 5 day course (last day [**2113-7-2**]), prednisone taper, nebs. PPI was given in [**Hospital1 **] dosing given that GERD can worsen vocal cord dysfunction. The patient will benefit from psychiatry follow up for anxiety and vocal cord dysfunction (relaxation techniques). She is also advised to discuss with PCP for an ENT referral. Given above reasons, this was unlikely to be an asthma exacerbation. But given the severity of the situation, she was treated with above. *** A repeat Chest XRY is recommended to evaluate the findings above and also consider CT chest if the pleural effusion persists/to follow up the nodule. She should continue to follow up with her GI physicians at [**Hospital1 18**] for management of Crohns disease. Ativan was continued prn for anxiety. Methadone (home dose) was continued for chronic LBP. UA revealed 5 RBC. She should get another UA with her PCP for follow up. Medications on Admission: 1. Albuterol 2. Advair Diskus 500/50 3. Singulair 10mg daily 4. Lorazepam 1-2mg [**Hospital1 **] prn 5. Flexeril 10mg QD prn 6. Methadone 40mg qHS 7. Protonix 40mg daily Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 1 days. Disp:*3 Tablet(s)* Refills:*0* 3. 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:*0* 4. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO DAILY (Daily). 5. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours) as needed. 7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 8. Prednisone Prednisone 40 mg PO daily for 3 days; then decrease to 30 mg po daily for 3 days; then decrease to 20 mg po daily for 3 days and then 10 mg po daily for 3 days and then stop. ( No refills) Discharge Disposition: Home Discharge Diagnosis: Acute respiratory failure likely due to vocal cord dysfunction Asthma RBC in urine h/o crohn's disease Anxiety Chronic low back pain Discharge Condition: Stable. Ambulating well. O2 sats - 100% on room air Discharge Instructions: Return to the emergency room if you have worsening wheezing, shortness of breath, chest pain, cough, fever, or any other symptoms. You may have vocal cord dysfunction. YOu are advised to follow up with your lung doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 13056**] hospital for a pulmonary function test. Also discuss with your doctor [**First Name (Titles) **] [**Last Name (Titles) 48825**] you to a ENT specialist, a psychiatrist for relaxation techniques. YOu were started on a medicine called pantoprazole for acid reflux that may be causing the vocal cord dysfunction. Make a follow up appointment with your primary doctor - Dr [**Last Name (STitle) **] as stated below in the next 1 week. Take your medicine as prescribed. Talk to your doctor about a repeat chest Xray in [**4-2**] weeks. Followup Instructions: Call Dr [**Last Name (STitle) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 48826**] to [**Telephone/Fax (1) **] a follow up appointment in the next 1 week. Also call your pulmonary doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment in the next 1 week.

[ "493.90", "276.2", "478.5", "555.9", "530.81", "518.81", "724.2" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

9549, 9555

7009, 8370

349, 361

9733, 9786

1506, 3640

10654, 10940

872, 930

8591, 9526

4444, 4580

9576, 9712

8396, 8568

9810, 10631

945, 1487

3749, 4407

3678, 3716

285, 311

4609, 6986

389, 586

608, 750

766, 856

75,053

125,154

41444

Discharge summary

report

Admission Date: [**2161-4-8**] Discharge Date: [**2161-4-15**] Date of Birth: [**2095-7-23**] Sex: M Service: MEDICINE Allergies: Gentamicin / clindamycin / Iodine Attending:[**First Name3 (LF) 425**] Chief Complaint: Endocarditis septic shock [**3-18**] MRSA bactermia, transfer for ICD lead removal Major Surgical or Invasive Procedure: Removal of Implantable Cardioverter Difibrillator History of Present Illness: 65 yo M with Hx of CAD with inferior MI (95) c/b post-infarction VSD urgently repaired at same time of single vessel bypass (SVG to RCA), recurrent VSD s/p repair, then out-of-hospital V Fib arrest (successfully resucitated) s/p additional single vessel bypass surgery (LIMA to LAD), additional VSD repair with residual shunting, and implantation of ICD. Additionally, patient has a hx of paroxysmal AFib/Flutter and is s/p successful electrical cardioversion on [**2161-3-18**] performed [**3-18**] worsening heart failure symptoms. . He presented to [**Hospital 732**] [**Hospital 107**] Hospital in [**Location (un) 90158**], NY on [**2161-3-29**] with complaints of fever, chills, and cough X 3 days. He was found to have a leukocytosis (16) with impressive bandemia (27), anion-gap metabolic acidosis, hypotension, possible PNA and AOCKI. . Ultimately the patient developed septic shock secondary to MRSA bacteremia with subsequent multi-organ failure requiring hemodialysis. He was treated with Vancomycin and Rifampin without clearance of blood cultures, and continued to experience rigors. TEE revealed a vegetation attached to the lead closest to the interatrial septum (within the RA) and a second vegetation as the lead crosses the tricuspid valve. He initially required dopamine and levophed for hypotension, and intermittent BiPAP ventilation. Per report, he was shocked inappropriately multiple times for runs of SVT and rapid A Fib, so he was started on IV Amiodarone (now transitioned to oral). The patient was transferred to our facility for ICD lead extraction and management of his MRSA endocarditis. . Currently the patient reports he feels alright. He is without chest pain, and his dyspnea is improving. He is having persistent hiccups. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for + dyspnea on exertion, paroxysmal nocturnal dyspnea, LE edema, and intermittent palpitations. Also absence of chest pain, orthopnea, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes II, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: X 2 -VSD s/p repair X 2 with reported residual leaking -PERCUTANEOUS CORONARY INTERVENTIONS: BMS to LCx and LAD -PACING/ICD: ICD placement in 90s, replacement in [**2160**] 3. OTHER PAST MEDICAL HISTORY: -Obesity -Chronic Kindey Injury (baseline 2.2-2.6) -Gout Social History: -Lives alone in apartment, has 3 children all healthy -Tobacco history: non-smoker -ETOH: occasional use of ETOH ([**4-17**] drinks on weekends) -Illicit drugs: none Family History: -Father died of MI at age of 69. Physical Exam: ADMISSION PHYSICAL: VS: T=97.4 BP=102/62 HR=89 RR=22 O2 sat= 96% GENERAL: obese male, mildly tachypneic, but 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, difficult to appreciate JVP given obesity and RIJ CARDIAC: + SEM across precordium, loudest at LLSB and apex. S1/S2, increased rate LUNGS: No chest wall deformities, scoliosis or kyphosis. Inspiratory bibasilar coarse crackles bilaterally ABDOMEN: soft, distended, non-tender. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: + pitting edema to thighs b/l, warm and well-perfused SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. . DISCHARGE PHYSICAL: Tc 37.1, P: 65, BP: 120/51, RR: 21. 97% on 3L, wt 105 kg GENERAL: obese male, NAD, Oriented x3, Mood, affect appropriate. HEENT: sclera anicteric, moist mucous membranes NECK: Supple, difficult to appreciate JVP given obesity, HD line in place L neck CARDIAC: + SEM across precordium, loudest at LLSB and apex. S1/S2, normal rate LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB ABDOMEN: soft, distended, non-tender, BS+ EXTREMITIES: [**3-19**]+ pitting edema of all extremities (UE, LE), warm and well-perfused, L picc ok Pertinent Results: ADMISSION LABS ([**2161-4-8**]): Chem: GLUCOSE-102* UREA N-32* CREAT-3.9* SODIUM-131* POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-26 ANION GAP-11 CALCIUM-7.3* PHOSPHATE-3.5 MAGNESIUM-1.7 LFTs: ALT(SGPT)-17 AST(SGOT)-25 LD(LDH)-176 ALK PHOS-62 TOT BILI-2.6* DIR BILI-2.2* INDIR BIL-0.4 ALBUMIN-2.3* Iron Studies: IRON-21* calTIBC-185* HAPTOGLOB-169 FERRITIN-361 TRF-142* RET AUT-2.0 CBC: WBC-11.8* RBC-2.77* HGB-8.2* HCT-24.9* MCV-90 MCH-29.5 MCHC-32.7 RDW-17.5* NEUTS-88.3* LYMPHS-7.7* MONOS-3.3 EOS-0.5 BASOS-0.2 PLT COUNT-156 Coags: PT-38.2* PTT-37.5* INR(PT)-4.0* . DISCHARGE LABS ([**2161-4-15**]): [**2161-4-15**] 03:53AM BLOOD WBC-7.7 RBC-2.68* Hgb-8.0* Hct-23.9* MCV-89 MCH-29.7 MCHC-33.3 RDW-18.9* Plt Ct-137* [**2161-4-15**] 03:53AM BLOOD Glucose-101* UreaN-50* Creat-6.2*# Na-134 K-4.1 Cl-98 HCO3-23 AnGap-17 [**2161-4-15**] 03:53AM BLOOD Calcium-8.0* Phos-6.9*# Mg-2.2 [**2161-4-15**] 03:53AM BLOOD Vanco-19.3 [**2161-4-10**] 03:45AM BLOOD HBsAg-NEGATIVE [**2161-4-9**] 06:15AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE [**2161-4-13**] 03:28AM BLOOD ALT-12 AST-22 AlkPhos-63 TotBili-0.9 . STUDIES: MICRO: - BCx ([**4-12**]): 1/6 bottles positive for GPCs - Bcx ([**4-10**]): 1/4 bottles (anaerobic bottle) with GPC in clusters - Bcx ([**2074-4-7**] and [**2077-4-10**]): NGTD - Stool C diff tox ([**4-9**] and 26): negative - IDC lead ([**4-9**]): negative . Radiology: CXR [**2161-4-8**]: REASON FOR EXAMINATION: Heart failure in a patient with infected ICD leads. Portable AP chest radiograph was reviewed with no prior studies available for comparison. Pacemaker leads terminate in right ventricle with the second lead not clearly seen on the current study. The right internal jugular line tip is at the level of low SVC. Cardiomediastinal silhouettes demonstrate prior sternotomy and mild cardiomegaly. The evaluation of the lung parenchyma demonstrates nodular opacities projecting over the right lung that might represent unusual appearance of pulmonary edema, but infectious process would be a consideration. Evaluation of the patient after diuresis is suggested and if findings persist, further evaluation with chest CT would be highly recommended. Small amount of bilateral pleural effusion cannot be excluded, in particular on the left given the relatively significant distance between the gastric bubble and the low cardiac border that might suggest subpulmonic effusion on the left. . TTE [**2161-4-9**]: Conclusions The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is moderate global left ventricular hypokinesis (LVEF = 30-35%). A left ventricular mass/thrombus cannot be excluded. There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. IMPRESSION: Moderately dilated left ventricle with moderate global LV hypokinesis. There is likely significant dyssynchrony present. Prior VSD repair is seen in the basal septum which is thinned and akinetic. Dilated and hypokinetic right ventricle. Mild aortic, moderate mitral and moderate to severe tricuspid regurgitation. No evidence of endocarditis (cannot exclude). The LV apex is heavily trabeculated, a LV thrombus cannot be excluded (unlikely as the apex has normal systolic function). . RUQ U/S [**2161-4-9**]: IMPRESSION: 1. Non-visualization of the gallbladder. The patient will be called back for further imaging at no additional charge by the radiology department. 2. Normal appearance of the liver without focal liver lesions. 2. Splenomegaly. 3. Simple cysts within the right kidney. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Mr. [**Known lastname **] is an 82 yo M with Hx of CAD complicated by inferior myocardial infarction, VSD s/p repair X 3, s/p 1V CABG X 2, multiple PCIs, V Fib arrest s/p ICD placement, as well as A Fib/Flutter s/p recent electrical cardioversion, and chronic kidney injury who was transferred from an outside hospital with septic shock secondary to MRSA endocarditis for planned ICD removal by Dr. [**Last Name (STitle) **]. . # MRSA ENDOCARDITIS/SEPTIC SHOCK: Per report, the patient presented to the OSH with multi-organ failure requiring pressure support and intermittent BiPAP. He was started on hemodialysis for oliguric renal failure. Blood cultures grew methicillin-resistant staphylococcus aureus for which he was started on Vancomycin and Rifampin. TTE revealed vegetations on ICD hardware (RA lead and lead crossing tricuspid valve) so the patient was transferred to our facility for ICD extraction. He underwent this procedure on [**4-9**], which went well. He was extubated quickly and only required small amounts of Levophed transiently for pressure support. TEE did not reveal clear infection of the VSD patch. Infectious Disease provided recommendations throughout his admission. He was continued on Vancomycin (dosed at hemodialysis). Rifampin was not started secondary to documented resistance at the outside hospital. Blood cultures remained negative until evening prior to discharge back to OSH ([**2161-4-10**] one set of blood cultures grew GPC in clusters, sensitivites and speciations pending). He will likely need suppressive antibiosis with Doxycycline or Bactrim for 6-12 months after 6 weeks of IV Vancomycin. Infectious Disease here at [**Hospital1 18**] did update Dr. [**Last Name (STitle) **] regarding the patient. . # ACUTE ON CHRONIC KIDNEY INJURY: Etiology most likely ATN secondary to hypoperfusion from septic shock. Additional work-up was negative (Renal U/S without gross abnormalities, C3/C4 normal). Patient was started on hemodialysis at the outside hospital and continued at our facility. His temporary HD line was re-sited to the left internal jugular vein. Given his clinical evidence of heart failure, his volume status was optimized by fluid removal at HD. We renally-dosed appropriate medications and avoided nephrotoxins. Prior to discharge, we placed a PPD which was negative and obtained hepatitis serologies in order for screening for outpatient dialysis center placement given his likely future need to continue treatment. Hepatitis B and C serologies were negative and PPD read was negative. Additionally, he was started on nephrocaps and calcium acetate with meals. Patient should be monitored for signs of renal recovery to determine if he can stop dialysis in the future. Last HD session at [**Hospital1 18**] was [**2161-4-14**]. He will likely need HD tomorrow ([**2161-4-16**]) and should have a nephrology consult to help facilitate this process. Vancomycin should be dosed with HD. . # HYPOXIA: Likely etiology is pulmonary edema; however, patient has nodular opacities on chest xray, which may be evidence of septic emboli. The patient's gross volume overload was managed at hemodialysis. He remained on 6L of oxygen supplementation via nasal cannula during the day, and BiPAP for suspected Obstructive Sleep Apnea at night. . # ACUTE ON CHRONIC SYSTOLIC CONGESTIVE HEART FAILURE: The patient has a history of ischemic cardiomyopathy. Echo obtained during this admission revealed a moderately dilated left ventricle with moderate global LV hypokinesis, likely significant dyssynchrony present, prior VSD repair seen in the basal septum which is thinned and akinetic, dilated and hypokinetic right ventricle, mild aortic, moderate mitral, and moderate to severe tricuspid regurgitation. He appeared grossly volume overloaded with rales and significant pitting anasarca. We attempted to initiate beta-blocker therapy for better rate control (see below); however, the patient began to have episodes of asymptomatic bradycardia to the 30s. We did not initiate an ace-inhibitor given his current renal function and unclear future course. The patient had volume removed during hemodialysis. . # CORONARY ARTERY DISEASE: The patient has a Hx of inferior myocardial infarction complicated by ventricular septal defect status post three repairs, as well as 2 single-vessel bypass grafts (SVG to RCA, and LIMA to LAD), as well as multiple PCIs. There was no evidence to suspect acute coronary syndrome during this admission. We continued him on Aspirin 325 daily and Atorvastatin 80 daily. . # ATRIAL FIB/FLUTTER: The patient presented with a history of Atrial Fibrillation for which he had a successful electrical cardioversion performed on [**2161-3-18**]. Per report, the patient had been receiving inappropriate shocks by his ICD for runs of SVT and AF with RVR. He was started on Amiodarone, which we continued. During this admission he remained in coarse atrial fibrillation and atrial tachycardia intermittently. He was also started on a heparin drip for anticoagulation. He will receive replacement ICD 6-8 weeks, because planned treatment course of antibiotics is currently set for 6 weeks. . # COAGULOPATHY: Patient presented with prolonged PT and PTT. Unclear if he had been receiving Coumadin at the outside hospital. Coagulopathy possibly secondary to poor nutrition, current antibiotics use, or prior liver injury. He received IV vit K to reverse his INR prior to ICD removal. Resumed on heparin gtt at end of [**Hospital1 18**] hospitalization with need for resumption of coumadin at OSH when appropriate. . # ANEMIA: Iron studies reflected anemia of chronic inflammation and iron depletion. The patient's stools were guaiac positive; however, he demonstrated no signs or symptoms of acute bleeding. He was started on pantoprazole daily. He may benefit from EPO with hemodialysis; current plan is to hold off and consider iron with hemodialysis. Additionally, given his cardiac history, he was transfused one unit of packed red blood cells at dialysis. . # HYPONATREMIA: Based on clinical exam, likely hypervolemic hyponatremia in etiology. Unable to obtain urine electrolytes. Hyponatremia was mild and improved with volume removal. He never demonstrated any mental status changes. . # ISOLATED DIRECT HYPERBILIRUBINEMIA: Present on admission and resolved within two days. Other transaminases were within normal limits and RUQ ultrasound was unrevealing; however, gallbladder was not visualized. Likely secondary to cholestasis from resolving sepsis. The patient had no RUQ abdominal pain to suggest infection such as cholangitis. As gallbladder was not visualized, a repeat abdominal ultrasound may be considered for further evaluation. . # UNCLEAN URINALYSIS: Urinalysis appeared infected with pyuria and hematuria; however, patient was making very little urine volume. Was given two doses of ceftriaxone, which was discontinued once culture returned negative for growth. . # DIARRHEA: Likely secondary to ceftriaxone, which was discontinued. Clostridium difficile toxin assay negative. . FEN: Patient remained on cardiac, low Na, diabetic diet ACCESS: Left IJ HD line, 2 PIVs, A-line for BP monitoring PROPHYLAXIS: -DVT ppx with pneumoboots -Pain management with tylenol as needed -Bowel regimen with senna and colace CODE: Full code COMM: patient, daughter ([**Name (NI) 402**]) @ [**Telephone/Fax (1) 90159**] Medications on Admission: HOME MEDICATIONS: -Pepcid 20 daily -Coumadin 1 daily -Aspirin 81 daily -Metoprolol 50 [**Hospital1 **] -Lasix 40 PO daily -Allopurinol 300 daily -Levsin 0.125 daily PRN -Glipizide XL 5 daily -Levitra 20 daily . TRANSFER MEDICATIONS: -Miconazole powder -Lactobacillus 10 [**Hospital1 **] -ASA 325 daily -Protonix 40 daily -Mupirocin 2% [**Hospital1 **] to nares -Vancomycin 200 IV after HD -Rifampin 300 [**Hospital1 **] -Coumadin (no dose today) -Heparin gtt -Nystatin S&S -Doxycycline 100 [**Hospital1 **] -Insulin aspart SQ -Amiodarone 400 daily -Albuterol 2.5 inh q6h -Atrovent 0.5 mg inh q6 -Acetaminophen -Zofran Discharge Medications: 1. insulin lispro 100 unit/mL Solution Sig: According to Scale Subcutaneous ASDIR (AS DIRECTED). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for itching, rash. 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily): Continue while on Dialysis. 7. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS): Continue while on dialysis. 8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol): Adjust according to Vancomycin Trough and HD. 10. heparin, porcine (PF) Intravenous 11. Levsin 0.125 mg Tablet Sig: One (1) Tablet PO once a day as needed for abdominal pain . Discharge Disposition: Extended Care Discharge Diagnosis: MRSA Endocarditis with infection of defibrillator Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], You were transfered to [**Hospital1 69**] for an infection in you heart. You were evaluated and treated by the cardiology service. You received removal of you Implantable Cardioverter Defibrillator and tolerated its removal well. You also received antibiotics for the infection of your defibrillator and dialysis for your kidney difficulties. You remained comfortable and stable throughout your admission. You are being transfered to [**Hospital **] Hospital - [**Location (un) 732**] where you will continue to recieve care for your heart infection. The following changes were made to your medications: -STOPPED Coumadin- this may be restarted at the transfer hospital -STOPPED Pepcid -STOPPED Furosemide (lasix) -STOPPED Allopurinol -STOPPED Glipizide -STOPPED Metoprolol -STARTED Amiodarone 400 mg by mouth daily -STARTED Heparin drip -STARTED Pantoprazole 40 mg daily -STARTED Insulin Sliding Scale -INCREASED Aspirin from 81 to 325 mg daily Followup Instructions: Department: RADIOLOGY When: MONDAY [**2161-4-20**] at 2:30 PM With: ULTRASOUND [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE

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Discharge summary

report

Admission Date: [**2149-4-10**] Discharge Date: [**2149-4-25**] Date of Birth: [**2085-6-26**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Demerol / Haldol Attending:[**First Name3 (LF) 4765**] Chief Complaint: Syncope. Major Surgical or Invasive Procedure: Permanent pacemaker placed. Internal jugular central venous line placed. Arterial line placed. Procedures performed prior to arriving at [**Hospital1 18**]: Endotracheal intubation Subclavian central venous line Transvenous pacing wires Interosseous line History of Present Illness: Ms. [**Known lastname 4553**] is a 63 yo woman with history of hypothyroid, lupus, non-hodgkin's lymphoma s/p xrt and chemotherapy 17 years ago who presented to [**Hospital3 1443**] hospital earlier today after a syncopal episode at home. A couple of weeks ago, Mrs. [**Known lastname **] was in the bathroom during the night. She awoke her husband and could not get off the toilet. She felt faint. Her husband helped her up, noticing that both of her legs and arms were cool. She lay back in her recliner - in which she has slept since her radiotherapy and lymphoma. Her husband asked if he should call EMS, but she didn't think it necessary. Today, Mrs. [**Known lastname 4553**] was at home. Mr. [**Known lastname 4553**] went to work. During the morning she felt faint and called EMS. They arrived to find that she had fallen from her chair to the floor, striking her head. Per [**Hospital3 1443**] ED, she was unresponsive when the EMS arrived, unable to answer questions. However, en route, she apparently complained of neck and back pain. She was bradycardic to the 20s and transcutaneous pacing was unsuccessful. Dopamine increased her heart rate and atropine did little. On arrival the [**Hospital3 1443**] ED, she was described as lethargic but communicative, but soon after became 'suddenly ashen/cyanotic'. Dopamine gtt was started. Slow capillary refil was noted. EKG was interpreted as 'complete heart block with AV dissociation'. An echo was performed, per the Cardiology consult note, which noted global hypokinesis and LVEF of 25-30% while paced. Echos have previously been near normal. She was intubated for airway protection and sedation in the setting of bradycardia and placement of the temp wire. Tranvenous pacing wires were placed via a right subclavian line under fluroscopy (the left actually has an adjacent 17-year-old Port-A-Cath, still in place from treatment of her lymphoma). Given likely necessity for a PPM/ICD and her hemodynamic instability, she was transferred to [**Hospital1 18**] CCU. She arrived in a rigid neck collar - although CT head and neck had been performed at [**Hospital1 487**], [**Location (un) 1131**] was not completed. Her vitals on arrival were 98.7 F, 85 BPM, 21 RR, 100%. Blood pressure messurements varied widely, but were typically from 80s to 100s systolic. Past Medical History: - Lupus, [**Doctor First Name **] supressed, manifests as pleural effusions, on prednisone - Hypothyroidism, s/p partial thyroidectomy w/ lymphoma of neck, chemoradiation plus resection, on levothyroxine - Hypertension - Gastroesophageal reflux disease - Fibromyalgia, on oxycodone 7.5 mg [**Hospital1 **] - Sleep apnea, diagnosed, but has not wanted CPAP yet - Depression, on fluoxetine - Obesity - Osteoporosis - Cerebrovascular (small vessel) disease (on ASA and Plavix) Social History: -Tobacco history: None. -ETOH: None. -Illicit drugs: None. Lives with husband in two family. Daughter and son-in-law live upstairs with their son and a dog. Significant discord with daughter and son-in-law at present. Also grandchildren upstairs. Family History: Family history of heart disease, but not of early onset. Physical Exam: General: morbidly obese woman HEENT: Pupils symmetrically and markedly dilated (s/p atropine), ears clear, tube in place, cannot inspect OP Neck: Hematoma and echymosis on right lateral neck (later - central line in place in right IJ), very thick neck, cannot evaluate JVP. Cardiac: Difficult to auscultate due to ventilator and habitus, near tachycardic and regular. Lungs: Symmetric air entry anteriorly with some transmitted upper airway sound and ventilator noise. Abdomen: Obese, non-tender to deep palpation. Extremities: Trace edema, IO access in place at admission (later removed). Extremities cool and dusky. Skin: Echymosis on neck, [**Female First Name (un) **] under panus and breasts. Pulses: Peripheral pulses barely palpable, but ulnar and radial arteries were Dopplerable bilaterally. At the time of discharge, Mrs.[**Known lastname 20252**] physical exam was unchanged but for the following: Hematoma and bandage over pacer site, right subclavian, [**Female First Name (un) **] cleared, extremities well perfused, alert, oriented and appropriate, although drowsy at times. Pertinent Results: Labs at Admission [**2149-4-10**] 05:24PM BLOOD WBC-10.9# RBC-4.37 Hgb-14.7 Hct-44.0 MCV-101* MCH-33.8* MCHC-33.5 RDW-12.3 Plt Ct-208 [**2149-4-10**] 05:24PM BLOOD Neuts-76.4* Lymphs-12.1* Monos-9.3 Eos-1.9 Baso-0.3 [**2149-4-10**] 05:24PM BLOOD PT-12.8 PTT-23.4 INR(PT)-1.1 [**2149-4-12**] 03:56AM BLOOD Ret Aut-1.2 [**2149-4-10**] 05:24PM BLOOD Glucose-120* UreaN-8 Creat-0.7 Na-140 K-3.8 Cl-103 HCO3-27 AnGap-14 [**2149-4-10**] 05:24PM BLOOD ALT-58* AST-90* LD(LDH)-488* CK(CPK)-299* AlkPhos-62 TotBili-2.3* [**2149-4-10**] 05:24PM BLOOD CK-MB-14* MB Indx-4.7 cTropnT-1.20* [**2149-4-10**] 05:24PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.6* Mg-1.3* [**2149-4-12**] 03:56AM BLOOD Hapto-18* [**2149-4-15**] 05:39AM BLOOD VitB12-559 Folate-8.2 [**2149-4-10**] 05:24PM BLOOD T4-8.1 [**2149-4-11**] 06:14AM BLOOD Free T4-1.5 [**2149-4-13**] 05:00AM BLOOD C3-122 C4-23 [**2149-4-10**] 10:17PM BLOOD Type-ART pO2-142* pCO2-36 pH-7.44 calTCO2-25 Base XS-1 [**2149-4-10**] 10:17PM BLOOD Lactate-2.0 [**2149-4-10**] 10:17PM BLOOD O2 Sat-98 [**2149-4-12**] 10:47AM BLOOD freeCa-1.01* [**2149-4-10**] 05:24PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Cardiac Enzymes and [**Doctor First Name **] [**2149-4-10**] 05:24PM BLOOD CK-MB-14* MB Indx-4.7 cTropnT-1.20* [**2149-4-11**] 12:49AM BLOOD cTropnT-1.02* [**2149-4-11**] 06:14AM BLOOD CK-MB-7 cTropnT-0.56* [**2149-4-14**] 08:45AM BLOOD [**Doctor First Name **]-NEGATIVE Labs Prior to Discharge [**2149-4-25**] 04:35AM BLOOD WBC-10.7 RBC-3.35* Hgb-11.4* Hct-35.2* MCV-105* MCH-34.1* MCHC-32.5 RDW-15.0 Plt Ct-493* [**2149-4-24**] 08:25AM BLOOD Neuts-77.2* Lymphs-13.1* Monos-6.3 Eos-3.2 Baso-0.2 [**2149-4-23**] 08:27AM BLOOD PT-15.5* PTT-27.0 INR(PT)-1.4* [**2149-4-25**] 04:35AM BLOOD Glucose-91 UreaN-12 Creat-0.7 Na-140 K-3.4 Cl-98 HCO3-35* AnGap-10 [**2149-4-15**] 05:39AM BLOOD ALT-39 AST-45* AlkPhos-61 TotBili-1.4 [**2149-4-25**] 04:35AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.2 [**2149-4-18**] 02:47PM BLOOD Lactate-1.4 K-3.9 Speech & Swallowing Assessment, [**4-21**] Functional Oral Intake Scale (FOIS) rating of 6. RECOMMENDATIONS: 1. Suggest a PO diet of thin liquids and soft, moist solids. 2. Small bites and sips. 3. Meds crushed w/ purees [**2-11**] esophageal strictures. 4. TID Oral care. EKG [**2149-4-10**] Sinus rhythm. Left axis deviation. Right bundle-branch block with left anterior fascicular block. There are Q waves in the inferior leads consistent with prior myocardial infarction. There is lack of R waves in the anterior and anterolateral leads consistent with possible prior myocardial infarction. Non-specific ST-T wave changes. Low voltage in the precordial leads. Compared to the previous tracing right bundle-branch block, left anterior fascicular block and evidence of myocardial infarction are new. Rate PR QRS QT/QTc P QRS T 87 170 134 398/445 60 -63 105 Echo [**2149-4-11**] Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are not well seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Very limited study. Grossly preserved biventricular systolic function. Unable to comment on any valvular vegetations. If clinical suspicion of endocarditis persists, recommend obtaining a transesophageal study. CT chest, abdomen, pelvis [**2149-4-12**] IMPRESSION: 1. Markedly low lung volumes, with asymmetric left basilar consolidation, with air bronchograms. This may represent atelectasis, though pneumonia is certainly not excluded. Clinical correlation is advised. 2. Adequate positioning of supportive and monitoring devices including endotracheal tube, Swan-Ganz catheter, and NG tube. 3. Marked fatty infiltration of the liver. 4. Fatty involution of the pancreas. 5. Sigmoid diverticulosis without diverticulitis. Small bowel diverticulosis. EKG [**2149-4-19**] Sinus rhythm. Left axis deviation. Anteroseptal, anterior and inferior myocardial infarction. Intraventricular conduction delay. Compared to the previous tracing of [**2149-4-17**] there is no significant change. Rate PR QRS QT/QTc P QRS T 81 174 108 426/[**Medical Record Number 20253**] 44 CXR [**2149-4-22**] COMPARISON: Chest radiograph one day prior and multiple previous. Examination is somewhat limited by patient positioning and difficulty penetration. However, there is persistent left basilar atelectasis and pleural effusion with possible airspace infectious consolidation superimposed. The right lung remains clear. A right chest pacing device appears in unchanged position since the most recent radiograph. The bony thorax is difficult to evaluate. IMPRESSION: Persistent left effusion with atelectasis and possible superimposed airspace consolidation. CT head [**2149-4-23**] IMPRESSION: 1. No acute intracranial process. 2. Sequelae of small vessel disease and old lacunar infarcts in the left basal ganglia. 3. Complete opacification of the sphenoid sinus with inspissated secretions, essentially unchanged since [**8-/2139**], consistent with chronic sinusitis, with possible contribution of fungal colonization. Brief Hospital Course: In summary a 63 yo woman with h/o lupus, morbid obesity, h/o large cell lymphoma and hypothyroidism who presented with syncope in the setting of bradycardia and hypotension. Syncope Likely due to bradycardia with conduction block. She has been presyncopal numerous times recently, suggestive of intermittent heart block. She was hypotensive and bradycardic in the OSH, and tranvenous wires were required with restoration of blood pressure by pacing to 70 BPM. Transcutaneous pacing was not successful given habitus. EKG significant for large voltages and prolonged QRS, normal PR, suggesting Hisian disease, rather than calcific (CXR does not show marked calcification), infiltrative disease (voltages only slightly low in precordial leads but otherwise normal), or Rickettsial disease (intermittent rather than progressive). However, past MI is suggested by EKG, which may be responsible for block. EP planned to place a pacer, but she became febrile and hypotensive briefly on HD2, delaying placement. Eventually a permanent pacemaker was placed. She was not pacemaker dependent during most of her admission, only intermittantly engaging her device. Pacemaker placement was complicated by right subclavian hematoma - stable and without pain (this does increase the risk of post-device infection, however, so suspicion should remain for this if she develops a fever and inflammation around the site). She will follow-up with electrophysiology. Head Injury upon Syncope She had a contusion on her occiput upon arrival. C-spine and head cleared per OSH CT's - discussed with OSH radiologist. Given delirium and recent fall, her head CT was repeated late in the admission, for concern of slow subdural bleed. This repeat head CT was also without any bleeding. Respiratory failure Patient was intubated prior to arrival to secure airway and also because of hypoxia. Unclear etiology of hypoxia, but despite negative sputum favor respiratory infection(see below). However, primary cardiac process, including Hisian disease could account for respiratory failure, hypotension, hypoxia. Endocarditis was also considered given old hardware, arrhythmia, and low grade temp. Very high doses of fentanyl, Versed and proprofol were required for sedation, likely due to partitioning into lipid in a very large volume of distribution. Dexmedetomidine was used a bridge to extubation with anesthesiology present. This was successful and she remained comfortable on nasal cannula and then room air soon afterward. Although not taking bronchodilators at home, she was given ipratropium and albuterol nebulizer treatments in hospital - these may later be discontinued. Sedation, Mental Status, Delerium High doses of sedative medications were used, as described above. She also takes both opioids and benzodiazepines at home and has long suffered depression. As she recovered from sedation, delirium was prominent, along with some hallucinations and delusions. Psychiatry was consulted and recommended Zydis if absolutely necessary (not needed) and restarting home benzodiazepines (at a lower dose). During her early recovery from sedation haloperidol was also required, particularly given some outburst - she thumped her husband and grabbed the respiratory therapist. However, she had QT prolongation in response to this medication and it was discontinued. By the time of discharge she was pleasant, cooperative, without delusions and hallucinations, was remebering environmental events accurately, but was still drowsy at times during the day. Coronary Artery Disease Evidenced by EKG changes, with impression of normal echo in a limited study. Continued aspirin (also indicated by cerebrovascular disease) and statin. Consolidation on Chest X-ray No clinical correlate. Daily body temperature maximum was typically 99s, but no infection was identified and pneumonia was not suspected upon physical examination. However, breath sounds are difficult to appreciate and she was intubated for several days, so this should be followed. Yeast was found in sputum and urine, but Infectious Diseases recommended not treating this as they did not feel she clinically had an infection. Hypotension and Hypertension In context of fever, mild leukocytosis, considered sepsis. Swan-Ganz initially demonstrated increased calculated CO and decreased SVR c/w sepsis. Treated broadly for seven days, with suspicion much lower immediately after initiation of antibiotics (vancomycin, cefepime, and flagyl) - however, given somewhat fragile patient we felt that continuing treatement was most prudent. Sites of infection considered included endo/myocarditis, bacteremia, aspiration pneumonia/itis, along with some infected hardware given placement of a Port-a-Cath (left subclavian) that was never removed 17 years ago after chemotherapy. Urine lytes and physiology was then most consistent with a pre-renal, dehydrated state and blood pressures overshot after fluid resuscitation was given (also in the context of increase of steroids for lupus to stress-doses). Hypertension is treated at home with propranolol, likely given desirable anxiolytic effects. This was restarted during the admission and blood pressure will need to be followed. Aggressive treatment did not occur as some hypertension was likely secondary to steroids and there was still quite some variation. Leukocytosis Resolved now. Neutrophilia and leukocytosis, fever, hypotension on HD2, together concerning for sepsis. She was broadly covered with vancomycin, cefepime, metronidazole, completing a seven day course despite spontaneous resolution of fever (short latency, unlikely antibiotic effect). Together concerning for sepsis/occult infection. Could well be Gram negative sepsis. Recrudescence of lymphoma seems unlikely. Cardiac Enzyme Leak LDH could be cardiac, CK partially cardiac and TropT obviously so. TropT and CKMB trended down, so we attributed this to pacing in context of hypotension and hypoxia. However, recent missed MI would be consistent with EKG findings and offer an explanation for her heart block (EKG changes were also septal). Sleep Apnea This has been diagnosed by sleep study in the past and noticed again during the admission. We discussed this with her and Mr. [**Known lastname 4553**] and recommended that they follow-up in the future with Sleep Medicine to start CPAP at home. Elevated Total Bilirubin Biliary and hemaptic processes were considered, RUQ ultrasound negative. Most likely secondary to hemolysis within hematoma in neck after central line placement on arrival. Anemia Hct drop from 40 to 32. Elevated direct bili and decreased haptoglobin, but felt to be more likely secondary to hemotoma than hemolysis given resolution. However, did consider DIC in septic picture, which later did not fit the clinical picture. Most likely dilutional change plus blood breakdown in hematoma. Lupus Manifested only as pleural effusions in past. Inactive during the admission. Her Rheumatologist, Dr. [**Last Name (STitle) **], saw her during the admission and explained that here [**Doctor First Name **] is supressed on prednisone. She will follow-up with Dr. [**Last Name (STitle) **] in [**Month (only) **]. Complement also within normal limits. Insulin sliding scale was used with stress dose steroids, but not needed when steroids were reduced. Nutrition Tube feeds were given while she was intubated. Speech and Swallow deemed soft solids and thin liquids safe for her about 24 hours after extubation. This can likely be progressed soon, however, she has long had difficulty swallowing, reports an esophageal diverticulum and crushes pills at home. Access Venous access was very difficult. A central line (internal jugular) was placed and removed after pacer placement to reduce chance of infection. A subclavian line (right) was placed at the OSH for transvenous pacing. This was removed and right subclavian access used for pacer wires and pacer pocket. Port-a-Cath of 17 years standing occupies the left subclavian position. Placement of arterial line was difficult also. Peripheral venous access was maintained. Hypothyroidism and Past Lymphoma Per Mrs. [**Known lastname 4553**]: Had a 'large cell' lymphoma of the neck that was attached to the thyroid, resulting in partial resection. Chemoradiotherapy was also given. She now requires levothyroxine. TSH was suppressed at 0.16 during the admission, suggesting that levothyroxine might be later adjusted downward after Chronic Pain Chronic low back pain and fibromyalgia were treated at home with Percocet 7.5/500 mg up to four times daily (typically two). We changed this to standing Tylenol with oxycodone breakthrough on discharge, ensuring that her intake of Tylenol is controlled. Depression and Anxiety Treated with fluoxetine throughout the admission. Trazadone is also given at a dose with some antidepressant efficacy, possibly, on the cusp of sedative/antidepressant doses (75 mg). Trazadone, fluoxetine, propranalol and Xanax are her anxiolytic medications. Hemoptysis Brief self-limited hemoptysis after extubation was thought to be due to endothelial scratch during ETT removal. There was only one episode. Hypokalemia Typically received 20-40 mEq per day in hospital. She is written for 20 mEq daily, but this will need to be followed, perhaps in three to four days. DVT Prophylaxis Mrs. [**Known lastname 4553**] was given 7500 [**Location 20254**] heparins TID. Code Status and Health Care Proxy She was full code throughout the admission. Her HCP is her very helpful, nice and supportive husband, [**Name (NI) **] [**Name (NI) 4553**]. Osteoporosis Vitamin D and calcium were restarted at discharge. Alendronate should be resumed as prior to the admission. Hypercholesterolemia Atorvastatin was continued at home dose during the admission. Given likely CAD, patient may warrant uptitration of this medication as an outpatient. Cerebrovascular Disease Continued Plavix and aspirin given CT evidence and history of cerebrovascular disease and stroke. Yeast Cutaneous Infection Resolved during the admission with cleansing and topical antifungal. GERD She was diagnosed with GERD in [**2146**], but without active treatment. She was maintained on famotidine throughout the admission, starting at intubation. This was stopped at discharge. Disposition She remained in the CCU throughout the admission for nursing support and was transferred directly to acute rehabilitation for physical therapy and to return to baseline before returning home. Medications on Admission: - Alendronate 70 mg once weekly - Alprazolam 2 mg qhs - Atorvastatin 10 mg qday - Clopidogrel 75 mg qday - Ergocalciferol 50,000 unit qweek - Fluoxetine 60 mg qday - Levothyroxine 200 mcg qday - Nystatin cream prn - Percocet 7.5-500 qid prn - Potassium chloride 20 mEq tid - Prednisone 6 mg qday - Propranolol 80 mg qday - Trazodone 75 mg qhs - ASA 325 qday - Cyanocobalamin 100 mcg qday - Multivitamin qday Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 7500 (7500) units Injection TID (3 times a day). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 6. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Prednisone 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath, wheezing. 12. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q8H (every 8 hours). 13. Propranolol 80 mg Capsule,Sustained Action 24 hr Sig: One (1) Capsule,Sustained Action 24 hr PO DAILY (Daily). 14. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO daily (). 15. Oxycodone 5 mg/5 mL Solution Sig: 7.5 mg PO Q8H (every 8 hours) as needed for pain. 16. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for redness at skin folds. 18. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 19. Trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 20. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 21. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: weekly on empty stomach with full 8oz of water, do not eat or lie down for 30 min after taking . Discharge Disposition: Extended Care Facility: Courtyard - [**Location (un) 1468**] Discharge Diagnosis: Primary Diagnoses: Syncope Symptomatic bradycardia Secondary Diagnoses: - Lupus - Hypothyroidism - Hypertension - Gastroesophageal reflux disease - Fibromyalgia - Sleep apnea - Depression - Obesity - cerebro-vascular disease Discharge Condition: Mental Status: Confused - sometimes - patient is usually clear during the day but sometimes becomes confused at night. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Patient requires assistance of a [**Doctor Last Name 9808**] to get out of bed to chair. Discharge Instructions: You were admitted to the hospital because you fainted and were found to have a very slow heart rate. You had a permanent pacemaker placed. You will need to follow-up in the pacemaker device clinic and with an electrophysiologist (a cardiologist who specializes in pacemakers). Followup Instructions: Please call the cardiology department at [**Telephone/Fax (1) 62**] on Tuesday [**4-29**] to get the dates and times of your device clinic and electrophysiology appointments. Please attend these follow-up appointments with your primary care doctor and your rheumatologist: [**2149-5-26**] 02:45p [**Last Name (LF) **],[**First Name3 (LF) **] W. [**Location (un) **] ([**Location (un) 2788**], MA), [**Location (un) **] [**Location (un) 2788**] INTERNAL MEDICINE (NHB) [**2149-6-13**] 01:00p [**Last Name (LF) 3310**],[**First Name3 (LF) **] (RHEUM LMOB) LM [**Hospital Unit Name **], [**Location (un) **] RHEUMATOLOGY LMOB WEST (SB)

[ "729.1", "038.9", "995.91", "427.89", "287.5", "530.81", "518.81", "733.00", "998.12", "786.3", "401.9", "710.0", "997.39", "293.9", "998.59", "300.4", "285.9", "V10.72", "780.57", "426.0", "507.0", "244.9" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "96.04", "37.83", "38.93", "37.72", "38.91" ]

icd9pcs

[ [ [] ] ]

23185, 23248

10158, 20741

301, 559

23517, 23517

4888, 10135

24167, 24819

3704, 3762

21200, 23162

23269, 23321

20767, 21177

23865, 24144

3777, 4869

23342, 23496

253, 263

589, 2925

23532, 23841

2947, 3422

3438, 3688

23,104

122,272

9103

Discharge summary

report

Admission Date: [**2136-6-6**] Discharge Date: [**2136-7-2**] Date of Birth: [**2078-4-18**] Sex: F Service: Vascular CHIEF COMPLAINT: Acute ischemic right leg. HISTORY OF PRESENT ILLNESS: (The history of present illness was obtained from the patient's other Discharge Summaries). This is a 58-year-old white female who presents with acutely ischemic right leg. She awoke suddenly in severe pain at about 4:30 today and presented to [**Hospital3 417**] Hospital with a cold pulseless foot. She was started on heparin 5000 units after 4500 unit bolus and was transferred to our institution for further care. The patient has required large doses of narcotics to be comfortable (i.e. 50 mg of Dilaudid intravenously over three hours). On arrival, the patient had an acutely ischemic leg with pain, pallor, cold, and pulseless. There was no paralysis, but toe movement was diminished. The leg appeared model, cold, unable to palpate Doppler pulses in the right leg or right groin or across the femoral-femoral. The patient has a history of poly microorganism right groin infection in [**2136-3-9**]. The groin is almost totally healed. There was just small gauze over the area. PAST MEDICAL HISTORY: (Past medical history Family history includes) 1. Hyperlipidemia. 2. Hypertension. 3. Coronary artery disease. 4. Peripheral vascular disease. 5. Nicotine abuse. PAST SURGICAL HISTORY: (Past surgical history includes) 1. Aortobifemoral in [**2126**]. 2. A femoral-femoral revision and removal in [**2131**]. 3. A left axillofemoral in [**2131**] with a revision in [**2125-7-9**] and [**2125-5-9**]. 4. A thrombectomy of the axillofemoral in [**2134-2-9**]. 5. A right groin infection in [**2136-2-10**]. 6. A left femoral thrombectomy with vein patch angioplasty in [**2134-7-10**]. 7. Left below-knee amputation. 8. Remote cholecystectomy. 9. Remote appendectomy. 10. Remote total abdominal hysterectomy. 11. Left femoral angioplasty with stent placement in [**2133**]. ALLERGIES: MORPHINE causes pruritus and a rash. MEDICATIONS ON ADMISSION: Medications included Lopressor 50 mg p.o. b.i.d., Tricor 67 mg p.o. b.i.d., Lipitor 80 mg p.o. q.d. SOCIAL HISTORY: She is married and lives at home with husband. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed an older white female in acute distress. Head, eyes, ears, nose, and throat examination was unremarkable. The neck was supple. There was no lymphadenopathy. Carotids with questionable bruits. Pulse examination showed palpable carotids bilaterally. Radial pulses were palpable bilaterally. Axillofemoral pulse was 2+. Right femoral pulse was 2+. There was no dopplerable or palpable pulses below the right femoral. The left femoral pulse was absent, and the patient is below-knee amputation. The chest was clear to auscultation bilaterally. Heart had a regular rate and rhythm. Abdominal examination was unremarkable. Rectal examination was deferred. Her left below-knee amputation was well-healed. The right foot was cool, modeled, was pulseless; unable to Doppler the right groin or right leg. No signals in the femoral-femoral bypass. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories included a white blood cell count of 9.8, hematocrit was 36.2, platelets were 149. Blood urea nitrogen was 8, creatinine was 0.6, potassium was 5.3. PT was 12.7, INR was 1.1, PTT was 70.7 (on 1000 units per hour). RADIOLOGY/IMAGING: Electrocardiogram revealed nonspecific ST-T wave changes in the inferior leads. A chest x-ray was unremarkable. HOSPITAL COURSE: The patient underwent urgent arteriogram. The findings were a thrombosed femoral-femoral bypass graft and proximal right leg runoff down to the distal superficial femoral artery. Transient restoration of the antegrade flow following catheter directed thrombectomy and balloon angioplasty of the proximal femoral-femoral bypass stricture up to 8 mm. There was diminished flow within the axillofemoral, suggesting a proximal inflow problem. These findings were reported the vascular team. The patient was transferred to the Surgical Intensive Care Unit for continued monitoring and care. Dr. [**Last Name (STitle) 1476**] was consulted and recommended appropriate revascularization. The patient underwent, that same day, right axillary to right popliteal above-knee bypass with polytetrafluoroethylene. The patient tolerated the procedure well and was transferred to the Surgical Intensive Care Unit for continued monitoring and care. Immediate postoperatively findings were that the patient had ecchymosis overlying the graft on the flank with a cool modeled left stump to the knee. The right foot was warm. The patient's postoperative hematocrit was 26.7, blood urea nitrogen was 8, and creatinine was 0.6. Total creatine phosphokinase was 1836; which peaked at 3281. The MB fraction was 18. There were diffuse ST-T wave changes in I, II, aVL, aVF, V1 through V6. A chest x-ray was unremarkable. On physical examination, the right dorsalis pedis was dopplerable. The posterior tibialis was palpable. Serial creatine kinase and troponin enzymes were done along with serial electrocardiograms. The patient was transfused to maintain a hematocrit of greater than 30. Cardiology was requested to see the patient. Cardiology felt that there was coronary ischemia in the setting of a postoperative source and that the approximate measurements were being taken. Serial enzymes, afterload reduction, or recurrent chest pain should be treated with intravenous nitroglycerin. Over the next 24 hours, her electrocardiogram returned to baseline without any further ischemic changes; although, her troponin level peaked to 24 and decreased to 18.6. Consideration for possible cardiac catheterization were given. Intravenous heparin was discontinued because of thrombocytopenia, and heparin-induced thrombocytopenia antibodies were sent. The patient was begun on anticoagulation on postoperative day three, and she was transferred to the regular nursing floor for continued monitoring and care. Heparin-induced thrombocytopenia antibodies were negative, and the Coumadin was held, and intravenous heparin was reinstituted. The patient underwent cardiac catheterization on [**2136-6-12**]. This study demonstrated a left main was normal, the left anterior descending artery had a previous stent and patent without restenosis. There was a mid 50% distal lesion in the mid segment of the left anterior descending artery. The second diagonal had a ostial lesion of 60% to 70% which was in a small vessel. The left circumflex was a nondominant vessel without critical stenosis. The right coronary artery was a dominant vessel with occlusion. An arteriogram was also done which demonstrated an occluded aorta at the level below the renal arteries and superior mesenteric artery. There was no runoff in the native iliac territory. Intravenous heparinization was continued. On [**2136-6-13**] the patient underwent a retroperitoneal approach with aorta to left profunda nonreversed left superficial femoral vein graft to a partial excision of axillofemoral femoral graft. The patient was transferred to the Postanesthesia Care Unit in stable condition. Postoperative hematocrit was 31. Blood urea nitrogen and creatinine were stable. She had a dorsalis pedis and posterior tibialis dopplerable signal pulses on the right leg. She continued to do well and was transferred to the Vascular Intensive Care Unit for continued monitoring and care. She did require fluid boluses for her low urine output with an adequate response. The patient's patient-controlled analgesia dosing was adjusted to improve analgesic control. Lopressor was increased, and the patient was up in chair. The nasogastric tube was discontinued. The patient remained in the Vascular Intensive Care Unit for continued monitoring and care. On postoperative day two, there were no overnight event. The patient was passing flatus. Hematocrit remained stable at 29. Potassium was 3.6 (which was repleted). Her examination remained unchanged. She was continued on the patient-controlled analgesia for analgesic control. She was converted to oral Lopressor. Clear liquids were begun. Lasix for diuresis. Ancef for perioperative antibiotics until lines were removed. On postoperative day three, over the last 24 hours the patient required a total of Lasix 30 mg intravenously over 24 hours. Her heparin was stopped, and coumadinization was begun. She did require 2 units of packed red blood cells for a hematocrit of 29. Her post transfusion hematocrit was only 27. The patient underwent an abdominal CT to rule out silent retroperitoneal bleed. The CT scan demonstrated a left posterior pararenal hematoma. The patient remained stable. She had serial hematocrits done; 7 p.m. hematocrit on [**6-26**] was 25. She required another 2 units of packed red blood cells and 2 units of fresh frozen plasma. The patient's post transfusion hematocrit was 28.4. Serial hematocrits were continued. All stools were guaiaced. Coumadin continued to be held. The patient was to be transfused for a hematocrit of less than 26. The patient was begun on linezolid and vancomycin for erythema of the wounds. Levofloxacin and Flagyl were added to the antibiotic regimen on [**6-19**]. The Social Service followed the patient and the family for support. Over the next 48 hours, her hematocrit remained stable at 28.2. Blood urea nitrogen and creatinine remained stable. The patient was begun on OxyContin for analgesic control. The A-line was discontinued. She was gently diuresed with 20 mg of Lasix q.8h. that day. The patient was transferred to the regular nursing floor. The central line was discontinued, and a peripheral intravenous access was placed. Noninvasive vein mappings of the lower extremities and the left saphenous vein were obtained on [**2136-6-20**]; for potential conduit. The patient continued to do well. On [**6-25**], the patient underwent removal of the remaining effective femoral-femoral graft and a vein graft patch to the right common femoral artery. The patient tolerated the procedure well and was transferred to the Postanesthesia Care Unit in stable condition. Postoperative hematocrit was 33.8. Blood urea nitrogen and creatinine were 14 and 0.5; respectively. Potassium was 4.5. Calcium required repletion. The patient continued to do well. She had palpable popliteal pulses bilaterally, and the posterior tibialis was not palpable. On postoperative day one (from her surgery), she had a low urine output requiring an intravenous fluids bolus. Her hematocrit remained stable. Levofloxacin, Flagyl, and linezolid were continued. She was de-lined and transferred to the regular nursing floor. Anticoagulation was begun. She continued to require diuresis over the next 48 hours. Boost was ordered for additional nutritional support. Wound dressings were b.i.d. Physical Therapy was requested to see the patient for assessment for discharge planning. They felt that the patient would be able to be discharged home when medically ready. DISCHARGE DISPOSITION: The patient continued to do well and was ultimately discharged on [**2136-7-2**] to home. She was to follow up with Dr. [**Last Name (STitle) **] in two weeks. Her hematocrit at discharge was 32.6. Her INR was 1. Blood urea nitrogen was 17 and creatinine was 0.4. Potassium was 4.1. The wounds were clean, dry, and intact. She had dopplerable right extremity pulses. She was to be discharged on OxyContin 30 mg p.o. b.i.d. with Percocet for breakthrough pain. Her Coumadin dosing was 3 mg p.o. q.d. (should be adjusted for a goal INR of 2.5 to 3). MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Warfarin 3 mg p.o. q.d. 2. Oxycodone sustained release 30 mg p.o. q.12h. 3. Percocet one to two tablets p.o. q.4-6h. as needed for breakthrough pain. DISCHARGE DIAGNOSES: 1. Acute right leg ischemia. 2. Status post angioplasty. 3. Status post right axillary-right popliteal bypass graft with polytetrafluoroethylene; emergent. 4. Infected axillofemoral graft; status post aorta left profunda bypass with a nonreversed left superficial femoral vein. 5. Partial excision axillofemoral graft. 6. Status post removal of remaining of femoral-femoral graft on [**2136-6-25**] with vein patch graft to the right common femoral artery. 7. Blood loss anemia; transfused. 8. Myocardial infarction secondary to anemia and surgical intervention; treated. 9. Status post cardiac catheterization. 10. Chronic pain; controlled. 11. Vancomycin-resistant enterococcus urinary tract infection; treated. 12. History of methicillin-resistant Staphylococcus aureus. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2136-9-26**] 16:19 T: [**2136-10-2**] 10:02 JOB#: [**Job Number 20629**]

[ "V45.82", "410.71", "401.9", "443.9", "272.4", "997.1", "996.62", "998.12", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "88.53", "39.49", "88.48", "39.25", "39.29", "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

11221, 11779

12018, 13095

11806, 11996

2105, 2206

3621, 11197

1420, 2078

153, 180

209, 1205

1228, 1396

2223, 3603

67,460

108,940

31952

Discharge summary

report

Admission Date: [**2154-10-10**] Discharge Date: [**2154-10-14**] Date of Birth: [**2092-2-4**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: Radiation Necrosis Right Brain Mass Major Surgical or Invasive Procedure: [**10-10**]: Right Crani for Mass resection Past Medical History: Polycythemia [**Doctor First Name **] Dx 7 yrs ago GERD NSCLC (See HPI) Social History: Lives with wife in [**Name (NI) 1559**] area. Ex executive at optics company. No ETOH. Ex- Smoker ages 16-26. No drugs. Father of 2 daughters. Family History: No Cancers, No DM. Grandfather with CAD. Both parents alive and well. Physical Exam: On Discharge: XXXXXXXXXXXXXX Pertinent Results: Labs On Admission: [**2154-10-11**] 01:28AM BLOOD WBC-22.0*# RBC-4.64 Hgb-13.0* Hct-37.6* MCV-81* MCH-28.0 MCHC-34.6 RDW-16.2* Plt Ct-653* [**2154-10-11**] 01:28AM BLOOD Glucose-170* UreaN-16 Creat-1.0 Na-138 Cl-101 HCO3-26 [**2154-10-11**] 01:28AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.0 [**2154-10-11**] 01:28AM BLOOD Phenyto-11.3 Labs on Discharge: XXXXXXXXXXXXXXXXXXX Imaging: Head CT [**10-10**]: IMPRESSION: Expected post-surgical changes status post right frontal craniotomy and biopsy of right frontal lesion. MRI [**10-11**]: XXXXXXXXXX Brief Hospital Course: Patient was electively admitted on [**10-10**] for a right crani for mass resection. He tolerated the procedure well. Post-operatively he was monitored with ICU level care for the next 24 hours. Post operative imaging studies were performed without incident(reports on previous page). He was seen and evaluated by PT who determined him to be appropriate for discharge to home. Hematology was curbsided to address the necessity for lovenox in the setting of his polycythemia [**Doctor First Name **]; and it was determined to not be indicated. In addition, his DVT was in [**2152**], and is no longer indicated to continued lovenox therapy. His was discharged with followup in the Brain Tumor Clinica, and with his oncologist. Medications on Admission: None Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 4. Dilantin Kapseal 100 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*0* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Dexamethasone 4 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day) for 3 doses. Disp:*3 Tablet(s)* Refills:*0* 8. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day) for 3 doses. Disp:*9 Tablet(s)* Refills:*0* 9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 doses. Disp:*3 Tablet(s)* Refills:*0* 10. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 doses. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Radiation Necrosis, Right Brain Mass Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. Please have results faxed to [**Telephone/Fax (1) 87**]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions You have an appointment to be seen in the brain tumor clinic on [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Bldg for [**11-11**] at 1pm. You have an MRI scheduled immediatley before at 11am, with will occur in the [**Hospital Ward Name 517**] Basement. Please call [**Telephone/Fax (1) 1844**] if you have any scheduling conflict, or require directions. You also have an appointment scheduled with your oncologist on: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2154-10-29**] 9:30 Completed by:[**2154-10-14**]

[ "909.2", "E879.2", "238.4", "162.8", "437.8", "530.81", "197.2", "198.3" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

3298, 3304

1377, 2105

356, 402

3385, 3409

810, 815

4983, 5608

675, 746

2160, 3275

3325, 3364

2131, 2137

3433, 4960

761, 761

775, 791

281, 318

1157, 1354

829, 1138

424, 498

514, 659

80,932

190,053

41503

Discharge summary

report

Admission Date: [**2120-2-16**] Discharge Date: [**2120-2-21**] Date of Birth: [**2051-5-14**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: ST elevation myocardial infarction Major Surgical or Invasive Procedure: [**2120-2-16**] - Emergency coronary artery bypass grafting x4 with left internal mammary artery to left anterior descending artery and saphenous vein graft to posterior descending artery and saphenous vein sequential graft to ramus and obtuse marginal arteries. History of Present Illness: 68 year old male who in [**Month (only) **] started developing left arm numbness/tingling with nausea and diaphoresis that resolved after few minuted of rest occuring intermittently. He underwent evaluation which included ruling out cardiac disease and was referred for GI workup as he was told the symptoms were not cardiac related. Underwent workup for gall bladder, u/s negative but referred to GI specialist. His sympotms yesterday became more frequent with 2 episodes lasting 10-15 minutes, one while walking with wife and other while running errands. Both episodes resolved with rest no further intervention. This am around 5 am had arm nembness, diaphoresis and nausea but resolved in few minutes. However at around 7am he developed chest pain in mid chest radiating to left side and EMS was called - on arrival he continued with Chest pain, b/p 202/100, HR 54 - relieve with oxygen - transferred to MWMC ED - ruled in for ST elevation myocardial infarction (STEMI) with elevations in lead v2, v3 and lateral leads per chart. He underwent cardiac catheterization that revealed 80% left main, RCA and LAD disease. He continued with chest pain and then jaw pain - was started on intergrilin, angiomax, and nitroglycerin with continued pain, transferred for surgical evaluation. On arrival he continued to have jaw and face pain treated with NTG SL and increased NTG gtt - Dr [**First Name (STitle) **] in to evaluate. He was taken to the operating room emergently for CABG. Past Medical History: Mild GERD s/p right hip replacement [**10/2119**] s/p bilateral knee surgery Social History: Last Dental Exam: 4 month ago Lives with: spouse Occupation: retired athletic director Tobacco: denies ETOH: 3 beers a week Family History: Mother at 80 CABG deceased at 85 Physical Exam: General: breathing easy with pain in face - relieved with NTG SL and increase on NTG gtt Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: alert and oriented x3 nonfocal Pulses: Femoral Right: arterial sheath Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Pertinent Results: ECHO [**2120-2-16**] PREBYPASS: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy (1.6 cm free wall thickness) with mildly dilated cavity size (4.3-5.8cm). The basal inferior wall is hypokinetic, the mid inferior wall is mildly hypokinetic and the the remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The 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. There is no pericardial effusion. The TV and PV are essentially normal. No PFO or clot in the LAA was seen. PWD flow velocities in the left atrial appendage was >55cm/sec Diastolic dysfunction is present with an E' =6.9 cm/sec. The coronary sinus is normal is size (no evidence of persistent left svc). Mild descending thoracic aortic atherosclerosis is present. POST BYPASS: Improved LV systolic funciton with LVEF>55%, no segmental wall motion abnormalities. (LV basal hypokinesis has resolved). No dissection seen after aortic cannula was removed. No valvular problems, good RV funciton. Brief Hospital Course: Mr. [**Known lastname 90278**] was admitted to the [**Hospital1 18**] on [**2120-2-16**] via transfer from [**Hospital6 **] for surgical management of his coronary artery disease. He was expeditiously worked-up in the usual preoperative manner and taken emergently to the operating room where he underwent coronary artery bypass grafting to four vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next few hours, he awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were started. On postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Mr. [**Known lastname 90278**] had a burst of atrial fibrillation which was treated with an increase in his beta blockade and amiodarone. He will take 200mg twice daily on discharge for 1 week and then decrease to 200mg daily thereafter for 1 month. An ace inhibitor was started given his preoperative myocardial infraction. Mr. [**Name14 (STitle) 90279**] continued to make steady progress and was discharged home on postoperative day five. An appointment has been scheduled for next week with his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] so that he may be referred to a cardiologist and have his renal function checked. He has also been scheduled to see Dr. [**First Name (STitle) **] in 3 weeks. Medications on Admission: Aspirin Pepcid OTC prn Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO Take 1 (200mg) tab twice a day for one week and then decrease to one (200mg) tab daily. Disp:*40 Tablet(s)* Refills:*1* 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary artery disease s/p CABG ST elevation Myocardial Infarction Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Trace Edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Take lasix 40mg and potassium 20mEq daily for one week then stop or as directed by your primary care physician. 7) Take amiodarone 200mg twice daily for one week and then decrease dose to 200mg daily thereafter until otherwise instructed. 8) Please discuss being referred to a cardiologist with Dr. [**Last Name (STitle) **] upon your follow-up visit in [**12-3**] weeks. 9) Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 766**] [**3-25**], 1:00PM Cardiologist: You will be referred to a cardiologist by Dr. [**Last Name (STitle) **]. Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] on Tuesday [**2-27**], 1:45PM [**Telephone/Fax (1) 6034**]. Please have him refer you to a cardiologist. **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2120-2-21**]

[ "997.09", "530.81", "427.31", "953.4", "E878.2", "V43.64", "410.41", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7334, 7393

4499, 6080

344, 609

7505, 7716

3072, 4476

8980, 9698

2384, 2419

6154, 7311

7414, 7484

6106, 6131

7740, 8957

2434, 3053

270, 306

637, 2126

2148, 2227

2243, 2368

23,642

114,665

6673

Discharge summary

report

Admission Date: [**2140-3-6**] Discharge Date: [**2140-3-13**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Placement of percutaneous cholecystostomy tube History of Present Illness: [**Age over 90 **] year old male who presents with 3 days of abdominal pain which has gotten progressively gotten worse. He has had 2 days of vomiting clear liquid and feeling nauseated. He denies fever/chills or night sweats. He had a bowel movement this morning. No diarrhea. He had a cholecystostomy tube placed in [**2137**] for a similar episode. Past Medical History: # Hypertension # Osteopenia [**3-8**] steriod use # Diabetes mellitus Type 2 # Diabetic peripheral neuropathy # Hypercholesterolemia # Osteoarthritis # Hemorrhoids # Peripheral vascular disease # Chronic left hip pain # Cataracts # Onychodystrophy # Mitral regurgitation # Giant cell temporal arteritis Social History: # Personal: [**Location 7972**], speaks Portuguese. Lives with wife. Independent in ADLs, but walks with a cane. # Substance use: No h/o ETOH, tobacco, or recreational drug use. Family History: Noncontributory Physical Exam: In ED: Vital Signs: T 97 HR 73 BP 180/82 18 100 General: No Acute distress Lungs: Clear to auscultation bilaterally Cardiac: Regular rate and rhythm Abdomen: Soft, tender in the right upper quadrant, no guarding, nondistended Rectal: Normal tone, no gross blood, guaiac negative Pertinent Results: [**2140-3-6**] 12:55AM WBC-9.2# RBC-3.84* HGB-10.9* HCT-33.9* MCV-88 MCH-28.3 MCHC-32.1 RDW-15.5 [**2140-3-6**] 12:55AM NEUTS-65.4 LYMPHS-24.5 MONOS-9.4 EOS-0.3 BASOS-0.3 [**2140-3-6**] 12:55AM PT-14.6* PTT-30.5 INR(PT)-1.3* [**2140-3-6**] 12:55AM LIPASE-40 GGT-115* [**2140-3-6**] 12:55AM ALT(SGPT)-35 AST(SGOT)-45* ALK PHOS-193* TOT BILI-0.5 [**2140-3-6**] 12:55AM GLUCOSE-108* UREA N-29* CREAT-1.5* SODIUM-138 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-21* ANION GAP-20 [**2140-3-6**] 01:02AM LACTATE-2.9* Liver/Gallbladder U/S: Distended gallbladder with pericholecystic fluid and gallbladder wall thickening measuring up to 8 mm and sludge ball with findings highly concerning for acute cholecystitis. CTAP: 1. Distended gallbladder with surrounding pericholecystic fluid and gallbladder wall enhancement and surrounding stranding that is highly concerning for acute cholecystitis that can be confirmed with ultrasound as clinically indicated. 2. Prostatic enlargement measuring up to 5.2 cm in transverse dimension. 3. Extensive atherosclerotic disease and plaque involving the abdominal aorta and all of its major branches. 4. Right inguinal hernia containing fat and loop of small bowel without associated obstruction. Brief Hospital Course: Mr. [**Known lastname 25456**] was admitted with acute cholecystitis and underwent percutaneous cholecystostomy tube placement. Because of his advanced age and other medical comorbidities, he was admitted to the surgical ICU and placed on IV antibiotics and had placement of a right internal jugular central line for fluid and medication delivery and monitoring. As he improved, he was transferred to the floor and his diet was slowly advanced as tolerated. Cultures from PTC drain grew gram negative rods and gram positive rods. When sensitivities were finalized antibiotics were narrowed to Ciprofloxacin. Patient remained afebrile with normal viatal signs prior to discharge. Medications on Admission: Albuterol, ASA 325, Metoprolol 50'', metop XL 200', Prednisone 5 mg ', Lisinopril 40', Amlodipine 5', Gabapentin 300', Alendronate 35mg Q Fri, Lipitor 40', GLipizide 5', HCTZ 25', Metformin 500', Ca+ D 500-200, colace, senna, protonix 40', tylenol Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale per sliding scale Injection ASDIR (AS DIRECTED). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 11. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*7 Tablet(s)* Refills:*0* 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed for constipation. 15. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day: Until gout flare resolves. Disp:*14 Tablet(s)* Refills:*0* 16. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for gout for 3 days. 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] - [**Location (un) **] Discharge Diagnosis: acute cholecystitis 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 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 [**6-13**] 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. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. General Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: Please call Dr.[**Name (NI) 2829**] office at ([**Telephone/Fax (1) 2363**] on Monday [**3-14**] in order to schedule a follow up appointment. Please follow up with your primary care provider within two weeks of discharge.

[ "357.2", "443.9", "250.60", "715.90", "575.0", "041.4", "274.01", "401.9", "272.0" ]

icd9cm

[ [ [] ] ]

[ "87.54", "51.01" ]

icd9pcs

[ [ [] ] ]

5478, 5548

2841, 3521

274, 323

5612, 5612

1578, 2818

8715, 8942

1245, 1262

3820, 5455

5569, 5591

3547, 3797

5789, 6693

7323, 8692

1277, 1559

6726, 7307

220, 236

351, 707

5626, 5765

729, 1033

1049, 1229

45,132

137,233

54792+59631

Discharge summary

report+addendum

Admission Date: [**2167-9-5**] Discharge Date: [**2167-9-15**] Date of Birth: [**2144-12-23**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5084**] Chief Complaint: Traumatic brain injury/ multiple brain contusions Major Surgical or Invasive Procedure: None History of Present Illness: This is a 22 year old male presents with ETOH level 259 status post ejected passenger in motor vehicle accident. The patient reportedly exhibited agonal breathing on the scene. He was taken to emergency room where he was intubated. The patient was a difficult intubation and during intubation became bradycardic to the 40s. He o2 saturation was never below 98%. Past Medical History: none Social History: Student; Mother and father at bedside Family History: NC Physical Exam: Gen:Intubated GCS 10T off sedation for 5 minutes HEENT: clear fluid right ear. Pupils: 5-4mm EOMs:not able to comply with exam- disconjugate gaze Neck: hard cervical collar Extrem: Warm and well-perfused. Neuro: Mental status/Orientation: opens eyes to loud voice, grips and opens eyes to command, non verbal intubated Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 5 to 4 mm bilaterally. Visual fields- unable to test III, IV, VI: Extraocular movements- unable to test V, VII,VIII,IX, X, [**Doctor First Name 81**], XII: unable to test due to poor mental status Motor:the patient is moving all extremities purposefully with good strength. he does not participate in a motor exam. he is localizing and has made multiple attempts to sit up in bed off sedation Toes downgoing bilaterally PHYSICAL EXAM UPON DISCHARGE: Pertinent Results: CT C-spine [**2167-9-5**] No acute overt vertebral body fracture. Linear lucency within the left lateral mass seen only on coronal images may represent nutrient foramina, however nondisplaced fracture, though less likely, cannot be completely excluded in the setting of trauma. FINAL ATTENDING COMMENT: above finding likely represents a nutrient foramen and not a fracture. CT head [**2167-9-5**] at 02:30 1. Fracture extending from the right occipital into the right temporal bone (petrous and squamous portions) with mild medial displacement of fracture fragment involving squamous temporal bone. Overlying subgaleal hematoma and soft tissue swelling. 2. Extra-axial blood layering over the right middle cranial fossa concerning for epidural hematoma. 3. Extra-axial hyperdensity layering over the left cerebral hemisphere concerning for left subdural hematoma. 4. Subarachnoid hemorrhage particularly within the left frontal lobe. 5. Left frontal parenchymal contusion cannot be completely excluded, although difficult to evaluate in setting of trauma. 6. Right subfalcine herniation and 2mm rightward shift of the midline structures. 7. Blood in the external auditory canal. Fluid, likely blood in right mastoid air cells. CT torso [**2167-9-5**] No acute fractures. No evidence of traumatic injury to chest, abdomen or pelvis. Minimal periportal edema likely due to volume resuscitation. CT head [**2167-9-5**] at 06:00 Parenchymal contusions (left frontal, right frontal and right temporal). New layering blood along the posterior falx and and along the tentorium bilaterally. These findings are more obvious on today's study and evaluation of hemorrhage however these findings may have been masked by motion degradation on the prior study. Other findings similar to the prior examination with similar degree of shift of normally midline structures. CT head [**2167-9-6**] at 07:55 Parenchymal contusions in the left frontal, right frontal, and right temporal lobes. The frontal contusions are increased since the prior study. Similar amount of layering blood seen along the posterior falx and along the tentorium bilaterally. Slight increase in the shift of the normally midline structures compared to the prior study, although this is not dramatically different CT head [**2167-9-7**] at 02:13 IMPRESSION: 1. Stable intraparenchymal contusions in the inferior frontal lobes and right temporal lobes. 2. Subdural and subarachnoid hemorrhage appears similar in distribution compared to prior examination. Degree of midline shift appears similar. 3. Unchanged appearance of minimally displaced right skull fracture as described above. CT head [**2167-9-7**] at 07:53 Multiple intraparenchymal contusions are redemonstrated within the inferior bilateral frontal lobes. Overall, distribution and severity appear similar to the most recent exam. Punctate right temporal contusion as well as minimal left subdural hematoma are unchanged. Layering hemorrhage along the posterior phalanx and extending to the tentorium bilaterally is also again present. Diffuse subarachnoid hemorrhage filling the suprasellar cistern is again present as is the midline shift of approximately 3 mm. There may also be a small amount of epidural hematoma overlying the skull fracture. In comparing multiple prior CTs, there does appear to be an increase in the amount of effacement of the suprasellar cistern concerning for progressive downward tentorial herniation. Minimally displaced right parietotemporal skull fracture is unchanged. IMPRESSION: 1. Stable hemorrhages including subdural, subarachnoid, epidural and intraparenchymal. 2. Dating back to [**9-5**] exam, increased effacement of the suprasellar cisterns. CT head [**2167-9-8**] at 07:06 1. Unchanged bifrontal and right temporal hemorrhagic contusions. 2. Expected evolution of subdural and subarachnoid hemorrhage. 3. Mild improvement in cisternal effacement. 4. Mildly increased compression of the temporal horns of the lateral ventricles, which may reflect increased temporal lobe edema. [**9-11**] NCHCT:No significant interval change in the size and extent of multiple hemorrhagic contusions causing diffuse cerebral edema. No change in the degree of ventricular and basal cistern effacement. Labs [**9-12**]: [**2167-9-12**] 05:50AM BLOOD Glucose-114* UreaN-15 Creat-0.7 Na-135 K-4.2 Cl-97 HCO3-28 AnGap-14 Brief Hospital Course: This is a 22 year old male who presented with ETOH level of 259 status post ejected passenger in motor vehicle accident. The patient reportedly exhibited agonal breathing on the scene. He was taken to emergency room where he was intubated. He was given dilantin and mannitol on arrival and continued on dilantin. He was monitored closely in the ICU. He was initially placed on spine precautions while a hard cervical collar but CT of spine did not reveal any fractures so the collar was removed. He self-extubated the morning of admission but his repiratory status remained stable to he remained on room air. Repeat imaging on [**9-5**] AM showed expected evolution of the contusions. He was kept in the ICU. Repeat imaging on [**9-6**] showed a slight increase in midline shift, but otherwise stable. The patient remained stable- awake, alert, oriented to self only, following commands, and MAE. The patient was transferred from the ICU to the Step down unit. Early [**9-7**] around 2am, the patient was noted to be more confused and agitated. The nurse noted that his R pupil was dilated but remained reactive. A STAT head CT was performed which showed some increase swelling. On return to the SDU from CT, his right pupil was dilated and fixed. He received 50gm of Mannitol and his R pupil became reactive. He was kept in the SDU. At 0730 the RN noted that bilateral pupils were dilated and fixed. Neurosurgery was called and assessed the patient- he was agitated and restless. He was moving all over the bed. R pupil was larger than the left by 2mm but both did not react. Mannitol 50gm was given and transfer to the ICU was requested. Serum NA was 128. The patient became less responsive and demonstrated respiratory distress, a code blue was called. The patient was successfully intubated, his hemodynamics remained stable throughout. He was taken immediately to CT where the CT showed worsening edema. He was then taken to the ICU for monitoring. On repeat examination his left pupil was smaller and reactive, he continued to MAE spont. A repeat NA was 129 and salt tabs were ordered. His right pupil remained fixed so the patient received another dose of Mannitol 100 gm. He put out almost 6L of urine and his R pupil came down in size and began to react. His afternoon serum NA was 139, salt tabs were discontinued but he remained on NS. He was successfully extubated in the evening and remained stable overnight. On [**9-8**], a repeat head CT showed improvement to his edema. On exam he was awake, alert, oriented to self only, bilateral pupils reactive, MAE, and following commands. Morning serum NA was 142, and his NS was reduced by half and able to be discontinued when taking sufficient POs. The patient remained in the ICU for observation. On [**9-9**] his NA 136 and his exam remained stable. He was kept in the ICU for observation. On [**9-10**] he was less confused and agitated. It was noted that he had difficulty closing his right eye and opthomology was consulted. They recommended artifical tears and follow up as an outpatient. He was transfered to the SDU. Overnight he was noted to have increased agitation. Upon finally sleeping his agitation was resolved. A routine Head CT was performed on [**9-11**] that was stable, no change in contusions. He was cleared for transfer to the regular floor. PT and OT were consulted for assistance with discharge planning and recommended acute neuro rehab. On the day of discharge [**9-12**], the patient was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. His serum Na on the day of discharge is stable at 135. Medications on Admission: Adderol XR 30mg daily Discharge Medications: 1. Acetaminophen-Caff-Butalbital [**1-12**] TAB PO Q6H:PRN ha 2. Adderall XR *NF* (amphetamine-dextroamphetamine) 30 mg Oral qd ADHD Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 3. Artificial Tear Ointment 1 Appl RIGHT EYE HS 4. Artificial Tears 1-2 DROP RIGHT EYE PRN irritation 5. Bisacodyl 10 mg PO/PR DAILY 6. Docusate Sodium 100 mg PO BID 7. Heparin 5000 UNIT SC TID 8. HYDROmorphone (Dilaudid) 1-2 mg PO Q3H:PRN pain RX *hydromorphone [Dilaudid] 2 mg half - 1 tablet(s) by mouth every 3 hours PRN pain Disp #*40 Tablet Refills:*0 9. Nicotine Patch 14 mg TD DAILY 10. Phenytoin Sodium Extended 200 mg PO TID 11. Senna 1 TAB PO BID Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Subdural hematoma Right occipital fracture Cerebral edema Altered mental status Hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Nonsurgical Brain Hemorrhage ?????? 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. ?????? **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**]. Followup Instructions: Follow-Up Appointment Instructions ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in ___4____weeks. ?????? You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ?????? We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury (TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**]. The patient needs to be followed up for neuro-oph consult after he leaves the hospital. Call the [**Hospital1 **] eye department [**Telephone/Fax (1) 253**] to schedule Consult with Dr [**Last Name (STitle) **] Completed by:[**2167-9-12**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 18395**] Admission Date: [**2167-9-5**] Discharge Date: [**2167-9-15**] Date of Birth: [**2144-12-23**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 10619**] Addendum: Not discharged on [**9-12**], kept inpatient, discharged on [**9-15**]. Physical Exam: [**9-15**] Exam: Awake, alert, interactive, oriented x3, following commands, MAE, frontal/impulsive. R pupil 5mm reactive, L pupil 3-2mm reactive. Third and seventh nerve palsy unchanged. Reports dbl vision and hand numbness - unchanged. Pertinent Results: [**2167-9-12**] 05:50AM BLOOD Glucose-114* UreaN-15 Creat-0.7 Na-135 K-4.2 Cl-97 HCO3-28 AnGap-14 [**2167-9-10**] 04:52PM BLOOD Glucose-105* UreaN-13 Creat-0.8 Na-135 K-4.1 Cl-96 HCO3-30 AnGap-13 [**2167-9-12**] 05:50AM BLOOD Albumin-4.8 Calcium-9.9 Phos-4.5 Mg-2.1 [**2167-9-12**] 05:50AM BLOOD Phenyto-7.6* Brief Hospital Course: Patient was kept inpatient at [**Hospital1 8**] as there was no 1:1 staffing available at [**Hospital1 **] over the weekend. Dilantin dosing was increased [**Date range (1) 18396**] for low level of 7.6 No changes to his clinical status. He remained stable. Additional 300mg Dilantin given x1 on [**9-15**]. He was discharged to [**Hospital3 **] on [**9-15**]. Discharge Medications: 1. Acetaminophen-Caff-Butalbital [**1-12**] TAB PO Q6H:PRN ha 2. Adderall XR *NF* (amphetamine-dextroamphetamine) 30 mg Oral qd ADHD Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 3. Artificial Tear Ointment 1 Appl RIGHT EYE HS 4. Artificial Tears 1-2 DROP RIGHT EYE PRN irritation 5. Bisacodyl 10 mg PO/PR DAILY 6. Docusate Sodium 100 mg PO BID 7. Heparin 5000 UNIT SC TID 8. Nicotine Patch 14 mg TD DAILY 9. Phenytoin Sodium Extended 200 mg PO TID 10. Senna 1 TAB PO BID 11. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10620**] MD [**MD Number(2) 10621**] Completed by:[**2167-9-15**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

14799, 15028

13754, 14117

358, 365

10849, 10849

13421, 13731

11826, 13148

859, 863

14140, 14776

10734, 10828

9825, 9848

10999, 11803

13163, 13402

269, 320

1733, 1733

393, 760

1215, 1702

10864, 10975

782, 788

804, 843

41,525

112,602

8583

Discharge summary

report

Admission Date: [**2161-10-8**] Discharge Date: [**2161-10-14**] Date of Birth: [**2085-6-8**] Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 2704**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: This is a 76 year-old female with a history of coronary artery disease s/p CABG in [**2152**] (LIMA to LAD, SVG to diagonal, SVG to OM-2, SVG to PDA), s/p AAA repair, right femoral bypass, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, presented to [**Hospital3 3583**] with worsening shortness of breath. At [**Hospital3 3583**], she had a work up including echocardiogram, labs and chest x-ray. At OSH, patient developed leukocytosis, diarrhea, abdominal pain and treated empirically with po vancomycin for presumed C Diff. Patient transferred to [**Hospital1 18**] for flutter ablation, but was deemed to be a poor candidate. While inpatient, she has had increased oxygen requirement of likely multifactorial etiology. Patient was started on a lasix gtt and was not tolerating diuresis because of drops in SBPs. Additionally, she had abdominal discomfort of unclear etiology. Patient has had a CT Abdoment that shows chronic [**Female First Name (un) 899**] blockage, but no evidence of bowel ischemia. On floor, patient triggered for low oxygen saturation and at time of transfer was on 6L 02 with sats in mid 90s. Past Medical History: -- CABG, in [**2152**] anatomy as follows: LIMA to LAD, SVG to diagonal, SVG to OM-2, SVG to PDA -- Severe PVD -- H/O GI bleeding -- H/O AAA -- Cataracts -- left hemidiaphramgatic paresis -- Chronic renal insuficiency Social History: Social history is significant for the absence of current tobacco use, prior smoker for many years. There is no history of alcohol abuse. Family History: There is a paternal history of coronary artery disease/peripheral artery disease, died at age 77. Physical Exam: 6:45pm [**2161-10-14**] Pt warm, pulseless, no heart sounds on auscultation, no respirations on auscultation, no corneal reflex and no oculocephalic reflex. Pertinent Results: [**2161-10-14**] 05:12AM BLOOD WBC-10.3# RBC-3.06* Hgb-10.1* Hct-29.6* MCV-97 MCH-32.9* MCHC-34.1 RDW-16.4* Plt Ct-207 [**2161-10-13**] 02:32AM BLOOD WBC-6.6 RBC-3.08* Hgb-10.1* Hct-29.3* MCV-95 MCH-32.8* MCHC-34.6 RDW-15.8* Plt Ct-178 [**2161-10-14**] 05:12AM BLOOD Neuts-95.6* Lymphs-2.8* Monos-1.2* Eos-0.3 Baso-0.2 [**2161-10-14**] 10:31AM BLOOD PT-31.6* PTT-73.6* INR(PT)-3.3* [**2161-10-14**] 05:12AM BLOOD Glucose-162* UreaN-20 Creat-1.3* Na-133 K-4.1 Cl-92* HCO3-29 AnGap-16 [**2161-10-9**] 11:55AM BLOOD FDP-10-40* [**2161-10-9**] 08:23AM BLOOD Fibrino-506* [**2161-10-13**] 02:32AM BLOOD ALT-30 AST-32 LD(LDH)-245 AlkPhos-95 TotBili-0.6 [**2161-10-8**] 10:22PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2161-10-9**] 11:55AM BLOOD Lipase-13 [**2161-10-13**] 02:32AM BLOOD Albumin-2.9* Calcium-6.7* Phos-2.4* Mg-1.6 [**2161-10-11**] 06:12AM BLOOD Triglyc-133 [**2161-10-9**] 08:23AM BLOOD Osmolal-275 [**2161-10-9**] 11:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE [**2161-10-9**] 11:55AM BLOOD AMA-NEGATIVE [**2161-10-14**] 10:31AM BLOOD Vanco-21.1* [**2161-10-9**] 11:55AM BLOOD HCV Ab-NEGATIVE [**2161-10-14**] 10:43AM BLOOD Type-[**Last Name (un) **] pO2-34* pCO2-64* pH-7.33* calTCO2-35* Base XS-4 [**2161-10-14**] 10:43AM BLOOD Lactate-1.5 [**2161-10-11**] 02:45PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.034 [**2161-10-11**] 02:45PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2161-10-11**] 02:45PM URINE RBC-62* WBC-30* Bacteri-FEW Yeast-FEW Epi-0 [**2161-10-9**] 12:18AM URINE CastGr-17* [**2161-10-9**] 12:18AM URINE AmorphX-RARE Uric AX-MANY [**2161-10-9**] 12:18AM URINE Mucous-RARE BCx [**10-8**]: neg BCx [**10-12**]: pending CDiff neg x 3 UCx [**10-9**]: neg UCx [**10-11**]: yeast CXR [**10-14**]: Moderate left pleural effusion unchanged since [**10-8**], while small right pleural effusion has increased since [**10-13**]. Opacification at the base of the left lung is attributable to atelectasis, but on the right, there could be pneumonia. Borderline interstitial pulmonary edema is still present. Severe cardiomegaly is longstanding. Right supraclavicular central venous line ends at the superior cavoatrial junction. No pneumothorax. CTA Abd [**10-9**]: 1. Extensive atherosclerotic calcifications throughout the aorta, iliac arteries and major branches. 2. Coronary calcifications. 3. Evidence of anasarca with subcutaneous edema and ascites. 4. Ground-glass patchy and emphysematous change in lung bases, bilateral pleural effusion and atelectasis, more prominent on the left side. 5. Stranding surrounding the left kidney with a small focal perinephric subcapsular fluid collection. 6. No evidence of bowel ischemia. There is no evidence of pneumatosis or bowel wall thickening. Brief Hospital Course: Patient is a 76 yo female with CAD, s/p AAA, PVD, CRI, who initially presented to OSH with CHF exacerbation, transferred from OSH for a. flutter ablation and course complication by hypoxia and anasarca. #. Dyspnea/Hypoxia: Pt had worsening hypoxia, thought to be volume overload (diuresed) with component of COPD, and pneumonia (treated with Vancomycin and Zosyn). Diaphragmatic hemiparesis also likely contributor. PE unlikely while anticoagulated. Pt was clear in her wished to avoid intubation and trach and she was maintained on CPAP until family agreed to make pt [**Name (NI) 3225**]. At that time she quickly desaturated, was started on Morphine drip and expired. Time of death was 6:45PM on [**2161-10-14**]. #. CAD: Patient has a history of severe three vessel disease s/p CABG. Pt was medically managed on ASA. Beta blocker held for hypotension, and statin held for elevated LFTs. #. AFlutter: Pt was medically managed on digoxin and amiodarone. Cardioversion was postponed given other medical issues. Anticoagulated with argatroban given confirmed history of HIT. #. Abdominal Pain/Distension/Diarrhea: Patient has a history of open AAA repair, cholecystectomy and ventral hernia repair recently. C. Diff negative x3 but completing course of PO Vanc. CT abdomen shows occluded [**Female First Name (un) 899**] but felt to be chronic as Lactate wnl. Vascular surgery followed, and plan was for flex sig once medically stable. At time of death pt's family expressed interest in particular attention being paid to pt's GI symptoms on autopsy. Medications on Admission: Amiodarone Furosemide Calcium Protonix Metoprolol Coumadin Multivitamin Trazodone Lorazepam Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Respiratory arrest Pneumonia COPD CAD Discharge Condition: expired Discharge Instructions: Pt passed away at 6:45 pm on [**2161-10-14**] Followup Instructions: None Completed by:[**2161-10-14**]

[ "V45.81", "V64.1", "440.0", "491.21", "427.32", "428.0", "414.8", "486", "518.81", "443.9", "427.31", "274.9", "585.9", "557.1", "008.45", "428.21" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

6776, 6785

5044, 6605

295, 302

6867, 6877

2183, 5021

6971, 7008

1892, 1991

6747, 6753

6806, 6846

6631, 6724

6901, 6948

2006, 2164

236, 257

330, 1481

1503, 1722

1738, 1876

21,280

147,856

5324+5325+5326+55665

Discharge summary

report+report+report+addendum

Admission Date: [**2159-2-13**] Discharge Date: [**2159-2-23**] Date of Birth: [**2114-8-15**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: This is a 44-year-old patient with past medical history significant for aortic root replacement times two for recurrent endocarditis, neurologic impairment of unclear etiology, and chronic dependence on mechanical ventilation who presents from an outside hospital with fever. He was recently at the [**Hospital6 649**] where he received a right hemicolectomy on the [**2159-1-28**] and was discharged to rehabilitation on [**2-9**]. On [**2-10**], he was noted to be tachypneic and anxious. He was sent to [**Hospital3 1280**] Hospital where he was found to be in pulmonary edema on the basis of elevated blood pressure and chest x-ray consistent with failure. He was diuresed with Lasix and ruled out for myocardial infarction by enzymes. On the [**2-11**] he spiked a temperature to 101.5 and was pancultured. He had a transthoracic echocardiogram to evaluate for valvular vegetations; this was negative. Additionally, the patient's feeding tube was felt to be obstructed but a gastrografin study showed the tube to be patent. Because of the extensive experience of this patient with the [**Hospital6 256**], he was transferred here for further management. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes. 3. Aortic root replacement times two per Dr. [**Last Name (STitle) 1290**]. 4. Endocarditis with abscess in [**2156-12-30**] and [**2158-10-29**]. 5. Seizure disorder since the age of 12 (seizure free on Keppra). 6. History of embolic stroke during episodes of endocarditis. 7. Bilateral pleural effusions. 8. History of fungemia. 9. History of type 1 renal tubular acidosis. 10. Coronary artery bypass graft in [**2158-10-29**] with saphenous vein graft to right coronary artery and saphenous vein graft to left anterior descending, status post right hemicolectomy in [**2159-1-27**]. 11. Encephalopathy, likely anoxic origin. 12. Lower extremity paralysis with upper extremity weakness. 13. History of paroxysmal atrial fibrillation in the setting of endocarditis. 14. GJ tube originally placed by Surgery, then changed by Interventional Radiology in [**2158-11-29**]. 15. Tracheostomy with chronic ventilator dependence. 16. ICU neuropathy. 17. Chronic intermittent chemical pancreatitis. 18. History of multiple pneumonias. 19. History of severe esophagitis. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: 1. Pantoprazole 40 mg per G tube q.d. 2. Epogen 4000 units subcutaneous q. Tuesday and Friday. 3. Metoprolol 25 mg per G tube b.i.d. 4. Regular insulin sliding scale. 5. Furosemide 60 mg intravenously b.i.d. 6. Acetaminophen prn. 7. Keppra 500 mg per G tube b.i.d. 8. Captopril 12.5 mg per G tube t.i.d. 9. Lipitor 10 mg per G tube q.d. 10. Metoclopramide 10 mg intravenously t.i.d. 11. Bacitracin ointment ou q. 6 hours. 12. Ativan and morphine prn. 13. Albuterol and Atrovent MDI prn. 14. Tube feeds, Peptamen at 90 cc per hour. SOCIAL HISTORY: He is a former office cleaner. He has two sons. [**Name (NI) **] is divorced, but has a current girlfriend. [**Name (NI) **] was born in [**Country **]. No ethanol or intravenous drug use or tobacco history. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Could not be obtained. PHYSICAL EXAMINATION: Vital signs: Temperature 100.0. Blood pressure 96/63 to 143/79. Heart rate 70. Respiratory rate 12. Oxygen saturation 96-99%. Ventilator settings: Pressure support of 20 with PEEP of 10, FIO2 of 0.4 via tracheostomy. In general, a chronically ill-appearing gentlemen with tracheostomy moving eyes and arms spontaneously but nonverbal. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light. Sclerae are anicteric. No nystagmus. There was chemosis. Neck: No jugular venous distention. No thyromegaly or lymphadenopathy. Pulmonary: There are bronchial breath sounds bilaterally with no wheeze or rales. Cardiovascular: Regular rate and rhythm, [**2-1**] murmur loudest at the left sternal border, but heard throughout the precordium. No S3 or S4. Abdomen: Midline surgical scar with staples. Wound clean, dry and intact. Feeding tube was present in the left upper quadrant. The abdomen was scaphoid, soft with positive bowel sounds. The extremities were without peripheral edema. There was 2+ dorsalis pedis and radial pulses bilaterally. There is no cyanosis or clubbing. Skin: Intact, no ulcers, but minor skin breakdown at the coccyx. There was no rash. Neurological: Nonverbal, moves lips unintelligibly, very rarely follows simple commands. Does not move lower extremities. LABORATORIES ON ADMISSION TO [**Location (un) **] [**Hospital3 **] HOSPITAL: White blood cell count of 26.2 with a hematocrit of 32.2 and platelet count 287,000. Sodium 147, potassium 4.0, chloride 110, bicarbonate 29, BUN 22, creatinine 1.0, glucose 85. INR was 1.0. Arterial blood gases: PH of 7.39, pCO2 of 47 and PO2 of 105. Sputum culture grew Pseudomonas. Blood cultures and urine cultures were negative. Echocardiogram revealed 4+ mitral regurgitation, well seated aortic root replacement, pulmonary hypertension and no vegetation. A KUB revealed gastrografin seen infusing through both the G and J ports at the GJ tube. Electrocardiogram showed normal sinus rhythm at 76 beats per minute with poor R wave progression. No ST-T wave changes and first degree AV block. ON TRANSFER TO THE [**Hospital6 **] LABORATORIES WERE: White blood cell count of 13.7 with a differential of 82% neutrophils, 2% bands, 12% lymphocytes, 3% monocytes and 1% metamyelocytes. Hematocrit was 36.4, platelet count of 356,000. Sodium was 147, potassium 3.8, chloride 108, bicarbonate 30, BUN 17, creatinine 0.9, glucose 93, albumin 2.2, calcium 8.7, phosphate 3.7, and magnesium 1.4. INR was 1.2. Amylase was 132. ALT 13, AST 19, alkaline phosphatase 352, total bilirubin 0.7, lipase was 293. GGT was 221. Chest x-ray showed improving left heart failure with some residual bilateral infiltrates. KUB showed J tube with a distal and overlying the left mid abdomen, unremarkable bowel gas pattern. Urinalysis was negative. IMPRESSION: This 44-year-old male with history of two aortic root replacements in the setting of endocarditis, hemicolectomy approximately two weeks prior to admission for cecal diverticulitis, severe mitral regurgitation, poor neurologic function, and ventilator dependent presents as a transfer from an outside hospital for fever and congestive heart failure. HOSPITAL COURSE TO DATE BY SYSTEM: 1. Pulmonary: The patient is chronically dependent on mechanical ventilation secondary to weakness. We gradually weaned his ventilator settings down over the course of the admission. At the time of this dictation, he was on a pressure support of [**11-11**], PEEP of 5 and FIO2 of 0.3. It is expected that with further weaning he may eventually come off the ventilator. Approximately one week into the [**Hospital 228**] hospital stay, his secretions became increasingly thick and yellow. There was concern for pneumonia but none was seen on repeat chest x-ray. There was some left lower lobe atelectasis and suggestion was raised for possible bronchoscopy, but this seemed stable and did not appear to be significantly affecting the patient's respiration. Sputum culture grew two colonies of Enterobacter and two colonies of Pseudomonas. However, these were not treated, because although they may have been contributing to his secretions, they did not seem to be particularly pathogenic. He did require additional suctioning, but his overall ventilatory status improved over the course of this admission. We initiated trials with Passy-Muir valve and patient was able to phonate, occasionally speaking intelligible words, but also speaking nonsensically for much of the time. Additionally, the patient was occasional able to phonate because of an intermittent tracheal cuff leak. The trache required intermittent repositioning. 2. Infectious Disease: The main reason for the [**Hospital 228**] transfer to us was for fever, but aside from the temperature spike at the outside hospital on [**2-11**], the patient remained afebrile for the first several days of his admission. On [**2-18**], the patient spike a fever to 101.2. He spiked again on [**2-19**] and was pancultured. Sputum again grew the two species of Pseudomonas and Enterobacter. Blood cultures were all negative. Urine culture grew the same highly resistant Pseudomonas that was seen in his sputum. Repeat urinalysis revealed pyuria, so it was felt that the patient's likely fever source was his Pseudomonas urinary tract infection. The only antibiotic that was affective against this strain of Pseudomonas was tobramycin so this was initiated. 3. Gastrointestinal: Initially, the patient's tube feeds were provided uneventfully, however, approximately three days into the [**Hospital 228**] hospital stay, he began vomiting and appeared to be aspirating. The Surgical Service who had performed the patient's hemicolectomy was consulted. They recommended abdominal CAT scan which showed no abscess and oral contrast reaching the rectum. The Gastrointestinal Service was consulted and upon review of the CAT scan they felt that the GJ tube had actually migrated distally and that the flange of the tube was abutting the pylorus and causing gastric outlet obstruction. We consulted the surgeon who had placed the tube and he concurred with this explanation. The tube was removed and a temporary Foley was placed and sutured down to prevent distal migration. Tube feeds were then restarted, but the patient had high residuals and TPN was initiated. At the time of this dictation, it is hoped that the obstruction is now resolved and that tube feeds will be able to be restarted shortly. 4. Cardiovascular: The patient has severe mitral regurgitation, although, his ejection fraction is preserved. There was no evidence of pulmonary edema throughout his admission up until [**2-23**]. Lasix was not needed, and in fact fluid boluses were occasionally provided, occasionally for decreased urine output. Once the patient's feeding issues are resolved, it may be necessary to restart furosemide, betablockade, and ACE inhibition. 5. Neurology: To address the patient's altered mental status and weakness, the Neurology Service was consulted. They felt that the most likely diagnosis was ICU neuropathy. It is still unclear exactly why the patient's mental status is still impaired, but it is very likely that due to his prolonged intubation during his admission from [**Month (only) 359**] until [**2157-12-30**] to [**2158**], that he could have suffered hypoxic injury. The patient was continued on Keppra for seizure prophylaxis. The patient had no seizures during this part of his admission. 6. Prophylaxis: Heparin subcutaneous and famotidine. 7. Code status: Code status was verified with the patient's sister. The patient is a full code. THE REMAINDER OF THIS DICTATION WILL BE DICTATED IN AN ADDENDUM. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**] Dictated By:[**Name8 (MD) 2734**] MEDQUIST36 D: [**2159-2-23**] 09:32 T: [**2159-2-25**] 19:13 JOB#: [**Job Number 21701**] Admission Date: [**2159-2-13**] Discharge Date: [**2159-2-28**] Date of Birth: [**2114-8-15**] Sex: M Service: ADDENDUM HOSPITAL COURSE: 1. Pulmonary: The patient continues to be vent-dependent at the time of discharge on pressure support of 20, PEEP of 5, FIO2 of 40%, doing well at these settings, as he has been for the past week since the last discharge summary. 2. Infectious disease: The patient was treated for pseudomonal urinary tract infection and pseudomonas in his sputum for a 7-day course that was completed today on [**2159-2-28**]. Pseudomonas was only sensitive to the Tobramycin, which he completed today on [**2159-2-28**]. 3. Gastrointestinal/nutrition: The patient started tolerating tube feeds last night on [**2159-2-27**], with the addition of Erythromycin as a pro-motility [**Doctor Last Name 360**]. He is still getting Reglan. The patient is also getting supplemental nutrition by TPN. We recommend that the patient's tube feeds continue at 30 cc/hr for the next two days and then when it is advanced, it is advanced very slowly at a rate of 10 cc every four hours or so. Check residuals q.4 hours. TPN may be stopped when the patient is tolerating tube feeds at a goal of 60 cc/hr. 4. Cardiovascular: The patient has had two aortic valve replacements and two aortic root replacements at 4+ mitral regurgitation. The patient was restarted on an ACE inhibitor on the 31st. The patient is being discharged on Captopril 25 t.i.d. and Lopressor 12.5 b.i.d. 5. Neurology: The patient's altered mental status and weakness is not really improved. It may be critical care neuropathy and myopathy; however, this has not improved over the past week that I have been taking care of him. 6. Seizure disorder: The patient is to continue his Keppra 500 mg p.o. b.i.d. 7. Heme: The patient's hematocrit has been stable. 8. Electrolytes: The patient's sodium was noted to be a little low at the time of discharge at 131. We recommend rechecking a CHEM10 in two days, on [**2159-3-2**]. 9. Prophylaxis: The patient is getting an H2 blocker currently in his TPN. Once TPN is stopped, the patient could get oral medications through the G-tube, whether its an H2 blocker or protime pump inhibitor. The patient is getting pneumoboots and would continue this. 10. Access: The patient has a PICC line and G-tube. The patient is full code. His contact person is his sister, ..................., who works at [**Hospital3 **] and can be reached at [**Telephone/Fax (1) 21702**]. His primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital3 **] at [**Hospital6 649**]. DISCHARGE MEDICATIONS: Levetiracetam which is Keppra 500 mg p.o. or per G-tube b.i.d., Erythromycin 250 mg IV q.8 hours for motility, Captopril 25 mg p.o. t.i.d., hold for systolic blood pressure less than 100, Lopressor 12.5 mg p.o. or per G-tube b.i.d., hold for systolic blood pressure less than 100 or heart rate less than 60, Tylenol 650 mg p.o. or per G-tube or p.r. q.6-8 hours p.r.n. fever or pain, Reglan 10 mg p.o. or per G-tube q.6 hours. DISCHARGE DIAGNOSIS: 1. Seizure disorder. 2. Aortic valve replacement and aortic root replacement. 3. Hypertension. 4. History of embolic stroke. 5. Pleural effusion. 6. History of fungemia. 7. History of coronary artery bypass grafting. 8. Right hemicolectomy. 9. .................. neuropathy. 10. Recent pseudomonal urinary tract infection. 11. Chronic intermittent pancreatitis. 12. Ventilator dependence status post tracheostomy. 13. G-tube placed by Surgery, Dr. [**Last Name (STitle) 954**]. FOLLOW-UP: The patient should follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient is being discharged to rehabilitation. CONDITION ON DISCHARGE: Fair. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-761 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2159-2-28**] 11:05 T: [**2159-2-28**] 11:07 JOB#: [**Job Number 21703**] Admission Date: [**2159-2-13**] Discharge Date: [**2159-3-27**] Date of Birth: [**2114-8-15**] Sex: M Service: ADDENDUM TO HOSPITAL COURSE - 1) CONGESTIVE HEART FAILURE/VALVULAR DISEASE: Patient status post aortic valve repair and aortic root repair. Patient oxygenating well at time of discharge with no evidence of overt CHF. Patient actually hypovolemic to euvolemic by exam, and has been getting gentle hydration x two days with improved urine output. Diuretics are being held, and patient is continued on his ACE inhibitor at the time of discharge. 2) CHRONIC VENT DEPENDENCE: Patient with chronic illness, myopathy and neuropathy with malnutrition and severe weakness contributing to chronic vent dependence. Patient stable on current vent settings which include pressure support ventilation during the day with pressure support of 18, PEEP 5, FIO2 40%. Patient has been comfortable, resting on assist control during the evening with tidal volume of 400 by respiratory rate of 10 with PEEP of 5 and FIO2 of 40%. Patient should be continued on these settings including AC in the evening until he has significant improvement in his nutritional status and improvement in his level of strength. Aggressive attempts to wean him by switching him to pressure support in the evening should not be attempted, at least in the short-term. 3) PSEUDOMONAL PNEUMONIA/CHRONIC SPUTUM COLONIZATION: Patient with a history of pseudomonal pneumonia and pseudomonal UTI earlier in this admission. Patient with persistent sputum cultures positive for Pseudomonas and has been placed on pseudomonal precautions. However, he shows no evidence of an acute infection, has been afebrile with stable oxygenation and minimal sputum production. Chest x-ray is notable for a persistent left lower lobe density which we have interpreted as a chronic resolving infiltrate versus atelectasis. 4) HYPERCALCEMIA: During the last two to three weeks of the patient's prolonged hospitalization, the patient developed refractory, severe hypercalcemia of unclear etiology. Work-up of his hypercalcemia revealed a low-normal PTH level with low Vitamin D levels. PTH-RP was also negative. The etiology of his hypercalcemia was thought more likely to represent chronic immobility with bone leeching of calcium versus a primary bony process such as Paget's disease. On bone scan, patient was noted to have increased uptake in the area of a soft tissue/bony mass adjacent to the left glenohumeral joint, but not invading the joint space itself. This lesion had been noted on a prior MRI in [**Month (only) 956**], but has increased in size since that time. Bone scan also revealed symmetric uptake in the knees and ankles bilaterally which was not thought to be significant. On [**2159-3-27**], patient underwent a CT-guided biopsy of the left bony mass with pathology pending at the time of discharge. For treatment of the patient's hypercalcemia, he initially was treated with aggressive IV fluids and diuretics. He received a dose of calcitonin. He ultimately responded to a dose of 30 mg IV of pamidronate wit a calcium level that began to trend down. However, on [**2159-3-25**], the calcium level stabilized and began to trend back upward in excess of 12.5. On [**2159-3-25**], the patient was redosed with pamidronate 50 mg IV x one. Vitamin D levels were aggressively repleted parenterally, and the patient was discharged on a stable dose of calcitriol Vitamin D. A repeat Vitamin D level is pending at the time of discharge, and I will follow-up on this and communicate results to rehab. Osteocalcin level as a part of a work-up for Paget's disease is also pending at the time of discharge. Bone biopsy results will also be passed on to rehab. The patient will be required to have daily calcium level checks to verify that he is neither hypercalcemic requiring further dosing of pamidronate versus hypocalcemic secondary to pamidronate. 5) PANCREATITIS: Patient with pancreatitis of unclear etiology earlier in his hospitalization. His amylase and lipase have trended down, and he has been tolerating tube feeds with a benign abdominal exam indicating that it is not currently an active issue. 6) HYPERNATREMIA: Patient has been continued on free water boluses to supplement his tube feeding to maintain a sodium level of approximately 140. Sodium level should be checked at least several times per week for the next several weeks. 7) VOLUME STATUS: As noted, the patient appears to be clinically hypovolemic to euvolemic with no evidence of overt volume overload or congestive heart failure. Urine output was approximately 40 cc/h at the time of discharge. 8) ANEMIA: Patient has had a stable hematocrit of approximately 28-30 for the majority of his hospitalization. Iron level was normal, but TIBC was low, and ferritin level was very elevated consistent with an anemia of chronic disease. His iron stores appear to be good. He was started on Epogen [**Hospital1 **]-weekly and had received one dose prior to discharge. 9) NUTRITION: Patient with poor nutritional status secondary to chronic hospitalization and immobility. He is unable to tolerate PO secondary to recurrent aspiration, and has a cuffed trach in place. He is to continue current tube feeds which are at goal of 85 cc/h until his nutritional level improves. 10) SEIZURE DISORDER: Patient was continued on Keppra with no evidence of seizure activity. 11) DEPRESSION: Patient was continued on Zoloft with stable mental status. The patient has been tearful and depressed at times, including plans to move him to rehab. 12) IV ACCESS: Patient with a left PICC line which was placed on [**3-4**], and shows no evidence of any surrounding erythema or drainage. 13) PROPHYLAXIS: Patient was maintained on subcu heparin and a proton pump inhibitor for prophylactic medications. DISCHARGE DIAGNOSES: 1) Congestive heart failure. 2) Chronic ventilatory dependence. 3) Pseudomonal pneumonia/sputum colonization. 4) Hypercalcemia of unclear etiology. 5) Pancreatitis of unclear etiology. 6) Left shoulder bony mass with biopsy results pending. 7) Pseudomonal urinary tract infection. 8) Anemia of chronic disease. 9) Seizure disorder. 10) Diabetes. 11) Critical illness myopathy and neuropathy. 12) Hypertension. DISCHARGE MEDICATIONS: 1) calcitriol 0.25 mcg po qd, 2) lisinopril 5 mg po qd, 3) erythropoietin alfa 3,000 U subcu twice per week, 4) albuterol, Atrovent 1-2 puffs q 6 h prn, 5) subcu heparin 5,000 U subcu [**Hospital1 **], 6) Prevacid oral solution 30 mg per NG tube [**Hospital1 **], 7) sertraline 50 mg po qd, 8) ativan 0.5-2 mg IV q 4 h prn agitation, 9) Keppra 500 mg po bid, 10) regular Insulin sliding scale--please see page 1, 11) promethazine 25 mg IV q 6 h prn, 12) Tylenol 650 mg q 4-6 h prn, 13) nystatin ointment to be applied prn, 14) lidocaine jelly to be applied prn, 15) Desitin to be applied prn. DISCHARGE INSTRUCTIONS: 1) Patient should have a daily to qod Chem-7 and calcium level for the next 2 weeks. Should his calcium level rise, he needs to be redosed with pamidronate ideally 30-60 mg IV. Calcium level at the time of discharge was 10.7, uncorrected for low albumin. Alternatively, if the patient's calcium level becomes very low secondary to pamidronate, which it may given his low Vitamin D stores, he will need to be repleted. A Vitamin D level is pending following parenteral repletion at the time of discharge, and this result will be communicated to rehab by the [**Hospital3 **] house staff. Results of his bone mass biopsy will also be communicated. 2) Patient will need to continue on tube feeds which currently consist of Criticare full strength at 85 cc/h. 3) Regarding his ventilatory dependence, the patient should not be aggressively weaned, but should be rested on AC during the evening as noted in the discharge summary. The patient's primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21704**] located at [**Hospital6 2018**] in [**Location (un) 86**]. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-761 Dictated By:[**Known lastname 4689**] MEDQUIST36 D: [**2159-3-27**] 12:00 T: [**2159-3-27**] 11:04 JOB#: [**Job Number 21705**] Name: [**Known lastname 447**], [**Known firstname **] Unit No: [**Numeric Identifier 3614**] Admission Date: [**2159-2-13**] Discharge Date: Date of Birth: [**2114-8-15**] Sex: M Service: HOSPITAL COURSE: 1. Pulmonary - The patient continues to have copious secretions, has completed a fifteen day course of Tobramycin and ten days of Cefepime. He is currently being treated on day six of seven with Tobramycin for pseudomonas in his sputum. Chest CT reveals no pneumonia. Chest x-ray appears improved. We are empirically treating him for this bronchitis with vent association. Cultures have been pending. He does continue to have pseudomonas growing in his sputum. 2. Hypercalcemia - The patient continues to have elevated calcium despite aggressive intravenous fluids and loop diuretic treatment. His Vitamin D 25 was low which are correcting. His 125 was normal. His PTH was low and his PTH RP is pending. We have started Calcitonin and has been getting that for four days and then on [**2159-2-16**], anticipate giving the patient Pamidronate after Vitamin D levels have been restored to within normal limits to prevent acute prolonged hypocalcemia associated with Pamidronate treatment when you have insufficient Vitamin D source. Endocrine service has been following. 3. Pancreatitis - The patient has chronic intermittent pancreatitis which is stable right now. His enzymes have been trending down, however, he continues to have abdominal discomfort with light palpation. 4. Congestive heart failure - This has been stable. The patient's fluid status has been fairly even every day. We are diuresing him with Bumex because we stopped Lasix with concern that it may be causing his pancreatitis. He will continue his ace inhibitor, Captopril 12.5 mg three times a day. He has not tolerated going to beta blockade yet. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from the congestive heart failure service has been following. 5. Psychiatry and Neurology - The patient is on Zoloft 50 mg once daily and Keppra for his seizure disorder 500 mg twice a day. 6. Nutrition - The patient had his gastrostomy tube changed to a jejunostomy tube by the gastroenterology service and has actually tolerated his tube feeds and now is off TPN. 7. Prophylaxis - The patient is on Heparin and a proton pump inhibitor. 8. Access - He has a left upper extremity PICC line that was placed on [**2159-3-4**]. Communication is via his sister who works at [**Hospital6 3348**] on the [**Hospital Ward Name 3621**]. He remains a full code. We anticipate discharge in the next week as soon as hypercalcemia issue is somewhat resolved. The final dictation will be done by the resident picking up his care on Monday, [**2159-3-19**]. [**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**] Dictated By:[**Name8 (MD) 3622**] MEDQUIST36 D: [**2159-3-17**] 12:13 T: [**2159-3-17**] 14:26 JOB#: [**Job Number 3623**]

[ "577.0", "482.1", "263.9", "V46.1", "518.84", "507.0", "599.0", "780.39", "428.0" ]

icd9cm

[ [ [] ] ]

[ "99.15", "77.42", "43.11", "96.72", "33.21", "96.6" ]

icd9pcs

[ [ [] ] ]

3305, 3323

21452, 21874

21898, 22492

14642, 15300

24120, 26918

22517, 24103

3390, 11588

3343, 3367

161, 1329

2517, 3058

1351, 2492

3075, 3288

15325, 21430

16,481

132,895

430+55214

Discharge summary

report+addendum

Admission Date: [**2161-2-14**] Discharge Date: [**2161-3-10**] Date of Birth: [**2098-9-3**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This 61 year-old male with a ten year history of progressive Parkinson's disease tripped over his own feet and fell down approximately seven steps. He states for a few seconds he was stunned and felt tingling in all four extremities. He also noted pain in his legs left greater then right and in his right chest. He was taken to [**Hospital **] Hospital where he was reportedly neurologically intact. He was in a cervical collar. A CT scan of the cervical spine was obtained. This showed a fracture of the anterior arch of C1. There was a moderately displaced, comminuted, odontoid fracture extending through the base, which moderately narrowed the spinal canal. The dens and C1 were displaced approximately 13 mm. The patient was able to void spontaneously times two before a Foley catheter was placed. The patient has been followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Neurology for his movement disorder. PAST MEDICAL HISTORY: The patient has a history of bipolar disorder and Parkinson's syndrome. ALLERGIES: He is allergic to Haldol. MEDICATIONS: 1. Sinemet. 2. Folate. 3. Valproic acid. 4. Seroquel. 5. Amantadine. LABORATORIES ON ADMISSION: White blood cell count of 9.3, hematocrit 41.4, platelet count 157, amylase 42, sodium 143, potassium 5.0, chloride 106, CO2 28, BUN 22, creatinine 1.1, glucose 122, lactacid 1.6. PHYSICAL EXAMINATION: The patient is alert and oriented times three. He is complaining of a headache, posterior neck pain and right chest pain. He has a marked resting tremor primarily effecting his left upper extremity and left lower extremity. There is cogwheel rigidity of both upper extremities. His cranial nerves are intact. He describes altered sensation and pain to light touch and pin prick over his left occiput and right chest at approximately the T2 to T5 levels. There is no clear sensory level to pin prick, light touch, position direction or vibration. The patient's cervical collar fits well. His toes are upgoing. His reflexes are 2+. His strength is good in his upper extremities and lower extremities. HOSPITAL COURSE: The patient's management was greatly complicated by his multiple medical problems. It was difficult to reduce his fracture and apply a halo, because of his movement disorder. He was initially kept in a cervical collar. An MRI scan of the cervical spine was obtained to rule out an epidural hematoma. This showed no evidence of any significant cord compression or epidural bleeding. He was placed in a halo traction. He was noted to have severe dyskinesias from his Sinemet, which made it difficult to maintain him in halo traction. Therefore he was seen once again by the neurologist who recommended decreasing his Sinemet and continuing the Amantadine. The patient was taken to radiology where he was placed in halo traction under fluoroscopy. Once again this was greatly limited by his dyskinesias and his inability to remain still during the procedure. The patient was noted to have multiple episodes, which seemed to be aspiration. He began spiking fevers up to 102 and 103. The patient's chest x-ray showed an infiltrate consistent with an aspiration pneumonia. He was kept on Levaquin. His white count was as high [**Numeric Identifier 3651**]. He was pan cultured with no other source apparent. By [**2-23**] the patient had two plain films, which showed excellent alignment and reduction of the C1-C2 subluxation. The patient was placed in the halo vest on [**2-23**]. A post procedure film once again showed excellent alignment. The patient was intubated for his inability to clear his secretions. A second post reduction film showed a bit more displacement approximately 8 mm at the C1-C2 level. However, at this point the patient was intubated and sedated. There is no evidence of any spinal cord compression on the films. It was felt safer to leave the patient intubated and sedated with the halo in that position rather then attempting to realign the fracture without the patient being monitored by his neurological examination. The patient would open his eyes at times. He periodically would get Dilaudid 1 to 2 mg and Ativan. He was inconsistently following commands. He continued to have high fevers up to 102 and 103. A CT scan of the abdomen was unremarkable. The patient was again seen by neurology. It was felt that his obtundation was likely due to his fevers. A follow up CT scan of the head and cervical spine were obtained. This showed no evidence of any intracranial masses or infection. The patient had no evidence of infection at the site of his fracture. Because of the need for continued ventilation the patient had a tracheostomy and G tube placed. These were well tolerated. He continued having fevers ranging from 101 to 103. His white count remained in the 18 to [**Numeric Identifier 3652**] range. He really was not responsive. A lumbar puncture was recommended, however, the patient's wife felt strongly she did not want this procedure done. The patient was continued on Oxacillin, Ceftriaxone and Flagyl. His sputum cultures grew out Methicillin sensitive staph aureus, Pneumococcus and strep viridans. A CT scan once again reconfirmed a dense right lower lobe infiltrate. The infectious disease consultant suggested the differential included a C-diff colitis, metastatic infection with MMSA, a possible meningitis, a drug fever or a line infection. The patient's lines were changed. At this point his white blood cell count began to come down, however, he still had nightly fevers. There was no improvement in his mental status. The patient's family felt strongly they would like him to go to rehab. Plans were made for this. FINAL DISCHARGE DIAGNOSES: 1. Parkinson's disease. 2. C1-C2 fracture. 3. Aspiration pneumonia. 4. Fever of unknown origin. CONDITION ON DISCHARGE: The patient is obtunded. He is in a halo. He will need to remain in the halo for a minimum of three months. If he improves neurologically and is awake, the halo should be readjusted. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3653**], M.D. [**MD Number(1) 3654**] Dictated By:[**Last Name (NamePattern4) 3655**] MEDQUIST36 D: [**2161-3-10**] 10:34 T: [**2161-3-10**] 10:34 JOB#: [**Job Number 3656**] Name: [**Known lastname 440**], [**Known firstname 441**] Unit No: [**Numeric Identifier 442**] Admission Date: [**2161-2-14**] Discharge Date: [**2161-3-13**] Date of Birth: [**2098-9-3**] Sex: M Service: This is an addendum to a previously dictated discharge summary. The patient was evaluated for transfer to the [**Hospital **] Hospital. From [**2161-3-10**] to [**2161-3-13**], there is absolutely no change in his neurologic status. The patient remained obtunded. He was tolerating his tube feeds. He periodically had temperatures from 99-100 degrees. His pin sites were clean. His chest x-ray showed no new infiltrates. Plans were made to transfer the patient to the [**Hospital6 443**] on [**2161-3-13**]. FINAL DISCHARGE DIAGNOSES: 1. Cervical spine fracture. 2. Parkinson's disease. 3. Fever. 4. Altered mental status. CONDITION ON DISCHARGE: Poor. FOLLOW-UP PLANS: Patient is being transferred to the [**Hospital6 444**] for further care. [**First Name11 (Name Pattern1) 121**] [**Last Name (NamePattern4) 122**], M.D. [**MD Number(1) 123**] Dictated By:[**Last Name (NamePattern4) 445**] MEDQUIST36 D: [**2161-4-7**] 12:37 T: [**2161-4-9**] 07:32 JOB#: [**Job Number 446**] (cclist)

[ "518.81", "805.01", "E880.9", "415.19", "296.7", "507.0", "332.0", "781.0", "780.6" ]

icd9cm

[ [ [] ] ]

[ "96.04", "02.94", "43.11", "31.1", "96.72", "93.41" ]

icd9pcs

[ [ [] ] ]

2300, 5911

1572, 2282

7461, 7820

7322, 7411

159, 1117

1368, 1549

1140, 1353

7436, 7443

73,058

166,312

53202

Discharge summary

report

Admission Date: [**2191-4-28**] Discharge Date: [**2191-5-8**] Date of Birth: [**2132-3-19**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: 59 yo M with newly discovered T6 mass infectious vs malignant now with LE sensory paresthesias and L1 mass Major Surgical or Invasive Procedure: L thoracotomy; T6 vertebrectomy; ant cage/plate History of Present Illness: 59 year old man who has been undergoing evaluation for worsening mid-back pain over about 6 weeks. Over the past couple of weeks, he has developed numbness and tingling throughout his legs which has extended cranially and now involves the entirety of both legs, his groin, and the lower part of his abdomen. He describes feeling his legs "give way" at times when trying to climb the stairs. A lumbar spine MRI at [**Hospital3 2568**] revealed a mass in his L1 vertebral body thought to be either malignant or a hemagioma. A subsequent PET CT on [**2191-4-22**] showed an FDG-avid mass within his T6 vertebral body causing a pathologic fracture and concern for cord compression; the L1lesions showed mild FDG-avidity. With this finding, he was referred to the [**Hospital1 18**] ED where an MRI of his thoracic spine (described below) confirmed the T6 mass and showed it impinging on the spinal cord with associated edema of the cord. Past Medical History: atrial fibrillation treated with catheter ablation (not on anticoagulation since) - he has never had a colonoscopy Social History: He works at the [**Last Name (un) **] and has a longterm girlfriend who is his healthcare proxy. [**Name (NI) **] smoked >1 pack per day up until age 35. He drinks socially. Family History: His mother had lung cancer but died of cardiovascular disease. His father is still living. He has two grown children. Otherwise, no known family history of malignancy Physical Exam: O: T: 97.2 HR:97 BP:167/99 R:16 O2Sats: 99% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3->2 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. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3->2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally with normal lateral gaze nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. (decreased slightly on R) IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-1**] throughout. No pronator drift Sensation: intact to light touch, pinprick and vibration down to the level of the umbilicus. Below this level, intact to pinprick, light touch but without 2 point discrimination. Decreased sensation to vibration. Reflexes: B T Br Pa Ac Right 2 2 2 1 1 Left 2 2 2 1 1 Toes mute bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements. Exam upon discharge [**5-8**]: T10 sensory level, motor intact Pertinent Results: MRI T-spine [**2191-4-28**] Mass lesion of T6 which causes collapse of the vertebral body and which extends into the right anterolateral paravertebral soft tissues and posteriorly into the posterior elements and the central canal causing compression and edema of the spinal cord. CT Torso [**2191-4-28**]: 1. Vertebral collapse of the T6 vertebral body as identified on prior MR study. An indeterminate area of low attenuation in the right 5th rib could represent a further osseous lesion. A radioisotope bone scan may be considered for further assessment of the skeleton. 2. No abnormal mass lesion is seen in the lungs. 3. A few hepatic cysts are identified. A number of other smaller hypoattenuating lesions in the liver are too small to characterize, but may also represent hepatic cysts. ECHO [**2191-5-4**]: Suboptimal image quality. Mild right ventricular cavity enlargement with free wall hypokinesis. Dilated thoracic aorta. Is there a history to suggest a primary pulmonary process (pulmonary embolism, sleep apnea, bronchospasm, etc.) If more definitive information regarding a possible left atrial appendage thrombus is needed, a TEE is suggested. CLINICAL IMPLICATIONS: Based on [**2188**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. CTA chest [**2191-5-4**]: 1)No pulmonary embolism, aortic dissection, or aneurysm. 2)Loculated effusion which contains air in the left lower lobe overlying the thoracotomy site with a small Left sided pneumothorax and partial left lower lobe collapse 3)Consolidation in the right lung is most likely pneumonia. 4)Post-surgical changes in the paraspinal soft tissues with new orthopedic fixation device and residual paraspinal soft tissue. L spine C-rays [**2191-5-6**]: Two views of the lumbar spine demonstrate five non-rib-bearing lumbar-type vertebral bodies. There are some degenerative changes with disc space narrowing, worse at L5/S1. Minimal anterior spurring is seen. There are no compression deformities or abnormal antero- or retrolisthesis. There is some residual contrast material seen within the colon. There are some degenerative changes of the bilateral hips, right side worse than left. Sacroiliac joints are normal. CXR [**2191-5-6**]: The heart size is normal. Mediastinal position, contour and width are unremarkable. Lungs are essentially clear except for opacity in the left lung which is related to recent thoracotomy. There is improved aeration of the lung bases. There is minimal left apical pneumothorax that may retrospectively be seen on the prior study restricted to the very left apex. Brief Hospital Course: Mr [**Known lastname 1968**] was admitted to the neurosurgery service. He underwent a number of tests to including a MRI which showed a lesion of the T6 vertebral body which causes collapse of the vertebra and which extends into the anterolateral paravertebral soft tissues and posteriorly into the posterior elements and the central canal. A CT of chest of negative was negative for any pulmonary involvement. An oncology consult recommended biopsy and a number of lab tests. He underwent a T6 vertebrectomy, anterior arthrodesis T5-T6 and T6-T7,insertion of interbody device, anterior instrumentation T4-T7. He had a chest tube post-op and was monitored overnight in the PACU. On Post op day 2 early am, he experience acute onset shortness of breath and peri scapular inspiratory pain, followed by supraventricular tachycardia. At 6AM, AFib versus Flutter to 160s. Metoprolol 5 mg x 2, 10 diltiazem with conversion to SR, then back to AFib shortly thereafter. Given 30 mg PO and another 10mg IV diltiazem. Pressure tolerated well, patient fully asymptomatic. AF again returned and he was transferred to the cardiac care unit for further management. Pain (peri scapular inspiratory) and shortness of breath resolved spontaneously earlier this a.m. and SVT had followed this event by about two hours he went into a rapid afib rates 120-170. A stat cardiology consult was obtained and he was transferred to the cardiology service for 24 hours. They performed a CTA which was negative for PE, he did have a loculated effusion which contains air in the left lower lobe overlying the thoracotomy site with a small Left sided pneumothorax and partial left lower lobe collapse. Follow up CXR on [**5-5**] saw improvement of XRay. He was transferred back to our service on [**5-5**] and had no further cardiac or respiratory issues. He did require one unit of PRBCs for declining HCT. He worked with PT. Dr. [**Last Name (STitle) 3929**] was contact[**Name (NI) **] to evaluate for radiation treatment. Lopressor dosage continued to be adjusted. On [**5-8**] his HCT was 29. He had bradycardia from 70's-50's. EKG ordered for irregular heart rate. This appeared to show NSR. Cardiology was called. They recommended increasing his Motoprolol to 150 QD and cleared him for DC. CT surgery recommended no further follow up. Hem/Onc was contact[**Name (NI) **] at time of DC and they agreed to call him for an outpt. appointment. The patient was given. Dr.[**Name (NI) **] office number for outpatient follow up. Medications on Admission: Vicodin, ibuprofen Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): Do not exceed 4g APAP(acetominophen/tylenol) in 24 hrs. 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: T4 Vertebral Mass Discharge Condition: Neurologically stable Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Do not smoke -Keep wound clean / Please shower daily --No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. -Limit your use of stairs to 2-3 times per day -Have a family member check your incision daily for signs of infection -If you are required to wear one, wear cervical collar or back brace as instructed -Take pain medication as instructed; you may find it best if taken in the a.m. when you wake if you experience muscle stiffness and before bed for sleeping discomfort -Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months. -Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????????????????????????????????????????? Followup Instructions: PLEASE RETURN TO THE OFFICE on [**5-11**] to remove your staples PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NEED AP/Lat T-spine XRAYS PRIOR TO YOUR APPOINTMENT Hematology/Oncology: You will need to be seen in outpatient follow up in one week. You will be called by their office with an appointment. Radiation/Oncology Dr. [**Last Name (STitle) 3929**]: Please call ([**Telephone/Fax (1) 8082**] to schedule an apointment within 2-3 weeks to discuss any need for radiation treatment. Please follow up with your PCP to discuss your cardiac status, new Lopressor medication. Completed by:[**2191-5-8**]

[ "238.6", "518.0", "512.1", "427.31", "997.1", "336.3", "733.13", "427.89" ]

icd9cm

[ [ [] ] ]

[ "81.04", "80.51", "81.62", "77.89", "77.71", "84.51" ]

icd9pcs

[ [ [] ] ]

9860, 9866

6298, 8803

425, 475

9928, 9950

3528, 4691

10873, 11564

1786, 1954

8873, 9837

9887, 9907

8829, 8850

10101, 10850

1969, 2195

4714, 6275

279, 387

503, 1439

2447, 3509

9965, 10077

1461, 1578

1594, 1770

27,947

115,100

32101

Discharge summary

report

Admission Date: [**2128-8-23**] Discharge Date: [**2128-8-27**] Date of Birth: [**2089-1-20**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: CC:[**CC Contact Info 75133**] Major Surgical or Invasive Procedure: None History of Present Illness: 40yoM involved in motorcycle collision - events unclear. GCS 14 upon arrival ED Past Medical History: PMHx:PUD Social History: Social Hx:+ EtOH Family History: noncontributory Physical Exam: PHYSICAL EXAM:Examined in ED just prior to intubation. O: BP:154 /91 HR: 120 R 18 O2Sats92 Gen: WD/WN, comfortable, NAD. HEENT: Pupils:3->2 EOMs full, abrasion left face, left eye ecchymosis, no battle sign,otorrhea or rhinorrhea. Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3to2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength appears intact and symmetric. VIII: Hearing intact to voice. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-8**] throughout. Toes downgoing bilaterally Pertinent Results: CT:multiple small foci SAH in bilat frontal and left temporal lobes, R temporal contusion, no fractures Labs: cbc: 9.9/41.2/317 coag: 13.6/24.1/1.2 [**2128-8-23**] 09:35PM PT-13.6* PTT-24.1 INR(PT)-1.2* [**2128-8-23**] 09:35PM WBC-9.9 RBC-4.48* HGB-14.5 HCT-41.2 MCV-92 MCH-32.4* MCHC-35.3* RDW-13.6 [**2128-8-23**] 09:35PM PLT COUNT-317 [**2128-8-23**] 09:35PM UREA N-7 CREAT-0.9 [**2128-8-23**] 09:35PM AMYLASE-46 Brief Hospital Course: Pt was admitted to the hospital on the trauma service and was monitored in the ICU. He was extubated on the first day. Repeat head CT showed stable hemorrhage. He was maintained on therapeutic dose of dilantin for seizure prophylaxis. He was transferred out of the ICU on the first hospital day to the neurosurgical service. His diet and activity were advanced. He had some difficulties with nausea and pain management but this improved. He was seen by OT and ultimately cleared for discharge to home. Family members drove to pick pt up and being him home to [**State **]. Medications on Admission: prilosec ? BP med Discharge Disposition: Home Discharge Diagnosis: Traumatic subarachnoid hemorrhage Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR HEAD INJURY ?????? Take your pain medicine as prescribed, wean off over next 2 weeks. ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? 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. ?????? You have been prescribed an anti-seizure medicine, take it three times a day until [**2128-9-2**]. CALL YOUR PCP OR GO TO NEAREST EMERGENCY ROOM 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: Follow up with your PCP for repeat head CT in one month.

[ "920", "851.80", "E812.3", "787.02", "802.8", "784.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

2512, 2518

1863, 2443

350, 357

2596, 2620

1411, 1840

3683, 3743

551, 568

2539, 2575

2469, 2489

2644, 3660

597, 892

280, 312

385, 467

964, 1392

907, 948

489, 500

516, 535

81,686

196,871

36372

Discharge summary

report

Admission Date: [**2127-4-9**] [**Month/Day/Year **] Date: [**2127-4-15**] Date of Birth: [**2052-11-13**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p Fall off bicycle Major Surgical or Invasive Procedure: None History of Present Illness: 74F s/p fall from bicycle; was wearing helmet at time. +report of LOC. She was taken to an area hospital in [**Location (un) 3844**] and was transferred to [**Hospital1 18**] becasue of subarachnoid hemorrhage. Past Medical History: HTN, osteopenia Social History: Married, lives with husband Family History: Noncontributory Physical Exam: T: 98.3 BP: 133/55 HR: 57 R: 14 O2Sats: 97%4LNC Gen: WD/WN, comfortable, NAD. HEENT: Pupils: Right 3-->2, Left 3.5-->2.5 EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, minimal tenderness, BS+ Extrem: Warm and well-perfused. Mental status: Awake and alert, cooperative with exam, normal affect, somewhat disorganized speech Orientation: Oriented to person, but not to place and date, states she is in [**Country 32814**] and it is [**2124**]. Cranial Nerves: I: Not tested II: Pupils unequal, both reactive, L>R 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. 4+/5 strength in R biceps, finger grip, 5 in triceps. [**3-25**] in LUE. Bilaterally 5/5 strength in lower extremities. Sensation: Intact to pain, withdraws all 4 extremities Pertinent Results: [**2127-4-9**] 04:02PM GLUCOSE-120* LACTATE-1.2 NA+-139 K+-3.8 CL--100 TCO2-26 [**2127-4-9**] 03:50PM UREA N-18 CREAT-0.9 SODIUM-136 POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-26 ANION GAP-15 [**2127-4-9**] 03:50PM CALCIUM-9.3 PHOSPHATE-2.9 MAGNESIUM-2.0 [**2127-4-9**] 03:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2127-4-9**] 03:50PM WBC-12.1* RBC-3.84* HGB-12.6 HCT-35.3* MCV-92 MCH-32.8* MCHC-35.6* RDW-12.0 [**2127-4-9**] 03:50PM PLT COUNT-219 [**2127-4-9**] 03:50PM PT-14.9* PTT-24.4 INR(PT)-1.3* CT Head [**2127-4-9**] IMPRESSION: Multiple small foci of subarachnoid hemorrhage bilaterally, at the left frontotemporal region, and small at the right vertex. Bilateral extra- axial hypodense fluid collections, more on the right. No evidence of shift of normally placed midline structures. No blood in the basilar cisterns, and ventricles. Study limited due to motion-related artifacts; however, no definite fracture is seen. CTA [**2127-4-9**] IMPRESSION: Left distal clavicle fracture, left fourth and fifth rib fractures (lateral). No lung or vessel injury. Repeat head CT scan [**2127-4-13**] IMPRESSION: 1. Interval resolution of superior bifrontal subarachnoid hemorrhage. The distribution of the remainder of the foci of subarachnoid hemorrhage appears unchanged. 2. Unchanged widening of extra-axial CSF spaces overlying both frontal lobes, may represnt subdural hygromas. Brief Hospital Course: She was admitted to the Trauma Service; Neurosurgery was consulted for the subarachnoid hemorrhage. She was loaded with Dilantin and remained on this for several days. Serial head CT scans were done and remained stable. Her mental status had slowly improved during her hospital stay. She will follow up with Dr. [**Last Name (STitle) **] as an outpatient for a follow head CT scan in 4 weeks. Orthopedics was consulted for the left clavicle fracture and this was also managed non operatively. She was placed in a sling and is to remain non weight bearing on her left arm. She will follow up in [**Hospital 5498**] clinic in 2 weeks time. Her pain is being managed with oral narcotics prn and around the clock Tylenol. A bowel regimen was also initiated. Physical and Occupational therapy were consulted and have recommended short rehab stay after her acute hospitalization. Medications on Admission: ?calcium channel blocker [**Hospital **] Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for constipation. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for HR<55; SBP<110. [**Hospital **] Disposition: Extended Care Facility: [**Hospital6 19504**] of [**Location (un) 1514**] - [**Location (un) 1514**], NH [**Location (un) **] Diagnosis: s/p Fall from bicycle Subarachnoid hemorrhage Left clavicle fracture Left rib fractures [**1-22**] Secondary diagnosis: Wedge compression fracture T7 (non acute) [**Month/Day (3) **] Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. [**Month/Day (3) **] Instructions: DO NOT bear any weight on your left arm because of your fracture. Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) 1005**], Orthopedics for your clavicle fracture. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in 4 weeks with Dr. [**Last Name (STitle) **], Neurosurgery for your subarachnoid hemorrhage. Call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will need a repeat head CT scan for this appointment. Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab. Completed by:[**2127-4-15**]

[ "E826.1", "810.02", "852.06", "807.02", "733.90", "401.9", "293.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3341, 4219

347, 353

1875, 3318

5728, 6260

693, 710

4245, 5295

725, 988

5327, 5427

287, 309

381, 593

1223, 1856

5448, 5705

1003, 1207

615, 632

648, 677

55,639

139,969

54925

Discharge summary

report

Admission Date: [**2153-7-31**] Discharge Date: [**2153-8-26**] Date of Birth: [**2076-5-20**] Sex: F Service: MEDICINE Allergies: Cipro / Codeine / Shellfish Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Intubation; blood product transfusions History of Present Illness: 77F with history of Crohn's disease, multiple myeloma, anemia requiring multiple prior tranfusions, who initially presented to OSH with fevers and suddent onset of bilateral lower abdominal pain x1 day. Has had nausea/heaving but no actual emesis, no diarrhea. At the OSH, non-contrast CT was concerning for a possible mass in the pancreas/duodenum, as well as possible perforation (extraluminal gas noted). Received zosyn. Hct was 25, and patient was transfused 3 units pRBCs. Also got 1L NS. Sent to [**Hospital1 18**] for further evaluation. HR was in 160s prior to transfer. In the ED, initial VS were: 170 97/67. RR was 32, O2 sat 97% on 2L. Spiked temp to 102.8. Patient was fatigued appearing but oriented x3. Labs notable for neutropenia with WBC 0.3 (16%N, 1 band, ANC 51), Hct 38.3, plt 61, Na 146, K 2.6, CO2 11, Cr 1.1 (baseline unknown), Ca 6.2, mag 1.1, trop 0.03. Lactate was 4.7. LFTs, coags normal. ABG 7.29/24/83/12. Repeat CT abd/pelvis here (on prelim read) showed [**Last Name (un) **] non-hemorrhagic free fluid in abdomen and pelvis w/ periportal edema, abnormal appearance of the ileocecal junction and proximal colon, significant wall thickening and inflammation suggestive of colitis, distal terminal ileum with minimal wall thickening, and a fluid-filled dilated appendix (14 mm) with surrounding inflammation (most likely reactive inflammation from primary process involving proximal colon). There was no extraluminal air or oral contrast to suggest perforation on prelim read. Patient was seen by Surgery, who reviewed imaging and felt it was c/w severe colitis, but that there was no evidence of free air/perforation or acute surgical pathology. Recommended admission to the MICU, and they will follow along. While in ED, she was tachy to the 150s-170s, unclear if sinus tachy vs. SVT. Patient received adenosine, and per report p waves seemed to [**Month (only) **] out. R IJ CVL placed, as well as NGT, with return of >1L coffee-grounds. GI consulted. Was question of tube being curled on CXR, but as it was still draining, was left in place. SBP dropped to 60s-70s. Was started on levophed, which is currently at 0.24. She received a total of 4L IVF, and is currently receiving albumin 12.5 mg per Surgery recs. Her lactate has trended down to 3.5-3.6. Received additional antibiotics with vancomycin 1 gram. Received fentantyl, dilaudid, and acetaminophen for pain control. Zofran for nausea. Magnesium repleted. Admitted to [**Hospital Unit Name 153**] with GI and Surgery to follow. VS prior to transfer 129 95/53 24 98%. On arrival to the MICU, patient's VS. 97.3, 126 (sinus) 119/61, 18 98% 2L recieving norepinephrine 0.24 mg/min. NGT was in place draining coffee ground appearing material. Patient was in considerable discomfort complaining of [**9-12**] abdominal pain. Per her daughter's report (patient unable to provide due to pain) she has been having worsening of her chron's symptoms, specifically diarrhea and abdominal pain over the last month. She was admitted to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital in the end of [**Month (only) **] for abomdinal pain and was discharged on Lialda (a new medication) and a 14 day course of cipro/flagyl. She developed nausea and vomitting while on these medications and self d/c'd the cipro. Her daughter is unsure whether she continued the other medications. She was readmitted to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**7-12**] with worsening abdominal pain and after out patient blood work demonstrated a K of 2.2. She was again discharged on cipro/flagyl as well as zofran. She went back to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] on [**7-30**] after her daughter found her at assited living having not eaten, having nausea with vomitting and complaining of abdominal pain. She is not sure when she began to have coffee ground emesis nor is she aware of any bloody bowel movements Review of systems: (+) Per HPI, patient unable to relate other than nausea and abdominal pain. Past Medical History: Crohn's disease COPD Multiple myeloma Chronic anemia requiring periodic transfusions Chronic pancytopenia Past Surgical History: s/p ex-lap for Crohn's disease no bowel resection s/p cholecystectomy [**10**]'s s/p D&Cs Social History: Lives at elderly nursing complex. Denies any tobacco or EtOH use. Family History: Mother with [**Name (NI) 4522**], Father with COPD Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 97.3, 126 (sinus) 119/61, 18 98% 2L recieving norepinephrine 0.24 mg/min. General: in significant pain, thinks she is at [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 112177**] hospitla HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: tender through out, mildly distented, Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: ADMISSION LABS Lactate: 4.7 -> 3.5 -> 3.6 freeCa: 0.67 -> 1.10 146 | 117 | 14 ----------------< 150 2.6 | 11 | 1.1 Ca: 6.2 Mg: 1.1 P: 3.4 ALT: 20 AST: 26 AP: 48 Tbili: 0.9 Alb: 2.6 Lip: 17 Trop-T: 0.03 WBC 0.3, Hgb 13.1, Hct 38.3, Plt 61 N:16 Band:1 L:75 M:4 E:0 Bas:0 Atyps: 4 PT: 11.9 PTT: 34.2 INR: 1.1 pH 7.29 / pCO2 24 / pO2 83 / HCO3 12 / BaseXS -12 UA: trace protein, trace ketones, 1 WBC, 1 RBC, few bacteria, no yeast, neg leuk, neg blood Micro: Blood cultures 8/28 x2: pending Urine culture [**7-31**]: pending MICRO: [**2153-8-3**] 10:37 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2153-8-4**]** C. difficile DNA amplification assay (Final [**2153-8-4**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). [**2153-8-10**] 4:06 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2153-8-11**]** C. difficile DNA amplification assay (Final [**2153-8-11**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). [**2153-8-21**] 12:05 pm BLOOD CULTURE Source: Line-PICC. Blood Culture, Routine (Preliminary): [**Female First Name (un) **] (TORULOPSIS) GLABRATA. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. SENSITIVITIES REQUESTED BY [**Doctor First Name **] [**Doctor Last Name **] #[**Numeric Identifier **]. [**Female First Name (un) **] SPECIES. SECOND MORPHOLOGY. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 354-7014F [**2153-8-21**]. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Anaerobic Bottle Gram Stain (Final [**2153-8-22**]): Reported to and read back by DR. [**Last Name (STitle) **]. TAN ON [**2153-8-22**] AT 2250. BUDDING YEAST. Aerobic Bottle Gram Stain (Final [**2153-8-23**]): BUDDING YEAST. [**2153-8-23**] 1:26 am CATHETER TIP-IV Source: PICC. **FINAL REPORT [**2153-8-25**]** WOUND CULTURE (Final [**2153-8-25**]): No significant growth. [**2153-8-24**] 2:07 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Preliminary): YEAST. BUDDING YEAST. Aerobic Bottle Gram Stain (Final [**2153-8-26**]): BUDDING YEAST. IMAGING: CT Abd/Pelvis with contrast [**2153-7-31**]: IMPRESSION: 1. Wall thickening and inflammation involving the distal ileum and proximal colon, as well as the appendix, most likely secondary to acute colitis related to known Crohn's disease and less likely due to typhlitis. No evidence of perforation. 2. Fecalized duodenal diverticulum. 3. Stigmata of chronic Crohn's disease in the RLQ with fibrofatty proliferation. 4. Moderate to large amount of non-hemorrhagic ascites with mesenteric and periportal edema, findings consistent with shock physiology and recent aggressive volume resuscitation. 5. Delayed excretion of contrast from both kidneys, findings suggestive of acute renal failure, correlate clinically. CXR [**2153-7-31**]: IMPRESSION: No acute cardiopulmonary process TTE [**2153-8-7**]: The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size 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 to moderate ([**12-4**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Borderline left ventricular systolic function. Mild to moderate mitral regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [**2153-8-1**], both left and right ventricular cavities are now smaller. Biventricular systolic function has substantially improved. No more than mild functional TR is now seen, likely as a consequence of the smaller RV cavity. TTE [**2153-8-24**]: Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF 80%). An apical intracavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The mitral E wave velocity spectrum actually represents E and A wave superimposition secondary to tacycardia. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2153-8-7**], the left ventricle is now quite small and hyperdynamic. Tachycardia is present. If clinically indicated, a transesophageal echocardiographic examination is recommended to exclude vegetations. IMPRESSION: Suboptimal image quality. No definite vegetations seen CXR [**2153-8-26**]: Portable AP radiograph of the chest was reviewed in comparison to [**2153-8-24**]. The ET tube tip is 4 cm above the carina. The NG tube passes below the diaphragm terminating in the stomach. The heart size and mediastinum are unchanged. There is interval development of widespread parenchymal opacities in the right lung and the left upper lobe, concerning for widespread infection. Asymmetric pulmonary edema would be another possibility. Re-assessment after diuresis is required. Brief Hospital Course: 77F with multiple myeloma, Crohn's disease, chronic pancytopenia, presented [**7-31**] with neutropenic fever, septic shock in the setting of a presumed Crohn's flare complicated by respiratory failure and prolonged intubation. #Respiratory failure: Pt intubated on the day of admission [**7-31**] for respiratory distress. She was extubated on [**8-18**] after successful prolonged SBT, but reintubated approximately 8 hours later for an increase in work of breathing and O2 requirement. The possibility of tracheostomy and PEG were discussed with her and her family, but were prevented by the development of fungemia. On the morning of [**8-26**], her O2 requirement increased, urine output decreased and she developed bilateral infiltrates on CXR concerning for infection or ARDS. A family meeting was held during which her family decided to transition to comfort care and she expired that afternoon. #Sepsis: The patient presented with neutropenic fever and shock requiring 3 pressors presumed secondary to sepsis from GI source given signs of colitis on CT imaging. She was weaned off pressors and completed 14 day course of Metronidazole and Cefepime. She was also briefly on PO/PR vancomycin which was discontinued after multiple C diff assays were negative. As above, she again developed signs of sepsis on [**8-26**] from presumed pulmonary source given poor oxygenation and diffuse bilateral infiltrates on CXR and broad antibiotic coverage was restarted. She was transitioned to comfort care after a meeting with her family and she expired that afternoon. #Goals of Care: After extubation on [**8-18**], the team asked the patient if she would want to be re-intubated in the case of respiratory failure. She did not express a clear preference and was re-intubated that evening. Multiple family meetings were held with her children, including her son who was her healthcare proxy. The possibility of tracheostomy and PEG placement were discussed with planned possible discharge to LTACH, but the patient developed fungemia before this was pursued. In the setting of her acute clinical deterioration on [**8-26**], a family meeting was held during which it was decided to transition her to comfort care and she expired that afternoon. Subsequently, the family consented to a limited autopsy. They also requested a DNA sample and pathology agreed to hold tissue blocks from the autopsy as well as a blood sample card. Her son, [**Name (NI) 449**] [**Name (NI) 32496**] [**Telephone/Fax (1) 112178**] was contact[**Name (NI) **] via phone and given the number for the pathology dept (Dr. [**Last Name (STitle) 7108**] in order to obtain the samples. #Fungemia: Blood cultures from [**8-21**] grew [**Female First Name (un) **] and pt was started on micafungin for planned 4 week course, PICC line removed. #Anemia: HGB/HCT trended down with initial HCT 38.8 and subsequent HCT in low to mid 20s requiring 5 blood transfusions throughout her admission. She had hemoccult positive, occasionally maroon colored stools thought to be secondary to ischemic colitis vs Crohn's flare. Additionally her retic count was low at .5% indicating poor bone marrow function in the setting of known multiple myeloma. #Colitis: Pt was followed by GI and started on high dose IV steroids for presumed Crohn's flare with slow taper (5mg/wk). She was also covered broadly with antibiotics for potential infectious etiology. #Edema: Pt became anasarcic with fluid resuscitation for sepsis. Diuresed briefly with lasix drip after which she showed brisk auto-diuresis with improvement in appearance of edema and return to near baseline weight. #[**Last Name (un) **]/ATN: Cr trended up from 1.1 on admission to peak at 4.1 on [**8-10**]. It was likely related to her initial hypotension, IV contrast,underlying multiple myeloma. It gradually trended down to stabilize at 1.9-2. #Thrombocytopenia: Likely multifactorial, related to underlying marrow suppression, antibiotics. Unlikely DIC given normal fibrinogen, unlikely HIT given slow downward trend. Received DDAVP and several platelet transfusions prior to line placements. #Ileus: Pt had profuse, bilious output from NG/OG and was started on Erythromycin for gut motility with some improvement. #HTN: Pt intermittently hypertensive to SBP 150s-170s and tachycardic to 110s. It was likely due to pain or agitation as it often related suctioning or repositioning especially when off sedation. Pain was managed with fentanyl boluses, agitation managed with olazepine and midazolam. #ELEVATED INR: INR noted to be elevated to peak 1.9, likely due to combination of poor nutrition and antibiotic therapy. Gradually normalized throughout hospital course. #Neutropenia: Chronically low secondary to multiple myeloma. #Multiple Myeloma: Last chemo was [**2152-11-2**]. Conservative managment with transfusions continued during hospitalization. As above, multiple goals of care discussions were held with family given poor prognosis with eventual decision to transition to comfort care. Medications on Admission: None listed. Discharge Medications: None, patient expired. Discharge Disposition: Expired Discharge Diagnosis: Sepsis, hypoxemic respiratory failure. Discharge Condition: Expired Discharge Instructions: None, patient expired. Followup Instructions: None, patient expired. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "424.0", "496", "785.52", "427.89", "276.2", "585.9", "E915", "789.59", "284.19", "790.29", "425.4", "518.81", "112.5", "995.92", "038.9", "275.2", "276.3", "560.1", "E879.8", "535.50", "E932.0", "276.8", "276.52", "203.00", "555.2", "E947.8", "933.1", "E849.7", "403.90", "584.5", "999.32", "276.0", "263.9", "787.91", "V66.7", "V49.86" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.04", "38.97", "99.15", "96.6" ]

icd9pcs

[ [ [] ] ]

16984, 16993

11836, 16874

311, 351

17075, 17084

5671, 6959

17155, 17316

4862, 4915

16937, 16961

17014, 17054

16900, 16914

17108, 17132

4669, 4761

4930, 5652

8165, 11813

4439, 4517

256, 273

379, 4420

4539, 4646

4777, 4846

9,702

188,630

21487

Discharge summary

report

Admission Date: [**2140-1-13**] Discharge Date: [**2140-1-17**] Date of Birth: [**2060-8-14**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 99**] Chief Complaint: OSH transfer with severe shortness of breath, fever, lethargy Major Surgical or Invasive Procedure: BiPAP, deep suctioning, chest physical therapy History of Present Illness: Briefly, patient is a 79 year old male with PMHx of CAD s/p CABG in [**2121**], COPD (no PFTs available), HTN, Afib, PVD s/p aortofemoral bypass who presents from [**Hospital1 **] with shortness of breath. Patient has had multiple episodes of aspiration pneumonia (including MSSA PNA) in the past 8 months. Wife states he had been doing well after his last discharge on [**2140-1-1**], had gone to rehab on antibiotics; his last dose of Vanc/Zosyn was on [**2140-1-4**]. The patient's wife reports that 2 days PTA the patient developed a poor appetite and shallow breathing. On the day of admission, per report the patient was clearly tachypneic, and was found to have a temp of 101.1. He was placed on BIPAP 12/5 with 5L of O2. An ABG was performed, which came back as 7.406/43/80/32. The patient was given 1 dose of ceftaz and sent to the [**Hospital1 18**] ED. . In the ED the patient was again placed on BiPAP. His SpO2 remained in the 80s with a respiratory rate approaching 40 breaths per minute. He appeared somnolent. In the ED he received a 200 cc bolus of NS and was given Levofloxacin, Flagyl, Vancomycin. A MICU evaluation was called, and the patient was admitted to the MICU. . In the MICU, the patient was treated with vancomycin and zosyn, as well as frequent neb treatments and steroids. He responded well to this regimen, and no intubation was required. BiPAP was not tolerated well, but the patient was found to be oxygenating and ventilating fairly well on FM + NC. The patient was found to have a left sided white-out on CXR, for which chest PT has been attempted with some improvement in O2 sats. . The patient was recently admitted from [**2139-12-25**] to [**2140-1-1**] for PNA. He was intubeted for 2 days after which he was extubated and placed on nocturnal BIPAP. He has a baseline O2 requirement of 3L by NC. Past Medical History: PVD s/p aortofemoral bypass [**2138-12-26**] Gastric mass visualized with above surgery Lung mass noted in [**8-24**] (apical scarring, RUL lung mass) CAD s/p CABG [**2121**] COPD atrial fibrillation HTN ECHO [**10-24**] EF 43% Arthritis Social History: Married, one child, retired electrician No ETOH or Tobacco Family History: Mother with esophageal CA Sister with MI Physical Exam: GEN: ill-appearing elderly M in NAD. Soft-spoken. Asking for ice. HEENT: OP clear, MMM. Anicteric. NECK: supple, no LAD appreciated. CHEST: Healed sternotomy scar. Decreased breath sounds at the left base. Faint breath sounds bilaterally. Scattered rhonchi. COR: Irregularly irregular. Normal S1S2, no M/R/G ABD: Soft, NT, ND EXT: 2+ pitting edema bilaterally. Peripheral pulses intact. Extremities cool. NEURO: follows commands. CN II-XII grossly intact. MAEx4. Not ambulated. Pertinent Results: [**2140-1-13**] 08:35PM TYPE-ART PO2-46* PCO2-51* PH-7.44 TOTAL CO2-36* BASE XS-8 INTUBATED-NOT INTUBA [**2140-1-13**] 04:47PM COMMENTS-GREEN TOP [**2140-1-13**] 04:47PM LACTATE-1.9 [**2140-1-13**] 04:45PM GLUCOSE-266* UREA N-30* CREAT-0.5 SODIUM-146* POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-34* ANION GAP-14 [**2140-1-13**] 04:45PM WBC-14.8* RBC-4.40* HGB-11.1* HCT-35.7* MCV-81* MCH-25.3* MCHC-31.2 RDW-18.5* [**2140-1-13**] 04:45PM NEUTS-93.7* BANDS-0 LYMPHS-4.1* MONOS-2.1 EOS-0.1 BASOS-0.1 [**2140-1-13**] 04:45PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL [**2140-1-13**] 04:45PM PLT SMR-HIGH PLT COUNT-484* [**2140-1-13**] 04:45PM PT-37.3* PTT-38.6* INR(PT)-4.1* . CXR [**1-13**]: Patient's head obscures evaluation of the left upper lung. The patient is status post median sternotomy. As compared to the prior study, the mid and lower left lung zones demonstrate increased opacity. Opacity in the right lower lobe not as prominent as on the prior study. The right apical opacity appears stable. A small left pleural effusion is present. Lungs [**Location (un) 381**] lung volumes, but given this limitation, there is no definite pulmonary edema. . CXR [**1-15**]: There is complete opacification of the left hemithorax with faint central air bronchograms; this represents a marked change within the last two days. There is no significant mediastinal shift. The right lung is clear. Findings of prior CABG (mediastinal clips and sternal wires) have been discussed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] on [**2140-1-15**]. . CXR [**1-16**]: Median sternotomy wires are seen, unchanged. There has been improvement of the opacification of the left lung. There are areas of improved aeration in the left upper lobe. There is complete opacification of the left lower lung field. There remain areas of consolidation within the left upper lobe. There is a pleural-based opacity seen within the right apex, which is unchanged. There is blunting of the right CP angle. Assessment of heart size is difficult secondary to the left lung opacification. . EKG [**1-15**]: Atrial fibrillation with moderate ventricular response Premature ventricular contractions Right bundle branch block Possible inferior infarct - age undetermined Since previous tracing of [**2140-1-13**], Q waves in inferior leads more prominent Brief Hospital Course: The patient was admitted to the MICU for intensive noninvasive respiratory therapy, includid BiPAP, chest PT, frequent nebulizer treatment, IV solumedrol, and antibiotic therapy with vancomycin and zosyn. It was thought that the patient likely had suffered a repeat aspiration event leading to a new aspiration pneumonia vs. pneumonitis, as well as a likely exacerbation of his baseline COPD, which likely occurred in the setting of this pneumonia. The patient symptomatically improved greatly on this regimen. He did not tolerate BiPAP well, but he did manage to oxygenate and ventilate well on facemask with frequent nebulizer treatments. His mental status quickly improved as well. He did suffer a near white-out of the left lung on [**1-15**], even as he was improving clinically. This was most likely due to mucus plugging, and left lung aeration improved with turning of the patient and intensive chest PT. The patient was transferred to the general medical floor on [**2140-1-16**] in stable condition. He was continued on the frequent neb treatments, PO prednisone, and IV vancomycin and zosyn. The patient was kept NPO due to his aspiration risk. He was satting well on 2L by NC in the evening of [**1-16**]. The patient's anticoagulation for atrial fibrillation was discontinued during his stay in the ICU. During the MICU stay, a family meeting was held to discuss the chronic aspiration problems of the patient. The patient did not want to have a feeding tube inserted, and was interested in eating, even though he knew that he would likely aspirate again eventually. During this discussion, the patient was made DNR/DNI. . Late in the night on [**1-16**] the patient was found to be bradycardic to 39 on routine vital signs check. He was asymptomatic during this episode, and normotensive. Nursing requested that the patient be placed on telemetry for closer monitoring. Later in the night the patient was found to have an 8 second asystolic pause, again reported as asymptomatic. The covering physician came to the bedside on hearing of this event, and found the patient to be in PEA arrest, which converted to asystole. No invasive interventions were performed, in keeping with the DNR/DNI order. The patient expired at 3:30AM on [**2140-1-17**]. Medications on Admission: Albuterol Sulfate 0.083 % Solution Q4H PRN Ipratropium Bromide 0.02 % Solution Q4H PRN Lansoprazole 30 mg Capsule QD RISS Heparin (Porcine) 5,000 unit/mL SC TID Salmeterol 50 mcg/Dose Q12H Metformin 500 [**Hospital1 **] Lasix 20 coumadin 2.5 qd Discharge Medications: Not applicable Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Aspiration pneumonia Atrial fibrillation Pulseless electrical activity Asystolic cardiac arrest Discharge Condition: Deceased Discharge Instructions: Not applicable Followup Instructions: Not applicable Completed by:[**2140-1-17**]

[ "507.0", "V45.81", "414.00", "401.9", "427.31", "427.5", "707.03", "496" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8235, 8307

5619, 7900

346, 394

8446, 8456

3172, 5596

8519, 8564

2616, 2658

8196, 8212

8328, 8425

7926, 8173

8480, 8496

2673, 3153

245, 308

422, 2261

2283, 2523

2539, 2600

26,313

165,684

18365

Discharge summary

report

Admission Date: [**2130-7-11**] Discharge Date: [**2130-8-10**] Date of Birth: [**2098-8-12**] Sex: M Service: SURGERY Allergies: Oxaliplatin / Minocycline Attending:[**First Name3 (LF) 5880**] Chief Complaint: 3 week history of nausea/vomiting, with intermittent bilious emesis Major Surgical or Invasive Procedure: [**2130-7-13**] Exploratory laparotomy, lysis of adhesions and small bowel resection; closed with [**Location (un) **] bag [**2130-7-14**] Bilateral nephrostomy tube placement [**2130-7-17**] Right colectomy, ileostomy, abdominal closure w/ dexon mesh [**2130-7-25**] Tracheostomy History of Present Illness: 31 y/o man with history of appendiceal adenocarcinoma presents with 3 week history of nausea and vomiting, presented to [**Hospital1 18**] for a 3-day admission, and was discharged. Following discharge, nausea and vomiting continued with intermittent bilious emesis, and he returned to [**Hospital1 18**] for a small bowel obstruction work-up. At the time patient attributed much of the original insult to a barium swallow CT scan. Past Medical History: Metastatic colon cancer, s/p palliative partial pelvic exoneration (Dr. [**Last Name (STitle) 1888**] Social History: +ETOH, +tobacco Married and lives with his wife Family History: Noncontributory Physical Exam: 98.5 102 162/118 18 98%RA Gen: in pain, and in mild distress CV: RRR Resp: CTAB/L Abd: distended, mild tenderness, soft with +BS; ileostomy and colostomy pink and patent Pertinent Results: R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2130-7-19**]): No VRE isolated [**2130-7-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {ESCHERICHIA COLI, KLEBSIELLA OXYTOCA} INPATIENT [**2130-7-19**] FLUID,OTHER GRAM STAIN-FINAL; FLUID CULTURE-FINAL {ESCHERICHIA COLI}; ANAEROBIC CULTURE-FINAL [**2130-7-21**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {ESCHERICHIA COLI} [**2130-7-26**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {ESCHERICHIA COLI}; FUNGAL CULTURE-FINAL INPATIENT [**2130-7-24**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2130-7-22**] FOREIGN BODY WOUND CULTURE-FINAL {GRAM NEGATIVE ROD #1, PROBABLE ENTEROCOCCUS, GRAM NEGATIVE ROD #2} INPATIENT [**2130-7-22**] SPUTUM FUNGAL CULTURE-FINAL {ASPERGILLUS [**Country **]} [**2130-7-26**] URINE URINE CULTURE-FINAL {STAPHYLOCOCCUS SPECIES}; FUNGAL CULTURE-FINAL [**2130-8-6**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [**2130-8-6**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {PSEUDOMONAS AERUGINOSA, GRAM NEGATIVE ROD #2} [**8-1**] HIDA: Likely cholestatis secon. shock liver or decreased liver function; Given poor hepatic extraction of tracer biliary obstruction cannot be evaluated. [**8-2**] neg. DVT [**8-2**] ABD US: Intra- and extra-hepatic biliary ductal dilat, Gallbladder sludge, w/o stones or evidence of cholecystitis. Mild left hydronephrosis. Ascites. [**8-3**] ABD US: no ascites [**8-3**] Urinary cath: R. antegrade nephrostogram demonstrating mod. hydronephrosis and caliectasis, but free passage of contrast into the conduit. Successful placement of new left percutaneous nephrostomy tube. Post-placement nephrostogram mod. hydronephrosis and contrast was only observed passing into the proximal ureter [**8-4**] CT Head w/o contrast: Hypodense lesion in the superior cerebellum on the left side, likely old infarct; metastasis cannot be ruled out CT abd/pelvis ([**7-13**]) 1. Marked dilation of small bowel loops secondary to small-bowel obstruction with a transition point likely at site of increased pelvic anastomosis and soft tissue mass that is consistent with local tumor invasion. 2. NG tube within the distal esophagus. 3. Unchanged mild bilateral hydronephrosis and hydroureter. Renal USx: Mild bilateral hydronephrosis similar to CT [**2130-7-12**]. 15 x 7.5 cm fluid-filled structure within the left lower quadrant may represent ileal loop Labs upon admission: [**2130-7-11**] 06:11PM GLUCOSE-104 UREA N-62* CREAT-4.6*# SODIUM-141 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-25 ANION GAP-21* [**2130-7-11**] 06:11PM ALT(SGPT)-47* AST(SGOT)-40 LD(LDH)-239 ALK PHOS-233* AMYLASE-68 TOT BILI-1.9* [**2130-7-11**] 06:11PM LIPASE-133* [**2130-7-11**] 06:11PM ALBUMIN-3.7 CALCIUM-9.8 PHOSPHATE-4.5 MAGNESIUM-2.6 [**2130-7-11**] 06:11PM WBC-7.6 RBC-4.04* HGB-9.1* HCT-27.9* MCV-69* MCH-22.6* MCHC-32.7 RDW-18.2* [**2130-7-11**] 06:11PM NEUTS-79.8* LYMPHS-11.8* MONOS-7.0 EOS-1.3 BASOS-0.1 [**2130-7-11**] 06:11PM ANISOCYT-2+ MICROCYT-3+ [**2130-7-11**] 06:11PM PLT COUNT-126* Brief Hospital Course: [**7-13**] ex lap/LOA/SBR, closed w/ bag; septic/pressors/PAC placed [**7-14**] B/L nephrostomy tube placement [**7-15**] washout, small bowel resection [**7-17**] washout, R colectomy, ileostomy, abd closure w/ dexon mesh [**7-18**] VAC change (white sponge) [**7-19**] transrectal JP placed in pelvis; B/L LENI's -ive; pelvic JP fluid E. coli [**7-21**] VAC change (white sponge) [**7-25**] perc trach, VAC change; added voriconazole Neuro: CT head on [**8-4**] showed hypodense lesion in the superior cerebellum on the left side, likely old infarct, but unable to r/o metastasis. Pt neurologically intact without focal deficits on d/c. CV: Echo on [**7-17**] showed regional LV dysfunction consistent with CAD/ischemia, patient treated with lopressor for BP control (stable on 12.5mg TID). Resp: patient has tracheostomy (with bronchoscopy) on [**7-25**] for ventilatory support. Pt d/c without tracheostomy, with good ventilation bilat. GI: exploratory lap/lysis of adhesions/small bowel resection on [**7-13**], washout, small bowel resection on [**7-15**], R colectomy, ileostomy, abd closure w/ dexon mesh on [**7-17**]; pt developed sepsis post-op from spillage of bowel contents. At d/c, patient has had recurrent emesis (improved with anzemet), tolerating po intake OK, with ileostomy in place (high-output); vac dressing in place over open abdominal wound (changed 3x/week in hospital, will continue vac changes by VNA as outpatient). Pat also developed elevated bilirubin/transaminases and jaundice - abd USX showed mild Gb ductal dilatation without cholelithiasis; MRCP deferred b/c of patient anxiety in MRI and lack of treatment options if positive for liver mets. GU: Patient had bilateral nephrostomy tubes placed on [**7-14**]; the left nephrostomy tube was replaced on [**8-3**]; pt on CVVHD early in hospital course, but d/c'd by nephrology b/c of incr UO ID: Pt developed sepsis with multi-organ failure E coli and Klebsiella isolated from sputum on [**7-20**], Tx with vanco/ceftriaxone; anaerobic flora from bowel content spillage Tx with Flagyl; Aspergillus grown from sputum ([**7-25**]) and pt Tx with voriconazole. At d/c, patient was not being treated for any ongoing infection and was discharged on no antibiotics. Heme: bilat LENIs [**7-19**] (negative for DVTs); pt received [**Last Name (un) **] transfusions of PRBCs during hospital course; Hct stable at discharge. FEN: At discharge, patient without nutritional support (feeding tube d/c'd on [**8-9**]), tolerating po OK but with high output from ostomy and nephrostomy tubes; will receive IVFs at home b/c of risk of dehydration. Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*2 * Refills:*1* 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*2 * Refills:*2* 3. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours) as needed for pain. Disp:*10 Patch 72HR(s)* Refills:*2* 4. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO Q12H (every 12 hours). Disp:*250 ML's* Refills:*2* 6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Dolasetron 50 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 9. IV therapy IV hydration from 8pm to 8am QD D5 [**1-9**] Normal Saline over 12 hours 10. IV medication Heparin 100 units/cc 5 ML's 11. IV medication Normal saline 10 cc Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: Small Bowel Obstruction Sepsis Hydronephrosis Discharge Condition: Stable Discharge Instructions: Return to the emergency room if you develop any fevers, chills, dizziness; nausea, vomiting, abdominal pain and/or any other symptoms that are concerning to you. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] on Tuesday, [**2130-8-29**]; call [**Telephone/Fax (1) 6439**] to schedule a time to be seen. Completed by:[**2130-8-10**]

[ "998.11", "276.0", "567.29", "995.92", "557.0", "197.4", "584.9", "427.1", "997.1", "038.9", "276.2", "196.2", "785.52", "197.6", "998.59", "591", "560.89" ]

icd9cm

[ [ [] ] ]

[ "45.62", "45.73", "96.72", "38.93", "99.15", "96.6", "55.03", "33.23", "54.23", "96.04", "31.1", "46.21" ]

icd9pcs

[ [ [] ] ]

8318, 8379

4592, 7215

353, 638

8469, 8478

1534, 3937

8688, 8858

1307, 1324

7238, 8295

8400, 8448

8502, 8665

1339, 1514

246, 315

666, 1100

3951, 4569

1122, 1225

1241, 1291

10,677

154,543

16804

Discharge summary

report

Admission Date: [**2152-5-7**] Discharge Date: [**2152-5-15**] Date of Birth: [**2073-8-14**] Sex: M Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 3705**] Chief Complaint: post-ERCP Major Surgical or Invasive Procedure: ERCP History of Present Illness: This is a 78 y/o Cantonese speaking male with a PMHx of CAD s/p LAD stent, HTN, dyslipidemia, a-fib, CRI (Cr 1.5) here after transfer from [**Hospital3 **] with cholangitis. Pt was feeling in his USOH until he developed worsening weakness x1 day, with RUQ pain. Denies any N/V, change in stools/urine/skin/jaundice. He arrived at [**Hospital1 392**] today, where he had labs that showed WBC 22.3 with 35% bands, t.bili 4.1(d.bili 2.2), ast 424, alt 429, alkphos 102, Cr 2.0, and an received a RUQ U/S that showed CBD dilatation to 1cm, thickened gallbladder to 4mm, intra- and extra-hepatic ductal dilatation, no pericholecystic fluid and multiple gallstones. An ABG performed at [**Hospital1 392**] was 7.43[30[80. He was given 3g Unasyn x1, Clinda 600mg x1, Gent 60mg x1 and transferred to [**Hospital1 18**] for ERCP. . In the ED, VS T98, HR86, BP99/52, RR14, 98%RA, but had Tmax 101.3. Past Medical History: 1) Coronary artery disease s/p LAD stent [**10-21**] c/b instent stentosis and subsequent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] [**4-/2151**] 2) Hypertension 3) Dyslipidemia 4) Atrial Fibrillation 5) Mild pulmonary artery hypertension 6) Mild AR 7) Chronic renal failure (baseline Cr 1.5) 8) Mild hyperthyroidism, not on therapy 9) 4.8x3.2cm L lobe liver mass, biopsy inconclusive in [**1-/2152**] (lost to f/u) 10) Prior Klebsiella PNA with bacteremia Social History: Immigrated from [**Location (un) 6847**] 3yrs ago Lives with his wife Previous tobacco use: 56yrs x2ppd, quit 3yrs ago Family History: unknown Physical Exam: VS: T100.1 HR88 BP135/49 RR25 o2sat: 100% 2L NC HEENT: Mildly icteric sclera bilat. MM dry. O/P clear otherwise. NECK: No elev JVP CV: Regular, nml s1,s2. RESP: CTAB. ABD: +abd breathing. (-) [**Doctor Last Name **] sign. +BS. EXT: No edema bilat. NEURO: AAOx3. SKIN: jaundice not appreciated. Pertinent Results: Labs: T.bili of 4.5, WBC of 21, lactate of 4.4 . Imaging: i(-)CT Abd [**1-/2152**]: 1. 4.8cm soft tissue mass in left lobe of the liver suspicious for malignancy. 2. Gallbladder filled with multiple large stones without evidence for acute cholecystitis. Culture Data [**2152-5-12**]: GRAM STAIN (Final [**2152-5-12**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): STAPH AUREUS COAG +. SPARSE GROWTH. ENTEROCOCCUS SP.. MODERATE GROWTH. GRAM NEGATIVE ROD(S). SPARSE GROWTH. SENSITIVITIES: Pending at discharge OVA + PARASITES: Pending Brief Hospital Course: 78 y/o man admitted to the medicine service with ascending cholangitis. Hospital course outlined by problem below: 1. Cholangitis Pt being transferred from [**Hospital1 392**] with cholangitis. At [**Hospital1 392**], ERCP showed a mobile mass obstructing the common bile duct. He was sent here for further care with the possiblity of having parasites in his CBD. Here he taken directly to the ERCP suite where a biliary stent was placed with resulting relief in his obstruction. On admission he had an elevated WBC with 13% bandemia, and fever to 101 F. Pt with a lactate of 4.4 in the ED; hemodynamically stable on admission to the [**Hospital Unit Name 153**]. Grew GNRs in [**2-22**] blood cx's which was isolated as pansensitive Klebsiella. His initial ABx coverage with Unasyn 3g IV q8 was changed to Levaquin. In fectious disease was consulted given the concern that he could have a parasitic infection involving his biliary tree. Given his demographics (from [**Location (un) 6847**]) they felt that Clonorchis sinensis was the most likely pathogen and recommended treating with praziquantel. This was given to him after a biliary aspirate was obtained. SEveral days after his initial ERCP and stent procedure, he was taken back for sphincterotomy and balloon sweep of his biliary tree. Three common bile duct stones were removed and there were no worms that were retreived. A bile aspirate was sent for analysis and grew Staph Aureus and Enterococcus. The ova and parasite analysis was not performed by the time he was discharged and should be followed up by his primary care physician. [**Name10 (NameIs) 2321**] this, he was treated empirically with praziquantel and his antibiotics were adjusted to ciprofloxacin total course of 12 days after his sphinchterotomy. He remained afebrile with resolution of his obstruction and transaminitis. His last set of surveillance blood cultures drawn [**2152-5-12**] were still sterile at the time of his discharge but should be followed up to ensure negative results. HE WILL ALSO NEED TO BE SEEN IN OUR SURGERY CLINIC TO EVALUATE HIM FOR A CHOLECYSTECTOMY IN 6 WEEKS. 2. Parasite in bile duct - as above. Pt with a visualized mobile filling defects which changed shape in the bile duct during ERCP that seemed consistant with parasites in the bile duct. Unclear exact parasite, ddx includes Clonorchis, echinococcus, ascaris. No eosinophilia was noted on dif. Due to his background from [**Location (un) 6847**], clonorchis most likely. O&P x3 were sent but remained (-). Repeat ERCP showed no worm, but was treated with praziquantel regardless. Bile aspirite sent for O&P; pending upon discharge. Likely the "mobile filling defect" was a stone that moved or the patient moved during the cholangiogram. 3. Liver mass Patient with a previously visualized liver mass on Abd CT from OSH in [**1-/2152**] that was not visualized on U/S today at OSH. Bx was inconclusive with only necrotic elements. DDx includes prior malignancy that necrosed, vs prior Klebsiella liver abscess that healed with Abx treatment, vs nonvisualized mass. An MRI/MCRP was obtained that showed multiple lesions within the liver that enhanced peripherally, however in the setting of cholangitis it could not be determined if they were benign lesions, metastatic lesions, or early abscesses. Given his clinical stability, it was felt that he would need his liver REIMAGED WITH A CONTRAST ABDOMINAL CT IN 6 WEEKS to allow better visibility. 4. CAD No ischemia was noted during this admission with a nml EKG; nml CEs (-) x1 at OSH. His statin was continued, but his ASA was held to perform a sphincterotomy. After consultation with his cardiologist, his Plavix was discontinued permanently as he was greater than 1 year post-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]. . 5. Rhythm - Pt with hx of PAF He had a rapid ventricular response in the setting of his infection. He converted to normal sinus rhythm spontaneously with resolution of his infection. He was continued on his amiodarone. He does have hyperthyroidism. Endocrine was consulted who felt this was related to amiodarone induced thyrotoxicosis. He will need follow up with endocrinology or cardiology when he leaves. . 6. UTI - Pt with evidence of UTI on U/A. He had a foley when he arrived. HE was being treated with Unasyn for cholangitis,which also covered the UTI. Foley was removed once his cholangitis resolved. . 7. Acute on CRF - during infection, which resolved after his infection was treated. . 8. Hyperthyroidism - remained asymptomatic. Per endocrinology consult, felt related to amiodarone toxicity. REcommended continuing amiodarone for now. No oral medciations were given for hyperthyroidism given their relative [**Name (NI) 47436**] in the setting of hepatitis. This should be reconsidered when he has recovered from his cholangitis fully and could be done through an outpatient endocrinology consult. Medications on Admission: Amiodarone 200 qD Aspirin 325 qD Clopidogrel 75 qD Lisinopril 40 qD Atenolol 25 qD Atorvastatin 10 qD Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 9 days. Disp:*36 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 doses. 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], phone # ([**Telephone/Fax (1) 9011**] to arrange for evaluation of cholecystectomy to be done around 6 weeks after he leaves the hospital. Discharge Condition: stable Discharge Instructions: Show your primary care physician this report. See your primary care physician this tuesday. You will need to make an appointment with the surgeons to remove the gallbladder. You will also need your primary care physician to obtain the results of your "bile aspirite gram stain, culture, and ova& parasite data." You will need to have follow up liver imaging in the next 6 weeks. We will contact your primary care physician about this. Mass Health denied coverage for home PT services. Followup Instructions: You have the following appointments scheduled: 1. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2152-7-26**] 9:40 2. Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3972**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2152-7-13**] 3:30 3. Dr. [**First Name8 (NamePattern2) 17362**] [**Name (STitle) **], LOCATION: [**Hospital1 392**] Site; [**Location (un) 47437**], [**Hospital1 17359**] [**Numeric Identifier 47438**], PHONE: [**Telephone/Fax (1) 10349**], NURSE: HAMY Date: Tuesday [**2152-5-16**], 1:00 pm

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8594, 8600

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276, 283

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38215

Discharge summary

report

Admission Date: [**2132-8-1**] Discharge Date: [**2132-8-4**] Date of Birth: [**2057-8-6**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: 74 M with metastatic melanoma here for evaluation of a right temporal mass Major Surgical or Invasive Procedure: R temporal craniotomy for resection of tumor History of Present Illness: Pt was initially diagnosed with ocular melanoma in [**2128**]. He subsequently underwent radioactive seed implant which achieved good local control. He subsequently developed a right axillary mass that was biopsied and found to be a metastatic melanoma. He has been evaluated for systemic chemotherapy. As a part of the staging process, the pt underwent imaging of the head. The image from [**11-20**] revealed a sub-centimeter mass (contrast enhancing) in the right temporal lobe. The patient had a repeat MRI that reveald interval increase in the mass size (now 1.6x1.8x1.6 cm). Pt presents for evaluation of surgical resection. Past Medical History: Subtotal gastrectomy, laminectomy, splenectomy (from trauma), peptic ulcer disease, HTN, cervical radiculopathy Social History: never smoked, history of alcohol abuse but joined AA in [**2112**] (no alcohol use since then). Denied ilicit drug use. Works as a teacher but retired recently due to oncologic issues Family History: pt adopted and has no knowledge of his biologic family Physical Exam: On examination, the pt is awake, alert, and appropriate Speech is fluent and comprehension intact, intact to naming LTM: intact to home address and birthday STM: [**1-16**] at 3 minutes AS: some difficulty with serial 3's from 30's at 18, difficulty spelling world backwards EOMI, VFF, left eye can finger count only. FS. T/U midline. SS symmetric, slight decreased hearing on right Normal bulk and tone. Full strength throughout. Decreased sensation in the left L5 distribution (baseline according to pt, since his laminectomy) to LL and PP. Reflexes 1+ and symmetric. No Hoffmans or clonus. Negative romberg. good [**Doctor First Name **]. Normal gait Pertinent Results: CT HEAD W/O CONTRAST [**2132-8-1**] 1. Expected postoperative appearance of right craniotomy with resection of the known right temporal lesion. Small amount of blood in the surgical site. Mild surrounding edema, but without significant mass effect. Mild-to-moderate pneumocephalus in the right frontal convexity and the right middle cranial fossa. 2. No shift of normally midline structures. No intraventricular hemorrhagic extension. No developing hydrocephalus. MR HEAD W & W/O CONTRAST [**2132-8-2**] Status post resection of right temporal lobe lesion without residual enhancement. Expected post-surgical changes are seen without hydrocephalus or increased edema Brief Hospital Course: 74 y/o M with PMHx significant for ocular melanoma presents to the [**Hospital 85195**] clinic s/p imaging of head revealing a lesion in R temporal lobe that increased in size on serial imaging. He was admitted to the neurosurgical service for surgical resection of lesion. He was taken to the OR on [**8-1**] for tumor excision via craniotomy. The patient tolerated the procedure well. His post operative head CT was stable with small amount of blood in resection site and pneumocephalus. The patient's post-operative examination remained non-focal. Cardiology was consulted post operatively for management of the patient's severe aortic stenosis. Cardiology recommendation were closely adhered. On POD2, the patient was transferred from the ICU to the floor. Post operative MRI revealed no residual tumor. PT/OT were consulted. PT/OT cleared the patient for discharge home without services. Medications on Admission: Simvastatin dose unknown, lisinopril 20 mg p.o.q.d., omeprazole 20 mg p.o.q.d., sucralfate 1 g 1 tablet p.o. 4 times daily, vitamin B12 1000 mcg p.o.q.d., Colace, and oxycodone p.r.n. Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Cyanocobalamin (Vitamin B-12) 100 mcg Tablet Sig: Ten (10) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*55 Tablet(s)* Refills:*0* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO q6 () for 1 days. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Metastatic melanoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you 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 haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**6-21**] 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. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. ?????? You also have a brain tumor clinic appointment scheduled for [**2132-8-25**] at 9:30am. Please call [**Telephone/Fax (1) 1844**] with further questions. Completed by:[**2132-8-4**]

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icd9cm

[ [ [] ] ]

[ "93.59", "01.59" ]

icd9pcs

[ [ [] ] ]

4916, 4922

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391, 438

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7217

Discharge summary

report

Admission Date: [**2131-1-3**] Discharge Date: [**2131-1-11**] Date of Birth: [**2086-6-2**] Sex: F Service: MEDICINE Allergies: Phenobarbital / Tegretol / Dilantin / Mysoline / Amoxicillin / Gantrisin Attending:[**First Name3 (LF) 3705**] Chief Complaint: Transfer from OSH for anoxic brain injury Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 20948**] is a 44 year old woman with history of EtOH cirrhosis, Hep C, and COPD who presented to OSH on [**2130-12-18**] after an episode of respiratory distress at home. Per OSH records, she developed respiratory distress, had hemoptysis, and then became unresponsive. At that point, EMS was called, and she was intubated in the field after being found apneic. She had a brief episode of asystole for which she received CPR (unknown duration, atropine, and epinephrine. She was febrile to 102F on arrival. She was treated with a hypothermia protocol and covered with levofloxacin/clindamycin to cover aspiration and community acquired pneumonia. She was seen by two separate neurologists for evaluation and prognosis; both thought that a component of her mental status was secondary to anoxic brain injury/persistent vegetative state. An EEG demonstrated diffuse attenuation and slowing, consistent with anoxic brain injury. Multiple conversations were had with the family regarding prognosis, and the patient remains a full code with full diagnostic workup and treatment. And wished her to be transfered to another hospital for further work up on [**1-3**]. She was persistently febrile with no clear source found (blood cultures, urine cultures, C. diff, chest X-ray), other than MRSA positive in sputum (turned positive on [**1-3**]). She was started on vancomycin on [**12-27**]. Ceftriaxone was started on [**12-22**] and levofloxacin was started on [**12-26**] for fever, for which no etiology was discovered. Transfered to MICU [**1-3**] oxygenative well on trach mask. Neurology consulted who felt she has a very poor prognosis with poor recovery chance. Felt that MRI would not add much. ? PEG at this point On [**2131-1-4**] she was found to have mucous plugging with left lung collapse that was shown on a chest ray done for PICC line position confirmation. Lobe re-expanded with chest PT and suctioning. Patient transferred to floor for further management. Past Medical History: - s/p respiratory arrest at home complicated by cardiac arrest enroute to hospital and in persistant vegetative state (tox screen + cocaine and methadone per notes but missing that lab data in transfer) - Cirrhosis secondary to alcohol abuse and hepatitis C -- recurrent episodes of encephalopathy -- chronic thrombocytopenia -- portal hypertension with esophageal varices, s/p banding - History of hepatitis C - COPD, history of tobacco use - Depression - History of opiate use on methadone - s/p tracheostomy; 8 french trach inserted by surgery at [**Hospital3 10310**] Hospital Social History: Smokes [**12-13**] ppd. Ongoing problems with alcohol. Family History: N/C Physical Exam: VITALS: 99.5 123/73:108-123/60-73 86 29 95%(35%Trach-mask) GENERAL: No acute distress, diffuse anasarca HEENT: PERRL, EOMI intact (although not purposeful) CARD: RRR, normal S1/S2, no m/r/g RESP: Diffuse rhonchi bilaterally. secretions from trach mask. ABD: Soft, non-tender, distended, + fluid wave, no hepatosplenomegaly appreciated EXT: 1+ DP pulses bilaterally; 2+ pitting edema bilaterally. NEURO: Pupils equal and reactive bilaterally, + corneal reflex, does not grimace to pain, eyes do not tract, moves all four extremities; no apparent purposeful movement, no vocalizations Pertinent Results: [**2131-1-3**] WBC-14.4*# RBC-2.49*# Hgb-8.9* Hct-27.9* MCV-112*# MCH-35.9*# MCHC-32.0 RDW-18.5* Plt Ct-139* [**2131-1-5**] WBC-11.6* RBC-2.49* Hgb-9.0* Hct-27.5* MCV-111* MCH-36.0* MCHC-32.6 RDW-18.0* Plt Ct-139* [**2131-1-6**] WBC-11.9* RBC-2.54* Hgb-9.4* Hct-28.8* MCV-114* MCH-37.2* MCHC-32.7 RDW-18.3* Plt Ct-157 [**2131-1-7**] WBC-10.7 RBC-2.42* Hgb-8.7* Hct-27.1* MCV-112* MCH-35.9* MCHC-32.0 RDW-17.5* Plt Ct-132* [**2131-1-10**] 06:45AM BLOOD WBC-7.5 RBC-2.54* Hgb-9.1* Hct-29.9* MCV-118* MCH-35.9* MCHC-30.5* RDW-18.0* Plt Ct-97* [**2131-1-8**] 08:50AM BLOOD Neuts-69 Bands-1 Lymphs-5* Monos-24* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2131-1-10**] 06:45AM BLOOD Plt Smr-LOW Plt Ct-97* [**2131-1-4**] PT-18.2* PTT-32.8 INR(PT)-1.7* [**2131-1-6**] PT-16.5* PTT-34.2 INR(PT)-1.5* [**2131-1-7**] PT-18.0* INR(PT)-1.6* [**2131-1-4**] Glucose-124* UreaN-21* Creat-0.7 Na-139 K-3.6 Cl-108 HCO3-24 [**2131-1-5**] Glucose-140* UreaN-20 Creat-0.6 Na-140 K-3.1* Cl-112* HCO3-22 [**2131-1-6**] Glucose-123* UreaN-18 Creat-0.6 Na-144 K-3.5 Cl-115* HCO3-20* [**2131-1-7**] Glucose-166* UreaN-17 Creat-0.7 Na-148* K-3.1* Cl-119* HCO3-22 [**2131-1-10**] Glucose-170* UreaN-17 Creat-0.6 Na-147* K-3.7 Cl-121* HCO3-21* [**2131-1-11**] Na-143 K-4.0 Mg-1.7 [**2131-1-3**] ALT-87* AST-135* LD(LDH)-507* AlkPhos-203* TotBili-3.8* [**2131-1-5**] ALT-62* AST-88* LD(LDH)-454* AlkPhos-179* TotBili-5.6* [**2131-1-6**] ALT-55* AST-72* LD(LDH)-450* AlkPhos-195* Amylase-80 TotBili-5.1* [**2131-1-7**] ALT-49* AST-66* AlkPhos-211* TotBili-3.4* [**2131-1-3**] 05:19PM BLOOD VitB12-GREATER TH Folate-17.2 [**2131-1-3**] 05:19PM BLOOD Ammonia-23 [**2131-1-3**] 05:19PM BLOOD TSH-4.2 [**2131-1-3**] CXR: No acute cardiopulmonary process. Lines and tubes in standard positions. [**2131-1-4**] CXR: New opacification of the left hemithorax and ipsilateral mediastinal shift indicates left lung collapse. Right lung hyperinflated and clear. Tip of the right PIC projects over the low SVC. Tracheostomy tube in standard placement. Nasogastric tube tip in the region of the pylorus unchanged. No pneumothorax. [**2131-1-5**] CXR: Interval re-inflation of a majority of the left lung. [**2131-1-6**] CXR: Improving left basilar opacity, most compatible with a small layering pleural effusion. Brief Hospital Course: 44 year old female with a history of ethanol/hepatitis C cirrhosis transferred from OSH after cardiac/respiratory arrest and prolonged recovery, with prolonged recovery, tracheostomy, and no purposeful movements, suggestive of anoxic brain injury. Anoxic encephalopathy with vegetative state: The patient was transferred from an OSH after suffering a respiratory arrest at home on [**2130-12-18**]. As part of her workup she has had a normal head CT. She had an EKG on [**2130-12-27**] which showed now evidence of seizure activity but showed great attenuation suggetive of encephalopathy. On arrival the patient's neurologic exam was consistent with severe cortical damage resulting in a vegetative state. She was evaluated by our neurology team who agreed with her prior neurologic evaluations and did not recommend any further neurologic workup. Her prognosis is considered guarded and she is unlikely at this point to achieve significant neurologic improvement. The patient's neurologic prognosis was discussed with the family in the presence of our palliative care service. The family expressed understanding of her condition and wished to pursue long term care. Acute respiratory failure: The patient is s/p tracheostomy for respiratory failure on [**2131-1-1**]. On arrival to [**Hospital1 18**] she was oxygenating well on 35% trach collar mask. She did require suctioning and experienced one episode of mucous plugging with left lung collapse on [**2131-1-4**] which resolved with suctioning and chest PT. During the remainder of his hospitalization she continued to oxygenate well. She did require frequent suctioning. She was discharged with plans for continued respiratory care. She does have a proline suture placed at her tracheostomy site which will need to be evaluated and removed in ten days. Acute tracheobronchitis: The patient experienced recurrent fevers prior to presentation to [**Hospital1 18**]. Broad fever workup revealed MRSA positive sputum on [**1-3**]. She received vancomycin from [**2130-12-27**] to [**2131-1-3**]. On [**2131-1-9**] she was noted to have erythema around the site of her tracheostomy as well as purulent tracheal secretions. Repeat CXR was clear. It was felt that she likely had developed a superficial skin infection as well as a tracheobronchitis. Sputum cultures on [**1-7**] revealed trace staph aureus. She was restarted on vancomycin with plans to complete a fourteen day course. She will need to have a vancomycin trough drawn on [**2131-1-12**] with appropriate dose adjustment for a goal trough of [**9-26**]. Hypernatremia: The patient was noted to have hypernatremia to 152 in the setting of decreased free water intake. She transiently required D5W to correct her hypernatremia and subsequently was started on free water boluses per NGT with good efficacy. On discharge her serum sodium was 143. She will continue on free water boluses per NGT at rehab. Thrombocytopenia: On presentation to the OSH her platelet count was noted to be significantly decreased at 37. During her admission to [**Hospital1 18**] her platelet count slowly improved to 97 on discharge without intervention. Her thrombocytopenia was thought to be secondary to her underlying liver disease. Cirrhosis: The patient has a history of ethanol and hepatitis C induced liver disease. She has a cirrhotic appearing liver on CT scan from the OSH. On transfer she was taking lactulose and neomycin. This regimen was switched to lactulose and rifaximin and nadolol was added given that the patient has a history of known varices. It was not felt at the time of discharge that hepatic encephalopathy was contributing significantly to her altered mental status. Oral Thrush: Patient noted to have oral thrush during this hospitalization. Given concern for aspiration she was started on oral fluconazole crushed through her NGT. She was discharged with plans to complete a ten day course. Nutrition: The patient was started on tube feeds via NGT. The patient was evaluated by gastroenterology who did not feel that PEG placement would be safe given the patient's liver disease with evidence of ascites. She was discharged with an NGT in place for tube feeds with free water boluses. She also received an insulin sliding scale to maintain her blood sugars. Prophylaxis. The patient received subcutaneous heparin during her hospitalization for DVT prophylaxis. Communication. Daughter [**First Name8 (NamePattern2) 6303**] [**Known lastname 20948**], cell:[**Telephone/Fax (1) 26744**]. Fiance [**Doctor Last Name **] home: [**Telephone/Fax (1) 26745**], cell: [**Telephone/Fax (1) 26746**] Access. PICC Code Status: DNR/DNI Medications on Admission: MEDICATIONS (at home): Nicotine patch Prilosec 20mg daily KCl 40 meq daily Spironolacone 50mg daily Thiamine Inderal Lasix 80mg daily Ativan 1mg daily Celexa 40mg daily Folic Acid 1mg daily Neurontin 600mg TID Lactulose 20gm TID Neomycin 500mg Q6H Methadone MEDICATIONS on Transfer: Insulin SC Sliding Scale Ipratropium Bromide Neb 1 NEB IH Q6H Lansoprazole Tab 30 mg PO DAILY Lactulose 30 mL PO TID Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Miconazole Powder 2% 1 Appl TP PRN Docusate Sodium (Liquid) 100 mg PO BID Nadolol 20 mg PO DAILY Guaifenesin [**4-21**] mL PO Q6H Heparin 5000 UNIT SC TID Rifaximin 200 mg PO TID Senna 1 TAB PO BID:PRN Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: One (1) PO BID (2 times a day). 2. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) Injection TID (3 times a day). 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. Rifaximin 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 6. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO TID (3 times a day). 7. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical PRN (as needed). 8. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: One (1) Subcutaneous ASDIR (AS DIRECTED): Please see insulin sliding scale. 9. Nadolol 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. Guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 12. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 14. Fluconazole 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every 24 hours) for 10 days. 15. 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 16. 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. 17. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: One (1) Intravenous twice a day for 10 days. 18. Lispro Insulin Sliding Scale QAC and QHS 0-60 1 amp D50 61-150 0 Units 151-200 2 Units 201-250 4 Units 251-300 6 Units 301-350 8 Units 351-400 10 Units Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Primary: Anoxic brain injury Alcohol induced cirrhosis Hepatitis C Tracheobronchitis Hypernatremia cellulitis at trach site Secondary Diagnoses: Pneumonia s/p tracheostomy [**2131-1-1**] at outside hospital oral thrush Discharge Condition: hemodynamically stable, using trach mask, no evidence of higher cortical function, extensor posturing, no spontaneous vocalizations. Discharge Instructions: Ms. [**Known lastname **] was transferred to this hospital for neurologic evaluation. The neurologists agreed with her prior evaluations that her mental status was consistent with anoxic brain injury. Please take all your medications as prescribed. Please keep all your follow up appointments. Proline suture around tracheostomy site will need to be removed by a physician [**Last Name (NamePattern4) **] 10 days. Please return to the hospital if you experience fevers, chest pain, cough, shortness of breath, abdominal pain, diarrhea, vomiting, seizures or other concerning symptoms. Followup Instructions: Please follow-up with your primary care physician on discharge from rehab

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icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

13735, 13815

6044, 10745

373, 379

14079, 14214

3721, 6021

14852, 14929

3097, 3102

11442, 13712

13836, 13961

10771, 11030

14238, 14829

3117, 3702

13982, 14058

292, 335

407, 2404

11055, 11419

2426, 3009

3025, 3081

8,037

179,177

9862+56072

Discharge summary

report+addendum

Admission Date: [**2153-12-25**] Discharge Date: [**2154-1-2**] Date of Birth: [**2086-9-27**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet / Heparin Agents Attending:[**First Name3 (LF) 1283**] Chief Complaint: chest pain/ODE/fatigue Major Surgical or Invasive Procedure: [**12-25**] redo [**Doctor Last Name **] AVR (mech) CABG x1 (SVG>PDA) History of Present Illness: 67 yo M with h/o CAD, followed by echo, now with severe AS.Repeat cath also showed occluded OM and RCA vein graft. Past Medical History: Hypertension Elevated triglycerides CAD s/p CABG [**2141**] (LIMA -> LAD, SVG ->RCA, SVG->D1->OM2->OM3) MI- age 35 Ischemic cardiomyopathy with an EF 25% on TTE [**6-4**] s/p ICD [**2150**] for a cardiac arrest (DDDR [**Company 1543**]) Aortic stenosis, valve area 0.88cm2 CRI BPH Right knee replacement GERD/Hiatal hernia Thrombocytopenia of unclear etiology Social History: - Denies current tobacco use. - Denies history of alcohol abuse. - Family history: mother with prior MI??????s. died in her 80??????s from heart disease. - Two brothers w/ CABG in their late 50??????s or 60??????s; sister had CABG in her 60??????s. Family History: - Two brothers w/ CABG in their late 50??????s or 60??????s; sister had CABG in her 60??????s. Physical Exam: NAD HR 62 RR 12 BP 104/60 well healed sternotomy/R ACW PPM site, L GSV harvest from ankle to groin Chest CTAB Heart RRR 3/6 SEM Abdomen benign Extrem warm, trace LE edema Pertinent Results: [**2154-1-1**] 08:10AM BLOOD WBC-6.1 RBC-3.37* Hgb-9.3* Hct-28.7* MCV-85 MCH-27.7 MCHC-32.5 RDW-17.1* Plt Ct-134* [**2154-1-2**] 07:25AM BLOOD PT-29.4* INR(PT)-3.0* [**2154-1-1**] 10:42AM BLOOD PT-37.9* INR(PT)-4.1* [**2154-1-1**] 08:10AM BLOOD PT-41.5* PTT-46.3* INR(PT)-4.6* [**2153-12-31**] 07:25AM BLOOD PT-33.7* PTT-51.4* INR(PT)-3.5* [**2154-1-2**] 07:25AM BLOOD Glucose-124* UreaN-20 Creat-1.4* Na-140 K-4.5 Cl-103 HCO3-28 AnGap-14 [**2154-1-1**] 08:10AM BLOOD Glucose-98 UreaN-25* Creat-1.5* Na-141 K-4.0 Cl-105 HCO3-26 AnGap-14 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 33123**]Portable TTE (Complete) Done [**2154-1-1**] at 3:30:00 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2086-9-27**] Age (years): 67 M Hgt (in): 66 BP (mm Hg): 142/54 Wgt (lb): 192 HR (bpm): 73 BSA (m2): 1.97 m2 Indication: Right ventricular function. Aortic valve replacement ([**Street Address(2) 11688**]. [**Male First Name (un) 923**]). CABG. ICD-9 Codes: 402.90, V43.3, 414.8, 424.0, 424.2 Test Information Date/Time: [**2154-1-1**] at 15:30 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**], RDCS Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6 Contrast: None Tech Quality: Suboptimal Tape #: 2007W043-1:20 Machine: Vivid [**8-5**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: *7.2 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.7 m/s Left Atrium - Peak Pulm Vein D: 0.3 m/s Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s Right Atrium - Four Chamber Length: *6.7 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 20% to 25% >= 55% Left Ventricle - Stroke Volume: 53 ml/beat Left Ventricle - Cardiac Output: 3.90 L/min Left Ventricle - Cardiac Index: *1.98 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *18 < 15 Aorta - Sinus Level: 2.6 cm <= 3.6 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Aortic Valve - Peak Velocity: *2.7 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *34 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 15 mm Hg Aortic Valve - LVOT VTI: 17 Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave: 1.6 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A ratio: 2.00 Mitral Valve - E Wave deceleration time: *119 ms 140-250 ms TR Gradient (+ RA = PASP): *37 mm Hg <= 25 mm Hg Pulmonic Valve - Peak Velocity: 1.2 m/sec <= 1.5 m/sec Findings This study was compared to the prior study of [**2153-8-14**]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Severely depressed LVEF. TDI E/e' >15, suggesting PCWP>18mmHg. Transmitral Doppler and TVI c/w Grade III/IV (severe) LV diastolic dysfunction. No resting LVOT gradient. RIGHT VENTRICLE: Dilated RV cavity. RV function depressed. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). Normal AVR gradient. Trace AR. [The amount of AR is normal for this AVR.] MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. Mild (1+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed but images of the RV are limited. The ascending aorta is mildly dilated. A bileaflet aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2153-8-14**], overall left ventricular systolic function has declined further. An AVR is now present with normal transvalvular gradients and trivial aortic regurgitation. The severity of mitral and tricuspid regurgitation has decreased. The other findings are similar. CHEST (PORTABLE AP) [**2153-12-29**] 3:10 PM CHEST (PORTABLE AP) Reason: r/o effusion [**Hospital 93**] MEDICAL CONDITION: 67 year old man with hypoxia REASON FOR THIS EXAMINATION: r/o effusion PORTABLE CHEST, [**2153-12-29**] AT 15:26 COMPARISON STUDY: [**2153-12-27**]. CLINICAL INFORMATION: Question effusion, history of hypoxia. FINDINGS: The heart is markedly enlarged. Patient is status post median sternotomy. Right AICD/pacer is present with three leads in the right atrium and right ventricle. Since the prior study, there has been interval clearing of right lower lobe opacity seen on the prior study. Both lungs are relatively clear. IMPRESSION: Marked cardiomegaly. Interval clearing of right lower lobe opacity. Brief Hospital Course: He was taken to the operating room on [**12-25**] where he underwent a redo sternotomy/AVR and CABG x 1. He was transferred to the ICU in critical but stable condition on epi, milrinone, levophed and propofol. He was extubated on POD #1. He was weaned from his vasoactive drips by POD #3. He was transfused for HCT of 23. He was started on coumadin for his mechanical valve. He awaited a therapeutic INR and was ready for discharge home on POD #8. Medications on Admission: Amiodarone 200 [**Last Name (LF) 4962**], [**First Name3 (LF) **] 325', Atorvastatin 40 QPM, CoReg 40', Lasix 80", Plavix 75', ImDur 60", Prilosec 20', Altace 10', Terazosin 5' Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for for stent. Disp:*30 Tablet(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*0* 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. Coumadin 2 mg Tablet Sig: 1.5 Tablets PO at bedtime for 2 doses: 3 mg [**1-2**] and [**1-3**], check INR [**1-4**] with results to Dr. [**Last Name (STitle) 9751**] for further dosing. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Aortic stenosis now s/p AVR CAD (MI in [**2117**], [**2150**], s/p CABG in [**2141**], PCI/stenting [**2152**],[**2153**]) VFIB arrest in [**2150**] s/p ICD [**2150**], upgrade to BiV [**2153**] chronic systolic heart failure HTN high cholesterol thrombocytopenia CRI BPH GERD Right TKR x 2 Discharge Condition: Good. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Take medications as prescribed on discharge. Coumadin for mechanical aortic valve. Goal INR 2.5-3.0. Have INR checked [**1-4**] with results called to Dr [**Last Name (STitle) 9751**] at ([**Telephone/Fax (1) 33124**]. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (STitle) 9751**] 1-2 weeks Dr. [**Last Name (STitle) 33125**] 2 weeks Dr. [**Last Name (Prefixes) **] 4 weeks Completed by:[**2154-1-2**] Name: [**Known lastname **],[**Known firstname 33**] L. Unit No: [**Numeric Identifier 5769**] Admission Date: [**2153-12-25**] Discharge Date: [**2154-1-2**] Date of Birth: [**2086-9-27**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet / Heparin Agents Attending:[**First Name3 (LF) 674**] Addendum: Spoke to [**Last Name (un) 5770**] at Dr. [**Last Name (STitle) 5771**] office who agreed to assume coumadin management. Faxed summary and doses. Discharge Disposition: Home With Service Facility: [**Location (un) 1082**] VNA [**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**] Completed by:[**2154-1-2**]

[ "414.02", "585.9", "530.81", "412", "V45.02", "V43.65", "414.8", "414.01", "428.0", "428.22", "403.90", "287.5", "424.1" ]

icd9cm

[ [ [] ] ]

[ "36.11", "39.61", "35.22" ]

icd9pcs

[ [ [] ] ]

12157, 12351

8327, 8776

315, 387

10913, 10921

1501, 7656

1198, 1294

9003, 10495

7693, 7722

10598, 10892

8802, 8980

10945, 11420

11471, 12134

1309, 1482

253, 277

7751, 8304

415, 531

553, 915

931, 998

59,976

130,701

8144

Discharge summary

report

Admission Date: [**2137-2-4**] Discharge Date: [**2137-2-11**] Date of Birth: [**2067-7-6**] Sex: F Service: MEDICINE Allergies: Ergocalciferol (Vit D2) / Codeine / Nifedipine / Allopurinol And Derivatives / Calcium Channel Blocking Agents-Dihydropyridines / Diltiazem Hcl Attending:[**First Name3 (LF) 896**] Chief Complaint: Nausea/Vomiting/Rigors Major Surgical or Invasive Procedure: Placement of New tunneled catheter for hemodialysis. History of Present Illness: 69yo Spanish-speaking female with h/o ESRD on HD Tuesday/Thursday/Saturday, MSSA graft infection and bacteremia s/p graft removal, HTN, Type II DM, ?AF brought in by her family for fever, productive cough, and progressive fatigue x2d. She was reportedly in her USOH until 2d PTA, when she experienced fever, exact temperature unknown to her family, and non-bloody emesis x1 in the setting of HD, prompting early termination of HD. Over the course of the next 2d, she developed productive cough without hematemesis and progressive fatigue. On the morning of admission, she was noted by her family to be tachypneic with increased work of breathing, but without subjective SOB. Per report, she did not take her home medications due to fatigue. On the afternoon of admission, she was found to be febrile to 102.5 and mentating poorly, prompting concern among her family members. She denies weight change, CP, abdominal pain, diarrhea, peripheral edema, PND/orthopnea, sick contacts, or recent travel. She urinates 2-3 times daily. In the ED, initial VS were as follows: T 103(PR)/98(PO), HR 103, BP 199/78, RR 30, O2 saturation 100% on non-rebreather. EKG initially demonstrated sinus tachycardia at 123 bpm. When she developed sustained VT x 2.5 min in the absence of HD instability, she was treated presumptively with Ca/Mg for hyperkalemia and subsequently broke spontaneously. Following administration of 150 mg amiodarone, she was placed on an amiodarone gtt and received 10 mg IV metoprolol for likely AF with aberrancy at the suggestion of the cardiology fellow. After BCx/UCx were obtained, she received IV vancomycin/Zosyn x1. At the time of transfer, she remains febrile to 102 PR with CVP 20, BP 148/78, RR 33, O2 saturation 98% on 3LNC. In the MICU, her tunneled line was removed but her cuff stayed in per recs of TXP/IR. She had a temporary right sided IJ placed and they attempted to dialyze her but she began to experience similar symptoms of nausea, vomiting and malaise so HD was aborted. Her ED cultures grew out GNR which were sensitive to ceftriaxone. She was started on rocephin and her white count decreased as did her fever. Heparin gtt was started secondary her atrial fibrillation. On [**2137-2-6**], she was tolerating PO, feeling better, and endorsing frequent soft bowel movements. She endorses myalgias, chest wall soreness around the site of her line removal, and chronic cough. Past Medical History: ESRD on dialysis Tuesday/Thursday/Saturday H/o MSSA graft infection and bacteremia in [**3-17**], now s/p graft removal ?AF on admission for graft infection, never anticoagulated Type II DM HTN/HL MGUS PVD Osteoporosis Anemia of chronic renal disease Gout Uremic pruritis Stable bilateral adrenal masses Cataracts S/p CCY S/p appendectomy S/p cesarean section S/p tonsillectomy Social History: Patient lives in [**Hospital1 **] with her husband. They moved to the US from [**Location (un) 29016**]15 years ago. She has 6 children, who now live locally. She has not worked outside the home. Her family hsa very limited finances. Tobacco: 10 cigarettes daily x 40 years (20 py) quit 3 years ago Alcohol: [**12-21**] drinks at a party 2-3x/year No illicit drugs Family History: Diabetes/HTN in Mother Denies family hx of cardiac disease, MI, cancer Physical Exam: Admission Exam: Vitals: T:100.8 PR BP:122/53 P:103 R:21 O2:98% on 3LNC General: Somnolent, but rousable, oriented x2 (c/w baseline per family), no acute distress HEENT: Cataracts Neck: supple, JVP difficult to appreciate due to body habitus CV: Limited in the setting of marked wheeze Lungs: Prominent wheeze throughout Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: +foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: As noted above Discharge exam: Vital signs: T 98.5 Tm 99.3 BP 128-168/69-80 HR 61-70 RR 18 98% RA FS 89/139. General: Spanish speaking, obese, pleasant, NAD. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to ausculatation bilaterally. CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur apex. Chest: Right tunneled IJ site C/D/I. Dressing intact TTP. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: no clubbing, cyanosis or edema. Pain with palpation of thighs b/l. Pertinent Results: Admission Labs: [**2137-2-4**] 07:50PM BLOOD WBC-6.4# RBC-3.32* Hgb-10.7* Hct-33.0* MCV-99* MCH-32.3* MCHC-32.5 RDW-13.1 Plt Ct-133* [**2137-2-4**] 07:50PM BLOOD Neuts-91.3* Lymphs-6.5* Monos-0.8* Eos-1.1 Baso-0.3 [**2137-2-4**] 07:50PM BLOOD Plt Ct-133* [**2137-2-5**] 03:48AM BLOOD PT-13.1* PTT-36.2 INR(PT)-1.2* [**2137-2-4**] 07:50PM BLOOD Glucose-225* UreaN-38* Creat-6.5*# Na-139 K-4.9 Cl-98 HCO3-29 AnGap-17 [**2137-2-4**] 07:50PM BLOOD CK(CPK)-77 [**2137-2-5**] 03:48AM BLOOD ALT-25 AST-32 AlkPhos-120* TotBili-0.6 [**2137-2-4**] 07:50PM BLOOD CK-MB-3 cTropnT-0.14* proBNP-[**Numeric Identifier 29017**]* [**2137-2-5**] 03:48AM BLOOD CK-MB-3 cTropnT-0.16* [**2137-2-5**] 09:33AM BLOOD CK-MB-2 cTropnT-0.13* [**2137-2-5**] 03:48AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.2 [**2137-2-5**] 09:33AM BLOOD Vanco-11.5 [**2137-2-5**] 12:12AM BLOOD Type-ART pO2-74* pCO2-46* pH-7.43 calTCO2-32* Base XS-4 [**2137-2-4**] 07:57PM BLOOD Lactate-2.3* [**2137-2-5**] 09:18AM BLOOD Glucose-129* Lactate-0.9 . EKG ([**2137-2-4**]): Atrial fibrillation with rapid ventricular response. Non-specific ST-T wave changes. Lateral ST segment depressions consistent with possible ischemia. Occasional wide complex beats which may be aberrant conduction. Cannot rule out a non-sustained ventricular tachycardia. . CXR ([**2137-2-4**]): Findings suggesting mild fluid overload or interstitial edema; no focal opacity demonstrated to suggest pneumonia. . TTE ([**2137-2-5**]): The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). Tissue Doppler imaging suggests a stiff left ventricle and an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. 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. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . CT TORSO WITH CONTRAST DATE: [**2137-2-9**]. COMPARISON: Abdominal ultrasound, [**2137-2-7**]; CT abdomen and pelvis, [**2135-7-28**]; chest radiograph, [**2137-2-6**]. CLINICAL INDICATION: 69-year-old woman with end-stage renal disease, productive cough x2 weeks, and chronic diffuse abdominal pain who presents with GNR bacteremia and wide complex tachycardia. Now stable on ceftriaxone and amiodarone. Afebrile, hemodynamically stable. Looking for source of bacteremia. TECHNIQUE: Axial images of the chest, abdomen, and pelvis were obtained after uneventful intravenous administration of 130 mL Omnipaque. Coronal and sagittal reformatted images were constructed. TOTAL EXAM DLP: 1036.33 mGy-cm. FINDINGS: CHEST: Imaged portions of thyroid gland are within normal limits. There is no axillary or hilar adenopathy. There are borderline enlarged mediastinal nodes, for example, measuring 1 cm in the left paratracheal location, 9 mm pretracheal, and 12 mm subcarinal. The heart is not enlarged. Dense coronary artery calcifications are present. There is also a small amount of aortic valvular calcification (2:30). There is no pericardial or pleural effusion. Linear strands of atelectasis or scarring are present at bilateral bases. There is no consolidation or bronchiectasis. The airways are patent to the subsegmental level. ABDOMEN: The liver and pancreas are within normal limits. The spleen is slightly enlarged measuring 14.3 cm. Bilateral adrenal nodules are visualized and, per report, are stable since [**2129**]. In the left adrenal gland, there is a 2.8 x 2.4 cm lesion with central fat density, consistent with a myelolipoma. In addition, in the lower aspect of the left adrenal gland, there is a 1.4 x 1.9 cm adrenal nodule. In the inferior aspect of the right adrenal gland, there is a 1.2 x 1.7 cm adrenal nodule. The two smaller adrenal nodules are indeterminate on this examination, however, given long term stability, likely represent adrenal adenomas. There is no intra- or extra-hepatic biliary dilation. The kidneys are atrophic with subcentimeter hypodensities, too small to accurately characterize. There is no hydronephrosis. A 3-mm calcification in the interpolar region of the right kidney (2:66) may represent a vascular calcification versus non-obstructive renal calculus. There is extensive atherosclerotic disease involving the aorta and all its branches including dense atherosclerotic calcification of the splenic artery, hepatic arteries, distal SMA, [**Female First Name (un) 899**], and renal arteries. There is bulky calcification at the origin of the right renal artery. There is no aneurysmal dilation. There is no mesenteric or retroperitoneal adenopathy. No free fluid or pneumoperitoneum. Bowel loops in the abdomen are unremarkable. PELVIS: The bladder, rectum, and adnexa are grossly unremarkable. Multiple linear calcifications within the uterus are vascular. The iliac arteries and visualized femoral arteries demonstrate dense atherosclerotic calcification as well. There is no free fluid in the pelvis. A mildly prominent 9-10 mm lymph node along the proximal right external iliac chain (2:90) is essentially unchanged in size from [**2133**]. No additional enlarged lymph nodes are identified in the pelvis. Multiple injection granulomas are present in the buttocks. OSSEOUS STRUCTURES: Degenerative changes are present within the thoracic and lumbar spine without evidence of wedge compression deformity. There are no destructive osseous lesions. IMPRESSION: 1. No evidence of intrathoracic, abdominal, or pelvic infection on CT. 2. Bilateral adrenal nodules, stable dating back to [**2129**]. 3. Extensive atherosclerotic disease as well as coronary artery calcifications and minimal aortic valvular calcification. 4. Borderline enlarged mediastinal lymph nodes, not previously imaged. There is no lymphadenopathy elsewhere. These may be reactive, and attention on followup is recommended. ------------- Labs while on general medicine. [**2137-2-11**] 06:10AM BLOOD WBC-7.0 RBC-3.04* Hgb-9.9* Hct-30.6* MCV-101* MCH-32.4* MCHC-32.2 RDW-13.6 Plt Ct-190 [**2137-2-10**] 06:10AM BLOOD WBC-6.0 RBC-3.11* Hgb-10.0* Hct-31.2* MCV-100* MCH-32.1* MCHC-32.0 RDW-13.6 Plt Ct-155 [**2137-2-9**] 01:20PM BLOOD WBC-5.6 RBC-3.14* Hgb-10.0* Hct-31.8* MCV-101* MCH-31.9 MCHC-31.6 RDW-13.4 Plt Ct-133* [**2137-2-8**] 05:50AM BLOOD WBC-4.6 RBC-2.79* Hgb-9.0* Hct-27.8* MCV-100* MCH-32.2* MCHC-32.4 RDW-13.6 Plt Ct-105* [**2137-2-7**] 06:20AM BLOOD WBC-5.6 RBC-2.79* Hgb-9.1* Hct-27.8* MCV-100* MCH-32.8* MCHC-32.9 RDW-13.3 Plt Ct-96* [**2137-2-11**] 06:10AM BLOOD PT-25.0* PTT-40.6* INR(PT)-2.4* [**2137-2-10**] 06:10AM BLOOD Plt Ct-155 [**2137-2-10**] 06:10AM BLOOD PT-17.2* PTT-36.5 INR(PT)-1.6* [**2137-2-9**] 01:20PM BLOOD Plt Ct-133* [**2137-2-8**] 05:50AM BLOOD PT-11.2 PTT-33.4 INR(PT)-1.0 [**2137-2-7**] 11:47PM BLOOD PT-11.7 PTT-72.3* INR(PT)-1.1 [**2137-2-11**] 06:10AM BLOOD Glucose-67* UreaN-20 Creat-5.0*# Na-135 K-3.8 Cl-97 HCO3-29 AnGap-13 [**2137-2-10**] 06:10AM BLOOD Glucose-103* UreaN-10 Creat-3.2*# Na-139 K-3.8 Cl-99 HCO3-28 AnGap-16 [**2137-2-9**] 01:20PM BLOOD Glucose-114* UreaN-19 Creat-4.9*# Na-135 K-3.9 Cl-96 HCO3-27 AnGap-16 [**2137-2-8**] 05:50AM BLOOD Glucose-79 UreaN-57* Creat-9.0*# Na-134 K-4.2 Cl-93* HCO3-26 AnGap-19 [**2137-2-8**] 05:50AM BLOOD Glucose-79 UreaN-57* Creat-9.0*# Na-134 K-4.2 Cl-93* HCO3-26 AnGap-19 [**2137-2-7**] 06:20AM BLOOD Glucose-83 UreaN-50* Creat-7.9*# Na-136 K-4.1 Cl-94* HCO3-24 AnGap-22* [**2137-2-6**] 04:05AM BLOOD Glucose-135* UreaN-40* Creat-6.8*# Na-138 K-4.4 Cl-97 HCO3-29 AnGap-16 [**2137-2-7**] 06:20AM BLOOD ALT-16 AST-23 AlkPhos-93 TotBili-0.2 [**2137-2-5**] 03:48AM BLOOD ALT-25 AST-32 AlkPhos-120* TotBili-0.6 [**2137-2-11**] 06:10AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.1 [**2137-2-10**] 06:10AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.0 [**2137-2-9**] 01:20PM BLOOD Calcium-8.1* Phos-3.3# Mg-2.2 [**2137-2-8**] 05:50AM BLOOD Calcium-7.4* Phos-4.9* Mg-2.4 [**2137-2-7**] 06:20AM BLOOD TSH-3.7 [**2137-2-9**] 05:20PM BLOOD Vanco-24.6* [**2137-2-6**] 04:05AM BLOOD Vanco-23.7* [**2137-2-5**] 09:33AM BLOOD Vanco-11.5 MICRO: **FINAL REPORT [**2137-2-10**]** FECAL CULTURE (Final [**2137-2-10**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2137-2-10**]): NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2137-2-10**]): NO E.COLI 0157:H7 FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2137-2-9**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). **FINAL REPORT [**2137-2-8**]** WOUND CULTURE (Final [**2137-2-8**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies. COAG NEG STAPH does NOT require contact precautions, regardless of resistance Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. 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---------- 0.5 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=0.5 S [**2137-2-4**] 7:50 pm BLOOD CULTURE **FINAL REPORT [**2137-2-7**]** Blood Culture, Routine (Final [**2137-2-7**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [**2137-2-5**]): Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 29018**] ON [**2137-2-5**] AT 0635. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [**2137-2-5**]): GRAM NEGATIVE ROD(S). [**2137-2-7**] 12:45 pm BLOOD CULTURE Blood Culture, Routine (Pending): Brief Hospital Course: Primary Reason for Admission: 69F h/o ESRD on HD, MSSA graft infection and bacteremia s/p graft removal with resolved wide-complex tachycardia in the setting of ongoing fever. Problem LIST: 1. Sepsis/septicemia secondary to e.coli 2. Line infection (catheter tip with coagulate negative staph) 3. ESRD on HD 4. Atrial fibrillation 5. Non-sustained VT 6. Hypertension 7. Diabetes type II, controlled 8. Thrombocytopenia, chronic 9. Bilateral adrenal nodules - stable 10. Mediastinal lymphadenopathy The patient presented to the emergency department febrile to 103, with nausea and vomiting, and tachycardia. Blood cultures were drawn and she was started empirically on vancomycin, zoysn, and tobramycin. In the emergency department, she was had wide complex tachycardia. This WCT was interpreted as atrial fibrillation with aberrancy with occasional runs of non-sustained ventricular tachycardia. Cardiology was consulted and she was loaded on amiodarone. Given her septic picture and cardiac dysrhythmia, her tunneled HD line was removed and she was sent to the medical ICU. In the medical ICU, sensitivities returned showing gram negative rods in [**1-20**] bottles which confirmed that the patient had gram negative septicemia. These bacteria were sensitive to ecoli. The tip was cultured and which grew out coagulase negative staph which was sensitive to vancomycin. Her antibiotics were narrowed to ceftriaxone. She showed continued response to the ceftriaxone as evidenced by her decreasing white count, lack of fever, and improved energy level and mood. She had a temporary IJ placed in the MICU for HD; however, HD had to be aborted because when she was initially dialyzed she started to developed nausea, vomiting, and signs hemodynamic instability. As she fever resolved and was hemodynamically stable on the ceftriaxone, the patient was transferred to the general medicine floor for further care. She continued to be treated with ceftriaxone and serial blood cultures were obtained. Once her blood cultures were negative for 48 hours, a new tunneled line was placed. The patient was successfully dialyzed. During HD, the patient was given vancomycin per HD sliding scale in order to treat her catheter associated infection. There was no clear source for the patient??????s gram negative septicemia. Therefore, we performed a CT torso to look for signs of occult infection. The CT torso was negative for infection but did show stable bilateral adrenal nodules and mediastinal lymphadenopathy which should be further investigated on an outpatient basis. Following the tunneled line procedure, she was started on coumadin for stroke prophylaxis in the setting of her new onset atrial fibrillation. Cardiology consult was curbsided. They said it would be ok to discontinue the patient??????s amiodarone and discharge her with an event monitor ([**Doctor Last Name **] of Hearts) with close follow up in cardiology clinic to better understand the patient??????s underlying cardiac rhythm abnormalities. The patient??????s hypertension remained difficult to control while on the floor. Her hydralazine was increased to 75mg TID, lisinopril 40mg qd, and metoprolol 75mg [**Hospital1 **]. Her blood pressure would still be in the 150-160s depending on when she was dialyzed. Upon discharge, the patient was transitioned to renally dosed cipro 500mg qd for 8 days (total 14 day course). 500mg was chosen because we wanted to aggressive treat her blood stream infection. She will be treated with vancomycin per HD protocol. *****Transitional issues******** 1. Gram negative septicemia. Patient will be treated with a total 14 day course of oral cipro and vancomycin per HD protocol. She should be monitored for any signs or symptoms of worsening infection and consider broadening spectrum of antibiotic coverage if there is clinical concern. 2. Atrial fibrillation: I) Rate control with metoprolol. Avoiding use of amiodarone secondary to long term toxicity and will evaluate dysrhymia with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts monitor. She has follow up with the cardiologist, Dr. [**Last Name (STitle) 5543**] in 2 weeks for further care. II) The patient was anticoagulated with coumadin for her atrial fibrillation for stroke prophylaxis. Her INR will require close monitoring especially when she is taking cipro and as the amiodarone washes out of her system (she received 6 days of loading amiodarone). [**Hospital 191**] Clinic notified and aware. 3. ESRD: Patient is being successfully dialyzed with tunneled line but would suggest referral to the [**Hospital 29019**] clinic at [**Hospital1 18**] (Drs. [**Last Name (STitle) **], [**Name5 (PTitle) **]) for possible av-graft or fistula. 4. Blood cultures have shown no growth since the [**2-6**]. Will require follow up for final growth. 5. Additional agents should be considered for tighter blood pressure control. 6. Adrenal nodule and mediastinal lymphadenopathy. Consider a possible malignancy workup or active surveillance. Medication CHANGES: 1. Metoprolol XL 150mg qd 2. Hydralizine increased from 50 to 75mg TID 3. Coumadin 1mg qd 4. Cipro 500mg PO x 8 days 5. Vancomycin per HD x 2 weeks 6. Zofran 4mg ODT prn nausea Medications on Admission: CINACALCET [SENSIPAR] 120 mg qd GUANFACINE 1 mg qpm HYDRALAZINE 50 mg tid LISINOPRIL 40 mg qd METOPROLOL TARTRATE 50 mg Tablet [**Hospital1 **] OMEPRAZOLE 20 mg qd PRAVASTATIN 10 mg qd SEVELAMER CARBONATE [RENVELA] 1600 mg Tablet tid ASA 81 mg qd NPH 36u qam, 10u qpm Discharge Medications: 1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. NPH Insulin 36 units QAM and 10 units QHS 3. cinacalcet 30 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. guanfacine 1 mg Tablet Sig: One (1) Tablet PO once a day. 5. hydralazine 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 6. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO once a day. Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2* 12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days: On Dialysis days please take after dialysis. Disp:*8 Tablet(s)* Refills:*0* 13. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day for 14 days. Disp:*42 Tablet, Rapid Dissolve(s)* Refills:*0* 14. vancomycin 500 mg Recon Soln Sig: One (1) Intravenous Dosed at Hemodialysis for 8 days: Please give per Dialysis slinding scale based on Vancomycin Level. Disp:*qs HD* Refills:*0* 15. warfarin 2 mg Tablet Sig: .5 Tablet PO once a day: You will be called by the anticoagulation nurses on Wednesday [**2137-2-13**] to discuss the dosage of this medication. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Gram Negative Bacteremia 2. Infected hemodialysis catheter 3. End Stage Renal Disease 4. Gastroenteritis 5. Type 2 Diabetes Mellitus 6. Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 29020**] [**Known lastname **] [**Last Name (un) **], You were hospitalized because you had e-coli (a type of bacteria) in your blood that can cause serious, life threatening infections. Your HD line was removed, you were treated with antibiotics to clear your blood of bacteria and a new line was placed. However, you will need to take antibiotics as directed to prevent future infections. You also had atrial fibrillation, given your high risk of developing blood clots and stroke we started you on a blood thinner coumadin. Coumadin is a medication that needs to be very frequently monitored by your PCP. [**Name10 (NameIs) **] will have your blood drawn several times a week until your blood level of coumadin is theraputic. The anti-coagulation nurses at [**Hospital6 733**] together with your PCP will manage your Coumadin dose going forward. The following changes were made to your medications: 1. You were STARTED on Coumdin (warfarin) 1mg daily, you will be contact[**Name (NI) **] by the anticoagulation nurses to adjust your dose based on lab tests obtained on Wednesday [**2-13**]. 2. You were STARTED on Zofran ODT 4mg every 8 hours for nausea 3. You were STARTED on Cipro 500mg daily (take after dialysis on dialysis days) for 8 more days (To be completed on [**2-20**]) 4. You were STARTED on Vancomycin IV (this will be given to you at dialysis) for 8 more days (To be completed on [**2-20**]) 5. Your Metoprolol 50mg twice daily was CHANGED to Metprolol XL 150mg once daily 6. Your Hydralazine 50mg three time daily was CHAGNED to Hydralazine 75mg three times daily You will also be monitored on a "[**Doctor Last Name **] of Hearts" device. This device will help your cardiologist monitor your heart if there are any irregular heart beats. A person from the heart monitor clinic will come by and help you learn how to use the device. If you experience any of the symptoms listed below please contact your primary care physician and go to the nearest emergency department. Followup Instructions: Department: [**Hospital3 249**] When: WEDNESDAY [**2137-2-13**] at 1:40 PM With: [**Name6 (MD) 10160**] [**Name8 (MD) 10161**], NP [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: THURSDAY [**2137-3-7**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2137-3-14**] at 2:30 PM With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], 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) 3202**] Campus: EAST Best Parking: Main Garage

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Discharge summary

report

Admission Date: [**2165-3-12**] Discharge Date: [**2165-3-20**] Date of Birth: [**2094-11-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: central venous line placement and subsequent removal hemodialysis line removal History of Present Illness: 70 yo M presented to ED from nursing home w/ altered mental status and low grade fever. Per the patient's son, patient's penile gangrene had worsened - prior dry gangrene isolated to glans penis treated conservatively given not operative candidate and followed closely by urology. On evaulation in the ED patient was oriented only to self. In the ER initial VS were: T 100.6 HR 53 BP 135/67 RR 14. VS prior to transfer to the ICU 86, BP 146/65 98% on 2L RR 12. He rec'd 20u sc insulin in total, he rec'd 500cc of IVF. Had a L SC CVL placed. He was transferred to the MICU for concern of sepsis. CT groin showed sq air diagnostic for fournier's gangrene. He was treated with vanc/zosyn/cipro and urology was consulted who had a long discussion with son about patient not being an operative candidate and the natural course of fournier's gangrene without surgical intervention. Decision made to make patient DNR/DNI with no escalation of care. Patient was hemodynamically stable throughout MICU course. He was transferred to the floor and upon evaluation patient denied pain, CP, SOB, abd pain or other ROS. Past Medical History: -5/08 L BKA for gangrene -[**12-30**] glans penis dry gangrene conservatively managed -DM2 -Hypertension -CKD baseline 3.5-4.2, up to 9 in [**6-28**] -blindness -neuropathy, possibly demyelinating polyneuropathy -systolic CHF EF 50% as of [**4-28**] Social History: Originally from [**Location (un) 4708**]. Very remote tobacco use. Denies EtOH or drugs. Wheelchair bound, lives at home with family who are very involved - has nurse visit 3x/day. Family History: Diabetes, CAD in children. One son died of MI. Physical Exam: VS: 138/67 87 15 98.7 90-98% on RA GEN: elderly gentleman, lying in bed,looking straight. HEENT: R corenal haziness, reduced vision, EOMI, no icterus, MMM NECK: no cervical lymphadenopathy CV: RRR, no r/g/m PULM: clear to auscultation bilaterally ABD: soft, mildy distended, non tender GROIN: deferred temporarily. EXT:warm and well perfused. R foot with dorsal edema, dry ulcer, well circumscribed, no drainage. left BKA. NEURO: difficult to assess, patient able to verbalize. hard of hearing. can follow some simple commands. could not move feet when asked. unclear if he understood. Exam at discharge: T 96 HR 99 158/60 92% RA GEN: elderly gentleman, lying in bed, alert and oriented to person, comfortable HEENT: R corenal haziness, reduced vision, EOMI, no icterus, MMM NECK: no cervical lymphadenopathy CV: RRR, no r/g/m PULM: clear to auscultation bilaterally ABD: soft, mildy distended, non tender GROIN: gangrene of glans and shaft with some purulence at coronal sulcus. Crepitus notable along lenth of penile shaft. Urethra with some purulence but appears patent. Erythema extending to suprapubic region EXT:warm and well perfused. R foot with dorsal edema, dry ulcer, well circumscribed, no drainage. left BKA. Pertinent Results: CT A/P: IMPRESSION: 1. Extensive subcutaneous and soft tissue emphysema involving essentially all compartments of the penis extending its entire length, consistent with Fournier's gangrene. Emergent surgical evaluation is recommended. 2. Extensive diffuse atherosclerotic disease, with possible right proximal superficial femoral artery occlusion as described. Please correlate clinically for further evaluation. Current study is not tailored for CT angiography. 3. Moderate-to-large bilateral pleural effusions with compressive atelectasis, right greater than left. 4. High-density exophytic small lower pole right renal lesion, new since [**2160**], is not fully characterized. This may be further evaluated by ultrasound on a non-emergent basis. 5. Diffuse severe anasarca. 6. Fat-containing umbilical hernia. 7. Moderate amount of fecal material throughout the colon. CT HEAD: No intracranial hemorrhage, large vascular territory infarct, or large mass. Please note MRI with gadolinium is superior for evaluation of intracranial mass if not contraindicated. LABS: - CBC: WBC-20.9 Hgb-8.3 Hct-28.3 MCV-80 Plt Ct-556 - DIFF: Neuts-91.5* Lymphs-5.3* Monos-2.9 Eos-0.2 Baso-0.2 - COAGS: PT-13.3 PTT-28.6 INR(PT)-1.1 - CHEM 10: Glucose-393 UreaN-80 Creat-8.4 Na-137 K-5.3 Cl-97 HCO3-24 AnGap-21 Calcium-8.5 Phos-6.6* Mg-2.6 - LFT's: ALT-13 AST-15 CK(CPK)-49 AlkPhos-363 TotBili-0.3 - cTropnT-0.83* - Lactate-1.4 Labs prior to discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 30.8* 3.89* 9.6* 30.8* 79* 24.7* 31.2 21.4* 475 Brief Hospital Course: ASSESSMENT & PLAN: 70 year old male with h/o DM, HTN, ESRD on HD and systolic CHF EF 30% presented with altered mental status, fever, found to have Fourniers gangrene of the groin. He was septic and started on Vanco/Zosyn/Clindamycin in the ICU. The patient was a high surgical risk, and any survival and per urology the benefit to be obtained from debridement would likely be small and associated with significant pain and painful dressing changes. He was continued on antibiotics and an aggressive pain regimen. This alleviated his symptoms. His mental status also cleared as his pain control improved. He was hemodynamically stable and he was tranferred to the floor where further discussion regarding goals of care were pursued with the assitance of the palliative care team. During a family meeting, it was made clear that the patient's Fournier's gangrene was non-operative and was terminal. Following this discussion with [**Hospital 228**] health care proxy, son [**Name (NI) 14175**], the decision was made that the patient would want his care to be focused at home with hospice without return to a health care facility if his condition worsened. Hemodialysis was discontinued, and his HD line was removed. Hospice care was arranged, and the patient was discharged on [**2165-3-20**] home with hospice. He had a mid-line placed so that he could continue to receive antibiotics for his non-operative Fournier's gangrene. Pain control was optimized with a fentanyl patch and sublingual morphine. The patient was comfortable and alert upon discharge. Medications on Admission: HOME MEDICATIONS: Amlodipine 5 mg daily Aspirin 325 mg po daily Atorvastatin 40 mg po daily Insulin Lispro sliding scale Metoprolol Succinate 25 mg SR daily B Complex-Vitamin C-Folic Acid 1 mg po daily Acetaminophen 325 mg 1-2 tablets q6hrs prn Ranitidine HCl 150 mg po daily Insulin Glargine 2 units daily Docusate Sodium 100 mg po bid Polyethylene Glycol 3350 17 gram/dose po daily Bisacodyl 5 mg po daily Senna 8.6 mg po bid MEDICATIONS ON TRANSFER: Acetaminophen 1000 mg PO/NG TID Artificial Tears 1-2 DROP BOTH EYES Q4 HOURS HYDROmorphone (Dilaudid) 0.25 mg IV Q3H:PRN pain Clindamycin 600 mg IV Q8H Piperacillin-Tazobactam 2.25 g IV Q12H Vancomycin 1000 mg IV HD PROTOCOL Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-22**] Drops Ophthalmic Q4 HOURS (). 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Zosyn 2.25 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours for 1 months. Disp:*qs * Refills:*2* 4. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Transdermal every seventy-two (72) hours. Disp:*5 0* Refills:*0* 5. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H (every 6 hours). 6. Morphine Concentrate 20 mg/mL Solution Sig: 1-2 mg PO Q1H (every hour) as needed for breakthrough pain/dyspnea. Discharge Disposition: Home With Service Facility: [**Hospital 269**] Hospice Care Discharge Diagnosis: Primary Diagnosis: Forneir's Gangrene End stage renal disease Type II Diabetes Mellitus Secondary Diagnosis: Hypertension Discharge Condition: Mental Status: alert and oriented to person Level of Consciousness: alert Activity Status: bedrest, out of bed with assist Discharge Instructions: Mr. [**Known lastname 12543**] - It was a pleasure to care for you during your hospitalization. You were admitted due to a very serious infection of the skin and soft tissue of the penis. You were evaluated by urology and surgery was thought to be very dangerous. You were continued on antibiotics. The urologists did not think that you would be able to tolerate a painful surgery to cure the infection, which is a terminal infection. The decision was made by you and your family to treat your pain and other symptoms with pain medications and antibiotics. Following a family meeting, arrangements were made for hospice services at home to continue comfort measures. Dialysis was discontinued, and your hemodialysis line was removed. You had another IV placed to continue receiving antibiotics at home. You went home on [**2165-3-20**] with the intent to continue comfort measures only and not to return to the hospital. See below for a list of medications you will given at home. You will continue to receive hospice care at home. Followup Instructions: You will continue to receive hospice care at home.

[ "995.91", "369.9", "038.9", "V49.75", "V66.7", "V58.67", "608.83", "428.0", "585.6", "250.62", "357.2", "276.2", "428.20", "403.91" ]

icd9cm

[ [ [] ] ]

[ "97.49", "38.93" ]

icd9pcs

[ [ [] ] ]

7869, 7931

4943, 6515

338, 419

8098, 8098

3374, 4247

9311, 9365

2052, 2101

7246, 7846

7952, 7952

6541, 6541

8247, 9288

2116, 2714

6559, 6970

2728, 3355

277, 300

447, 1562

4256, 4920

8062, 8077

7971, 8041

8113, 8223

6995, 7223

1584, 1835

1851, 2036

23,315

184,962

30965+57729

Discharge summary

report+addendum

Admission Date: [**2138-4-7**] Discharge Date: [**2138-4-7**] Date of Birth: [**2077-11-22**] Sex: F Service: MEDICINE Allergies: Ibuprofen Attending:[**First Name3 (LF) 2297**] Chief Complaint: Easy bruising Major Surgical or Invasive Procedure: Intubation Brief Hospital Course: The patient was admitted with a recent history of easy bruising and fevers. More recently she developed a persistent headache. The patient was found to have a profound pancytopenia and small intraventricular hemorrhorage at an outside hospital. Upon transfer, the patient underwent head CT that revealed a small intraventricular as well as subarachnoid hemorrhage. She underwent peripheral blood smear revealing initially a normal differential and then blossoming to 15% promyelocytes concerning for APML. The patient presented with a profound coagulopathy consistent with DIC further concerning for this diagnosis. The patient received aggressive blood products (platelets, FFP and cryoprecipitate) for goal platelets >100, Fibrinogen >100 and INR<1.5. She revealed a profound consumptive process with minimal response to transfusions. The patient underwent bone marrow biopsy. She received her first dose of t-retinoin on [**2138-4-7**]. In the evening on the day of admission, the patient developed respiratory distress and a period of asystole. She was successfully intubated after a witnessed aspiration event. Later in the evening a code blue was called for asystole. Immediately pre-code ABG revealed 7.33/49/79 with a K of 4.5. The patient received multiple rounds of epinephrine (3 amps total) and atropine (1 amp total) as well as calcium chloride and bicarb. At 23:12 on [**2138-4-7**] the patient was pronounced deceased in the setting of persistent asystole and newly dilated, unresponsive pupils (at the onset of the code, the patient's pupils were equal, round and minimally responsive). Also of note, the patient was thought to have witnessed seizure activity within minutes of the code call for which she received IV ativan 2mg. The most likely etiology for the patient's demise was APML complicated by DIC and intracranial hemorrhage causing herniation (as evidenced by dilated, unresponsive pupils). The patient's family was contact[**Name (NI) **] and they asked for an autopsy which is pending at this time. Discharge Disposition: Expired Discharge Diagnosis: Acute promyelocytic leukemia complicated by DIC and intracranial hemorrhage. Discharge Condition: None Discharge Instructions: None Followup Instructions: None Name: [**Known lastname 5077**],[**Known firstname 460**] J Unit No: [**Numeric Identifier 12188**] Admission Date: [**2138-4-7**] Discharge Date: [**2138-4-7**] Date of Birth: [**2077-11-22**] Sex: F Service: MEDICINE Allergies: Ibuprofen Attending:[**First Name3 (LF) 5448**] Addendum: The patient underwent an echocardiogram prior to the code which preliminarily revealed no significant effusion or mechanical dysfunction. Discharge Disposition: Expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5451**] MD [**MD Number(2) 5452**] Completed by:[**2138-4-8**]

[ "401.9", "571.8", "431", "135", "205.00", "284.1", "286.6", "430", "518.81", "272.0", "514", "250.00" ]

icd9cm

[ [ [] ] ]

[ "99.05", "99.04", "38.93", "88.72", "96.71", "41.31", "96.04" ]

icd9pcs

[ [ [] ] ]

3074, 3239

318, 2348

283, 295

2501, 2508

2561, 3051

2401, 2480

2532, 2538

230, 245

4,313

130,275

29854

Discharge summary

report

Admission Date: [**2176-1-9**] Discharge Date: [**2176-1-11**] Date of Birth: [**2145-5-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 358**] Chief Complaint: loss of conciousness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 30 year old male with diabetes and ESRD on dialysis who presents from home after being found down at home. He was recently discharged from this hospital on [**12-22**] after being admitted for a line infection and had his line replaced. He completed a course of cefazolin on [**2176-1-6**]. Patient recalls that his blood sugar was elevated the night prior to presentation in the 350s. He says that he took 6 U of NPH and 12 [**Location **] and went to sleep. He usually eats a meal at bedtime and but did not yesterday evening. He woke up at midnight and felt diaphoretic but did not feel confused as he normally does when he is hypoglyemic. He took his shirt off because he was so sweaty. He got up to use the bathroom and remembers deficating on himself and then fell down and lost consciousness. He was found unresponsive by his brother at approximately 5 AM. EMS was called. Finger stick in the field was 42 and he received 100 mg thiamine and 25 g D50 with improvement in his level of consciousness. Temperature in the field was 88 degrees. . On arrival the emergency room his initial vitals were T: 86 HR: 99 BP: 144/88 RR: 18 O2: 96% on RA. Blood glucose on arrival was 131. He had a non-contrast CT head which was negative. CXR with no acute intrathoracic process. He received vancomycin 1 gram IV, ceftriaxone 1 gram IV. His potassiumw as elevated at 6.0 and he received calcium gluconate, insulin and D50. EKG showed J waves in V3-V4. He was transferred to the [**Hospital Unit Name 153**] for further management. . On arrival to the [**Hospital Unit Name 153**] he reported that he felt well. He reported that he had dialysis on Saturday as usual and was due for dialysis today. He endorsed feeling chilled and hungry but otherwise had no complaints. No fevers, lightheadedness, dizziness, chest pain, shortness of breath, nausea, vomiting, abdominal pain, dysuria, hematuria, leg pain or swelling. No confusion. Past Medical History: -Alcoholic pancreatitis ([**10-16**]) -[**Doctor First Name **]-[**Doctor Last Name **] tear([**11-15**]) -Stage V Chronic Kidney Disease: Currently on hemodialysis and being being evaluated for [**Month/Year (2) **] -Diabetes Mellitus -Diabetic foot ulcers -Alcoholic hepatitis -Hypertension -Hyperlipidemia -Diabetic Myonecrosis Social History: He lives with his brother and is currently unemployed. He used to drink heavily but will not specify how much. He currently denies any drinking. He formerly smoked but says that he no longer does so for the past "few months." Family History: Significant for both parents and three siblings with diabetes. He denies any family history of heart disease, hypertension, cancer, or bleeding disorders in the family. Physical Exam: VS: T 94.5, BP 131/80, HR 93, RR 10 O2 100% on RA. FS 158. Gen: Alert, oriented, no acute distress HEENT: PERRL, sclera anicteric, oropharynx clear, mucus membranes moist Neck: supple, no LAD, R neck with slightly dirty bandages, non-tender, non-erythematous, tunnelled line in place Cardiovascular: RRR, s1 + s2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, +BS, no organomegaly Extremities: WWP, 1+ pulses, no clubbing, cyanosis or edema Skin: no rashes Neuro: non-focal Pertinent Results: Imaging: ====== CT HEAD W/O CONTRAST Study Date of [**2176-1-9**] 7:33 AM IMPRESSION: No evidence of acute intracranial abnormalities. . CHEST (PORTABLE AP) Study Date of [**2176-1-9**] 8:17 AM IMPRESSION: No acute intrathoracic process. . Labs: ==== [**2176-1-9**] 06:45AM BLOOD WBC-11.5* RBC-3.91*# Hgb-11.0* Hct-33.7*# MCV-86 MCH-28.1 MCHC-32.6 RDW-16.4* Plt Ct-375# [**2176-1-11**] 06:30AM BLOOD WBC-5.5 RBC-3.16* Hgb-8.9* Hct-26.6* MCV-84 MCH-28.1 MCHC-33.4 RDW-16.3* Plt Ct-327 [**2176-1-9**] 06:45AM BLOOD Glucose-99 UreaN-78* Creat-11.2*# Na-137 K-6.0* Cl-99 HCO3-18* AnGap-26* [**2176-1-9**] 04:23PM BLOOD Na-142 K-4.9 Cl-104 [**2176-1-11**] 06:30AM BLOOD Glucose-86 UreaN-51* Creat-9.9*# Na-140 K-5.4* Cl-103 HCO3-23 AnGap-19 [**2176-1-9**] 06:45AM BLOOD CK(CPK)-375* [**2176-1-9**] 04:23PM BLOOD CK(CPK)-243* [**2176-1-9**] 09:47AM BLOOD CK-MB-11* MB Indx-3.0 cTropnT-0.16* [**2176-1-9**] 04:23PM BLOOD CK-MB-6 cTropnT-0.16* [**2176-1-9**] 06:45AM BLOOD Calcium-8.3* Phos-6.3* Mg-2.5 [**2176-1-11**] 06:30AM BLOOD Calcium-8.3* Phos-4.9* Mg-2.1 [**2176-1-10**] 05:05AM BLOOD TSH-0.92 [**2176-1-11**] 06:30AM BLOOD TSH-0.81 [**2176-1-11**] 06:30AM BLOOD Cortsol-13.8 [**2176-1-9**] 09:47AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Micro: ===== Blood Cultures [**2176-1-9**] no growth to date Brief Hospital Course: 30 year old male with DM1, ESRD on dialysis who presents from home after being found down at home found to have hypoglycemia and hypothermia in the field. This did not appear to be cardiovascular or infectious in nature, but rather an inbalance of insulin administration and food ingestion. He responded well to gluocose administration and was discharged from the ICU in stable condition. While on the floor he underwent dialysis without event and was seen by the [**Last Name (un) **] team who suggested modifications to his insulin regimen. He remained on his outpatient regimen, and aside from the new insulin regimen he had the following changes in his BP regimen: His labetolol 100 mg tid and metoprolol 125 mg [**Hospital1 **], was changed to metoprolol 125 tid, and the patient tolerated this well. The thought was that perhaps this could be changed to Toprol XL 300 mg daily in the future. After discussion with the patient and the medical team, all were in agreement that Mr. [**Known firstname 71396**] [**Known lastname **] was a suitable candidate for discharge. Medications on Admission: Amlodipine 5 mg daily Atorvastatin 40 mg daily Calcium Acetate 1334 TID with meals Cinacalcet 60 mg daily Labetalol 100 mg TID Lisinopril 40 mg daily Metoprolol 125 mg [**Hospital1 **] NPH 6 U QAM and 2 U QAM Pantoprazole 40 mg daily Lanthanum 500 mg TID Aspirin 81 mg daily Discharge Medications: 1. Amlodipine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Atorvastatin 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Calcium Acetate 667 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Capsule(s)* Refills:*0* 4. Cinacalcet 30 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 5. Lanthanum 500 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet, Chewable(s)* Refills:*0* 6. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*80 Tablet, Chewable(s)* Refills:*0* 7. Lisinopril 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 10. Humalog Mix 75-25 100 unit/mL (75-25) Insulin Pen [**Last Name (STitle) **]: Ten (10) Units Subcutaneous qam: For every increase of 100 above a pre-dose glucose level of 100, add 1 unit of insulin. Disp:*qs for one month * Refills:*2* 11. Humalog Mix 75-25 KwikPen 100 unit/mL (75-25) Insulin Pen [**Last Name (STitle) **]: Eight (8) U Subcutaneous at bedtime: For every increase of 100 above a pre-dose glucose level of 100, add 1 unit of insulin. Disp:*qs for one month * Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypoglycemia, Hypothermia . Secondary Diagnoses: -Alcoholic pancreatitis ([**10-16**]) -[**Doctor First Name **]-[**Doctor Last Name **] tear([**11-15**]) -Stage V Chronic Kidney Disease: Currently on hemodialysis and being being evaluated for [**Month/Year (2) **] -Diabetes Mellitus -Diabetic foot ulcers -Alcoholic hepatitis -Hypertension -Hyperlipidemia -Diabetic Myonecrosis Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating without assistance. Discharge Instructions: You were admitted to the ICU with hypoglycemia and hypothermia and responded well to glucose infusion and warming. Your final insulin regimen will consist of: 10U Humalog 75/25 in the morning 8U Humalog 75/25 in the evening. . For every 100 points above your pre-insulin dose glucose level of 100, please increase your Humalog 75/25 dose by 1 unit. For instance if your pre-insulin glucose level in the morning is 80-199, take 10U. If the level is 200-299, take 12 units, if the level is 300-399, take 13U, and so on. These changes also applies to the evening dose. . In order to avoid hypoglycemia in the future, please keep some candy in your pocket or by your bedside if you start to get symptoms. . 1. Please take all medication as prescribed. 2. Please make all medical appointments. 3. Please return to the Emergency Room if you have any concerning symptoms. Followup Instructions: Please call [**Last Name (un) **] to schedule a follow-up appointment. . You have an appointment with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7538**] on [**2176-1-25**] @ 8:00pm. . Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2176-3-18**] 1:20 . Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name11 (NameIs) **] SOCIAL WORK Date/Time:[**2176-3-18**] 2:00 . Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2176-3-18**] 2:30 Completed by:[**2176-1-12**]

[ "250.63", "780.65", "403.91", "577.1", "V45.11", "357.2", "585.6", "250.83", "272.4", "276.7" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

8217, 8223

5071, 6153

334, 340

8666, 8745

3710, 5048

9659, 10404

2940, 3110

6479, 8194

8244, 8244

6179, 6456

8769, 9636

3125, 3691

8312, 8645

274, 296

368, 2326

8263, 8291

2348, 2681

2697, 2924

28,949

108,246

34022

Discharge summary

report

Admission Date: [**2149-5-8**] Discharge Date: [**2149-5-17**] Date of Birth: [**2075-10-23**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Bactrim / Ciprofloxacin / Clindamycin / Dilaudid / Percocet / Oxycontin / Ceftin / Vicodin / Morphine Attending:[**First Name3 (LF) 1267**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: [**2149-5-12**] - CABGx2 (Left internal mammary->Left anterior descending artery, Vein graft->Diagonal artery). [**2149-5-8**] - Cardiac Catheterization History of Present Illness: 73 y/o with a PMH of HTN, HLP, CHF with preserved EF (EF 80% on C Cath on [**5-8**] @ [**Hospital1 1474**]), paroxysmal A fib (not on coumadin) who was admitted to [**Hospital 1474**] hospital 2 weeks ago with CHF and AF. At that time she had a nucler stress that showed apical ischemia. Cardiac Catheterization was recommended, but she refused and was discharged to home on medical managment. Then she re-preseneted to [**Hospital1 1474**], continuing to complain of shortness of breath. On [**5-8**] she underwent elective cath showing LAD 90% lesion and she was transferred to [**Hospital1 18**] for PCI (dye load=116cc). Upon arival, prior to C Cath, pre-procedure creat was noted to be 1.8 (basline 1.1-1.3) so she was given mucomyst and sodium bicarbonate. Cardiac Catheterization at [**Hospital1 18**] showed 80-90% lesion in the mid LAD with unsuccessful PCI attempt of the mid LAD despite multiple attempts. Dr. [**Last Name (STitle) 2230**] was called, and plan for surgical revascularization of the LAD with a LIMA after plavix washout. Past Medical History: Hypertension Hyperlipidemia CHF with normal EF (EF 80% on [**2149-5-8**] C Cath) GERD TIA GOUT CRI (basline creat 1.1-1.3) PAF Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: Positive family history of premature coronary artery disease (brother with CAD in his 40s), no fhx or sudden death. Physical Exam: VS - Tc 98.7, Tm 98.4, 150/75 (128-150/52-80), 81 (76-96), R20, O2 94%RA Gen: 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 8 cm. 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, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: Right groin site with no hematoma, clean dressing, No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: [**2149-5-8**] 10:50PM PT-17.1* PTT-34.7 INR(PT)-1.5* [**2149-5-8**] 09:43PM PT-20.1* PTT-66.1* INR(PT)-1.9* [**2149-5-8**] 09:43PM THROMBN-150* [**2149-5-8**] 09:30PM POTASSIUM-4.1 [**2149-5-8**] 09:30PM CK(CPK)-36 [**2149-5-8**] 09:30PM CK-MB-NotDone [**2149-5-8**] 09:30PM PLT COUNT-231 [**2149-5-8**] 07:55PM GLUCOSE-150* UREA N-55* CREAT-1.5* SODIUM-137 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-23 ANION GAP-14 [**2149-5-8**] 07:55PM estGFR-Using this [**2149-5-8**] 07:55PM ALT(SGPT)-13 AST(SGOT)-10 ALK PHOS-76 TOT BILI-0.3 [**2149-5-8**] 07:55PM ALBUMIN-3.5 [**2149-5-8**] 07:55PM %HbA1c-5.5 [**2149-5-8**] 07:55PM HBc Ab-NEGATIVE [**2149-5-8**] 07:55PM WBC-5.6 RBC-3.79* HGB-12.5 HCT-34.5* MCV-91 MCH-33.0* MCHC-36.2* RDW-12.6 [**2149-5-8**] 07:55PM PLT COUNT-208 [**2149-5-8**] 07:55PM PT-44.5* PTT-150* INR(PT)-5.0* . . Studies: EKG demonstrated NSR@64 nml axis, nml intervals, Q in III, TWI in aVL, no ST elevations/deprssions. . 2D-ECHOCARDIOGRAM performed in [**4-17**] @ [**Hospital **] Hospital: with reported EF 55-60% [**First Name8 (NamePattern2) **] [**Hospital 1474**] Hospital D/C summary. . Percutaneous coronary intervention, on [**5-8**] at [**Hospital **] Hospital anatomy as follows: RHC: nml RA pressure, elevated pul artery pressure (40/15 mean 23), PCWP nml, Shows evidence of pulm artery htn. Left Heart Assessment: EF 80%, LV chamber size small. Elevated lv systolic pressure. Nml lv end diastolic pressure. LVEDP 15 mmHg. No mitral stenosis. Grade 1 MR. [**First Name (Titles) **] [**Last Name (Titles) **] calcification. Normal LV wall motion. Hyerkinetic LV contractility. Cononary Angiography: Right dominant. Left main: no sig stonosis LAD: 99% focal mid stenosis after 1st diag branch LCX: mild intimal irreg without sig stenosis RCA: mild intimal irregularities without sig stenosis . Percutaneous coronary intervention, on [**5-8**] at [**Hospital1 18**] anatomy as follows: 1. Initial angiography revealed a 80-90% lesion in the mid LAD.The LM coronary artery was normal. The LAD was as above. The distal LAD was normal. The LCx was normal. The RCA was not engaged. 2. Limited hemodynamics revealed a central aortic pressure of 142/73 3. Unsuccessful PCI attempt of the mid LAD despite multiple attempts. [**2149-5-12**] ECHO PREBYPASS No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The descending thoracic aorta is tortuous. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-11**]+) mitral regurgitation is seen. Tricuspid regurgitation is present but cannot be quantified. POSTBYPASS Biventricular systolic function is preserved. MR remains mild to moderate. The study is otherwise unchanged compared to prebypass. Brief Hospital Course: Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2149-5-8**] via transfer from [**Hospital 1474**] Hospital for a cardiac catheterization and angioplasty. This revealed an 80% stenosed left anterior descending artery which was unamenable to angioplasty or stenting. The cardiac surgery service was consulted and Ms. [**Known lastname **] was worked-up in the usual preoperative manner. As she had a history of atrial fibrillation and poor compliance with coumadin, it was decided a concommittant MAZE procedure would also be performed. The psychiatry service was consulted for assistance with her care as she was at times unagreeable and argumentative. Through further evaluation, she was found to be at her baselne however no conclusion of her decision making ability was made. A 1:1 sitter was maintained and social work was consulted. Plavix was allowed to wash out over the next several days. On [**2149-5-12**]. Ms. [**Known lastname **] was taken to the operating room where she underwent coronary artery bypass grafting to two vessels and a MAZE procedure. Please see operative note for details. Postoperatively she was transferred to the intensive care unit for monitoring. By postoperative day one, she had awoke neurologically intact and was extubated. She developed rapid atrial fibrillation which was treated with amiodarone. She was transfused with packed red blood cells for postoperative anemia. Coumadin, aspirin and beta blockade were resumed. Chest tubes were removed. She was transferred to the floor by POD#3 and wires were removed and she did well. She was discharged to rehab on [**2149-5-17**]. Medications on Admission: Lisinopril 40 mg daily Plavix 75 mg daily Protonix 40 mg daily Lipitor 20 mg daily Primadone 50 mg HS Lopressor 75 mg [**Hospital1 **] Lasix 60 mg daily (took 80 mg as 1 lb. wt. gain) Colchicine 0.6 mg daily ASA 325 mg daily. Norvasc 5 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Insulin Lispro 100 unit/mL Solution Sig: AS DIRECTED AS DIRECTED Subcutaneous ASDIR (AS DIRECTED). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 12. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO BID (2 times a day): HOLD for K>4.5. 13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): HOLD for SBP<100, HR<60. 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day). 15. Furosemide 20 mg IV Q12H 16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 17. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: Please check INR daily and dose Warfarin daily. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: CAD s/p CABGx2 HTN Hyperlipidemia CHF GERD TIA Gout AF Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 78538**] Follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] 2 weeks. [**Telephone/Fax (1) 8725**] Follow-up with Dr. [**Last Name (STitle) 16004**] in 2 weeks. [**Telephone/Fax (1) 3183**]

[ "584.9", "414.01", "428.32", "428.0", "427.31", "274.9", "530.81", "285.9", "403.90", "585.9" ]

icd9cm

[ [ [] ] ]

[ "36.15", "88.55", "39.61", "99.20", "88.52", "36.11", "37.33", "37.22" ]

icd9pcs

[ [ [] ] ]

9557, 9624

6027, 7670

390, 545

9723, 9732

2994, 6004

10475, 10767

1921, 2038

7965, 9534

9645, 9702

7696, 7942

9756, 10452

2053, 2975

343, 352

573, 1630

1652, 1780

1796, 1905

81,268

141,538

34422

Discharge summary

report

Admission Date: [**2149-12-17**] Discharge Date: [**2149-12-24**] Date of Birth: [**2108-4-13**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Morphine / Darvocet-N 50 / Midazolam / Dilaudid Attending:[**First Name3 (LF) 5790**] Chief Complaint: elective admission for tracheoplasty h/o tracheobronchomalacia Major Surgical or Invasive Procedure: tracheoplasty History of Present Illness: 41yoF lifetime non-smoker w/ tracheobronchomalacia s/p Y stent [**2149-10-20**] Past Medical History: hypothyroidism, tracheobronchomalacia, elevated testosterone, lap CCY Social History: non smoker Family History: non contributory Physical Exam: VS: T 98.3 HR: 95 SR BP: 102/68 Sats: 93% RA General: NAD Card: RRR Resp: decreased breath sounds few rhonchi left lower lobe GI: benign Extr: warm no edema Incision: R thoracotomys site clean/dry/intact Neuro: non-focal Pertinent Results: [**2149-12-22**] WBC-11.2* RBC-3.74* Hgb-10.9* Hct-30.6* Plt Ct-267 [**2149-12-21**] WBC-9.3 RBC-3.32* Hgb-9.8* Hct-27.7* Plt Ct-214 [**2149-12-20**] WBC-10.7 RBC-3.26* Hgb-9.5* Hct-27.2* Plt Ct-205 [**2149-12-18**] WBC-11.6* RBC-3.84* Hgb-11.5* Hct-31.8* Plt Ct-221 [**2149-12-16**] WBC-7.3 RBC-4.28 Hgb-12.0 Hct-35.5* Plt Ct-240 [**2149-12-24**] Glucose-107* UreaN-6 Creat-0.6 Na-138 K-3.7 Cl-100 HCO3-30 [**2149-12-23**] Glucose-143* UreaN-7 Creat-0.7 Na-137 K-3.5 Cl-98 HCO3-32 [**2149-12-22**] Glucose-111* UreaN-7 Creat-0.6 Na-133 K-3.8 Cl-91* HCO3-31 [**2149-12-16**] UreaN-12 Creat-0.9 Na-138 K-4.5 Cl-102 HCO3-28 AnGap-13 [**2149-12-21**] CK(CPK)-1641* [**2149-12-20**] CK(CPK)-4681* [**2149-12-19**] CK(CPK)-6402* [**2149-12-19**] CK(CPK)-7437* [**2149-12-18**] CK(CPK)-9169* [**2149-12-18**] BLOOD CK(CPK)-[**Numeric Identifier 79135**]* CXR: [**2149-12-24**] IMPRESSION: No significant interval change with stable appearance of right lung with right pleural fluid and area of loculation, and right atelectasis. [**2149-12-22**]: Following removal of right-sided chest tube, no pneumothorax is identified. Loculated right pleural effusion and patchy and linear foci of atelectasis in the right lung appears similar to the recent study allowing for technical differences between the exams. [**2149-12-19**]: IMPRESSION: Interval placement of PICC now appropriately positioned in mid to low SVC. Otherwise, unchanged postoperative changes and bibasilar atelectasis Brief Hospital Course: Ms. [**Known lastname 3761**] was admitted on [**2149-12-17**]. She underwent a tracheoplasty without complications and was extubated and transferred to the ICU postoperatively. Due to her extensive issues with opiate-induced nausea, her pain was managed on a bupivacaine + dilaudid epidural. Due to concern for her prolonged OR time CK's were checked and peaked at [**Numeric Identifier 79135**] with positive urine myoglobin, she was treated with fluids, and her urine output remained excellent with a normal creatinine. On POD#1 her epidural was split, and she was tried on fentanyl then morphine PCAs before being returned to her bupivacaine/dilaudid epidural. On POD #2 she undeerwent bronchoscopy which showed thin secretions and unchanged tracheal stenosis, she received aggressive pulmonary toilet and was started on clears, which she tolerated without difficulty. Diuresis was started with lasix with a goal of - 1 L per day. On POD #3 her chest tube was placed on bulb suction, a regular diet was started. Her arterial line was discontinued as well. On POD #5 she was transferred to the floor, and her [**Doctor Last Name **], foley, and epidural were all discontinued. She was started on oral pain medication (standing tylenol + oxycodone + IV dilaudid & Zofran PRN). She also had an episode of hypotension (SBP 90s) and tachycardia while ambulating, at this point her diuretics were held and she was allowed to auto-diurese. She required aggressive pulmonary toileting and chest PT. Her husband was taught chest PT She continued to make steady progress and was discharged to a hotel on POD7. She will follow-up as an outpatient. Medications on Admission: protonix 40mg [**Hospital1 **], Synthroid 175 daily, Cytomel 5 daily, metformin 1500mg daily, tussionex Discharge Medications: 1. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Liothyronine 5 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-5**] Sprays Nasal QID (4 times a day) as needed for dry mucous membranes. 4. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day) as needed for thick secretions. 5. Metformin 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Saline Saline Nebs tid Disp: 60 cc of saline 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) Inhalation every 4-6 hours as needed for cough. Disp:*qs * Refills:*0* 10. Ipratropium Bromide 0.02 % Solution Sig: Two (2) ML Inhalation Q6H (every 6 hours). Disp:*240 ML* Refills:*2* 11. Chlorpheniramine-Hydrocodone 8-10 mg/5 mL Suspension, Sust.Release 12 hr Sig: Five (5) ML PO Q12H (every 12 hours) as needed. Disp:*30 ML(s)* Refills:*0* 12. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day. Disp:*14 * Refills:*2* 13. Oxycodone 5 mg Capsule Sig: [**12-5**] Capsules PO every 4-6 hours as needed for pain. Disp:*100 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Tracheobronchomalicia Hypothyroid Recurrent pulmonary infections Elevated testosterone level Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience. -Fever > 101 or chills -Increases shortness of breath, cough or sputum production -Chest pain -Incision develops drainage Continue chest PT, saline nebs, and cough medicine Lovenox 40mg once daily for 2weeks Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 3 months [**Telephone/Fax (1) 2348**] Follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Friday [**12-26**] at 1:30pm in the [**Hospital Ward Name 121**] Building [**Hospital1 **] I Chest Disease Center. Completed by:[**2149-12-24**]

[ "244.9", "728.88", "519.19", "530.81" ]

icd9cm

[ [ [] ] ]

[ "31.79", "38.93", "33.48", "33.22", "33.24" ]

icd9pcs

[ [ [] ] ]

5636, 5642

2437, 4084

393, 408

5779, 5788

935, 2414

6124, 6438

655, 673

4238, 5613

5663, 5758

4110, 4215

5812, 6101

688, 916

291, 355

436, 517

539, 611

627, 639

10,884

108,267

24736+57415

Discharge summary

report+addendum

Admission Date: [**2118-5-5**] Discharge Date: [**2118-5-21**] Date of Birth: [**2061-1-21**] Sex: M Service: [**Last Name (un) **] CHIEF COMPLAINT: Worsening hepatorenal failure from outside hospital. HISTORY OF PRESENT ILLNESS: The patient was initially admitted to the hepatology service, and then transferred onto the transplant service on [**2118-5-5**]. The patient is a 57-year-old male admitted with worsening hepatorenal failure from outside hospital where he was admitted on [**5-5**] for increasing resistance to diuretics, ascites, and renal failure. He managed briefly at the outside hospital and then transferred to [**Hospital1 18**] on [**5-5**]. He was previously admitted to [**Hospital1 18**] on [**2118-2-26**] for same problems, MELD score of 30. Upon admission paracentesis was done for worsening abdominal distention. Fluid culture was negative for bacterial or fungal growth. Urine culture on admission was done and this was less than 10,000 organisms. CMV IGG was done. This was negative. Hepatology initially managed this patient. He is using lactulose. ADMISSION PHYSICAL EXAMINATION: Temperature 96.5, BP 111/61, heart rate 82, respiratory rate 18, 100% on room air. GENERAL: Frankly icteric male appearing his stated age, lying in bed comfortably. HEENT: Neck supple. CARDIOVASCULAR: S1 and S2 with no MRG. LUNGS: Clear. ABDOMEN: Soft, nontender, distended. Positive distention. EXTREMITIES: 2+ pedal edema. LABORATORY DATA: Labs at the outside hospital show AST 209, ALT 106, T.bili 10.9, direct bili 5.6, sodium 123, potassium 4.9, chloride 92, CO2 19, BUN 63, creatinine 3.4, and glucose of 126, hemoglobin 11.7, hematocrit 30.8, and platelet count less than 120. An ultrasound done on [**2118-3-3**] demonstrated cirrhotic liver with large ascites, sluggish hepatopedal flow. Transplant service was consulted. MEDICATIONS: 1. Wellbutrin 150 mg once daily. 2. Nadolol 20 mg once daily. 3. Ambien 5 mg q.at bedtime He is off diuretics. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: Hepatic cirrhosis, alcohol associated condition; ceased drinking in [**2117-4-28**]. Shortly thereafter developed pedal edema and jaundiced throughout the latter half of [**2116**]. Ascites, encephalopathy, acute renal failure, GERD, hypertension. SOCIAL HISTORY: The patient has numerous supportive brothers and sisters throughout the country, a total of 9. He is divorced, has two children who was not overly involved in care. HABITS: Alcohol abuse in the past, stopped in [**2117-4-28**]. He denies tobacco. No history of IV drug abuse. SOCIAL HISTORY: Former bus driver. Currently on disability. Transplant service was consulted and followed along. On [**2118-5-7**], an offer for liver transplant occurred. He was taken to the OR by Dr. [**First Name (STitle) **] [**Name (STitle) **] for orthotopic liver transplant from standard brain dead donor, piggyback technique, portal vein to portal vein, with replaced left hepatic artery to hepatic artery branch patch anastomosis, bile duct to bile duct. Liver biopsy was done at that time. Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] assisted. Estimated blood loss was 1 liter. Please see operative report for further details. The patient remained hemodynamically stable throughout the case. The patient was in stable condition, intubated and transferred to the surgical intensive care unit for postoperative management. Postoperatively his LFTs decreased. He was initially transfused with 2 units of packed red blood cells and 1 unit of platelets for hematocrit of 24.5, down from 32.4 and platelet count of 46. His vital signs were stable. His creatinine trended down slowly over the course of the hospitalization to 1.8. Immediately postoperative, hepatic duplex was done. This demonstrated all vessels in the liver being patent. A recipient liver donor biopsy demonstrated established cirrhosis, stage 4 fibrosis. Please see pathology report for further details. Nephrology consult was also obtained. Nephrology followed the patient in the immediate postoperative period, deferring hemodialysis with improvement of creatinine. He was extubated on [**5-9**]. [**2117**]. Vital signs were stable. He received the standard induction immunosuppression of CellCept 1 gram IV and 500 mg of Solu-Medrol. over the hospital course he continued on CellCept 1 gram PO b.i.d. with a Solu-Medrol taper per protocol. His protocol steroid taper was altered on postoperative day 10 for alteration of mental status which was initially noted in the surgical intensive care unit. The patient was confused. Neurology consult was obtained. He was inattentive. He was able to follow simple commands but these were sparse. Sedation was minimized. It was felt the patient had a metabolic derangement. He underwent an EEG to rule out seizure activity. No seizure activity was noted. A head CT was done. This was also negative. No evidence of intracranial hemorrhage or mass effect was noted. Head MRI was done as well with and without contrast. This demonstrated mild age inappropriate prominence of the sulci and ventricles. No acute infarct was noted. No mass effect or hydrocephalus was noted. No abnormal enhancement was noted. Altered mental status was attributed to steroids and his prednisone was decreased on postoperative day 10 to 15 mg. This was further decreased to 10 mg on postoperative day 12 with improvement in the patient's mental status. His speech was more fluent. He was more attentive and appropriate. Speech therapy consult was obtained for concerns for altered mental status. In summary, it was felt that the patient was experiencing a toxic metabolic insult. He did not have an expressive or receptive dysphagia. It was expected that the patient's communication abilities would return to baseline once medical issues were resolved. Given concerns for multifactorial confusion secondary to increased creatinine and decreased sodium, he did undergo a hemodialysis briefly on [**2118-5-10**]. His sodium remained in the 127 range. He underwent dialysis again on [**2118-5-11**]. His sodium gradually improved up to 132 with improvement in his creatinine to 1.9 without dialysis. Due to poor PO intake, a nutrition consult was obtained. TPN was started. [**Last Name (un) **] consult was obtained for management of hyperglycemia with improvement in mental status. The patient's oral intake improved and TPN was stopped. Physical therapy worked with him initially recommending rehab but with improvement in mental status. It was felt that the patient would be safe to be discharged to home or to family member's home. He was ambulatory in the hallway with supervision. The patient experienced significant weight gain and pedal edema. This was treated with IV Lasix with improvement of edema. He was switched to Lasix 20 mg PO once daily. His weight dropped down to 100.3 from preoperative weight of 114.1. He had two JP drains. These were removed and sutured and he experienced large volume output from the medial JP up to 2 liters per day. The JP drain was removed and the site sutured without further leaking his incision. A duplex of the abdomen was done on [**5-10**]. Patent hepatic and portal vessels were noted. Bilateral lower extremity non-invasive studies were done to evaluate edema. This was done on [**5-17**]. There was no evidence of DVT. On [**5-18**], a post-pyloric bleeding tube was placed for concerns that the patient would not be able to meet his caloric intake need. Unfortunately the patient pulled out his post-pyloric feeding tube during the night. This was not replaced given improved mental status. The patient was taking in at least 1800 Kcal the following day. Improved mental status was attributed to less steroids given. In summary, the patient has been in stable condition, ambulatory, tolerating a regular diet, his incision clips were opened at the top of the incision in his left lateral side for leaking of serosanguineous drainage. Normal saline damp to dry dressings were placed on the open areas b.i.d. His liver function tests improved with an AST of 22, ALT of 39, alkaline phosphatase 75, and total bilirubin of 0.8, creatinine was down at 1.9. His hematocrit was stable in the range of 25.2 to 27.3. Platelet count was 114. He continued on immunosuppression with CellCept, prednisone and Prograf which was adjusted. This was titrated to 1 mg PO b.i.d for a level of 17.9. Plan was to send the patient home and not to rehab given improved mental status. It is anticipated that he will be discharged home to his brother's home with follow up in the outpatient clinic. DISCHARGE MEDICATIONS: 1. Prograf 1 mg PO b.i.d. 2. Prednisone 10 mg PO once daily, started on [**5-18**]. 3. CellCept 1 gram PO b.i.d. 4. Protonix 40 mg PO once daily. 5. Bactrim single strength q Monday, Wednesday and Friday, renally dosed. 6. Valcyte 450 mg PO once daily. 7. Thiamine 100 mg PO once daily. 8. Folic acid 1 mg PO once daily. 9. Fluconazole 400 mg PO once daily. 10. Lasix 20 mg PO once daily. 11. NPH insulin 16 units s.c. q.a.m. and NPH 10 units s.c. q.h.s. with sliding scale regular insulin QID. DISCHARGE DIAGNOSES: 1. Alcoholic cirrhosis. 2. Hepatorenal syndrome. 3. Gastroesophageal reflux disease. 4. Hypertension. 5. Chronic renal insufficiency. 6. Status post orthotopic liver transplant on [**2118-5-7**]. 7. Glucose intolerance secondary to steroids. 8. Altered mental status secondary to steroids. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 62381**] Dictated By:[**Name8 (MD) 4664**] MEDQUIST36 D: [**2118-5-20**] 10:54:20 T: [**2118-5-21**] 00:21:10 Job#: [**Job Number 62382**] Name: [**Known lastname 11203**],[**Known firstname 33**] Unit No: [**Numeric Identifier 11204**] Admission Date: [**2118-5-5**] Discharge Date: [**2118-5-26**] Date of Birth: [**2061-1-21**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2800**] Addendum: He remained in the hospital for evaluation for a drop in hematocrit down to 22.1 for which he received 2 units of PRBC with increase 25.7. A hemolysis workup was done that revealed a haptoglobin <2 and ldh of 341. Heme/Onc was called to review case. It was felt that this was not hemolysis given negative coombs and no schistocytes seen on peripheral smear. Also, the t.bili was stable at 0.8. He remained in hospital pending his family being ready to take him home. On the last hospital day, his right leg appeared larger than the left leg. A non-invasive ultrasound was done to evaluate for dvt. No dvt was seen. He was discharged home in stable condition, ambulating and toleraterating a regular diet. Discharge Medications: 1. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day. 2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO four times a day. 3. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous daily in the morning. 11. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection four times a day: Fingerstick QACHSInsulin SC Fixed Dose Orders Breakfast NPH 10 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular 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 61-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-140 mg/dL 2 Units 0 Units 2 Units 0 Units 141-160 mg/dL 3 Units 0 Units 3 Units 0 Units 161-180 mg/dL 4 Units 0 Units 4 Units 0 Units 181-200 mg/dL 5 Units 3 Units 5 Units 0 Units 201-220 mg/dL 6 Units 5 Units 6 Units 2 Units 221-240 mg/dL 7 Units 7 Units 7 Units 3 Units 241-260 mg/dL 8 Units 8 Units 8 Units 4 Units 261-280 mg/dL 9 Units 9 Units 9 Units 5 Units 281-300 mg/dL 10 Units 10 Units 10 Units 7 Units > 300 mg/dL Notify M.D. Notify M.D. Notify M.D. Notify M.D. Ordered by [**Last Name (LF) **],[**First Name3 (LF) 441**] A., MD Beeper#: [**Numeric Identifier 11205**] on [**5-19**] @ 0915 . Disp:*1 100* Refills:*2* 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. syringes for insulin injection 1 box refill:2 14. Test stips 1 box refill:2 Discharge Disposition: Home With Service Facility: [**First Name9 (NamePattern2) **] [**Location (un) 5040**], [**Location (un) 11206**] Center [**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**] Completed by:[**2118-5-27**]

[ "E932.0", "303.03", "428.0", "789.5", "570", "572.4", "349.82", "276.1", "784.3", "574.10", "585.9", "571.2", "287.5", "530.81", "V13.01", "584.5", "286.7", "572.2", "401.9", "251.8" ]

icd9cm

[ [ [] ] ]

[ "96.6", "54.91", "51.22", "38.93", "00.93", "50.11", "38.95", "39.95", "99.15", "99.04", "50.59", "99.05", "89.64" ]

icd9pcs

[ [ [] ] ]

13062, 13344

9259, 10907

10930, 13039

1140, 2041

171, 225

254, 1117

2064, 2313

2626, 8702

53,372

190,467

2252

Discharge summary

report

Admission Date: [**2171-4-29**] Discharge Date: [**2171-5-2**] Date of Birth: [**2087-8-4**] Sex: F Service: MEDICINE Allergies: Ibuprofen Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is an 83 year-old woman with history of recent hospitalization with upper GI bleed found to have gastric AVMs, atrial fibrillation, thyroid cancer s/p thyroidectomy, hypertension, hyperlipidemia, osteoarthritis, and CAD s/p MI presenting with bright red blood per rectum starting this morning. She awoke from sleep at 1:30 AM to have bowel movement and had bright red blood mixed with dark stool. Patient had four episodes of BRBPR at home and came to ED. Pt also noted intermittent epigastric cramping. No nausea, vomiting, hematemesis. . Patient was discharged from [**Hospital1 18**], yesterday [**2171-4-28**] following hospitalization for BRBPR and melena secondary to upper GI bleed while on dabigatran for atrial fibrillation. Patient was admitted to MICU and received a total of 3 units PRBC for a transfusion goal of 30. She received vitamin K 10 mg PO for elevated INR and was started on PPI. An EGD showed multiple AVMs and gastritis and the AVMs were ablated. The ppi gtt was continued and plans were made for colonoscopy. She underwent colonoscopy which demonstrated no acute source for her bleeding. At discharge, anticoagulation was held. . Patient's hospitalization course was complicated by atrial fibrillation with tachycardia in 110s. She received metoprolol IV and diltiazem IV and her home oral medications were restarted. Patient was rate controlled prior to discharge. Patient's anticoagulation was held during admission and at discharge given GI bleed. . In the ED, initial vs were: P 100, BP 100/60 R 16 O2 98% on RA. Patient underwent NG lavage, which initally returned 10 - 15 cc of bright red blood (no coffee grounds) and then ran clear. Pt was noted to have 50 - 100 cc of bright red blood from rectum, no melena. Exam was notable for epigastric tenderness. Patient received 1 L NS and Type & Cross. She underwent non-contrast CT of abdomen to assess for perforation given recent colonsocopy. Labs were notable for a HCT of 37 (increased from 30 on discharge yesterday). On transfer HR 77, BP 97/62. . On the floor, patient is complaining of intermittent crampy abdominal pain, but has not has any further episodes of BRBPR since the ED. Past Medical History: * Coronary artery disease with MIs (?X3 in [**2119**]) * Hypertension * Atrial fibrillation: on digoxin in the past, now on dabigatran started ~[**2-/2171**] * Hyperlipidemia * Osteoarthritis * Cholecystectomy + ERCP in [**2163**] * Partial hysterectomy * Thyroid cancer s/p thyroidectomy and parathyroidectomy Social History: Worked at [**Location (un) 8599**]Hospital as nursing aide in the Alcoholics Unit for years. Retired, lives in retirement community. [**12-9**] glasses of wine/month (social), denies illicits. Remote history of tobacco (quit over 40 years ago). Has refused to ever have colonoscopy. Family History: Father had an MI in his 50s and died of renal cancer. Mother had an MI in her 40s. No family history of sudden cardiac death. Daughter died at 54 years old of liver cancer, brother died at 77 years old (4 years ago) of gastric cancer. No other family history of malignancies, IBD, celiac disease, blood dyscrasias. Physical Exam: On admission: Vitals: T: 95.6 BP: 101/73 P: 80 R: 20 O2: 94% on RA General: Alert, oriented, no acute distress HEENT: Pale, 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 On discharge: Vitals: T 96.5, HR 100, BP 123/80, RR 23, O2 Sat 94% on 3L General: Alert, oriented, no acute distress HEENT: Pale, 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, Ext: trace pitting edema Pertinent Results: ADMISSION LABS: [**2171-4-28**] 08:10AM BLOOD WBC-6.8 RBC-3.45* Hgb-10.3* Hct-30.9* MCV-89 MCH-29.7 MCHC-33.2 RDW-16.9* Plt Ct-196 [**2171-4-29**] 09:25AM BLOOD PT-13.5* PTT-23.6 INR(PT)-1.2* [**2171-4-28**] 08:10AM BLOOD Glucose-101* UreaN-14 Creat-1.2* Na-144 K-3.8 Cl-106 HCO3-29 AnGap-13 [**2171-4-29**] 09:25AM BLOOD ALT-27 AST-77* AlkPhos-59 TotBili-0.7 [**2171-4-29**] 02:19PM BLOOD CK-MB-4 cTropnT-<0.01 [**2171-4-30**] 03:07AM BLOOD cTropnT-<0.01 [**2171-4-30**] 12:44PM BLOOD CK-MB-3 cTropnT-<0.01 [**2171-4-28**] 08:10AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9 [**2171-4-29**] 08:06PM BLOOD Lactate-2.5* Discharge labs: [**2171-5-2**] 03:56AM BLOOD WBC-7.5 RBC-3.83* Hgb-11.6* Hct-34.2* MCV-90 MCH-30.3 MCHC-33.9 RDW-17.1* Plt Ct-244 [**2171-5-2**] 03:56AM BLOOD Glucose-114* UreaN-43* Creat-1.9* Na-139 K-3.7 Cl-107 HCO3-26 AnGap-10 [**2171-5-2**] 03:56AM BLOOD Calcium-8.1* Phos-4.5 Mg-2.6 CT ABDOMEN/PELVIS: IMPRESSION: 1. Edematous wall of a loop of distal small bowel and hazy mesentery is worrisome for ischemic bowel. No evidence of perforation. 2. Right adnexal cystic lesion with layering hyperdense free fluid in the pelvis. This suggests blood in the pouch of [**Location (un) **] and surrounding the cystic lesion; significance is uncertain in this postmenopausal patient. Suggest pelvic ultrasound or MRI for further evaluation. 3. Small left pleural effusion. 4. Large hiatal hernia with nasogastric tube in the stomach, above the level of the diaphragm. 5. Multiple cystic lesions in the kidneys bilaterally, some of which are not simple on this noncontrast examination. Recommend ultrasound on non-emergent basis for further evaluation if clinically indicated. Brief Hospital Course: 83 year-old woman with history of recent hospitalization for UGIB [**1-9**] gastric AVM, atrial fibrillation not on anticoagulation, hypertension, and CAD s/p MI presenting with BRBPR x 1 day. . #. Mesenteric ischemia: Patient initally presented with small amounts of bright red blood per rectum and epigastric pain. Hcts stable 30-37 during ICU course. Patient had no further episodes of BRPPR after admission. CT scan showed ischemic colitis. Patient likely either had a watershed infarct from self-limited upper GIB or embolic mesenteric infarct from atrial fibrillation and discontinuation of anticoagulation. The GI service wasd consulted and felt that she did not need an emergent endoscopic procedure. Surgery was not consulted as it was not consistent with patient's goals of care. She did not want to have surgical intervention. She was treated supportively with IVF and antibiotics and diet advanced prior to discharge. Patient will complete 10 day course of IV flagyl and IV cipro to be complete [**2171-5-8**]. . #. Acute renal failure: Patient's Cr increased to 2.3 from baseline .7. Began to decrease and was 1.9 on transfer to the floor. Most likely etiology ATN in the setting of acute volume loss. Patient was oliguric on admission, but urine output gradually picked up throughout hospitalization. . # Atrial fibrillation: Prior to recent upper GI bleed patient had been on dabigatran and aspirin, which were stopped during last hospitalization. Patient takes atenolol and nifedipine at home, anticoagulation stopped (dabigatran) on last admission. Patient in slow AFib currently with rates at 80. When patient stabilized, started metoprolol tartrate 12.5 [**Hospital1 **]. Atenolol was held because of poor renal function. Patient will follow-up with her cardiologist regarding re-starting anticoagulation in the future. . # Coronary artery disease: Patient with remote history of MI. No current chest pain. Pt with non-specific inferolateral ST changes. CE cycle negative. Continued simvastatin 20 mg daily and started metoprolol 12.5 mg [**Hospital1 **]. . # Hypertension: Pt was hypotensive on admission to the ICU. All home anti-hypertensive medications were held. Patient was normotensive on transfer from ICU. Started metoprolol tartrate 12.5 mg [**Hospital1 **]. Consider restarting lisinopril 10 mg daily if patietn's blood pressure tolerates. Titrate blood pressure medications as necesary. . # Hyperlipidemia: Continued Simvastatin 20. . # Thyroid cancer: Inactive, s/p thyroidectomy and reported in remission for years. . # Code: DNR/DNI (confirmed with patient and health care proxy) Medications on Admission: - Simvastatin 20 mg dialy - nitroglycerin 0.3 SL tab PRN - nitroglycerin 0.1 mg patch Q24H - atenolol 50 mg daily - lasix 60 mg qAM, 20 mg qPM - zolpidem 5 mg qHS PRN insomnia - pantoprazole 40 mg Q12H - nifedipine 120 mg Tablet ER daily - lisinopril 80 mg daily - clonidine 0.3 mg PO BID - Tylenol-Codeine #3 300-30 mg 1-2 Tablets PO Q6 PRN pain Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO twice a day. 3. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 6 days: Course to be complete [**2171-5-8**]. 4. ciprofloxacin 400 mg/40 mL Solution Sig: Four Hundred (400) mg Intravenous once a day for 6 days: Course to be complete [**2171-5-8**]. . 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 7. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual PRN as needed for chest pain: Please take 1 tab as needed for chest pain. 1 tab every 5 minutes, for up to 3 tabs in 15 min. . 8. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: PRIMARY: Mesenteric ischemia, bright red blood per rectum, hypotension, acute renal failure SECONDARY: Atrial fibrillation, coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure to participate in your care Ms. [**Known lastname **]. You were admitted to the hospital with abdominal pain and rectal bleeding. We found that you had inflammation in your colon that was likely because you did not get enough blood to your colon. We treated you with IV fluids and antibiotics and your symptoms improved. We also found that your kidneys were not working well, either because you were dehydrated or your blood pressure was too low. Your kidney function improved during your hospitalization. Please make the following changes to your medications: 1. Add cipro 400 mg IV BID - course will be complete [**2171-5-8**] 2. Add flagyl 500 mg IV Q8H - course will be complete [**2171-5-8**] 3. Start metoprolol tartrate 12.5 mg [**Hospital1 **] 4. HOLD lisinopril 80 mg daily for now - you will restart this medication as needed to control your blood pressure 5. HOLD nitroglycerin 0.1 mg patch Q24H - you will restart this medication as needed to control your blood pressure 6. HOLD atenolol 50 mg daily - you will restart this medication to control your heart rate when your kidney function improves (you are on metoprolol instead of atenolol at this time) 7. HOLD lasix 60 mg qAM, 20 mg qPM - you will restart this medication at rehab when your kidney function improves 8. HOLD nifedipine 120 mg Tablet ER daily - you will restart this medication as neede for hypertension 9. HOLD clonidine 0.3 mg PO BID - you will restart this medication as neede for hypertension Followup Instructions: You will follow-up with the physicians at the extended care facilities. Department: CARDIAC SERVICES When: TUESDAY [**2171-6-4**] at 12:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "530.81", "276.7", "401.9", "557.1", "715.90", "412", "414.01", "272.4", "584.9", "285.1", "V10.87", "427.31" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10278, 10344

6277, 8913

304, 310

10536, 10536

4568, 4568

12236, 12770

3202, 3521

9310, 10255

10365, 10515

8939, 9287

10712, 11267

5194, 6254

3536, 3536

4089, 4549

11296, 12213

236, 266

338, 2549

4584, 5178

3550, 4075

10551, 10688

2571, 2885

2901, 3186

72,000

189,157

47545+59011

Discharge summary

report+addendum

Admission Date: [**2176-10-24**] Discharge Date: [**2176-11-13**] Date of Birth: [**2096-8-17**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2176-10-31**] 1. Mitral valve replacement with a 33-mm St. [**Male First Name (un) 923**] Epic bioprosthesis. 2. Full left-sided Maze procedure using a combination of AtriCure bipolar Synergy RF device as well as CryoCath with resection of left atrial appendage. [**2176-10-31**] 1. Emergent coronary artery bypass grafting times 1 with reverse saphenous vein graft from aorta to the second obtuse marginal coronary artery. 2. Endoscopic greater saphenous vein harvesting. [**2176-11-8**] 1. Ultrasound-guided puncture of right common femoral artery. 2. Third-order catheterization of left superficial femoral artery. 3. Balloon occlusion of left superficial femoral artery. 4. Ultrasound-guided thrombin injection to the left superficial femoral artery pseudoaneurysm. 5. Angiography of left common femoral and superficial femoral arteries. [**2176-10-28**] Cardiac cath [**2176-10-30**] IABP insertion [**2176-10-31**] Cardiac cath History of Present Illness: 80 year old male with severe MVR w/pacemaker for sudden cardiac arrest presents with 3 days of worsening DOE and new onset of afib with RVR. He was seen by PCP and started on augmentin on [**2176-10-22**] for possible PNA, with possible infiltrate vs. pulmonary edema. Pt notes worsening dyspnea, with significant extertional dyspnea. Pt has also had a dry cough that started around Monday as well. He denies fever/chills/chest pain/hemoptysis/orthopnea/PND/extremity edema/pleuritic pain/calf pain. In the ED he was started on heparin gtt, given lasix 20mg IV, and Levoquin 500mg PO for possible PNA on CXR. He was admitted for further workup. Past Medical History: -PACING/ICD: [**Company 1543**] pacemaker, implanted on Right side, for sick sinus syndrome. Last interrogated in [**7-22**]. -Dyslipidemia -HTN -Mitral valve insufficiency -seizure disorder -left anterior wall acetabular fracture in [**2175**] -Prostate Ca -Colonic adenoma -rheumatoid arthritis -Anemia -Gout -subdural hematoma -lichen simplex chronicus Past Surgical History: s/p burr holes from SDH s/p pelvic fx Social History: Race: caucasian Last Dental Exam: [**4-22**] Lives with: wife Occupation: retired mechanical engineer Cigarettes: Smoked no [x] yes [] last cigarette Hx: Other Tobacco use: smoked pipe, quit [**2143**] ETOH: < 1 drink/week [] [**2-19**] drinks/week [x] >8 drinks/week [] Illicit drug use Family History: Non-contributory Physical Exam: Pulse:104 AF Resp:20 O2 sat: 95% ra B/P Right: 105/72 Left: Height: 70" Weight: 68.5 KG General: 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 [] grade ______ Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema [] __no___ Varicosities: None [x] very prominent bilat wrist bones Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [**10-25**] Head CT: 1. Small subacute subdural hematoma along the right tentorium and left frontal lobe. 2. Gliosis in the right frontal lobe likely secondary to prior trauma. . [**10-26**] Head CT: The subdural collection along the right tentorium and right frontal lobe seen yesterday is not appreciated today. Gliosis in the right frontal lobe is unchanged. Prominence of the ventricles and sulci is again noted which is likely secondary to age-related involutional changes. White matter hypodensity suggests sequela of chronic small vessel ischemic disease. There is no evidence for acute intracranial hemorrhage, large mass, mass effect, edema, or hydrocephalus. There is preservation of [**Doctor Last Name 352**]-white differentiation. The visualized portions of the mastoid air cells and paranasal sinuses are well aerated. No skull fracture is seen. Prior burr hole in the left parietal skull area is again noted. There is also a similar skull indentation along the left frontal convexity. . [**10-30**] Head CT: Thin subdural hematoma along the left frontal pole, with both chronic and subacute components, unchanged. . [**11-12**] Head CT: The small left frontal subdural hematoma, intermediate in density, is unchanged in size and demonstrates no evidence of new blood products. There is no mass effect on the underlying left frontal lobe, as the extraaxial spaces and ventricles are enlarged due to cerebral atrophy. A small area of encephalomalacia is again noted in the inferior right frontal lobe, likely secondary to prior trauma, or less likely prior infarction. There are multiple foci of low density in the deep and periventricular white matter of the cerebral hemispheres, as before, likely sequela of chronic small vessel ischemic disease. . [**10-28**] Cath: 1. Selective coronary angiography in this left dominant system demonstrated no angiographically apparent flow limiting stenoses. The LMCA, LAD, LCx, and RCA were patent. 2. Resting hemodynamics revealed mildly elevated right sided filling pressures with an RVEDP of 14 mmHg and severely elevated left sided filling pressures with a mean PCWP of 29 mmHg and a prominent V wave. There was moderate pulmonary artery systolic hypertension with a PASP of 48 mmHg. The cardiac index was depressed at 1.3 L/min/m2. There was low normal systemic arterial systolic pressures with an SBP of 100 mmHg. . [**10-28**] Carotid U/S: Right ICA less than 40% stenosis. Left ICA less than 40% stenosis. . [**2176-10-31**] Echo: PRE-BYPASS: The patient is AV paced, on norepinephrine, epinephrine, and milrinone infusions. No spontaneous echo contrast is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. The left atrial appendage is not seen status post ligation. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is regional left ventricular systolic dysfunction with severe hypokinesis of the inferior, inferoseptal, and inferolateral walls. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). The ascending, transverse and descending thoracic aorta are normal in diameter. There is an intra-aortic balloon pump in place 3 cm distal to the takeoff of the right subclavian artery. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The transmitral gradient is normal for this prosthesis. No mitral regurgitation is seen. The tricuspid valve leaflets are moderately thickened. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results at time of surgery. POST-BYPASS: The patient is AV paced. The patient is on norepinephrine, epinephrine, and milrinone infusions. Inferior, inferoseptal, and inferolateral wall hypokinesis appears improved, but remains mildly hypokinetic. No mitral regurgitation is seen. No change in tricuspid regurgitation or aortic regurgitation. The aorta is intact post-decannulation. . [**2176-11-1**] Echo: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis (LVEF = 45-50%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. Moderate (2+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2176-10-30**], left ventricular function is now mildly depressed and bioprosthetic aortic valve is now in place. . [**11-11**] CXR: Sternal cerclage wires are intact. A right-sided generator pack with lead position in the region of the right atria, and right ventricle appear stable. There is some increased aeration of the right lung base with decreased effusion and decreased consolidation and atelectasis. The right lung is clear. No pneumothorax is present. A left-sided PICC catheter tip appears stable in position in the mid SVC. A right IJ line has been removed. The mediastinum remains shifted to the left, stable. . [**2176-10-24**] 11:50AM BLOOD WBC-12.3*# RBC-3.88* Hgb-12.5* Hct-36.0* MCV-93 MCH-32.1* MCHC-34.7 RDW-13.6 Plt Ct-200 [**2176-10-30**] 01:10PM BLOOD WBC-11.9* RBC-4.12* Hgb-12.7* Hct-40.1 MCV-97 MCH-30.9 MCHC-31.7 RDW-13.5 Plt Ct-325 [**2176-10-31**] 01:39PM BLOOD WBC-19.2* RBC-3.24* Hgb-10.3*# Hct-31.8*# MCV-98 MCH-31.8 MCHC-32.4 RDW-13.8 Plt Ct-161 [**2176-11-1**] 02:38AM BLOOD WBC-14.5* RBC-3.57* Hgb-11.6* Hct-34.1* MCV-95 MCH-32.4* MCHC-33.9 RDW-14.8 Plt Ct-99* [**2176-11-6**] 02:05AM BLOOD WBC-12.8* RBC-4.27* Hgb-13.4* Hct-39.6* MCV-93 MCH-31.5 MCHC-33.9 RDW-15.8* Plt Ct-190 [**2176-11-11**] 06:08AM BLOOD WBC-13.8* RBC-3.57* Hgb-11.5* Hct-35.0* MCV-98 MCH-32.4* MCHC-33.0 RDW-15.0 Plt Ct-268 [**2176-11-12**] 05:21AM BLOOD WBC-12.2* RBC-3.57* Hgb-11.0* Hct-34.2* MCV-96 MCH-30.8 MCHC-32.1 RDW-14.6 Plt Ct-352 [**2176-10-25**] 06:00AM BLOOD PT-14.2* PTT-98.4* INR(PT)-1.2* [**2176-10-31**] 12:10PM BLOOD PT-17.4* PTT-35.2* INR(PT)-1.5* [**2176-11-9**] 12:45AM BLOOD PT-13.2 PTT-22.6 INR(PT)-1.1 [**2176-11-10**] 02:58AM BLOOD PT-15.3* PTT-25.2 INR(PT)-1.3* [**2176-11-11**] 06:08AM BLOOD PT-19.3* PTT-24.3 INR(PT)-1.7* [**2176-11-12**] 05:53AM BLOOD PT-29.6* INR(PT)-2.9* [**2176-10-24**] 11:50AM BLOOD Glucose-128* UreaN-30* Creat-0.9 Na-139 K-5.2* Cl-107 HCO3-20* AnGap-17 [**2176-10-31**] 02:34AM BLOOD Glucose-139* UreaN-51* Creat-1.0 Na-146* K-4.1 Cl-106 HCO3-29 AnGap-15 [**2176-11-11**] 06:08AM BLOOD Glucose-106* UreaN-26* Creat-0.8 Na-146* K-4.0 Cl-111* HCO3-28 AnGap-11 [**2176-11-12**] 05:21AM BLOOD UreaN-25* Creat-0.8 Na-143 K-4.2 Cl-108 [**2176-11-8**] 07:46PM BLOOD ALT-30 AST-47* LD(LDH)-442* AlkPhos-412* Amylase-48 TotBili-2.0* [**2176-11-11**] 06:08AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.0 [**2176-11-13**] 02:38AM BLOOD WBC-12.2* RBC-3.28* Hgb-10.5* Hct-31.8* MCV-97 MCH-31.9 MCHC-33.0 RDW-14.7 Plt Ct-307 [**2176-11-13**] 02:38AM BLOOD PT-26.9* INR(PT)-2.6* [**2176-11-13**] 02:38AM BLOOD UreaN-23* Creat-0.7 Na-138 K-3.6 Cl-105 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname **] is a 80 year old male with severe MVR w/pacemaker for sick sinus syndrome p/w 3 days of worsening DOE and new atrial fibrillation with RVR. He likely had a CHF exacerbation and afib in the setting of MV prolapse with severe regurgitation. . Pre-op Issues: # CHF exacerbation: BNP 8563 on [**10-24**]. Received 20 mg IV Lasix in ED, 20 mg IV Lasix on the floor, and 40 mg IV Lasix x2. Was placed on Lasix 80 mg [**Hospital1 **] on [**10-25**] with initial good UOP with net negative on [**10-26**] of 1.5 L which decreased to ~700 ml net negative on [**10-27**] and then fell to net negative 175 ml on [**10-28**] and on [**10-29**] Lasix drip ([**5-26**] ml/ hr) was initiated to titrate to goal net negative of [**1-13**].5L daily. Pts sats dropped on the am of [**10-30**] with possible flash pulmonary edema. Bedside echo noted worsening mitral regurgitation and significant tricuspid regurg and the decision was made to transfer the pt to the CCU, where he was electively intubated. He was taken to the Cath Lab, where an intra-aortic balloon pump was placed in preparation for surgical mitral valve repair. . # New onset afib observed [**10-24**]. Rate has been better controlled since admission and remained in the low 100s with metoprolol tartrate 50 mg [**Hospital1 **]. TSH WNL. CHADS2 score was 3; anticoagulation was continued with heparin gtt, holding off on Coumadin now due to possibility of surgery. . # Mitral valve insufficiency: Initial presentation was likely [**2-14**] progression of MV dz, or rupture of chordae, mitral valve prolapse. TEE showed severe mitral regurgitation secondary to posterior leaflet flail, no thrombus. . # CORONARIES: Troponins and CKMB have been flat. Cycle enzymes to ROMI and they remained negative. Cardiac cath prior to surgery to eval for CAD showed no coronary artery disease. . # Small sub acute left frontal subdural hematoma secondary to fall 2 months: Neurosurgery consulted. Underwent several Head CT's prior to surgery. Resolved. No Urgent or Emergent Neurosurgery needed. [**Month (only) 116**] restart Heparin gtt and Aspirin. Safe for Coumadin therapy if required. Follow up in the [**Hospital 4695**] Clinic in 4 weeks with a Non Contrast Head CT with Dr [**Last Name (STitle) 739**]. . # Leukocytosis: WBC 12.3 and 88% PMNs on [**10-24**]. CXR [**10-24**] shows no acute process and pt was afebrile with no cough and satting well albeit DOE. Lactate 1.6 on [**10-24**]. There was low suspicion for PNA and so Levaquin which was started in the ED was discontinued. WBC remained elevated in the 11-12,000 range with left shift but pt was afebrile from admission to [**10-30**] when he was transferred to ICU. Op/Post-op course: Cardiac surgery recommended Mitral valve replacement and MAZE and he underwent appropriate work-up for surgery. On [**10-31**] he was brought to the operating room where he underwent a mitral valve replacement and MAZE procedure. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in fair condition. Initially on transfer to the CVICU, patient required multiple Inotropes and Vasopressor support with an extremely low mixed venous SaO2 at 48% and cardiac index of 1.5 with on Epinephrine and Levophed. A transesophageal echo demonstrated inferior wall motion abnormalities and when the patient was not being paced, there were ST elevations in the inferior leads. He was taken emergently to the cath lab which demonstrated total occlusion in the mid circumflex distribution after a big dominant obtuse marginal coronary artery had taken off from the main circumflex and very near the cuff of the mitral valve as seen by the radiographic images. The interventional cardiologist attempted to cross the obstructed vessel to intervene but was unsuccessful. He was therefore transferred to the operating room and underwent emergent coronary artery bypass grafting with saphenous vein graft to the distal circumflex system. Following this he was transferred back to the CVICU again for invasive management. On this day his IABP was removed. Over the next several days he remained sedated and intubated, pressors were slowly weaned and Amiodarone and Coumadin were started for atrial fibrillation. He was finally weaned from sedation, awoke mostly neurologically intact but slightly disoriented and extubated on post-op day four. Electrolytes were repleted as needed, beta-blockers and diuretics were started and he was diuresed towards his pre-op weight. Over the next couple of days he was stable but remained somewhat confused but cooperative. On post-op day six he was noted to have increased ecchymosis and swelling in his left groin and was found to have a left femoral artery pseudoaneurysm. Vascular surgery was consulted. On [**11-8**] he underwent repair of his pseudoaneurysm with thrombin injection to the left superficial femoral artery pseudoaneurysm. Following this procedure he was transferred back to the CVICU for monitoring. Chest tubes and epicardial pacing wires were removed per protocol. On post-op day ten he was transferred to the step-down floor for further care. Of note, he was being treated for a stage 1 blanchable stage 1 coccyx ulcer. Over the next couple days he continued to improve with resolving delirium and working with physical therapy for strength and mobility. On post-op day twelve he was going to be discharged to rehab but became slightly lethargic in later AM. Neurology was consulted and a stat head CT was performed. Head CT was negative for acute event, his mental status improved on reexamination in afternoon and appeared to be back at baseline. Neurology felt that the event may have been a seizure. Overnight he complained of inability to void, Flomax was started, Foley catheter was inserted and output was 450cc. UA and culture were sent. On the POD 13 he was doing well, neurologically intact and was discharged to rehab facility ([**Hospital3 2558**]) with the appropriate medications and follow-up appointments. Foley will remain in place and will need a voiding trial done at rehab. Cipro was started prophylactically for possible urinary tract infection (pending UA with recent valve surgery). Medications on Admission: -PHENYTOIN SODIUM EXTENDED 100 MG CAP: take 1 capsule every morning and 2 capsules every evening -CHOLECALCIFEROL (VITAMIN D3) 1,000 UNIT TAB, 1 daily -MVI daily -ASA 81mg daily -Glucosamine Hcl oral Discharge Medications: 1. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. phenytoin sodium extended 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 3. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. glucosamine HCl 500 mg Tablet Sig: One (1) Tablet PO once a day. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Please take 2 200mg tablets twice daily for 5 days. Then 1 200mg tablet twice daily for 7 days. Then 1 200mg tablet once daily until stopped by cardiologist. 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. warfarin 1 mg Tablet Sig: 1-2 Tablets PO once a day: Adjust for a goal INR of [**2-14**].5 for atrial fibrillation. Coumadin held [**11-12**] d/t INR of 2.9. 12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 15. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 16. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Please d/c when Foley is removed. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: New-onset atrial fibrillation s/p MAZE procedure Mitral valve insufficiency s/p mitral valve replacement Occluded mid circumflex artery s/p coronary artery bypass graft x 1 Pseduoaneurysm left femoral s/p repair ?Post-op urinary tract infection Heart failure exacerbation Sick sinus syndrome Dyslipidemia Hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema - Trace lower ext, 1+ Upper ext Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) 100511**] on [**2176-12-16**] at 2PM Cardiologist: Dr. [**Last Name (STitle) 19**] on [**12-3**] at 2:50pm Neurosurgery: Dr. [**Last Name (STitle) 739**] on [**2176-12-18**] at 11AM at [**Hospital Unit Name **], [**Last Name (NamePattern1) **]., [**Hospital Unit Name 12193**] Non-Contrast Head CT on [**12-18**] at 10am at [**Hospital1 **], [**Location (un) **] [**Location (un) 470**] radiology Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30186**] [**Telephone/Fax (1) 3530**] in [**4-16**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication: Atrial fibrillation Goal INR 2-2.5 First draw [**2176-11-14**] Completed by:[**2176-11-13**] Name: [**Known lastname 16149**],[**Known firstname **] Unit No: [**Numeric Identifier 16150**] Admission Date: [**2176-10-24**] Discharge Date: [**2176-11-13**] Date of Birth: [**2096-8-17**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1543**] Addendum: Neurology saw the patient and recommended that he get an outpatient EEG and follow up with his primary care and a neurologist. I contact[**Name (NI) **] Dr. [**Last Name (STitle) 16151**] and conveyed these recommendations. Discharge Disposition: Extended Care Facility: [**Hospital3 901**] - [**Location (un) 382**] [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2176-11-13**]

[ "427.31", "442.3", "998.12", "E878.1", "432.1", "996.72", "424.0", "272.4", "V45.01", "416.8", "274.9", "584.9", "185", "345.90", "V58.61", "428.33", "401.9", "428.0", "707.21", "997.5", "698.3", "429.5", "707.03", "785.51", "293.0", "410.71", "997.2", "714.0", "997.1" ]

icd9cm

[ [ [] ] ]

[ "35.32", "37.61", "96.72", "37.21", "88.48", "96.6", "37.36", "88.56", "39.61", "99.29", "35.23", "88.72", "36.11" ]

icd9pcs

[ [ [] ] ]

22302, 22534

10916, 17178

319, 1260

19526, 19776

3435, 3447

20699, 22279

2697, 2715

17428, 19072

19186, 19505

17204, 17405

19800, 20676

2335, 2374

2730, 3416

272, 281

1288, 1934

4587, 10893

1956, 2312

2390, 2681

24,981

180,109

48252

Discharge summary

report

Admission Date: [**2195-1-31**] Discharge Date: [**2195-2-6**] Date of Birth: [**2121-4-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Melena Major Surgical or Invasive Procedure: EGD History of Present Illness: Mr [**Known lastname **] is a 73 y.o. M with history of squamous CA of the soft palate (T2N0)- s/p XRT/chemo in [**2192**]- now presenting with 3 days of black stools. Pt was feeling well until Thursday when he noticed very mild nausea and 2 episodes of black stool. He had 2-3 episodes of black stool on Friday, and then awoke on Saturday AM feeling so weak that he could barely stand. +LH/SOB. Additional black BM --> called 911-> [**Hospital1 18**]-[**Last Name (un) 4068**]. . At OSH ED, he was noted to have HCT of 10 and coffee grounds that didn't fully clear on NG lavage. BP at [**Last Name (un) 4068**] dropped to the 80s, with tachycardia to the 120s- he received several liters of fluid and two units of O-negative blood. Received dose of nexium- sent to [**Hospital1 18**]. . Takes ASA/plavix but denies other NSAIDs. Notes ?prior ulcer bleed many years ago. . In the [**Hospital1 18**] ED he was seen by GI, who lavaged bright red blood but unable to clear it. He was transfused 2u pRBCs for a hct of 23. SBP were stable at 130-140s. Past Medical History: 1. soft palate squamous CA diagnosed in [**2191**], T2NO- s/p XRT/[**Doctor Last Name **]/taxol completed in [**12-7**]. Prior G-tube. No evidence of recurrence on recent laryngoscopy by ENT in [**8-9**]. Proximal esophageal dilation procedure for UES stricture on [**9-7**]. - complicated by hospitalization for pna and chf - followed by Dr. [**Last Name (STitle) 101673**] (ent) and rad-onc 2. Prior EGD [**10-7**] during PEG placement- noted gastritis and ?duodenal varices 3. carotid stenosis- s/p carotid stenting to R-side in [**11-8**] 4. HTN 5. MCA aneurysm s/p L craniotomy [**2176**] Social History: Retired florist. He lives alone in [**Location (un) 620**]. Family involved. 50pkyrs, quit 8weeks ago. Reports heavy ETOH in the past, quit 15years ago. Family History: Father with AML Physical Exam: MICU admission PE: Physical Exam: 98.8 92 137/58 99% 2LNC NAD- alert and conversent very dry mucous membranes, edentulous RRR, distant S1S2 lungs clear abdomen soft- no hepatosplenomegaly on my exam, well healed PEG tube site per GI: rectal with trace amount of melena in otherwise empty vault no peripheral edema, 1+ pulses, warm Brief Hospital Course: . # UGIB: Pt was found with a HCT of 10 at [**Hospital 4068**] Hospital and coffee grounds that didn't fully clear on NG lavage. His BP at [**Last Name (un) 4068**] dropped to the 80s, with tachycardia to the 120s. He received several liters of fluid and two units of prbcs. He was subsequently transferred to [**Hospital1 18**] where he was evaluted by GI and lavaged bright red blood taht could not be cleared. He was transfused 2 additional units of prbcs for a hct of 23. SBP were stable at 130-140s. He had an EGD on the night of admission which did not show a clear source of bleed. In addition there was an initial question of duodenal varices. He was then transferred to the ICU for closer monitoring and started on a PPI gtt. Had abdominal ultrasound with dopplers which was unremarkable and without evidence of portal hypertension making duodenal ulcers unlikely. He then had a repeat EGD which showed folding in the duodenum likely accounting for intial concern of varices. It did show duodenal ulcer. Pt subsequently had a stable Hct and was transferred to the floor. His PPI was changed to an oral PPI. He underwent a colonoscopy which showed diverticui in the sigmoid and descending colon as well as internal hemorroids. Given that there was still a concern that the source of bleed was not found, he had a capsule endoscopy (placed via EGD). The capsule study was not capturing but during the procedure but he was found to have a small bleeding AVM that was clipped and cauterized. Thus it was felt his bleed could have been due to this AVM and further pursuit of a capsule study during this hospitalization was felt unneccessary. His diet was subsequently advanced. His Hct remained stable. He was discharged with instructions that GI would be in touch in case they were indeed able to capture the study as hoped and if he needed additional follow up as an outpatient. . # Cardiac/HTN: Pts Metoprolol and ACE were intially held but restarted once his Hct and BP were stable. . # Carotid stent/atherosclerosis: Both the pts asa/plavix were initially held in setting of bleed. [**Hospital1 **] surgery was following and wanted pt to be restarted as soon as possible however given bleed they were not restarted. His asa was restarted at 81mg daily on hospital day #2 but plavix not restarted before discharge as it was felt to be too high of a risk. The patient will follow up with his PCP and will likely need to restart his medication in [**6-11**] days as long has his Hct is stable and he does not have further signs of bleeding. His PCP was [**Name (NI) 653**] via letter to let him know that the plavix had been held and would need to be restarted. . #Fever-Pt had a fever to 101.9 2 days prior to discharge. He was asymtomatic and did not have an elevation in his WBC. A U/A was negative, blood cultures were sent (NGTD on day of discharge) and a CXR showed no evidence of infiltrate. No further intervention felt necessary. Medications on Admission: Medications: asa 81mg plavix 75 lisinopril 20mg Daily metoprolol XL 25mg daily prevacid (ran out 3 days ago, was being transitioned to nexium) zocor 20mg QD Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. 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* 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Diverticulosis Duodenal Ulcer AVM . Secondary HTN Squamous cell CA of soft palate s/p XRT/Chemo Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital because you were found to have a low blood count and had some bleeding from your colon. You received 2 Units of blood while you were here. You had some procedures done to identify the site of bleeding. You have an ulcer in your stomach and were started on a medication called Pantoprazole to help reduce stomach acid. In addition you were found to have some diverticuli in your colon as explained while you were here which likely contributed to the bleed. . Your Plavix was held because it causes thinning of your blood and makes the bleeding worse. You will need to continue to hold this medicine until you follow up with your primary care doctor. You can continue your aspirin. . If you have any ongoing lightheadedness, dizziness, bleeding from below, chest pain or shortness of breath, please call your doctor or return to the ER. . Please follow up as below. Please call and make an appointment with. Dr [**Last Name (STitle) **]. He was notified that you were hospitalized and he will try to get you in to see him in the next few weeks. If you don't hear from him by Monday please call his office to make an appointment. Followup Instructions: Please follow up with your PCP DR [**Last Name (STitle) **]. Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2195-3-9**] 8:45 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1953**], [**Name12 (NameIs) 280**] Date/Time:[**2195-3-24**] 9:20 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2195-6-9**] 11:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "401.9", "455.0", "V10.02", "288.50", "285.1", "532.90", "537.83", "562.10", "569.84", "433.10", "428.0" ]

icd9cm

[ [ [] ] ]

[ "44.43", "99.04", "45.43", "45.13" ]

icd9pcs

[ [ [] ] ]

6307, 6313

2600, 5563

319, 324

6453, 6462

7676, 8259

2211, 2228

5770, 6284

6334, 6432

5589, 5747

6486, 7653

2277, 2577

273, 281

352, 1405

1427, 2023

2039, 2195

745

162,004

4858

Discharge summary

report

Admission Date: [**2202-3-22**] Discharge Date: [**2202-5-3**] Date of Birth: [**2142-6-14**] Sex: M Service: [**Last Name (un) **] The patient is a 59 year old, diabetic male status post renal transplant in [**2196**] and right THR in [**2197**], who was admitted from an outside hospital on the 26th with approximately seven days of right hip pain and chills. At that time the patient also had an increasing creatinine with right upper quadrant tenderness on exam. At the outside hospital the patient was also diagnosed with MRSA bacteremia. A right upper quadrant ultrasound revealed a 1.5 cm CBD with stone. Upon initial consultation, the renal service felt that the patient's worsening creatinine was consistent with ATN with question of FK toxicity. The patient was intubated on [**3-24**] for airway protection. The patient had fluoro guided aspiration of the right hip on the 28th and 29th. He had an ERCP performed on [**3-26**], hospital day five, for removal of CBD stone. An MRI on hospital day five also revealed iliopsoas bursitis. As a result, the orthopaedic service was consulted and removed the right hip prosthesis and replaced it with a Girdlestone on hospital day eight. The patient was in the SICU on a ventilator and was getting nutrition by tube feeds. Significant events while on the unit were continued fevers. On hospital day 11 the patient had a postpyloric feeding tube placed and Zosyn was started for t-max of 100.7 and a white count of 17.9, trending down to 16.6. Also with positive sputum cultures growing out GNR. By hospital day 15 the patient's creatinine had improved back to 2.5. However, he began to exhibit profound weakness and cogwheel rigidity. As a result, the question of some sort of neurologic deficit was raised and a workup was begun. On hospital day 15 EEG was performed which revealed diffuse encephalopathy without seizures. EMG was also performed and revealed severe generalized polymyopathy. No clear polyneuropathy with no clear evidence of myopathy. Central dysfunction seemed to be the cause or major source of weakness. On hospital day 16 the patient had a tracheostomy placed due to his dependent ventilation needs. The patient was seen by neurology on hospital day 18. The impression was patient with evidence of encephalopathy and severe sensory motor polyneuropathy on the background of staph bacteremia. Their impression was that this was likely secondary to acute problems including infection, renal failure and medications. However, no definitive cause was identified. Patient was continued on his regimen of medications. Meanwhile, the patient's renal function had continued to improve with his creatinine dropping down to 2.0. However, the patient continued to have low grade fevers and workup was continued. On hospital day 20 the patient had coffee ground emesis aspiration. As a result the patient was placed back on the vent. Pancultures were started. Tube feeds were held. The patient ending up spiking to 102.7. The patient's operative site where the Girdlestone was performed was deemed to be erythematous and full. It was hypothesized that a possible tap would make sense, however, due to the patient being on broad spectrum antibiotic coverage, it was decided to take a wait-and-see approach. On hospital day 23 the patient had a PEG placed and continued to spike some low grade temperatures. However, the wound site began to improve on its own and became less suspicious. As a result, it was decided to not intervene at that time. The patient continued to spike fevers and with cultures pending. The patient's medications were titrated as well, however, his white count was 11.2 on hospital day 28 with no other signs or symptoms of infection. Due to concern for fluid collection, thoracentesis was performed on the right lung which revealed 900 cc. Chest x-ray was negative for pneumo, however, the patient had fungemia as a result and was started on fluconazole on hospital day 29. On hospital day 31 an ophtho consult was sought to rule out any ophthalmologic involvement, which was the case. The patient continued on fluc. Amphotericin B was held off to treat the candidemia. On hospital day 34 the patient was taken up to the floor. The patient received aggressive P.T. and O.T. therapy while on the floor. He was also screened for rehab. On hospital day 43 the patient will be discharged to an acute rehab hospital. DISCHARGE MEDICATIONS: 1. Prednisone 5 mg tabs, one tab p.o. q.d. 2. Miconazole powder one application q.i.d. 3. Hydralazine 25 mg tabs, one tab p.o. q.six hours. 4. Lopressor 50 mg tabs, one tab p.o. b.i.d. 5. Lansoprazole 30 mg capsule, one capsule delayed release p.o. b.i.d. 6. Tylenol 325 mg tabs, one to two tabs sig. p.o. q.four to six hours p.r.n.. 7. Clonidine 0.1 mg per 24 hour patch, one patch weekly transdermal q.Saturday. 8. Amlodipine 5 mg tabs, two tabs p.o. q.day. 9. Albuterol nebs. 10. Hydromorphone 4 mg tabs, one tab p.o. q.four to six hours p.r.n. 11. Citalopram 20 mg tabs, 0.5 tab p.o. q.day. 12. Tacrolimus 0.5 mg capsule, one capsule p.o. b.i.d. 13. Sirolimus 1 mg per ml solution, sig. 0.5 ml p.o. q.day. 14. Fluconazole 200 mg per 100 ml piggyback, sig. 100 ml IV q.24. 15. Furosemide 10 mg per ml solution, 4 ml injection b.i.d. 16. Vanco 10 gm recon solution, sig. 1 gm recon solution IV for a dose less than 15 of vanco level. The patient will follow up with Dr. [**Last Name (STitle) 15473**] at 1:00 p.m. on [**5-12**] in clinic. DISCHARGE DIAGNOSES: Sepsis. Infected orthopaedic hardware status post removal. Status post CRT. MRSA bacteremia. Hypertension. CAD. GERD. Hypercholesterolemia. Herpes zoster. IDDM. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 16773**] Dictated By:[**Doctor Last Name 13307**] MEDQUIST36 D: [**2202-5-3**] 14:30:46 T: [**2202-5-3**] 15:54:12 Job#: [**Job Number 20295**]

[ "250.51", "996.81", "996.62", "250.61", "996.67", "038.11", "112.5", "511.9", "711.05" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "81.91", "51.88", "43.11", "96.04", "96.72", "31.1", "34.91" ]

icd9pcs

[ [ [] ] ]

5613, 6043

4489, 5591

26,509

177,614

18587

Discharge summary

report

Admission Date: [**2121-3-11**] Discharge Date: [**2121-3-14**] Date of Birth: [**2059-9-1**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 61-year-old female, who underwent a gastric bypass surgery for the treatment and management of morbid obesity. The patient underwent laparoscopic gastric bypass on [**2121-3-11**]. The procedure was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and there were no complications during the surgery. Patient tolerated the procedure without any difficulty. Following the procedure, the patient was unable to be intubated secondary to low tidal volumes and weakness. The patient was brought to the PACU intubated. Patient initially failed her spontaneous ventilation trial. The patient remained intubated overnight and was extubated approximately eight hours after returning to the recovery room. Following extubation, the patient had no further pulmonary issues and was stable enough to go to the floor. Postoperatively, the patient had no complications during her postoperative period. Was able to tolerate Stage II diet without any difficulty. Her Foley was D/C'd on postoperative day number two, and the pain was well controlled on Roxicet. By postoperative day number three, the patient continued to have an uneventful postoperative course. Was passing bowel movements and flatus, and was tolerating her Stage III diet without difficulty. Her [**Location (un) 1661**]-[**Location (un) 1662**] drain was removed, and the patient was discharged to home. DISCHARGE DISPOSITION: Patient was discharged to home, and asked to followup with Dr. [**Last Name (STitle) **] within two weeks. The patient was instructed to please call Dr.[**Name (NI) 20848**] office for this appointment. DISCHARGE DIAGNOSES: 1. Status post laparoscopic gastric bypass. 2. Morbid obesity. 3. Hypertension. 4. Diabetes mellitus. 5. Coronary artery disease. 6. Status post coronary artery bypass graft times three. 7. Gastroesophageal reflux disease. 8. Rheumatoid arthritis. 9. Depression. DISCHARGE MEDICATIONS: 1. Avandia 4 mg p.o. q.d. 2. Aspirin 81 mg p.o. q.d. 3. Diovan 80 mg p.o. b.i.d. 4. Lipitor 10 mg p.o. q.d. 5. Lasix 20 mg p.o. q.d. 6. Zantac 150 mg p.o. b.i.d. 7. Paxil 30 mg p.o. q.d. 8. Naprosyn 500 mg p.o. b.i.d. 9. Actigall 300 mg p.o. b.i.d. for six months. 10. Roxicet [**5-12**] mL p.o. q.4-6h. prn pain. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-331 Dictated By:[**Last Name (NamePattern1) 19938**] MEDQUIST36 D: [**2121-5-15**] 10:37:01 T: [**2121-5-16**] 11:08:55 Job#: [**Job Number 51057**] cc:[**Last Name (NamePattern4) 39276**]

[ "401.9", "250.00", "311", "272.0", "V45.81", "278.01" ]

icd9cm

[ [ [] ] ]

[ "44.31" ]

icd9pcs

[ [ [] ] ]

1599, 1804

1825, 2090

2113, 2706

160, 1575

14,664

101,857

30787

Discharge summary

report

Admission Date: [**2140-7-16**] Discharge Date: [**2140-8-5**] Date of Birth: [**2095-12-26**] Sex: F Service: MEDICINE Allergies: Macrodantin / Heparin Agents Attending:[**First Name3 (LF) 1377**] Chief Complaint: Transfer from [**Hospital3 **] for variceal bleeding. Major Surgical or Invasive Procedure: EGD Dobhoff Post-Pyloric Feeding Tube History of Present Illness: Ms. [**Known lastname **] is a 44yo F with ETOH abuse, HCV, h/o IVDA presented to OSH with intermittent hematemasis and on [**2140-7-14**] is for TIPS. Pt has been having black tarry stools and hematemasis since [**2140-7-11**]. At OSH, initial hct 31, INR 1.9, TB 3.2, AST 99, ALT 41, alk phos 99,plt 43,000, ETOH 173. Pt was given vitamin K 10mg SC and was admitted and started on octreotide. Pt received 2 units PRBC for hct 25.9 and 6 bags of platelets for platelets of 37K on [**7-15**]. Pt underwent EGD [**7-15**] and showed 4 grade [**3-12**] distal esophageal varices, which were banded and there was a concern for a couple of gastric varices. On day of admission, she had 400cc of melanotic stools with clots, and her hct was noted to have dropped from 33.5 to 18 with SBP in 70s. Pt was given 4 units PRBC, central line placed and was transferred to [**Hospital1 18**] for TIPS. . Currently, denies any n/v, abdominal pain, chest pain, or sob. Past Medical History: 1. Hepatitis C 2. DM II c/b neuropathy 3. EtOH abuse 4. Tobacco abuse 5. h/o IVDA quit more than 20 years ago Social History: h/o IVDA 20 years ago, drinks 2 glasses of wine daily, + smoking. Family History: non-contributory Physical Exam: PE: 100.6, 82, 62/46, 14, 97% on RA, CVP 4 GEN: AOx 3, answering questions appropriately HEENT: + scleral icterus, PERRL, EOMI, No JVD appreciated. Skin: jaundiced CV: RRR without m/r/g LUNGS: CTA bilat, no wheezes, rhonchi, crackles. ABD: obese, hypoactive BS, NT. EXT: palpable pulses bilaterally. No edema Neuro: AOx 3, CN II to XII grossly intact. moving extremities. grossly normal sensation to touch. No asterixis. Pertinent Results: [**2140-7-16**] 10:03PM GLUCOSE-176* UREA N-20 CREAT-0.6 SODIUM-144 POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-22 ANION GAP-16 [**2140-7-16**] 10:03PM CALCIUM-8.0* PHOSPHATE-4.3 MAGNESIUM-2.7* [**2140-7-16**] 10:09PM LACTATE-4.3* [**2140-7-16**] 10:09PM TYPE-[**Last Name (un) **] PO2-47* PCO2-48* PH-7.32* TOTAL CO2-26 BASE XS--1 [**2140-7-16**] 10:03PM HCT-30.8*# [**2140-7-16**] 07:53PM HGB-8.8* calcHCT-26 [**2140-7-16**] 06:43PM HGB-9.1* calcHCT-27 [**2140-7-16**] 04:26PM LACTATE-3.4* [**2140-7-16**] 03:39PM WBC-4.5 RBC-2.35*# HGB-8.2*# HCT-21.9* MCV-93 MCH 34.8* MCHC-37.3* RDW-19.0* [**2140-7-16**] 03:39PM PLT COUNT-114*# [**2140-7-16**] 02:49PM HCT-25.2*# [**2140-7-16**] 11:11AM GLUCOSE-128* UREA N-23* CREAT-0.6 SODIUM-145 POTASSIUM-4.3 CHLORIDE-113* TOTAL CO2-20* ANION GAP-16 [**2140-7-16**] 11:11AM ALT(SGPT)-35 AST(SGOT)-109* LD(LDH)-263* ALK PHOS-65 AMYLASE-30 TOT BILI-10.4* [**2140-7-16**] 11:11AM LIPASE-20 [**2140-7-16**] 11:11AM WBC-7.6 RBC-3.70* HGB-12.1 HCT-34.0* MCV-92 MCH-32.6* MCHC-35.5* RDW-19.0* [**2140-7-16**] 11:11AM NEUTS-75.5* LYMPHS-18.4 MONOS-5.8 EOS-0.1 BASOS-0.3 [**2140-7-16**] 11:11AM PLT SMR-VERY LOW PLT COUNT-57* [**2140-7-16**] 11:11AM PT-23.9* PTT-43.2* INR(PT)-2.4* . Imaging at OSH: Liver u/s with doppler: Coarse echogenic liver, suggestive of fatty liver but cannot exclude a micronodular cirrhosis in the appropriate clinical setting. Mild splenomegaly. patent portal vein. no vevidence of varices or portal hypertension. A small amount of ascites. 14.cm echotextures. Spleen 13.8cm. . CXR [**2140-7-16**]: RSC in SVC. No acute cardiopulm processes. . Abdominal ultrasound [**2140-7-18**]: IMPRESSION: Very limited study. TIPS stent is patent but velocities could not be obtained due to respiratory motion and therefore satisfactory baseline data could not be obtained. . Feeding tube placement [**2140-7-20**]: IMPRESSION: Successful placement of post-pyloric feeding tube in the fourth portion of the duodenum. . Abdominal Ultrasound [**2140-7-29**]: IMPRESSION: 1. Patent TIPS with slightly increased velocities. 2. New 4 cm echogenic wedge-shaped structure in the right lobe. Given its development since examinations of 9 and 11 days ago, it is unlikely to be a mass, however, MRI can be performed on a nonemergent basis for further characterization. 3. Slight increase in ascites. . Portable CXR [**2140-7-31**]: There has been interval extubation and removal of right-sided vascular catheter and sheath. Right PICC line has been placed, terminating in the proximal superior vena cava. Cardiac silhouette is upper limits of normal in size allowing for low lung volumes. Previously present mild pulmonary edema has resolved. There is improved aeration in the left retrocardiac region with residual patchy opacity containing several air bronchograms. Although possibly due to resolving atelectasis and dependent edema, infectious pneumonia is also possible in the appropriate setting. Minor right basilar atelectasis is noted as well as a possible small right pleural effusion. . Renal U/S [**2140-7-31**]: FINDINGS: The right kidney measures 12.2 cm and the left 11.2 cm. The renal parenchymal thickness and echogenicity are normal. There is no evidence of hydronephrosis or calculi. Small amount of ascites is noted. . IMPRESSION: Unremarkable renal ultrasound. . EGD [**2140-8-3**]: IMPRESSION: 1. A feeding tube passing into duodenum was noted. No significant varices noted in esophagus. Granularity, friability, erythema, congestion, abnormal vascularity and mosaic appearance in the whole stomach 2. Duodenum was not entered due to the feeding tube. No bleeding noted in stomach. 3. Otherwise normal EGD to second part of the duodenum. Brief Hospital Course: # Alcoholic Cirrhosis/Acute Alcoholic Hepatitis: Admitted to [**Hospital3 **] from outside hospital after recent variceal bleed s/p variceal banding. Here, repeat EGD was performed which showed previously banded esophageal varices and gastric varices with stigmata of recent bleeding. No new bands placed. Subsequently underwent uncomplicated TIPS on [**2140-7-16**]. Completed 5 day course of octreotide and 7 day course of levofloxacin for SBP prophylaxis. Unfortunately, patient continued to decompensate, with rising bilirubin and INR. She was treated with lactulose and rifaximin for encephalopathy. Ultrasound [**7-18**] and [**7-20**] both showed patent TIPS. . Given rising bili/INR, she was given a trial of pentoxyfilline and ursodiol for suspected acute alcoholic hepatitis. Corticosteroids not given because of recent bleeding. However, her synthetic function did not improve, and her creatinine subsequently rose from 0.6 to 3.0. A diagnostic paracentesis was performed (on [**7-29**]), which demonstrated no evidence of SBP. Her pentoxyfilline and ursodiol were discontinued as there was no clear improvement on treatment. She was started empirically on octreotide/midodrine for possible hepatorenal syndrome. Nephrotoxic medications were held and she was given volume repletion both with normal saline and albumin. Creatinine subsequently improved to 1.2-1.4 at the time of discharge. . For nutritional support a post-pyloric feeding tube was placed and tube feeds were intiated per nutrition recommendations. She will be discharged for continued nutritional support to meet caloric goals. . She was seen by social work for substance abuse support. In addition, she was provided with information on post-discharge support services. . MELD at time of discharge was 33, driven by a bilirubin of 19.8, creatinine of 1.4, and an INR of 2.9. . Diuretics held given renal failure and lack of ascites on ultrasound, s/p TIPS. . # s/p Upper GI bleed: Initial hct was 34 which drifted down to 25 then 21.9 on day of admission. She underwent EGD a few hours after arrival, and it showed 3 esophageal variceal bands and gastric varices which had recent stigmata of bleeding but no active bleeding. She was supported with blood products and underwent TIPS as above. Her hematocrit subsequently remained stablized with no further evidence of active GI bleeding. Repeat EGD on [**2140-8-3**] prior to discharge showed no significant varices in the esophagus. There was noted granularity, friability, erythema, congestion, abnormal vascularity and mosaic appearance in the whole stomach consistent with portal gastropathy, but no active bleeding. . # Acute renal insufficiency: As outlined above, developed rising creatinine, initially concerning for hepatorenal syndrome (HRS), with UOP <30 cc/hour in setting of known ETOH cirrhosis. Started empirically on midodrine/octreotide. However urine sodium >10, so was not completely consistent with HRS. Paracentesis [**7-29**] demonstrated no evidence of bacterial peritonitis. Urinalysis demonstrated no eosinophils. Ultrasound on [**7-30**] showed no hydronephrosis, but did show a new echogenic wedge shaped structure in right lobe, of unclear clinical significance. No other evidence of infarcts/ischemia were noted, and lupus anti-coagulant was sent and was negative as well. Renal service was consulted and nephrotoxic medications were held. She was repleted with IV fluids and renal function subsequently improved, with creatinine trending down from 3.0 to 1.4, with good urine output. . # Hypotension: Initially likely from GIB, hypovolemia. Subsequently remained stable in low 90's-100's systolic, in setting of chronic liver disease. Initially started on Zosyn and Vancomycin as well as Levaquin for concern for infectious etiology, however antibiotics subsequently discontinued as no infectious source identified. Of note, blood cultures from [**7-17**] grew 1/4 bottles STAPHYLOCOCCUS, COAGULASE NEGATIVE. This was considered contaminant and repeat blood cultures were negative. . # HCV: Repeat HCV viral load on this admission ([**2140-7-21**]) showed no HCV viral RNA. . # DM II: On Metformin prior to hospital admission. Covered as inpatient on sliding scale insulin and glargine. Discharged on glargine 24units/night, and the patient demonstrated how to use SSI at home. Metformin and alternative oral hypoglycemics contra-indicated in setting of her cirrhosis. . # HIT antibody positive: HIT antibody sent due to thrombocytopenia, and was noted to be positive on this admission; however, she could not be anti-coagulated given her recent variceal bleed and coagulopathy from liver disease. All heparin products were held. Platelet count remained low secondary to liver disease, but stable, with no clear evidence of clinical thrombosis. . # Nutritional Deficiency: Post-pyloric dobhoff placed for nutritional support to meet caloric goals. Tube feeds will continue upon discharge with outpatient services arranged. . # Communication: [**Name (NI) **] (boyfriend [**Telephone/Fax (1) 72890**]), [**Name (NI) **] (mother) [**Telephone/Fax (1) 72891**]. Medications on Admission: MEDS at home: metformin 500 [**Hospital1 **]. . MEDS on Transfer: Protonix 40mg IV BID MVI po daily Thiamine 100mg qday Folate i mg po daily nicotine patch 14gm qday nadolol 20mg qday oxazepam q2 prn for agitation per CIWA [**6-18**] 10mg 13-20 20mg Octreotide gtt Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*90 Capsule(s)* Refills:*2* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:*2700 ML(s)* Refills:*2* 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*1 container* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Health Services Discharge Diagnosis: Primary Diagnoses: 1. Alcoholic Cirrhosis 2. Acute Alcoholic Hepatitis 3. Esophogeal Varices with Variceal Bleed Secondary Diagnoses: 1. Nutritional Deficiency 2. Acute Renal Failure 3. HIT antibody Positive Discharge Condition: Liver cirrhosis requiring ongoing nutritional support. Discharge Instructions: You were admitted for alcoholic cirrhsosis and variceal bleed. Your liver is extremely sick, and it is important that you continue to abstain completely from alcohol. Alcohol cessation is required for you to be a candidate for a liver transplant. Information on substance abuse centers has been provided to you to help with this. Nutrition is also very important, and a feeding tube was placed for nutritional support. You were set up for services at home to continue the tube feeds. Please call your primary physician or return to the ER if you develop fever >101, abdominal pain, bright red blood per rectum, melanotic stools, or any other concerning symptoms. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] [**2140-8-23**] @ 2:15pm. You may call to confirm your appointment at [**Telephone/Fax (1) 2422**]. Please follow-up with your primary physician [**Name Initial (PRE) 3390**]: [**Name10 (NameIs) 72892**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 50168**] in [**2-9**] weeks after discharge. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**] Completed by:[**2140-8-6**]

[ "285.1", "599.0", "456.20", "303.00", "571.1", "357.2", "286.7", "E934.2", "250.60", "578.9", "287.4", "572.2", "584.9", "456.8", "571.2", "305.1", "572.3", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "45.24", "00.17", "96.6", "44.44", "96.71", "54.91", "45.13", "38.93", "39.1" ]

icd9pcs

[ [ [] ] ]

12020, 12095

5844, 10967

343, 383

12347, 12404

2075, 5821

13117, 13644

1600, 1618

11283, 11997

12116, 12230

10993, 11041

12428, 13094

1633, 2056

12251, 12326

250, 305

411, 1367

1389, 1501

1517, 1584

11059, 11260

46,088

134,762

38269

Discharge summary

report

Admission Date: [**2190-7-9**] Discharge Date: [**2190-7-25**] Date of Birth: [**2128-2-27**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: fever, recurrent cough with hemoptysis Major Surgical or Invasive Procedure: [**2190-7-16**] Aortic valve replacement with a 27-mm [**Company 1543**] Mosaic Ultra valve, serial number [**Serial Number 85284**]. Mitral valve repair with a 30-mm [**Company 1543**] CG Future annuloplasty ring, serial number [**Serial Number 85285**] History of Present Illness: 62 yo M c HTN, HL initially presented to [**Hospital 1725**] Hospital on [**6-27**] with a fever and cough 2-3 months after a trip to [**Doctor Last Name **] [**Country **]. The patient has no symptoms in his usual state of health other than occasional headaches. He spent most of his vacation at a resort on the coast and did some diving in the ocean, but did not go into the rainforest or have exposure to exotic animals. . He states that his initial symptoms occurred 2-3 weeks ago, when he developed "chest heaviness", fevers to 101, and a cough productive of yellow sputum. When he initially presented, CXR was unremarkable and patient was d/ced on Z-pak. Patient re-presented on [**7-1**] with persistent fever, cough and was noted to have a mild transaminitis (AST ~ 50). He also had developed some nausea and vomiting. His simvastatin was discontinued. At that time, abdominal ultrasound showed mild hepatomegaly without biliary dilation or gallstones and hepatitis panel was reportedly normal. CT sinus showed mild mucosal thickening; CT head was normal. He was again discharged home but again re-presented on [**7-3**] with fever and headache. At this time, an LP (glucose 62, protein 23, WBC 4, culture negative, Lyme PCR negative), CT chest/abd, repeat CXR, Lyme serology, CMV IgG, malaria smear, and serologic test for babesia was performed. All of these tests were normal but the patient was discharged on empiric doxycycline pending final results. . He was re-admitted on [**7-6**] with fever, shaking chills, and recurrent cough productive of yellow sputum with mild streaking of blood. In the OSH ED, a D-dimer was positive, and the patient was sent for CTA chest. Both this and a CXR showed evidence of R lung airspace disease (RUL/RML/RLL) and small effusions, R > L. He was started on CTX and continued on doxycycline. He underwent a bronchoscopy and BAL that was limited by intraprocedural hypoxemia. Lavage was sent for bacterial, fungal, AFB/TB cultures. At this time, the patient requested a transfer to [**Hospital1 18**]. At the time of discharge, as it was felt the patient may have a nosocomial infection, his CTX was switched to Zosyn. . The patient states that his fevers are episodic, lasting hours at a time, and are associated with shaking chills and sweats, especially when they are high (peaking at 104). The episodes occur every few days and occur both at day and night. . At the time of transfer, pending tests included BAL results, ANCA and anti-GBM antibodies. . The patient denies rash, weight loss, diarrhea, constipation, arthralgias. Endorses genralized weakness. ROS otherwise noncontributory. Past Medical History: - hypertension - hyperlipidemia - BPH - erectile dysfunction - rt knee arthroscopy Social History: Denies tobacco use presently, very distant 5 pack-yr history of smoking. Drinks 6 drinks/day on weekends, but otherwise abstains during the week. No h/o IVDU. GI in [**Country 3396**]. Has been in a monogamous relationship with his wife for many years. Most recent tattoos were eight years ago. Patient has one cat at home, which he has had for eight years. No other pets. Recent travel to [**Doctor Last Name **] [**Country **] [**4-8**] mos. ago as detailed in HPI. Family History: mother - breast ca, migraine headaches father - [**Name (NI) 5895**] disease The patient has two sons, both of whom are healthy. Physical Exam: Vitals - T: 100.6 BP: 148/40 HR: 96 RR: 20 02 sat: 95% 3L GENERAL: NAD, no respiratory distress, AAOx3 HEENT: NCAT, PERRL. Oropharynx clear and without exudates or erythema. Tongue with central darkening, although patient had recently drank root beer. No evidence of leukoplakia or other mucosal lesions. CARDIAC: RRR c [**4-10**] holosystolic murmur heard throughout precordium, including at apex. LUNG: CTA on L side. R side has diffuse inspiratory rhonchi and mild rales, especially at apex. ABDOMEN: mildly obese, S, NT/ND, +BS EXT: WWP, 2+ pulses. 1+ pitting edema to ankles bilaterally. No stigmata of endocarditis. NEURO: Grossly intact. DERM: No evidence of rashes. Pertinent Results: CT PELVIS [**7-4**]: No acute findings. CT ABDOMEN [**7-4**]: Splenomegaly (spleen 15 cm). CXR [**7-3**]: Normal. . CMV IgG/IgM: NEGATIVE Babesia microti PCR: negative . HBcAb: neg HBsAb: neg HBsAg: neg [**Doctor First Name **]: neg Lyme IgG/IgM: neg Monospot: neg HCV IgG: neg HAV Ab: neg . CTA chest [**7-7**]: 1. No evidence of PE. 2. Diffuse patchy airspace infiltrates involving the RUL/RML/RLL. 3. Small pleural effusions, R > L. 4. Coronary artery calcification. Labs [**Hospital1 18**]: [**2190-7-10**] 12:52AM BLOOD WBC-9.1 RBC-3.42* Hgb-10.4* Hct-31.2* MCV-91 MCH-30.3 MCHC-33.3 RDW-14.2 Plt Ct-214 [**2190-7-10**] 12:52AM BLOOD PT-13.3 PTT-24.4 INR(PT)-1.1 [**2190-7-10**] 12:52AM BLOOD Plt Ct-214 [**2190-7-10**] 12:52AM BLOOD Glucose-133* UreaN-17 Creat-1.0 Na-134 K-4.1 Cl-103 HCO3-21* AnGap-14 [**2190-7-10**] 12:52AM BLOOD ALT-49* AST-46* LD(LDH)-155 CK(CPK)-52 AlkPhos-99 TotBili-0.9 [**2190-7-12**] 01:05PM BLOOD CK-MB-3 cTropnT-0.02* [**2190-7-10**] 12:52AM BLOOD calTIBC-194* VitB12-1528* Folate-14.4 Ferritn-564* TRF-149* [**2190-7-14**] 05:45AM BLOOD %HbA1c-5.5 eAG-111 [**2190-7-23**] 05:33AM BLOOD WBC-10.7 RBC-3.30* Hgb-9.3* Hct-29.2* MCV-89 MCH-28.3 MCHC-31.9 RDW-14.5 Plt Ct-449* [**2190-7-23**] 05:33AM BLOOD Plt Ct-449* [**2190-7-20**] 02:38AM BLOOD PT-13.6* PTT-27.9 INR(PT)-1.2* [**2190-7-23**] 05:33AM BLOOD Glucose-112* UreaN-16 Creat-1.1 Na-137 K-4.2 Cl-107 HCO3-24 AnGap-10 [**2190-7-16**] 05:18AM BLOOD ALT-63* AST-52* LD(LDH)-157 AlkPhos-101 TotBili-0.4 Radiology Report CHEST (PA & LAT) Study Date of [**2190-7-22**] 3:37 PM [**Hospital 93**] MEDICAL CONDITION: 62 year old man with AVr/MV ring REASON FOR THIS EXAMINATION: eval for chnage in bilat opacities Final Report HISTORY: 62-year-old man with AVR and MV repair. TECHNIQUE: PA and lateral chest radiograph. COMPARISON: Compared to chest radiograph from [**2190-7-20**]. FINDINGS: There are improving bilateral parenchymal opacities. There is minimal bilateral blunting of costophrenic angles. There is a small right apical pneumothorax. Cardiac, hilar, and mediastinal silhouettes are stable. There are midline sternotomy intact wires. Patient is status post AVR and MV repair. IMPRESSION: 1. Mildy improving bilateral parenchymal opacities. 2. Minimal bilateral blunting of costophrenic angle. 3. Small right apical pneumothorax. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] BBIDMC ECHOCARDIOGRAPHY REPORT Indication: Intraoperative TEE for AVR and MVR Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Peak Pulm Vein S: 0.6 m/s Left Atrium - Peak Pulm Vein D: 0.7 m/s Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Ascending: *3.7 cm <= 3.4 cm Aortic Valve - Peak Velocity: *2.4 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *22 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 11 mm Hg Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal regional LV systolic function. Overall normal LVEF (>55%). [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Normal aortic arch diameter. Normal descending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Large vegetation on aortic valve. No AS. Moderate to severe (3+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR. TRICUSPID VALVE: Mild [1+] TR. PERICARDIUM: Small pericardial effusion. Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). [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 ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is a large vegetation on the aortic valve. (Right coronary cusp) There is no aortic valve stenosis. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is a small pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**2190-7-16**] at 900am. Post bypass Patient is AV paced and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. Annuloplasty ring seen in the mitral position. It appears well seated and there is trivial mitral regurgitation. The mean gradient across the mitral valve is 2 mm Hg. There is no [**Male First Name (un) **]. There is a bioprosthetic valve seen in the aortic position. The valve appears well seated and the leaflets move well. The peak gradient across the aortic valve is 28 Hg. The mean gradient is 14 mm Hg. There is trace central aortic insufficiency. Aorta is intact post decannulation. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Aortic tissue ultimately grew H.Parainfluenza sensitive to Ceftriaxone. Brief Hospital Course: The patient was febrile on admission. Blood cultures continued to be unrevealing, and a CXR showed a unilateral R-sided infiltrate. A TTE was performed in the setting of fevers, heart murmur on exam, and infiltrate that could potentially be pulmonary edema [**3-9**] eccentric regurgitant jet. The TTE showed evidence of a large aortic vegetation resulting in moderate/severe AR; this was confirmed by a subsequent TEE. The patient's SOB progressed and his infiltrates subsequently were noted to be bilateral and consistent with pulmonary edema. Diuresis with afterload reduction was initiated in an effort to control his symptoms with some effect. Cardiology and Cardiac Surgery were consulted and a pre-operative workup was performed with the intent of aortic valve replacement given his acute heart failure. The patient was brought to the operating room on [**7-16**] at which time he had: 1. Aortic valve replacement with a 27-mm [**Company 1543**] Mosaic Ultra valve, serial number [**Serial Number 85284**]. 2. Mitral valve repair with a 30-mm [**Company 1543**] CG Future annuloplasty ring, serial number [**Serial Number 85285**]. His bypass time was 103 minutes with a crossclamp time of 85 minutes. Please see operative report for details. He tolerated the operation well and was transferred from the operating room to the cardiac surgery ICU in stable condition.During the immediate post-operative period the patient was hemodynamically stable however he did have some heart block and he was somewhat hypoxic. A chest XRay revealed a large effusion for which a chest tube was placed. His pulmonary status improved and he was extubated on the morning of POD1. He stayed in the ICU to monitor his heart block, during this time he went into a rapid atrial fibrillation. Electrophysiology was consulted and the patient was begun on Bblockers, Amiodarone was held as he had already demonstrated some nodal disease. On POD4 he was transferred from the ICU to the stepdown floor. While he was on the stepdown floor he continued to have periods of rapid atrial fibrillation and ultimately was started on Coumadin. EP continued to follow, and the patient was started on amiodarone. The remainder of his hospital course was uneventful. On POD 9 he was ready for discharge home with visiting nurses and Home Therapy Infusion Solutions for antibiotic infusions. Additionally, he is discharged on the [**Doctor Last Name **] of Hearts monitor. Cardiology follow up will be arranged through the office of Dr. [**First Name (STitle) **] (PCP). He is to have followup with Dr [**Last Name (STitle) **] and with Infectious disease clinic(Dr [**First Name (STitle) **]. INR will be checked regularly and coumadin dosing will be managed by Dr. [**First Name (STitle) **]. Medications on Admission: MEDICATIONS (HOME): doxazosin 8 mg po qd APAP ibuprofen ramipril 10 mg qd ASA 81 mg qd . MEDICATIONS (TRANSFER): doxazosin 8 mg po qd ASA 81 mg qd ibuprofen 600 mg q8h prn pain, fever APAP 650 mg q6h prn pain, fever ?CTX 1g IV qd doxycycline 100 mg po bid dilaudid 0.5-1 mg IV po q4h prn pain duoneb q4h prn SOB, wehzze chlorpheniramine/hydrocodone 5 ml po bid zofran 4 mg IV q6h prn nausea zosyn 3.375 mg po q6h Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). Disp:*1 bottle* Refills:*1* 4. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: Two (2) gm Intravenous Q24H (every 24 hours) for 3 weeks: total 4 weeks from surgery. Disp:*21 doses* Refills:*0* 5. Outpatient Lab Work CBC/diff, Bun/Creat, LFT's weekly fax to [**Telephone/Fax (1) 1419**] Dr. [**First Name (STitle) **] infectious disease 6. Outpatient Lab Work INR draw on [**2190-7-26**] and then every other day as per Dr. [**First Name (STitle) **] fax results to PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone [**Telephone/Fax (1) 85286**] Fax [**Telephone/Fax (1) 85287**] 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: as directed ML Intravenous QD and PRN as needed for line flush: Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. . 11. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Lorazepam 0.5 mg Tablet Sig: .5 Tablet PO BID PRN () as needed for anxiety. Disp:*10 Tablet(s)* Refills:*0* 13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO three times a day: 200mg TID x 3 weeks, then 200mg daily until further instructed. Disp:*120 Tablet(s)* Refills:*2* 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 15. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: dose will change daily for goal INR 2-2.5. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Home and Hospice of [**Location (un) 8117**] Discharge Diagnosis: Severe aortic insufficiency s/p aortic valve replacement Endocarditis. Moderate mitral regurgitation s/p mitral valve repair Congestive heart failure. Hyperlipidemia Hypertension Erectile dysfunction Rt knee arthroscopic surgery [**2150**]'s Discharge Condition: Alert and oriented x3, nonfocal. Ambulating with steady gait. Incisional pain managed with Ultram Discharge Instructions: 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. No lotions, cream, powder, or ointments to incisions. Each morning you should weigh yourself and then in the evening take your temperature, These should be written down on the chart . No driving for approximately one month, until follow up with surgeon. No lifting more than 10 pounds for 10 weeks. Please call with any questions or concerns ([**Telephone/Fax (1) 170**]). **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: Recommended Follow-up: You are scheduled for the following appointments: Cardiac Surgeon: Dr [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2190-8-24**] 1:30 [**Hospital **] clinic- Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2190-8-10**] 3:00 - Please call to schedule appointments with your Primary Care: Dr [**First Name (STitle) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 85286**] in [**2-6**] weeks Dr. [**First Name (STitle) **] will manage coumadin dosing Cardiologist: in [**2-6**] 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:[**2190-7-25**]

[ "600.00", "079.89", "273.8", "E878.1", "785.0", "421.0", "428.0", "512.1", "396.3", "584.9", "428.31", "E849.7", "276.1", "746.4", "427.31", "285.9", "423.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "38.93", "96.71", "88.56", "35.21", "37.22", "35.33", "96.04" ]

icd9pcs

[ [ [] ] ]

16005, 16080

10449, 13232

358, 623

16366, 16467

4767, 6333

17222, 18090

3923, 4053

13695, 15982

6370, 6403

16101, 16345

13258, 13672

16491, 17199

4068, 4748

280, 320

6432, 10426

651, 3310

3332, 3416

3432, 3907

70,985

124,922

19266+57034

Discharge summary

report+addendum

Admission Date: [**2183-6-12**] Discharge Date: [**2183-6-18**] Date of Birth: [**2099-2-21**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2183-6-13**] Mitral Valve Replacement utilizing a 27mm St. [**Male First Name (un) 923**] Epic Porcine Valve History of Present Illness: Ms. [**Known lastname 52491**] is an 84-year-old female who has a history of mitral regurgitation. Her MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] to severe in [**2178**] and is now severe based on an echocardiogram from [**2182-11-1**]. She feels well overall and denies any chest discomfort. Her main symptom is dyspnea, which presents itself with anxiety or exertion. She recently saw Dr. [**Last Name (STitle) 171**] who strongly recommended surgery for her mitral valve and presents today for surgical evaluation. Past Medical History: Hypertension Hyperlipidemia with high triglycerides Polycythemia [**Doctor First Name **] History of Cerebellar CVA in [**2175**] when PCV diagnosed Major Depression disorder, Anxiety Disorder Osteoporosis Pseudogout History of C4 fracture, [**2175**] Varicose Veins, Right Leg History of Nosebleeds with daily Aspirin s/p Hysterectomy s/p Tonsillectomy Social History: Lives alone Occupation: Retired social worker [**Name (NI) 1139**]: Denies ETOH: Denies Family History: Negative for coronary artery or valvular disease Physical Exam: Pulse: 78 Resp: 16 O2 sat: 100% B/P Right: 139/78 Left: 139/82 Height: 4'[**82**]" Weight: 113 lb General: Pleasant elderly female in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur - [**5-7**] holosytsolic murmur best heard at the LLSB Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: trace Varicosities: Right GSV varicosed Neuro: Grossly intact [x] Pulses: Femoral Right: 2 Left: 2 DP Right: 1 Left: 1 PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 1 Left: 1 Carotid Bruit: None bilaterally, pulses 2+ bilaterally Pertinent Results: [**2183-6-14**] WBC-12.0* Hgb-12.2# Hct-35.6* RDW-16.3* Plt Ct-291 [**2183-6-15**] WBC-12.4* Hgb-12.3 Hct-35.8* RDW-16.7* Plt Ct-235 [**2183-6-16**] WBC-10.2 Hgb-11.0* Hct-32.8* RDW-16.5* Plt Ct-293 [**2183-6-17**] WBC-8.0 Hgb-10.1* Hct-30.0* RDW-16.4* Plt Ct-302 [**2183-6-14**] Glucose-136* UreaN-14 Creat-0.8 Na-140 K-4.2 Cl-106 HCO3-26 [**2183-6-15**] Glucose-124* UreaN-19 Creat-0.8 Na-137 K-4.1 Cl-102 HCO3-27 [**2183-6-16**] UreaN-19 Creat-0.8 Na-140 K-3.7 Cl-103 [**2183-6-17**] UreaN-22* Creat-0.7 Na-140 K-3.6 Cl-106 [**2183-6-17**] Mg-2.2 . [**2183-6-17**] Chest X-ray: There is some improved aeration at the left base, though continued evidence of volume loss and pleural effusion. Small right pleural effusion is seen. Continued enlargement of the cardiac silhouette without definite vascular congestion or acute focal pneumonia. . [**2183-6-13**] Intraop TEE: PREBYPASS No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. [Intrinsic left ventricular systolic function is possibly more depressed given the severity of valvular regurgitation.] Right ventricular chamber size is normal. with mild global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is partial anterior mitral leaflet flail. An eccentric, posteriorly directed jet of Severe (4+) mitral regurgitation is seen. POSTBYPASS There is a well seated, well functioning bioprosthesis in the mitral position. Ther is trace valvular MR. [**First Name (Titles) **] [**Last Name (Titles) 8097**]c function is normal. The remaining study is unchanged from prebypass. . [**2183-6-12**] Cardiac Catheterization: 1. Coronary angiography revealed no angiographically apparent coronary artery disease. The LMCA, LAD, LCX, and RCA were without disease. 2. Resting hemodynamics revealed mildly elevated right-sided filling presssures with mean RA pressure of 11 mmHg. There was [**Month/Day/Year 1192**] pulmonary hypertension, with mean PA pressure of 44 mmHg. The left-sided filling pressures were increased with mean PCW pressure of 26 mmHg, with large 'v' waves indicative of severe mitral regurgitation. The cardiac index was normal at 2.5 L/min/m2. There was mild systemic hypertension, with SBP of 157 mmHg. Brief Hospital Course: Ms. [**Known lastname 52491**] was admitted [**6-12**] and underwent routine preoperative evaluation which included cardiac catheterization which revealed normal coronary arteries. The remainder of her preoperative workup was unremarkable and she was cleared for surgery. The following day, she underwent mitral valve replacement. For surgical details, please see operative note. After surgery, she was brought to the CVICU for invasive monitoring.She awoke and was extubated that evening. transferred to the floor on POD #1 to begin increasing her activity level. Chest tubes and pacing wires removed per protocol. Gently diuresed toward her preop weight. Developed A Fib and coumadin was started. Target INR 2.0-2.5. Continued to make good progress and was cleared for discharge to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] rehab on POD #5. All f/u appts were advised.Expected length of stay is less than 30 days. Medications on Admission: DILTIAZEM HCL [CARTIA XT] - 240 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a day HYDROXYUREA - 500 mg Capsule - One Capsule(s) by mouth Every other day: MWF LISINOPRIL - 40 mg Tablet - One Tablet(s) by mouth Daily MIRTAZAPINE - (Prescribed by Other Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 39118**]) - 15 mg Tablet - 1 Tablet(s) by mouth each evening SERTRALINE - (Prescribed by Other Provider) - 100 mg Tablet - one Tablet(s) by mouth daily Medications - OTC ASPIRIN [ADULT LOW DOSE ASPIRIN] - 81 mg Tablet, Delayed Release (E.C.) - one Tablet(s) by mouth every other day BISACODYL - 5 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth at bedtime as needed for constipation CALCIUM CHEWABLE PLUS - 600 mg-200 unit Tablet, Chewable - 1 Tablet(s) by mouth three times a day ERGOCALCIFEROL (VITAMIN D2) - 400 unit Tablet - 2 Tablet(s) by mouth once a day MULTIVITAMIN - Tablet - one Tablet(s) by mouth daily PSYLLIUM HUSK - 0.52 gram Capsule - 1 Capsule(s) by mouth daily 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 DAILY (Daily) for 2 weeks. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 8. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 10. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 3X/WEEK (MO,WE,FR): Mon, Wed, Friday only. 11. ampicillin 500 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 1 weeks: through [**6-24**] for enterococcal UTI. 12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours) for 1 weeks: hold for K+ > 4.5. 14. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. 15. warfarin 1 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM for 1 days: dose today [**6-18**] is 2 mg; all further daily dosing per rehab provider; target INR 2.0-2.5 for A Fib. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: Mitral Regurgitation - s/p Mitral Valve Replacement postop A Fib Hypertension Hyperlipidemia with high triglycerides Polycythemia [**Doctor First Name **] History of Cerebellar CVA in [**2175**] when PCV diagnosed Major Depression disorder, Anxiety Disorder Osteoporosis Pseudogout History of C4 fracture, [**2175**] Varicose Veins, Right Leg History of Nosebleeds with daily Aspirin Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema .......... Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication A Fib Goal INR 2.0-2.5 First draw tomorrow [**6-19**] *** Please arrange for coumadin/INR f/u prior to discharge from rehab Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2183-7-10**] 1:15 Cardiologist: Dr. [**Last Name (STitle) 171**] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2183-7-9**] 3:40 Please call to schedule appointments with your: Primary Care Dr. [**First Name8 (NamePattern2) 3742**] [**Last Name (NamePattern1) **] in [**5-6**] weeks [**Telephone/Fax (1) 250**] **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 A Fib Goal INR 2.0-2.5 First draw tomorrow [**6-19**] *** Please arrange for coumadin/INR f/u prior to discharge from rehab Completed by:[**2183-6-18**] Name: [**Known lastname 9765**],[**Known firstname 9766**] Unit No: [**Numeric Identifier 9767**] Admission Date: [**2183-6-12**] Discharge Date: [**2183-6-18**] Date of Birth: [**2099-2-21**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 741**] Addendum: The pt. had an enterococcus UTI and the sensitivities revealed VRE. The ampicillin she had been treated with was discontinued and she was started on Linezolid. She will be treated with 3 days of Linezolid and will have a repeat urine culture at rehab when her dose is completed. 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 DAILY (Daily) for 2 weeks. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 8. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 10. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 3X/WEEK (MO,WE,FR): Mon, Wed, Friday only. 11. Linezolid 600 mg PO BID for 3 days. 12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours) for 1 weeks: hold for K+ > 4.5. 14. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. 15. warfarin 1 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM for 1 days: dose today [**6-18**] is 2 mg; all further daily dosing per rehab provider; target INR 2.0-2.5 for A Fib. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3008**] [**Last Name (NamePattern1) **] - [**Location (un) 164**] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2183-6-18**]

[ "V12.54", "458.29", "424.0", "427.31", "285.9", "733.00", "416.8", "272.4", "041.04", "272.1", "401.9", "712.30", "275.49", "296.20", "599.0", "429.5" ]

icd9cm

[ [ [] ] ]

[ "35.23", "37.23", "39.61", "37.21", "88.56" ]

icd9pcs

[ [ [] ] ]

13181, 13426

4830, 5775

330, 444

8983, 9166

2350, 4807

10261, 11739

1509, 1560

11762, 13158

8576, 8962

5801, 6903

9190, 10238

1575, 2331

271, 292

472, 1009

1031, 1387

1403, 1493

29,533

192,024

32725

Discharge summary

report

Admission Date: [**2192-4-16**] Discharge Date: [**2192-4-21**] Date of Birth: [**2129-2-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: Transferred for evaluation for TIPs Major Surgical or Invasive Procedure: post-pyloric NG tube placement History of Present Illness: The patient is a 63 yo M with ESLD and refractory ascities admitted to an OSH on [**2192-4-15**] with SOB. He had recently been admitted to the OSH with cellulitis/osteo of his lower extremity and had debridement at that time. Had been sent home on cipro/linezolid. Also during that admission had a 13 L large volume para. Was doing well until [**2192-4-15**] when he developed SOB. On admission, was found to have acute renal failure with creatinine to 3.4 and potassium of 7.6. He was treated in the ED with kayexalate, lasix, insulin, albuterol, and bicarb and admitted to the ICU. A HD catether was placed and HD was initited (got yesterday and today). . Of note, found to have elevated cardiac enzymes (Trop 1.17 and MB 26). EKG without evidence of ischemia and patient denied chest pain. He was seen by cardiolgy at the OSH who originally felt the elevated enzymes were likely secondary to the ARF and not ongoing ishchemia but repeat EKG's supposedly showed ST changes consisent with a non-ST elevation MI. He was started on a heparin drip. He was also noted to have markedly elevated LFTs (AST 3485/ALT 1009). He was transferred to [**Hospital1 18**] for evaluation for TIPS. Past Medical History: -- ESLD (cryptogenic) -- Diabetes mellitus. -- Coronary artery disease. MI in [**2182**]. -- PAF -- C Diff -- Portal HTN and esophageal varices - EGD was done in [**Month (only) 359**] of [**2190**] and it showed a grade II-III esophageal varices with evidence of post-band ligation scarring. -- Hyperlipidemia -- HTN -- Depression Social History: He worked in the music business and he reports heavy alcohol drinking before the year [**2164**] as above. He quit smoking 2 years ago. Widowed. Lives alone Family History: There is no significant history of liver disease. Physical Exam: Vitals - 98.2 93/64 96 20 95%5L General - chronically ill appearing male, NAD, breathing comfortably HEENT - dentures not in place, dry MM CV - 3/6 systolic murmur Lungs - clear to auscultation bilaterally Abdomen - distended, mildly tender diffusely, small firm tender nodule beneath skin in RLQ Ext - bilateral feet wrapped Pertinent Results: [**2192-4-16**] 09:40PM BLOOD WBC-14.6* RBC-3.17* Hgb-8.9* Hct-26.4* MCV-83 MCH-27.9 MCHC-33.6 RDW-14.7 Plt Ct-135* [**2192-4-21**] 11:45AM BLOOD WBC-5.2 RBC-4.45* Hgb-12.6* Hct-38.8* MCV-87 MCH-28.2 MCHC-32.5 RDW-15.0 Plt Ct-45* [**2192-4-21**] 11:45AM BLOOD Plt Smr-VERY LOW Plt Ct-45* LPlt-1+ [**2192-4-21**] 11:45AM BLOOD PT-15.2* PTT-29.2 INR(PT)-1.3* [**2192-4-16**] 09:40PM BLOOD Glucose-100 UreaN-34* Creat-2.3* Na-133 K-4.0 Cl-99 HCO3-23 AnGap-15 [**2192-4-21**] 11:45AM BLOOD Glucose-266* UreaN-94* Creat-6.2* Na-130* K-5.1 Cl-94* HCO3-15* AnGap-26* [**2192-4-16**] 09:40PM BLOOD ALT-984* AST-[**2147**]* LD(LDH)-1753* CK(CPK)-184* AlkPhos-682* TotBili-1.3 [**2192-4-21**] 11:45AM BLOOD TotBili-3.6* [**2192-4-16**] 09:40PM BLOOD CK-MB-10 MB Indx-5.4 cTropnT-1.01* [**2192-4-16**] 09:40PM BLOOD Albumin-2.7* Calcium-7.5* Phos-5.8* Mg-1.9 [**2192-4-21**] 11:45AM BLOOD Calcium-7.8* Phos-10.2* Mg-2.5 [**2192-4-17**] 04:35AM BLOOD calTIBC-133* Ferritn-GREATER TH TRF-102* [**2192-4-16**] 09:40PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2192-4-18**] 04:39AM BLOOD AFP-1.1 [**2192-4-18**] 04:39AM BLOOD HIV Ab-NEGATIVE [**2192-4-19**] 03:44AM BLOOD Vanco-10.8 [**2192-4-17**] 04:35AM BLOOD Acetmnp-NEG [**2192-4-21**] 11:53AM BLOOD Lactate-2.8* Brief Hospital Course: 63 yo M with ESLD and refractory ascites who presented to OSH with ARF, non-ST elevation MI, and elevated LFTs now with decompensated ESLD, not transplant candidate given comorbidities and was transferred for evaluation for TIPS. Here his renal failure continued to worsen despite fluid challenges. He was briefly sent to the ICU for CVP measurement and it was 14, so fluids were stopped and he was transferred back to the floor. He renal function continued to worsen and he became progressively more hypothermic and acidotic. On the morning of [**4-21**] a discussion was had with the patient and he decided that he wanted to be DNR/DNI but continue to take other measure including possible dialysis to improve his condition. Zosyn and vancomycin were added to his antibiotic regimen and blood cultures were sent. The Renal consult team saw him and decided that ultrafiltration could be beneficial. While at dialysis the patient developed some abdominal pain with a benign abdominal exam other than ascites. It improved with a large BM and was felt to be secondary to cramping after recent start of tube feeds. He was given morphine 2 mg x1 for pain. He underwent ultrafiltration and was transferred from dialysis with SBP in the 80s and mentating, but by the time he got to the floor he was agitated SOB with O2 sats 80 % on 2 L, T 91 and unable to get a BP. His brother and HCP was at the bedside and it was decided that the focus should be comfort. The patient was given small doses of morphine and Ativan for agitation, pain and air hunger. He died at 17:40. His brother was at the bedside and an autopsy was offered but declined. Medications on Admission: Medications on transfer: Hydromorphone -- Oxycodone PRN -- Lamotrigine 200mg Daily -- Pantoprazole 40mg Daily -- Nadolol 80mg Daily -- Aspirin 81mg Daily -- Lasix 40mg IV BID -- Spironalactone 50mg [**Hospital1 **] -- Linezolid 600mg [**Hospital1 **] -- Cipro 250mg [**Hospital1 **] -- IV Heparin -- NPH/ISS Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: Renal failure End stage liver disease PVD Diabetes Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "V58.67", "572.3", "401.9", "456.21", "707.15", "250.80", "789.59", "412", "311", "443.9", "571.5", "112.0", "730.27", "731.8", "287.5", "427.31", "272.4", "250.70", "285.29", "410.71", "584.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "54.91", "99.04", "39.95" ]

icd9pcs

[ [ [] ] ]

5909, 5918

3860, 5509

349, 381

6012, 6021

2554, 3837

6077, 6087

2141, 2192

5869, 5886

5939, 5991

5535, 5535

6045, 6054

2207, 2535

274, 311

409, 1595

5561, 5846

1617, 1951

1967, 2125

8,060

125,303

17645

Discharge summary

report

Admission Date: [**2164-1-4**] Discharge Date: [**2164-2-8**] Date of Birth: [**2111-11-26**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Levofloxacin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Reason for admission - from ED, HoTN/jaundice Major Surgical or Invasive Procedure: Intubation Extubation Right IJ CVL Left IJ HD catheter arterial line thoracentesis Chest Tube History of Present Illness: This is a 52 y/o female s/p LRLT [**1-9**] c/b graft dysfunction on transplant list, h/o VRE and Klebsiella cholangitis, HTN, CKD, who p/w symptoms of worsening jaundice, fever to 103 at home, and "not feeling well" over the last 1 week. After Thansgiving day last week, she began to feel nauseous and had multiple episodes of yellowish/bilious emesis with no hematemesis. She also noted worsening diarrhea (has loose stools at baseline), no melena or BRBPR and took immodium over the weekend. She describes new LLQ pain, which is dull and throbbing in nature, not associated with any factors and relieved with morphine earlier in the ED. She has baseline RUQ pain of unclear etiology that is unchanged in nature. Her UOP has decreased over the last week and is darker, but she denies any dysuria or hematuria. She took her temperature a few days ago and noted that is was 103, but has not taken her temperature sicne then. Her n/v resolved briefly until earlier yesterday when it began again. She noted new yellowing of her skin 1 day PTA - she notes the last time she was jaundiced was prior to her transplant. She went to the liver clinic yesterday for follow-up and in the office, was noted to be jaundiced with SBP's in the 70's. She was referred to the ED for further evaluation. In the ED, initial VS were T 98.6, BP 76/46, HR 101, RR 29, SaO2 95%/RA. She given 4 L NS total with partial improvement in her blood pressures initially to 90's systolic, however her pressures dropped to the 70's systolic again. A right IJ CVL was placed and she was started on levophed with improvement in her MAP's to the 60's (SBP's 80's to 90's). She received Vancomycin/CTX/flagyl for broad-spectrum coverage after she was pan-cultured. CXR, CT abd were performed (see below for results). She continued to mentate well throughout. She was recently hospitalized at [**Hospital1 18**] from [**Date range (1) 49131**] for n/v/abdominal and diarrhea, of unclear etiology, improved with reglan (workup including stool cultures, colonoscopy, gastic emptying study all unremarkable). Of note, she has never had SBP and rarely needs paracentesis - perhaps, 1-2x/year therapeutically. She is on the transplant list for over a year now. Past Medical History: PMH - 1. alcoholic cirrhosis - s/p living related liver transplant (sister) in [**1-9**], currently being relisted for transplant because of course complicated by graft dysfunction [**3-10**] biliary complications from hepatic arterial thrombosis. - grade II varices on last EGD 06/[**2161**]. Last biopsy [**10/2161**] with stage 1-2 fibrosis. 2. Hypertension 3. Hypothyroidism 4. s/p cholecystectomy, appy, and TAH 5. h/o VRE and Klebsiella cholangitis 6. Osteoporosis 7. h/o sigmoidoscopy with proctitis, ulceration and granularity in the descending colon in [**2161**]. 8. GERD 9. anxiety/depression 10. Factor VII deficiency. 11. CRI - baseline 1.4-1.5, stage III CKD, eGFR of 40 ml/min/1.73 meter2, seen by outpt nehrology. +secondary hyperparathyroidism and vit D deficiency. 12. history of hemorrhoids 13. Incision hernia repair with mesh [**2163-10-14**] 14. IVC stent occlusion Social History: 1. alcoholic cirrhosis - s/p living related liver transplant (sister) in [**1-9**], currently being relisted for transplant because of course complicated by graft dysfunction [**3-10**] biliary complications from hepatic arterial thrombosis. - grade II varices on last EGD 06/[**2161**]. Last biopsy [**10/2161**] with stage 1-2 fibrosis. 2. Hypertension 3. Hypothyroidism 4. s/p cholecystectomy, appy, and TAH 5. h/o VRE and Klebsiella cholangitis 6. Osteoporosis 7. h/o sigmoidoscopy with proctitis, ulceration and granularity in the descending colon in [**2161**]. 8. GERD 9. anxiety/depression 10. Factor VII deficiency. 11. CRI - baseline 1.4-1.5, stage III CKD, eGFR of 40 ml/min/1.73 meter2, seen by outpt nehrology. +secondary hyperparathyroidism and vit D deficiency. 12. history of hemorrhoids 13. Incision hernia repair with mesh [**2163-10-14**] 14. IVC stent occlusion Family History: Mother 52 - Breast cancer. Father 73 - AAA. No liver disease in the family. Grandmother with DM. No thyroid disease. Physical Exam: VS: Tc 96.1, BP 88/64, HR 86-90, RR 30-33, SaO2 100%/2 L NC General: jaundiced-appearing female who is fatigued, but in NAD, AO x 3, mentating clearly HEENT: NC/AT, PERRL, EOMI. +scleral icterus. MM dry, OP clear Neck: supple, RIJ in place with minimal oozing, JVP flat Chest: crackles over the left base, markedly diminished breath sounds over the right base, no egophany, no wheezes CV: RRR s1 s2 normal, no m/g/r Abd: distended, soft, +TTP over right lower and upper quadrants and LLQ. Liver span approximately 4 fingerbreadths past the costal margin, spleen diffusely englarged as well. Ext: no c/c/e, wwp with good distal pulses b/l Neuro: AO x 3, speaking clearly, moving all extremities Pertinent Results: [**1-4**] CXR - AP upright portable chest radiograph is obtained. There is a new right IJ central line with its tip in the approximate location of the right atrium. Persistent right hemidiaphragmatic elevation is noted with right basilar atelectasis and pleural thickening along the lateral aspect of the right lower lung. Left lung remains clear. Cardiomediastinal contour is stable. There is no pneumothorax. The visualized osseous structures remain intact. The IVC/right atrial stent is unchanged. . [**1-4**] CT abd/pelvis with po contrast only - 1. New poorly defined nodular opacities at the lung bases, which are nonspecific, likely representing an infectious etiology. Given history of immunosuppression, atypical infection such as fungal infection cannot be entirely excluded. 2. Moderate intra-abdominal ascites. 3. Resolved bowel wall thickening. 4. New small right-sided pleural effusion. . Brief Hospital Course: 52 y/o female with alcoholic cirrhosis, s/p LRLT [**2159**] c/b graft dysfunction, now p/w fever, hypotension, LLQ abdominal pain. She met septic shock criteria on admission, requiring pressors (levophed/vasopression) for her hypotension. Patient was subsequently found to have MRSA bacteremia, large RA clot extending from the IVC stent that was placed after the graft implantation, the course complicated by septic embolic, and subsuquent respiratory distress requiring ICU readmission. Patient becoming more lethargic, aspirating, with a L effusion concerning for empyema s/p chest tube placement on the left, with transient improvement but change of goals of care to DNR/DNI/CMO. The patient passed away on [**2164-2-8**], approximately 5 hours after care was withdrawn. # ID/sepsis - She was initially started on broad-spectrum antibiotics (dapto, caspo, flagyl, cefepime) which was tapered to Vancomycin when she grew out [**5-11**] blood cultures MRSA from [**1-4**] and 3/4 [**1-5**]. CT chest showed multiple lung nodules and paracentesis was negative for SBP. ID was consulted regarding high-grade bacteremia and possibility of endocarditis. A TTE demonstrated a large, friable thrombus in the RA and SVC, prolapsing into the RV on diastole. Initial CT of the chest demonstrated multiple pulmonary nodules, which were concerning for septic emboli given the high-grade bacteremia and evidence of septic thrombophlebitis. Heparin gtt was started for goal PTT 60-80. Pressors were weaned slightly over the days and repeat TTE on [**1-9**] demonstrated similar clot burden. Interventional and CT surgery were both consulted regarding possibility of intervention; however given her clinical instability, the decision was made to continue with medical management at this time. Repeat TTE on [**1-12**] showed a decreased size in the thrombus but with new adherence to the tricuspid valve. Due to her continued pressor requirements, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim was done which she failed, so she was started on stress-dose steroids x 1 week. She was continued on vancomycin with clearance of her blood cultures since [**1-6**] and has been off pressors for >1 week. Her right IJ line, which was associated with the clot, and left IJ HD catheter were pulled on [**2164-1-19**] after a PICC line was placed on [**1-18**]. Since [**1-20**], she has been having new fever spikes without a clear source. Cefepime was added on [**1-21**] for empiric coverage until further data is available. It was continued for a seven day course, and she remained afebrile and normotensive. She was continued on heparin gtt for the RA clot. On [**2164-2-8**] the patient began to have episodes of complete heart block. There was concern about an aortic abscess. A repeat ECHO was peformed and did not reveal an abscess but did show a moderate to large pericadial effusion. Later that day, the patient was made CMO and care was withdrawn. She went into asystole and passed away at approximately 9pm. # Respiratory - On [**1-6**], the patient went into acute respiratory distress, likely due to embolization of the septic thrombus, and was intubated emergently. A heparin gtt was started for goal 60-80. She was extubated on [**1-10**] without complications. She was noted to have a enlarging left pleural effusion on imaging and due to concern that this was likely infected as well as contributing to her respiratory status, a thoracentesis of 800 cc was done on [**1-19**]. The fluid was exudative without growth to date. A chest tube was placed for drainage of an empyema and was eventually removed. # Acute renal failure - The patient also upon admission was in ARF, secondary to ATN due to sepsis/hypotension based on her sediment. Renal was consulted and as there were no emergent needs for dialysis, supportive care with IVF and pressors was continued. She had worsening acidosis and mental status while intubated, even off sedation, so CVVH was initiated on [**1-14**] and completed on [**1-16**] with some improvement in her renal function. Since then, her urine output has picked up but she continues to have a non-gap m. acidosis with low bicarb levels. Bicarb tablets were started on [**2164-1-22**]. # Sinus tachycardia - since [**1-16**], the patient has had persistent sinus tachycardia with baseline HR in 120's. Her rate intermittently increases to 150's, with no obvious associations (fever, pain, distress, etc). EKG without any ischemic changes. She responds only minimally to volume so has gotten IV lopressor prn for sustained tachycardia >140 with good effect. On [**2164-2-8**] the patient began to have episodes of complete heart block. There was concern about an aortic abscess. A repeat ECHO was peformed and did not reveal an abscess but did show a moderate to large pericadial effusion. Later that day, the patient was made CMO and care was withdrawn. She went into asystole and passed away at approximately 9pm. # Ileus - Throughout her hospital course, the patient developed an ileus, likely secondary to the sedation she received while intubated (fentanyl). She was put on an aggressive bowel regimen, po narcan intermittently, and reglan with her tube feeds being held. She was given TPN in the interim. Her ileus has slowly resolved and she has been tolerating tube feeds. NGT was self-d/c'd by patient on [**2164-1-22**] and plan is to obtain a S+S consult to assess the patient's capability to take orals. # Anemia/thrombocytopenia - patient has had intermittent anemia and thrombocytopenia of unclear etiology. Both her Hct and platelets have been lower than her normal baseline since admission. Initially thought to be secondary to sepsis. DIC and hemolysis was ruled out multiple times throughout the admission. She received PRBCs and platelets intermittently throughout her course. On [**2164-1-22**], the patient developed acute dyspnea, hypoxia, tachypnea and tachycardia during a transfusion with platelets. The transfusion was immediately stopped and the patient was given solumedrol and benadryl with slow improvement in her symptoms. The blood bank was contact[**Name (NI) **] and made aware and will investigate this possible transfusion reaction. She was on a coumadin bridge for her thrombus; in light of her decreasing Hct and possible bleeding source, coumadin was d/c'd on [**2164-1-22**] and heparin gtt was continued. # s/p liver transplant - complicated by graft dysfunction, on transplant list. Followed by hepatology service in-house. She was continued on tacrolimus for goal level [**6-14**], which was dosed accordingly given her fluctuating renal clearance. She was also continued on rifaximin, lactulose, and ursodiol. Paracentesis on admission was without e/o SBP. # Hypothyroidism - continued on synthroid, TFTs rechecked given persistent tachycardia and now pending Medications on Admission: 1. Rifaximin 200 mg tid 2. Omeprazole 20 mg daily 3. Mirtazapine 15 mg qhs 4. Citalopram 20 mg daily 5. Ursodiol 300 mg [**Hospital1 **] 6. Calcium Carbonate 500 mg tid 7. Tacrolimus 0.5 mg [**Hospital1 **] 8. Levothyroxine 25 mcg daily 9. Oxycodone 5 mg q6 hrs prn 10. Aluminum-Magnesium Hydroxide qid prn 11. Metoclopramide 5 mg tid Discharge Medications: Expired on [**2164-2-8**] Discharge Disposition: Expired Discharge Diagnosis: Right Atrial Clot Empyema MRSA bacteremia/endocarditis Complete heart block Discharge Condition: Expired on [**2164-2-8**] Discharge Instructions: Expired on [**2164-2-8**] Followup Instructions: Expired on [**2164-2-8**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "415.12", "785.52", "403.90", "041.11", "038.11", "584.9", "244.9", "426.0", "995.92", "276.1", "287.5", "286.3", "511.9", "996.82", "429.89", "585.9", "416.0", "518.81", "451.89", "V09.0", "421.0", "572.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.95", "96.04", "96.72", "96.6", "34.91", "54.91", "38.95", "34.04" ]

icd9pcs

[ [ [] ] ]

13616, 13625

6305, 13180

349, 445

13744, 13771

5377, 6282

13845, 14009

4528, 4647

13566, 13593

13646, 13723

13206, 13543

13795, 13822

4662, 5358

264, 311

473, 2696

2718, 3610

3626, 4512

54,392

160,027

34889

Discharge summary

report

Admission Date: [**2182-12-5**] Discharge Date: [**2182-12-13**] Date of Birth: [**2106-8-26**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2182-12-9**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to Ramus, SVG to OM) History of Present Illness: 76 y/o male c/o increased dyspnea over last several weeks but has increased in severity over last few days. Presented to OSH and admitted with CHF. Subsequently underwent cardiac cath which revealed severe three vessel coronary disease. Transferred to [**Hospital1 18**] for coronary surgery. Past Medical History: Coronary Artery Disease s/p Myocardial Infarction, Hypertension, Hyperlipidemia, Diverticulitis s/p colectomy, Degenerative disc disease, left eye blindness, Bladder cancer s/p removal, s/p Prostate surgery Social History: Cigarette h/o 50yr pack hx but quit in [**2150**]. Smoked [**9-14**] cigars/day for last 25 years. Denies current ETOH use (last drink in [**2168**]). Family History: Father had MI at 40 y/o. Physical Exam: VS: 57 18 163/80 Gen: NAD Skin: Multiple healed scars on abd HEENT: left eye blind otherwise PERRLA Neck: Supple, FROM, -JVD Chest: CTAB -w/r/ Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -edema, -varicosities Neuro: A&O x 3, MAE Pertinent Results: [**12-5**] Carotid U/S: Minimal plaque with bilateral less than 40% carotid stenosis. [**12-5**] Vein mapping: Duplex evaluation was performed of both lower extremities. The greater saphenous vein on the right is patent with diameters of 0.19 and 0.3, the lesser 0.14-0.22. On the left, the greater shows diameters of 0.18-0.3 in the lesser 0.17-0.26. [**12-5**] Chest CT: 1. Moderate emphysema. 2. Bibasilar septal thickening and peribronchiolar ground-glass opacities, probably representing CHF with hydrostatic pulmonary edema, but differential diagnosis includes a viral pneumonia as well as more chronic interstitial diseases. 3. Four noncalcified pulmonary nodules measuring up to 6 mm in diameter. Followup CT in six months is recommended per the [**Last Name (un) 8773**] guidelines to exclude the possibility of a small lung cancer. At that time, the interstitial abnormalities can be reassessed for resolution. 4. High attenuation of the gallbladder suggesting vicarious excretion of contrast. As the patient received recent iodinated contrast administration, there are also apparent dependent small calcified gallstones. 5. Marked atherosclerotic calcifications in the abdominal aorta and proximal renal arteries. 6. Punctate calcifications in the kidneys and small cystic lesion in upper pole of the left kidney. 7. Three-vessel marked coronary artery calcifications. [**12-6**] Echo: The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with inferior and septal akinesis and apical akinesis/dyskinesis. Overall left ventricular systolic function is moderately to severely depressed (LVEF= 30 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The aortic valve leaflets are mildly thickened. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The pulmonic valve leaflets are thickened. There is no pericardial effusion. [**2182-12-13**] 05:58AM BLOOD WBC-16.8* RBC-3.82* Hgb-11.8* Hct-34.2* MCV-89 MCH-30.9 MCHC-34.5 RDW-14.0 Plt Ct-246 [**2182-12-13**] 01:45PM BLOOD PT-14.8* INR(PT)-1.3* [**2182-12-13**] 05:58AM BLOOD Glucose-98 UreaN-25* Creat-1.1 Na-137 K-3.8 Cl-100 HCO3-24 AnGap-17 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 79857**] was transferred to [**Hospital1 18**] for cardiac surgery. He was appropriately worked up which included usual lab work along with PFT's, Carotid U/S, Echo, Vein mapping, Chest CT, and GI consult. On [**12-9**] he was brought to the operating room where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. Later on this day he was transferred to the telemetry floor for further care. On POD #2, he went into A Fib and was treated with amiodarone. Chest tubes and epicardial pacing wires were removed per csurg protocol. He was placed on Keflex for an erythematous mediastinal incision. He made good progress and was cleared for discharge to home with services on POD 4. Medications on Admission: Aspirin 81mg qd, Labetalol 400mg [**Hospital1 **] (changed to Coreg at OSH), Lisinopril 10mg qd, Lipitor 40mg qd, HCTZ 25mg qd, Proscar, Prilosec, NTG prn, Metamucil Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 7. 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* 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Please take 2 pills twice a day for one week, then one pill twice a day for 2 weeks, then one pill once a day for one week. Disp:*120 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 11. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 13. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1 doses: take 4mg once and then as directed by the office of Dr. [**Last Name (STitle) 3497**] ([**Telephone/Fax (1) 79768**]. INR to be drawn on Monday [**2182-12-16**] and sent to Dr. [**Last Name (STitle) **]. Disp:*60 Tablet(s)* Refills:*0* 14. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 5 days. Disp:*20 Capsule(s)* Refills:*0* 15. Outpatient Lab Work INR to be drawn on Monday [**2182-12-16**] and sent to the office of Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 79768**]. Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 postop A Fib PMH: Myocardial Infarction, Hypertension, Hyperlipidemia, Diverticulitis s/p colectomy, Degenerative disc disease, left eye blindness, Bladder cancer s/p removal, s/p Prostate surgery Discharge Condition: Good Discharge Instructions: no lifting more than 10 pounds for 10 weeks no driving for 4 weeks and off all narcotics report any drainage from, or redness of incisions report any temperature greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week shower daily, no simming or baths no lotions, creams or powders to incisions take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 3497**] in [**3-10**] weeks. INR results to Dr. [**Last Name (STitle) 3497**] ([**Telephone/Fax (1) 79768**].Plan confirmed with [**Doctor Last Name 1060**]. Dr. [**Last Name (STitle) 58623**] in [**2-6**] weeks Wound check in 1 week. Completed by:[**2182-12-13**]

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icd9cm

[ [ [] ] ]

[ "39.61", "38.93", "36.15", "36.13" ]

icd9pcs

[ [ [] ] ]

7569, 7632

4066, 5135

307, 409

7933, 7939

1458, 4043

8348, 8682

1145, 1171

5351, 7546

7653, 7912

5161, 5328

7963, 8325

1186, 1439

260, 269

437, 731

753, 961

977, 1129

29,050

123,707

32899

Discharge summary

report

Admission Date: [**2100-12-1**] Discharge Date: [**2100-12-4**] Date of Birth: [**2039-1-17**] Sex: F Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6736**] Chief Complaint: IR PCN placement Major Surgical or Invasive Procedure: L PCN History of Present Illness: 61 F with h/o right Wilms tumor and left calculi now presents with left flank pain radiating to left groin with fevers, shaking chills and nausea but no emesis. She reports that the pain started on Sunday morning, was intermittent and then appeared to resolve on Monday, however she developed rigors, pain and became anuric Tuesday and was brought to [**First Name3 (LF) **] by her two sons. At [**Name2 (NI) **] she was noted to have a low grade fever of 100.5, a WBC of 3.1 and 15 bands. She was given levaquin and ceftriaxone. A non-contrast CT done there showed a 5mm obstructing left UVJ stone with moderate hydronureteronephrosis and a roughly 15x15cm lower pole renal mass. She was transfered to [**Hospital1 18**] for further management. On arrival in the ED she was hypotensive with blood pressure 70/palp and was stabilized on pressors. She is currently on levophed. She denies recent antibiotic use. Past Medical History: PMH: Wilms tumor HTN PSH: Right nephrectomy [**2078**] CCY-open C-section x 2 Tubal ligation Social History: none Family History: none Physical Exam: PE: 98.9 83 118/61 95% RA NAD CTAB RRR S, ND, left flank, LLQ and epigastric tenderness, no rebound, no guarding. Firm mass palpable left flank. Foley in place with drainage of scant cloudy, yellow urine No C/C/E Pertinent Results: [**2100-12-1**] 06:34PM CK(CPK)-575* [**2100-12-1**] 06:34PM CK-MB-4 cTropnT-0.08* [**2100-12-1**] 10:43AM CK(CPK)-805* [**2100-12-1**] 10:43AM CK-MB-4 cTropnT-0.10* [**2100-12-1**] 08:54AM GLUCOSE-101 UREA N-53* CREAT-3.4* SODIUM-133 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-14* ANION GAP-18 [**2100-12-1**] 08:54AM CALCIUM-7.6* PHOSPHATE-4.4 MAGNESIUM-1.5* [**2100-12-1**] 08:54AM WBC-44.2*# RBC-3.93* HGB-10.9* HCT-32.8* MCV-84 MCH-27.9 MCHC-33.4 RDW-13.8 [**2100-12-1**] 08:54AM NEUTS-72* BANDS-18* LYMPHS-3* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-1* [**2100-12-1**] 08:54AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2100-12-1**] 08:54AM PLT SMR-NORMAL PLT COUNT-238# [**2100-12-1**] 08:54AM PT-15.4* PTT-32.1 INR(PT)-1.4* [**2100-12-1**] 07:05AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014 [**2100-12-1**] 07:05AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD [**2100-12-1**] 07:05AM URINE RBC-[**10-6**]* WBC->50 BACTERIA-MANY YEAST-FEW EPI-[**4-26**] [**2100-12-1**] 05:38AM PT-15.4* PTT-122.6* INR(PT)-1.4* [**2100-12-1**] 03:21AM LACTATE-1.9 [**2100-12-1**] 03:00AM GLUCOSE-96 UREA N-51* CREAT-3.5* SODIUM-134 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-19* ANION GAP-15 [**2100-12-1**] 03:00AM estGFR-Using this [**2100-12-1**] 03:00AM CK(CPK)-940* [**2100-12-1**] 03:00AM CK-MB-4 cTropnT-0.15* [**2100-12-1**] 03:00AM CALCIUM-7.7* PHOSPHATE-3.3 MAGNESIUM-1.5* [**2100-12-1**] 03:00AM WBC-18.1* RBC-3.59* HGB-10.4* HCT-30.0* MCV-84 MCH-29.1 MCHC-34.8 RDW-13.0 [**2100-12-1**] 03:00AM NEUTS-78* BANDS-9* LYMPHS-3* MONOS-6 EOS-1 BASOS-0 ATYPS-0 METAS-3* MYELOS-0 [**2100-12-1**] 03:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2100-12-1**] 03:00AM PLT COUNT-153 [**Last Name (NamePattern4) 76569**]al Course: 61F with urosepsis and obstructing left 5 mm UVJ stone in solitary kidney. Secondarily she also has likley acute, but possibly some chronic, renal failure. Thirdly, she has newly diagnosed large left renal mass concerning for malignancy that will need further evaluation once acute issues are dealth with. -Emergent ICU admission and IR PCN placement, pt toelrated procedure well, UCX OSH sensitive to cipro, placed on cipro, tol po, hd stable, pain well controlled and d/c hoem w/ services and abx course. Obtained MRI abdomen while inpatient to assess renal mass. To f/u Dr. [**Last Name (STitle) **] as outpatient regaridng Renal mass and cystoscopy. Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): for use when taking narcotic pain medicine to prevent constipation. Disp:*60 Capsule(s)* Refills:*2* 3. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*24 Tablet(s)* Refills:*0* 4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain for 30 doses: do not operate machinery. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 8300**] VNA Discharge Diagnosis: L ureteral calculus, sepsis, L PCN, left renal masses Discharge Condition: Stable. Discharge Instructions: -You may shower 2 days after surgery, but do not tub bathe, swim, soak, or scrub incision for 2 weeks. Bandage strips will fall off over time. No heavy lifting for 4 weeks. [**Hospital 16237**] medical attention for fevers (temp>101.5), worsening pain, drainage or excessive bleeding from incision, chest pain or shortness of breath. -Follow up with Dr. [**Last Name (STitle) **], call to make appointment -Please do not drive or consume alcohol while taking pain medications. -Please resume home medication but avoid aspirin and advil for one week. Followup Instructions: -Follow up with Dr. [**Last Name (STitle) **], call to make appointment [**Telephone/Fax (1) 921**] -Please call IR to set up f/u appt.

[ "584.9", "585.9", "403.90", "038.9", "591", "593.9", "592.1", "995.94", "V10.52" ]

icd9cm

[ [ [] ] ]

[ "55.03" ]

icd9pcs

[ [ [] ] ]

4869, 4928

331, 339

5026, 5036

1691, 4305

5635, 5774

1436, 1442

4328, 4846

4949, 5005

5060, 5612

1457, 1672

275, 293

367, 1280

1302, 1398

1414, 1420

62,009

173,127

14163

Discharge summary

report

Admission Date: [**2166-10-5**] Discharge Date: [**2166-10-8**] Date of Birth: [**2092-1-16**] Sex: M Service: MEDICINE Allergies: morphine / Atorvastatin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none. History of Present Illness: This is a 74 y/o russian speaking male with PMH of CAD s/p CABG with CHF (EF 35%), afib on coumadin, CKD (baseline Cr 2.2) who now presents from [**Hospital 100**] Rehab with hypoxia and respiratory distress. . Per records, pt was on treatment for a pneumonia, started on CTX on [**10-1**] for a 7day course. At 4am today, pt was noted to be in respiratory distress and hypoxic to 86% on 2L NC. Pt was using accessory muscles for breathing. Was give 10mg Lasix IV. EMS was called. EMS started the patient on noninvasive positive pressure ventilation. Also, treated pt with SL nitroglycerin as he was complaining of chest pain. Of note, pt was on NC at [**Hospital 100**] rehab since last week bc of the pneumonia. . In the ED, initial vs were: T 97.3 HR 69 BP 120/p RR 25 O2 sat 99% CPAP. Patient triggered on arrival for respiration on non-invasive positive pressure ventilation. Labs revealed Cr 3.3, Lactate 2.5, Hct 27. proBNP was >9000 and TnT was 0.24. He underwent bedside u/s which showed b/l pleural effusions, poor heart squeeze and a non collapsing IVC. CXR showed evidence of volume overload w/ bilateral blunting of the costophrenic angles. Patient received 40 mg lasix IV and aspirin 600 mg PR. Pt briefly placed on nitroglycerin gtt, however, did not tolerate it well with borderline blood pressures so it was dc'd. Pt was given Vancomycin and Cefepime for HCAP. She was transferred to the ICU for further management. VS on transfer were: T 97.3, HR 91, BP 108/61, RR 27, O2 sat 97% NIPPV. . On arrival to the ICU, pt is resting in bed, appears comfortable. Denies pain. Unable to communicate due to fatigue, sleepiness. Also, [**3-12**] language barrier. . Review of systems: unable to obtain Past Medical History: -HTN (noted to be labile) -CAD s/p CABG, MI's -CRF, w/baseline creatinine ~2.2 - s/p thalamic CVA with residual falls, dysphagia, vision impairment, left hemi, 3rd nerve palsy, diminished cognition (MMSA 20/29) -Chronic Atrial Fib on Coumadin -Dementia -PVD -GERD -CHF -Hyperlipidemia -Depression/Anxiety -Protein S Deficiency Thrombophilia (on coumadin, goal [**3-13**]) -Divergent Strabismus -Enlarged Prostate Social History: lives at [**Hospital 100**] rehab, wheelchair bound. needs assistance with ADLs. Married, wife still lives at home in [**Name (NI) 745**]. Has 1 daughter in [**Name2 (NI) **], 3 grandchildren, 1 great-grandchild. Family History: non-contributory Physical Exam: Admission PEx: Vitals: T 97 HR 74 BP 166/50 RR 16 O2 sat 100% NRB General: awakes easily but sleepy HEENT: Sclera anicteric, MMM, oropharynx clear Neck: +JVD Lungs: +[**Last Name (un) 6055**]-Stoke breathing, good breath sounds bilat, +crackles at left base CV: irrgeularly irregular, rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley in place with 250cc clear yellow urine Ext: no clubbing, cyanosis or edema Neuro: unable to assess ===================================== Discharge PEx: Tmax: 37.5 ??????C (99.5 ??????F) Tcurrent: 36.4 ??????C (97.5 ??????F) HR: 51 (41 - 72) bpm BP: 146/52(75) {124/37(68) - 172/81(103)} mmHg RR: 22 (11 - 33) insp/min SpO2: 97% General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, unequal pupils Lymphatic: Cervical WNL Cardiovascular: S1S2 irreg, 2/6 SEM Peripheral Vascular: radial pulses intact Respiratory / Chest: Crackles : right ant, not diffuse, No Wheezes, Diminished at left base, [**Last Name (un) 6055**] [**Doctor Last Name **] breathing Abdominal: Soft, Non-tender Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Warm Neurologic: Follows simple commands Pertinent Results: Labs on admission: [**2166-10-5**] 09:35AM BLOOD WBC-9.8 RBC-2.96* Hgb-9.2* Hct-27.7* MCV-94 MCH-31.2 MCHC-33.3 RDW-15.2 Plt Ct-167 [**2166-10-5**] 09:35AM BLOOD Neuts-86.6* Lymphs-8.3* Monos-4.7 Eos-0.2 Baso-0.2 [**2166-10-5**] 09:35AM BLOOD PT-30.1* PTT-32.7 INR(PT)-2.9* [**2166-10-5**] 09:35AM BLOOD Glucose-127* UreaN-65* Creat-3.3* Na-147* K-4.9 Cl-113* HCO3-21* AnGap-18 [**2166-10-5**] 09:35AM BLOOD LD(LDH)-265* [**2166-10-5**] 03:30PM BLOOD ALT-14 AST-15 LD(LDH)-211 AlkPhos-64 TotBili-0.6 [**2166-10-5**] 03:30PM BLOOD Albumin-3.9 Calcium-9.2 Phos-4.6* Mg-2.9* Iron-24* [**2166-10-5**] 03:30PM BLOOD calTIBC-248* Ferritn-288 TRF-191* [**2166-10-5**] 10:07AM BLOOD Lactate-2.5* [**2166-10-5**] 09:35AM BLOOD proBNP-9288* [**2166-10-5**] 09:35AM BLOOD cTropnT-0.24* [**2166-10-5**] 03:30PM BLOOD cTropnT-0.29* [**2166-10-5**] 10:41PM BLOOD cTropnT-0.27* [**2166-10-6**] 03:52AM BLOOD cTropnT-0.26* Labs on Discharge: [**2166-10-7**] 04:44AM BLOOD WBC-8.6 RBC-3.00* Hgb-9.2* Hct-28.1* MCV-94 MCH-30.7 MCHC-32.8 RDW-14.9 Plt Ct-176 [**2166-10-7**] 04:44AM BLOOD Glucose-104* UreaN-63* Creat-2.9* Na-146* K-4.2 Cl-109* HCO3-23 AnGap-18 [**2166-10-7**] 04:44AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.7* CXR ([**10-5**]): 1. Bibasilar opacities with bibasilar consolidations, likely reflecting components of atelectasis and pleural effusion, although underlying infection cannot be excluded - post-diuresis radiograph may be considered to further assess. 2. Cardiomegaly and perihilar opacities compatible with pulmonary edema secondary to heart failure. CXR ([**10-6**]): Improved aeration of the lungs compared to [**10-5**] am. Stable cardiomegally. Small left pleural effusion. Echo ([**10-6**]): The left atrium is markedly dilated. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with inferior and infero-lateral akinesis, The distal septum and septal apex are hypokinetic. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with borderline normal free wall function. There is abnormal septal motion/position. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: This is a 74 y/o russian speaking male with PMH of CAD s/p CABG with CHF (EF 35%), afib on coumadin, CKD (baseline Cr 2.2) who now presents from [**Hospital 100**] Rehab with hypoxia and respiratory distress. . Active Issues: # Hypoxia/respiratory distress and CHF: diff is broad but likely [**3-12**] acute CHF exacerbation. Patient doing much better after IV lasix with approximately 2-3L net negative output. No clear source of infection as to why patient had acute CHF exacerbation; infectious workup negative. Continued supportive O2 with NC and face mask. Echo showed worsening MR (3+), pulmonary HTN, and EF of 35%. Continued home Ipratropium nebs as needed. Patient was evaluated by speech/swallow and thought to be at risk for aspiration but we discussed at length with wife about goals of care and she wants him to be comfortable and eat if he's hungry. We placed him on a soft, honey thickened diet. -on [**2166-10-7**] given total of 80mg IV lasix with -2.5 L net output. Continues to have bibasilar crackles and will need to be frequently reassessed. -Goal negative 1-2 L/day - Recommend transition to regular oral diuretic regimen - Recommend beginning an afterload reducing regimen for crhonic management of heart failure . # Acute on chronic RF: likely [**3-12**] poor perfusion from volume overload state. UA neg for infection. Have avoided nephrotoxins, renally dosed meds. . # Hypernatremia: Patient's sodium 149 on day of discharge, likely secondary to reduced free water intake in the setting of diuresis. He was given 1 liter of D5W. We recommend encouraging increased free water intake by actively giving him water/juice as he is unable to keep up with intake on his own. . # Anemia: likely chronic [**3-12**] renal failure, however 7 point drop from baseline of 35 in [**6-18**]. Patient should be evaluated for restarting home Fe/Vit B12 upon arrival at [**Hospital 100**] Rehab. . # Atrial Fibrillation: currently rate-controlled with frequent PVCs. Patient asx. On Coumadin and INR checks. PCP at [**Hospital1 100**] may want to re-evaluate whether this patient needs to be on Coumadin given frequent INR checks and goals of care. -many meds held due to BP/clinical status, will need to be evaluated whether need to restart once stable. -INR 3.1 today, have reduced warfarin to 1mg from 1.5mg po daily. Will need to continue INR checks periodically to maintain therapeutic dosing. . # Psych: stable while here at ICU. - will reeval restarting Remeron and Risperidone at [**Hospital1 100**]; was NPO for most of time here and held meds. . # Communication: Patient, [**Name (NI) **] (wife) [**Telephone/Fax (1) 42153**] . # Code: DNR/DNI (discussed with HCP) . Pending tests: none. . Transitional issues: Patient will need continued diuresis pending clinical improvement and twice daily labs while on IV diuretics. Patient will likely resume PO lasix regimen once more stable. Also will need to evaluate need for remeron, risperdol, coumadin, vitamins, anti-hypertensives and others as above. Patient should also be assessed for use of afterload reduction medications. Also INR will need to be followed with reduced dose of Warfarin. Medications on Admission: Ceftriaxone 1g daily (started on [**10-1**]) Thorazine 50mg [**Hospital1 **] PRN Nitro ointment Warfarin 1.5mg daily ASA 81mg daily Zetia 10mg daily Risperidone 0.25mg QHS FeSO4 325mg daily Vit B12 100 mcg daily Hydralazine 50mg [**Hospital1 **] Tylenol 650mg Q6H PRN Senna 17.2mg QHS Amlodipine 10mg daily Remeron 15mg QHS Lasix 40mg daily Isosorbide Mononitrate 120mg daily Ipratropium Q4H PRN Albuterol Q4H PRN Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 3. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed for SOB. 4. furosemide 10 mg/mL Solution Sig: as needed mg Injection ONCE (Once): please give IV lasix as needed while fluid overloaded; can transition to daily PO lasix once stable. 5. Outpatient Lab Work please obtain twice daily labs including PM electrolytes while actively diuresing with lasix. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: acute congestive heart failure exacerbation pulmonary edema acute kidney injury Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname 42154**], It was a pleasure taking care of you at the [**Hospital1 771**]. You presented to the hospital with difficulty breathing and was found to have pulmonary edema, fluid in your lungs, likely secondary to an acute heart failure exacerbation. . You have congestive heart failure, which is a condition in which the pumping function of your heart is impaired. As a result of your heart's impaired pumping function, you are prone to accumulating excess fluid in parts of the body where fluid should not normally be; fluid that accumulates in the lower extremities causes swelling, and fluid that accumulates in the lungs causes shortness of breath. . During this hospitalization, you were given medicines that removed the exess fluid from your body and your heart medicines were optimized; however, what we have done for you in the hospital is not the end of your treatment. You will continue to have more fluid removed at [**Hospital 100**] Rehab MACU unit, as well as twice daily labs. . It is very important that you adhere to fluid restrictions prescribed and that you refrain from consuming salt; failure to do so may result in you accumulating excess fluid and requiring re-hospitalization. . Please get weighed frequently and have your PCP reassess your need for diuretics should be noted to more than 5 pound weight gain. Followup Instructions: will be going to [**Hospital 100**] Rehab (longterm resident) Medical Acute Care Unit (MACU) with high level of care. Will see physician there and they will arrange necessary followup. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "V49.86", "V46.3", "799.02", "414.00", "V45.81", "530.81", "V58.61", "600.00", "285.21", "403.90", "276.0", "416.8", "428.23", "584.9", "428.0", "585.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11157, 11223

6951, 7162

311, 319

11347, 11347

4155, 4160

12870, 13194

2754, 2772

10580, 11134

11244, 11326

10141, 10557

11486, 12847

2787, 4136

9684, 10115

2051, 2070

252, 273

7177, 9663

5085, 6928

347, 2032

4175, 5065

11362, 11462

2092, 2507

2523, 2738

1,350

151,527

23888

Discharge summary

report

Admission Date: [**2153-2-23**] Discharge Date: [**2153-3-2**] Date of Birth: [**2086-12-15**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Atrial Myxoma Major Surgical or Invasive Procedure: [**2153-2-23**] Cardiac Catheterization [**2153-2-26**] Atrial myxoma removal with patch repair History of Present Illness: 66 yo Haitian woman (recently moved from [**Country 2045**], French Creole speaking) presented to [**Hospital3 1443**] on [**2153-2-21**] with progressive exertional dyspnea and fatigue, as well as chest pain and decreased appetite. A TEE [**2153-2-22**] showed a large mass attached to the interatrial septum-4x3cm. Since admission she has been stable without symptoms of chest pain or shortness of breath. She ruled out for a myocardial infarction. She will undergo a cardiac catheterization and possible cardiac surgery. Past Medical History: Hypertension Gastroesophageal reflux disease Migraine Headaches Social History: recently moved from [**Country 2045**] in [**11-29**], speaks French Creole only, currently living with her son. Family History: non-contriubutory Physical Exam: Afeb 72 175/63 20 98%RA No acute distress, alert and orientedx3, lying on bed post cath History taken by creole translator. Poor dentition, no Lymphadenopathy, no JVD RRR with II/VI SEM Clear lungs soft, nontender, nondistended, +Bowel sounds No cyanosis or edema, Warm Pertinent Results: [**2153-2-23**] 01:00PM GLUCOSE-174* UREA N-21* CREAT-0.9 SODIUM-135 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-24 ANION GAP-12 [**2153-2-23**] 01:00PM ALT(SGPT)-21 AST(SGOT)-19 ALK PHOS-72 AMYLASE-99 TOT BILI-0.3 [**2153-2-23**] 01:00PM ALBUMIN-3.4 [**2153-2-23**] 01:00PM WBC-8.5 RBC-4.34 HGB-10.5* HCT-34.2* MCV-79* MCH-24.2* MCHC-30.7* RDW-15.0 [**2153-2-23**] 01:00PM NEUTS-56.5 LYMPHS-36.4 MONOS-4.4 EOS-2.6 BASOS-0.1 [**2153-2-23**] 01:00PM HYPOCHROM-2+ MICROCYT-1+ [**2153-2-23**] 01:00PM PLT COUNT-320 [**2153-2-23**] 01:00PM PT-13.3 INR(PT)-1.1 [**2153-2-23**] 12:00PM INR(PT)-1.1 [**2153-2-23**] 04:28PM URINE RBC-8* WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 Cardiac Cath [**2153-2-23**]: 1. Selective coronary angiography demonstrated no angiographically apparent flow limiting coronary artery disease. The LMCA was without flow limiting stenosis. The LAD and its two small diagonal branches were without flow limiting disease. The Ramus Intermedius was without flow limiting disease. The LCX and its moderate sized OM1 were without flow limiting disease. The RCA was a dominant vessel without flow limiting disease. Small vessels supplying the presumed left atrial mass were seen originating from the RCA and LCX. 2. Left ventriculography demonstrated preserved systolic function with LVEF of 60%. No regional wall motion abnormalities seen. No mitral regurgitation seen. 3. Limited resting hemodynamics demonstrated systemic systolic hypertension of 177/81. There was elevated left sided filling pressures with LVEDP of 20mmHg. No aortic stenosis gradient seen on catheter pullback. FINAL DIAGNOSIS: 1. No angiographically apparent flow limiting coronary artery disease. 2. Mild diastolic LV dysfunction. 3. Moderate systemic hypertension. [**2153-2-28**] Chest X-Ray Mild cardiomegaly and improving CHF. No pneumothorax. Status post extubation, right IJ line removal and removal of mediastinal tubes, chest tubes and NG tube. No pneumothorax. Increased bilateral pleural effusion with atelectasis. [**2153-2-26**] EKG Sinus rhythm 85. Right bundle-branch block. Compared to the previous tracing the right bundle-branch block is new. Brief Hospital Course: Ms. [**Known lastname 60922**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical Center on [**2153-2-23**] for further management of her atrial myxoma. A cardiac catheterization was performed which revealed clean coronaries. The cardiac surgical service was consulted and Ms. [**Known lastname 60922**] was worked-up in the usual preoperative manner. On [**2153-2-26**], Ms. [**Known lastname 60922**] was taken to the operating room where she underwent removal of her left atrial myxoma with a patch repair. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Ms. [**Known lastname 60922**] [**Last Name (Titles) **]e neurologically intact and was extubated. Coumadin was started for anticoagulation for her patch repair. Her drains and pacing wires were removed per protocol. Later on postoperative day one, she was transferred to the cardiac surgical step down unit for further recovery. She was gently diuresed towards her preoperative weight. Ms. [**Known lastname 60922**] became tachycardic for which beta blockade was started and adjusted for optimal heart rate and blood pressure control. The physical therapy service was consulted for assistance with her postoperative strength and mobility. Ms. [**Known lastname 60922**] continued to make steady progress and was discharged home on postoperative day four. She will follow-up with Dr. [**Last Name (STitle) **], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Transfer mediciations: HCTZ 25mg daily, protonix 40mg daily, Lopressor 50mg [**Hospital1 **]. Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 7 days. Disp:*14 Capsule, Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: then per Dr.[**Name (NI) 60923**] office. Disp:*30 Tablet(s)* Refills:*0* 8. Outpatient Lab Work 9. Outpatient Lab Work please draw PT/INR [**3-5**] and call results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office @([**Telephone/Fax (1) 60924**] Discharge Disposition: Home With Service Facility: MULTICULTURAL HOME CARE Discharge Diagnosis: atrial myxoma s/p removal of atrial myxoma Discharge Condition: stable Discharge Instructions: you may take a shower and wash your incisions with mild soap and water do not swim or take a bath for 1 month do not apply lotions, creams, ointments or powders to your incisions do not lift anything heavier than 10 pounds for 1 month do not drive for 1 month Followup Instructions: follow up with Dr. [**Last Name (STitle) **] in 1 week follow up with Dr. [**Last Name (STitle) **] in [**1-26**] weeks go to Dr.[**Name (NI) 60923**] office [**3-5**] for blood draw Completed by:[**2153-3-19**]

[ "429.9", "790.6", "530.81", "212.7", "401.9" ]

icd9cm

[ [ [] ] ]

[ "34.04", "35.50", "89.68", "88.56", "39.61", "99.04", "39.64", "88.53", "37.22", "37.33" ]

icd9pcs

[ [ [] ] ]

6653, 6707

3734, 5320

335, 433

6794, 6802

1548, 3156

7110, 7329

1220, 1239

5464, 6630

6728, 6773

5346, 5441

3173, 3711

6826, 7087

1254, 1529

282, 297

461, 986

1008, 1074

1090, 1204

31,882

127,515

32208

Discharge summary

report

Admission Date: [**2192-11-9**] Discharge Date: [**2192-11-14**] Date of Birth: [**2121-9-2**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: Coffee, ground emesis with known h/o paraesophageal hernia repair Major Surgical or Invasive Procedure: Open repair of recurrent paraesophageal hernia with graft reinforcement, Nissen fundoplication, [**Last Name (un) **] gastroplasty, and flexible gastroscopy History of Present Illness: 71 y/o female w/ h/o hiatal hernia repair ('[**86**]) presented to [**Hospital **] Hospital last Friday ([**11-2**]) w/the sudden onset of epigastric pain and vomiting. A work-up was performed and the patient was transferred to [**Hospital1 18**] as a direct admit to Dr. [**Last Name (STitle) **] for repair of her hiatal hernia via an abdominal approach. The patient denies hematemesis, hematochezia/BRBPR, black & tarry stools, chest pain, SOB, visual changes, diaphoresis, diarrhea . This woman has had a recurrent paraesophageal hernia. She originally presented with an incarceration which resolved with nasogastric suction and was discharged. Past Medical History: PMH: Hypothyroid, Hiatal Hernia, Anxiety, GERD, s/p H.pylori treatment [**10-10**] w/Prevpac (Lansoprazole,Amoxicillin,& Clarithromycin) . PSH: Hiatal Hernia repair ('[**85**]),Carpal tunnel release, Appendectomy, Cholecystectomy, Hysterectomy Social History: Retired. Married. Lives with husband. Denies use of tobacco products and illicit drugs. Reports drinking ETOH occasionally during social events. Family History: noncontributory Physical Exam: ED Report-Transferred from [**Hospital **] Hospital Vitals: T-96.7, HR-74, BP-105/72, RR-18, O2 sat-97% Const: NAD, A/Ox3 Head/Eyes: PERRLA, EOMI ENT/NECK: OP clearn, NGT in place Resp: CTAB ABD: minimal TTP epigastrium, no rebound/guarding Extrem: no C/C/E SKIN: W/D/I Pertinent Results: [**2192-11-12**] 05:40AM BLOOD WBC-10.7 RBC-3.88* Hgb-11.8* Hct-33.9* MCV-87 MCH-30.5 MCHC-34.9 RDW-14.3 Plt Ct-214 [**2192-11-9**] 03:40AM BLOOD WBC-5.4 RBC-2.57*# Hgb-7.8*# Hct-23.0*# MCV-89 MCH-30.2 MCHC-33.8 RDW-14.2 Plt Ct-140* [**2192-11-9**] 02:38PM BLOOD PT-14.0* PTT-29.9 INR(PT)-1.2* [**2192-11-12**] 05:40AM BLOOD Glucose-102 UreaN-11 Creat-0.6 Na-134 K-3.9 Cl-103 HCO3-27 AnGap-8 [**2192-11-9**] 03:40AM BLOOD Glucose-73 UreaN-10 Creat-0.2* Na-151* K-1.8* Cl-125* HCO3-20* AnGap-8 [**2192-11-12**] 05:40AM BLOOD Calcium-8.0* Phos-1.3* Mg-1.8 [**2192-11-9**] 02:38PM BLOOD Albumin-3.3* Calcium-8.1* Phos-3.1 Mg-1.8 Iron-101 [**2192-11-10**] 12:34AM BLOOD Glucose-164* Lactate-2.1* Na-143 K-3.4* Cl-110 [**2192-11-10**] 12:34AM BLOOD Hgb-13.5 calcHCT-41 O2 Sat-98 [**2192-11-10**] 02:26AM BLOOD freeCa-1.10* . Pathology Examination Procedure date [**2192-11-9**] DIAGNOSIS: I. Hernia sac: Fibrovascular adipose tissue with chronic inflammation and reactive changes (hiatal hernia). II. Fundus of stomach: - Fundic mucosa with mild chronic inflammation. - Fragment of fibroadipose tissue and smooth muscle with mild chronic inflammation. . RADIOLOGY Final Report CHEST (PA & LAT) [**2192-11-12**] 3:43 PM REASON FOR THIS EXAMINATION: Rule out pneumonia, assess for atelectasis; also r/o pneumothorax - left pleural space entered during recent surgery IMPRESSION: Mild cardiomegaly. Bibasilar pleural effusions of mild extent. Retrocardiac atelectasis. Brief Hospital Course: Mrs. [**Known lastname 16968**] was transferred from [**Hospital **] Hospital, and work-ed up in [**Hospital1 18**] ED for Upper GI Bleed. NGT output was 1 liter of coffee ground. GI and General Surgery services were consulted. She received 2 units of PRBC, and was transferred to the SICU for an endoscopy. . ABD/GI: Previous imaging from most recent hospitalization revealed:[**11-4**] CXR-Large hiatal hernia w/predominantly intrathoracic stomach, [**11-5**] SBFT-large Type 3 hernia with the GE junction visualized above the left diaphragm. The endoscopy completed on [**2192-11-10**] revealed a Esophagitis, Blood in the fundus and antrum, & Large hiatal hernia Otherwise normal EGD to antrum. . RESP:She required 3 liters of oxygen via nasal cannula post-op to maintain sats above 94%. She was routinely weaned on POD1, and desaturated to 86-88% on RA, and to 78% with activity. She required oxygen support for a few days. A PA/Lat was obtained revealing atelectasis. Her lung sounds remained clear, but were decreased middle to lower bases with mild exp wheeze in middle right lobe. She was managed with Albuterol/Atrovent nebs q6 hours, aggressive chest PT, Incentive spirometer use, and frequent ambulation. She was evaluated per Physical Therapy throughout her admission. She was able to successfully wean off oxygen on POD3. Her sats have remained above 95% with no SOB/DOE/wheeze. . NUT:She was made NPO upon admission. An NGT was inserted in the ED, and removed on POD 2. Her diet was advanced gradually. She is tolerating regular diet without complaints of nausea/vomiting. . ELIM:She had a foley catheter inserted intra-op. The catheter was removed, and she was able to urinate without difficulty. She reports passing flatus, but has not had a bowel movement since surgery. . PAIN:Her pain was managed with IV Morphine pre-op. She was managed with an IV PCA post-op with adequat relief. She was transitioned to oral Percocet with relief. She will continue with this regimen for 2 weeks post-discharge. . Medications on Admission: Synthroid 150 mcg daily QOD 4 days/wk, Lopressor 25 mg daily, Ativan 0.5mg PRN Discharge Medications: 1. Nystatin 100,000 unit Tablet Sig: One (1) Tablet Vaginal HS (at bedtime). 2. Levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO every other day. 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 months: Take with Percocet. Disp:*60 Capsule(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:*35 Tablet(s)* Refills:*0* 6. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. Discharge Disposition: Home Discharge Diagnosis: Primary: Paraesophageal hernia Upper GI bleed Post-op atelectasis . Secondary: Hypothyroid, Hiatal Hernia, Anxiety, GERD, H.Pylori Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to amubulate several times per day. . Incision Care: -Your staples will be removed at your follow-up appointment with Dr. [**Last Name (STitle) **]. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: 1. Provider: [**Name10 (NameIs) **] RM 2 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2192-12-6**] 11:00 2. Please make a follow-up appointment with Dr. [**Last Name (STitle) **] in 3 weeks, [**Telephone/Fax (1) **]. 3. Make a follow-up appointment with Dr. [**Last Name (STitle) 31446**] [**Name (STitle) 8521**], [**Telephone/Fax (1) **] in [**12-6**] weeks or as needed. Completed by:[**2192-11-14**]

[ "244.9", "530.19", "518.0", "578.9", "300.00", "552.3", "530.81" ]

icd9cm

[ [ [] ] ]

[ "44.66", "45.13", "44.69", "53.7" ]

icd9pcs

[ [ [] ] ]

6280, 6286

3483, 5504

380, 539

6460, 6537

1987, 3211

7955, 8372

1665, 1682

5634, 6257

6307, 6439

5530, 5611

6561, 7605

7620, 7932

1697, 1968

275, 342

3240, 3460

567, 1219

1241, 1487

1503, 1649

54,289

162,528

34670+57935

Discharge summary

report+addendum

Admission Date: [**2106-7-11**] Discharge Date: [**2106-7-11**] Date of Birth: [**2031-11-1**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2777**] Chief Complaint: 74 F [**Hospital 4747**] transfer from OSH with bilateral LE acute ischemia and infra-renal aortic occlusion. Major Surgical or Invasive Procedure: Bilateral groin cutdown incisions, thrombectomy of the aorta and bilateral iliac arteries, bilateral iliac artery stents, and bilateral 4 compartment fasciotomies History of Present Illness: At around 9:30 PM the patient was in the rest room with some diarrhea. She noticed she was unable to rise from the toilet and had to call her husband for help. She has severe pain in both legs with weakness. She presented to [**Hospital 882**] hospital where she was found to have no pulses in both her lower limbs. She developed sensory and motor loss in bilateral lower limbs. CTA performed demonstrated infra-renal aortic occlusion. She was transferred to [**Hospital1 18**] for further management. Vascular surgery consulted STAT. Past Medical History: Past Medical History: Afib, diastolic CHF, HTN, mild valvular disease (1+ MR [**First Name (Titles) **] [**Last Name (Titles) **]), GERD, Colitis, COPD, depression, sigmoid colitis, chronic back pain with compression fractures Past Surgical History: c-section, surgery for endometriosis (? surgery), open cholecystectomy Social History: She is married and lives with husband. She is retired. She used to work as a telephone operator and also in schools serving school lunches. She has smoked in the past and quit to [**2096**]. She does not drink alcohol or use recreational drugs. Family History: Mother died at 72 of MI. Father died at 75 of MI. She has 2 to half brothers, 1 who died at age 54 of gastric cancer, the other died at age 30 of an accident. She had 1 sister who died at age 56 of unknown cause. Physical Exam: At time of consultation VS: HR 110-120's SBP 80's/40's (consistent both arms) Gen: AOx3, in significant discomfort CVS: irreg Pulm: no distress Abd: S/NT/ND LE: cold, pale bilateral/cyanotic. no motor strength no sensation from thighs down. no edema. Pulses: no pulses dopplerable bilaterally in lower extremities Pertinent Results: [**2106-7-11**] 01:48AM WBC-11.3*# RBC-4.78 HGB-14.1 HCT-46.2 MCV-97 MCH-29.6 MCHC-30.6* RDW-15.5 [**2106-7-11**] 01:48AM GLUCOSE-169* UREA N-20 CREAT-1.4* SODIUM-132* POTASSIUM-5.2* CHLORIDE-100 TOTAL CO2-10* ANION GAP-27* [**2106-7-11**] 01:48AM cTropnT-0.13* Brief Hospital Course: Mrs. [**Known lastname 33976**] was transferred from [**Hospital 882**] Hospital with infrarenal aortic occlusion and bilateral lower extremity ischemia. She underwent urgent bilateral groin cut-down with thrombectomy of her aorta and iliac arteries, bilateral common iliac artery stents, and bilateral 4 compartment fasciotomies. Post-operatively she was transferred to the CVICU where she remained in critical condition. She required vasopressor support(epinephrine and neosynephrine) to maintain a normal blood pressure and remained intubated. She remained extremely acidemic despite treatment with bicarbonate and fluid resuscitation. Her vasopressor requirement increased. A bedside echocardiogram was performed and demonstrated lateral wall hypokinesis. Dobutamine was started. Her family was notified of her worsening status and they elected to make her DNR. It was agreed between the family and the Vascular Surgery team to increase vasopressor support as needed to provide time for more family members to arrive but if she went into cardiac arrest we would not resuscitate her. Her family was with her at the bedside when she expired at 3:52pm. They declined an autopsy. Dr. [**Last Name (STitle) **] was promptly notified. Medications on Admission: Advair Diskus 100 mcg-50 mcg/Dose for Inhalation, Furosemide 20mg daily, Prilosec 10mg daily, Nifedipine 10mg daily, Percocet 2.5 mg-325mg prn Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Infrarenal aortic occlusion with bilateral lower extremity ischemia. Multi-system organ failure. Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Name: [**Known lastname 9019**],[**Known firstname 194**] Unit No: [**Numeric Identifier 12773**] Admission Date: [**2106-7-11**] Discharge Date: [**2106-7-11**] Date of Birth: [**2031-11-1**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 726**] Addendum: 1. The patient had bilateral iliac stents only. None were placed into the aorta. 2. The patient had compartment fasciotomies because she had prolonged lower extremity ischemia. 3. Multi system organ failure involved cardiac, pulmonary, and renal organs. Discharge Disposition: Expired [**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 730**] MD [**MD Number(2) 731**] Completed by:[**2106-8-27**]

[ "458.9", "459.89", "530.81", "444.09", "728.89", "V66.7", "V49.86", "V15.82", "276.2", "440.21", "428.32", "518.81", "998.01", "496", "411.89", "584.9", "V58.61", "787.91", "427.31", "444.89", "428.0" ]

icd9cm

[ [ [] ] ]

[ "38.08", "39.90", "39.56", "00.43", "88.42", "99.19", "83.09", "00.46", "39.50", "39.79", "88.48" ]

icd9pcs

[ [ [] ] ]

4979, 5146

2627, 3871

413, 578

4245, 4255

2335, 2604

4311, 4956

1770, 1985

4066, 4072

4125, 4224

3897, 4043

4279, 4288

1418, 1491

2000, 2316

264, 375

606, 1145

1189, 1395

1507, 1754

5,645

116,937

51872

Discharge summary

report

Admission Date: [**2143-3-21**] Discharge Date: [**2143-3-26**] Date of Birth: [**2102-8-24**] Sex: M Service: NEUROLOGY Allergies: Penicillins / Vancomycin / Gentamicin Attending:[**First Name3 (LF) 6075**] Chief Complaint: seizure Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 40 yo man (unknown if L or R handed), with paraplegia following MVA, asthma, GERD, substance abuse, ? seizure disorder, decubitus ulcers, s/p osteomyelitis who was brought to ED by EMS. Per EMS records, the family called EMS for confusion at home. He apparently had been taken off benzo's and narcotics recently (not known when and what he had been taking). He was found to have shaking in his upper body, but was able to respond to voice. On the way in he was given ativan 5mg im. Upon arrival in the ED (23.06), he still had rhythmical movements in his upper body and respiratory muscles. He was able to mumble to voice but could not follow any commands. Shorlty after arrival, the seizure activity appeared to stop, but then it resumed. He was given 6mg ativan iv and 5mg valium iv and was loaded on Dilantin 1.5g iv. Around 23.45, after the dilantin was loaded, the seizure broke. ROS: not able to obtain Past Medical History: 1. Paraplegia s/p MVA at age 15 2. hx of decubitus ulcer on right buttock s/p failed attempt at closure 3. Asthma 4. GERD 5. hx of pos PPD - treated 17 yrs ago 6. hx of UTIs 7. hx of substance abuse Social History: [**12-3**] ppd tobacco occasional EtOH - none in last month; lives in [**Location **] village, recently living with sister. [**Name (NI) **] reported cocaine use 2 weeks before event, claims none more recently than that. Family History: Noncontributory. Physical Exam: VITALS: T100.6 BP210/170 -->156/90 in ED --->70's/40's after med load RR21 sO2 100 HR 86 GEN: lethargic, responding to voice with mumbling, not following commands HEENT: mmm NECK: no LAD; no carotid bruits; neck supple LUNGS: Clear to auscultation bilaterally HEART: Regular rate and rhythm, normal S1 and S2 ABDOMEN: normal bowel sounds, soft, nontender, nondistended; old scars EXTREMITIES: decubitus ulcers buttocks and several lesions R-foot; amputated toes bilat. MENTAL STATUS: letahrgic; not following commands; mumbles when asked to give his name CRANIAL NERVES: II: Blink to threat, pupils equally round and reactive to light both directly and consensually, 4-->2 mm bilaterally. III, IV, VI: during seizure, eyes midline to slight R-deviation; does not track following seizure. Respond to tickle nose. Face looks symmetrical. Able to vocalize. MOTOR SYSTEM: during seizure, moves both upper extremities as well as abdominal muscles; no facial twitching. After seizure, tries to take off mask with R-hand, good strength. Some spontaneous movement in L-arm, but much less than R and no response on L to noxious. LE: no spontaneous movements or movements elicited by noxious stimuli. Wasting of distal muscles L-hand >R-hand. SENSORY SYSTEM: Withdraws to noxious stimuli in R hand, not left. No response in LE (s/p paraplegia) REFLEXES: Not able to elicit reflexes. Toes: mute bilaterally. COORDINATION: not able to test GAIT: not able to test Pertinent Results: [**2143-3-21**] 08:57PM PHENYTOIN-18.0 [**2143-3-21**] 05:40AM GLUCOSE-134* UREA N-6 CREAT-0.6 SODIUM-144 POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-25 ANION GAP-15 [**2143-3-21**] 05:40AM ALT(SGPT)-14 AST(SGOT)-27 LD(LDH)-253* ALK PHOS-88 AMYLASE-113* TOT BILI-0.5 [**2143-3-21**] 05:40AM LIPASE-25 [**2143-3-21**] 05:40AM CK-MB-8 cTropnT-<0.01 [**2143-3-21**] 05:40AM ALBUMIN-3.9 CALCIUM-8.8 PHOSPHATE-3.3 MAGNESIUM-1.5* [**2143-3-21**] 05:40AM TSH-0.87 [**2143-3-21**] 05:40AM PHENYTOIN-27.3* [**2143-3-21**] 05:40AM WBC-12.1* RBC-5.33 HGB-15.6 HCT-45.2 MCV-85 MCH-29.3 MCHC-34.6 RDW-14.7 [**2143-3-21**] 05:40AM NEUTS-81.8* LYMPHS-13.3* MONOS-3.1 EOS-1.4 BASOS-0.3 [**2143-3-21**] 05:40AM PLT COUNT-229 [**2143-3-21**] 05:40AM PT-12.6 PTT-31.6 INR(PT)-1.1 [**2143-3-20**] 11:53PM GLUCOSE-93 LACTATE-1.6 NA+-145 K+-3.8 CL--108 TCO2-28 [**2143-3-20**] 11:45PM UREA N-8 CREAT-0.6 [**2143-3-20**] 11:45PM ALT(SGPT)-16 AST(SGOT)-25 LD(LDH)-215 CK(CPK)-309* ALK PHOS-80 AMYLASE-95 TOT BILI-0.4 [**2143-3-20**] 11:45PM LIPASE-34 [**2143-3-20**] 11:45PM CK-MB-6 [**2143-3-20**] 11:45PM ALBUMIN-3.7 CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-1.9 [**2143-3-20**] 11:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2143-3-20**] 11:45PM URINE HOURS-RANDOM [**2143-3-20**] 11:45PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG [**2143-3-20**] 11:45PM WBC-9.6 RBC-4.71 HGB-13.9* HCT-39.9* MCV-85 MCH-29.6 MCHC-34.9 RDW-14.5 [**2143-3-20**] 11:45PM PLT COUNT-183 [**2143-3-20**] 11:45PM PT-13.0 PTT-30.8 INR(PT)-1.1 [**2143-3-20**] 11:45PM FIBRINOGE-330 [**2143-3-20**] 11:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2143-3-20**] 11:45PM URINE RBC-[**10-21**]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 CXR: IMPRESSION: Bibasilar opacities likely due to lower lobe collapse or possibly pneumonia secondary to aspiration. CT head [**3-21**]: Non-contrast head CT. FINDINGS: High-attenuation material is identified layering within several right parietal sulci concerning for subarachnoid hemorrhage. There is no evidence of mass effect, shift of normally midline structures or hydrocephalus. A 2.1 x 2.0cm low-attenuation focus in the right posterior parietal lobe with a slightly higher attenuation center, concerning for possible mass with surrounding edema. Additional ill- defined areas of low attenuation are seen in the white matter tracts of the bilateral occipital lobes and may represent vasogenic edema. No other definite parenchymal abnormality is identified. The surrounding soft tissue and osseous structures are unremarkable. Visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: 1. High-density material layering within several right parietal lobe sulci consistent with subarachnoid hemorrhage. 2. A 2-cm focal area of hypoattenuation within the right superior parietal lobe with central area of low attenuation concerning for possible underlying mass lesion with surrounding edema; alternatively, this may simply represent edema surrounging [**Doctor Last Name 352**] matter. 3. Hypoattenuation within the white matter tracts of the bilateral occipital lobes, which may reflect vasogenic edema. These findings are concerning for underlying lesion and followup with MR or contrast-enhanced CT is recommended when the patient is more stable. These findings were discussed with Dr. [**Last Name (STitle) 28438**] at 1:00 a.m. on [**2143-3-21**]. EEG following AM: BACKGROUND: Showed an alpha frequency at times but was most often a lower voltage fast record. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: The patient appeared to remain awake or mildly drowsy throughout the recording. No stage II sleep was obtained. CARDIAC MONITOR: Showed an irregular rhythm at times. There were long periods of a normal sinus rhythm, but there were other periods with far less regular rhythm. IMPRESSION: Normal EEG in the waking and drowsy states. The faster background rhythms raise the possibility of medication effect. There were no areas of focal slowing, and there were no epileptiform features. An abnormal cardiac rhythm was noted, but this would be assessed better through routine ECG tracings. Cervical spine. HISTORY: Pre MRI, neck hardware. A single AP view of cervical spine shows cerclage wires likely about the spinous processes of lower cervical vertebrae. There is no lateral view for assessment of the location of these wires. MRI BRAIN AND MRV AND MRA OF THE HEAD CLINICAL INFORMATION: Patient with subarachnoid hemorrhage and possible mass on CT, for further evaluation. TECHNIQUE: T1 sagittal and FLAIR T2 susceptibility and diffusion axial images of the brain were obtained. 3D time-of-flight MRA of the circle of [**Location (un) 431**] was acquired. 2D time-of-flight MRV of the head was obtained. The examination was limited by motion and several sequences were repeated. FINDINGS: BRAIN MRI: The FLAIR and T2 images demonstrate increased signal along the post-parietal and occipital regions bilaterally. There is no corresponding slow diffusion identified. The ventricles and extraaxial spaces are normal in size without midline shift, mass effect, or hydrocephalus identified. Subtle increased signal along the sulci in the right parietal region is consistent with subarachnoid hemorrhage seen on CT. There is no evidence of increased signal identified within the region of superior sagittal sinus. IMPRESSION: Bilateral parietal and superior occipitals T2 and FLAIR hyperintensities without corresponding diffusion abnormalities. These findings could be secondary to contusions or less likely secondary to reversible encephalopathy . Clinical correlation recommended. No acute infarcts. MRA OF THE HEAD: The head MRA is limited by motion. Somewhat tortuous intracranial arteries are visualized. Flow signal is seen in both middle cerebral arteries, internal carotid, right vertebral and basilar artery. The left vertebral appears to be ending in posterior-inferior cerebellar artery. IMPRESSION: Motion-limited MRA demonstrates flow signal in the major intracranial arteries. MRV OF THE HEAD: The head MRV is also severely limited by motion. Flow signal is identified in the superior sagittal sinus and also in the deep venous system. IMPRESSION: Motion-limited MRV of the head demonstrates flow signal in the major venous sinuses. Head CT dated [**2143-3-21**]. FINDINGS: Again, note is made of hyperdense hemorrhage within the sulci of right parietal lobe, overall unchanged compared to the prior study. Again, note is made of hypodense areas in subcortical white matter in bilateral frontal and parietal lobes, which may represent edema or contusion, unchanged compared to the prior study. No shift of normally limited structures. No new mass effect. Bilateral ventricles are symmetric in size. Note is made of mucosal thickening in bilateral ethmoid sinuses. The osseous and soft tissue structures are unremarkable. IMPRESSION: 1. Overall unchanged appearance of subarachnoid hemorrhage in the right parietal lobe sulci compared to the prior study. 2. Unchanged appearance of hypodensity in the subcortical white matter in bilateral frontal and parietal lobes, which may represent contusion; however, further characterization is not possible on this CT scan. Further clinical assessment as well as further evaluation by MRI if necessary, should be considered. LEFT SHOULDER, THREE VIEWS: No fracture, dislocation, or focal osseous abnormality seen. The glenohumeral and acromioclavicular joint spaces are preserved. Visualized left lung apex is clear. Surrounding soft tissues are within normal limits. IMPRESSION: No fracture or dislocation. Brief Hospital Course: 40 yo man with paraplegia following MVA, asthma, GERD, substance abuse, ?seizure disorder, decubitus ulcers, s/p osteomyelitis who presented in apparent partial status. The seizures broke following ativan, valium and dilantin load (1.5g). Tox screen positive for cocaine, opioids and benzo. Per records, he had been taken off benzo's and narcotics recently by pcp. [**Name10 (NameIs) **] exam (postictal) he was noted to have spontaneous movements in R-arm, trace movements in L arm (may be baseline as he is paraplegic), lethargic, not able to follow commands. Etiology was thought to be likely related to withdrawal from benzos and opiates, as well as recent cocaine use, causing a seizure and hypertensive encephalopathy. He was admitted to the neurology ICU for further workup. As the presentation was suspicious for partial status epilepticus, EEG was performed showing no ongoing seizure activity; head imaging initially showed high-density material layering within several right parietal lobe sulci consistent with subarachnoid hemorrhage, as well as a 2-cm focal area of hypoattenuation within the right superior parietal lobe with central area of low attenuation concerning for possible underlying mass lesion with surrounding edema; alternatively, this was felt simply represent edema surrounging [**Doctor Last Name 352**] matter. MRI was performed to rule out an underlying neoplastic or vascular lesion - high signal in the parietal lobes bilaterally were suggestive of a reversible leukencephalopathy. LP ruled out meningitis as a cause of seizure and current presentation. As blood pressure normalized and the patient woke up more from post-ictal state, he was transferred to the floor for further management. His exam improved to baseline, with C7 and below weakness, as well as plegia of the lower limbs. Mental status was intact. Dilantin, which had been started for seizure, was d/c'ed once EEGs showed there to be no evidence of an underlying sz d/o. The seizure was felt likely to be a withdrawal seizure from benzos. As his blood pressure was under control in hospital, hypertensive encephalopathy was thought likely some autonomic dysfunction with his known upper cord lesion history. The patient declined substance abuse counseling, to prevent future episodes like this. He did well on neurontin; as withdrawal had caused the clinical picture, the neurology team recommends not continuing these meds. However, PCP will be following the patient after discharge, and the patient will call to make further plans to adopt a good pain control regimen. With exam at baseline, and no need for acute rehab per PT, he was discharged home with services, including wound care for his chronic pressure ulcers. Medications on Admission: neurontin 400 mg tid, valium and dilaudid recently discontinued vs patient ran out. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. 2. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 4. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Hypertensive encephalopathy Seizure Benzodiazepine and opioid withdrawal Discharge Condition: Stable, at baseline Discharge Instructions: Please return to ED if you have new symptoms of seizure or stroke. Followup Instructions: F/u with Dr. [**Last Name (STitle) 1266**] - call for appointment. Also, please call him for prescriptions should you wish to continue dilaudid and valium, which we are currently not recommending in light of recent withdrawal. Completed by:[**2143-3-29**]

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Discharge summary

report

Admission Date: [**2199-5-1**] Discharge Date: [**2199-5-5**] Date of Birth: [**2142-3-18**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: coronary artery bypass grafting x 3 (left internal mammary artery grafted to left anterior descending artery/saphenous vein grafted to Diagnal /posterior descending arteries) History of Present Illness: 57yo male with history of hypertension, hyperlipidemia and diabetes. He had an episode of chest pain 2 weeks ago while walking, which was relieved with SL NTG. Cath today reveals 3 vessel disease. He is referred for surgical evaluation. Past Medical History: hypertension, diabetes mellitus, hypercholesterolemia, nephrolithiasis s/p lithotripsy, Vit D deficiency, probable asbestos exposure, psoriasis, asthma, plantar fasciitis- right Social History: Race: caucasian Last Dental Exam: 6 wks ago Lives with: wife, [**Name (NI) **] [**Name (NI) 17**], in [**Name (NI) 1411**], no children Occupation: police officer Tobacco: occasional cigar ETOH: 15 drinks/week Family History: father died 77 MI mother died 66 leukemia Physical Exam: Pulse:63 Resp: 24 O2 sat: 95%RA B/P Right: Left: 138/81 Height: 5'[**98**]" Weight: 213lb General: Skin: Dry [x] intact [x] psoriatic plaques right lower extremity HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] no edema or varicosities 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: Left: no bruits Pertinent Results: [**2199-5-4**] 07:00AM BLOOD WBC-12.5* RBC-3.48* Hgb-10.3* Hct-31.2* MCV-90 MCH-29.7 MCHC-33.1 RDW-13.8 Plt Ct-217 [**2199-5-1**] 02:15PM BLOOD WBC-16.4*# RBC-3.90* Hgb-12.7* Hct-34.5* MCV-88 MCH-32.4* MCHC-36.7* RDW-14.0 Plt Ct-182 [**2199-5-4**] 07:00AM BLOOD UreaN-21* Creat-1.0 K-4.3 [**2199-5-1**] 02:15PM BLOOD UreaN-10 Creat-0.9 Cl-108 HCO3-31 [**2199-5-4**] 07:00AM BLOOD ALT-33 AST-17 LD(LDH)-222 AlkPhos-51 Amylase-20 TotBili-1.5 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 69603**] (Complete) Done [**2199-5-1**] at 12:12:46 PM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2142-3-18**] Age (years): 57 M Hgt (in): 70 BP (mm Hg): 120/65 Wgt (lb): 213 HR (bpm): 65 BSA (m2): 2.15 m2 Indication: Intraop CABG ICD-9 Codes: 424.0 Test Information Date/Time: [**2199-5-1**] at 12:12 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW 1-: Machine: AW 5 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.3 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.6 m/s Left Atrium - Peak Pulm Vein D: 0.4 m/s Left Atrium - Peak Pulm Vein A: 0.1 m/s < 0.4 m/s Right Atrium - Four Chamber Length: 3.9 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.3 cm Left Ventricle - Fractional Shortening: 0.31 >= 0.29 Left Ventricle - Ejection Fraction: 50% to 60% >= 55% Left Ventricle - Stroke Volume: 75 ml/beat Left Ventricle - Cardiac Output: 4.86 L/min Left Ventricle - Cardiac Index: 2.26 >= 2.0 L/min/M2 Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm Hg Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *20 < 15 Aorta - Annulus: 2.4 cm <= 3.0 cm Aorta - Sinus Level: *3.8 cm <= 3.6 cm Aorta - Sinotubular Ridge: *3.1 cm <= 3.0 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aorta - Arch: 2.4 cm <= 3.0 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 9 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 5 mm Hg Aortic Valve - LVOT VTI: 18 Aortic Valve - LVOT diam: 2.3 cm Aortic Valve - Valve Area: *2.3 cm2 >= 3.0 cm2 Mitral Valve - Peak Velocity: 1.0 m/sec Mitral Valve - Mean Gradient: 2 mm Hg Mitral Valve - Pressure Half Time: 96 ms Mitral Valve - MVA (P [**12-29**] T): 2.3 cm2 Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A ratio: 1.00 Mitral Valve - E Wave deceleration time: 246 ms 140-250 ms Findings LEFT ATRIUM: Normal LA and RA cavity sizes. No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous hypertrophy of the interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Normal LV wall thickness. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Trivial MR. The MR vena contracta is <0.3cm. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No 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. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Pre Bypass: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. Left ventricular wall thicknesses are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%).The aortic root is mildly dilated at the sinus level. There are complex (>4mm) atheroma in the aortic arch and in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened, with partial calcifcation of the posterior leaflet. Trivial mitral regurgitation is seen. Post Bypass: Patient is A paced on phenylepherine infusion. Preserved biventricuar function LVEF >55%. Mitral regurgitation remains mild. Aortic contours intact. Remaining exam is unchanged. All findings discussed with srugeons at the time of the exam. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting physician ?????? [**2191**] CareGroup IS. All rights reserved. Brief Hospital Course: [**2199-5-1**] Mr.[**Known lastname **] was taken to the operating room and underwent coronary artery bypass grafting x 3. Please see Dr[**Doctor Last Name 14333**] operative report for further details. He tolerated the procedure well and was transferred to the CVICU in stable but critical condition. Within 24 hours he was weaned off of sedation, awoke neurologically intact and was extubated without difficulty. He was weaned off pressors. All lines and drains were discontinued in a timely fashion, without complication. Beta-blocker/Aspirin/Statin, and diuresis was initiated. He continued to progress and was transferred to the step down unit on POD#1 for further monitoring. Physical therapy was consulted for strength and mobility evaluation. He continued to progress. [**Last Name (un) **] consulted regarding Mr.[**Known lastname 69604**] glucose control. The remainder of his postoperative course was essentially uneventful. POD#4 he was cleared for discharge to home. All follow up appointments were advised. Medications on Admission: albuterol inh prn, atorvastatin 80 daily, clobetasol 0.05% cream prn, glipizide 10 [**Hospital1 **], lisinopril 20 daily, metformin 1000 [**Hospital1 **], Toprol XL 75 daily, testosterone 1%gel daily, asa 81 daily, Vit D3 [**2188**] unit [**Hospital1 **], loratadine/pseudoephedrine SR 240/10 daily, MVI, fish oil Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing . Disp:*1 * Refills:*0* 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*2* 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 11. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 12. Insulin Glargine 100 unit/mL (3 mL) Insulin Pen Sig: One (1) Subcutaneous once a day: 22 units every AM. Disp:*1 * Refills:*2* 13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours) for 3 days. Disp:*6 Tablet Sustained Release 12 hr(s)* Refills:*0* 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 15. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: coronary artery disease status post coronary artery bypass grafting x3 hypertension, diabetes mellitus, hypercholesterolemia, nephrolithiasis s/p lithotripsy, Vit D deficiency, probable asbestos exposure, psoriasis, asthma, plantar fasciitis- right Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with 3 worth days of Oxycontin 20(2) and Dilauded as needed Sternal - healing well, no erythema or drainage Leg -Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **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: Surgeon: Dr.[**First Name (STitle) **] #[**Telephone/Fax (1) 170**], appointment arranged for [**2199-6-3**] at 1pm Please call to arrange appointment with your PCP:[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 17753**] in [**12-29**] weeks and your Cardiologist- referred by Dr.[**Last Name (STitle) **], in [**12-29**] weeks Please call for appointment to follow up with [**Last Name (un) **] Diabetes Center:#[**Telephone/Fax (1) 2384**] *** Please check your finger stick blood sugar premeal and at bedtime. Log results to minitor. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2199-5-5**]

[ "401.9", "285.9", "272.0", "427.31", "250.00", "493.90", "414.01", "268.9", "272.4" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11303, 11361

8025, 9048

330, 507

11654, 11905

1993, 6494

12744, 13422

1222, 1265

9413, 11280

11382, 11633

9074, 9390

11929, 12721

6543, 8002

1280, 1974

279, 292

535, 776

798, 978

994, 1206

58,278

145,733

25500

Discharge summary

report

Admission Date: [**2119-1-13**] [**Month/Day/Year **] Date: [**2119-1-21**] Date of Birth: [**2084-11-27**] Sex: M Service: MEDICINE Allergies: Risperdal / Abilify Attending:[**Doctor First Name 3298**] Chief Complaint: Encephalopathy after Quetiapine overdose Major Surgical or Invasive Procedure: Intubation Mechanical Ventilation History of Present Illness: 34 year old male with PMH chronic paranoid schizophrenia with auditory hallucinations treated with qutiapine is admitted to the intensive care unit intubated after being found unresponsive at home. He had returned home from [**Hospital1 18**] inpatient psychiatry after hospitalization from [**Date range (3) 63707**] for auditory hallucinations. According to the family, he was found unresponsive at 7pm [**1-13**] with a suicide note and empty bottles of seroquel. There were no other pill bottles found and no alcohol or illicit substances found at the scene. EMS was called and the patient was intubated in the field. After intubation, rhythmic shaking in the limbs was observed and he was given 2mg IV lorazepam with resolution of the movement. He was transported to [**Hospital1 18**]. In the ED, labs were remarkable for Cr 1.9 (baseline 0.9) Lactate 11.6, ABG:7.26/31/607/15, urine toxicology was positive for methadone and tricyclic anti depressants, serum toxicology negative for aspirin and acetaminophen. CT head was performed which was negative for acute process. EKG showed sinus tachycardia at 127 with QRS 94ms, QTc 350ms non-pathologic q waves in I, II, III and aVF. He was seen by toxicology who recommended EKGS and checking tylenol and asa levels, otherwise supportive care. Vitals 128/87 99 16 100% Fio2 40 Vt:550 Peep5 will increase rate to 18. On arrival to the MICU, he was intubated and sedated and unable to contribute to the medical history. After discussion with his family, there has been previous attempts at self harm consisting of head strikes against a wall however no suicide attempts. Past Medical History: Chronic paranoid schizophrenia Social History: Lives with sister [**Name (NI) **], family is very supportive. Per Sister history of marijuana use. Per [**Name (NI) **] prior heroin, cocaine, and marijuana use. Tobacco: 1ppd Family History: Mother hypertension, asthma Physical Exam: Admission exam Vitals: T:97.8 BP:123/72 P:101 R:19 O2: 100% on Fio2 40 Vt:550 Peep5 General: eyes closed, not responsive to voice commands, not withdrawing to pain. HEENT: Sclera anicteric, pupils 4mm and slugishly reactive, slight ecchymosis over right upper eyelid Neck: supple, JVP not elevated, CV: Tachycardic regular, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds normoactive GU: foley in place Ext: Excoriations on the anterior surfaces of the shins, warm, 2+ pulses, no edema SKIN: brown/tan plaque over right neck with scaling [**Name (NI) **] exam: Vitals: Tc 97.8, Tm 99.0 HR 84, BP 103/51, 18, 96% on RA General: Alert and oriented to self, place, and month. Cooperative, pleasant, in no acute distress. HEENT: Sclera anicteric, PERRLA, moist mucus membranes, dry lips Neck: supple, JVP not elevated CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation b/l, no wheezes, rales, rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds normoactive Ext: warm, 2+ pulses, no edema Neuro: Alert and oriented, CN II - XII intact, no rigidity on exam, 5/5 strength in upper and lower extremities, becoming paranoid about staying in hospital. Pertinent Results: ADMISSION LABS ============== [**2119-1-13**] 08:15PM BLOOD WBC-10.8 RBC-3.89* Hgb-11.8* Hct-35.2* MCV-90 MCH-30.3 MCHC-33.6 RDW-12.8 Plt Ct-232 [**2119-1-13**] 08:15PM BLOOD Neuts-91.7* Lymphs-5.0* Monos-3.1 Eos-0 Baso-0.2 [**2119-1-13**] 08:15PM BLOOD Plt Ct-232 [**2119-1-13**] 08:15PM BLOOD PT-12.4 PTT-30.9 INR(PT)-1.1 [**2119-1-13**] 08:15PM BLOOD Glucose-106* UreaN-22* Creat-1.9* Na-147* K-3.7 Cl-106 HCO3-11* AnGap-34* [**2119-1-13**] 08:15PM BLOOD ALT-11 AST-23 CK(CPK)-1675* TotBili-0.4 [**2119-1-13**] 08:15PM BLOOD Calcium-8.6 Phos-5.6*# Mg-2.9* [**2119-1-13**] 08:21PM BLOOD Type-ART pO2-607* pCO2-31* pH-7.26* calTCO2-15* Base XS--11 [**2119-1-13**] 08:21PM BLOOD Glucose-102 Lactate-11.6* Na-142 K-3.5 Cl-108 [**Month/Day/Year 894**] LABS ============== [**2119-1-21**] 06:20AM BLOOD WBC-4.6 RBC-3.13* Hgb-9.5* Hct-28.3* MCV-90 MCH-30.4 MCHC-33.6 RDW-12.2 Plt Ct-353 [**2119-1-21**] 06:20AM BLOOD Glucose-106* UreaN-5* Creat-0.8 Na-141 K-3.7 Cl-104 HCO3-25 AnGap-16 [**2119-1-21**] 06:20AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.9 [**2119-1-13**] CXR: FINDINGS: An endotracheal tube terminates in the mid trachea. An orogastric tube courses into the stomach, including its side hole, although its more distal course is not imaged. The heart is normal in size. The mediastinal and hilar contours appear within normal limits. The lungs appear clear. There are no pleural effusions or pneumothorax. IMPRESSION: Status post endotracheal intubation. No evidence of acute cardiopulmonary disease. [**2119-1-15**] CXR: FINDINGS: Heart size is normal. New pulmonary vascular congestion is present. Bibasilar confluent opacities are new, and raise a concern for either acute aspiration or developing infectious pneumonia. A dependent distribution of pulmonary edema is considered less likely. New small bilateral pleural effusions are also demonstrated. [**2119-1-19**] CXR: Chest x-ray: FINDINGS: Multifocal poorly defined areas of consolidation predominantly involving the lower lobes have improved compared to the recent chest radiograph. No new areas of consolidation are identified. Heart size and mediastinal contours remain normal. There are possible very small pleural effusions. IMPRESSION: Improving bilateral predominantly lower lobe pneumonia, possibly an aspiration pneumonia considering the dependent distribution. EKG: Sinus tachycardia 100bpm, QRS 86ms, QTc 360ms non-pathologic q waves in I, II, III and aVF. [**2119-1-14**] 9:28 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Preliminary): STAPH AUREUS COAG +. PRELIMINARY SENSITIVITY. These preliminary susceptibility results are offered to help guide treatment; interpret with caution as final susceptibilities may change. Check for final susceptibility results in 24 hours. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | OXACILLIN------------- S Anaerobic Bottle Gram Stain (Final [**2119-1-15**]): GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by [**Last Name (un) 63708**] [**Doctor First Name 2801**]. Aerobic Bottle Gram Stain (Final [**2119-1-16**]): GRAM POSITIVE COCCI IN CLUSTERS. Sputum culture: **FINAL REPORT [**2119-1-18**]** Blood Culture, Routine (Final [**2119-1-18**]): STAPH AUREUS COAG +. 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. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.5 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Urine culture - no growth ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal (probably trileaflet but not well seen) with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. No vegetation seen. Brief Hospital Course: A 34 year old male with PMH chronic paranoid schozophrenia and substance abuse presents with depressed consciousness after an apparent intentional overdose of seroquel. # Overdose: By report, patient was found down with seroquel bottles nearby and suicide note. In the MICU, he was given supportive care consisting of iv rehydration, benzodiazepines, and sodium bicarbonate. His EKG was monitored for signs of QT prolongation, which was not demonstrated. Though his CK was elevated, he did not demonstrate signs of NMS and CK trended down throughout the hospitalization. He was additionally given calcium gluconate for membrane stabilization. # Altered mental status: Patient found down after 8-10 hours clinical history is suggestive of ingestion of seroquel in overdose causing acutely depressed consciousness. Seizure was reported in the field and postictal state could explain his initial altered consciousness. CT head did not show signs of acute bleed and there was no apparent trauma or coagulopathy. After extubation, he continued to remain agitated, particularly on the first day following. He received multiple doses of ativan, but had minimal response until given a small dose of haldol after which his delirium cleared. He remained relatively calm and cooperative on the medical floor until he was transferred to psychiatry. # Airway protection: The patient was intially intubated in the field for airway protection. Though he had thick secretions from his ET tube, a sputum culture grew only commensal respiratory flora. He was extubated without difficulty on [**1-14**]. # Acute renal failure: The patient's creatinine was initally elevated to 1.9 from his baseline 0.9. He was found down in the setting of overdose which placed him at risk for rhabdomyolysis, thus he was given sodium bicarbonate to alkalinize the urine as well as aggressive fluid support. His creatinine at time of [**Month/Year (2) **] was 0.8. # Seizure: by report, patient had tonic clonic seizure in the field after intubation. seizure activity was likely precipitated by atypical antipsychotic overdose, he will likely not need anti-epileptics long term. At the time of admission to the MICU, he was maintained on a midazolam drip for sedation as well as for seizure prophylaxis. After he was extubated, he received standing doses of lorazepam. # Chronic paranoid schizophrenia: patient recently hospitalized on psychiatry service for decompensation of chronic schizophrenia related to medication non-compliance. He had follow up arranged with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]-[**Doctor Last Name **] at [**Hospital3 15623**]. Per psychiatry team he was restarted on seroquel 800mg qhs. He may eventually require depot fomrations of antipsychotic. # MSSA Pneumonia: MSSA 1/4 bottles from [**1-14**] and positive sputum culture. He was kept on cefalozin until he became afebrile. Now afebrile for >24 h, w/o cough, SOB or chest pain, further cultures have been negative since starting antibiotics. He was transitioned to oral antibiotics on linezolid. No evidence of skin abscess or cellulitis. No new murmur and TTE does not show vegitations. Repeat CXR did not show new effusion. Per ID recommendations patient should continue linezolid until [**1-28**] [**2119**]. # Medication interactions. Please note that linezolid has many drug interactions. Before starting any new medications please cross reference with linezolid. Transitions in care: - Pt will require follow up upon completion of his antibiotics to ensure clearance of blood cultures and pneumonia are resolved. - Patient will require weekly blood work with CBC and LFTs to ensure no side effect of linezolid. - Follow up of all pending blood cultures Medications on Admission: Seroquel 800mg daily [**Year (4 digits) **] Medications: 1. quetiapine 400 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO at bedtime. 2. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day: last dose [**1-28**]. [**Month (only) **] Disposition: Extended Care [**Month (only) **] Diagnosis: PRIMARY: seroquel overdose, staph aureus pneumonia SECONDARY: Paranoid schizophrenia [**Month (only) **] Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [**Month (only) **] Instructions: It was a pleasure to participate in your care Mr. [**Known lastname 63703**]. You were admitted to the hosptial because you overdosed on seroquel. You needed to be intubated to protect your lungs. You stayed in the ICU for several days and started to get better, so you were transferred to the medical floor. You developed a pneumonia and needed IV antibiotics for your infection. Your fever got better and you were changed to oral antibiotics. Please make the following changes to your medications: 1. START linezolid 600 mg by mouth until [**1-28**]. 2. START ferrous sulfate 325 mg PO daily Followup Instructions: Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from [**Hospital1 **] 4.

[ "305.1", "518.81", "E950.3", "785.0", "V15.81", "295.32", "997.31", "787.1", "728.88", "780.39", "349.82", "995.92", "584.9", "969.3", "V49.87", "E879.8", "280.9", "038.11", "285.29", "292.81" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

8733, 9388

335, 370

3676, 6180

13836, 13964

2290, 2319

12515, 13051

2334, 3657

6224, 8710

13718, 13813

255, 297

398, 2023

13066, 13689

2045, 2077

2093, 2274

60,947

181,779

34116

Discharge summary

report

Admission Date: [**2158-3-2**] Discharge Date: [**2158-4-11**] Date of Birth: [**2103-4-11**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: transverse [**First Name3 (LF) 499**] CA Major Surgical or Invasive Procedure: [**3-2**] s/p transverse colectomy [**3-6**] s/p ex lap, R colectomy, end ileostomy, Hartmann's procedure [**3-15**] s/p Perc Chole placement, drainage of subhepatic fluid collection [**3-22**] extubated [**3-20**] R Pleural Eff tap History of Present Illness: This was a 54-year-old woman with a several month history of intermittent hematochezia. A preoperative colonoscopy demonstrated an ulcerated mass in the mid transverse [**Month/Year (2) 499**]. Biopsies demonstrated adenocarcinoma of uncertain depth. The patient had a substantial history of alcohol ingestion with an enlarged liver on physical examination. Her preoperative liver function tests were significant only for mild elevation of her transaminases. Her CEA was 4.5. A preoperative CT scan of the torso demonstrated no evidence of metastasis. She did not have any findings suggestive of portal hypertension. She had no ascites or carcinomatosis. Resection of her tumor was advised and accepted. Past Medical History: [**Month/Year (2) **] CA, OA of multiple joints, varicose veins, PAD, leg cramps, emphysema, ETOH fatty liver Social History: smoker 44 pack years, ETOH 12 pack per day 3x per week Family History: maternal uncle and aunt with [**Name2 (NI) 499**] cancer Physical Exam: At d/c: Gen: a and o x 2 person and place V.S: 98.6, 100, 141/79, 20, 93% 4L CV: tachycardia no m/r/g Resp: faint wheezing, bilat crackles at bases Abd: soft, tender at incision site, nd, stoma beefy red Wound: abd, open surgical wound packed w-d. Pertinent Results: [**2158-4-9**] 07:05AM BLOOD WBC-8.1 RBC-3.16* Hgb-9.9* Hct-30.7* MCV-97 MCH-31.3 MCHC-32.2 RDW-20.2* Plt Ct-314 [**2158-4-2**] 08:00AM BLOOD Neuts-82* Bands-0 Lymphs-8* Monos-7 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2158-4-2**] 08:00AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL [**2158-4-9**] 07:05AM BLOOD Plt Ct-314 [**2158-4-10**] 05:40AM BLOOD Glucose-105 UreaN-3* Creat-0.3* Na-140 K-3.9 Cl-101 HCO3-31 AnGap-12 [**2158-4-4**] 10:05AM BLOOD CK(CPK)-15* [**2158-4-4**] 10:05AM BLOOD CK-MB-3 cTropnT-0.01 [**2158-4-10**] 05:40AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.7 [**2158-3-29**] 05:12AM BLOOD Albumin-3.4 Calcium-9.1 Phos-4.3 Mg-2.4 [**2158-4-6**] 04:06AM BLOOD Free T4-0.90* [**2158-3-20**] 03:35PM PLEURAL WBC-465* RBC-685* Polys-13* Lymphs-66* Monos-5* Eos-4* Baso-1* Meso-3* Macro-1* Other-7* [**2158-3-20**] 03:35PM PLEURAL TotProt-2.6 Glucose-106 LD(LDH)-98 Albumin-1.1 [**2158-3-15**] 03:13PM ASCITES TotPro-2.9 Glucose-13 LD(LDH)-2170 . Micro [**3-5**] sputum: 1+ GPC, 1+ GNR - oropharyngeal flora [**3-6**] BCX: no growth [**3-6**] Intra op CX: 4+GNR, 2+GPR, 1+GPC, Cx E.coli, Klebseilla-ciprosens [**3-7**] BCX: no growth [**3-7**] MRSA: negative 3/14,[**3-12**], [**3-13**] BCX: no growth [**3-11**] RespCX: now growth [**3-14**] Wound cx: Ecoli - pan [**Last Name (un) 36**] [**3-15**] Subhepatic fluid Ecoli - pan [**Last Name (un) 36**] [**3-20**] Pleural fluid: 2+ poly, NGTD [**3-29**] Stool: C. Diff positive, VRE . [**3-5**] Torso CT scan: no PE, moderate bilateral pleural effusions, s/p transverse colectomy, with apparently intact anastomotic site and no large fluid collection around anastomotic site, increasing pneumoperitoneum, no evidence of obstruction or breakdown at the anastomotic site. [**3-15**] CT Abd/Pelvis: Rectal contrast was fills long Hartmann pouch, suboptimally filling the apical region. NO extravasation of contrast, though extraluminal air adjacent to the suture at the apex of the pouch has increased since [**3-14**], raising concern for a leak at the apex of the pouch. unchanged bilateral pleural effusions, There has been a very mild increase in fluid in the lesser sac. Fluid anterior to the left lobe of liver is decreased since [**3-14**] . [**3-19**] CT Thorax: Moderate size simple bliateral effusions with associated compressive atelectasis, slightly decreased from prior. No evidence for loculations. . [**3-21**] CT Abd: Contrast filling the Hartmann's pouch, without definite evidence of extraluminal contrast, however, persistent air and stranding, unchanged from prior study is still noted. . [**3-27**] B/L LENI: No DVT . [**4-9**] CXR: Moderate bilateral pleural effusions larger on the left side and associated with atelectasis are unchanged. There is no pulmonary edema. Cardiomediastinal contours are unchanged. There is no pneumothorax. Brief Hospital Course: On [**2158-3-2**] a transverse colectomy was performed without complication. On POD#1 noted to have hct drop from 25 to 20, requiring 4uPRBCs on POD#1 to POD#2. On POD#2, Pt became SOB, which was worse lying completely flat, and kept her from taking deep breaths. Patient had increasing O2 requirement, cxr showed edema, no diuresis was done. Pt also admits cough w/ occasional sputum -clear, and fevers/chills. On POD#3 (day of transfer to ICU), respiratory distress worsened with increasing O2 requirements to nc and face mask to keep sats >95%. A CT of torso performed, (-) for PE, (+) pneumoperitoneum without limitated extravasation of contrast, thought likely small performation that had sealed off. Patient given 20mg IV lasix for diuresis, initiated transfer to [**Hospital Unit Name 153**]. Vital signs prior to transfer: t99 (was 101.1 1hr prior to transfer), 105, 120s/70, rr24, 98% 8L, access 2pIVs. . 54yoF pod #3 from transverse colectomy, hx pad, emphysema, ethanol abuse, transferred for hypoxemic respiratory failure. . In the ICU: 1. Hypoxemic respiratory failure- started POD#2, with hypoxia on NC. DDx includes PE, but CTA is negative and pt is on SQH. Pt may have become fluid overloaded s/p 4u PRBC. Pt shows moderate pleural effusions that were not present on the CT scan on [**2-22**]. TRALI syndrome also a possiblity, which has been known to occur upto 6 hours after blood transfusion. Infection unlikely w/o wbc and infiltrate on CT. Pt also shows atalectasis that may be contributing. - O2 on NC/facemask - check serial ABGs - BNP and Echo . 2. [**Name (NI) 27812**] pt??????s HR 130s, in sinus tach on EKG. Also pt??????s BP dropped to 80/60. - bolus with imporvement . # Leukopenia- may show early sepsis. Pt beginning to become hypotensive, . # Pneumoperitoneum- [**1-30**] surgery. - vanco/zosyn - serial lactates - serial abd exams . # Etoh withdrawl - valium 5 q4, CIWA >10 . # COPD- none at home - alb/ipratrop nebs ___________________________________________ [**2158-3-6**] anastomotic bleed then leak >> [**2158-3-6**] returned to OR for ex lap, R colectomy, end ileostomy, Hartmann's procedure [**3-8**] - pt given colloid- Albumin 25g after UOP near 30-40cc, w/o signifcant change - restarted vasopresin, then later levophed - f/u hct 25.6 stable ______________________________________ [**3-9**] - U/o excellent with lasix 10 IV - Off pressors - Goal u/o per [**Doctor First Name **] is 100cc/h, redose lasix when u/o drops below 100cc/h - NGT in right place _________________________________________ [**3-10**] - diuresed - tachypneic - checked abg _________________________________________ [**3-11**] - Pt was not on pressure support of 12, stayed on 15, when turned down to 12 (around MN)pt's RR incr 40s. Pt also became agitated and given sedative, and needed to be on Assist, now back on pressure support at 15. - lasix 10mg IV x1 tapered off around 10pm, given lasix 20mg IV x1 around 10pm. At 6am pt was -1.2L and given another 10 IV lasix at 6am - swab from fluid- speciation back: growing E.coli, Klebsiella - pan-sensitive - tbili coming down ________________________________________ [**3-12**] - Started lasix gtt because the pt was hypotensive this am in the setting of sedation and bolused lasix - Got 50ml albumin for hypotension - Started fentanyl gtt in order to get the pt off benzos as there is some concern for worsening MS in the setting of Versed ________________________________________ [**3-13**] - Repeatedly febrile, although BP and HR stable. - Resited CVL to R IJ as site appeared erythematous and not fully covered by dressing. Line sent for culture - Surgery opened surgical site and drained some purulent material. - considered thoracentesis but held off given other potential etiologies. - Diuresing well, PM lytes stable ________________________________________ [**3-14**] - Around 4pm pt became febrile to 101.2 and tachycardic to 120s (previously never tachycardic). Also RR increased to 40s. Surgery wanted to try Precedex, started. - Pt??????s ABG prior to this (in am) was 7.46 / 43/ 96 / 32, and the new abg at 5pm was similar 7.45 / 37 / 81 / 27 ?????? but pt??????s minute venilation was significantly increased from then and would expect pC02 lower ?????? suggesting incr dead spacing, and pt was concerning for PE. - Pt??????s pressure support was inc to 25 w/o benefit on RR, - Pt??????s 02 sat dropped to 90%, and pt??????s Fi02 was increased from 40 to 70% and started back on AC Vt 450, fio2 70, peep 8, RR 32. Given hypoxia and tachycardia w/ new dead spacing decision was made to attempt CTA for PE. - Also around this time from pt??????s lasix gtt she was already -2L,. Also considered pt??????s tachycardia. - new CXR showed no new infiltrates and was unchanged. - LENI was negative - blood cx sent, more tylenol given - Pt was to get 25g albumin, but surgery decided to give 2 u PRBC instead, hct stable at 25 at the time. - Around 6pm ?????? pt??????s WBC increased from 13 earlier that day to 24 (Hct stable at 25.4) Cdiff was sent. And a new lactate was sent and was 4.1 - Spoke to surgery about expanding abx ?????? agreed to adding Flagyl 500 IV q8, and surgery contd to want to r/o PE - bladder pressure 19 - stable - Pt became hypotensive to sbp 70s, map 40s, and gave 1L bolus, w/ 1unit PRBC being transfused during that time. Pt still required levophed 0.3, and then added vasopresin 1.2 then 2.4. - Pt??????s map stabalized > 65 lactate came down to 3.8, pt went to CT -> CTA neg prelim read. Pt weaned from levophed. - Pt stayed stable until 4am, fever of 103.5, new blood cx sent. Lactate back to 4.0 restarted on levophed, now 0.12, and vasopresin 2.4, map stable , at 7am lactate 3.8 ____________________________________________ [**3-15**] - Per ID recs added PO Vanc - Per [**Doctor First Name **] recs added IV cipro - On [**3-14**] Flagyl added - Percutaneous cholecystostomy by IR at bedside, drain in place draining bilious fluid. Fluid sent for GS and Cx - Perc drain of loculated subdiaphragmatic fluid (LUQ), fluid sent for GS and Cx - Per Dr [**Last Name (STitle) 519**] plan for ex lap on [**3-17**], pt's family consented by [**Doctor Last Name 519**] and anesthesia - Repeat Hct 25, [**Doctor First Name **] asked for transfusion - D/c'ed left art line, placed new right radial art line ________________________________________ [**3-16**] - repeat CT scan with rectal, PO and IV contrast without significant change in air collection near hartmanns pouch - culture of peritoneal fluid drained on [**3-15**] growing GNR - deferred surgery today, reconsider tomorrow. - failed pressure support - tachypneic into 50s, agitated - weaned off pressors and sedation, consider haldol in AM. - face becoming purple when lying flat _______________________________________________ [**3-17**] - Initially decreased pt's PEEP and pressure support. Surgery wanted pt on Precedex - later that day around 1pm surgery decided to extubate pt. Pt's tolerated extuabtion for 45min, then pt's 02 sat began to drop -> 90%, cpap and neb did not help -> reintubated and put on AC. - Many attempts to get a-line unsuccesful, surgery even tried - ID: narrow abx when sensitivies return to cipro/flagyl or ctx/flagyl - Haldol prn started, continuing fentanyl - standing nebs put on - lasix 10, then 20 IV given prior to extubation - after reintubated put on lasix drip 1-3mg/hr ________________________________________________ [**3-18**] - On lasix gtt, then BP's dropped to 70s systolic. Per [**Doctor First Name **] give 25% albumin, hold lasix gtt, pt's pressures went to 80's systolic - ID rec'd stopping Zosyn as cx growing pan sensi E coli, but couldn't reach [**Last Name (LF) 519**], [**First Name3 (LF) **] still on Zosyn - Off lasix gtt overnight ________________________________________________ [**3-19**] - CT chest to eval pleural effusions unremarkable - present but not huge, unlikely to fix the problem but if no other ideas, can tap prior to trach - Increasing PEEP as BP and airway pressures allow to recruit more lung and assist with extubation - Changed antibiotics to PO - Overbreathing the vent, becoming alkalotic - tried pressure support to decrease minute volume but pt became tachypneic to 40s/50s and with very shallow breaths. Restarted AC and increased sedation. - Restarted lasix gtt ____________________________________________ [**3-20**] - IP tapped the effusion, right side - Maroon stool - Febrile->tylenol ___________________________________________ [**3-21**] - Tried to go down on PEEP, pt thrashing, returned PEEP to [**12-11**] - Pt tachycardic to 130's, stopped lasix gtt, then pt's BP in 70's systolic with temp of 104, gave 1L bolus, ordered albumin per [**Doctor First Name **] - CT showed ? new consolidation on chest aspiration v pna - Started Vanc Zosyn - At MN had ~500 cc BRBPR ____________________________________________ [**3-22**] - SELF EXTUBATED at 1:30 pm (had been planned for extubation or trach at 3pm) and started saying "I don't need this tube" Continued to sat high 90s with supplemental oxygen (NC and shovel mask). Was OOB to chair sitting up, asking for coffee. - no more fevers but bandemia from AM concerning so kept on antibiotics. Potentially planned for CT guided drainage of abdominal collections tomorrow. - Respiratory distress o/n with sat's to 70's, responded to bolus of lasix gtt, nebs, repositionning - 7:15 AM ([**3-23**]), tachy to 130's, hypertensive to 160's, sat's in 70's. got 50 IV lasix (10 bolus gtt then 40 IV), total 4 mg morphine, placed on bipap, ABG 7.38/50/55, after 45 minutes finally tolerating BiPAP and sats up to mid 90's (very agitated and SOB, mottled, would not tolerate mask). Lasix gtt had been held for marked hypokalemia (2.8) but was still putting out 80cc/hr urine. Surgery at bedside and did not want re-intubation ________ [**3-23**] - Pt negative 500ml by 5pm, then UOP tapering off to 30cc/h. Surgery at that point began lasix bolus on top of gtt, 20 IV, and Acetazolamide 250 IV x6 x4doses, and 25g albumin. - Pt alert but very agitated, tried ativan 1mg, then haldol 4mg POx1 which helped - Around 11pm, bt became tachycardic to 120s, RR 40, changed from facemask to bipap, but still 02 sat decr 90%. Neb tx given, and additional 40 IV lasix. Pt was given morphine 2mg IV x2 (since this helped w/ similar episode at 7am), ativan 1mg, ABG 7.37 /50/ 86/ 30. Did not reintubate. Pt eventually calmed down, and went to sleep. ____________________ [**3-24**] - Pt on bipap most of day - Stopped lasix gtt in am as pt hypotensive in 70's and symptomatic (improved in trendelenberg), did not end up getting fluid bolus. - [**Doctor First Name **] placed dobhoff to start feeding - PICC placed but ended up in RIJ, so pulled back to make a midline - Started TF at Dr[**Name (NI) 1745**] goal of 20cc/h - Per [**Doctor First Name **] recs got Lasix 20 IV x1 in afternoon _______________________ [**3-25**] - surgery goal to reeval sunday evening after 48 hrs of steroid re tube/trach or improving. Want to optimize with diuresis as well. - today on bipap except 2 short bursts of 2h and 45min on facemask. Becomes confused and agitated, wanting to take off masks (likely hypoxic/hypercarbic, ABGs not checked) - starting to have nasal skin breakdown - attempting diuresis with lasix boluses - dobhoff did not advance with reglan, likely because bipap mask holding it in place. Continuing reglan and surgery will try to manually advance it on morning rounds tomorrow. - Did not sleep overnight, no response to haldol or trazadone, delirius, trying to crawl out of bed. ______________________________ [**3-26**] - anxiety much better controlled w/ ativan 2mg alternating w/ haldol - decreased solumedrol 40mg q12 now - LENI reordered this AM, not done - lasix 20 IV x1 at MN (got 40 in AM), pt neg 300, goal neg 500 __________________________________ [**3-27**] - HCT stable despite Hartmann bleeding - LENI negative [**3-28**] -negative 1650, got 40 IV lasix x2 yesterday, K=repleated -tried chest PT but pt kept slipping down in bed - [ ] check to see if PT came -did require going back on BiPAP as had increased RR, oxygen sat was in low 90s, and she pulled out dubhoff... concern could have aspirated. On face mask 1:30-3:45 -dubhoff replaced, TF to start in AM -middle of night bipap came off and pt in 2:1 block, ekg checked continues to have inverted T waves -CK and MB neg x2, third set to be drawn -alb nebs changed to xopenex nebs given pt tachycardic [**3-29**] Diuresed about 2.4L Per surgery ok to optimize med mgmt of CAD: BB, ASA, statin-started TTE- poor quality but slightly decreased EF, global hypokinesis of RV with mod pulm HTN Switched to NC/shovel for short time maintained sats Cardiac enzymes negative ------------- [**3-30**] Per surgery, patient to continue FWB. Would like to see if IV Meds can go in with 1/2NS. - Continue diuresis [**3-31**] - at 4:30 in atfernoon had A fib with RVR got lopressor 2.5 IV x2 and then back in sinus -nausea not responsive to zofran but was to compazine, TF stopped because of nausea -10pm I/Os -231 -pt weaned down to 60s during early afternoon, then A fib with RVR so back up to 90s -increased free water boluses (may have gotten held when TF held) [**4-1**] Restarted TF Decreased free water boluses Switched Xopenex back to albuterol Took sips of water PO Still on shovel mask for O2 [**4-2**] - Weaned to 5L NC - Advanced TFs - Patient AO x3, coherent - d/c diamox - Increased SCH to TID - Decreased Vanco enemas to [**Hospital1 **] [**4-3**] -A fib with RVR did not respond to metoprolol 5 IV x3, converted to sinus on dilt gtt, then switched to PO dilt and PO metoprolol discontinued -surgery did not want to diurese, just wanted pt to settle out on her own -3 pm lytes repleted K+. Mg came back > 12 and then repeated was > 11. No signs of cardiac toxicity. Pt hyperreflexive not hyporeflexive. Repeated again (drawn peripherally) and came back as 2.4. -had nausea in pm -TF at 50 then turned off (A fib with RVR) then 20 -> increased to 30 = = = = = ================================================================ [**4-4**] Diuresed 2100cc Weaned to 6L NC Surgery considering calling out [**4-5**] [**4-5**] Patient about even I/O for LOS Abd discomfort improved Surgery considering calling out on [**4-6**] [**4-6**] -A fib with RVR got metoprolol 5IV x2 then started dilt drip and gave 10 IV dilt bolus -morphine for pain -did not go to surgery b/c of A fib with RVR [**4-7**] No afib w/ RVR Cardiac Consult - Last Updated by [**Last Name (LF) **],[**First Name3 (LF) **] B. on [**2158-4-7**] @ 1540 Patient Location: 4I-404-01 54yo s/p transverse colectomy, long ICU stay w/ resp failure. intermittent min-hrs; sinus. AF 120-150s. dilt PO 30 QID + Metoprolol 12.5mg [**Hospital1 **]. w/ occ BB IV. 1x day. C.diff. . [**4-8**] Pt transferred to [**Hospital Ward Name **] 5. She was screened for Rehab, family aware. Pt has altered mental status at times but reoriented easily. The patient will be d/c'd to acute rehab and will f/u with Dr. [**Last Name (STitle) 519**] on [**4-24**] at 9:30 am. Medications on Admission: None Discharge Medications: 1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-30**] Sprays Nasal QID (4 times a day) as needed. 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed: Please give tylenol first. . 8. Diltiazem HCl 30 mg Tablet Sig: 2.5 Tablets PO QID (4 times a day). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 11. insulin Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL [**12-30**] amp D50 [**12-30**] amp D50 [**12-30**] amp D50 [**12-30**] amp D50 61-159 mg/dL 0 Units 0 Units 0 Units 0 Units 160-199 mg/dL 2 Units 2 Units 2 Units 2 Units 200-239 mg/dL 4 Units 4 Units 4 Units 4 Units 240-279 mg/dL 6 Units 6 Units 6 Units 6 Units 280-319 mg/dL 8 Units 8 Units 8 Units 8 Units 12. Heparin Flush 10 unit/mL Kit Sig: Two (2) ML Intravenous once a day: Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above, daily and PRN per lumen. 13. Saline Flush 0.9 % Syringe Sig: One (1) Injection once a day: Flush with 10mL Normal Saline daily and PRN. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary: transverse [**Location (un) 499**] CA Post-op: Hypoxemic respiratory failure Tachycardia a-fib Leukopenia Pneumoperitoneum Etoh withdrawl COPD anastomotic bleed then leak Fevers Malnutrition . Secondary: [**Location (un) **] CA, OA of multiple joints, varicose veins, PAD, leg cramps, emphysema, ETOH fatty liver Discharge Condition: Stable. Tolerating regular diet Pain well controlled with oral medications. Discharge Instructions: Rehab: please contact MD if pt * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Mid-line incision healed with distal part open and packed w-d twice a day. . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 1000mL to 1500mL per day. -If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours . Telemetry: -Please continue to assess pt's heart rate. -Pt had new onset A-fib while in hospital. Followup Instructions: 1. Please follow up with Dr. [**Last Name (STitle) 519**] on [**4-24**] at 9:30. [**Telephone/Fax (1) 6554**] 2. Please follow up with your PCP, [**Name10 (NameIs) 10779**],[**Name11 (NameIs) 10778**] [**Telephone/Fax (1) 1144**], in one week or as needed. . Scheduled Appointments Provider: [**Name10 (NameIs) 2352**] MAMMOGRAPHY Phone:[**Telephone/Fax (1) 4832**] Date/Time:[**2158-8-1**] 10:40 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2158-4-11**]

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icd9cm

[ [ [] ] ]

[ "51.01", "45.73", "96.04", "46.10", "34.91", "54.91", "96.72", "45.74" ]

icd9pcs

[ [ [] ] ]

21676, 21747

4771, 19838

355, 591

22113, 22191

1890, 4748

23934, 24490

1549, 1607

19893, 21653

21768, 22092

19864, 19870

22215, 23318

23333, 23911

1622, 1871

275, 317

619, 1325

1348, 1460

1477, 1533

45,995

126,878

14182

Discharge summary

report

Admission Date: [**2136-11-26**] Discharge Date: [**2136-12-5**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2901**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2136-11-30**] - Right-sided pleural effusion drainage with pigtail catheter placement [**2136-12-3**] - Transesophageal echocardiogram with bedside electrical cardioversion History of Present Illness: The patient is a [**Age over 90 **]F with a medical history of atrial fibrillation not on coumadin, coronary artery disease who is transferred from [**Hospital3 4107**] after presenting there with progressively worsening dyspnea. At baseline, she ambulates with a walker but does not go very far due to leg pain. She had a recent hospitalization several months ago for "congestive heart failure" and was started on lasix. She reports increasing dyspnea for the past several weeks, which she attributes to a viral infection. With any activity she becomes short of breath. This has become significantly worse over the past 48hours. She also endorses new productive cough. She denies orthopnea, PND. She denies chest, arm, or jaw pain. She denies fever, chills. She endorses stable left lower extremity swelling. This evening her daughter called EMS due to her worsening shorntess of breath. EMS initial vitals were: BP 88/50, O2 sat 90% on 4L nasal cannula. She was brought to [**Hospital3 4107**]. . At [**Hospital3 4107**] she was noted to be tachypnic to mid twenties with oxyhgen saturation of 88% on room air. She was started on Bipap. She was noted to be hypotensive w/ systolics in the 80s so started on levophed. Troponin I <0.06, BNP 375. She was given levofloxacin for possible pulmonary infection but this infiltrated. She was given duoneb w/out improvement in respiratory status. She was transferred to [**Hospital1 18**] for further management. . In the ED, initial vitals were 96.6 60 94/82 20 100%NRB. On exam, decreased breath sounds at the right base, A0x3. Labs notable for WBC of 10 w/ 5% bands, troponin <0.01, lactate of 12.6, BNP of 4116. ABG on NRB 7.28/21/224. Blood cultures obtained. CVL placed and CVP 20. CXR showed CVL placement at atrialcaval junction. EKG obtained. She was evaluated by cardiology, bedside echocardiogram performed that was of limited quality due to poor echo windows but showed that basal segments of the heart contract normally, cannot exclude a focal wall motion abnormality, poor visualization of RV. Vitals on transfer: 98/70 on 0.05 levophed, HR in 70s, RR: 20, 100%NRB. Code status discussed w/ patient (full code). . In the ICU, she reports shortness of breath. She is asking to sit in the chair with legs dependent as this helps with work of breathing. Feels constipated but denies abdominal pain. Denies nausea, vomitting, leg pain or weakness. . 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. Diabetes mellitus, type 2 2. Hypertension 3. Coronary artery disease 4. Atrial fibrillation 5. Peripheral vascular disease (prior femoral and carotid disease with peripheral stenting) Social History: Lives in [**Location 2624**], MA with her husband. The patient is retired. Patient denies smoking history or alcohol history. She denies recreational substance use. Family History: Father died in his 60s due to cancer or CAD. Mother died at 83 due to an unknown cause. Physical Exam: ADMISSION EXAM: . GENERAL: Caucasian female, appears younger than state age, AOx3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVP to jawline CARDIAC: S1, S2. irregular LUNGS: labored respirations w/ accessory muscle use, decreased breath sounds at right base, no crackles or wheezes appreciated ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: left lower extremity swelling 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/PT difficult to obtain w/ doppler Pertinent Results: ADMISSION LABS: . [**2136-11-26**] 11:02PM BLOOD WBC-10.0 RBC-3.88* Hgb-8.8* Hct-30.0* MCV-77* MCH-22.6* MCHC-29.2* RDW-19.8* Plt Ct-210 [**2136-11-26**] 11:02PM BLOOD Neuts-80* Bands-5 Lymphs-7* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-2* [**2136-11-26**] 11:02PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-OCCASIONAL Microcy-2+ Polychr-OCCASIONAL Ovalocy-1+ Burr-1+ Pencil-OCCASIONAL [**2136-11-26**] 11:02PM BLOOD PT-18.9* PTT-48.6* INR(PT)-1.7* [**2136-11-26**] 11:02PM BLOOD Plt Smr-NORMAL Plt Ct-210 [**2136-11-27**] 02:07AM BLOOD Fibrino-193 [**2136-11-27**] 02:07AM BLOOD FDP-40-80* [**2136-11-26**] 11:02PM BLOOD Glucose-163* UreaN-33* Creat-1.6* Na-135 K-4.6 Cl-95* HCO3-12* AnGap-33* [**2136-11-26**] 11:02PM BLOOD ALT-587* AST-1238* LD(LDH)-1551* CK(CPK)-92 AlkPhos-163* TotBili-1.1 [**2136-11-26**] 11:02PM BLOOD Lipase-19 [**2136-11-26**] 11:02PM BLOOD CK-MB-3 proBNP-4113* [**2136-11-26**] 11:02PM BLOOD Albumin-3.8 Calcium-8.5 Phos-7.0* Mg-2.3 [**2136-11-26**] 10:48PM BLOOD Type-ART pO2-224* pCO2-21* pH-7.28* calTCO2-10* Base XS--14 [**2136-11-26**] 10:48PM BLOOD Lactate-12.6* . PERTINENT LABS: . [**2136-11-27**] 02:07AM BLOOD Fibrino-193 [**2136-11-27**] 02:07AM BLOOD FDP-40-80* [**2136-11-26**] 11:02PM BLOOD ALT-587* AST-1238* LD(LDH)-1551* CK(CPK)-92 AlkPhos-163* TotBili-1.1 [**2136-11-27**] 02:07AM BLOOD ALT-604* AST-1049* CK(CPK)-98 AlkPhos-163* TotBili-0.7 [**2136-11-27**] 05:41PM BLOOD ALT-493* AST-437* AlkPhos-145* TotBili-0.3 [**2136-11-28**] 04:38AM BLOOD ALT-376* AST-296* AlkPhos-131* TotBili-0.2 [**2136-11-29**] 05:06AM BLOOD ALT-272* AST-124* AlkPhos-112* TotBili-0.3 [**2136-11-26**] 11:02PM BLOOD Lipase-19 [**2136-11-27**] 05:41PM BLOOD Lipase-17 [**2136-11-26**] 11:02PM BLOOD CK-MB-3 proBNP-4113* [**2136-11-26**] 11:02PM BLOOD cTropnT-<0.01 [**2136-11-27**] 02:07AM BLOOD CK-MB-4 cTropnT-<0.01 [**2136-11-27**] 11:34AM BLOOD CK-MB-5 cTropnT-<0.01 [**2136-11-28**] 04:38AM BLOOD calTIBC-330 Ferritn-72 TRF-254 [**2136-11-27**] 02:07AM BLOOD Hapto-140 [**2136-11-28**] 04:38AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2136-11-28**] 04:38AM BLOOD HCV Ab-NEGATIVE [**2136-11-26**] 10:48PM BLOOD Lactate-12.6* [**2136-11-27**] 02:35AM BLOOD Lactate-10.4* [**2136-11-27**] 11:51AM BLOOD Lactate-2.0 . MICROBIOLOGIC DATA: [**2136-11-26**] Blood culture - negative [**2136-11-26**] Blood culture - negative [**2136-11-27**] Legionella antigen - negative [**2136-11-27**] MRSA screen - negative [**2136-11-27**] Urine culture - negative [**2136-11-30**] Right pleural fluid - 2+ PMNs, no organisms; no growth . IMAGING: [**2136-11-27**] LIVER OR GALLBLADDER US - Normal hepatic echotexture with small-volume perihepatic ascites. Thickened gallbladder wall, which is mildly distended without gallstones or son[**Name (NI) 493**] [**Name (NI) **] sign. These findings could reflect third spacing given the concurrent presence of ascites and left pleural effusion. . [**2136-11-27**] CHEST (PORTABLE AP) - There is no pneumothorax. Moderate right pleural effusion is stable. Small left pleural effusion and left lower lobe atelectasis or consolidation have increased. The cardiac silhouette is moderately enlarged. The pulmonary vasculature is normal and there is no pulmonary edema. Right jugular line ends in the upper SVC. . [**2136-11-29**] CTA CHEST W&W/O C&RECON - No evidence of pulmonary embolism. Bilateral moderate-to-large pleural effusions with the complete passive collapse of right lower lung and near complete collapse of the left lower lobe. Mild pulmonary edema. Moderate-to-large hiatus hernia. Mild cardiomegaly with moderate-to-severe coronary artery and severe mitral annulus calcification. . [**2136-12-3**] 2D-ECHO - The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic function may be depressed given the severity of mitral regurgitation.] 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. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Severe (4+) mitral regurgitation is seen with reversal of flow in the pulmonary veins. There is no pericardial effusion. No spontaneous echo contrast or throbus visualized int the LA/LAA/RA/RAA. Severe mitral regurgitation. Mild to moderate tricuspid regurgitation. Extensive simple aortic atheroma. . [**2136-12-3**] CT CHEST W/O CONTRAST - No CT evidence of pneumomediastinum. Near resolution of right pleural effusion following pigtail pleural catheter placement. New ground-glass opacities and septal thickening in right lower and right middle lobes probably reflects reexpansion edema in the setting of recent pleural fluid evacuation. Slight increase in moderate left pleural effusion with adjacent worsening left lower lobe atelectasis. Nonspecific mediastinal lymphadenopathy. Evidence of previous asbestos exposure. 4-mm left upper lobe and 2-mm right upper lobe noncalcified nodules which should be followed by CT in one year given the risk factor of asbestos exposure. Calcification in left upper lobe which could reflect a calcified granuloma and less likely a calcified broncholith. Brief Hospital Course: Mrs. [**Known lastname 9449**] is a [**Age over 90 **] year-old Female who presented with hypotension, tachypnea concerning for septic shock vs. cardiogenic shock who was initially stabilized on pressors but improved with antibiotics and diuresis. . # HYPOTENSION - Although initially the patient's presentation was unclear between distributive vs. cardiogenic shock, the patient's 2D-Echo revealed an EF of 55%, making the likelihood of cardiogenic shock less likely. The patient initially required Levophed infusion to support her blood pressure, but on the day following admission, her hypotension improved and she was actually hypertensive. She did have an infectious process on CXR and was started on Cefepime and Levofloxacin IV (day 1, [**11-27**] for 7-day treatment, which she completed this admission). Given the patient's unclear picture and sedentary lifestyle, pulmonary embolism was high in the differential and she was empirically anticoagulated with heparin initially until her creatinine stabilized for CTA imaging. Initially, her creatinine was elevated, thus eliminating the possibility of CTA, but her creatinine improved to 0.7 and CTA was performed, which was negative for evidence of pulmonary embolism. The patient had an elevated lactate to 12, but the patient improved with a lactate of 2.0. Her cardiac biomarkers were negative for three sets and she had flat CK-MBs, peaking around 5. Her hypotension improved as noted above and she actually became hypertensive which improved with diuresis and reinitiation of her home antihypertensive agents (but at lower doses). . # CONGESTIVE HEART FAILURE WITH MITRAL REGURGITATION - Patient initially presented with fluid overload with crackles on lung exam and elevated JVP. She was started on Valsartan for afterload reduction given her degree of mitral regurgitation. She was aggressively diuresed to maintain optimal volume status following an initial period of resuscitation. He mitral regurgitation was severe enough to warrant surgical consideration, but given her age and comorbidities, this was deferred as an option. She will need repeat echocardiography to evaluate her mitral regurgitation, as an outpatient. She was continued on her home [**Last Name (un) **], but we decreased the dosing to Valsartan 80 mg PO daily. We re-intitiated her home Lasix dosing at 80 mg PO daily and her goal for diuresis would be 0.5 to 1L daily. The patient was also continued on her calcium channel blocker, but at a lower dose of Verapamil 180 mg PO ER daily. Her electrolytes were optimized and she was monitored on telemetry. . # ATRIAL FIBRILLATION - Patient presented with a history of atrial fibrillation, at home she has been rate controlled on Verapamil, initially in junctional rhythm on EKG. She has a CHADS-2 score of 3 (age, HTN, DM) but was not previously anticoagulated after discussion of the risks and benefits with her PCP. [**Name10 (NameIs) **] patient was in A.fib, intermittently with RVR, throughout her hospital stay. Given the large burden of her atrial fibrillation we opted to perform transesophageal echocardiogram which showed no evidence of clot burden and she underwent electrical cardioversion on [**2136-12-3**] which was sucessful and she remained in normal sinus rhythm following the procedure. The patient was then started on Amiodarone 400 mg PO BID for 7-days total with plan to transition to 200 mg PO daily thereafter. She tolerated the initial dosing of Amiodarone for chemical cardioversion very well. She also elected to undergo chronic anticoagulation with Coumadin and was dosed 2.5 mg PO daily here following an IV heparin gtt. She was bridged with Lovenox 80 mg SC daily as an outpatient until her INR reaches a goal of [**2-2**]. . # HYPOXIA - At time of presentation, the patient had subacute progressive worsening of shortness of breath. This was most likely secondary to V/Q mismatch due to pleural effusion and mild pulmonary vascular congestion and possibly shunt from pneumonia. The patient??????s hypoxia improved during her stay with aggressive diuresis and. Cefepime and Levofloxacin were started, as above, and she completed a 7-day course for community acquired pneumonia coverage. . # TRANSAMINITIS - She presented with a global transaminitis with some evidence of hyperbilirubinemia which was most likely due to shock liver in the setting of hypotension from cardiogenic shock or a distributive process vs. congestive hepatopathy. Patient denied abdominal pain with a benign exam; and her right upper quadrant ultrasound was also benign. Hepatitis and iron studies were negative. LFTs trended down quickly with diuresis and resuscitation. Her INR was also elevated, likely also secondary to shock liver as it normalized as the patient became hemodynamically stable. She was then anticoagulated following this. . # CORONARY ARTERY DISEASE - The patient has never had coronary angiography but P-MIBI in [**4-/2136**] was negative for reproducing pain; it also showed small lateral wall infarct with large area of lateral wall ischemia, moderate area of anterior wall ischemia without infarct, mild inferior wall ischemic infarct, mid-lateral wall hypokinesis, mild anterior wall hypokinesis, and an LVEF of 55%. She was continued on Aspirin 81 mg PO daily this admission. She had no cardiac biomarker elevation. We also indefinitely held her home Plavix dosing for her peripheral vascular stenting given her need for antiplatelet and anticoagulation therapy. She was also continued on a statin medication. . # ACUTE RENAL INSUFFICIENCY - She initially presented with acute kidney injury, with a creatinine of 1.6, which trended down to 0.7. This was most likely ATN in the setting of reduced renal perfusion from a cardiogenic or distributive process. . # PERIPHERAL VASCULAR DISEASE - Patient has a history of peripheral vascular disease status-post stenting of the left foot. Initially it was difficult to interpret pulses in left foot, but the patient maintained doppler signals bilaterally. She was on Plavix for her stenting procedure, which was discontinued this admission given her anticoagulation needs.. # HYPERTENSION - She resumed her home medications of Verapamil and Valsartan (but at lower dosing) by the time of discharge. . TRANSITION OF CARE ISSUES: 1. The patient's code status was confirmed as FULL in discussion with her daughter [**Name (NI) **] and [**Name (NI) 42202**] ([**Telephone/Fax (1) 42203**]). 2. The patient presented with evidence of significant mitral regurgitation on her echocardiogram and responded to therapy. She is not likely a surgical candidate. Given her heart failure regimen and diuresis, she will need repeat 2D-Echo evaluation as an outpatient to follow her degree of mitral regurgitation and her surgical candidacy can be addressed at that time. 3. The patient will be discharged with home oxygen therapy of [**1-1**] liters of oxygen via nasal cannula (new therapy); wean supplemental oxygen as tolerated. 4. Patient will be anticoagulated with Lovenox 80 mg SC daily with bridging to Coumadin 2.5 mg PO daily with plan for long-term anticoagulation for atrial fibrillation. She will continue on this regimen and be followed with serial INR draws (goal INR [**2-2**]) as an outpatient. Her Cardiologist will follow these values and adjust her dosing accordingly. 5. The patient declined Pneumovax administration this admission. Readdress as an outpatient. 6. On CT imaging, the patient had an incidental finding of 4-mm left upper lobe and 2-mm right upper lobe non-calcified nodules which should be followed by CT in one year given the risk factor of asbestos exposure. 7. Consider restarting a statin medication based on her LFT trend and fasting lipid panel, as an outpatient. 8. Plavix was discontinued this admission (indication was for peripheral artery stenting) given her Aspirin and Coumadin needs. Readdress as an outpatient. Medications on Admission: 1. Aspirin 325 mg PO daily 2. Plavix 75 mg PO daily 3. Isosorbide mononitrate ER 30 mg PO daily 4. Lasix 80 mg PO daily 5. Valsartan 160 mg PO daily 6. Verapamil 240 mg ER PO daily 7. Glyburide 7.5 mg PO BID 8. Folic acid 1 mg PO daily 9. Pantoprazole 20 mg PO daily 10. Nitroglycerin 0.4 mg SL tablet as needed for chest pain Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 2. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. verapamil 180 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*0* 5. glyburide 5 mg Tablet Sig: 1.5 Tablets PO twice a day. 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 7. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous DAILY (Daily): While bridging to Coumadin (INR goal [**2-2**]). Disp:*10 doses* Refills:*0* 9. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: INR goal [**2-2**]. Disp:*30 Tablet(s)* Refills:*0* 10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): for 7-days total - started [**2136-12-4**] and complete dosing [**2136-12-10**] - then start 200 mg PO daily thereafter. Disp:*20 Tablet(s)* Refills:*0* 11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: start this dose on [**2136-12-11**] indefinitely. Disp:*30 Tablet(s)* Refills:*0* 12. Outpatient Lab Work 2 liters of home supplemental oxygen; pulse-dosed for portability to maintain oxygen saturations greater than 91%. 13. Outpatient Lab Work Please check INR on Mondays and Thursdays (twice weekly) - for INR goal [**2-2**]. . FAX RESULTS TO: [**Last Name (LF) **],[**First Name3 (LF) 251**] T. MD [**Telephone/Fax (1) 4475**] 14. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual once a day as needed for chest pain: take with the onset of chest pain; may repeat dose every 5-minutes for 3-doses; call your doctor if needed. Discharge Disposition: Home With Service Facility: Bayada Nurses Inc Discharge Diagnosis: Primary Diagnoses: 1. Acute systolic congestive heart failure exacerbation 2. Hypotension 3. Right-sided pleural effusion 4. Community-acquired pneumonia 5. Atrial fibrillation 6. Acute renal insufficiency 7. Moderate transaminitis attributed to congestive hepatopathy . Secondary Diagnoses: 1. Coronary artery disease 2. Hypertension 3. Hyperlipidemia 4. Diabetes mellitus, type 2 5. Peripheral vascular disease 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: Patient Discharge Instructions: . You were admitted to the Coronary Care Unit service at [**Hospital1 1535**] on [**Hospital Ward Name 121**] 6 regarding management of your volume overload and pulmonary issues. You had a evidence of pneumonia on imaging and required aggressive diuresis with improvement in your symptoms. You also had a drainage procedure of your right pleural effusion (lung fluid) and the drain was removed prior to your discharge. In terms of your heart rhythm, you were electrically cardioverted which resulted in your heart rhythm switching back to a normal rhythm. You also were started on Amiodarone (an anti-arrhythmic [**Doctor Last Name 360**]) to promote a normal heart rhythm. You were also started on anticoagulation with Coumadin and Lovenox to prevent stroke given your atrial fibrillation. You will continue Lovenox until your INR is therapeutic in the 2-3 range and then you will continue on Coumadin only, thereafter. You were feeling well prior to discharge. . Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If 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 an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. . CHANGES IN YOUR MEDICATION RECONCILIATION: . * Upon admission, we ADDED: We CHANGED: Aspirin from 325 to 81 mg by mouth daily We CHANGED: Verapamil from 240 to 180 mg by mouth daily We CHANGED: Valsartan from 160 to 80 mg by mouth daily START: Lovenox 80 mg SC daily (while bridging to Coumadin; can stop once your INR is [**2-2**]) START: Warfarin 2.5 mg by mouth daily with outpatient INR monitoring (goal INR [**2-2**]) START: Amiodarone 400 mg by mouth twice daily for 7-days total (last day [**2136-12-10**]) and then Amiodarone 200 mg PO daily thereafter . * The following medications were DISCONTINUED on admission and you should NOT resume: DISCONTINUE: Plavix DISCONTINUE: Isosorbide mononitrate . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: You have scheduled follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on Tuesday, [**2136-12-11**] at 2:30PM. He will also continue to follow-up your INR level and Coumadin dosing. His FAX number is [**Telephone/Fax (1) 11321**] and his OFFICE number is [**Telephone/Fax (1) 4475**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

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icd9cm

[ [ [] ] ]

[ "99.62", "34.91", "38.97" ]

icd9pcs

[ [ [] ] ]

20454, 20502

10254, 18163

272, 450

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40676

Discharge summary

report

Admission Date: [**2138-8-23**] Discharge Date: [**2138-8-25**] Date of Birth: [**2060-8-29**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 598**] Chief Complaint: Trauma: fall head injury ICH Major Surgical or Invasive Procedure: 3cm R parietal scalp laceration ( stapled) History of Present Illness: HISTORY OF PRESENTING ILLNESS This patient is a 77 year old male who complains of FALL. Fall from standing Found unresponsive on floor in pool of blood, with head lac. EMS called hypotensive, but moaning. IVf Past Medical History: PMH: CAD s/p stent, HTN, hypothyroidism, throat CA [**45**] years ago s/p resection and XRT, pancreatic CA s/p whipple 8 years ago, AAA s/p repair Social History: Lives with wife Family History: unknown Physical Exam: PHYSICAL EXAMINATION HR: 60 BP: 50/ O(2)Sat: 94 Low Constitutional: Moaning HEENT: Scalp lac on occiput with visible oozing. Pupils equal, round and reactive to light, Extraocular muscles intact Collar Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash Neuro: Speech fluent Psych: Normal mood Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Pertinent Results: [**2138-8-24**] 02:19AM BLOOD WBC-5.7 RBC-3.35* Hgb-8.6* Hct-25.6* MCV-77* MCH-25.6* MCHC-33.4 RDW-18.8* Plt Ct-207 [**2138-8-23**] 09:07PM BLOOD WBC-7.4 RBC-3.50* Hgb-8.9*# Hct-26.9* MCV-77* MCH-25.4* MCHC-33.0 RDW-18.8* Plt Ct-202 [**2138-8-23**] 04:40PM BLOOD WBC-6.0 RBC-2.94* Hgb-7.0* Hct-22.5* MCV-76* MCH-23.8* MCHC-31.2 RDW-19.0* Plt Ct-310 [**2138-8-24**] 02:19AM BLOOD Plt Ct-207 [**2138-8-23**] 09:07PM BLOOD Plt Ct-202 [**2138-8-23**] 04:40PM BLOOD PT-20.1* PTT-45.7* INR(PT)-1.8* [**2138-8-24**] 02:19AM BLOOD Glucose-98 UreaN-12 Creat-1.2 Na-132* K-4.7 Cl-101 HCO3-24 AnGap-12 [**2138-8-23**] 09:07PM BLOOD Glucose-117* UreaN-12 Creat-1.2 Na-130* K-5.0 Cl-97 HCO3-24 AnGap-14 [**2138-8-23**] 04:40PM BLOOD cTropnT-<0.01 [**2138-8-23**] 04:40PM BLOOD CK-MB-3 [**2138-8-24**] 02:19AM BLOOD Calcium-7.6* Phos-4.5 Mg-1.7 [**2138-8-23**] 09:07PM BLOOD Calcium-7.5* Phos-4.3 Mg-1.7 [**2138-8-23**] 06:08PM BLOOD Hgb-10.4* calcHCT-31 [**2138-8-23**]: chest x-ray: IMPRESSION: Low lung volumes with patchy opacity in left lung base and subtle nodular opacities in the right lower lung field. Findings may reflect an infectious process or possibly aspiration. [**2138-8-23**]: ct of c-spine: IMPRESSION: 1. No acute process. No fracture or dislocation. Degenerative changes as described above. 2. Right sternocleidomastoid muscular atrophy. [**2138-8-23**]: cat scan of the head: IMPRESSION: No acute intracranial process. Small laceration noted overlying the right frontoparietal bone. [**2138-8-23**]: abdominal cat scan: No acute process, fracture or dislocation identified. 2. Mediastinal lymphadenopathy with evidence of small airway infection/inflammation. Lymphadenopathy is likely reactive to the changes described in the lung. 3. Emphysematous changes. 4. Calcified subpulmonic and left major fissure pleural plaques; has the patient had prior pleurodesis? 5. The patient is status post a Whipple procedure with expected pneumobilia noted in the left lateral lobe. No evidence of mass in the surgical bed. 6. Patient with abdominal aortic aneurysm and aortic [**Hospital1 **]-iliac graft. Thrombosis in the aneurysmal sac without evidence of active extravasation. 5. Left inguinal fat-containing hernia. Brief Hospital Course: 77 year old gentleman admitted to the acute care service after a fall in which he sustained a head laceration. Upon admission, he was made NPO, given intravenous fluids, and underwent radiographic imaging. He was found to have a right parietal scalp laceration which required closure. He was hemodynamicallly unstable requiring 2 units packed red blood cells and crystallloid to maintain his blood pressure. His imaging studies did not show any head injury or cervical spine injury. He was transferred and monitored in the intensive care unit where he received additional packed red blood cells. Once he stablized he was transferrd to the surgical floor on [**8-24**]. His vital signs are stable and he is afebrile. He is tolerating a regular diet and is voiding without difficulty. His hematocrit is maintained at 25.6. He does report mild dizziness when ambulating. He has refused cognitive evaluation by occupational therapy. He is preparing for discharge home with VNA services. He will need to have a repeat hematocrit on [**8-28**]. He has been instructed to follow-up with the acute care service in 2 weeks with the acute care service. His scalp sutures will be removed by the VNA on [**9-1**]. Of note: he has been instructed to follow-up with his PCP [**Last Name (NamePattern4) **] 1 week for repeat hematocrit, coagulation, and electrolytes. He will have them repeated by VNA on [**8-27**] He has been instructed to resume aspirin and plavix. His potassium is 5.0, creat 1.4. Medications on Admission: [**Last Name (un) 1724**]: Plavix (last 7/28 per EMS report), Pancrease 2 tabs PO with meals, zoloft 50', clonidine 0.1', simvastatin 20', levothyrox 50', toprol xl 50', asa 325 Discharge Medications: 1. levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. nitroglycerin 0.3 mg Tablet, Sublingual Sig: 0.3 Tablet, Sublingual Sublingual PRN (as needed) as needed for angina. 9. pancrease Sig: Two (2) tabs with meals. 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours: as needed for pain. 11. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day: to begin [**8-26**]. 12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: to begin [**8-26**]. 13. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Trauma: fall head injury scalp laceration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after you tripped and fell. You hit your head and sustained a laceration on your head. You required sutures to close the wound on your head. You are preparing for discharge home with VNA assistance. You should also follow up with your primary care provider [**Last Name (NamePattern4) **] 1 weeks so your lab work can be repeated. You will be discharged with the following instructions: Please report: *increased headache *visual changes *weakness one side of your body *slurred speech *bleeding from head laceration *fever, chills *drainage from head laceration Followup Instructions: Please follow-up with the acute care service in 2 weeks. The telephone number to schedule your appointment is # [**Telephone/Fax (1) 600**]. You can schedule this appointment when you are discharged. You will also need to follow-up with your primary care provider [**Last Name (NamePattern4) **] 1 week to have your hematocrit, PT/INR repeated and your electrolytes repeated. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2138-9-2**]

[ "V45.82", "E885.9", "244.9", "873.0", "414.01", "V10.02", "458.9", "V10.09" ]

icd9cm

[ [ [] ] ]

[ "86.59" ]

icd9pcs

[ [ [] ] ]

6494, 6552

3742, 5246

334, 379

6641, 6641

1473, 3719

7421, 7936

838, 847

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862, 1454

263, 296

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103,789

3668

Discharge summary

report

Admission Date: [**2155-9-3**] Discharge Date: [**2155-9-10**] Date of Birth: [**2090-5-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: Nausea, vomiting and hypertension Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 65F with DMI on an insulin pump, HTN p/w nausea vomiting and SBP to 200s. Pt states that symptoms started the night before admission with nausea and inability to keep down POs. sugars at the time was in the 120s. Patient woke up from sleep the morning of admission with nausea and vomiting (non-bloody/non-bilious). Blood sugar noted to be 440. Patient called EMS and on arrival blood sugar 381. She had a similar presentation just over a year ago and nausea/vomiting attributed to gastroparesis vs gastritis and esophagitis (seen on EGD). Per patient and husband, she has been told that she has gastroparesis [**1-3**] DM. . ED: bp 190/72 on arrival. Given anti-emetics and labetalol prn. BP later 170 systolic. Given pr aspirin. iv fluids given. EKG without change. 1st set CEs negative. Lack of iv access, so femoral line attempted x 2 without success (one femoral arterial stick). Patient was chest pain free. 2 peripheral ivs were placed. ABG performed: 7.57/25/101. Past Medical History: 1. Sciatica with h/o laminectomy. 2. DM1 for 36 years, on insulin pump 3. Hypercholesterolemia 4. h/o CP in [**2137**], cardiac cath clean - sx's felt to be ?spasms. 5. HTN 6. Hiatal hernia 7. s/p hysterectomy Social History: Married, lives with husband, has 4 children, smokes 10 cig/day, occassional EtOH, no illicit drug use. Family History: Mother MI [**97**]'s Father MI [**07**]'s Physical Exam: Vitals: T: 97.5 P: 72 BP: 132/72 R: 16 SaO2: 98% RA. General: alert and oriented x 3, NAD HEENT: NC/AT, PERRL, EOMI without nystagmus, anicteric sclera, dry mucous membranes, top dentures ill fitting but no OP lesions Neck: supple, no JVD Pulmonary: Lungs CTA bilaterally although air movement somewhat limited Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, nondistended, nontender, no rebound or guarding Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted, skin tanned. Pertinent Results: [**2155-9-3**] 12:05PM freeCa-1.09* [**2155-9-3**] 12:05PM GLUCOSE-260* LACTATE-2.0 NA+-136 K+-4.0 CL--97* [**2155-9-3**] 12:05PM TYPE-ART PO2-101 PCO2-25* PH-7.57* TOTAL CO2-24 BASE XS-2 [**2155-9-3**] 01:40PM PT-12.1 PTT-26.5 INR(PT)-1.0 [**2155-9-3**] 01:40PM PLT COUNT-244 [**2155-9-3**] 01:40PM NEUTS-85.0* LYMPHS-10.4* MONOS-3.8 EOS-0.5 BASOS-0.3 [**2155-9-3**] 01:40PM WBC-8.8 RBC-4.37 HGB-14.1 HCT-40.9 MCV-94 MCH-32.2* MCHC-34.4 RDW-13.6 [**2155-9-3**] 01:40PM ALBUMIN-4.4 CALCIUM-10.2 PHOSPHATE-1.5*# MAGNESIUM-1.9 [**2155-9-3**] 01:40PM CK-MB-NotDone [**2155-9-3**] 01:40PM ALT(SGPT)-31 AST(SGOT)-34 CK(CPK)-99 ALK PHOS-102 AMYLASE-46 [**2155-9-3**] 01:40PM estGFR-Using this [**2155-9-3**] 01:40PM GLUCOSE-227* UREA N-40* CREAT-1.5* SODIUM-135 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-20* ANION GAP-20 [**2155-9-3**] 01:56PM LACTATE-2.4* [**2155-9-3**] 02:00PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2155-9-3**] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2155-9-3**] 02:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2155-9-3**] 02:00PM URINE GR HOLD-HOLD [**2155-9-3**] 02:00PM URINE HOURS-RANDOM [**2155-9-3**] 07:20PM PLT COUNT-221 [**2155-9-3**] 07:20PM WBC-8.5 RBC-3.77* HGB-12.4 HCT-37.2 MCV-99* MCH-32.9* MCHC-33.3 RDW-13.1 [**2155-9-3**] 07:20PM CALCIUM-8.1* PHOSPHATE-3.1# MAGNESIUM-1.6 [**2155-9-3**] 07:20PM CK-MB-5 cTropnT-<0.01 [**2155-9-3**] 07:20PM CK(CPK)-93 [**2155-9-3**] 07:20PM GLUCOSE-222* UREA N-30* CREAT-1.1 SODIUM-138 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-19 Brief Hospital Course: In [**Hospital Unit Name 153**]: pt was kept NPO due to persistent nausea and vomiting. she was started on iv reglan as well as other antiemetics. her symptoms are improving but not yet resolved. her blood pressure was better controlled with a combination of captopril, clonidine and labetalol iv. will need to further titrate dose as well as consolidate and switch to po when tolerating. pt's dm was aggressively managed with iv rehydration and insulin. her gap has since closed and sugar came down. [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendation, her insulin pump's d'ced while she's not able to tolerate po. she's currently on glargin baseline and sliding scale. she's to restart insulin pump once tolerating po. . #) Nausea/vomiting - felt due to gastroparesis. Improved with IV antiemetics. Was ultimately controlled with oral reglan. By discharge, this had resolved. . #) HTN - no evidence of end organ damage seen. Initially treated with IV labetolol, and this was changed to oral formulation by discharge. Her ace inhibitor was continued. Clonidine patch was started. BP was well controlled at discharge. . #) DMI - on insulin pump at home. Presented with ketones in urine and AG = 16 suggestive of mild DKA. Started on IVF resuscitation and insulin gtt for improved control - gap resolved and BG controlled. Transitioned to lantus and lispro (HS and sliding scale) and pump turned off. [**Last Name (un) **] consulted. Agreed with this plan. Plan to leave pump of indefinately. . #) Sciatica - [**Last Name (un) 16604**] and oxycodone held in hospital as pt. was slightly confused on presentation. This was not restarted, and she did not experience overt opiate withdrawal. At the time of discharge, she was not complaining of back pain, so the opiates were not restarted/continued. . Pneumococcal vaccine status confirmed (last [**2152**]); gave influenza vaccine. Medications on Admission: albuterol inh prn ?aspirin 325mg daily calcitriol 0.5mcg po daily citalopram 40mg daily Humalog pump lisinopril 30mg daily lorazepam 0.5mg daily prn neurontin 800mg po qam, qpm, 1600mg qhs [**Year (4 digits) 16604**] 40mg qam and 10mg qhs oxycodone 5mg po q6hrs prn ranitidine 300mg po qday reglan 10mg po qid zocor 40mg daily Discharge Medications: 1. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 2. Gabapentin 400 mg Capsule Sig: Four (4) Capsule PO HS (at bedtime). Disp:*120 Capsule(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*2* 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety or insomnia. Disp:*30 Tablet(s)* Refills:*0* 7. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 10. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). Disp:*4 Patch Weekly(s)* Refills:*2* 13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28) Units, insulin Subcutaneous at bedtime. Disp:*10 mL* Refills:*2* 14. Insulin Lispro 100 unit/mL Solution Sig: as per sliding scale (attached) Units, insulin Subcutaneous QACHS insulin. Disp:*6 mL* Refills:*2* 15. Syringe Misc Sig: One Hundred (100) syringes, insulin Miscellaneous as directed. Disp:*100 syringes, insulin* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Hyperglycemia and hypertensive crisis Discharge Condition: Stable Discharge Instructions: Take all medications as prescribed. Return to the Emergency Department at [**Hospital1 18**] for: Lightheadedness, nausea, vomiting, uncontrolled high blood pressure or blood sugar, headache, changes in vision Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2155-9-15**] 10:30 Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2155-10-1**] 10:40 Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2155-12-18**] 7:50

[ "403.00", "276.3", "250.63", "272.0", "536.3", "250.13", "276.52", "V58.67", "724.3" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

8105, 8111

3996, 5907

348, 354

8193, 8202

2308, 3973

8462, 8878

1733, 1776

6285, 8082

8132, 8172

5933, 6262

8226, 8439

1791, 2289

275, 310

382, 1361

1383, 1596

1612, 1717

13,864

189,937

49305

Discharge summary

report

Admission Date: [**2179-9-2**] Discharge Date: [**2179-9-6**] Service: MED Allergies: Procainamide / Bactrim Attending:[**First Name3 (LF) 613**] Chief Complaint: cc:[**CC Contact Info 103318**] Major Surgical or Invasive Procedure: none History of Present Illness: 86 female w/ h/o CAD s/p CABG, CHF/MR w/ EF 15% 8/03 s/p BiV pacer [**8-29**], paroxsymal afib on coumadin, htn, hyperlipidemia, diverticulosis s/p colectomy now being admitted for BRBPR w/ nuclear scan positive at splenic flx, aortogram neg, colonoscopy with diverticulosis as likely source of bleed. Past Medical History: CHF ef 15%, [**6-29**], CAD s/p CABG '[**56**] and '[**66**], BiV pacer [**8-29**], PAF, severe MR, HTN, hyperlipidemia, diverticular dz s/p colectomy, ?mesenteric emboli, arthritis, restless leg syndrome, depression, dementia Social History: remot h/o tob no etoh Pt lives at [**Hospital 582**] Nursing Home Physical Exam: 97.3 108/80 80 18 99%RA thin elderly woman in NAD OP clear MM-dry decreased BS at bases B irreg irreg no m/r/g abd soft NT ND 2+ DP PT carotids and radial pulses B trace edema Pertinent Results: [**2179-9-2**] 09:15PM HCT-26.9* [**2179-9-2**] 05:10AM PT-16.9* PTT-31.4 INR(PT)-1.8 [**2179-9-2**] 05:10AM PLT SMR-NORMAL PLT COUNT-298 [**2179-9-2**] 05:10AM cTropnT-<0.01 [**2179-9-2**] 05:10AM CK(CPK)-75 [**2179-9-2**] 05:10AM CK-MB-3 Brief Hospital Course: MICU COURSE: 1. GIB: likely diverticulosis, now on full diet, 2 large bore ivs, daily crits, type and cross for 4 units at all times, GI off case, PPI; f/u stool studies 2. CAD: re-started ASA, on beta, ACe , ruled out 3. CHF: beta, ace, diuretics, nitrates 4. HTN: management as above 5. Afib: amio for now no anti-coagulation, at this point, d/w cards ?re-start coumadin 6. anemia: following crits 7. Fen: follow lytes, mucomyst post angio, gentle ivf 8. dementia: cont pyschotropic meds 9. Access: 2 large bores 10. Dispo: pending coumadin issues, pending placement? pending SW consult ?need for guardianship GI Consult - Last Updated by [**Last Name (LF) **],[**First Name3 (LF) **] Y on [**2179-9-5**] @ 2302 86 y/o woman with hx of CAD, PAF, mesenteric ischemia, s/p right hemicolectomy presented with BRBPR. Tagged scan light up in splenic flexure but angio did not show active bleeing. Transferred to ICU. Hct dropped from 38 to 28. Stable overnight. We did colnoscopy on Friday, many tics one large with stigmata of recent bleed that we cautrerized. Called out to flor WKND: Follow Hct from periphery. Hct 32.0 --> 33.2 --> 34.9 --> ... 33.9 Gold Surgery - Last Updated by [**Last Name (LF) **],[**First Name3 (LF) 275**] M on [**2179-9-3**] @ 1837 CONSULT [**Doctor Last Name **] UPDATE on FLOOR: 1. GIB: active bleed at splenic fx was detected during the nuclear study; 2 large bore ivs were placed and pt did require four units of pRBCs along with 2 units of FFP. Since the patient's crit did not bump appropriately, pt was sent to ICU where she was ultimately taken for colonoscopy, which revealed multiple diverticuli, one of which demonstrated stigmata of recent bleed-this was cauterized and the pt had no further bleeding. Tolerated po well & was asymptomatic. Pt's ASA and coumadin were held initially. The ASA was restarted due to her extensive CAD hx but the coumadin has been discontinued at discharge in light of her life-threatening bleed. This pt does have a substantial stroke risk due to her afib and CHF but the risks of coumadin therapy seem to outweigh the benefits after this admission for severe LGIB. 2. CAD: Pt ruled out for MI; she at no point complained of chest pain and serial ekgs were unremarkable and continue to demonstrate a paced rhythm. 3. CHF: Pt demonstrated no signs of acute CHF and her CHF regimen of ace, beta blocker, lasix, aldactone and imdur were gently restarted during her course of imptovement. 4. HTN: PT now back on her HTN regimen with good BP control. 5. Afib: amio was continued along with her beta blocker. Pt had good rate control during the later portions of the hospitalization. Pt has been taken off of coumadin as described above. 6. anemia: serial crits were followed and were stable after initial transfusion. 7. dementia: donepizil continued; pt seemed reasonably well oriented but continued to have short term memory/memory consolidation problems. 8. [**Name2 (NI) **]: guardianship is being pursued at [**Name (NI) 582**]; pt transferred back there to resume this process Medications on Admission: Aldactone 25 qd, Amio 200 qd, Norvasc 5 qd, Buspar 10 tid, Coreg 12. 5 [**Hospital1 **], effexor 75 qd, ferrous sulfate 325 qd, lasix 20 qd, imdur 30 qd, lisinopril 40 qd, prilosec 20 qd, coumadin 2.5 qhs, asa 81 qd, ariricept 10 qd, mvi, zyprexa 5 qhs, lexapro to start 5 qd on [**9-10**] Discharge Medications: 1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day). 3. Buspirone HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO QD (once a day). 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO QD (once a day). 7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day). 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 10. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (once a day). Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: Diverticulosis Lower GI bleed Congestive Heart Failure Atrial Fibrillation Hypertension Alzheimer's Dementia Discharge Condition: tolerating po, asymptomatic Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 Liters restriction Followup Instructions: Please arrange follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] upon discharge from acute rehab. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "331.0", "562.12", "333.99", "427.31", "414.00", "401.9", "272.4", "V45.01", "294.10", "455.0", "428.0", "285.1" ]

icd9cm

[ [ [] ] ]

[ "99.07", "45.43", "88.47", "99.04" ]

icd9pcs

[ [ [] ] ]

6210, 6287

1415, 4473

254, 261

6439, 6468

1139, 1392

6656, 6912

4813, 6187

6308, 6418

4499, 4790

6492, 6633

942, 1120

183, 216

289, 593

615, 843

859, 927

7,102

177,319

21089+21090

Discharge summary

report+report

Admission Date: [**2146-4-22**] Discharge Date: [**2146-4-26**] Date of Birth: [**2101-11-17**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 44-year-old gentleman who has a 3-month to 4-month history of exertional angina described as chest tightness with tingling in both of his forearms and wrists. The patient underwent a stress test in [**2146-3-10**] which was positive, and he was referred for cardiac catheterization. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Positive tobacco (half a pack per day). 3. Idiopathic thrombocytopenia purpura. 4. Status post appendectomy. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS ON ADMISSION: Lipitor 20 mg by mouth once per day. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was taken to the Cardiac Catheterization Laboratory on [**2146-4-11**]. In the Laboratory, the patient was found to have an ejection fraction of 52 percent, 60 percent left main ostial lesion, 80 percent proximal left anterior descending lesion, 100 percent left circumflex lesion, with normal left ventricular filling pressures. The patient was referred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for coronary artery bypass grafting. The patient returned to [**Hospital1 346**] on [**2146-4-22**] for coronary artery bypass grafting times three with left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal, and saphenous vein graft to diagonal. Total cardiopulmonary bypass time of 64 minutes and a cross-clamp time of 49 minutes. Please see the Operative Note for full details. The patient was transferred to the Intensive Care Unit in stable condition. The patient was weaned an extubated from mechanical ventilation on his first postoperative day DICTATION ENDED [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], MD 2229 Dictated By:[**Last Name (NamePattern4) 8524**] MEDQUIST36 D: [**2146-4-26**] 11:18:51 T: [**2146-4-26**] 15:05:31 Job#: [**Job Number 55982**] Admission Date: [**2146-4-22**] Discharge Date: [**2146-4-26**] Date of Birth: [**2101-11-17**] Sex: M Service: CSU ADDENDUM: SUMMARY OF HOSPITAL COURSE CONTINUED: The patient was weaned and extubated from mechanical ventilation on postoperative night zero. The Cardiac Surgery Service discussed antiplatelet therapy with the patient's hematologist who said that there was no contraindication to aspirin therapy. The patient was started on aspirin. The patient was transferred from the Intensive Care Unit to the regular part of the hospital. On postoperative day two, the patient was noted to have an elevated temperature of 101.2 with a white blood cell count of 12.7. The patient was encouraged to undertake coughing and deep breathing. On postoperative day three, the patient continued to have low- grade fevers of 101 with a white blood cell count again of 12.7. The patient was pan-cultured. The patient's central venous line was removed, and subsequently the patient defervesced. He had no further fevers, and his white blood cell count decreased to 9. The patient was cleared by Physical Therapy. He was able to ambulate 500 feet and climb one flight of stairs. By postoperative day four, the patient was cleared for discharge to home. Temperature maximum was 100.1, pulse was 92 (in a sinus rhythm), his blood pressure was 109/63, his respiratory rate was 15, and his oxygen saturation was 97 percent on room air. Laboratory data revealed a white blood cell count was 9.1, his hematocrit was 33.3, and his platelet count was 277. Sodium was 138, potassium was 4, chloride was 100, bicarbonate was 28, blood urea nitrogen was 22, creatinine was 1, and blood glucose was 128. The patient's weight on [**4-26**] was 98.7 kilograms. His preoperative weight was 102 kilograms. Neurologically, the patient alert, awake, and oriented times three. A nonfocal neurologic examination. Heart was regular in rate and rhythm. No rubs or murmurs. Respiratory examination revealed breath sounds were clear bilaterally. Gastrointestinal examination revealed there were positive bowel sounds. The abdomen was soft, nontender, and nondistended. Sternal incision with staples intact. The incision was clean and dry. There was no erythema or drainage. The sternum was stable. Right lower extremity vein harvest site with Steri-Strips intact. There was no erythema or drainage. The patient had bilateral lower extremity edema of 1 plus (right greater than left). DISCHARGE DISPOSITION: The patient was to be discharged to home in stable condition. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg by mouth twice per day (times seven days). 2. Potassium chloride 20 mEq by mouth twice per day (times seven days). 3. Protonix 40 mg by mouth once per day. 4. Percocet 5/325-mg tablets one to two tablets by mouth q.4- 6h. as needed. 5. Lipitor 20 mg by mouth once per day. 6. Enteric coated aspirin 81 mg by mouth once per day. 7. Lopressor 50 mg by mouth twice per day. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass grafting. 3. Idiopathic thrombocytopenia purpura. DISCHARGE INSTRUCTIONS-FOLLOWUP: 1. The patient was instructed to follow up with Dr. [**Last Name (STitle) 47403**] in one to two weeks. 2. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in three to four weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], MD 2229 Dictated By:[**Last Name (NamePattern4) 8524**] MEDQUIST36 D: [**2146-4-26**] 11:25:55 T: [**2146-4-26**] 15:19:42 Job#: [**Job Number 55983**]

[ "414.01", "780.6", "272.0", "413.9", "287.3", "998.89" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4617, 4680

5121, 5785

4706, 5100

701, 745

774, 4593

166, 462

484, 674

70,278

173,005

28261

Discharge summary

report

Admission Date: [**2149-3-2**] Discharge Date: [**2149-3-10**] Date of Birth: [**2102-10-1**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p fall down escalator 2 days prior to presentation. Presenting with neck and left flank pain. Major Surgical or Invasive Procedure: Angioembolization X3 with coils and factor 7 History of Present Illness: 46 yo male who presented to an outside emergency department 2 days after falling down and escalator, his pain had become significantly worse so he sought care. CT scan at the outside hospital showed retroperitoneal bleed. He was on Coumadin therapy for history of DVT and INR was 9.2 and was given fresh frozen plasma as well as vitamin K. He was transferred to [**Hospital1 18**] for further managment. On CT imaging here he was found to have a large retroperitoneal hematoma extending from the left psoas muscle, and minimally displaced fractures to the left transverse processes of L3 and L4. Past Medical History: PMH/PSH: anxiety, vascular malformation s/p stripping, broke ankle, shoulder and femur after a work accident, HTN, GERD w/ ulcer, chronic back pain, diverticulitis s/p sigmoid resection c/ iliac vein DVT and PE Social History: Recently separated from wife. Unemployed. Significant history of alcohol abuse. Family History: Neuroblastoma Physical Exam: Upon presentation to ED: P:94, BP:113/76, RR:18, T:98.8, O2 sat 98% RA HEENT: atraumatic Respiratory: CTA bilaterally CV:RRR Abd: NT/ND Musculoskeletal: Pain in midlumbar region with ecchymosis Neuro: Awake and alert Pertinent Results: [**2149-3-9**] 09:45AM BLOOD WBC-8.8 RBC-3.45* Hgb-9.9* Hct-29.3* MCV-85 MCH-28.6 MCHC-33.6 RDW-15.5 Plt Ct-244 [**2149-3-8**] 06:55AM BLOOD WBC-8.1# RBC-3.06* Hgb-9.2* Hct-26.3* MCV-86 MCH-29.9 MCHC-34.8 RDW-15.5 Plt Ct-226 [**2149-3-3**] 12:30PM BLOOD Neuts-90.5* Lymphs-6.3* Monos-2.6 Eos-0.6 Baso-0.1 [**2149-3-9**] 09:45AM BLOOD Plt Ct-244 [**2149-3-5**] 01:51AM BLOOD PT-10.4 PTT-21.6* INR(PT)-0.8* [**2149-3-8**] 06:55AM BLOOD Glucose-90 UreaN-16 Creat-0.8 Na-133 K-3.9 Cl-98 HCO3-25 AnGap-14 [**2149-3-7**] 01:45AM BLOOD Glucose-95 UreaN-8 Creat-0.6 Na-136 K-3.9 Cl-103 HCO3-25 AnGap-12 [**2149-3-2**] 07:30AM BLOOD ALT-21 AST-30 AlkPhos-76 Amylase-38 TotBili-0.4 [**2149-3-8**] 06:55AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8 Micro:[**2149-3-6**] Ucx ENTEROCOCCUS SP>100,000 R Tetra, S vanc,amp,nitrofurantoin [**3-2**] Imaging: CT abd/pelv: IMPRESSION: 1. Large retroperitoneal hematoma extending from the left psoas muscle which has increased in size since the recent CT performed at 4:00 a.m. this morning. 2. Peripherally calcified hypodensity within the mid pole of the left kidney, which may slightly enhance on the outside hospital CT. This may represent old infarct/calcified cyst or prior RF ablation site. If not previously characterized, this could be further evaluated with MRI on non-emergent basis. 3. Minimally displaced fractures to the left transverse processes of L3 and L4. 4. Diffuse fatty infiltration of the liver. Brief Hospital Course: He was admitted to the Trauma service and transferred to the Trauma Intensive Care unit for closer monitoring. On admission [**2149-3-2**], his hematocrit was 32.1. He was brought to the Angio suite and the lumbar arteries at L2-L5 were visualized and no active bleeding was noted, these vessels appeared normal. Because of his elevated INR and hypertension, the right femoral catheter sheath was left in place. His hematocrits continued to drop as low as 20.4 accompanied with tachycardia. On [**3-3**] he returned to the Angio suite for repeat evaluation of the lumbar arteries and the source of the bleeding was determined to be the L5 artery and embolization of the distal left L5 branch was performed. The vessel was successfully embolized with six microcoils. The microcatheter was removed and repeat arteriogram showed no signs of active bleed. His hematocrits continued to drop requiring further embolization and coiling on [**3-4**]; area of active extravasation adjacent to the psoas muscle. Prior to returning to the Angio suite he had bilateral lower extremity ultrasound to rule out DVT which were negative. He was again returned to the Angio suite for possible re-embolization. Abdominal aortogram and selective arteriograms of the left lumbar L3, L4, and L5 levels as well as the left iliolumbar artery demonstrated no definite foci of active extravasation, Gelfoam embolization of the left L5 lumbar artery was preformed given persistent flow across previously placed coils. Complete occlusion of this vessel was achieved, and infusion of recombinant factor VII (total dose 1 mg) into both the left iliolumbar artery and left L5 lumbar artery. He required 7 units of packed red blood cells over his hospitalization. After this embolization his hematocrit, vital signs, and flank hematoma were monitored and remained stable. Because of the use of factor VII, he had repeat ultrasound of his lower extremities which ruled out any thrombosis. He was transferred to the floor for further monitoring. On [**2149-3-8**] his temperature was 101.5. Urinalysis and culture were sent, as well as blood cultures. A chest Xray was done. Urine culture from [**2149-3-6**] grew enterococcus and he was started on a 3 day course of ciprofloxacin. Sensitivities were then preformed and the antibiotic regimen was changed to ampicillin 500 mg every 6 hours for 7 days. His hospital course was further complicated by acute alcohol withdrawal for which he was monitored with CIWA scale and treated with Valium. In a state of acute agitation he was transferred again to the TSICU for stabilization. His mental status cleared and he was placed on standing Valium and transferred back to the regular nursing unit. Psychiatry and social work were consulted to evaluate his safety and alcohol use. It was noted in social work documentation that patient declined assistance with his alcohol with the intention of following up with his 12 step program. He remained hemodynamically stable on the floor and was discharged to home on [**2149-3-10**]. Medications on Admission: Coumadin 10mg qd Lopressor 50mg [**Hospital1 **] percocet 10mg-325mg prn Campral 666mg qd Cymbalta 60mg qd Omeprazole 20mg qd Alprazolam 0.5prn Risperidone 1mg [**Hospital1 **] Trazodone 50mg QHS Discharge Medications: 1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 7 days: stop antibiotics [**2149-3-16**]. Disp:*52 Capsule(s)* Refills:*0* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**3-18**] hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Discharge Disposition: Home Discharge Diagnosis: s/p Fall Right retroperitoneal bleed Lumbar transverse process fractures [**2-13**] Delirium tremors Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted to the hospital after a fall down an escalator which resulted in fractures in your lumbar (lower back) spinous processes [**2-13**]. You also suffered an internal bleed resulting from your fall from an artery near your lower spine which. You had been taking coumadin at the time of your fall which made you more likely to bleed and this was stopped as your treatment for the blood clot has been for more than 6 months. You spent some time in the intensive care unit, and during this time you were brought to the radiology angiography suite three times to stop the bleeding in the artery. You now have a large bruise on your lower flank which will resolve with time and it is safe for you to be discharged home. You were found to have an infection in your urinary tract which we will treat with Ampicillin 500mg every 6 hours for one week. Please take the antibiotic as written on the medication bottle and continue to take the medication until the bottle is empty. You will no longer need to take coumadin therapy to prevent DVT's in your legs. You met with our social work team during your admissionn and we encorage you to continue to make the changes you had been working on in regaurds to alcohol use prior to your fall. Please reach out to your sponsor and your support groups. Please resume all of your home medications as prescribed by your health care provider. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in the trauma outpatient clinic in 2 weeks, call [**Telephone/Fax (1) 2359**] for an appointment. Please followup with your Primary Care Provider [**Name9 (PRE) 19605**] your home medications within the next week. Completed by:[**2149-3-18**]

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icd9cm

[ [ [] ] ]

[ "88.47", "99.04", "99.07", "99.06", "88.49", "39.79" ]

icd9pcs

[ [ [] ] ]

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Discharge summary

report+addendum

Admission Date: [**2196-5-13**] Discharge Date: [**2196-5-20**] Date of Birth: [**2123-10-9**] Sex: M Service: NEUROSURG ADMITTING DIAGNOSIS: 1. Subarachnoid hemorrhage. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 13448**] is a 72 year old left-handed male who presented with severe frontal and midline headache since last night in the Emergency Room. He treated this headache with a nonsteroidal with very little relief and woke up this morning with a persistent headache and occipital pain. He complains of no visual disturbances, no motor disturbances, no nausea or vomiting, and no neck pain. By the time of examination in the Emergency Room, he had no headache. PHYSICAL EXAMINATION: Upon examination, he is afebrile; heart rate 64; blood pressure 180/79; respiratory rate 16; saturation 98% on room air. On Neurological examination, he is awake, alert and oriented times three. He follows commands. Cranial nerves II through XII intact. No nuchal rigidity. Motor bilateral upper extremity and lower extremity was full strength, that is five by five. Sensory examination was intact. Cardiovascular system: Rate and rhythm regular. Respiratory: Air entry bilaterally, equal breath sounds heard. Abdomen soft, bowel sounds present. Examination of back: No tenderness. PAST MEDICAL HISTORY: 1. Status post coronary artery bypass graft. 2. Right basal ganglion bleed in [**2195-5-8**]. 3. Left carotid endarterectomy in [**2189**]. 4. Hypertension. 5. Coronary artery disease status post myocardial infarction in [**2191**]. 6. Right internal carotid artery stenosis. 7. Elevated cholesterol. CURRENT MEDICATIONS: 1. Zestril 20 mg q. day. 2. Metoprolol 25 mg twice a day. 3. Aggrenox 25 mg twice a day. SOCIAL HISTORY: The patient had a 50 pack year smoking history. ALLERGIES: He has no known drug allergies. LABORATORY INVESTIGATIONS: Done from the Emergency Room, hematocrit 38.8, white blood cell count 8.1, platelets 250. Sodium 143, potassium 4.7, chloride 108, bicarbonate 25, urea 22, creatinine 1.9, blood sugar 109. INR 1.1, PT 12.8, PTT 25.6. A CT scan revealed an acute subarachnoid hemorrhage within the right suprasellar system, on Sylvian fissure. There was no mass effect, no midline shift, no hydrocephalus and no intraventricular hemorrhage. The plan was to admit him to the Neurosurgery Intensive Care Unit and do q. one hour neurological checks. An arterial line was placed and a Nipride infusion was started to maintain his systolic blood pressures less than 40 mm of Mercury systolic. The patient received an angiogram on [**5-13**]. The angiogram revealed an occluded right internal carotid artery and there was no evidence of an aneurysm and therefore no coiling was attempted. The patient remained in the Neurosurgical Intensive Care Unit until the [**5-17**]. COURSE IN THE INTENSIVE CARE UNIT: [**Unit Number **]. Cardiovascular: The patient remained stable. He received intravenous anti-hypertensive therapy. He was on a Nipride infusion and intermittently needed additional intravenous Labetalol. He was in sinus rhythm and his blood pressures and cardiovascular system remained stable. His cardiac enzymes were cycled which were negative for any acute ischemic cardiac event. 2. Neurological system: His cranial nerves remained intact. He demonstrated no pronator drift. Lower extremity was full strength. He was gradually mobilized from bed to chair and no further activity was advanced at this time. He was awake, alert and oriented at all times with no periods of confusion. He did not complain of a headache during his stay in the Intensive Care Unit and neither did he develop any nuchal rigidity. His hematocrit and the electrolyte parameters remained stable. 3. Renal: Mr. [**Known lastname 13448**] is known to have chronic renal impairment. This renal impairment remained stable. Despite the angiogram and the CT scan angiogram, his creatinine and urea remained stable and did not need any further intervention. 4. Respiratory system: Mr. [**Known lastname 13448**] maintained his own airway and did not need any airway intervention. He did receive incentive spirometer for chest Physical Therapy. 5. Gastrointestinal: Mr. [**Known lastname 13448**] was started on oral diet and his diet was advanced as tolerated. 6. Endocrine: His blood sugar remained stable during his course in the hospital. Mr. [**Known lastname 13448**] was transferred to the Neurosurgical Floor on the [**5-18**]. In the Neurosurgical Floor, he has remained awake, alert and oriented. He has developed no new neurological deficits. Physical Therapy assessed him on the [**5-18**] and during ambulation, they found that his left side was weak and it was decided that it was unsafe to discharge Mr. [**Known lastname 13448**] home, therefore, the physical therapists have recommended a rehabilitation facility placement to facilitate Mr. [**Known lastname 98669**] recovery. INPATIENT MEDICATIONS: 1. Percocet one to two tablets p.o. q. four to six hours p.r.n. for pain. 2. Metoprolol 25 mg p.o. twice a day; hold for systolic less than 110 or heart rate less than 55. 3. Lisinopril 20 mg p.o. q. day. 4. Ranitidine 150 mg p.o. q. day. 5. Amlodipine 60 mg p.o. q. four hours. 6. Tylenol 325 to 650 mg p.o. q. four to six hours for pain. In addition, there was an order for Hydralazine 10 mg intravenously q. three to six hours p.r.n. if the systolic blood pressure is elevated beyond 180 and Mr. [**Known lastname 13448**] has not needed this supplementary Hydralazine. As of the [**5-19**], his laboratory results are hematocrit 31.3, white blood cell count 7.9, platelet count 256. Sodium 138, potassium 4.6, chloride 105, bicarbonate 22, urea 22, creatinine 1.8, blood sugar 99. His CT angiogram revealed a stable subarachnoid hemorrhage and near absence of contrast enhancement within the visualized right internal carotid artery without evidence of associated aneurysm and dysgenesis of the corpus callosum. Details of the carotid angiogram can be found in the CCC. CONDITION AT DISCHARGE: Mr. [**Known lastname 13448**] is awake, alert, afebrile, with stable vital signs. He has no sensory deficit. Cranial nerves are intact. He demonstrates no pronator drift and demonstrates a shuffling gait. At this point, the rehabilitation facility to which he will be discharged is unclear. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern5) 98704**] MEDQUIST36 D: [**2196-5-19**] 16:08 T: [**2196-5-19**] 16:35 JOB#: [**Job Number 20075**] Name: [**Known lastname 15759**], [**Known firstname 657**] Unit No: [**Numeric Identifier 15760**] Admission Date: [**2196-5-13**] Discharge Date: [**2196-5-20**] Date of Birth: [**2123-10-9**] Sex: M HISTORY OF PRESENT ILLNESS: The patient is a 72 year old gentleman with the acute onset of headache in the front and middle of his head with pain refractory to Aleve. Upon awakening the morning of admission, the pain was in his some residual weakness from a stroke in his left hand from the year previous. There was no change noted in his motor sensory function. PAST MEDICAL HISTORY: 1. Right basal ganglion bleed in [**2195-5-8**]. 2. Hypertension. 4. Myocardial infarction in [**2191**]. 5. Right internal carotid artery stenosis by MRI report. 6. Hypercholesterolemia. PAST SURGICAL HISTORY: 1. Left carotid endarterectomy in [**2189**]. MEDICATIONS: 1. Zestril 20 mg p.o. q. day. 2. Lopressor 25 mg p.o. twice a day. 3. Aggrenox 25 mg twice a day. ALLERGIES: He has no known allergies. PHYSICAL EXAMINATION: His temperature was 99.9 F.; his blood pressure was 177/60; heart rate 64; respiratory rate 18; saturation 100% on room air. He was awake, alert, oriented times three. Neck: Some tenderness upon flexion and extension without rigidity. Pupils are equal and reactive to light. His speech was stable. Neck supple with some tenderness upon flexion and extension. Chest clear to auscultation. Cardiac: Regular rate and rhythm. Abdomen soft, nontender, nondistended. Extremities with good motor strength in all four extremities with some residual weakness from a previous stroke in the left hand. LABORATORY: CT scan shows an acute subarachnoid hemorrhage with blood in the suprasellar cistern and the Sylvian fissure with no midline shift. White blood cell count 8.1, hematocrit 38, platelet count 250. Sodium 143, potassium 4.7, chloride 108, CO2 25, BUN 23, creatinine 1.9, glucose 109. HOSPITAL COURSE: The patient was admitted to the Surgical Intensive Care Unit and monitored. He had an arteriogram which showed no evidence of aneurysm. He did have an occlusion of his right internal carotid artery but no evidence of aneurysm. He has no patent anterior communicating artery and is deriving his right cerebral hemispheric perfusion from the right posterior communicating artery. The patient was kept in the Intensive Care Unit for close monitoring until the [**5-17**] when he was transferred to the regular floor where he remained neurologically stable with stable vital signs and afebrile. MEDICATIONS AT THE TIME OF DISCHARGE: 1. Lopressor 25 mg p.o. twice a day. 2. Lisinopril 20 mg p.o. q. day. 3. Zantac 150 mg p.o. q. day. 4. Amlodipine 60 mg p.o. q. four hours. 5. Tylenol 650 p.o. q. four hours p.r.n. 6. Percocet one to two tablets p.o. q. four hours p.r.n. for pain. CONDITION AT DISCHARGE: The patient's vital signs were stable; he was afebrile. The patient was in stable condition at the time of discharge and found to require acute rehabilitation prior to discharge to home. DISCHARGE MEDICATIONS: 1. He is to follow-up with Dr. [**Last Name (STitle) 365**] in three to four weeks. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5862**] Dictated By:[**Last Name (NamePattern1) 366**] MEDQUIST36 D: [**2196-5-19**] 10:03 T: [**2196-5-19**] 11:03 JOB#: [**Job Number **]

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icd9cm

[ [ [] ] ]

[ "88.41" ]

icd9pcs

[ [ [] ] ]

9800, 10134

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7529, 7733

7756, 8656

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1671, 1764

6952, 7290

163, 193

7312, 7506

1781, 6113

70,937

161,614

41541

Discharge summary

report

Admission Date: [**2150-2-9**] Discharge Date: [**2150-3-6**] Date of Birth: [**2078-12-6**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 6088**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2150-2-9**]: Open abdominal aortic aneurysm repair History of Present Illness: Patient is a 71 y/o gentleman recently discharged from [**Hospital 3278**] Medical Center s/p ex-lap, resection of colocutaneous fistula, transverse colon resection, and resection of gastrocolic fistula to [**Hospital3 2558**] who now presents to the [**Hospital1 18**] with hypotension and respiratory failure. He was intubated in the ED and had a STAT CT ABD to assess a known AAA. CT consistent with a 6.9 x 6.5 infrarenal AAA. Patient complained of abdominal pain with palpation but was hemodynamically stable. Past Medical History: CVA [**2147**] (left hemiplegia), TB, lung granuloma, HTN, hypernatremia, AAA PAST SURGICAL HISTORY: ex lap ([**Hospital 3278**] Medical Center [**1-30**] - [**2-6**]) for fecal drainage around PEG site: resection of c Social History: Mandarin speaking only. Son is involved in medical decision making. Family History: NA Physical Exam: Neuro/Psych: Abnormal: Intubated, sedated. Heart: Regular rate and rhythm. Lungs: Clear, abnormal: Intubated. Gastrointestinal: Abnormal: Slightly distended, soft. Rectal: Not Examined. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RLE Femoral: P. DP: P. LLE Femoral: P. DP: P. Pertinent Results: LABORATORY DATA: 150 112 21 AGap=7 --------------< 127 3.2 34 1.3 ALT: 22 AP: 62 Tbili: 0.6 AST: 22 Lip: 57 6.8 12.8 >< 142 20.7 N:85.0 L:11.6 M:2.5 E:0.8 Bas:0.1 PT: 12.4 PTT: 30.7 INR: 1.0 STUDIES: [**2150-2-9**] CT ABD (wet read): Large 6.9 (TRV) x 6.5 (TRV) x 9 cm (CC) infrarenal AAA extending into the right common iliac artery with periaortic stranding concerning for impending rupture CXR: FINDINGS: There has been interval placement of a right-sided PICC line with [**Known firstname **] in the low SVC. An intestinal tube is seen traversing below the diaphragm with [**Known firstname **] likely within the stomach. Compared to most recent prior, the patient has been extubated. Cardiomegaly is unchanged. Note is made of calcified aorta. There is persistent left basilar opacity. There are bilateral pleural effusions with atelectasis. IMPRESSION: Right-sided PICC with [**Known firstname **] in the lower SVC. This finding was reported to [**First Name9 (NamePattern2) 90359**] [**Last Name (un) **]-Mailet by Dr. [**Last Name (STitle) 7867**] by telephone at 10:50 a.m. on [**2150-2-11**] [**2150-2-10**] 3:21 pm BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2150-2-13**]** GRAM STAIN (Final [**2150-2-10**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2150-2-13**]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML. 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. STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S [**2150-2-10**] 2:35 am MRSA SCREEN Source: Nasal swab. FINAL REPORT [**2150-2-14**]** MRSA SCREEN (Final [**2150-2-14**]): STAPH AUREUS COAG +. 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. STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S [**2150-2-17**] 9:13 am STOOL CONSISTENCY: WATERY Source: Stool. FINAL REPORT [**2150-2-17**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2150-2-17**]): Feces negative for C.difficile toxin A & B by EIA. [**2150-2-16**]: Uncomplicated conversion of a surgically placed G-tube to a 18-French gastrojejunostomy feeding tube. The tube is ready for use. [**2150-2-27**] Venous duplex LL:No evidence of DVT in bilateral lower extremities [**2150-3-5**] CXR : Persistent left lower lobe density, as identified on single AP portable chest view, most likely representing atelectasis, which has not cleared up as yet. No evidence of new pulmonary abnormalities Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2150-2-9**] with concern for a symptomatic AAA. 3 hours after admission an repeat Hct was 20 from 24, so patient was transfused 2U PRBC. A repeat CT scan was performed which did not show any significant change with persistent concern for impending rupture. In light of his decreased hematocrit, AAA, and persistent abdominal pain, the patient was taken to the OR emergently for an open AAA repair. Postoperatively, patient was stable and transferred to the CVICU, intubated and sedated. He was started on broad spectrum antibiotics in light of recent colon surgery and new prosthetic aortic graft. The remainder of his course is detailed below by system: Cardiovascular: Patient tolerated procedure 9open triple a repair well and had palpable DPs bilaterally throughout his stay. He was treated with metoprolol perioperatively and given aspirin daily.His wound was healing well with no signs of infection. Respiratory: Patient was noted to have an aspiration episode prior to admission. Postoperatively, he was extubated on POD1 after a bronchoscopic BAL. BAL grew MRSA and patient was treated with IV vanco (total course will be 14 days). He was given daily chest PT and nebulizer treatments for his copious secretions. On [**2150-3-5**], he had excessive secretions which were sent for culture. There was no fever or rise in WBC count. GI: Patient's tube feeds were held perioperatively and restarted on POD#4. On POD#5, patient had an episode of emesis, likely due to an element of gastroperesis. His Gtube was exchanged for a G-J tube on [**2150-2-16**] and patient tolerated tube feeds at goal thereafter. Patient had watery diarrhea once bowel function returned. Cdiff was negative x 3. On discharge he is on Isosource 1.5 @ 60cc/hr tube feeds. Renal/GU: Patient's urine output was monitored closely by foley catheter perioperatively. His urine output was adequate with aggressive resuscitation. Once stabilized, patient was diuresed with lasix until scrotal edema resolved and LE edema improved. Patient required daily potassium repletion during diuresis. His foley is DC, urinating well ID: Patient was initially treated with broad spectrum antibiotics. BAL culture grew MRSA and patient's antibiotics were tailored to IV vanco only. Patient will continue IV vanco for total of 14 days. This was DC before DC, pt on total dose for 14 days Heme: Hct stable after initial transfusion mentioned above. Medications on Admission: None Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution [**Date Range **]: One (1) Injection TID (3 times a day): untill ambulatory. 2. docusate sodium 50 mg/5 mL Liquid [**Date Range **]: One (1) PO BID (2 times a day). 3. bisacodyl 10 mg Suppository [**Date Range **]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation: hold for loose stool. 4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a day). 6. aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]: One (1) Adhesive Patch, Medicated Topical DAILY AS DIRECTED (): may renove if pain resolves. 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q2H (every 2 hours) as needed for sob/wheezing . 9. metoclopramide 10 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 10. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: One (1) PO Q6H (every 6 hours) as needed for pain. 11. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours). 12. diphenoxylate-atropine 2.5-0.025 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 13. oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Symptomatic abdominal aortic aneurysm Pneumonia ARF resolved with hydration Anemia post durgical requiring PRBC's Hypernatremia 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: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**5-20**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**1-15**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2150-3-4**] 9:30 Completed by:[**2150-3-6**]

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icd9cm

[ [ [] ] ]

[ "96.6", "38.44", "46.32", "33.24", "96.71" ]

icd9pcs

[ [ [] ] ]

9481, 9524

5332, 7792

316, 371

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1580, 5309

12587, 12758

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64,014

177,721

4286

Discharge summary

report

Admission Date: [**2181-6-17**] Discharge Date: [**2181-6-21**] Date of Birth: [**2118-3-10**] Sex: F Service: MEDICINE Allergies: Bactrim DS Attending:[**First Name3 (LF) 12131**] Chief Complaint: Chief Complaint: acute SOB Reason for MICU transfer: suspected PE, sepsis [**3-8**] UTI Major Surgical or Invasive Procedure: None History of Present Illness: 63F w/ recurrent stage IIIC papillary serous ovarian CA on cycle 8 day 14 of carboplatin, gemcitabine, bevacizumab (avastin), complicated by ureter obstruction requiring left ureteral stent and right nephrostomy tube. She had a week of SOB PTA but on [**6-16**] had acute onset of SOB when at home, with fever, without cough, and no abd pain, no dysuria. Oncologic course has been complicated by b/l hydronephrosis thought to be [**3-8**] malignancy, as well as utereral obstructions requiring right nephrostomy tube. In the ED, initial VS were: 101 108 158/67 24 100% 2L (highest temp was 102.3). EKG showed ST 106 incomplete RB on previous, incomplete L bundle. CTA was deferred due to elevated Cr. Non-con belly scan was ordered and bedside u/s showed normal fast, no pericardial effusion, no right heart strain, mild left hydronephrosis, normal right kidney. She was started on Vanc/Cefepime and given APAP. Urine from nephrostomy was cloudy; Foley'd urine was the second drawn. Heparin gtt was commenced for suspected PE. She had an elevated pro-BNP but normal trop, and no right axis deviation on ECG or on u/s: was not a candidate for TPA. On arrival to the MICU, she does not c/o any pain, but is still feeling SOB, better when supine as opposed to sitting up. She denies CP, HA, abdom pain, pain upon deep inspiration, pain in calves/thighs. Adds that on day of admission, she felt more SOB fairly abruptly while sitting outside; at baseline, has no h/o heart problems or SOB when walking. She still urinates and also has UOP through the nephrostomy tube; is maintaining PO intake and says she still made urine at home today. Review of systems: Per HPI Past Medical History: ONCOLOGIC HISTORY: -- [**2180-2-7**] diagnosed with epithelial ovarian cancer at the time of exploratory laparotomy performed by Dr [**Last Name (STitle) 2028**]. Pathology revealed stage IIIC poorly differentiated (G3) papillary serous carcinoma. Two pelvic lymph nodes and one groin node were involved. There was no visible disease at the end of the operation. -- [**2180-2-28**] C1D1 IP Cis/Taxol as per GOG 172 -- [**2180-3-20**] C2D1 IP Cis/Taxol as per GOG 172 -- [**2180-4-10**] C3D1 IP Cis/Taxol as per GOG 172 -- [**2180-5-1**] C4D1 IP Cis/Taxol as per GOG 172 -- [**2180-5-23**] C5D1 IP Cis/Taxol as per GOG 172 -- [**2180-6-12**] C6D1 IP Cis/Taxol as per GOG 172 . Past Medical History: HTN. orthostatic hypotension. Right femoral hernia repair [**2153**]. Cesarean section. . OB/GYN History: G3P3. 2 spontaneous vaginal deliveries and one cesarean section. No h/o pelvic infections. No h/o abnormal pap smears. Menopause five years ago without complication and no postmenopausal bleeding. Social History: Tobacco: Denies. Alcohol: Occasional. Drugs: Denies. She lives with her husband in [**Name (NI) 5176**], who is an optometrist at the [**Hospital **] Clinic. Family History: Father: colon cancer in his 50s. Son: testicular cancer at 19, with no evidence of recurrence. No other family history of cancer. Physical Exam: Admission Physical Exam: Vitals: T: 100 HR: 94 BP: 118/39 100% 2L NC General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP 7-8cm, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding. Right nephrostomy tube draining yellow urine with some white clots; entry site is w/o erythema or drainage. GU: foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; no erythema or swelling or tenderness in calves Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally. Discharge Physical Exam: Vitals: 98.8, 136/82, 73, 20, 100% RA General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP 7-8cm, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding. Right nephrostomy tube draining clear yellow urine; entry site is w/o erythema or drainage. GU: foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; no erythema or swelling or tenderness in calves Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally. Pertinent Results: ADMISSION LABS: [**2181-6-16**] 09:50PM BLOOD WBC-7.9 RBC-2.45* Hgb-7.8* Hct-24.9* MCV-102* MCH-31.9 MCHC-31.3 RDW-18.6* Plt Ct-65*# [**2181-6-16**] 09:50PM BLOOD Neuts-90.8* Lymphs-6.5* Monos-2.6 Eos-0.1 Baso-0.1 [**2181-6-16**] 09:50PM BLOOD PT-11.7 PTT-28.1 INR(PT)-1.1 [**2181-6-17**] 06:41AM BLOOD Ret Aut-0.2* [**2181-6-16**] 09:50PM BLOOD Glucose-150* UreaN-23* Creat-1.9* Na-140 K-4.3 Cl-104 HCO3-22 AnGap-18 [**2181-6-16**] 09:50PM BLOOD ALT-15 AST-16 LD(LDH)-184 CK(CPK)-34 AlkPhos-94 TotBili-0.3 [**2181-6-16**] 09:50PM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-788* [**2181-6-17**] 04:18AM BLOOD CK-MB-1 cTropnT-<0.01 [**2181-6-16**] 09:50PM BLOOD Albumin-4.3 Calcium-9.8 Phos-0.7*# Mg-2.0 UricAcd-6.6* [**2181-6-16**] 09:50PM BLOOD D-Dimer-2249* [**2181-6-17**] 04:18AM BLOOD Hapto-225* [**2181-6-16**] 09:50PM BLOOD Lactate-3.0* [**2181-6-17**] 07:05AM BLOOD Lactate-1.0 [**2181-6-16**] 11:20PM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.009 [**2181-6-16**] 11:20PM URINE Blood-MOD Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG [**2181-6-16**] 11:20PM URINE RBC-27* WBC->182* Bacteri-MOD Yeast-NONE Epi-0 [**2181-6-17**] 12:15AM URINE Hours-RANDOM Creat-67 Na-44 K-36 Cl-40 . DISCHARGE LABS: [**2181-6-21**] 06:00AM BLOOD WBC-10.2 RBC-2.51* Hgb-8.1* Hct-24.5* MCV-98 MCH-32.5* MCHC-33.3 RDW-18.2* Plt Ct-54* [**2181-6-21**] 06:00AM BLOOD Neuts-80.9* Lymphs-12.2* Monos-6.0 Eos-0.7 Baso-0.1 [**2181-6-21**] 06:00AM BLOOD Plt Ct-54* [**2181-6-20**] 05:51AM BLOOD Fibrino-470* [**2181-6-20**] 05:51AM BLOOD Ret Aut-1.6 [**2181-6-21**] 06:00AM BLOOD Glucose-95 UreaN-14 Creat-1.2* Na-143 K-3.9 Cl-108 HCO3-28 AnGap-11 [**2181-6-21**] 06:00AM BLOOD ALT-26 AST-19 LD(LDH)-182 AlkPhos-115* TotBili-0.2 [**2181-6-21**] 06:00AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0 MICROBIOLOGY: [**2181-6-16**] 10:30 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final [**2181-6-17**]): GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [**2181-6-17**]): GRAM NEGATIVE ROD(S). [**2181-6-16**] URINE CULTURE (Preliminary): STAPH AUREUS COAG +. >100,000 ORGANISMS/ML. . IMAGING: [**2181-6-16**] CXR:IMPRESSION: No acute cardiopulmonary abnormality. [**2181-6-17**] CT abd/pelvis: IMPRESSION: 1. Worsened left sided hydronephrosis with ureteral stent in unchanged position. New stranding around the left kidney is noted which may represent new inflammation versus forniceal rupture. Contiued stranding is noted along the course of the left ureter. 3. Urothelial thickening is noted on the right, with increase in renal pelvis dilation but no gross hydronephrosis. 4. Right groin mass (series 2, image 78) previously identified as local recurrence is unchanged in size compared to the prior examination. . -[**6-17**] b/l LENIs: IMPRESSION: No evidence of deep vein thrombosis either the right or left lower extremity. . -[**6-17**] VQ scan: Very low likelihood ratio for recent pulmonary embolism. MICROBIOLOGY [**2181-6-16**] 10:30 pm BLOOD CULTURE 2 OF 2. **FINAL REPORT [**2181-6-19**]** Blood Culture, Routine (Final [**2181-6-19**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [**2181-6-17**]): Reported to and read back by NIDHI SUKUL,5/13/12,10:40AM. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [**2181-6-17**]): Reported to and read back by NIDHI SUKUL,5/13/12,10:40AM. GRAM NEGATIVE ROD(S). [**2181-6-16**] 11:20 pm URINE **FINAL REPORT [**2181-6-19**]** URINE CULTURE (Final [**2181-6-19**]): STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S NITROFURANTOIN-------- 32 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S Brief Hospital Course: Ms. [**Known lastname 18573**] is a 63F w/ recurrent stage IIIC papillary serous ovarian CA on cycle 8 day 14 of carboplatin, gemcitabine, bevacizumab (avastin), and b/l hydronephrosis [**3-8**] ureter obstruction requiring left ureteral stent and right nephrostomy tube. She p/w acute onset SOB in the setting of one week of dyspnea and fatigue, which was initially concerning for PE. Further w/u ended up ruling out PE, and her SOB was likely in the context of her fever and GNR bacteremia, which were likely [**3-8**] urinary source. . ACTIVE ISSUES: . # Dyspnea: Pt p/w acute onset SOB, and was found to be in sinus tach with elevated d-dimer and BNP in setting of malignancy, although bedside u/s showed no e/o R heart strain. She did not undergo CTA due to elevated Cr, but was started on a heparin gtt in the ED. Upon admission to [**Hospital Unit Name 153**], she had no Si/Sx of hemodynamic or respiratory collapse. ACS, PNA or pulmonary edema were r/o. LENIs were obtained, which were negative. A VQ scan was subsequently performed, and it was low probability for PE and the heparin was d/c'd. In the [**Hospital Unit Name 153**] her SOB vastly improved without further intervention. Her dyspnea was most likely due to her anemia as she significantly improved after transfusion of 2 units pRBCs for a HCT of 18. . # Fevers and UTI: UTI was likely cause for her fevers to 102.3 and diff with 91% PMNs. Pt has a h/o b/l hydronephrosis [**3-8**] ureter obstruction requiring left ureteral stent and right nephrostomy tube, and all UA's have been positive with pyuria and hematuria since [**2-15**]. Upon admission, she again had positive UA's from both foley and nephrostomy tube. She received vanc/cefepime in the ED; her past urine Cx's have grown E coli sensitive to cefepime. Per past urology notes, her R kidney is not functioning as well as the left, and no other urological interventions were necessary; she is scheduled for a left stent change in [**7-17**]. While in the [**Hospital Unit Name 153**], GNRs grew out of her blood Cx from [**6-16**], and she was continued on cefepime (d1=[**6-16**]), and continued on vanc (d1=[**6-16**]) given that she has a port. Her urine culture grew coag + staph and per Urology, it was recommended to continue treating the UTI w/o indication for stent removal at this time. Her urine culture eventually speciated as pansensitive staphylococcus aureus, and she was transitioned to oral augmentin to compelte a total 14 day course following discharge. Her blood cultures speciated as pansensitive E. coli and she was transitined to oral ciprofloxacin, also to complete a 14 day course, priro to dishcarge. She remained afebrile and stable on oral antibiotics for 24 hours prior to discharge. . # [**Last Name (un) **]: Baseline Cr is about 1.2-1.3; pt initially p/w Cr 1.9. Likely prerenal etiology given fever and UTI and FeNa of 0.9%. She has a h/o obstruction, but had been maintaining good UOP from urethra and nephrostomy. Her Cr improved in the [**Hospital Unit Name 153**] to 1.4 after 2 units pRBCs, and subsequently improved further to 1.2 by the time of discharge. . # Anemia: Macrocytic anemia with Hct 24.9 and MCV 102 on admission; baseline Hct is in high 20's. She had no Si/Sx of active bleeding upon admission, although the pt endorses small amts of blood in stool while on avastin, known to heme-onc. She had a 6-point Hct drop after admission to the [**Hospital Unit Name 153**] with no identified source; her Hct bumped appropriately after 2U PRBC's. Her stool was guaiac negative. . CHRONIC OR INACTIVE ISSUES: . # Thrombocytopenia: Most likely [**3-8**] chemo per her primary oncologist, as per hx of similar s/p chemo and is unlikely HIT as her platelets were decreased upon admission and before the initiation of the heparin gtt. . # Recurrent stage IIIC papillary serous ovarian CA on cycle 8 day 14 of carboplatin, gemcitabine, bevacizumab (avastin). . # HTN: initially held home lisinopril 5mg daily given fevers, UTI, and [**Last Name (un) **]. Once her creatinine decreased to 1.4, her home lisinopril was re-started. Medications on Admission: Home Medications: Lisinopril 5mg PO daily Vitamin D Colace Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Vitamin D3 Oral 4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 11 days: last day [**2181-7-1**]. Disp:*22 Tablet(s)* Refills:*0* 5. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 11 days: last day [**2181-7-1**]. Disp:*22 Tablet(s)* Refills:*0* 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. Disp:*30 Powder in Packet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Eschirichia coli bactermeia Methicillin sensitive staphylococcus aureus urinary tract infection Anemia Thrombocytopenia Secondary: Stage IIIC papillary serous ovarian carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 18573**], It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted with shortness of breath and fevers. You were initially admitted to our intensive care unit, where you were treated with antibiotics. Your blood counts were found to be low, and you were given blood transfusions. You were initally started on a blood thinner to treat you for a potential blood clot in your lungs, but subsequent studies showed that you were unlikely to have developed a blood clot, and the blood thinner was stopped. Your breathing improved after blood transfusion. We found that you have an infection in your blood and urine. You were treated initially with intravenous antibiotics, and eventually switched to oral antibiotics. You will need to compelte a course of oral antibiotics as an outpatient. Please followup with Dr. [**Last Name (STitle) **] in clinic. We made the following changes to your medications: STARTED -Augmentin until [**2181-7-1**] -Ciprofloxacin until [**2181-7-1**] -Senna and Polyethylene glycol to help you move your bowels Please continue taking your other medications as usual. Please followup with your doctors, see below. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2181-6-25**] at 9:30 AM With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2181-6-25**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY CARE UNIT When: WEDNESDAY [**2181-7-11**] at 9:00 AM [**Telephone/Fax (1) 446**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Completed by:[**2181-6-23**]

[ "E933.1", "196.8", "591", "287.49", "285.9", "599.0", "183.0", "995.91", "593.4", "038.42", "V44.6" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15362, 15368

10356, 10895

364, 370

15599, 15599

5068, 5068

16969, 17917

3288, 3419

14567, 15339

15389, 15578

14483, 14483

15750, 16676

6324, 6955

3459, 4254

14501, 14544

6999, 7203

16705, 16946

2058, 2068

251, 326

10910, 13924

7238, 10333

398, 2039

13941, 14457

5084, 6308

15614, 15726

2790, 3096

3112, 3272

4279, 5049

23,097

172,892

19705+19706+57080+57081

Discharge summary

report+report+addendum+addendum

Admission Date: [**2184-11-29**] Discharge Date: [**2185-1-20**] Date of Birth: [**2107-8-22**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old gentleman with a history of coronary artery disease who is status post coronary artery bypass graft and mitral valve replacement in [**2171**]. The patient awoke on the day of admission with paroxysmal nocturnal dyspnea which was not improved with getting out of bed. The patient denied any history of the same and is able to walk two miles every day without dyspnea or chest pain. The patient was taken to an outside hospital where he was found to be in respiratory distress. The patient was placed on [**Hospital1 **]-level positive airway pressure and was transferred to [**Hospital1 69**] for further treatment of his congestive heart failure. Prior to his transfer, the patient was given Lasix and Solu-Medrol with improvement in his respiratory status. At the time, the patient denied any chest pain or diaphoresis. The patient had not had any chest pain since his coronary artery bypass graft. The patient denied any recent changes in his medications or dietary indiscretions. PAST MEDICAL HISTORY: 1. Status post mitral valve replacement with a #27 [**Location (un) **] and coronary artery bypass graft times four in [**2171**]. 2. Paroxysmal atrial fibrillation; status post permanent pacemaker for tachy-brady syndrome. 3. Chronic obstructive pulmonary disease (with an FEV1 of 1 liter). 4. Status post cerebrovascular accident in [**2184-5-2**] (treated with t-PA with no residual). 5. Depression. 6. Borderline diabetes. 7. Hypertension. 8. Hypercholesterolemia. PREOPERATIVE MEDICATIONS: 1. K-Dur 20 mEq by mouth once per day. 2. Hydralazine 25 mg by mouth four times per day. 3. Isordil 30 mg by mouth three times per day. 4. Aspirin 81 mg by mouth once per day. 5. Lasix 80 mg by mouth once per day. 6. Zocor 20 mg by mouth once per day. 7. Verapamil 120 mg by mouth once per day. 8. Fluoxetine 20 mg by mouth once per day. 9. Nexium 40 mg by mouth every other day. 10. Coumadin. ALLERGIES: The patient has reported an allergy to INTRAVENOUS CONTRAST as well as ACE INHIBITORS. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to [**Hospital1 69**] for further workup of his congestive heart failure. An echocardiogram obtained on the day of admission revealed an ejection fraction of 55% with a flail mitral leaflet, 3+ mitral regurgitation, elevated pulmonary artery pressures, decreased right ventricular systolic function, and no regional wall motion abnormalities. The patient's initial cardiac enzymes were negative for a myocardial infarction. The patient was started on diuretics. The patient was also noted on admission to have elevated liver function tests with an aspartate aminotransferase of 147, alanine-aminotransferase of 100, alkaline phosphatase was 552, and total bilirubin was 0.4 This was initially attributed to hepatic congestion from heart failure. The patient was also noted to have an elevated white blood cell count. It was felt that the patient had a bronchitis or pneumonia; however, subsequent sputum cultures were negative. A Pulmonary Medicine consultation was obtained due to the patient's developing hemoptysis. They felt the hemoptysis was due to the patient's congestive heart failure and anticoagulation for atrial fibrillation and recommended following chest x-rays and obtaining a computed tomography scan. They felt the patient was at moderate risk for surgery as the patient had a FEV1 of 1 liter. The patient had a computed tomography scan of his chest and abdomen which was negative for any evidence of malignancy. The patient was also started on Natrecor to aid in his diuresis. The patient was taken to the Cardiac Catheterization Laboratory on [**12-2**] prior taking the patient to taking the patient to surgery. The cardiac catheterization showed a pulmonary capillary wedge pressure of 28, pulmonary artery pressure of 90/39, and left ventricular end-diastolic pressure of 19. There was a totally occluded mid left anterior descending artery, totally occluded proximal left circumflex, totally occluded proximal right coronary artery. There was a patent saphenous vein graft to first obtuse marginal, and second obtuse marginal, and left anterior descending artery. There was an 80% lesion in the saphenous vein graft to the posterior descending artery. The lesion was stented with a cypher stent. The patient also underwent an evaluation by the Dental Service preoperatively for his mitral valve replacement. The Dental Service recommended an Oral Surgery consultation for extraction of several teeth. The patient was seen by Oral Surgery, and they recommended extraction of teeth prior to being taken to the operating room. On [**12-2**], it was noted that the patient's lower extremities were cool but with dopplerable pulses. It was noted late in the day that the patient developed a diffuse erythematous rash for which he was treated with Benadryl. A Neurology Service consultation was obtained to evaluate the patient for his operative risk due to his prior cerebrovascular accident. Carotid ultrasounds were obtained which showed mild plaque in the right and left internal carotid arteries with a narrowing of less than 40%. The patient underwent an arterial examination of his lower extremities due to the delayed capillary refill and cool temperature. This showed mild-to-moderate right tibial disease with a normal atrial flow in the left leg. Early in the morning on [**12-4**], the patient became acutely short of breath and hypoxic. The patient was noted to have cool hands and feet with delayed capillary refill. There was a very erythematous rash on face, torso, thighs, and back. It was decided later in the day to transfer the patient from the floor to the Coronary Care Unit for further workup. Upon transfer to the Coronary Care Unit, the patient was started on Nipride infusion to try to decrease his pulmonary artery pressures and improve his heart failure. The Neurology Service read the results of the computed tomography scan which showed a lacunar infarction without evidence of embolic or water shed infarctions. They felt the patient was cleared for cardiac surgery. In the Coronary Care Unit, the patient was mildly improved with afterload reduction. A Dermatology consultation was obtained for the patient's rash. There was concern that the patient's rash was early TEN versus orthodromic drug reaction versus staph scalded skin syndrome. Several punch biopsies were taken. The patient's antibiotics, Plavix, and captopril were discontinued. The results of these biopsies showed hypersensitivity dermatitis which was felt to be most likely due to captopril. On [**12-5**], the patient was taken to the operating room with Oral and Maxillofacial Surgery Service for teeth extractions. The patient tolerated the procedure well. The patient was placed on clindamycin peri-procedure for endocarditis prophylaxis. Blood cultures which were drawn at the time to rule out staph scalded skin were negative. On [**12-6**], Pulmonary Medicine felt that the patient's preoperative hemoptysis was due to heart failure and anticoagulation. They recommended postoperative pulmonary followup. At this time in the Coronary Care Unit, the patient was on a Nipride drip with a stable pulmonary status. The patient's rash continued to slowly improve with some skin fluffing and significant erythema. The patient had an elevated white blood cell count which was felt possibly to be due to the rash. The patient was continued on clindamycin for prophylaxis. Cardiac surgery continued to be delayed until the patient's rash improved. On [**12-8**], the Allergy Service was consulted for the rash which by then diagnosed to be hypersensitivity dermatitis. It had initially been felt that the intravenous dye could be a culprit; however, because of the biopsy results, it was felt that captopril was the most likely etiology. The Allergy Service noted that it was a .................... process, and skin testing was not a reliable diagnostic tool. However, as an outpatient, they recommended delayed hypersensitivity patch testing using thin [**Doctor Last Name 1754**] testing for captopril. They recommended avoiding captopril and all ACE inhibitors. It was felt that perhaps the patient would be a candidate to try an angiotensin receptor blocker at a later date, as there was unlikely to be any cross reactivity. It was felt that the patient was fine to be placed back on Plavix. On [**12-9**], with the aggressive diuresis, the patient's creatinine had risen to 2.5 from 1.6. It was decided that the patient would require a pulmonary artery catheter be placed to further determine appropriate management. It was also determined that the patient would greatly benefit from the insertion of an intra-aortic balloon pump to temporize the patient prior to cardiac surgery. When the pulmonary artery catheter was inserted, the cardiac index was 1.7 which improved to greater than 2 with the intra-aortic balloon pump. On [**12-10**], the patient's creatinine had risen to 2.9. The patient was started on a dobutamine infusion to improve cardiac output which also improved the patient's urine output, and the patient's creatinine started to decrease. The patient continued to have mild respiratory compromise. On [**12-12**], the patient's Lasix infusion was discontinued as it was felt that the patient was intravascularly dry. The patient continued to make good urine. [**Last Name (STitle) **] DR.[**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] 02-351 Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2185-1-20**] 16:08 T: [**2185-1-20**] 17:30 JOB#: [**Job Number 53301**] Admission Date: [**2184-11-29**] Discharge Date: [**2185-1-21**] Date of Birth: [**2107-8-22**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old gentleman with a history of coronary artery disease who is status post coronary artery bypass graft and mitral valve replacement in [**2171**]. The patient awoke on the day of admission with paroxysmal nocturnal dyspnea which was not improved with getting out of bed. The patient denied any history of the same and is able to walk two miles every day without dyspnea or chest pain. The patient was taken to an outside hospital where he was found to be in respiratory distress. The patient was placed on [**Hospital1 **]-level positive airway pressure and was transferred to [**Hospital1 69**] for further treatment of his congestive heart failure. Prior to his transfer, the patient was given Lasix and Solu-Medrol with improvement in his respiratory status. At the time, the patient denied any chest pain or diaphoresis. The patient had not had any chest pain since his coronary artery bypass graft. The patient denied any recent changes in his medications or dietary indiscretions. PAST MEDICAL HISTORY: 1. Status post mitral valve replacement with a #27 [**Location (un) **] and coronary artery bypass graft times four in [**2171**]. 2. Paroxysmal atrial fibrillation; status post permanent pacemaker for tachy-brady syndrome. 3. Chronic obstructive pulmonary disease (with an FEV1 of 1 liter). 4. Status post cerebrovascular accident in [**2184-5-2**] (treated with t-PA with no residual). 5. Depression. 6. Borderline diabetes. 7. Hypertension. 8. Hypercholesterolemia. PREOPERATIVE MEDICATIONS: 1. K-Dur 20 mEq by mouth once per day. 2. Hydralazine 25 mg by mouth four times per day. 3. Isordil 30 mg by mouth three times per day. 4. Aspirin 81 mg by mouth once per day. 5. Lasix 80 mg by mouth once per day. 6. Zocor 20 mg by mouth once per day. 7. Verapamil 120 mg by mouth once per day. 8. Fluoxetine 20 mg by mouth once per day. 9. Nexium 40 mg by mouth every other day. 10. Coumadin. ALLERGIES: The patient has reported an allergy to INTRAVENOUS CONTRAST as well as ACE INHIBITORS. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to [**Hospital1 69**] for further workup of his congestive heart failure. An echocardiogram obtained on the day of admission revealed an ejection fraction of 55% with a flail mitral leaflet, 3+ mitral regurgitation, elevated pulmonary artery pressures, decreased right ventricular systolic function, and no regional wall motion abnormalities. The patient's initial cardiac enzymes were negative for a myocardial infarction. The patient was started on diuretics. The patient was also noted on admission to have elevated liver function tests with an aspartate aminotransferase of 147, alanine-aminotransferase of 100, alkaline phosphatase was 552, and total bilirubin was 0.4 This was initially attributed to hepatic congestion from heart failure. The patient was also noted to have an elevated white blood cell count. It was felt that the patient had a bronchitis or pneumonia; however, subsequent sputum cultures were negative. A Pulmonary Medicine consultation was obtained due to the patient's developing hemoptysis. They felt the hemoptysis was due to the patient's congestive heart failure and anticoagulation for atrial fibrillation and recommended following chest x-rays and obtaining a computed tomography scan. They felt the patient was at moderate risk for surgery as the patient had a FEV1 of 1 liter. The patient had a computed tomography scan of his chest and abdomen which was negative for any evidence of malignancy. The patient was also started on Natrecor to aid in his diuresis. The patient was taken to the Cardiac Catheterization Laboratory on [**12-2**] prior taking the patient to taking the patient to surgery. The cardiac catheterization showed a pulmonary capillary wedge pressure of 28, pulmonary artery pressure of 90/39, and left ventricular end-diastolic pressure of 19. There was a totally occluded mid left anterior descending artery, totally occluded proximal left circumflex, totally occluded proximal right coronary artery. There was a patent saphenous vein graft to first obtuse marginal, and second obtuse marginal, and left anterior descending artery. There was an 80% lesion in the saphenous vein graft to the posterior descending artery. The lesion was stented with a cypher stent. The patient also underwent an evaluation by the Dental Service preoperatively for his mitral valve replacement. The Dental Service recommended an Oral Surgery consultation for extraction of several teeth. The patient was seen by Oral Surgery, and they recommended extraction of teeth prior to being taken to the operating room. On [**12-2**], it was noted that the patient's lower extremities were cool but with dopplerable pulses. It was noted late in the day that the patient developed a diffuse erythematous rash for which he was treated with Benadryl. A Neurology Service consultation was obtained to evaluate the patient for his operative risk due to his prior cerebrovascular accident. Carotid ultrasounds were obtained which showed mild plaque in the right and left internal carotid arteries with a narrowing of less than 40%. The patient underwent an arterial examination of his lower extremities due to the delayed capillary refill and cool temperature. This showed mild-to-moderate right tibial disease with a normal atrial flow in the left leg. Early in the morning on [**12-4**], the patient became acutely short of breath and hypoxic. The patient was noted to have cool hands and feet with delayed capillary refill. There was a very erythematous rash on face, torso, thighs, and back. It was decided later in the day to transfer the patient from the floor to the Coronary Care Unit for further workup. Upon transfer to the Coronary Care Unit, the patient was started on Nipride infusion to try to decrease his pulmonary artery pressures and improve his heart failure. The Neurology Service read the results of the computed tomography scan which showed a lacunar infarction without evidence of embolic or water shed infarctions. They felt the patient was cleared for cardiac surgery. In the Coronary Care Unit, the patient was mildly improved with afterload reduction. A Dermatology consultation was obtained for the patient's rash. There was concern that the patient's rash was early TEN versus orthodromic drug reaction versus staph scalded skin syndrome. Several punch biopsies were taken. The patient's antibiotics, Plavix, and captopril were discontinued. The results of these biopsies showed hypersensitivity dermatitis which was felt to be most likely due to captopril. On [**12-5**], the patient was taken to the operating room with Oral and Maxillofacial Surgery Service for teeth extractions. The patient tolerated the procedure well. The patient was placed on clindamycin peri-procedure for endocarditis prophylaxis. Blood cultures which were drawn at the time to rule out staph scalded skin were negative. On [**12-6**], Pulmonary Medicine felt that the patient's preoperative hemoptysis was due to heart failure and anticoagulation. They recommended postoperative pulmonary followup. At this time in the Coronary Care Unit, the patient was on a Nipride drip with a stable pulmonary status. The patient's rash continued to slowly improve with some skin fluffing and significant erythema. The patient had an elevated white blood cell count which was felt possibly to be due to the rash. The patient was continued on clindamycin for prophylaxis. Cardiac surgery continued to be delayed until the patient's rash improved. On [**12-8**], the Allergy Service was consulted for the rash which by then diagnosed to be hypersensitivity dermatitis. It had initially been felt that the intravenous dye could be a culprit; however, because of the biopsy results, it was felt that captopril was the most likely etiology. The Allergy Service noted that it was a .................... process, and skin testing was not a reliable diagnostic tool. However, as an outpatient, they recommended delayed hypersensitivity patch testing using thin [**Doctor Last Name 1754**] testing for captopril. They recommended avoiding captopril and all ACE inhibitors. It was felt that perhaps the patient would be a candidate to try an angiotensin receptor blocker at a later date, as there was unlikely to be any cross reactivity. It was felt that the patient was fine to be placed back on Plavix. On [**12-9**], with the aggressive diuresis, the patient's creatinine had risen to 2.5 from 1.6. It was decided that the patient would require a pulmonary artery catheter be placed to further determine appropriate management. It was also determined that the patient would greatly benefit from the insertion of an intra-aortic balloon pump to temporize the patient prior to cardiac surgery. When the pulmonary artery catheter was inserted, the cardiac index was 1.7 which improved to greater than 2 with the intra-aortic balloon pump. On [**12-10**], the patient's creatinine had risen to 2.9. The patient was started on a dobutamine infusion to improve cardiac output which also improved the patient's urine output, and the patient's creatinine started to decrease. The patient continued to have mild respiratory compromise. On [**12-12**], the patient's Lasix infusion was discontinued as it was felt that the patient was intravascularly dry. The patient continued to make good urine. [**Last Name (STitle) **] DR.[**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] 02-351 Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2185-1-20**] 16:08 T: [**2185-1-20**] 17:30 JOB#: [**Job Number 53302**] Name: [**Known lastname **], [**Known firstname 2360**] Unit No: [**Numeric Identifier 9935**] Admission Date: [**2184-11-29**] Discharge Date: [**2185-1-20**] Date of Birth: [**2107-8-22**] Sex: M Service: ADDENDUM: This is an Addendum to the original Discharge Summary dictation. CONCISE SUMMARY OF HOSPITAL COURSE (CONTINUED): On [**12-13**], the patient had improving urine output, a decrease in creatinine, and improving body rash. The patient was on a dopamine infusion as well as Natrecor which was transitioned to hydralazine. By [**12-16**], the patient was felt to be hemodynamically optimized. The rash was sufficiently resolved, and the patient was to the operating room with Dr. [**First Name (STitle) 255**] [**Last Name (Prefixes) **] for a redo mitral valve replacement with #27 mosaic valve via a right thoracotomy. The patient was transferred to the Intensive Care Unit in critical condition on a dobutamine, milrinone, Levophed, and propofol infusions. On arrival to the Intensive Care Unit, the patient was started inhaled nitric oxide for his consistently evaluated pulmonary artery pressures. The patient had an adequate cardiac output. He good oxygen saturation on mechanical ventilation. The patient's ejection fraction in the operating room had been noted to 45% to 50%. A Cardiology and Electrophysiology consultation was obtained to reprogram the patient's permanent pacemaker and chest for function. The patient was found to be atrial flutter. The atrial flutter was paced terminated. The patient was started on amiodarone, and the pacemaker was found to be in good working condition. The patient continued to have adequate cardiac output. The inhaled nitric oxide was weaned to 35 parts per million. The patient tolerated this well. By postoperative day three, the patient had weaned to 2.5 mg of dobutamine, milrinone at 0.5, inhaled nitric oxide at 30 parts per million, and intra-aortic balloon pump at 1:1. The patient continued to have adequate cardiac indices. The patient was started on a Lasix infusion for diuresis. On postoperative day four, the dobutamine was discontinued. The milrinone was weaned down. The patient continued to be diuresed. The patient remained intubated on mechanical ventilation. The patient was started on tube feeds. By postoperative day four, the nitric oxide was attempted to be weaned to off; however, the patient had significant rebound pulmonary hypertension and it was restarted. On the afternoon on postoperative day four, the patient's intra-aortic balloon pump was removed. It was noted after removal that there was a loss of pulse in the right lower extremity. By the time the Vascular Surgery team saw the patient the perfusion to the limb was improved. It was felt that the limb was not threatened. Recommended a low-dose heparin drip. A femoral ultrasound was obtained which showed no evidence of pseudoaneurysm or arteriovenous fistula in the right groin. The patient continued to be dependent on nitric oxide and milrinone. The Vascular team thought that the examination of the right lower extremity was much improved. On postoperative day five, the inhaled nitric oxide was again attempted to be weaned off; however, the patient had significant rebound pulmonary hypertension. It was recommended that the patient be started on nitroprusside for afterload reduction as well as reduction in the pulmonary vascular resistance to facilitate weaning of the nitric oxide. The patient's was continued on a Lasix drip. The milrinone infusion was increased. By postoperative day seven, the inhaled nitric oxide was weaned to off. Pulmonary Medicine was consulted again to facilitate the weaning the anatropes and the management of the pulmonary hypertension. They recommended aggressive diuresis, aggressive afterload reduction, and gentle weaning of the anatropic support. On postoperative day eight, the patient was again found to be in atrial fibrillation. The Electrophysiology Service recommended direct current cardioversion. The patient was cardioverted with 200 joules times one to a sinus rhythm. The patient was continued on a heparin infusion as well as a Lasix drip for diuresis. The patient's ventilator was weaned to continuous positive airway pressure with pressure support which he tolerated well with adequate oxygenation. The milrinone was weaned down to 1.25, and the patient was weaned and extubated on postoperative day 11. However, after extubation the patient had an increase in his pulmonary artery pressures. The patient's milrinone drip was increased. The patient was started on Natrecor, and the Lasix drip was increased to increase his diuresis. However, three hours of extubation the patient required reintubation for respiratory distress and hypoxia. Reintubation was without significant event. The patient's milrinone infusion continued at 0.37. The patient was noted to have rising white blood cell count up to 15. The patient's lines were re-sited. By postoperative day 13, it was thought that the patient was euvolemic and the Lasix and Natrecor infusions were stopped. The patient had been started on vancomycin for increasing white blood cell counts. The line and blood cultures from the [**Last Name (STitle) 1383**] DR. [**Last Name (Prefixes) **],[**First Name3 (LF) **] 02-351 Dictated By:[**Last Name (NamePattern1) 5788**] MEDQUIST36 D: [**2185-1-20**] 16:44 T: [**2185-1-20**] 19:27 JOB#: [**Job Number 9936**] Name: [**Known lastname **], [**Known firstname 2360**] Unit No: [**Numeric Identifier 9935**] Admission Date: [**2184-11-29**] Discharge Date: [**2185-1-21**] Date of Birth: [**2107-8-22**] Sex: M Service: CARDIOTHORACIC SURGERY ADDENDUM: The patient is to be discharged to rehab in stable condition. T-max and T-current 97.5, pulse 80--AV paced by his internal pacemaker, blood pressure 119/54, oxygen saturation 97% on ventilator settings of CPAP, FIO2 40%, PEEP of 5, and pressure support of 12. LABORATORY DATA: White blood cell count 12.3, hematocrit 32, platelet count 194, sodium 147, potassium 4.5, chloride 112, bicarb 29, BUN 50, creatinine 1.2, glucose 117. PHYSICAL EXAM: Neurologically, the patient is awake, alert, oriented to person, place, situation. Moves all extremities equally. Neurologically nonfocal. Heart - regular rate and rhythm. Lungs are coarse bilaterally. The patient is being suctioned via his tracheostomy tube for scant whitish secretions. Abdomen - positive bowel sounds, soft, nontender, nondistended. The patient is tolerating tube feeds through a feeding tube, Respalor at 40 cc/h. The patient is having loose bowel movements. Extremities are warm and well-perfused. There is 1+ pitting edema in his lower extremities. His thoracotomy incision, the anterior portion is well-healed. The posterior portion has a small 1 cm skin separation that has a small amount of serous drainage, and there is minimal erythema. DISCHARGE MEDICATIONS: 1. Tylenol 650 mg po q 4-6 h prn. 2. Aspirin 325 mg po qd. 3. Colace 100 mg po bid--hold for diarrhea. 4. Lansoprazole 30 mg po qd. 5. Albuterol nebulizers q 6 h prn. 6. Plavix 75 mg po qd. 7. Percocet 5/325, 1-2 tabs q 6 h prn. 8. Isordil 20 mg po tid. 9. Hydralazine 10 mg po q 8 h. 10.Potassium chloride 20 mEq po qd. 11.Bumex 2 mg po qd. 12.Amiodarone 200 mg po qd. 13.Simvastatin 20 mg po qd. 14.Fluoxetine 20 mg po qd. 15.Diuril 250 mg po qd with lasix. DISCHARGE DIAGNOSES: 1. Coronary artery disease, mitral regurgitation, status post percutaneous transluminal coronary angioplasty and stent on [**12-2**]. 2. Hemoptysis. 3. History of cerebrovascular accident. 4. Severe hypersensitivity reaction to captopril. 5. Renal insufficiency. 6. Multiple tooth extractions. 7. Pulmonary hypertension. 8. Redo mitral valve replacement. 9. Postoperative respiratory failure. 10.Congestive heart failure. 11.Atrial fibrillation. 12.Status post tracheostomy. FO[**Last Name (STitle) **]P: 1. The patient should follow-up with Dr. [**Last Name (Prefixes) **] in 1 month. 2. The patient should follow-up with his primary care doctor, Dr. [**Last Name (STitle) **] in 1 month. 3. The patient should follow-up with Dr. [**Last Name (STitle) **] in 1 month. DISPOSITION: The patient is to be discharged to rehab in stable condition [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**] Dictated By:[**Last Name (NamePattern1) 5788**] MEDQUIST36 D: [**2185-1-21**] 09:32 T: [**2185-1-21**] 09:39 JOB#: [**Telephone/Fax (3) 9937**]

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icd9cm

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icd9pcs

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53005

Discharge summary

report

Admission Date: [**2188-3-21**] Discharge Date: [**2188-3-27**] Date of Birth: [**2125-1-31**] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / Aztreonam / Latex Attending:[**Doctor Last Name 10493**] Chief Complaint: foot ulcer Major Surgical or Invasive Procedure: I&D I&D with toe amputation RIJ placed and removal PICC History of Present Illness: Story per record as patient is intubated 63 M with IDDM 2, hx of L foot ulcer, who presents with worsening L foot pain and swelling, and three days of chills. He saw his podiatrist who recommended he go to the ED for admission. Denies N/V, diarrhea, CP, SOB, Abd pain. In the ED patient was initially stable, but near midnight was noted to be more confused, spiked a fever to 101, and became diaphoretic. He was seen by podiatry who found gas in the tissues of his foot and decided to take him for emergent surgery. While he was getting his pre-op CXR, his oxygen saturations dropped, he started agonal breathing, became blue, and may have been transiently apneic, and possibly pulseless. A Code Blue was called. The timing is unclear but he soon began breathing again on his own, with good femoral pulses. He was intubated for airway protection and since he was due to go to the OR. He went to the OR for an I & D and debridement of his L foot. . Patient received 3 liters of NS, Vanco, Clinda, Flagyl, levo. His lactate was 4.5 so patient was transferred from the OR to MICU for sepsis. Past Medical History: diabetes-with peripheral neuorpathy-on insulin obstructive sleep apnea, elevated cholesterol, depression. He had a broken neck at age 13 with C1-C2 repair. He also has some cognitive decline for which she is seeing a behavioral neurology, Dr. [**First Name (STitle) 6817**]. L index finger pain-s/p steroid injections by Dr.[**First Name (STitle) **] Social History: (+) tobacco use x40 years, quit, patient denies past etoh abuse, although OMR notes indicate past chronic alcohol use. Denies illicit drug use. Married. Family History: non-contributory Physical Exam: VS: 97.4 80/53 75 19 100% HEENT: intubated Gen: intubated, sedated CV: RRR, heart sounds distant Resp: CTA on ant exam Abd: soft, NT/ND, (+)BS, soft mobile mass in LRQ Ext: + 2 pulse in R, L with c/d/i dressings, large area of erythema and warmth from edge of dressings to knee on ant surface of leg NEURO: intubated, sedated Pertinent Results: Labs: [**2188-3-20**] 10:20PM BLOOD WBC-10.4 RBC-3.00* Hgb-10.3* Hct-29.4* MCV-98 MCH-34.2* MCHC-34.9 RDW-13.2 Plt Ct-272 [**2188-3-20**] 10:20PM BLOOD Neuts-80.0* Lymphs-9.5* Monos-8.0 Eos-1.9 Baso-0.5 [**2188-3-27**] 05:39AM BLOOD ESR-84* [**2188-3-20**] 10:20PM BLOOD Glucose-82 UreaN-17 Creat-0.9 Na-137 K-4.6 Cl-98 HCO3-26 AnGap-18 [**2188-3-21**] 01:00AM BLOOD CK(CPK)-204* [**2188-3-21**] 01:00AM BLOOD CK-MB-5 cTropnT-<0.01 [**2188-3-27**] 05:39AM BLOOD CRP-52.8* [**2188-3-21**] 01:05AM BLOOD Lactate-4.5* . Foot x-ray [**2188-3-20**] Large ulcer with extensive subcutaneous gas. Findings are highly concerning for a gas-forming organism infection. No definite radiographic evidence of osteomyelitis at this time. . CT LOW EXT W/O C LEFT [**2188-3-20**] 11:38 PM Markedly abnormal appearance to the plantar soft tissues, with deep ulcer reaching bone in the region of the fourth metatarsal head. There is extensive subcutaneous emphysema, which may relate to the reported recent probing and irrigation (noted in the preliminary report). However, the extensive gas bubbles at its dorsal aspect, removed from the ulcer, as well as the intramedullary gas within the fourth metatarsal head are highly suspicious for osteomyelitis, perhaps with gas-forming organism. No focal fluid collection is identified. . Pathology submittede [**2188-3-21**], report [**2188-3-25**] SPECIMEN SUBMITTED: LEFT INFECTED 4 METATARSAL AND INFECTED 4 PHRALNAN SPACE 4. DIAGNOSIS: Fourth metatarsal: Acute osteomyelitis. . Foot x-ray [**2188-3-22**] There has been an interval osteotomy involving the fourth tarsal metatarsal joint with soft tissue removal in that region. Post-surgical changes are again evident in the second and third metatarsals. The third metatarsal proximal phalanx cortical margin is not well defined and infection cannot be excluded in this region. IMPRESSION: Postoperative changes. Acute osteomyelitis of the surrounding bones cannot be totally excluded due to osteopenia in these regions. Recommend followup. . Pathology: Tissue: 4TH TOE (1) PENDING Brief Hospital Course: A/P: 63 M with IDDM 2, hx of L foot ulcer, who presents with worsening L foot pain and swelling, chills, now with elevated lactate and s/p Code Blue in ED, s/p I & D in OR, MICU admission for sepsis, repeat I&D with toe amputation on long course of antibiotics. . # Sepsis/foot infection: Most obvious source is his L foot abscess. Patient off pressors since [**3-21**] in am. Lactate improved from 4.5 to 1.2 SvO2 77%. Per surgeon, the infection was quite severe, requiring deep debridement and removal of infected bone. Pathology of first I&D was consistent with acute osteomyelitis. A second I&D was performed this time with toe amputation and pathology is still pending at the time of discharge. The patient has a history of MRSA and has grown out organisms resistant to clinda in the past. Blood cx (-) so far. Bone biopsies were not sent for culture so the patient was treated with broad coverage antibiotics. ID receommended vanco, levofloxacin, flagyl for 4-6 weeks. Swab cultures growing out MSSA, however given allergy to PCN, treated with vancomycin. Physical therapy recommended home with PT vs rehab and based on the patient's desire to go home plus good support at home, patient was discharge with follow up and VNA services. . # Resp Failure: Patient intubated after being agonal prior to arriving in OR. It is unclear whether this was sepsis induced respiratory failure, fatigue or new PNA. CXR report with evolving right lower lung field airspace consolidation, worrisome for pneumonia versus aspiration and also with volume overload. The patient's antibiotic regimen included vancomycin, levoquin and flagyl as above. Good response to diuresis. The patient was extubated without complication, insentive spirometry was encouraged. O2 was gradually weaned. . #Anemia: Low HCT after surgical procedure but stable and vital signs stable. No need for transfusion. Guaiac negative. Iron studies consistent with ACD. Patient given iron supplement. . #T2 DM: Patient on Lantus and HISS. . #CAD: MIBI in [**2184**] no ischemia. -ASA, statin . # Access: PIVs, RIJ. RIJ removed. PICC line in place at time of discharge. Medications on Admission: Ibuprofen PRN amlodipine 5 mg PO BID buproprion 150 mg PO TID Rosuvastin calcium 40 PO QD Gabapentin 800 mg PO BID Gabapentin 1200 PO QHS venlafaxine 150 mg PO BID insulin SS and glargine 48 U qhs trazadone 50-150 po QHS lisinopril 40 PO QD . Discharge Medications: 1. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 4. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 5. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. 6. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Insulin Glargine 100 unit/mL Solution Sig: As directed As directed Subcutaneous at bedtime. 8. Insulin Lispro (Human) 100 unit/mL Solution Sig: As directed As directed Subcutaneous As directed. 9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 5 weeks: Please draw trough once weekly. Disp:*70 gram* Refills:*0* 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 weeks. Disp:*105 Tablet(s)* Refills:*0* 12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24 () for 5 weeks. Disp:*840 Tablet(s)* Refills:*0* 13. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): Do not drive or operate heavy machinery while taking this medication. . Disp:*10 Patch 72 hr(s)* Refills:*0* 14. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**3-28**] hours as needed for pain: Do not drive or operate heavy machinery while taking this medicaiton. Disp:*45 Tablet(s)* Refills:*0* 15. Saline Flush 0.9 % Syringe Sig: One (1) syringe Injection once a day as needed for for line flushes as needed: Saline flushes . Disp:*60 units* Refills:*0* 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 17. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Outpatient Lab Work Vancomycin trough once weekly. Fax results to Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 432**] 20. Outpatient Lab Work First week of [**2188-4-22**], check CBC, BUN, Creatinine, LFTs and send results to PCP and fax to Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 432**] 21. Heparin Flush 100 unit/mL Kit Sig: Two (2) units Intravenous once a day: 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. . Disp:*5 week supply* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnosis: - Sepsis - Osteomyelitis . Secondary diagnosis: - Diabetes mellitus type 2 - Peripheral neuropathy - Obstructive sleep apnea - Hypercholesterolemia Discharge Condition: Stable, ambulatory with assistance Discharge Instructions: You were admitted with a foot ulcer/infection and found to have sepsis. While in the hospital you had 2 podiatry surgeries and received antibiotics for the infection. You will need to continue to receive antibiotics for a total of 6 weeks. Please take all medications as directed. You will be taking vancomycin IV twice daily to complete a 6 week course. You will also take flagyl and levofloxacin as directed for 6 weeks. You have also been prescribed pain medicaiton. A fentanyl patch to be replaced every 3 days. Also, percocet as needed for breakthrough pain. Do not drive or operate heavy machinery while taking these medications. If you develop fever, chills, shortness of breath, chest pain, or any other symptom that concerns you, call your doctor or if unavailable, go to the emergency room. Please attend all follow up appointments. Continue to check your blood sugar regularly and administer insulin as directed by your doctor. If your blood sugar is less than 60 or greater than 350, call your doctor. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2188-4-1**] 11:40 Provider: [**Name Initial (NameIs) **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2188-4-16**] 3:30 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2188-5-5**] 10:00 You will need weekly vanco trough, CBC, LFTs, BUN/Cr faxed to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 432**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]

[ "995.92", "682.6", "518.81", "040.0", "707.14", "285.1", "711.07", "038.9", "250.60", "272.0", "250.80", "682.7", "731.8", "327.23", "730.07", "785.52", "357.2", "250.70", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "77.68", "38.93", "84.11" ]

icd9pcs

[ [ [] ] ]

9497, 9555

4536, 6681

321, 379

9766, 9803

2447, 4513

10878, 11571

2067, 2085

6975, 9474

9576, 9576

6707, 6952

9827, 10855

2100, 2428

271, 283

407, 1505

9643, 9745

9595, 9622

1527, 1879

1895, 2051

47,284

112,983

53556

Discharge summary

report

Admission Date: [**2143-5-9**] Discharge Date: [**2143-5-10**] Date of Birth: [**2062-10-19**] Sex: M Service: MEDICINE Allergies: ibuprofen Attending:[**First Name3 (LF) 2387**] Chief Complaint: CHIEF COMPLAINT: claudication REASON FOR CCU ADMISSION: hypertensive urgency Major Surgical or Invasive Procedure: [**2143-5-9**] lower extremity angiography History of Present Illness: Mr. [**Known lastname 3501**] is an 80y/o gentleman with CAD s/p CABG [**2118**], ischemic CM (EF 40%), HTN, HLD, DM2 on oral hypoglycemics, and PAD (ABI R:0.6, L:0.67) who has had ongoing claudication, underwent elective angiography today, and is now admitted to the CCU due to post-procedural hypertension. . With regards to his claudication, he has had progressive bilateral calf pain with exertion relieved with rest. Gets pain even walking 25 feet. He denies chest pain, shortness of breath, palpitations or lightheadedness. He was scheduled for elective RLE angiography, and this morning he had breakfast and held his oral hypoglycemics (Metformin, Glyburide) though he says he took his antihypertensives (Atenolol, Amlodipine, Quinapril, HCTZ, Spironolactone). . During the angiogram, he was found to have severe disease in the bilateral aorto-iliac junction and critical RCFA disease. Kissing stents were placed in the proximal common iliac arteries, and Vascular Surgery was consulted for surgical management of RCFA disease. . Post-procedure, he became nauseated with elevation in SBP 220s, asymptomatic (specifically, no CP, SOB, H/A, worsened vision). He was started on NTG gtt with improvement in BP 170s. Glucose 350. He was admitted to the CCU for BP management and glucose control. . 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. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: CAD s/p CABG x 3 in [**2118**] (LIMA to LAD, SVG to ramus, SVG to RCA) Ischemic cardiomyopathy, LVEF 40% Hypertension Hyperlipidemia PAD Diabetes Type 2 Colon polyps Basal cell carcinoma s/p resection Macular degeneration [**2135**]: GIB in the setting of Ibuprofen requiring transfusion Hard of hearing (bilateral hearing aids) Remote resection of left testicle Social History: - Home: widowed; lives alone - Occupation: retired; previously worked as an engineer - Tobacco history: quit [**2118**] - ETOH: [**1-14**] glasses per week - Illicit drugs: None Family History: No known family history of premature CAD Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T=97.8 BP=143/33 HR=61 RR=11 O2 sat=96% 2L NC GENERAL: NAD. Oriented x3. Mood approppriate, affect slightly inappropriate (answers questions but with inappropriate jokes, odd comments) HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, no JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Obese, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Right and left groin cath sites without any hematoma. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AAOx3, 5/5 strength biceps, hand grip PULSES: 1+ DP and PT pulses bilaterally; 2+ carotid and radial pulses Pertinent Results: ADMISSION LABS: [**2143-5-9**] 10:11PM BLOOD WBC-9.0 RBC-3.76* Hgb-11.5* Hct-33.9* MCV-90 MCH-30.6 MCHC-34.0 RDW-12.9 Plt Ct-202 [**2143-5-9**] 10:11PM BLOOD Glucose-359* UreaN-23* Creat-0.9 Na-132* K-4.5 Cl-95* HCO3-26 AnGap-16 [**2143-5-9**] 10:11PM BLOOD CK-MB-2 [**2143-5-10**] 03:55AM BLOOD CK-MB-2 [**2143-5-9**] 10:11PM BLOOD Calcium-9.0 Phos-4.3 Mg-2.1 . DATA: - RLE ANGIOGRAPHY: final report pending Brief Hospital Course: Mr. [**Known lastname 3501**] is an 80y/o gentleman with CAD s/p CABG [**2118**], ischemic CM (EF 40%), HTN, HLD, DM2 not on insulin, and PAD (ABI R:0.6, L:0.67) who has had ongoing claudication, underwent elective angiography today with post-procedure hypertension and hyperglycemia and was admitted to the CCU due to hypertensive urgency with SBP to 220s. His BP resolved after taking his home meds and he was discharged home. . ACTIVE ISSUES . #. Hypertension: hypertensive urgency, resolved. Pt was admitted with hypertensive urgency with SBP to 220s. His HTN may have been in the setting of groin pain after the procedure; he denied missing any doses of home meds but this is a possibility. There was no evidence of end-organ damage based on history, exam, EKG, labs. His BP was much better controlled on a low-dose NTG drip and he was quickly weaned to his home oral meds. No change was made to his antihypertensive regimen. . #. PAD: severe aortoiliac and common femoral disease (ABI R:0.6, L:0.67). The aortoiliac disease was treated with kissing stents on [**5-9**]. He was started on Plavix 75mg daily, continued ASA 81mg daily, statin. Right groin post-cath check was unremarkable. He will follow up with Dr. [**Last Name (STitle) **] (Vascular surgery) as an outpatient regarding his right common femoral disease. . #. DM2: hyperglycemia, resolved. His fingersticks was elevated >300, likely in the setting of having breakfast and holding his meds. Also probably a component of stress. ). Small amount of insulin corrected his hyperglycemia. Continued home Glyburide and plan to hold Metformin until Saturday [**2143-5-11**] (b/c of angio dye). . INACTIVE ISSUES . #. Ischemic CM: EF 40%. Currently euvolemic, well-compensated. Continued ACE, Spironolactone, BB. . #. CAD s/p CABG [**2118**]: stable. Continued ASA, statin, ACE, BB as above. . #. HLD: stable. Continued statin, fibrate. . TRANSITIONS OF CARE -new medication started: Plavix -follow-up: with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2912**], and Vascular Surgery (Dr. [**Last Name (STitle) **] Medications on Admission: HOME MEDICATIONS: [confirmed] ASPIRIN [ECOTRIN LOW STRENGTH] - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth every morning ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth every evening FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - (Prescribed by Other Provider) - 145 mg Tablet - 1 Tablet(s) by mouth every morning ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth twice a day AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1 (One) Tablet(s) by mouth every morning QUINAPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1 (One) Tablet(s) by mouth every morning HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth every morning SPIRONOLACTONE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth daily GLYBURIDE MICRONIZED - (Prescribed by Other Provider) - 3 mg Tablet - 1 Tablet(s) by mouth twice a day METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1 (One) Tablet(s) by mouth every morning ASCORBIC ACID [C-500] - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 400 unit Capsule - 1 Capsule(s) by mouth every morning POLYSACCHARIDE IRON COMPLEX [FERREX 150] - (Prescribed by Other Provider) - 150 mg Capsule - 1 Capsule(s) by mouth every morning VIT C-VIT E-COPPER-ZNOX-LUTEIN [PRESERVISION] - (Prescribed by Other Provider) - 226 mg-200 unit-[**Unit Number **] mg-0.8 mg-34.8 mg Capsule - 1 Capsule(s) by mouth daily Discharge Medications: 1. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. fenofibrate nanocrystallized 145 mg Tablet Sig: One (1) Tablet PO every morning. 5. atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. quinapril 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. glyburide micronized 3 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day: restart on Saturday. 12. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a day. 14. cholecalciferol (vitamin D3) 400 unit Capsule Sig: One (1) Capsule PO once a day. 15. Ferrex 150 150 mg Capsule Sig: One (1) Capsule PO once a day. 16. PreserVision 226-200-5 mg-unit-mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: hypertensive urgency peripheral artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 3501**], You came to [**Hospital1 18**] for a lower extremity angiogram because of leg pain, and were found to have blockages in your leg arteries. One of the blockages was treated with stents (for which you have to start taking Plavix, a blood thinner, in addition to daily Aspirin you take), and the other blockage was evaluated by Vascular Surgery (you will follow up with them as an outpatient, see below for details). . After your procedure, you had very high blood pressure, which was possibly related to pain, so you were observed in the cardiac ICU overnight. Now, on your home medications, your blood pressure is much better controlled. . In addition, you had elevated blood sugar, which was likely related to eating breakfast and not taking your diabetes medications. This has resolved as well. . We made the following changes to your medications -START Plavix 75mg daily -HOLD Metformin until Saturday [**2143-5-11**] (to avoid complications relating to the dye you received for the angiogram) Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] C. Location: [**Hospital1 **] BLDG, [**Apartment Address(1) 8540**] Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 9749**] Phone: [**Telephone/Fax (1) 8543**] When: [**Last Name (LF) 766**], [**5-20**], 2:15 PM VASCULAR SURGERY Please call ([**Telephone/Fax (1) 10880**] within [**2-15**] business days to arrange a follow-up visit with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].

[ "250.00", "272.4", "440.21", "401.9", "414.8", "V45.81", "440.8" ]

icd9cm

[ [ [] ] ]

[ "39.50", "00.44", "00.46", "00.66", "88.48", "39.90", "00.41" ]

icd9pcs

[ [ [] ] ]

9467, 9473

4348, 6446

349, 394

9564, 9564

3915, 3915

10774, 11280

2817, 2859

8226, 9444

9494, 9543

6472, 6472

9715, 10751

2874, 2884

6491, 8203

2906, 3896

249, 311

422, 2215

3931, 4325

9579, 9691

2237, 2603

2619, 2801

17,800

180,874

29974+29975

Discharge summary

report+report

Admission Date: [**2137-4-22**] Discharge Date: [**2137-4-26**] Date of Birth: [**2094-5-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 12**] Chief Complaint: Neoadjuvant Chemo for Sarcoma (cycle 2) Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 42 yo male with history significant for chondrosarcoma of the left femur complicated by pulmonary metastasis s/p resection and local recurrence involving left gluteal muscle and isiach nerve. Today patient is being admitted for second cycle of low dose adriamycin. He is having a lot of pain more recently. He has no other complaints, his breathing is comfortable. He has no cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, weight loss, anorexia, or other muscular pain. Past Medical History: Healthy young man. He has no known major medical problems Social History: He is a nonsmoker. He drinks alcohol occasionally. He is married, has two children ages 7 and 3. He works as an electronics technician and lives in [**Location 701**]. Family History: . Physical Exam: T: 98.7 BP: 132/76 HR 95 RR: 16 O2 96% RA Weight: 140Ib General:pleasant malein NAD HEENT: COP, MMM, no LAD, Neck: supple, no thyromegaly, no LAD Lungs: CTA bilaterally Heart: RRR, no m/r/g/ Abdomen; soft, NT, no HSM Extremities: left dorsolateral gluteal firm, slightly tender mass, past surgical keloidal scar Skin: no rash Neuro: decreased sensation left later thigh, 5/5 strength in abductor and adductor muscles of both lower extremities Brief Hospital Course: 42 M with local reoccurrence of chondrosarcoma. . # Sarcoma: initiated continuous infusion Adriamycin at a low-dose to help sensitize the cancer cells to radiation x 4 days. This was his second of five cycles, which he tolerated without major complains. During his hospital course patients pain regiment was increased for better control and he also was started on PPI given continues epigastric discomfort, which subsequently improved. Medications on Admission: OxyContin 100 mg b.i.d., oxycodone 5 mg t.i.d., Flexeril, Colace, senna, Advil. Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*15 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. Disp:*300 ML(s)* Refills:*0* 9. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 10. 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* 11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 12. OxyContin 40 mg Tablet Sustained Release 12 hr Sig: Two (2) Tablet Sustained Release PO every eight (8) hours: to be taken every 8 hours. Discharge Disposition: Home Discharge Diagnosis: Chondrosarcoma Discharge Condition: Good Discharge Instructions: You were admitted for low dose chemotharapy and radiation. you are being discharged today and have to return for admission on this comming Tuesday. We changed some of your medication (see below). . Please call your doctor or 911 if you have any nausea, vomiting, diarrhea, fever or other health concern Followup Instructions: Provider: [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 4225**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2137-5-6**] 2:15 Admission Date: [**2137-4-29**] Discharge Date: [**2137-5-10**] Date of Birth: [**2094-5-17**] Sex: M Service: MEDICINE Allergies: Tape Attending:[**First Name3 (LF) 6565**] Chief Complaint: fevers and chills Major Surgical or Invasive Procedure: None History of Present Illness: [**Known firstname 122**] [**Known lastname 4507**] is a 42-year-old gentleman with history of proximal femur chondrosarcoma s/p resection and left prosthesis, known mets to lung s/p wedge resection, recurrent tumor in left hip soft tissue undergoing active chemo-XRT (weekly Adriamycin infusion M-F, completed 2 cycles; last XRT [**2137-4-26**]) who presented to the Emergency Department on [**2137-4-28**] with complaints of fever to 102.5. Patient reports that his symptoms began approximately 3 days prior to admission, when he noted gradual increase in pain in his L buttock region. The following morning, pain increased further and he developed fevers, chills, and diaphoresis. No other localizing symptoms. He denied cough, headache, dysuria, visual changes, abdominal pain, rash, new joint pains, or pain/redness at his port. He contact[**Name (NI) **] his oncologist who referred him to the ED for evaluation. No recent travel. No pets. Of note, son diagnosed with strep throat 1 day prior to his port placement. . In the ED his inital vitals signs were T 103.6 HR 147 BP 133/76 RR 20 O2 100%RA. He received 6L of NS as well as pain meds. Blood and urine cultures were collected. He later spiked as high as 105.0. He received vanc/cefepime. Orthopedics was consulted who recommended CT pelvis that showed replacement of normal gluteal musculature with tumor with some evidence of necrosis but no abscess. Given low BPs responsive to fluid boluses in ED, he was admitted to the [**Hospital Unit Name 153**] for management. . In the [**Hospital Unit Name 153**], patient remained hemodynamically stable without need for pressors, but did spike daily temeperatures as high as 101.2. [**4-12**] Blood culture bottles returned positive within 24h for Group A strep, and antibiotics were changed to Ceftriaxone 2g IV q24h. We were consulted regarding duration of therapy and infectious concerns related to port and hip prosthesis. Patient received XRT to Left hip on [**2137-5-1**] prior to consultation. Past Medical History: ONCOLOGIC: First presented with vague left hip pain in the fall of [**2135**]. Seen by ortho in [**1-/2136**] given persistent pain; x-ray and AP and lateral views of the femur revealed a radiolucent lesion in the left proximal femur with cortical scalloping, no evidence of fracture. An MRI of the whole femur revealed a marrow replacing process which extended from the femoral neck, but not crossing the old physeal scar down to the junction of the middle and distal thirds of the femur. Proximally there was surrounding periosteal reaction within the soft tissues external to the bone as well as the soft tissue mass in the anterior aspect of the proximal thigh and this measured 2 x 0.5 cm. At the time of his evaluation, he also had a chest CT done that revealed a right lower lobe pulmonary nodule. He underwent a CT-guided biopsy of the femur that did reveal chondrosarcoma. He then underwent resection with allograft replacement of the left proximal femur in 01/[**2136**]. In [**11/2136**], he went on to have wedge resections of his pulmonary metastases. He had a resection in the right upper lobe, right lower lobe, left upper lobe and left lower lobe. Three of the four wedges were found to be involved with chondrosarcoma. The patient had been doing well until [**1-14**] when he noted a vague pain in his left buttock, initially thought to be MSK via hamstring tendinitis. However, the pain got worse and he started to feel a mass at which time he was seen by his PCP who performed an MRI that did reveal a soft tissue mass in the gluteus maximus muscle. He had a CT-guided biopsy done here, which confirmed chondrosarcoma in [**3-16**]. Decision made to pursue Chemo-XRT. Port placed by Dr. [**Last Name (STitle) 1924**] [**2137-4-15**] for access. Social History: He is a nonsmoker. He drinks alcohol occasionally. He is married, has two children ages 7 and 3. He works as an electronics technician and lives in [**Location 701**]. Family History: non-contributory Physical Exam: Gen: young man lying in bed in no acute distress, pleasantly conversant HEENT: EOMI, PERRL, OP moist without lesion Neck: supple, no LAD Lungs: CTA bilaterally CV: reg rate, normal S1/S2, no murmur Abd: soft, NT, ND, BS present, no HSM Ext: large hard mass on left gluteal area, moderately tender Pertinent Results: [**2137-4-28**] 10:20PM WBC-11.5* RBC-4.02* HGB-12.9* HCT-35.1* MCV-87 MCH-32.1* MCHC-36.7* RDW-13.4 [**2137-4-28**] 10:20PM NEUTS-98.8* BANDS-0 LYMPHS-0.7* MONOS-0.4* EOS-0.1 BASOS-0 [**2137-4-28**] 10:20PM PLT COUNT-218 [**2137-4-28**] 10:20PM PT-12.8 PTT-29.9 INR(PT)-1.1 [**2137-4-28**] 10:20PM GLUCOSE-121* UREA N-9 CREAT-0.8 SODIUM-136 POTASSIUM-2.7* CHLORIDE-102 TOTAL CO2-23 ANION GAP-14 . CXR [**2137-4-28**]: No acute cardiopulmonary process . Hip films [**2137-4-29**]: Appearance of left hip bipolar arthroplasty is little changed since [**2137-2-4**]. There is no sign of hardware-related complication, or change in alignment. There is no sign of osseous erosion or bone destruction. There is no abnormal soft tissue calcification or radiopaque foreign object. . Pelvic CT [**2137-4-29**]: Markedly abnormal appearance of the left gluteal musculature, similar in size and extent to PET CT of [**2137-4-12**]. Replacement of the musculature with abnormal low attenuation is most consistent with local recurrence of chondrosarcoma, possibly with tumoral necrosis secondary to chemo radiation treatment. Mass is noted to enter the pelvis along the course of the piriformis and obturator musculature, where it surrounds the sciatic nerve and inferior gluteal artery. . Echocardiogram [**2137-4-30**]: The left atrium is normal in size. 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%). The estimated cardiac index is high (>4.0L/min/m2). 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, but cannot be fully excluded due to suboptimal image quality. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . Chest CTA [**2137-5-2**]: The pulmonary arteries opacify thoroughly without evidence for pulmonary embolus. No pericardial effusion. There are new small right greater than left pleural effusions. Respiratory motion limits the evaluation of pulmonary parenchyma slightly, however, in the presence of previously resected nodules there are postoperative changes, and a new focal nodular opacity in the left lower lobe measuring 7 mm (6, 88), which was not present on prior study. Additional more subtle nodular focus is seen in right upper lobe measuring 3 mm (6, 44). These two foci may represent atelectatic lung, due to slightly expiratory phase of imaging, however, they do bear attention on followup studies as they were not present on most recent prior. . Abdomen U/S [**2137-5-6**]: The liver demonstrates normal echotexture. Within the right lobe of the liver near the dome, there appears to be an hyperechoic ill-defined area measuring approximately 3.9 x 1.8 x 1.7 cm. A linear hyperechoic structure is identified extending beyond the margin of the liver and this suggests that this entire lesion may be artifactual and secondary to suture line seen at the right lung base. No other liver lesions are identified. Within the gallbladder, a 7 x 4 mm polyp is identified. The common bile duct measures 7 mm. There is normal hepatopetal flow in a patent portal vein. There is no evidence of intrahepatic biliary dilatation. The aorta is of normal caliber throughout. The right kidney measures 11.8 cm and the left kidney measures 10.1 cm. There is no evidence of hydronephrosis or renal calculi. The spleen measures 11.8 cm. Brief Hospital Course: 42-year-old man with history of metastatic chondrosarcoma with mets to lung and relapse in gluteal muscle presented with fever, increasing buttock pain found to be bacteremic and tachycardic. . # Chondrosarcoma: doxorubicin was started on [**2137-5-6**]. The pain in his left leg was well controlled with narcotics. Patient was discharged on [**2137-5-10**] with instructions to be admitted the following week for more chemotherapy. . # Group A Strep bacteremia: with multiple bottles of group A strep. He was started on penicillin for a planned 14-day course. Discharge day was day 7 of the penicillin. He was discharged home with an antibiotic pump. Surveillance blood cultures were to be drawn after the end of the antibiotic. Suppressive therapy would be considered. . # Tachycardia: patient had sinus tachycardia in setting of infection. He remained intermittently tachycardic throughout his admission without any symptom. a CTA of the chest was negative for PE. His TSH was 5.2. . # Transaminitis: with elevated AST and ALT since [**2137-4-30**], after the patient was initially started on ceftriaxone. A RUQ ultrasound showed no biliary obstruction. After the discontinuation of ceftriaxone and initiation of penicillin once blood culture sensitivity came back, his LFTs trended down again. . # FULL CODE Medications on Admission: - oxycontin 80 mg q8 - colace 100 mg [**Hospital1 **] - motrin 600 mg q8 - pantoprazole 40 mg daily - zantac 150 mg [**Hospital1 **] - oxycodone 15 mg q4:prn breakthrough (using 1 dose daily) - senna 8.6 mg tab daily - gabapentin 300 mg TID - Maalox prn Discharge Medications: 1. Penicillin G Potassium 4 million units IV Q4H Dispense this through Monday [**2137-5-13**] 2. 0.9% Saline 5ml flush SASH & prn Dispense: 3 days supply 3. Heparin 100 units/ml 5ml per dose & prn/QD for line maintenance Dispense: 3 days supply 4. Port-a-cath line care [**First Name8 (NamePattern2) **] [**Last Name (un) 6438**] protocol 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*14 Tablet(s)* Refills:*0* 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:*21 Capsule(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*28 Capsule(s)* Refills:*0* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. Disp:*qs 2 weeks' supply* Refills:*0* 10. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). Disp:*140 Tablet Sustained Release 12 hr(s)* Refills:*0* 11. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*qs 2 weeks' supply* Refills:*0* 12. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO every 6-8 hours. Disp:*qs 2 weeks' supply* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (un) 6438**] Discharge Diagnosis: Primary diagnosis: chondrosarcoma Secondary diagnoses: none Discharge Condition: Stable Discharge Instructions: You presented to [**Hospital1 18**] for chemotherapy for your chondrosarcoma. You tolerated the chemotherapy well. You were found to have a blood infection, for which you have been receiving penicillin. Please continue to take the antibiotic at home as instructed. Please take all your medications. You're scheduled to return to the hospital next Monday for more chemotherapy. Followup Instructions: Scheduled admission for more chemotherapy on [**2137-5-14**]. [**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]

[ "995.91", "285.22", "276.8", "794.8", "V43.64", "198.5", "284.1", "197.0", "V15.3", "V10.89", "198.89", "038.0", "E879.8" ]

icd9cm

[ [ [] ] ]

[ "99.25", "92.29" ]

icd9pcs

[ [ [] ] ]

15932, 15988

12869, 14183

4566, 4573

16093, 16102

8951, 12846

16527, 16718

8601, 8619

14488, 15909

16009, 16009

14209, 14465

16126, 16504

8634, 8932

16065, 16072

4509, 4528

4601, 6611

16028, 16044

6633, 8399

8415, 8585

27,292

154,138

32276

Discharge summary

report

Admission Date: [**2173-12-29**] Discharge Date: [**2174-1-25**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: headache Major Surgical or Invasive Procedure: [**12-29**] left subdural hematoma evacuation [**2-4**] free latissimus flap scalp [**1-5**] stress MIBI [**1-12**] burr holes for subdural collection History of Present Illness: 85 y/o female with a history of squamous cell carcinoma resected from her forehead approximately 18 months ago. The patient did well following the procedure, and physicians were under the impression that the surgical margins were clean. Approximately 6 months ago she noted progressive difficulty with ambulation and over the past 2-3 weeks increasing headaches. She denies any falls or head trauma during this period,however,head CT obtained at an outside hospital reveals left frontal parietal chronic subdural hematoma approximately 1.7cm in thickness with 1.2cm midline shift. There is no evidence of acute hemorrhage, but left frontal bone superior to the orbit is eroded with possible local invasion of carcinoma. Pt presented to [**Hospital1 18**] for cranioplasty with free flap. Past Medical History: PMHx: atrial fib hypothyroidism CAD low back pain squamous cell carcinoma of the forehead Social History: Social Hx: denied tobacco, EtOH, or IVDU; she lived alone at home - retired Family History: Family Hx: noncontributory Physical Exam: PHYSICAL EXAM: Gen: Appears cachectic, unconscious, NAD. HEENT:Cerebral flap w/xeroform and gauze, depressed cranium Pupils: [**4-9**] bilaterally Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+, NGT d/c'd [**2174-1-24**] Extrem: Warm and well-perfused. Neuro: Mental status: Unconscious, not following commands, no eye opening, spontaneous movement of all extremeties, BUE's contracted with extensive posturing to noxious stimuli. Orientation: UTA-unconscious Language: nonverbal Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1.5mm bilaterally. III, IV, VI: not tested V, VII: not tested VIII: not tested IX, X: not tested [**Doctor First Name 81**]: not tested XII: not tested Motor: BUE's contracted, extend to noxious stimuli, BLE's with min w/d to deep noxious stimuli Pertinent Results: SCALP PATHOLOGY RESULTS: Clinical: 85 year old woman with metastatic tumor, frontal scalp involving skull and dura. The tumor from all five specimens shows similar features. Tumor cells are epithelioid, pleiomorphic and variably discohesive. Nuclei are enlarged and irregular and many are vesicular with prominent nucleoli. Mitotic figures are frequent. In the skin excision tumor is present in the dermis and extends to involve the deep subcutaneous tissue. An origin from the epidermis is not identified nor is there definitive morphologic evidence of squamous differentiation. Immunohistochemical stains show the tumor to be immunoreactive for vimentin. A large subpopulation of tumor cells are immunoreactive for cytokeratins as pankeratins (AE1/AE3/CAM 5.2), MNF 116 and focally for cytokeratin [**6-13**] and EMA, and to show strong nuclear reactivity for p63. There is variable reactivity in a subset of cells for CD138, CD31, CD68 and CD45. They are non-reactive for the melanocytic markers S-100, Mart-1, HMB-45, cytokeratins -7 and -20, CD79, CD34, Factor VIII, TTF-1 or the estrogen receptor. The morphologic features in conjunction with these immunohistochemical findings favor that this tumor is a poorly differentiated carcinoma. It may represent extension / recurrence of a tumor originally located at or near this site but a distant metastasis cannot be excluded. Correlation with the clinical findings is suggested. CT HEAD W/O CONTRAST [**2174-1-18**] 11:09 AM Reason: f/u study [**Hospital 93**] MEDICAL CONDITION: 85 year old woman with s/p bifrontal craniectomy, in sicu REASON FOR THIS EXAMINATION: f/u study INDICATION: Status post bifrontal craniectomy, in CICU; assess interval change. COMPARISON: [**2174-1-16**]. TECHNIQUE: Non-contrast head CT. FINDINGS: Stable appearance of large hypodensity involving the left frontal lobe with a central high- attenuation focus with unchanged rightward shift of normally midline structures (10 mm). Stable appearance of left subdural collection. The basilar cisterns and ventricular system are stable in size. Again seen are air-fluid levels in the sphenoid sinuses. IMPRESSION: Essentially unchanged head CT from [**2174-1-16**]. HEAD CT: FINDINGS: There is worsened subfalcine herniation today with the midline shift measuring 15 mm, previously 10 mm, with worsening effacement of rightwardly displaced left ventricle. There is worsened uncal herniation with increased shift towards the midline of the temporal [**Doctor Last Name 534**]. The large hypodensity involving the left frontal lobe appears increased in size today at 5.5 cm (previously 5.2 cm) again containing a central hyperdensity that has slightly decreased in size. The left subdural collection appears essentially stable. Air-fluid levels are again seen in the sphenoid sinuses. IMPRESSION: Worsening subfalcine and uncal herniation with slightly increased size of left frontal hypodensity and stable-appearing left subdural hematoma. BILATERAL LOWER EXTREMITY ULTRASOUND: FINDINGS: Ultrasound evaluation of the right and left lower extremity deep venous system using grayscale, color, and pulse wave Doppler reveals the veins to be fully compressible with normal color flow, Doppler waveforms, augmentation, and respiratory variation in flow. IMPRESSION: No evidence of DVT involving the right or left lower extremity. ECHO: Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). Transmitral Doppler and TVI c/w Grade I (mild) LV diastolic dysfunction. 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. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of mitral valve chordae. [**Male First Name (un) **] of the mitral chordae (normal variant). No resting LVOT gradient. Trivial MR. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Ms [**Known lastname **] was admitted to neurosurgical ICU on [**2173-12-29**] for left frontal parietal chronic SDH with midline shift. There is also erosion to left orbit with possible local invasion of skin carcinoma. She was taken to the OR on HD#2 for evacuation of left subdural hematoma. She underwent the procedure and remained intubated until POD#2. Her mental status improved after the surgery. She self d/c'd NGT on [**1-1**]; she passed bedside swallow evaluation on [**1-2**] and her PO diet was resumed. She underwent latissimus flap cranioplasty by plastic services on [**2174-1-5**] and she tolerated the procedure well with no complications. Postoperatively she was transfered back to the ICU intubated with 1 penrose, 2 JP drains, xeroform over the donor skin graft site, and xeroform over the flap. She was extubated on [**2174-1-7**] without difficulty. She slowly improved to the ability to follow commands and open eyes to voice. Plastic services continued to follow her throughout her hospitalization. She was evaluated by speech and swallowing on [**1-11**] and was recommended NPO until further re-eval. On [**1-12**] the patient became less responsive and less able to follow commands. Repeat Head CT showed left frontal infarct/increasing SDH with increased midline shift. She was taken back to the OR for a craniotomy for evacuation of SDH. She stayed in ICU postop and was extubated on [**1-13**]. Neurologically she opens eyes spontaneously, but following commands inconsistently. She has mild weakness with RUE and [**6-12**] with LUE; she moves both LE antigravity. Repeat CTH [**1-16**] with slight worse L SDH, and stable on CTH [**1-18**]. She was transferred out of ICU to stepdown on [**2174-1-19**] and was started with PT and chest PT. Patient's mental status slowly deteriorated to more somnolence, not open eyes and inconsistently following commands. She was tachypneic sometimes with O2 sat maintained in 90s on humidified room air. CXRs are negative for pneumonia; her breathing pattern improved with atrovent inhalor and expectant guaifenesin. **************** Family meeting took place on [**1-24**],at which point the decision was to refocus care towards comfort measures only. See Palliative Care Note as follows: Date: [**2174-1-24**] Signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP on [**2174-1-24**] Affiliation: PRIVATE PRACTICE Request to meet family to discuss hospice care. Family spoke with neurosurgery this morning and have changed focus of care to comfort with hospice care. Pt is 85 yo woman with sq. cell cancer with multiple surgeries, recent subdural with evacuation but no response. After aggressive care to maintain while hoping for mental status improvement, pt has not made any gains and has remained unresponsive. Her brother and her neice are HCP and both agree she would not want her life prolonged if unable to recover. Discussed with her neice She understands move to hospice level of care will mean d/c NGT, no IVF, meds for comfort only. At the [**Name (NI) 1501**] pt may receive hospice services dependent on insureance and family wishes. Will request hospice eval once pt goes to [**Hospital1 1501**]> ** upon discharge, she is in bed, unrespsonsive. RR high 20s but unlabored. Her mouth is open and very dry. Has humidified air on. Case mgmt working on transfer to [**Location (un) 4979**] area [**Hospital1 1501**]. Acetaminophen 650 mg PR q4 prn fever Ativan 1-2 mg SL ( tablets may be used SL after mostening mucosa) q2 prn agitation/seizures/dyspnea Morphine 5-20 mg SL q2 prn distress Medications on Admission: metoprolol 25 qd levoxyl 12.5 qd boniva lipitor 20 qd folic acid coumadin Discharge Medications: 1. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed. 2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4H (every 4 hours) as needed. 3. Morphine Concentrate 20 mg/mL Solution Sig: 5-20mg PO Q2H (every 2 hours) as needed for distress. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: Liberty Commons Nursing & Rehab Center - [**Location (un) 4979**] Discharge Diagnosis: Squamous cell carcinoma cranioplasty via latissimus flap subdural hematoma evacuation x 2 on left side Discharge Condition: Neurologically patient with poor prognosis. Discharge Instructions: -Pt may have [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain pulled out when output<30cc/hr. -Cranial dressing - may leave on Xeroform and change gauze dressing as needed -comfort measures as ordered by rehab. Followup Instructions: Pt's care redirected to comfort measures. Completed by:[**2174-1-25**]

[ "198.3", "348.4", "432.1", "198.5", "434.91", "V66.7", "784.3", "244.9", "427.31", "V10.83", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "01.39", "02.12", "99.77", "01.32", "86.75", "96.6", "86.69", "76.39", "02.06" ]

icd9pcs

[ [ [] ] ]

11693, 11785

7562, 11181

277, 430

11932, 11978

2382, 3885

12268, 12341

1475, 1504

11306, 11670

3922, 3980

11806, 11911

11207, 11283

12002, 12245

1534, 1810

228, 239

4009, 4586

458, 1251

2046, 2363

4595, 7539

1825, 2030

1273, 1365

1381, 1459

14,332

184,423

18267

Discharge summary

report

Admission Date: [**2102-1-24**] Discharge Date: [**2102-1-31**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8684**] Chief Complaint: Abdominal pain. Major Surgical or Invasive Procedure: percutaneous cholecystostomy tube History of Present Illness: This is a 89F history of CVA, dementia, Type 2 DM, hypertension and "h/o pancreas problems" who presented initially with chest pain and and abdominal pain. Patient found to have elevated white count and cholecystitis on CT scan, and was evaluated by general surgery and ERCP. She received percutaneous cholecystostomy tube by interventional radiology and was started on antibiotics. Of note, she was also found to have infrarenal aortic ulceration/dissection on abdominal CT and has been followed by vascular surgery for this. . Cardiac enzymes were borderline elevated during admission but patient did not have chest pain upon medical team evaluation. . ROS: Denied fever, chills, SOB, cough, chest pain, abdominal pain Past Medical History: 1. CAD 2. CHF - Echo at [**Hospital1 112**] with LVEF 50-55% and hypokinetic septum & apex 3. Right-sided atrial and ventricular pacemaker for sinus pause 4. Type 1 DM 5. Hypertension 6. Hypercholesterolemia 7. CVA - left parietal lobe infarct 8. Peripheral vascular disease Social History: Lives with daughter and has visiting nurse. Family History: N/C. Physical Exam: Vitals: T:99.3 P:68 R:20 BP:148/62 SaO2:98% on RA General: NAD. HEENT: NC/AT, PERRL, EOMI, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD, radiating aortic murmur Pulmonary: Lungs CTA anteriorly Cardiac: RRR, nl. S1S2, 3/6 systolic murmur at RUSB radiating to neck Abdomen: soft, NT/ND, decreased bowel sounds, cholecystostomy tube in place draining bilious fluid. Subcutaneous nodules noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: no rashes or lesions noted. Neurologic: Alert, oriented to person and says she is in [**Hospital1 50398**] hospital. Moves all 4 extremities. CN II - XII grossly intact. Pertinent Results: [**2102-1-23**] 09:00PM URINE RBC-[**2-6**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**2-6**] [**2102-1-23**] 09:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2102-1-23**] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2102-1-23**] 09:00PM PT-11.4 PTT-22.5 INR(PT)-1.0 [**2102-1-23**] 09:00PM PLT COUNT-232 [**2102-1-23**] 09:00PM MICROCYT-3+ [**2102-1-23**] 09:00PM NEUTS-84.3* LYMPHS-9.4* MONOS-5.1 EOS-1.0 BASOS-0.2 [**2102-1-23**] 09:00PM WBC-16.8* RBC-5.04 HGB-11.7* HCT-36.2 MCV-72* MCH-23.2* MCHC-32.3 RDW-15.7* [**2102-1-23**] 09:00PM ALBUMIN-4.4 PHOSPHATE-3.1 MAGNESIUM-2.1 [**2102-1-23**] 09:00PM CK-MB-3 [**2102-1-23**] 09:00PM cTropnT-<0.01 [**2102-1-23**] 09:00PM LIPASE-1136* [**2102-1-23**] 09:00PM ALT(SGPT)-117* AST(SGOT)-212* CK(CPK)-134 ALK PHOS-213* AMYLASE-576* TOT BILI-1.0 [**2102-1-23**] 09:00PM estGFR-Using this [**2102-1-23**] 09:00PM GLUCOSE-155* UREA N-20 CREAT-1.1 SODIUM-137 POTASSIUM-6.3* CHLORIDE-105 TOTAL CO2-22 ANION GAP-16 [**2102-1-24**] 03:13AM PT-12.9 PTT-23.3 INR(PT)-1.1 [**2102-1-24**] 03:13AM PLT COUNT-211 [**2102-1-24**] 03:13AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL ELLIPTOCY-1+ [**2102-1-24**] 03:13AM NEUTS-86.3* BANDS-0 LYMPHS-9.3* MONOS-2.8 EOS-1.4 BASOS-0.2 [**2102-1-24**] 03:13AM WBC-11.7* RBC-4.44 HGB-10.7* HCT-31.4* MCV-71* MCH-24.1* MCHC-34.1 RDW-15.3 [**2102-1-24**] 03:13AM ALBUMIN-3.8 CALCIUM-10.2 PHOSPHATE-3.4 MAGNESIUM-1.8 [**2102-1-24**] 03:13AM CK-MB-3 cTropnT-0.02* [**2102-1-24**] 03:13AM LIPASE-271* [**2102-1-24**] 03:13AM ALT(SGPT)-101* AST(SGOT)-109* LD(LDH)-257* ALK PHOS-191* AMYLASE-314* TOT BILI-0.7 [**2102-1-24**] 03:13AM GLUCOSE-248* UREA N-18 CREAT-0.9 SODIUM-137 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-21* ANION GAP-14 [**2102-1-24**] 03:58PM CK-MB-NotDone cTropnT-0.02* [**2102-1-24**] 03:58PM CK(CPK)-68 . CT abd/pelvis: 1. The gallbladder is distended, with wall edema, pericholecystic fluid and hyperemia of the adjacent liver. The findings are suggestive of acute cholecystitis. 2. Severe atherosclerosis of the aorta. There is a penetrating ulcer vs. focal dissection of the abdominal aorta, from the level just inferior to the right renal artery origin, extending for approximately 2 cm. 3. Small amount of ascites fluid adjacent to the liver. 4. Fluid and stranding near the pancreatic head. This could be related to adjacent cholecystitis, or could be a manifestation of pancreatitis. There is a somewhat focal dilation of the common duct to 11 mm in the pancreatic head, which subsequently tapers. 5. Calcified structures in both sides of the pelvis, which may represent ovaries. There is a rounded area of fluid between small bowel loops in the pelvis, which may reflect ascites fluid or a duplication cyst. 6. Sigmoid diverticulosis, without evidence of diverticulitis. . head CT: evidence of acute intracranial hemorrhage. Chronic microvascular infarction. Please note that MRI with diffusion-weighted imaging is more sensitive for the detection of acute ischemia. . CXR:Question COPD. Upper zone redistribution, without overt CHF. No pneumonic infiltrate. Brief Hospital Course: This is an 89 y.o. female with a h/o CVA, dementia, Type 1 DM, hypertension and "h/o pancreas problems" who presented initially with chest pain and and found to have cholecystitis and infrarenal aortic ulceration/dissection. . 1) Cholecystitis: Patient status post cholecystostomy tube placement, cholecystectomy deferred due to comorbidities. No signs of cholangitis, as blood pressure stable, her fever curve trended down, and WBC count and alk. phos. trending downward. Her bile fluid grew [**Female First Name (un) **] but ID said to hold on treaating this unless she is unstable or blood cultures positive for [**Female First Name (un) **] The antibiotics were first narrowed to cipro and flagyl and then changed to PO. Per surgery, cholecystostomy tube should be in place for 6 weeks and she will be followed by interventional radiology for this. . 2) Acute renal failure - The patient had a slight creatinine bump, likely secondary to dehydration/pre-renal picture given the cr improved with IVF. Her lisinopril and atenolol were initially held but restarted after her ARF improved. . 3) Aortic dissection ulceration - As repeat scan done at [**Hospital1 18**] did not show worsening dissection, vascular recommended improving blood pressure control by uptitrating her regimen as tolerated. Nifedipine was increased to 120 mg qdaily and she was continued on atenolol and lisinopril. She will need a repeat CTA of the abdomen and pelvis with and without contrast in [**2-7**] months to evaluate the focal dissection of the abdominal aorta, from the level just inferior to the right renal artery origin. . 4) Non-anion gap acidosis - The patient had low bicarbonate, likely secondary to biliary drainage, and this remained stable. . 5) CAD - The patient has a history of remote NQWMI per [**Hospital1 112**] records, but had no issues here and was continued on all appropriate medications including nifedipine, lisinopril, atenolol, and ASA. Given her LFT elevation her atorvastatin was held. It was trending down at discharge and should be rechecked as an outpatient. Her statin should be restarted if her LFT's are normal. . 6) transaminitis: The patient had elevated liver enzymes, likely [**1-6**] reactive hyperaemia of liver surrounding inflamed gall bladder, as this improved during her course. These should be checked at rehab and if completely normal would restart mirtazapine 15 mg daily and atorvastatin 10 mg daily as these were held . 7) Diabetes mellitus - Has been on sliding scale in house, and was initially given 10NPH in AM and 6NPH in PM based on recent sliding scale requirements. This was increased per daily needs and should continue to be followed as an outpatient. . 8) Depression - We held the patient's mirtazapine given transaminitis; continue to hold until she demonstrates stable hepatic function and then would restart her mirtazapine. . 9) Fever - The patient had a low grade fever which resolved. Her CXR and urine culture was negative. Her blood has no growth to date, but should be followed up final cultures by her PCP. [**Name10 (NameIs) **] may have had a viral syndrome as she had a slight cough, fevers and chills. At discharge she was afebrile with no signs of infection. . 10) Dispo - The patient will be at [**Hospital3 1186**] [**Telephone/Fax (1) **], where a physician from Dr.[**Name (NI) 8687**] practice, or Dr. [**Last Name (STitle) **] will see the patient.[**First Name8 (NamePattern2) 14735**] [**Last Name (NamePattern1) 5545**] will be help coordinate the cholecystostomy tube removal, call [**Telephone/Fax (1) 5546**] for more information . 11) Code: The patient is DNR/DNI Medications on Admission: 1. Lisinopril 40mg qdaily 2. Nifedipine CR 60mg qdaily 3. Pantoprazole 40mg qdaily 4. Mirtazapine 15mg qdaily 5. Atorvastatin 10mg qdaily 6. ASA 7. Insulin 8. Atenolol 100mg qdaily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): hold for sbp < 100 and hr < 55. 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed. 4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 5. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily): hold for sbp < 100. 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Humalog 100 unit/mL Cartridge Sig: per sliding scale Subcutaneous per ss: follow provided ss. 9. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: 17 Units in am and 6 units in pm Subcutaneous as above. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: primary: cholecystitis focal dissection of abdominal aorta . secondary: 1. CAD 2. CHF 4. Type 1 DM 5. Hypertension 6. Hypercholesterolemia 8. Peripheral vascular disease Discharge Condition: good. tolerating orals Discharge Instructions: 1. You have cholecystitis and were treated with antibiotics and a tube. . 2. Please return to the hospital if you experience increasing abdominal pain, nausea, vomiting, fever, or any symptoms that concern you. . 3. Please follow medications on your list. . 4. You will have follow-up with Dr. [**Last Name (STitle) **] and have your tube pulled in 5 weeks. Followup Instructions: 1. You will need to have a repeat CTA of the abdomen and pelvis with and without contrast in [**2-7**] months to evaluate the focal dissection of the abdominal aorta, from the level just inferior to the right renal artery origin. 2. You will need your drain pulled in 5 weeks, NP [**First Name8 (NamePattern2) 14735**] [**Last Name (NamePattern1) 5545**] will coordinate with Dr. [**Last Name (STitle) **], if needed call [**Telephone/Fax (1) 5546**] for more information 3. Dr. [**Last Name (STitle) **] will follow you at rehab. For problems she can be reached at ([**Telephone/Fax (1) 8417**]

[ "789.5", "294.8", "441.02", "V58.67", "584.9", "250.01", "428.0", "276.2", "276.51", "577.0", "V45.01", "575.0" ]

icd9cm

[ [ [] ] ]

[ "51.01" ]

icd9pcs

[ [ [] ] ]

10430, 10503

5528, 9178

278, 314

10717, 10742

2235, 5217

11148, 11748

1442, 1448

9410, 10407

10524, 10696

9204, 9387

10766, 11125

1463, 2216

223, 240

342, 1065

5226, 5505

1087, 1365

1381, 1426

28,021

130,177

33102

Discharge summary

report

Admission Date: [**2136-2-3**] Discharge Date: [**2136-2-19**] Date of Birth: [**2079-12-11**] Sex: M Service: MEDICINE Allergies: Colace Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Transfer from OSH for staph bacteremia, R hand abscess/cellulitis Major Surgical or Invasive Procedure: R hand abscess debridement History of Present Illness: 56 yo M with h/o "diet controlled DM" s/p Right AKA, admitted on [**2136-2-2**] to [**Hospital **] [**Hospital 1459**] Hospital with purulent drainage from his right thumb and progressive erythema up his arm to his elbow over the days just prior to admission. The patient reports that the initial injury occurred 5 days ago when he tried to open a can of cat food. Given the progression of the wound as above, his brother called an ambulance on [**2-2**] so that the patient would undergo further evaluation. CT of the arm from OSH revealed gas in the soft tissue. Additionally thumb swab from OSH is now growing Staph aureus and rare GNRs and blood cultures are growing Gram positive cocci. He was initially started on cefazolin, but was transitioned to aztreonam/clindamycin late on the [**2136-2-2**]. Vancomycin was added on [**2136-2-3**]. Also of note, his hct at OSH was reportedly 23 (baseline not known) on presentation for which he received 2 units PRBCs with post transfusion hct 29. His WBC count at that time was 26K. Additionally, he was noted to be jaundiced with scleral icterus with t.bili 10 prior to transfer. Gallstones were reportedly visualized on abd CT without clear e/o obstruction. Hepatitis A Ab was negative, Hep B surface Ag negative (no surface Ab), Hep C Ab negative. Also on CT abdomen (with oral not IV contrast), marked jejunal thickening to as much as 1cm was noted. Given his hct and jaundice, hematology was consulted out of concern for hemolysis. Direct coombs was negative. As he was thought to have anemia of chronic disease based on iron studies at OSH, possible renal contribution so he received erythropoeitin. He was transferred from OSH on [**2136-2-3**] initially to the medicine service and for urgent orthopedic evaluation. Initial vitals on the floor were T 101.2 BP 139/62 HR 100 O2 96%. Plastics evaluated him upon presentation to the floor and he was taken emergently to the OR for debridement. Intraoperatively, his SBPs dropped to 70s requiring initiation of phenylephrine. Of note, he had been started on propofol for sedation. He received approximately 3L IVFs intraoperatively with estimated 10cc blood loss. Gross purulence was drained in the OR. In the PACU, SBPs dipped to 70s again when titration of neosynephrine was attempted and he was noted to have made only approximately 200cc UOP including OR and PACU course (prior to that not well documented). He received 4.5g IV zosyn and vanco 1g IV. ROS: Unable to obtain given intubated/sedated however OSH documents report pt. denied abdominal pain, nausea, vomiting, blood in stool/black stool. Past Medical History: Diet controlled DM2 S/P right leg amputation [**1-9**] Abscess right middle finger s/p amputation S/P cataract surgery Social History: Lives with two brothers, "occasional" etoh although reports past heavy use in college. No tobacco. Family History: non-contributory Physical Exam: Vitals: T: 101 BP: 142/60 HR: 85 RR: 16 O2sat: 100% Vent settings: AC 550/14 PEEP 5.0 FiO2 0.40; Neosynephrine at 0.50 mcg/kg/min General: Middle aged male lying in bed, intubated and sedated Skin: jaundiced, left anterior shin with large area of erythema, warmth, no fluctuance, no purulent drainage HEENT: Left pupil 3mm->2.5mm, right pupil 3.5mm->3mm, icteric sclerae. Dry mucous membranes. Neck: Supple Chest: Slightly less air movement on left laterally, however sounds clear anteriorly and laterally Cardiac: soft early systolic murmur LUSB, RRR Abdomen: soft, normoactive bowel sounds, does not appear to grimace with palpation of abdomen Extremities: Right hand with multiple lesions over the fingers, half amputated Right middle finger. Right thumb dressed, right arm suspended. Left LE with multiple excoriations anterior shin. Also has an area of erythema over the midshin with increased warmth (as above). 1+ LLE edema. Left toes with ?ischemic emboli. s/p AKA on right. Pertinent Results: LABS ON ADMISSION: [**2136-2-4**] 12:00AM WBC-18.9* RBC-3.06* HGB-10.2* HCT-28.3* MCV-92 MCH-33.2* MCHC-35.9* RDW-16.7* [**2136-2-4**] 12:00AM NEUTS-96.0* BANDS-0 LYMPHS-2.0* MONOS-1.5* EOS-0.5 BASOS-0.1 [**2136-2-4**] 12:00AM PLT COUNT-270 [**2136-2-4**] 12:00AM PT-18.0* PTT-34.6 INR(PT)-1.6* [**2136-2-4**] 12:00AM ALBUMIN-2.4* CALCIUM-7.7* PHOSPHATE-2.8 MAGNESIUM-1.8 [**2136-2-4**] 12:00AM LIPASE-26 [**2136-2-4**] 12:00AM ALT(SGPT)-39 AST(SGOT)-85* LD(LDH)-194 ALK PHOS-208* AMYLASE-17 TOT BILI-16.0* [**2136-2-4**] 12:00AM GLUCOSE-185* UREA N-51* CREAT-1.6* SODIUM-126* POTASSIUM-5.0 CHLORIDE-94* TOTAL CO2-21* ANION GAP-16 OSH BLOOD CULTURES 4/4 bottles MSSA bacteremia EKG in MICU: NSR rate 88, nml axis, TWI V2, TWI V3 now resolved. Radiologic Data from OSH: [**2136-2-2**] CXR: No acute cardiopulmonary process. [**2136-2-2**] CT abdomen w/o IV contrast, oral contrast only [**2-2**]: 1. Diffuse thickening of jejunum measuring up to 1cm. Etiology is unknown. Infiltrative disease or edema cannot be ruled out. There is no bowel obstruction. 2. The liver is enlarged with fatty infiltration. 3. One cm stone int he left kidney that is nonobstructing. 4. Layering stones in the gallbladder. [**2136-2-3**] CT right upper extremity: Gas within soft tissue planes right arm from level of thumb and index finger to just above the elbow. RUQ US [**2-4**] - 1. Stones and sludge seen within the gallbladder, with wall thickening and edema although no pericholecystic fluid. Differential diagnosis includes hypoalbuminemia, CHF, hepatitis and acute cholecystitis. If acute cholecystitis remains a consideration, HIDA scan could be helpful for further evaluation. 2. Echogenic liver suggesting fatty infiltration. However, other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded. TTE [**2-4**] - The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is smaller than usual. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. IMPRESSION: Normal left ventricular systolic and diastolic function. The left ventricle appears somewhat underfilled. The right ventricle is mildly dilated with normal function. The mitral and aortic valves appear to function well with no vegetations identified. CXR [**2-4**] - Lines and tubes as described. Prominent cardiomediastinal silhouette of indeterminate significance given low lung volumes. This should be further assessed on a film obtained with better inspiration when the patient can tolerate. Left lower lobe collapse and/or consolidation. Brief Hospital Course: 56 yo M with DM, MSSA bacteremia due to a R hand abscess due to a cut, transfered here from OSH for debridement in OR. Initially admitted to the medical floor from OSH and taken emergently to the OR by plastic/hand surgery for debridement of the R hand abscess. Intraoperatively, the pt dropped his SBPs, requiring neosynephrine gtt for BP support. As the pt remained intubated and on pressors in the PACU, he was tranferred to the MICU for further care. Neo was titrated off the following morning and the pt was given a total of 9Ls IVF boluses for CVPs < 12. He was extubated successfully on the day of admission to the MICU. He briefly required levophed overnight after extubation for SBPs in the 80s, MAPs < 65 after being aggressively fluid resuscitated, which was weaned off the following morning. The pt was placed on vancomycin and zosyn until further culture data was available. A wound swab from the R hand showed 4+ GPC and 2+ GNRs and eventually grew MSSA. Blood cultures from the OSH were also with MSSA while blood cultures here remain NGTD. Given his persistent hyperbilirubinemia, the decision was to keep the pt on vancomycin (dosed by level) rather than switching to nafcillin. A TTE was checked and was negative for vegetations. off of pressors since [**2-5**]. Most likely source of infection was infected hand wound. He then required a second ICU stay for UGIB and hypotension after and EGD. His course is complicated by liver failure with underlying newly diagnosed liver cirrhosis secondary to ongoing EtOH use, new renal failure requiring CVVH due to ATN associated with hypotenation/ATN, also with UGIB with evidence of nonbleeding GE junction ulcer requiring blood transfusions. The patient was persistently hypotensive to the 70's (with good mentation) which was felt to be due to fluid shifts. He was doing well until 4am on the morning of [**2136-2-19**], when the patient became bradycardic and had a PEA arrest. He was successfully resuscitated after 1 atropine and 3 epinephrine doses and 10 minutes of CPR. The cardiac arrest was complicated by large witnessed aspiration, intubation, subsequent hypoxia x 5 minutes and dilated fixed pupils. It is unclear what precipitated this event, it was most likely secondary to acidemia. Throughout the course of the next 12 hours, the patient needed increasing blood pressure support ending up on 3 pressors. His antibiotics were broadened to include meropenom, vancomycin and caspofungin. He was difficult to oxygenate even on high PEEP and 100% FiO2. He remained acidemic despite our efforts to give him bicarb. It was felt that given his low blood pressure it was not possible to use CVVH. After a discussion with his brother [**Name (NI) **] (HCP), it was felt that given the grim prognosis, the patient would not want further life sustaining measures. The patient was made CMO. Pressors were stopped and the patient expired within a few minutes. He expired at 9:02pm on [**2136-2-19**]. Medications on Admission: Home medications: none Medications on transfer: Aztreonam Clindamycin Vancomycin Discharge Medications: The patient expired at 9:02pm on [**2136-2-19**]. Discharge Disposition: Extended Care Discharge Diagnosis: Cardiac Arrest Hypoxic Respiratory Failure MSSA sepsis R hand infection s/p I&D Hyperbilirubinemia with jaundice Acute on chronic renal Failure Discharge Condition: The patient expired at 9:02pm on [**2136-2-19**]. Discharge Instructions: The patient expired at 9:02pm on [**2136-2-19**]. Followup Instructions: The patient expired at 9:02pm on [**2136-2-19**]. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "785.52", "518.81", "571.2", "682.4", "285.9", "584.9", "038.11", "427.5", "250.00", "578.9", "585.9", "995.92" ]

icd9cm

[ [ [] ] ]

[ "99.60", "96.04", "82.01", "38.95", "39.95", "38.93", "54.91" ]

icd9pcs

[ [ [] ] ]

11021, 11036

7831, 10816

340, 368

11224, 11275

4343, 4348

11373, 11561

3298, 3316

10947, 10998

11057, 11203

10842, 10842

11299, 11350

3331, 4324

10860, 10865

235, 302

396, 3023

4363, 7808

10890, 10924

3045, 3165

3181, 3282

62,798

179,683

54831

Discharge summary

report

Admission Date: [**2201-6-17**] Discharge Date: [**2201-6-24**] Date of Birth: [**2140-7-14**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 32612**] Chief Complaint: 1. Aspiration pneumonia required intubation 2. CBD injury status post open cholecystectomy Major Surgical or Invasive Procedure: [**2201-6-19**]: ERCP . [**2201-6-19**]: Successful placement of 8 French external Amplatz anchor drain into the distal right hepatic duct with external drainage to the bag. History of Present Illness: 60M PMH stage 1 bladder cancer s/p radiation Rx in [**2195**], with two years of intermittent RUQ pain 6 hours after fatty meals and presumed to be cholecystitis, with partial intermittent cystic duct obstruction confirmed by HIDA scan. He also had a RUQ ultrasound that showed a contracted gallbladder with small stones and a thickened wall. He was scheduled for laparscopic cholecystectomy on [**6-16**], however after 30 minutes of attempting to strip dense adhesions between the gallbladder and the omentum, the procedure was converted to open. A challenging and lengthy dissection ensued, requiring extensive stripping of omental adhesions as well as adhesions between the gallbladder and liver bed. An accessory bile duct was identified and ligated, and clipped again later when it was noted to be leaking. A high ligation near the gallbladder neck was undertaken given the gallbladder neck was edematous and friable, and so it was also oversewn. On [**6-17**], transaminases were noted to be elevated with AST 148, ALT 245, Tbili 1.4, Dbili 0.3. Later that day, the patient underwent ERCP which showed multiple filling defects in the CBD. A sphincterotomy was performed and several stones were extricated. Cholangiogram did not demonstrate filling of the right and left hepatic ducts and subsequently there was extraluminal contrast outside of the CBD and intestine concern for bile leak. During the ERCP the patient had an aspiration event, requiring intubation. Given concern for possible bile duct injury, the patient was transferred to [**Hospital1 18**] Surgical ICU. On presentation the patient was noted to be febrile to 101.9. Past Medical History: PMH: stage 1 bladder cancer treated in [**2195**] with radiation PSH: open cholecystectomy [**2201-6-16**] Social History: Married, former smoker Family History: Diabetes, CVA, HTN, melanoma Physical Exam: On Admission: VS: T 101.9, 96, 160/79, 21, 100% on CMV 550x16, peep 5, FiO2 60% - general: intubated, sedated - HEENT: NC, AT, NGT with bilious output; ET tube in place - CV: RRR, no M/R/G, S1/S2 normal - Resp: mechanical breath sounds clear to auscultation, no W/R/R - Abdomen: soft, obese, right subcostal incision closed with staples that appears to be healthy (no erythema or discharge) though minimal bruising noted; JP drain with bilious fluid - Extremities: warm and well-perfused On Discharge: VS: 98.7, 75, 144/76, 12, 96% RA GEN: NAD CV: RRR, no m/r/g RESP: CTAB ABD: Right subcostal incision open to air with steri strips. RLQ JP drain to bulb suction and site c/d/i. Right flank with IR drain to gravity drainage, site c/d/i. EXTR: Warm, no c/c/e Pertinent Results: [**2201-6-23**] 06:20AM BLOOD WBC-8.8 RBC-3.39* Hgb-11.1* Hct-32.9* MCV-97 MCH-32.6* MCHC-33.6 RDW-13.8 Plt Ct-202 [**2201-6-24**] 06:45AM BLOOD Glucose-119* UreaN-10 Creat-0.6 Na-148* K-3.3 Cl-106 HCO3-32 AnGap-13 [**2201-6-24**] 06:45AM BLOOD ALT-103* AST-70* AlkPhos-68 TotBili-1.2 [**2201-6-24**] 06:45AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.1 [**2201-6-17**] 10:17 pm BLOOD CULTURE Source: Venipuncture #1. **FINAL REPORT [**2201-6-23**]** Blood Culture, Routine (Final [**2201-6-23**]): NO GROWTH. [**2201-6-18**] 3:47 am URINE Source: Catheter. **FINAL REPORT [**2201-6-19**]** URINE CULTURE (Final [**2201-6-19**]): NO GROWTH. [**2201-6-18**] ABD CTA: IMPRESSION: 1. Multifocal aspiration in the lower lungs. 2. Post-cholecystectomy changes with drain and surrounding stranding without focal fluid collection to suggest biliary leak or hematoma; however the right hepatic artery is not well seen and interruption/occlusion cannot be excluded with slightly decreased right hepatic enhancement on the arterial phase imaging. [**2201-6-19**] ERCP: Impression: Evidence of a previous sphincterotomy was noted in the major papilla. Cannulation of the biliary duct was successful and deep with a balloon catheter using a free-hand technique. Contrast medium was injected resulting in complete opacification of the distal common bile duct. Filling of contrast was noted in the distal bile duct. Wire could not be passed into the proximal bile duct. Common hepatic duct and intrahepatics could not be opacified. This is concerning for complete bile duct transection. There was extravassation of bile consistent with a post operative bile leak. [**2201-6-21**] MRCP; IMPRESSION: 1. Examination is limited due to non-breathhold sequence acquisition and no dynamic imaging was performed secondary to same. 2. Diffuse fatty deposition within the liver. 3. Decompression of the right posterior intrahepatic bile ducts from the PTBD drain. There is, however, intrahepatic dilatation of the right anterior and left intrahepatic biliary tree. The common hepatic duct is not identified throughout its length. The distal common bile duct is nondilated. 4. Preferential hyperenhancement noted of the left lobe of the liver which is transient and equilibrates on more delayed phase of imaging. Findings most likely reflect the findings on prior CTA from [**2201-6-18**], where the right hepatic artery was not identified on that study. Brief Hospital Course: The patient was transferred from OSH and admitted to the General Surgical Service for evaluation. He was admitted in SICU intubated s/t aspiration pneumonia and started empirically on Unasyn. On [**2201-6-18**], the patient underwent abdominal CTA, which demonstrated post-cholecystectomy changes with drain and surrounding stranding without focal fluid collection to suggest biliary leak or hematoma; the right hepatic artery is not well seen and interruption/occlusion was suspected. On [**2201-6-19**] the patient underwent ERCP which was concerning for complete bile duct transection with surgical clip. At the same day, patient underwent PTBD drain placement into right posterior intrahepatic bile ducts for decompression. After procedure patient was extubated and kept in SICU for observation, the patient's LFTs were stable. On [**2201-6-21**] patient underwent MRCP, during which common hepatic duct was not identified throughout its length. The MRCP was limited secondary to non-breathhold sequence acquisition and claustrophobia. On [**2201-6-22**], patient was hemodynamically stable, his respiratory status improved and he was transferred on the floor tolerating clears IV fluids and antibiotics, with a foley catheter, and Dilaudid PCA for pain control. The patient was hemodynamically stable. Neuro: The patient received Dilaudid PCA on the floor with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient was found to have mild hypertension and was started on Metoprolol with good effect. The patient was discharged home on PO Lopressor 25 mg [**Hospital1 **] with instruction to follow up with PCP within next 1-2 weeks. Pulmonary: The patient was treated empirically with IV Unasyn for possible aspiration pneumonia. ON HD # 2, patient was extubated and his supplemental O2 was weaned off on HD # 7. The patient's pulmonary function was continued to improve; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: On admission, patient's JP drain output was positive for bile leak. PTBD catheter was placed on HD # 2 and has an average daily output around 500-600 cc. The patient's electrolytes were checked daily and repleted when necessary. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. The patient's LFTs were stable and he was discharged home on regular low fat diet. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Blood and urine cultures were negative. The patient was treated with Unasyn x 7 days for possible aspirational pneumonia. He was discharged home on PO Ciprofloxacin for empirical treatment of possible cholangitis. Endocrine: The patient doesn't have a history of diabetes, however his serum glucose was slightly elevated during hospitalization. The patient advised to follow up with his PCP for additional work up of possible borderline diabetes. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating 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. Medications on Admission: ASA81, vicodin Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 weeks. Disp:*42 Tablet(s)* Refills:*0* 5. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 2 weeks. Disp:*14 Tablet, ER Particles/Crystals(s)* Refills:*0* 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: 1. Transection of common hepatic duct with surgical clip [**Clip Number (Radiology) **]. Biliary leak s/p open cholecystectomy 3. Aspiration pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-28**] 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. . Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. . PTBD Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: Department: SURGICAL SPECIALTIES When: FRIDAY [**2201-7-10**] at 1:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 79168**], MD [**Telephone/Fax (1) 274**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Please follow up with Dr. [**Last Name (STitle) **] (PCP) in [**1-19**] weeks to discuss you blood pressure medication and possible borderline diabetes. Completed by:[**2201-6-24**]

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icd9cm

[ [ [] ] ]

[ "51.98", "51.10", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

10411, 10460

5789, 9528

395, 571

10655, 10655

3267, 5766

13514, 14025

2441, 2472

9594, 10388

10481, 10634

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2990, 3248

265, 357

599, 2253

2501, 2976

10670, 10782

2275, 2384

2400, 2425

74,910

180,097

41002

Discharge summary

report

Admission Date: [**2124-6-2**] Discharge Date: [**2124-6-9**] Date of Birth: [**2095-4-7**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2782**] Chief Complaint: GI bleed, syncope Major Surgical or Invasive Procedure: IR guided coil embolization of bleeding vessel [**2124-6-4**] History of Present Illness: 29 y/o M with recently diagnosed ulcerative colitis presenting with frequent bloody bowel movements and recurrent episodes of syncope. Over the past two days, he has had [**9-13**] frankly bloody bowel movements and three episodes of syncope. He was diagnosed 3 weeks ago with UC and has been followed by Dr. [**Last Name (STitle) 2161**]. Prior to dx, he was started on a 2 wk course of cipro and flagyl. He had been improving with mesalamine 3.6-4.8g/day. The bloody BMs were not preceded by worsening diarrhea or other symptoms suggestive of an UC exacerbation. Syncopal episodes occurred upon standing, were associated with several minutes LOC, and were not associated with trauma upon syncope. Other than dizziness, bloody BM and mild abdominal pain he denies any other associated symptoms such as Nausea/vomiting, fevers/chills, or myalgias/arthralgias. . In the ED, initial vs were: T:96.3 P:118 BP:102/67 R:18 O2 sat:100% RA. Patient was found to be orthostatic [Supine BP117/64 HR98; Seated BP90/64 HR123; Fainted while standing] and found to have a Hct of 19 (baseline of 39). Pt given 1L NS bolus, typed/crossmatched, and given 2 units PRBC. Past Medical History: -Ulcerative colitis, diagnosed in [**2124-5-3**] Social History: - Patient is a 4th year medical student at [**Last Name (un) 56920**] - Tobacco: None - Alcohol: Occassional (1-2 beers/wk) - Illicits: None Family History: Father with proctitis 26 years ago and HTN, Mother with 1 episode of diverticulitis. Physical Exam: Physical Exam: Vitals: T:96.3 BP:104/68 P:96 R:25 O2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, 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, mild TTP in RUQ, 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: [**2124-6-2**] 10:40AM BLOOD WBC-16.1* RBC-2.30*# Hgb-6.2*# Hct-19.9*# MCV-86 MCH-27.1 MCHC-31.3 RDW-14.4 Plt Ct-733* [**2124-6-3**] 12:13AM BLOOD Hct-17.6* [**2124-6-3**] 06:38AM BLOOD WBC-8.2 RBC-3.44*# Hgb-9.8*# Hct-28.1*# MCV-82 MCH-28.5 MCHC-34.8# RDW-14.7 Plt Ct-412 [**2124-6-3**] 11:14AM BLOOD Hct-30.0* [**2124-6-3**] 05:02PM BLOOD Hct-23.1* [**2124-6-3**] 10:45PM BLOOD WBC-9.4 RBC-3.56* Hgb-10.5* Hct-29.4*# MCV-83 MCH-29.5 MCHC-35.6* RDW-15.1 Plt Ct-400 [**2124-6-4**] 03:00AM BLOOD Hct-32.0* [**2124-6-4**] 06:25AM BLOOD WBC-8.6 RBC-3.69* Hgb-11.2* Hct-30.3* MCV-82 MCH-30.3 MCHC-36.9* RDW-14.5 Plt Ct-300 [**2124-6-4**] 11:07AM BLOOD Hct-30.1* [**2124-6-4**] 03:49PM BLOOD Hct-29.0* [**2124-6-4**] 07:32PM BLOOD Hct-29.0* [**2124-6-5**] 01:32AM BLOOD WBC-7.8 RBC-3.03* Hgb-9.2* Hct-25.5* MCV-84 MCH-30.4 MCHC-36.1* RDW-15.2 Plt Ct-264 [**2124-6-5**] 05:00AM BLOOD Hct-29.7* [**2124-6-5**] 01:06PM BLOOD Hct-27.8* [**2124-6-2**] 10:40AM BLOOD Neuts-49* Bands-17* Lymphs-26 Monos-6 Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2124-6-3**] 12:13AM BLOOD PT-15.1* PTT-47.7* INR(PT)-1.3* [**2124-6-4**] 06:25AM BLOOD PT-14.3* PTT-39.7* INR(PT)-1.2* [**2124-6-5**] 01:32AM BLOOD PT-17.1* PTT-55.6* INR(PT)-1.5* [**2124-6-5**] 01:06PM BLOOD Glucose-112* UreaN-4* Creat-0.7 Na-134 K-3.8 Cl-99 HCO3-24 AnGap-15 [**2124-6-3**] 06:38AM BLOOD ALT-13 AST-10 AlkPhos-47 TotBili-1.7* Brief Hospital Course: Mr. [**Known lastname **] is a 29 year old man with PMHx significant for new onset UC who presents with gross lower GI bleeding x 1 day. #GI Bleeding: Initial DDx included AVM, UC flare, C. diff and diverticular bleed. Doubt diverticular bleed due to young age. He was admitted to ICU and continued to have frank hematochezia, requiring 14units of PRBC and 4FFP. [**Doctor First Name **] and IR were both involved and discussed treatment options for the patient, who after CT Angio showed a solitary bleed in the cecum elected to try coil embolization. After embolization, his HCT stabilized and he no longer had frank BRBPR. He currently shows no signs or symptoms of ischemic bowel. He required one unit of PRBC several hours following the procedure, but no units in the 36 hours following the last transfusion. His hematocrit on [**6-6**] was 27.6. He underwent colonoscopy on [**6-7**] which showed diffuse active colitis and no mass or other cause for his GI bleed besides active UC in his R side colon. His ilium appeared normal. Colon biopsies and CMV cultures were taken during the colonoscopy. He was started on prednisone 40mg PO daily on [**6-7**] and continued on mesalamine. #UC: Newly diagnosed by tissue in [**2124-5-3**]. He underwent colonoscopy on [**6-7**] which showed diffuse active colitis and no mass or other cause for his GI bleed besides active UC in his R side colon. His ilium appeared normal. Colon biopsies and CMV cultures were taken during the colonoscopy showed: 1. Chronic, moderately active colitis. No viral inclusion identified on H&E-stained levels; immunostain results for CMV will be reported in an addendum. No granulomata or dysplasia identified. and CMV culture NEG He was started on prednisone 40mg PO daily on [**6-7**] and continued on mesalamine. Because he had fever on [**6-6**] and a WBC of 12.8, antibiotics (cipro/flagyl) were started on [**6-6**] and he remained afebrile from [**6-7**] onwards. He should complete a 7d course through [**6-13**]. His diet was advanced and he tolerated bland solids on [**6-7**] in the evening and his stool became more formed on [**2124-6-8**]. #Chest Xray finding: [**6-6**] PA and lateral: On the right lung base and in a location matching the right lower lobe anterior segment, there exists a well-demarcated, approximately 1 cm diameter, partially calcified density that is typical for a granuloma. No other pulmonary parenchymal abnormalities are identified, and the pleural spaces are free. A reference abdominal CT of [**4-18**] has been entered in our records. Review of this examination matches the finding of a granulomatous well-demarcated abnormality in the right lower lung fields. final results of blood cultures are pending but are negative as of [**6-9**] Medications on Admission: asacol delayed release 800mg TID Discharge Medications: 1. mesalamine 800 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*270 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): please contact your gi doctor [**First Name (Titles) **] [**Last Name (Titles) 15123**] the medication. Disp:*60 Tablet(s)* Refills:*0* 3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days. Disp:*12 Tablet(s)* Refills:*0* 4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:*8 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: ulcerative colitis lower GI bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You should call Dr. [**Last Name (STitle) 2161**] at ([**Telephone/Fax (1) 9478**] in next weeks to discuss your prednisone dose and schedule a follow up appointment. If you develop any new GI symptoms before that time including bloody stool, fever, increased diarrhea, or abdominal pain you should also call his office. Followup Instructions: You should call Dr. [**Last Name (STitle) 2161**] at ([**Telephone/Fax (1) 9478**] in two weeks to discuss your prednisone dose and schedule a follow up appointment. You may also hear from his office in that period

[ "783.21", "780.60", "780.2", "285.1", "556.6" ]

icd9cm

[ [ [] ] ]

[ "45.25", "39.79", "88.47" ]

icd9pcs

[ [ [] ] ]

7379, 7385

3882, 6662

319, 382

7463, 7463

2479, 3859

7961, 8180

1820, 1907

6745, 7356

7406, 7442

6688, 6722

7615, 7938

1937, 2460

262, 281

410, 1569

7478, 7591

1591, 1642

1658, 1804

5,689

199,384

5740

Discharge summary

report

Admission Date: [**2125-1-8**] Discharge Date: [**2125-1-8**] Date of Birth: [**2048-7-14**] Sex: F Service: SURGERY Allergies: Codeine Attending:[**First Name3 (LF) 695**] Chief Complaint: abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: [**2125-1-8**] ex lap for mesenteric ischemia History of Present Illness: 76 y.o. female with h/o NIDDM, CRF on HD,s/p failed kidney transplant, HTN, AFIB and pacemaker, gastric ulcers with GI bleeds s/p endoscopy [**2124-12-29**] with 24 hour complaint of abdominal pain associated with nausea, vomiting and diarrhea. She presented to [**Hospital1 18**] [**Location (un) 620**] and was transferred to [**Hospital1 18**] with question of abdominal ischemia. WBC 19.6 and stool guaiac positive. She had experienced one week of malaise, nausea and vomiting. Unable to eat. Last HD yesterday. Stool was guaiac positive. Had been off coumadin since GI bleed last year. IV levaquin and flagyl were started and she was sent for abdominal CT. CTA showed occlusion of the mid SMA branch with vessel contrast visible distal to this. Questionable colonic thickening. Most of the small bolwel did enhance with the IV contrast. No pneumatosis or portal venous gas noted. Past Medical History: PMH: - ESRD on HD qTues, Thurs, Satuday. Baseline Cr 3.5-5.0. s/p failed transplant [**10-9**]. Left AV fistula. Patient does not make urine. - UGIB [**2124-9-8**], received 3 U PRBCs, EGD showed ulcers in the antrum, above pylorus, at 12 o'clock and 2 o'clock. 2nd ulcer had visible vessel, nonbleeding. (thermal therapy). - CAD s/p NSTEMI treated at [**Hospital1 112**] [**12-10**], ?NSTEMI/demand mediated ischemia with recent GIB. Patient has a baseline Troponin T of 0.08-0.16 ([**Hospital1 **] [**Location (un) 620**] records). - HTN - Hyperlipidemia - Atrial fibrillation currently off Coumadin [**1-6**] UGIB, s/p pacemaker placement - CHF: per cards note Echo [**4-10**]: s/p MVR, Mod-Severe TR, Atrial dilatation, LVEF 45%, followed mostly at [**Hospital1 112**] (last TTE here [**2120**]); report of eval at [**Hospital **] hospital [**2123-5-11**]: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] 55-60% with LVH and new wall motion abnormalities, severe pHTN (>65mmHg). - pulmonary hypertension as above - DM2, last HgA1c 6.7% on [**10-9**]. - Peptic ulcer disease, recently finished triple abx therapy (Clarithromycin 500 mg daily, Flagyl 500 mg PO bid, Protonix 40 mg [**Hospital1 **]) for H. pylori - Multiple pelvic fractures: CT pelvis ([**Hospital1 **] [**Location (un) 620**]) [**8-12**] showed MULTIPLE PELVIC FRACTURES INVOLVING SUPERIOR AND INFERIOR PUBIC RAMI BILATERALLY AS WELL AS THE RIGHT SIDE OF THE SACRUM. THE PATIENT IS S/P ORIF OF LEFT HIP FRACTURE. THIS IS WELL HEALED AND NO ACUTE HIP FRACTURES ARE SEEN. - GERD - Cirrhosis - Ascities - Inguinal Hernia - Lower Extrem Edema - Valvular Disease - stage II/III sacral decubitis ulcer - R sided sciatic pain Social History: Prior to recent admit with multiple pelvic fractures had been living at home, independent of ADL's. Since then she has been living in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (rehab). No tobacco, occ. alcohol, no illicit drug use. Supportive son. Family History: Family Hx: NC Physical Exam: 98.4 88 180/75 18 100% NRB moderated distress, A&O x4, hard of hearing Cor irregular, no murmurs lungs CTA Abd-diffusely tender, voluntary guarding, no rebound, no HSM rectal-guaiac +, no BRBPR ext femoral pulses 2+ bilat, distal pulses nonpalp, 1+edema Pertinent Results: [**2125-1-7**] 05:35PM NEUTS-84* BANDS-0 LYMPHS-3* MONOS-11 EOS-0 BASOS-0 ATYPS-2* METAS-0 MYELOS-0 NUC RBCS-2* [**2125-1-7**] 05:35PM WBC-18.4*# RBC-4.61 HGB-12.8 HCT-40.9 MCV-89 MCH-27.7 MCHC-31.2 RDW-23.7* [**2125-1-7**] 05:35PM DIGOXIN-1.9 [**2125-1-7**] 05:35PM CK-MB-6 cTropnT-0.19* [**2125-1-7**] 05:35PM ALT(SGPT)-22 AST(SGOT)-39 CK(CPK)-42 ALK PHOS-176* TOT BILI-0.7 [**2125-1-7**] 05:35PM LIPASE-13 [**2125-1-7**] 05:35PM GLUCOSE-105 UREA N-30* CREAT-3.7*# SODIUM-145 POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-34* ANION GAP-18 [**2125-1-7**] 06:08PM LACTATE-2.9* [**2125-1-7**] 07:45PM PT-16.1* PTT-29.2 INR(PT)-1.4* [**2125-1-8**] 12:34AM LACTATE-4.5* Brief Hospital Course: In the ED during CT she experienced an episode of unresponsiveness x 20 seconds and afib. A non-rebreather was applied. EKG showed a wide QRS with ST elevation. IV fluid was given. Dilaudid and zofran were given for persistent complaints of abdominal pain. She was transferred to the SICU. A Heparin drip was started for the distal SMA thrombus. A cardiac echo was performed to r/o intracardiac thrombus. Cardiac echo showed moderate symmetric LVH with a mild mid-cavitary gradient (16mm Hg). Hyperdynamic left ventricular systolic function. Diastolic dysfunction. Severe pulmonary artery systolic hypertension with a dilated, hypokinetic right ventricle. Left pleural effusion. A CVL was inserted to assess CVP. Serial abominal exams were performed with serial lactic acid levels monitored. Lactate increased from 2.9 to 4.5 IV antibiotics (Cipro and Levo) continued. Nephrology was consulted and planned to do CVVHD. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] examined her and reviewed CT scan. She developed increasing abdominal pain and wbc count. Given these findings, she was taken to OR where and ex lap was performed for ischemic bowel. Please see operative report for complete details. Per operative report extensive gangrenous changes of the small bowel beginning in proximal to midjejunum and extending all the way to the right colon were found. No doppler or palpable signals within the mesenteric arcade of the gangrenous sections were identified. Vascular surgery was consulted, but did not feel that further intervention was warrented. After discussion with the patient's proxy/son, the decision was made to make her CMO given the poor prognosis of 75-80% of the small [**Last Name (un) **] infarction. She was transferred back to the SICU. She was maintained on a morphine drip for comfort while her son and family were at the bedside. She was extubated and expired shortly after extubation. Medications on Admission: ASA, prilosec 20'', oxycodone, NPH insulin (10 U Qam, 3 U Qpm), lopressor 50'', simvastatin 40', Vit C, colace 100'', senna, celexa 20', digoxin 125 QOD, folate Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: sma thrombus with ischemic small bowel Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2125-5-1**]

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icd9cm

[ [ [] ] ]

[ "54.11", "38.93" ]

icd9pcs

[ [ [] ] ]

6526, 6535

4341, 6285

297, 344

6617, 6626

3640, 4318

6679, 6840

3332, 3347

6497, 6503

6556, 6596

6311, 6474

6650, 6656

3362, 3621

225, 259

372, 1259

1281, 3025

3042, 3316

48,153

170,129

35175

Discharge summary

report

Admission Date: [**2166-11-13**] Discharge Date: [**2166-11-20**] Service: MEDICINE Allergies: Coumadin / Aspirin / Nsaids Attending:[**First Name3 (LF) 800**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Intubation [**2166-11-13**] Extubation [**2166-11-15**] History of Present Illness: Patient is an 86 year old male with past medical history of atrial fibrillation, not on anticoagulation, coronary artery disease, COPD, chronic renal insufficiency, and recent resection of transitional cell carcinoma who was found to be less responsive today at his nursing home. Per report from the emergency room, at baseline, patient has been confused at times confused but conversant. Today patient was only responsive to some commands and noxious stimuli. . Upon arrival to the [**Hospital1 18**] emergency room, his presenting vital signs were 98.2, HR 76, BP 117/71, RR 18, and 100% on NRB. Per discussion with emergency room staff, his mental status was so poor there was considerable concern for airway protection, so he was intubated. An ABG was completed after intubation on 100% FiO2, which was 7.34 pCO2 54 pO2 440 HCO 30. A chest x-ray was completed, which was concerning for possible RLL infiltrate. He received vancomycin and zosyn. He also received a total of 2 liters of normal saline. A head CT was completed which was negative for any acute pathology. A CT of the abdomen and pelvis was also completed as noted below. Blood and urine cultures were obtained. Per ED notes, patient had transient hypotension after intubation, resolved with IVFs. Bedside echocardiogram done without good visualization, but no pericardial fluid visualized. . Upon arrival to the floor, patient was noted to be moving extremities in response to tactile stimuli and calling of name. . History is obtained from ED, chart review, discussion with son, and nursing home attending physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 24202**], as patient is unable to provide any history. Past Medical History: - Bladder cancer with metastatasis, recent cystoscopy. - Chronic renal disease - Chronic obstructive pulmonary disease - History of asbestosis with intermittent oxygen use - Atrial fibrillation not on anticoagulation due to GI bleeding - Congestive heart failure with systolic ejection fraction of 50-55% in [**9-/2166**] - Hypertension - Hyperlipidemia - GERD - Prostatitis - Anemia, on Procrit Social History: Patient has been [**Street Address(1) 61496**] Place for the last month, being transitioned there with support from his son. [**Name (NI) 3003**] to that, according to his son, he had been living at home. By report, he does not smoke or drink alcohol. He is a retired [**Location (un) 86**] police officer. Family History: Per chart notes, remarkable for coronary artery disease. Physical Exam: On Admission: Temperature 96.7, Heart rate 73, Blood pressure 129/69, Respiratory rate 16, 94% on FiO2 40% General: Intubated, sedated, moving arms and legs spontaneously at times. HEENT: NC/AT. Slightly dry mucous membranes. PERRL. No scleral icterus or conjunctival pallor. Neck: Supple, difficult to assess JVP in setting of ventilator, but appears flat. CV: Irregularly irregular, distant heart sounds, no clear m/g/r Lungs: Transmitted upper airway noises, occasional rhonchi, no wheezes Abdomen: Soft, ND, +BS, no HSM appreciated Extr: Warm, excoriations over both lower extremities. Trace edema of feet. No clubbing or cyanosis. Neuro: Moves all extremities spontaneously. PERRL. Moves when name is called, withdrawals all extremities to noxious stimuli. Skin: Excoriations over lower extremities as noted, over left shoulder. Pertinent Results: [**2166-11-13**] 11:55PM TYPE-ART PO2-103 PCO2-47* PH-7.38 TOTAL CO2-29 BASE XS-1 [**2166-11-13**] 09:34PM TYPE-ART PO2-109* PCO2-44 PH-7.41 TOTAL CO2-29 BASE XS-2 [**2166-11-13**] 09:34PM GLUCOSE-93 LACTATE-0.3* NA+-142 K+-3.8 CL--108 [**2166-11-13**] 09:34PM HGB-10.3* calcHCT-31 O2 SAT-99 CARBOXYHB-1 MET HGB-0 [**2166-11-13**] 09:34PM freeCa-1.17 [**2166-11-13**] 07:50PM CK(CPK)-35* [**2166-11-13**] 07:50PM CK-MB-NotDone cTropnT-0.08* proBNP-6213* [**2166-11-13**] 07:50PM DIGOXIN-<0.2* [**2166-11-13**] 07:50PM DIGOXIN-<0.2* [**2166-11-13**] 07:50PM URINE HOURS-RANDOM [**2166-11-13**] 07:50PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2166-11-13**] 03:15PM GLUCOSE-111* UREA N-35* CREAT-1.6* SODIUM-145 POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-30 ANION GAP-11 [**2166-11-13**] 03:15PM ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-100 TOT BILI-0.7 [**2166-11-13**] 03:15PM TOT PROT-5.1* CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.0 [**2166-11-13**] 03:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2166-11-13**] 03:15PM TYPE-ART PO2-440* PCO2-54* PH-7.34* TOTAL CO2-30 BASE XS-2 [**2166-11-13**] 03:08PM GLUCOSE-107* NA+-143 K+-4.7 CL--104 TCO2-28 [**2166-11-13**] 02:33PM LACTATE-1.5 [**2166-11-13**] 02:25PM GLUCOSE-100 UREA N-34* CREAT-1.7* SODIUM-145 POTASSIUM-5.1 CHLORIDE-109* TOTAL CO2-29 ANION GAP-12 [**2166-11-13**] 02:25PM estGFR-Using this [**2166-11-13**] 02:25PM CK(CPK)-69 [**2166-11-13**] 02:25PM cTropnT-0.10* [**2166-11-13**] 02:25PM CK-MB-NotDone [**2166-11-13**] 02:25PM WBC-4.7 RBC-3.43* HGB-10.7* HCT-32.2* MCV-94 MCH-31.1 MCHC-33.2 RDW-15.4 [**2166-11-13**] 02:25PM NEUTS-64.5 LYMPHS-23.0 MONOS-4.8 EOS-7.2* BASOS-0.5 [**2166-11-13**] 02:25PM PLT COUNT-171 [**2166-11-13**] 02:25PM PT-14.0* PTT-24.0 INR(PT)-1.2* Brief Hospital Course: Patient is an 86 year old male with past medical history of coronary artery disease status post bypass, atrial fibrillation, chronic renal insufficiency, COPD, and bladder cancer who presents from a nursing home with altered mental status, intubated in the ED for airway protection. #) Transitional cell carcinoma/ hematuria: Patient had recent surgery for removal of transitional cell carcinoma. Per discussion with son and [**Name2 (NI) 80283**] at the nursing home, patient had had hematuria requiring re-admission. At time of admission, patient was making good urine, however was noted to have dark maroon colored urine with significant hematuria. Urology was consulted the morning after admission, and in light of his recent carcinoma resection, continuous bladder irrigation was recommended and initiated. Pt continued to have CBI even while on the floor. This was continued until his urine was no longer bloody grossly on appearance, and was then discontinued upon urology recommendations. His foley was also discontinued, and the patient continued to have dark red urine. Urology said this is expected with foley removal from dislodging clots. Pt was watched overnight. The next morning the patient still had hematuria, and Urology saw the patient. They were not concerned and thought he should continue to improve since the clots have become very infrequent. The foley was replaced so that these final clots can be irrigatated and the patient is expected to get better over the next week. It is expected that the patient will continue to have hematuria at time of discharge. - foley should be kept in for at least 3 days, if the patients urine returns to completely yellow it can be taken out at that time, but the foley may be kept in place if pt continues to have hematuria. - please irrigate foley any time patient has blood clots or urinary obstruction in the foley - only if the clots become so severe that the urinary retention does not improve from flushing the foley, or the urine becomes very thick like tomatoe paste, only then should he return to the hospital, and to call the patient's primary Urologist #) Altered mental status: It was unclear what prompted the patient's acute mental status change. Based on his initial arterial blood gas post-intubation, it was supsected that there was some degree of carbon dioxide retention secondary to his COPD, which may have contributed in the setting of an infection. Potential sources of infection included pulmonary given that his CT appeared possibly consistent with an aspiration event, urinary given his recent instrumentation, or prostatitis. Other possibilities considered included arrhythmias, seizure, or stroke given that patient has anticoagulation but is not on anticoagulation. There was no focal neurologic deficits to suggest a stroke or seizure activity as patient would follow commands. A head CT was negative for an acute process. During his ICU stay, an MRI was obtained that did not reveal any evidence for acute stroke, metastases, or focal findings. An EEG was not consistent with seizure activity. His electrolytes were within normal limits. A toxicology screen was negative, and per his nursing home physician and records, he had not been on any narcotics or other new medications. He was ruled out for a myocardial infarction. His telemetry initially had some evidence of ectopy, however there were no arrhythmias that would account for a change in mental status. A lumbar puncture was attempted, however was unsuccessful, to evaluate for abnormal cytology. Patient's mental status slowly improved, and he was oriented to month, place, and year. He remained sleepy, but easily aroused and would follow commands appropriately. Once pt was on the floor pt remained A&Ox3. He had no episodes of confusion. #) Respiratory failure/ Presumed Aspiration pneumonia: Patient was intubated initially for airway protection given concerns about his mental status. Due to the fact that his mental status was slow to improve, he remained extubated until [**2166-11-15**], at which time he was successfully extubated. Per report from his son and nursing home, he is on oxygen at home. His x-ray on [**2166-11-16**] was consistent with fluid overloaded state (he had previously appeared dry and had received some intravenous fluids), so diuresis was initiated. He was maintained on his home advair, along with albuterol and atrovent nebulizer treatments. Based on his chest x-ray and CT scan, patient was treated empirically for hospital-acquired pneumonia given his recent admission to [**Hospital3 **], with vancomcyin, zosyn, and azithromycin. Pt completed 6 days of vanco/zosyn, and 2 days of azithromycin before it was switched to levoquin/flagyl. By time of discharge pt did not complain of SOB even though he continued to have rales on exam R>L. Pt has only 2 more days of Levaquin/Flagyl remaining. . #) Congestive heart failure: Likely [**3-15**] being overloaded. Per report, patient has a normal ejection fraction. [**Month (only) 116**] be the case that the patient also has some component of diastolic dysfunction. Given the bibasilar crackles, and incr JVP 10cm. Pt's lasix was increased to 40mg IV BID. Once pt was adequetely diuresed he was lowered to 20mg PO BID and sent home on that regimen. Pt was restarted on Metop/Diovan once pt was adequetely diuresed. #) COPD exacerbation: Once pt was on the floor he continued to have expiratory wheezes. He was managed with DuoNebs, and said his SOB completely resolved. #) Rhythm: Patient appears to be in accelerated idioventricular rhythm on monitoring and EKG, with some PVCs. On EKG, rhythm appears regular, but alternatively patient could be in slower atrial fibrillation. Old EKGs demonstrate this is not a new finding. He has been ruled out for MI. #) CAD: Continue home statin. Holding BB and diovan in setting of borderline BP and diovan (given unknown baseline creatinine) and borderline BP. Not on ASA at home. Ruled out for MI. #) Renal insufficiency: Creatinine was 1.5 over last week per OSH records. Unclear what baseline is, could be in part related to history of renal metastases that son provides. Today is improved to 1.3. Pt was eventually overdiuresed and Cr increased to 1.7, but lasix was decreased at that point. #) Anemia: Slightly down today. Will hold off on transfusion as he does not have significant hematuria, but transfuse if <25 or symptoms. Given B12 was borderline low, will check MMA. Continuing iron supplementation. Medications on Admission: - Protonix 40 mg [**Hospital1 **] - Diovan 40 mg - Sodium Bicarbonate 650 mg TID - Lasix 20 mg PO daily - Lactobacillus 1 tab PO BID - Allopurinol 200 mg daily - Metoprolol 12.5 mg daily - Iron Sulfate 325 mg daily - Zocor 40 mg daily - Colace 100 mg [**Hospital1 **] - Advair Diskus 250/50 one puff [**Hospital1 **] - Albuterol nebulizer treatment Q2H PRN shortness of breath - Duoneb 3mL QID via nebulizer - Procrit 10,000 units every other week - Tylenol 650 mg Q6H PRN - Multivitamin daily - Cepacol throat lozenges PRN - Mucinex 600 mg two tabs [**Hospital1 **] Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:*1 Tablet(s)* Refills:*0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 1 days. Disp:*4 Tablet(s)* Refills:*0* 3. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 7. Lactobacillus Acidophilus Tablet Sig: One (1) Tablet PO twice a day. 8. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 14. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation four times a day. 15. Procrit 10,000 unit/mL Solution Sig: One (1) Injection every other week. 16. Mucinex 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO twice a day as needed for cough. 17. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 18. Cepacol Sore Throat 3 mg Lozenge Sig: [**2-12**] Mucous membrane every 6-8 hours as needed for sore throat. Discharge Disposition: Extended Care Facility: [**Hospital6 4657**] - [**Location 1268**] Discharge Diagnosis: Primary diagnosis: - Altered mental status - hematuria Secondary Diagnosis: - probable aspiration pneumonia - Acute on chronic heart failure - transitional cell carcinoma - COPD Discharge Condition: good, vitals stable, breathing well, still has rales [**3-15**] resolving pneumonia R > L, and continues to have hematuria Discharge Instructions: You had confusion that was thought to be from respiratory failure and an infection. You are being treated for pneumonia, currently which is resolving well. You were also fluid overloaded after the ICU which was diuresed off. Your urine is still bloody from the the bladder cancer but it is improving and eventually you will be able to get the foley removed. Medications changes: - you lasix was increased to 20mg twice per day - potassium 10 mEq was added once per day - your bicarbonate was discontinued since you no longer needed it - you albuterol neb and was discontinued so it was redundant since you are already getting DuoNebs (which includes albuterol in it) If your breathing significantly worsens of you have a fever > 101 please return to the ED immediately. Followup Instructions: Test for consideration post-discharge: Methylmalonic Acid Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 24202**] [**2169-12-1**]:15am [**Street Address(1) **] office Please follow up with your Urologist, Dr. [**First Name (STitle) **] on [**11-27**] @ 1:45PM at the [**Location (un) 5087**] Office (near [**Hospital3 **]) Address: [**Street Address(2) 80284**], Bldg #A10. [**Telephone/Fax (1) 64585**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2166-11-20**]

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Discharge summary

report

Admission Date: [**2196-2-24**] Discharge Date: [**2196-3-2**] Date of Birth: [**2112-3-5**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 2745**] Chief Complaint: Fevers Major Surgical or Invasive Procedure: NGT placement History of Present Illness: Mr. [**Known lastname 97639**] is an 83M with a PMH s/f advanced dementia, and recurrent aspirations s/p PEG placement in [**2-/2195**] who presents from the [**Hospital3 **] after a suspected aspiration event. He was in his USOH until this morning at 9AM, when he had an episode of yellow vomitus. His exam at that time was notable for a firm and distended abdomen, for which a trial of laxatives were given, with little relief. As day progressed, the patient began to develop respiratory distress, and developed a fever. He was give Ceftriaxone 1 Gm IM x1, was suctioned and given neb treatments. As his respiratory status continued to decline, he was brought to the ED. In the ED, presenting vital signs were: T=101.4 rectally, HR=106, BP=95/73, RR=24, O2SAT=95% on 4L NRB. Physical exam was notable for rhonchorous lung sounds, and a distended abdomen with a reducible hernia. Laboratory data was significant for a leukocytosis to 44,000 with 23% bands, ARF (creatinine increased to 1.5 from baseline of 1), a positive UA, and a lactate of 5.0. A CXR revealed new airspace disease in the left lower lobe. A CT of the abdomen and pelvis was obtained to evaluate for an SBO, which showed a LLL consolidation, SBO, and cystitis. Surgical consultation was obtained, and it was felt that there was no indication for surgery at this time. The patient recieved a total of 3L NS, 1g vancomycin, zosyn, and BP increased to 110s systolic. Past Medical History: Dementia Recurrent aspiration s/p G tube [**2-28**] MSSA bactermia Seizure disorder Depression Osteoarthritis IBS Vitamin B12 deficiency chronic hypernatremia s/p ORIF [**January 2192**] Social History: Lives full time at [**Hospital3 2558**]. Brother lives on [**Hospital3 **] and is POA. Family History: Non-contributory Physical Exam: VITAL SIGNS: T=99.4... BP=118/94... HR=78... O2=96% 5L PHYSICAL EXAM GENERAL: Eldery man, non-toxic appearing, NAD. Contracted, responds to verbal stimuli, but does not interact. HEENT: Normocephalic, atraumatic. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP=7cm LUNGS: Patient has audible secretions, with a weak cough. Chest expands symmetrically. Inspiratory rhonchi, transmitted from the upper airway, expiratory wheezes. ABDOMEN: Distended, hypoactive bowel sounds, patient signals pain when deeply palpated in the RLQ. Tympanitic. No HSM. EXTREMITIES: Contracted, warm, well-perfused with 2+ bilateral radial and DP pulses. No C/c/e SKIN: Sacral decubitus ulcer. Pertinent Results: [**2196-2-27**] 04:39AM BLOOD WBC-16.1* RBC-3.18* Hgb-10.1* Hct-31.0* MCV-98 MCH-31.8 MCHC-32.6 RDW-14.7 Plt Ct-231 [**2196-2-24**] 07:00PM BLOOD WBC-31.4*# RBC-4.40* Hgb-14.5 Hct-42.2 MCV-96 MCH-32.9* MCHC-34.4 RDW-14.9 Plt Ct-354 [**2196-2-25**] 04:00AM BLOOD Neuts-82* Bands-5 Lymphs-9* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2196-2-24**] 07:00PM BLOOD Neuts-65 Bands-23* Lymphs-2* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-8* Myelos-0 [**2196-2-27**] 04:39AM BLOOD Glucose-92 UreaN-19 Creat-0.7 Na-147* K-3.2* Cl-113* HCO3-20* AnGap-17 [**2196-2-24**] 07:00PM BLOOD Glucose-213* UreaN-40* Creat-1.5* Na-140 K-4.7 Cl-98 HCO3-24 AnGap-23* [**2196-2-24**] 07:29PM BLOOD Glucose-198* Lactate-5.0* Na-145 K-5.6* Cl-91* calHCO3-22 [**2196-2-26**] 01:10AM BLOOD Lactate-1.7 CXR [**2196-2-26**]: In comparison with the study of [**2-25**], there are again low lung volumes. The opacifications in the left upper and lower lung zones are slightly less discrete than on the previous study. This would be consistent with some clearing of aspiration. Another possibility would be gravitational edema if the patient has been lying on his left side. The nasogastric tube extends to the upper portion of the stomach, where it is cut off by the bottom of the film. AB CT [**2196-2-24**] 1. Small-bowel obstruction which can be traced to the ileum with a short segment of thickened small bowel likely accounting for the obstruction. The cause of thickening along the short segment of small bowel is unclear and diagnostic considerations include infectious, inflammatory, or ischemic processes. Please note, neoplastic considerations cannot be entirely excluded. 2. Periumbilical hernia containing non-obstructed loop of sigmoid colon. 3. Severe urothelial enhancement and perivesical stranding compatible with cystitis. Please note, there is no clear evidence for pyelonephritis on the current study though ascending infection cannot be excluded. 4. Diverticulosis without evidence of diverticulitis. 5. Stable right adrenal adenoma. 6. Left lower lobe consolidation, may represent pneumonia/aspiration versus atelectasis. 7. Normal appendix. 8. Renal hypodensities likely representing cysts, though incompletely assessed. One large left renal cyst has collapsed since prior exam from [**2193-10-18**]. 9. Adequate position of GJ tube. [**2196-2-25**] 12:20 pm SPUTUM Source: Induced. **FINAL REPORT [**2196-2-29**]** GRAM STAIN (Final [**2196-2-25**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2196-2-29**]): 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. GRAM NEGATIVE ROD #1. SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. GRAM NEGATIVE ROD #3. SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | PSEUDOMONAS AERUGINOSA | | AMIKACIN-------------- 16 S 16 S CEFEPIME-------------- 8 S 8 S CEFTAZIDIME----------- 4 S 2 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R =>16 R MEROPENEM------------- 0.5 S 4 S PIPERACILLIN---------- <=4 S <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ =>16 R =>16 R [**2196-3-1**] pCXR: Preliminary Report !! WET READ !! Lung volumes remain low. Slight increased density over left lung could be due to layering pleural effusion. patchy opacities in left lung and dense left retrocardiac opacity persist. New right PICC terminates in mid-SVC. [**2196-3-1**] 10:38 pm STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2196-3-2**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2196-3-2**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Brief Hospital Course: Mr. [**Known lastname 97639**] is an 83M with a PMH s/f advanced dementia, and recurrent aspirations, who presents with fevers in the setting of a presumed aspiration event, SBO, and a UTI. #. Sepsis: On admission the patient met SIRS criteria with fevers, leukocytosis, bandemia, tachycardia, and tachypnea. He also had signs of hypoperfusion with elevated lactate and transient hypotension. After 4L of NS the pt's blood pressure was stable. The pt's suspected sources of infection were a possible aspiration/health-care associated pneumonia, UTI, or the thickened bowel seen on CT abdomen. The pt was initially treated with vancomycin and zosyn for coverage of health-care associated PNA, but the pt developed a morbilloform rash that, on examination of prior OMR records, the pt has a history of with vancomycin. Vancomycin was discontinued and the pt's rash resolved. Zosyn was continued for a plan to treat for 14 days for pseudomonal HAP and ileitis. In setting of broad antibiotic coverage, pt developed diffuse abdominal pain and increased green stool output concerning for C Diff (although WBC continued to trend down). Stool cultures were sent and [**3-1**] stool was negative for c.diff. Empiric flagyl which had been started was discontinued. Also of note, pt had one set of blood cultures with 1 out of 4 bottles positive for Gram positive cocci in clusters. Given pt's clinical improvement and negative MRSA screen, pt was not started on additional coverage, and repeat cultures were sent to confirm presumed contamination. Pt continued to clinically improve, requiring less frequent suctioning. However, due to persistent low grade fever and WBC stabilizing in low teens, pt had repeat CXR to eval for abscess, empyema, etc. CXR was notable for diffuse left sided fluffy infiltrate. -Given that the patient had pseudomonal pneumonia, he will complete a 14 day total course of zosyn (the 2 pseudomonal colonies were sensitive to this abx). #. SBO: Pt was able to communicate some abdominal pain, and CT abdomen showed SBO with transition point at ilium near a segment of bowel wall thickening, which could be neoplastic, infectious, ischemic, or inflammatory in nature. Pt was evaluated by surgery and felt to not be a surgical candidate. The pt improved with NGT decompression, and on [**2196-2-26**] NGT was discontinued and the pt continued to do well and denied abdominal pain. Pt's tube feeds were then slowly restarted, as well as some free water flushes for worsening hypernatremia (peak 152, without mental status changes from baseline). He was to receive 100ml free water per feeding tube every 2 hours, to correct the deficit over 3 days. Once corrected, his free water flushes were decreased to 100ml q6hrs. #. Seizure disorder: continue home regimen of phenobarb #. Dementia: stable at baseline #. Chronic aspiration: The pt was continued on his home scopolamine and nebulizers. The pt required frequent suctioning for secretions. Code Status: The patient's son and HCP [**Name (NI) **] [**Name (NI) 97639**] was contact[**Name (NI) **] by Dr. [**First Name4 (NamePattern1) 8771**] [**Last Name (NamePattern1) 97646**] and a discussion regarding the patient's code status was held. The patient's son indicated that the patient would want to be DNR/DNI and he asked that the patient's code status be made DNR/DNI. Medications on Admission: Acetaminophen 325 -650 mg PO Q6H as needed. MOM Bisacodyl suppository prn Home O2, at 2L to maintain sats >90% Famotidine 20 mg PO Q12H Scopolamine 1.5 mg patch q72H Phenobarbital 20mg/5mL elixir 60 mg PO BID via G tube Docusate Sodium 50 mg/5 mL Liquid 100 mg PO BID Ipratropium Bromide 0.02 % Nebulizer Q6H. Albuterol nebs q6H Discharge Medications: 1. Phenobarbital 30 mg Tablet [**Last Name (NamePattern1) **]: Two (2) Tablet PO BID (2 times a day). 2. Ipratropium Bromide 0.02 % Solution [**Last Name (NamePattern1) **]: One (1) neb Inhalation Q6H (every 6 hours). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (NamePattern1) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed. 4. Scopolamine Base 1.5 mg Patch 72 hr [**Last Name (NamePattern1) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: 325-650 mg PO Q6H (every 6 hours) as needed. 7. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) injection Injection TID (3 times a day). 8. Piperacillin-Tazobactam 2.25 gram Recon Soln [**Last Name (STitle) **]: 2.25 grams Intravenous Q6H (every 6 hours) for 8 days: Discontionue on [**3-10**]. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Pseudomonal Pneumonia Sepsis Acute Respiratory Distress Small Bowel Obstruction Hypernatremia Purulent penile discharge Right heel Ulcer Diarrhea Dementia Discharge Condition: Vital Signs Stable Discharge Instructions: You presented with sepsis and pseudomonal pneumonia. You will be treated with 14 days of IV abx. Followup Instructions: Patient to f/u with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 608**].

[ "995.92", "599.0", "507.0", "560.9", "707.22", "294.8", "038.9", "482.1", "276.0", "707.14", "518.81", "V44.1", "345.90", "707.03", "584.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

12015, 12085

7220, 10570

276, 291

12283, 12303

2938, 7197

12449, 12581

2087, 2106

10950, 11992

12106, 12262

10596, 10927

12327, 12426

2121, 2919

230, 238

319, 1755

1777, 1966

1982, 2071

32,598

135,125

7931

Discharge summary

report

Admission Date: [**2110-11-17**] Discharge Date: [**2110-11-24**] Date of Birth: [**2044-1-4**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Vancomycin Attending:[**First Name3 (LF) 2969**] Chief Complaint: Tumor of Right 10th rib Major Surgical or Invasive Procedure: 1. Bronchoscopy. 2. Right thoracotomy with wide-excision of right chest wall lesion and [**Doctor Last Name 4726**]-Tex reconstruction. History of Present Illness: Pt is a 66 y/o male with h/o severe insulin-dependent diabetes, vascular disease and autonomic dysfunction along with chronic renal insufficiency and a remote history of bladder cancer status post cystectomy and ileal loop, who presents with an expansile lesion in the right tenth rib. This has been present for at least 4 years but is really expanding on serial exams. The tumor appears, at this point, confined to the marrow space. Review with our musculoskeletal experts felt that percutaneous biopsy was unlikely to yield sufficient tissue for a discrete diagnosis. Based on this, I recommended wide-excision, as low-grade chondrosarcoma remained within the differential diagnosis. The patient agreed to proceed. Past Medical History: IDDM CRI autonomic neuropathy peripheral neuropathy hypercholesterolemia L carotid stenosis (70% per pt) bladder CA with ostomy Social History: Pt denies use of tobacco, ethanol, recreational drugs Family History: Non-contributary Physical Exam: Vitals: 99.6 98.4 77 118/50 18 95%RA Gen: NAD, Alert and Oriented x 3 CV: RRR no m/r/g Pulm: CTA B, no chest tube present Abdomen: Soft, NT, ND, (+) BS Wound: C/D/I Ext: Warm, well perfused, no C/C/E Pertinent Results: [**2110-11-17**] 10:56PM CORTISOL-26.6* [**2110-11-17**] 05:59PM TYPE-ART TEMP-35.4 PO2-213* PCO2-40 PH-7.35 TOTAL CO2-23 BASE XS--3 INTUBATED-INTUBATED [**2110-11-17**] 05:18PM GLUCOSE-151* UREA N-29* CREAT-1.1 SODIUM-138 POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-23 ANION GAP-12 [**2110-11-17**] 05:18PM CK-MB-NotDone cTropnT-<0.01 [**2110-11-17**] 05:18PM CK(CPK)-70 [**2110-11-17**] 05:18PM CALCIUM-8.4 PHOSPHATE-3.0 MAGNESIUM-2.1 [**2110-11-17**] 05:18PM WBC-7.6 RBC-3.73* HGB-11.9* HCT-34.4* MCV-92 MCH-32.0 MCHC-34.7 RDW-14.0 [**2110-11-17**] 04:10PM HGB-11.7* calcHCT-35 Brief Hospital Course: Mr. [**Known lastname 28483**] is a 66-year-old gentleman, with severe insulin-dependent diabetes, vascular disease and autonomic dysfunction along with chronic renal insufficiency and a remote history of bladder cancer status post cystectomy and ileal loop, who presented with an expansile lesion in the right tenth rib. The lesion has been present for at least 4 years but is really expanding on serial exams. The tumor appeared to be confined to the marrow space. On [**2110-11-17**] the patient was admited to [**Hospital1 18**] for elective resection of his right 10th rib tumor. Follwing induction of anesthesia in the L lateral decubitus position, the patient became profoundly hypotensive with a wide-complex ventricular rhythn and required CPR, IV fluids, and pressors to regain adequate MAP and sinus rhythm in the OR. The patient was transferred to the TSICU following resuscitation; EP and Cardiology were consulted to investigate his pacemaker and CV function (St. [**Male First Name (un) 923**] Integrity SFx). A TEE immediately post-episode showed incomplete LV/RV filling with resolution following IVF resuscitation. His cardiac enzymes were negative x 3 and he was On [**2110-11-18**] [**Last Name (un) **] was consulted and recommendations were made to continue his current insulin pump regimen with sliding scale coverage. On [**2110-11-19**] the patient underwent a Right 10th rib resection. His insulin pump was stopped. There were no complications and the patient tolerated this procedure well. He was extubated in the OR and transferred to the SICU post-operatively for control of his hyperglycemia on an insulin drip. [**Last Name (un) **] was again consulted and recommendations were made to adjust his sliding scale and NPH dosing. His pain was controlled with a Dilaudid PCA. On [**2110-11-22**] the patient was transferred to [**Hospital Ward Name 121**] 2 for recovery, was given a regular diet, and his chest tube was placed to water seal. On [**2110-11-23**] the patient's chest tube was discontinued and his insulin pump was restarted. There were no changes to his insulin pump regimen. At the time of discharge, the patient was afebrile, tolerating a regular diet, ambulatng without assistance, and with good pain control via PO medication. Medications on Admission: 1. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO QD (). 2. Lescol XL 80 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 3. Fludrocortisone 0.1 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Reglan 10 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. insulin pump please resume home insulin pump, as previously prescribed 8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 9. Atacand 8 mg Tablet Sig: Three (3) Tablet PO qPM. 10. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO twice a day. Discharge Medications: 1. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO QD (). 2. Lescol XL 80 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 3. Fludrocortisone 0.1 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Reglan 10 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. insulin pump please resume home insulin pump, as previously prescribed 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. Atacand 8 mg Tablet Sig: Three (3) Tablet PO qPM. 12. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Bony tumor of right chest wall Discharge Condition: Stable Discharge Instructions: Call Dr.[**Last Name (STitle) 28484**] office [**Telephone/Fax (1) 170**] or report to the ED if you develop fever, chills, chest pain, and/or shortness of breath. Please monitor incision sites and call if you notice increased tenderness, redness, swelling, or obvious signs of infection. - You may shower on Tuesday, [**11-25**]. After showering, remove your chest tube site dressing and cover the area with a clean dressing daily until healed. No bathing or swimming for 6 weeks. - After showing, pat dry the stapled incision. [**Month (only) 116**] leave incision uncovered. Staples will be removed at follow-up appointment. - Do not drive while you are taking narcotic pain medicine - Take stool softeners every day you take pain medication: colace, senna, dulcolax, and mild of magnesia are all good options - You should eat a regular diet and resume your home insulin pump. - No heavy lifting (10-15lbs) for 4-6 weeks. - You should continue to do your breathing exercises with the incentive spirometry, coughing, and deep breathing. - You should remain as active as tolerated and gradually increase your activity level on a daily basis. Followup Instructions: Please call [**Telephone/Fax (1) 917**] to schedule followup appointment with Dr [**Last Name (STitle) **] in [**11-16**] days. Please arrive 45 minutes earlier than scheduled appointment and report to [**Hospital Ward Name 23**] [**Location (un) 861**] to obtain Chest X-Ray.

[ "443.81", "357.2", "E878.8", "585.9", "733.29", "427.1", "V10.52", "997.1", "V58.67", "458.29", "250.61", "V44.6", "427.5", "250.71", "337.1", "272.0", "V45.01" ]

icd9cm

[ [ [] ] ]

[ "33.22", "88.72", "99.60", "34.4" ]

icd9pcs

[ [ [] ] ]

6386, 6392

2312, 4602

316, 454

6467, 6476

1698, 2289

7668, 7948

1440, 1458

5398, 6363

6413, 6446

4628, 5375

6500, 7645

1473, 1679

253, 278

482, 1202

1224, 1353

1369, 1424

30,095

130,308

33602

Discharge summary

report

Admission Date: [**2180-7-21**] Discharge Date: [**2180-8-5**] Date of Birth: [**2118-8-18**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: fevers and increasing white blood cell count, from rehab Major Surgical or Invasive Procedure: Right thoracotomy decortication and drainage of empyema History of Present Illness: 61M who was discharged yesterday to rehab s/p transthoracic esophagectomy with cervical anastomosis (McCune procedure), bronchoscopy, wedge resection of right lower lobe nodule through right thoracotomy, placement of left chest tube, replacement of jejunostomy tube and esophagogastroduodenoscopy on [**2180-7-11**]. He did well post-operatively except that he went into rapid afib and he did spike a fever which he was pancultured for and all cultures were negative. He is now coming back from rehab with fevers and increased WBC. He was having low fever of 101.0 in the rehab. WBC of 20. No diarrhea, no nause or vomiting. No dysuria or increase in frequency. Sputum production is the same as over the last week. Past Medical History: CAD s/p CABG [**11-19**](EF55% 12/07), hyperlipidemia, atrial fibrillation(coumadin), HTN, IDDM, anemia Social History: Lives in two story house. Spouse and two youngest children live on [**Location (un) 448**] while he lives on [**Location (un) 1773**] with stepson and family friend. [**Name (NI) **] is a retired sportswriter with no history of drug, alcohol or smoking problems. Family History: Noncontributory. Physical Exam: VS: stable Gen: No acute distress. Awake and alert. Oriented x3. CV: Irregularly irregular consistent with atrial fibrillation. No murmurs, gallops, or rubs appreciated Lungs/Thorax: Coarse bilaterally, R>L with fair aeration. Adequate cough. Maintaining adequate saturations on room air. Anterior and posterior right empyema tubes with minimal drainage surrounding tubes and purulent drain coming out of both tubes (as expected). Right thoracotomy incision with rim of reactive erythema, without signs of infection, healing well, with staples removed. GI: J-tube, dressing clean, dry and intact. Soft. Non-tender. Non-distended. Bowel sounds present. Incision well healed with staples removed. GU: foley Ext: 2+ pitting edema bilateral lower extremities with faint erythema consistent with venous stasis. Edema symmetric and calves non-tender. Pertinent Results: [**2180-7-21**] 02:45PM BLOOD WBC-20.4*# RBC-3.02* Hgb-8.7* Hct-26.2* MCV-87 MCH-28.8 MCHC-33.3 RDW-16.9* Plt Ct-335 [**2180-7-29**] 12:23AM BLOOD WBC-10.1 RBC-3.36* Hgb-9.4* Hct-28.9* MCV-86 MCH-27.9 MCHC-32.5 RDW-14.9 Plt Ct-396 [**2180-8-1**] 05:40AM BLOOD WBC-10.0 RBC-3.42* Hgb-9.5* Hct-29.7* MCV-87 MCH-27.6 MCHC-31.8 RDW-15.2 Plt Ct-424 [**2180-7-21**] 02:45PM BLOOD Glucose-63* UreaN-29* Creat-0.9 Na-130* K-4.1 Cl-92* HCO3-30 AnGap-12 [**2180-8-1**] 05:40AM BLOOD Glucose-137* UreaN-15 Creat-0.7 Na-135 K-3.7 Cl-92* HCO3-38* AnGap-9 [**2180-8-3**] 06:55AM BLOOD Glucose-186* UreaN-20 Creat-0.9 Na-131* K-4.6 Cl-91* HCO3-36* AnGap-9 [**2180-7-24**] 02:33AM BLOOD ALT-16 AST-21 LD(LDH)-207 AlkPhos-101 TotBili-0.8 [**2180-7-21**] 02:45PM BLOOD Calcium-7.6* Phos-2.9 Mg-2.1 [**2180-8-3**] 06:55AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.9 Brief Hospital Course: The patient was admitted to the surgical ICU from rehab on [**7-21**] for fevers and increasing white cell count to rule out leak and abcess from his cervical anastomosis. He was pancultured and placed on vancomycin and zosyn for broad spectrum coverage prending cultures. On [**7-22**], he was taken to the OR by Dr. [**First Name (STitle) **] for Right thoracotomy and decortication of right lung, therapeutic bronchoscopy, and flexible esophagoscopy. On esophagoscopy, the gastric conduit and gastric tip appeared to be healthy. There was evidence of a small dehiscence of the esophagogastric anastomosis at 25 cm. At thoracotomy, there was purulent fluid and fibrinous debris within the right chest. This was removed and the right lung was decorticated. Three chest tubes were placed: apical, posterior apical and basilar. Pleural fluid and debris cultures grew Beta Strep Group B. The patient was returned to the surgical ICU, intubated. His was weaned off the went without any respiratoy events, and was extubated on [**7-26**]. While in the ICU, he received 5 units of blood for a dropping hematocrit. He remained hemodynamically stable except for an episode of hypotension that was treated with fluids. The patient had a fever to 103.5 on [**7-23**]. Diflucan was added for prophylaxis. His white count peaked at 14.1 and his blood cultures were negative. Pain was well-controlled with a PCA. J-tube feedings, Replete with fiber, were started on [**7-24**] and slowly advanced to a goal of 90cc/hr. He was transferred to the floor on [**7-27**]. He experienced shortness of breath on [**7-28**], which resolved. A CT scan showed no signs of pulmonary embolism. On [**7-29**], he went into ventricular tacycardia at about 100bpm. He was asymptomatic during the episode. He was treated with lopressor and he converted back to atrial fibrillation. He A barium swallow on [**7-31**] showed no signs of leakage at the anastomotic site. His chest tubes had steadily decreasing output. On [**7-29**], his right apical chest tube was removed. On [**8-2**], his rigt posterior-apical and basilar chest tubes were converted to empyema tubes. His right IJ tube was removed on [**7-31**]. While he was on the floor, he was gently diuresed. On [**8-2**], he experienced urinary retention and dribbling. A bladder scan showed 900cc in his bladder. A foley was placed. His home dose of Hytrin was restarted on [**8-4**] per his feeding tube. His foley should be removed in the next few days to decrease the risk of UTI. On [**8-4**], the patient was noted to have significant bilateral lower extremity edema with some faint erythema. His calves were soft and legs were symmetric in size. This is most likely due to the fact that the patient prefers to spend most of the day and evening in a chair. Edema improved somewhat with ACE wraps to the legs and leg elevation. The ACE wraps were changed to [**Male First Name (un) **] stockings on [**8-5**] and the patient was again encouraged to elevate his legs while sitting in the chair. On [**8-5**], the patient and staff felt that it was appropriate to discharge the patient to rehab. He is being discharge stable, in good condition. Medications on Admission: ASA 81, Colace, Coumadin (held), Hytrin 5, novolog 12/lantus 32 am/pm, lasix 40, prilosec, Toprol XL 150, Zetia, Zocor, Simvastatin 80, neferex 150'' Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) Injection TID (3 times a day). 2. Acetylcysteine 20 % (200 mg/mL) Solution [**Month/Year (2) **]: [**2-16**] MLs Miscellaneous Q6H (every 6 hours) as needed. 3. Acetaminophen 160 mg/5 mL Solution [**Month/Day (1) **]: Six [**Age over 90 1230**]y (650) mgs PO Q6H (every 6 hours) as needed. 4. Amiodarone 200 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily): crush finely and give via J-tube. 5. Ipratropium Bromide 0.02 % Solution [**Age over 90 **]: One (1) Inhalation Q6H (every 6 hours). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Age over 90 **]: One (1) Inhalation Q4H (every 4 hours). 7. Terazosin 5 mg Capsule [**Age over 90 **]: One (1) Capsule PO HS (at bedtime): crush finely and give via J-tube. 8. port a acth flush port a cath flush Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. 9. Potassium Chloride 20 mEq Packet [**Age over 90 **]: Two (2) Packet PO DAILY (Daily): via j-tube. 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day: via j-tube. 11. Lorazepam 2 mg/mL Syringe [**Last Name (STitle) **]: One (1) mg Injection TID (3 times a day). 12. Metoprolol Tartrate 5 mg/5 mL Solution [**Last Name (STitle) **]: Ten (10) mg Intravenous Q6H (every 6 hours). 13. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: 1000 (1000) mg Intravenous Q 12H (Every 12 Hours) for 14 days. 14. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback [**Last Name (STitle) **]: 4.5 grams Intravenous Q8H (every 8 hours) for 14 days. 15. Furosemide 10 mg/mL Solution [**Last Name (STitle) **]: Twenty (20) mg Injection DAILY (Daily). 16. morphine PCA morphine .25 mg q 6 minutes one hour lock out 2.5mg/hr NO basal rate 17. humalog sliding scale Breakfast Lunch Dinner Bedtime Humalog 0-60 mg/dL [**12-15**] amp D50 [**12-15**] amp D50 [**12-15**] amp D50 [**12-15**] amp D50 61-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-160 mg/dL 2 Units 2 Units 2 Units 2 Units 161-200 mg/dL 4 Units 4 Units 4 Units 4 Units 201-240 mg/dL 6 Units 6 Units 6 Units 6 Units 241-280 mg/dL 8 Units 8 Units 8 Units 8 Units 18. glargine 36 units glargine insulin SQ QHS Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: Right thoracotomy decortication and drainage of empyema on [**2180-8-3**] after esophageal leak s/p esophagectomy on [**2180-7-11**]. Discharge Condition: deconditioned Discharge Instructions: call Dr.[**Name (NI) **] office [**Telephone/Fax (1) 4741**] if you develop fevers, chills, chest pain, shortness of breath, foul smelling drainage from the chest tubes or chest tube sites or thoracotomy site. Keep NPO on tube feeds until seen in follow up by DR. [**Last Name (STitle) **]. Continue on antibiotic course until seen in follow up. Followup Instructions: You have a follow up appointment w/ Dr. [**First Name11 (Name Pattern1) 2389**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]/ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**] NP[**MD Number(3) **] [**Hospital Ward Name **] [**Hospital Ward Name **] building [**Hospital1 **] one in the Chest disease center Date/Time:[**2180-8-9**] 2:00. Please arrive 45 minutes prior to your appointment and report to the [**Location (un) 470**] radiology for a chest XRAY.

[ "414.00", "997.5", "V45.81", "510.9", "790.01", "V10.03", "996.69", "V58.67", "427.31", "E878.8", "V44.4", "788.20", "250.00", "272.4", "E878.2", "V58.61", "427.1" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.72", "96.6", "34.51", "33.23", "42.23" ]

icd9pcs

[ [ [] ] ]

9440, 9481

3369, 6557

377, 435

9659, 9675

2506, 3346

10069, 10571

1608, 1626

6757, 9417

9502, 9638

6583, 6734

9699, 10046

1641, 2487

281, 339

463, 1183

1205, 1311

1327, 1592

42,663

183,917

33758

Discharge summary

report

Admission Date: [**2200-7-10**] Discharge Date: [**2200-7-29**] Date of Birth: [**2144-5-24**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2777**] Chief Complaint: Thoracoabdominal aortic anuerysm Major Surgical or Invasive Procedure: [**2200-7-10**] open thoracoabdominal aortic aneurysm repair [**2200-7-10**] left lower lobe wedge resection [**2200-7-11**] Exploratory laparotomy, repair of small bowel enterotomy, and multiple serosal tears History of Present Illness: This is a 56yo man with a thoracoabdominal aortic aneurysm complicated by paraplegia. He had prior stenting of the aortoiliac segments given the extension particularly of the left common iliac. He is admitted now for surgical resection and replacement of the thoracic and abdominal aorta. Past Medical History: 1. Chronic type B aortic dissection complicated by paraplegia. 2. Hypertension. 3. Chronic diastolic congestive heart failure. 4. Atrial fibrillation. 5. History of sick sinus syndrome. 6. Chronic renal insufficiency. 7. History of gallstone pancreatitis, status post ERCP. 8. Dyslipidemia. 9. Lung nodule in the left lower lobe. 10. Prior TIA in [**2184**]. 11. History of gout. 12. History of GI bleed. 13. Anemia. PSH: [**2197**] - Excision of right groin arteriovenous fistula. Aortic dissection repair, [**2196**] aortic fenestration and stenting of the distal aorta as well as common iliac arteries, Distal aortic and bilateral CIA stenting.[**2185**], cholecystectomy in [**2196-12-30**] Social History: At baseline lives at home with partner Family History: unknown aortic aneurysm hx Physical Exam: Gen: WDWN male in NAD; paraplegic; alert and oriented x 3 Card: Irreg (afib) Lungs: CTA bilat Abd: Soft no m/t/o Extremities: warm, well perfused, palpable femoral/dp/pt pulses bilat Wound: Thoracoabdominal incision c/d/i, staples in place Pertinent Results: RENAL U.S.; DUPLEX DOPP ABD/PEL Clip # [**Clip Number (Radiology) 78088**] Reason: renal doppler study [**Hospital 93**] MEDICAL CONDITION: 56 year old man with acute renal failure s/p thoracoabd aortic aneurysm repair - REASON FOR THIS EXAMINATION: renal doppler study Wet Read: SHSf MON [**2200-7-28**] 9:56 PM Normal arterial wave form involving the main renal arteries bilaterally with slightly elevated resistive indices. Wet Read Audit # 1 Preliminary Report !! WET READ !! Normal arterial wave form involving the main renal arteries bilaterally with slightly elevated resistive indices. [**2200-7-28**] 11:09 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2200-7-29**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2200-7-29**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Chemistry UreaN Creat [**2200-7-29**] 03:25AM 52* 4.3*# [**2200-7-28**] 02:56AM 95* 6.5* [**2200-7-27**] 04:00AM 66* 5.6*# [**2200-7-26**] 05:36AM 43* 4.1*# [**2200-7-25**] 05:58AM 93* 5.5* [**2200-7-25**] 12:07AM 90* 5.4* [**2200-7-24**] 03:26PM 81* 5.0* [**2200-7-24**] 03:14AM 66* 4.6* [**2200-7-23**] 06:28AM 71* 4.7* [**2200-7-22**] 01:38AM 50* 4.0* [**2200-7-21**] 02:42AM 48* 3.7* [**2200-7-20**] 03:11AM 31* 2.8*# [**2200-7-19**] 02:55AM 49* 3.9* [**2200-7-18**] 02:33AM 54* 4.7* [**2200-7-17**] 04:30AM 62* 5.5* [**2200-7-16**] 01:40PM 54* 5.2* [**2200-7-15**] 02:54AM 41* 4.6* [**2200-7-13**] 02:55AM 34* 3.7* [**2200-7-12**] 02:46AM 29* 2.9* [**2200-7-11**] 08:46PM 27* 2.6* [**2200-7-10**] 08:17PM 22* 1.4* [**2200-7-10**] 8:17 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2200-7-13**]** MRSA SCREEN (Final [**2200-7-13**]): No MRSA isolated. **FINAL REPORT [**2200-7-17**]** GRAM STAIN (Final [**2200-7-13**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2200-7-17**]): RARE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 4 S CEFTAZIDIME----------- 8 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 2 S MEROPENEM------------- 0.5 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 59927**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78089**]TTE (Complete) Done [**2200-7-14**] at 3:43:24 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2144-5-24**] Age (years): 56 M Hgt (in): 68 BP (mm Hg): 140/90 Wgt (lb): 172 HR (bpm): BSA (m2): 1.92 m2 Indication: Left ventricular function. S/p abd ao repair ICD-9 Codes: 424.0, 424.2 Test Information Date/Time: [**2200-7-14**] at 15:43 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21212**], RDCS Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2011W000-0:0 Machine: Vivid q-2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.7 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: >= 75% >= 55% Left Ventricle - Stroke Volume: 68 ml/beat Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *15 < 15 Aorta - Sinus Level: *4.5 cm <= 3.6 cm Aorta - Ascending: *3.9 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 15 Aortic Valve - LVOT diam: 2.4 cm Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - E Wave deceleration time: *63 ms 140-250 ms TR Gradient (+ RA = PASP): *61 mm Hg <= 25 mm Hg Findings This study was compared to the prior study of [**2200-6-27**]. LEFT ATRIUM: Marked LA enlargement. LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Hyperdynamic LVEF >75%. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV systolic function. Abnormal septal motion/position. AORTA: Moderately dilated aorta at sinus level. Mildly dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **]S. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Moderate [2+] TR. Severe PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: No PS. PERICARDIUM: Very small pericardial effusion. No echocardiographic signs of tamponade. Conclusions The left atrium is markedly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. RV with normal free wall contractility. There is abnormal septal motion/position. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**6-27**]/201, the degree of TR and pulmonary hypertension detected has increased Brief Hospital Course: Date of admission: [**2200-7-10**] Date of discharge: The patient was admitted for planned operative management of known thoracoabdominal aneurysm with type B dissection. He was taken to the OR [**2200-7-10**] with vascular and cardiac surgery. He underwent repair of the thoracoabdominal aortic aneurysm from distal descending thoracic aorta down to both common iliac arteries. In addition to an aorto-biiliac graft, a multi-branch graft was also placed with individual anastomoses to the celiac artery, superior mesenteric artery, and right and left renal arteries. The patient also had a preoperative CT scan demonstrating an area of nodularity in the left lower lobe. During the same anesthesis he underwent left lower lobe wedge resection of this abnormality. Two chest tubes were left in place. The patient was brought to the ICU postoperatively in stable condition, intubated. However, over the course of POD0, he began to develop a pressor requirement and had two guaiac positive bowel movements. Additionally, CT abdomen demonstrated stranding within the mesentery and small bowel thickening suspicious for ischemia. West 1 surgery was consulted due to the suspicion of mesenteric ischemia and the patient underwent an exploratory laparotomy on [**2200-7-11**] that was negative for mesenteric ischemia or other pathology. He was again brought to the ICU post-operatively and remained intubated on pressors. While in the ICU he began to experience decreased urine output with increased serum creatinine. He was started on a lasix drip which was not able to produce sufficient diuresis. At this point nephrology was also following this patient. Hemodialysis was initiated [**2200-7-17**] and the patient remained on HD for the duration of the hospital stay. On [**2200-7-18**] he successfully self-extubated, and remained stable with face mask oxygen initially. However he also at this time had a sputum culture positive for pseudomonas and although remained afebrile was treated for pneumonia. He was reintubated on [**2200-7-18**] and remained intubated overnight. He was succesfully extubated [**2200-7-19**]. He remained in the ICU and recieved blood transfusions for a goal hematocrit of 30. On [**2200-7-20**] he was evaluated by speech and swallow, and after passing was advanced to a regular diet and tube feeds were discontinued. He continued to be treated with broad spectrum antibiotics for pneumonia, and require BiPap for hypoxia. He continued to receive daily dialysis while in the ICU to treat his fluid overload. On [**2200-7-22**], patient was transfered from the ICU to the step-down VICU. At this point he was tolerating regular diet, chest tubes had been removed, dobhoff was removed, extubated and on nasal cannula, and hemodynamically stable. He remained stable in the VICU. Nutrition was following this patient and he tolerated a general diet with no issues. He continued to undergo every other day hemodialysis. He was kept on telemetry monitoring as he has a pacemaker and did have sporadic EKG changes, although cardiac workup was negative. Cardiology was consulted and continued to follow. On [**2200-7-25**] he had a tunneled line placed for continued hemodialysis after discharge. At time of discharge, he continues to require ongoing hemodialysis for acute renal failure. His long-term renal function is unknown. He is requiring intermittent straight catheterization as he does make some urine. He has required this in the past, prior to this hospitalizatin. He is tolerating a general diet with nutritional supplements. He is working with physical therapy and will require further PT after discharge to regain his baseline functional status. He continues to require IV cipro/flagyl for graft protection, telemetry monitoring for cardiac status, and close follow-up with a nephrologist for monitoring of his acute renal failure. He is discharged to [**Hospital3 **] in [**Hospital1 8**] for further management of these issues in a long-term care setting. Medications on Admission: Medications - Prescription CLONIDINE [CATAPRES-TTS-2] - (Prescribed by Other Provider) - 0.2 mg/24 hour Patch Weekly - once a week Q Monday FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth twice a day METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 100 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth twice a day NIFEDIPINE - (Prescribed by Other Provider) - 90 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by mouth once a day POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 20 mEq Tablet, ER Particles/Crystals - 1 Tab(s) by mouth twice daily SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once daily WARFARIN - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth daily 7.5mg Thurs/Sunday; 5 mg daily x 5 days or as directed for INR goal [**1-2**] Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for fever or pain. 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 3. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 4. nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for hypertension: PRN syst BP >170. Capsule(s) 5. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day: hold for hr<55, sbp<100. 6. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for skin yeast. 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 13. Outpatient Lab Work pleaes check pt/inr starting [**2200-7-29**]; check at least three times per week and as needed, may decrease frequency when off antibiotics 14. 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. 15. ciprofloxacin 400 mg/40 mL Solution Sig: Four Hundred (400) mg Intravenous once a day for 1 weeks. 16. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous every eight (8) hours for 1 weeks. 17. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: thoracoabdominal aortic aneurysm acute renal failure Type B aortic dissection s/p endovascular stent distal aorta s/p exploratory laparotomy s/p left lower lung resection Discharge Condition: Alert and oriented x3 Non-ambulatory at baseline Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] 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: Cardiac Surgeon: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2200-8-19**] 1:30 Cardiologist:Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 62081**] [**2200-8-6**] at 2:15pm Thoracic Surgeon: CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2200-8-28**] 1:15 Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] Date/Time:[**2200-8-28**] 3:00 Vascular surgeon: Please call to schedule appointments with: Primary Care: Dr.[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3273**] ([**Telephone/Fax (1) 45347**]) in [**3-4**] weeks Labs: PT/INR for Coumadin ?????? indication :atrila fibrillation Goal INR 2.0-2.5 First draw day after discharge ***** please arrange for coumadin /INR followup prior to discharge from rehab Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2200-8-13**] 2:15 Completed by:[**2200-7-29**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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24074

Discharge summary

report

Admission Date: [**2183-8-4**] Discharge Date: [**2183-8-20**] Date of Birth: [**2152-7-2**] Sex: M Service: SURGERY Allergies: peanut / latex Attending:[**First Name3 (LF) 1390**] Chief Complaint: Cellulitis Major Surgical or Invasive Procedure: 1. [**2183-8-7**] left above-the-knee amputation 2. [**2183-8-7**] Debridement of left lower extremity wound and placement of a wound VAC 3. [**2183-8-10**] Revision of left AKA with partial closure and placement of VAC 100 cm2 and debridement of upper sacral wound and back decubitus with placement of wet-to-dry dressings 4. Debridement of presacral ulcer, placement of V.A.C. on left amputation below-knee amputation stump, tracheostomy History of Present Illness: 31 year old male with spina bifida, s/p spinal fusion, hydrocephalus s/p shunt, bilaterally dislocated hips and clubbed feet presented to OSH with chills/night sweats and a known likely infected left foot (has a history of many lower extremity infections in the past). At the OSH, noted to be septic with HR in the 120s, hypotensive to the 70s responsive to IVF, afebrile with source likely cellulitis in his left leg; UA and CXR negative, blood cultures NGTD. Initially was put on vanc/clinda however pt continued to be septic with WBC count trending upwards (17 on [**8-2**] to 33 on [**8-4**], day of transfer) and with spreading of his cellulitis, so his abx were changed to vanc/zosyn. He was seen by surgery at the OSH who felt that he likely did not have nec fasc and recommended adding IV diflucan. Skin/wound cultures reportedly growing group G strep, blood cultures negative. He was transferred for further multidisciplinary workup; normally he is seen at [**Hospital1 2025**] for his lower extremity infections, it is unclear why he was not transferred there. His custom wheelchair recently broke and he has since been in one that is not well fitted to him. He developed lower extremity abrasions and sacral skin breakdown complicated by lower extremity and sacral cellulitis for the past few weeks. On the floor he appears tired and ill but not toxic, intermittently falling asleep. He is oriented to person and time but not place, and exhibits [**Doctor Last Name 688**] concentration. Endorses chills, night sweats, mild shortness of breath. States that he can feel his lower extremities but does not feel pain in them currently. Endorses dysuria. Pt was initially admitted to HMED service. He became increasingly toxic overnight and was transferred to the MICU for dropping pressures in the setting of afib with RVR. On arrival to the MICU, pt was hypotensive to 70s systolic, still in RVR. Past Medical History: PMH: Spina bifida, chronic lymphedema, hydrocephalus s/p shunt, lower extremity paralysis with bilateral clubbed foot deformities PSH: s/p VP shunt placement, s/p spinal fusion Social History: Lives with parents who are caregivers. Worked in the past at kiosk in the mall, but not currently employed. Not married, no children. No tobacco, ethanol, drugs. Family History: Mother with chronic fatigue syndrome and allergies, Dad unknown Physical Exam: 97.2 108/42 110 26 94%2L Admission Exam: GEN Alert, oriented to person/time, states he is at [**Hospital1 2025**], no acute distress HEENT NCAT dry MM, EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Only able to auscultate anteriorly due to habitus, good aeration, CTAB no wheezes, rales, ronchi CV regular tachycardia normal S1/S2, no mrg ABD obese soft NT ND normoactive bowel sounds EXT L: massive lymphedema with club foot deformity, capillary refill <2sec distally, over medial thigh and lateral club foot area of skin with cellulitic appearance with skin sloughing and weeping of serous fluid, dermis underneath appears beefy red, nontender to palpation, no area of fluctuance noted. No crepitus. Some areas with dark purple discoloration. Fungal appearing coat over some areas of skin. R: mild lymphedema with club foot deformity, no areas of skin breakdown noted. Sacrum: erythematous non-necrotic ulcer noted without penetration to bone/muscle. Non purulent. NEURO CNs2-12 intact, upper motor function grossly normal GU fungal appearing discharge from meatus Pertinent Results: Admission labs: [**2183-8-5**] 01:55AM BLOOD WBC-41.7* RBC-4.42* Hgb-11.8* Hct-38.2* MCV-86 MCH-26.7* MCHC-30.9* RDW-18.5* Plt Ct-270 [**2183-8-5**] 01:55AM BLOOD Neuts-85* Bands-1 Lymphs-11* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-2* [**2183-8-5**] 01:55AM BLOOD PT-12.4 PTT-25.2 INR(PT)-1.1 [**2183-8-5**] 01:55AM BLOOD Glucose-118* UreaN-52* Creat-1.6* Na-130* K-4.3 Cl-97 HCO3-22 AnGap-15 [**2183-8-5**] 01:55AM BLOOD ALT-13 AST-37 AlkPhos-207* TotBili-0.8 [**2183-8-5**] 01:55AM BLOOD Albumin-2.0* Calcium-8.4 Phos-4.2 Mg-2.7* [**2183-8-5**] 07:01AM BLOOD Lactate-1.7 [**2183-8-5**] 09:58AM BLOOD Lactate-1.3 [**2183-8-5**] 07:01AM BLOOD Type-ART O2 Flow-4 pO2-137* pCO2-73* pH-7.15* calTCO2-27 Base XS--5 Intubat-NOT INTUBA [**2183-8-5**] 11:04AM BLOOD Type-ART Temp-36.2 Rates-21/ PEEP-5 FiO2-100 pO2-165* pCO2-60* pH-7.14* calTCO2-22 Base XS--9 AADO2-490 REQ O2-83 Intubat-INTUBATED Abscess culture/wound swab [**2183-8-6**] Staph [**Last Name (LF) 61227**], [**First Name3 (LF) **], bacteroides [**2183-8-20**] 12:39AM BLOOD WBC-4.6 RBC-2.78* Hgb-8.2* Hct-27.2* MCV-98 MCH-29.4 MCHC-30.1* RDW-19.5* Plt Ct-212 [**2183-8-20**] 12:39AM BLOOD Plt Ct-212 [**2183-8-20**] 12:39AM BLOOD Glucose-89 UreaN-30* Creat-1.4* Na-141 K-4.4 Cl-112* HCO3-25 AnGap-8 [**2183-8-13**] 01:00AM BLOOD ALT-15 AST-18 AlkPhos-121 TotBili-0.6 [**2183-8-20**] 12:39AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.5 [**2183-8-18**] 04:10AM BLOOD Vanco-15.9 Brief Hospital Course: Mr. [**Name13 (STitle) **] is a 31 yo M w/ PMH of spina bifida with paraplegia and is wheelchair bound at baseline who was transferred from an OSH for concern re: his left leg cellulitis. Upon admission, he was found to be hypotensive despite aggressive fluid resuscitation. He was transferred to the MICU initially, and surgery was consulted for concern regarding necrotizing fasciitis in the face of elevated WBC and signs of sepsis. He was taken urgently to the OR and did require AKA for necrotizing fasciitis; he was transferred to the surgical service postoperatively. His course is summarized by systems below: N: He was initially mentating well. He was sedated while intubated, but remained responsive when sedation was weaned. After sedation was d/c'd, he was A&Ox3. He worked with PT and was out of bed to chair and interacting appropriately. CV: At admission, his pressures did drop and upon transfer to the MICU on [**8-5**] he required three pressors to maintain his BP. His rhythm at this point was afib; he was started on an amiodarone drip. It was at this point that the patient was taken urgently to the OR. He remained on pressors post-operatively, but they were able to be significantly weaned. After the initial operation, he was weaned down to a small dose of levophed, which he continued to require. He was weaned off the amiodarone drip on POD 1 and remained in sinus rhythm. He was weaned off pressors and remained in sinus rhythm. Patient was stable from a cardiovascular standpoint at time of discharge Pulm: He was initially intubated on [**8-5**] after transfer to the MICU due to worsening ventilation and combined respiratory and metabolic acidosis on ABG. He was kept intubated postoperatively initially due to the need to return to the OR for washout. However he did continue to require high PEEP, and attempts to wean off the ventilator were unsuccessful. He was taken to the OR on [**8-13**] for trach placement. At time of discharge patient with stable 02 saturations on trach collar at 40% FiO2 GI: The patient was initially kept NPO with IVF. On [**2183-8-9**] he was started on tube feeds via NGT. These were held as needed for a return trip to the OR on [**8-10**] for washout and partial closure, and then restarted postoperatively. They were titrated up to goal and he tolerated them with low residuals. Patient was tolerating tube feeds at goal at time of discharge and was advanced to a soft solid diet with trach cuff inflated while taking po intake. GU: Urine output was monitored with a foley catheter. His UOP remained good however his creatinine did increase during the course of his ICU stay. This was monitored daily. ID: At initial presentation he was septic [**1-23**] necrotizing fasciitis in his left lower extremity. His preop WBC was 59. He was started on vanc/zosyn/clinda/flagyl for broad spectrum coverage and ID was consulted. ID continued to follow throughout his course. After the initial operation his WBC dropped to 26 on POD1; his hemodynamic status stabilized. His antibiotics were narrowed to vanc/zosyn/clinda. The cultures of his leg returned MRSA. Patient was continued on antibiotics until time of discharge and was discharged without antibiotics, afebrile with stable WBC. Patient was discharged to Rehabilitation facility with trach collar, tolerating tube feeds at goal with a soft diet and vac in place. Vac will be changed every 3 days tube feeds will be managed by the rehab facility pending po intake requirements. Abx were discontinued at time of discharge and patient will call to arrange a follow up appointement with [**Hospital 2536**] clinic in 2 weeks time. Medications on Admission: Medication on transfer from Medical service: metrogel q12h to face tylenol prn albuterol nebs prn oxycodone 5-10mg q3h prn pain zosyn 3.375g q6 vancomycin 2g q12 diflucan 200 qd Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN fever/pain 2. Artificial Tear Ointment 1 Appl BOTH EYES PRN redness/dry eyes 3. Bisacodyl 10 mg PO/PR DAILY 4. BusPIRone 10 mg PO BID anxiety 5. Collagenase Ointment 1 Appl TP DAILY apply to sacral decubitus ulcer daily 6. Docusate Sodium (Liquid) 100 mg PO BID 7. Gabapentin 300 mg PO DAILY 8. Heparin 7500 UNIT SC TID 9. HydrOXYzine 25-50 mg PO Q6H:PRN anxiety/puritus 10. Lactulose 30 mL PO BID 11. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX *oxycodone [Oxecta] 5 mg [**12-23**] tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 12. Sarna Lotion 1 Appl TP TID:PRN itching 13. Senna 1 TAB PO BID *AST Approval Required* 14. Zolpidem Tartrate 10 mg PO HS 15. MetronidAZOLE Topical 1 % Gel 1 Appl TP [**Hospital1 **] Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**] ([**Hospital3 1122**] Center) Discharge Diagnosis: RLE necrotizing fasciitis Discharge Condition: Stable Discharge Instructions: You were admitted to the General surgery service for Necrotizing fasciitis of the Right lower extremity. Please call your doctor or go to the emergency department if: *You experience new chest pain, pressure, squeezing or tightness. *You develop new or worsening cough, shortness of breath, or wheeze. *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 an unusual discharge. *Your pain is not improving within 12 hours or is not under control within 24 hours. *Your pain worsens or changes location. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. The rehabilitation facility will be caring for your wound vac and your wound will be reevaluated at your follow up visit with ACS General Surgery Followup Instructions: Please call the [**Hospital 2536**] clinic to make a follow up appointment in 2 weeks.

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icd9cm

[ [ [] ] ]

[ "96.72", "38.97", "96.6", "86.22", "84.3", "31.1", "96.04", "84.17" ]

icd9pcs

[ [ [] ] ]

10407, 10543

5704, 9359

283, 727

10612, 10620

4247, 4247

12588, 12677

3060, 3125

9588, 10384

10564, 10591

9385, 9565

10644, 11639

3140, 4228

11671, 12565

233, 245

755, 2664

4263, 5681

2686, 2865

2881, 3044

7,014

155,195

4320

Discharge summary

report

Admission Date: [**2165-10-19**] Discharge Date: [**2165-10-25**] Date of Birth: [**2111-3-5**] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 50 year old man with a past medical history significant for coronary artery disease, status post myocardial infarction as well as a minimally invasive coronary artery bypass grafting with the left internal mammary artery to the left anterior descending by Dr. [**Last Name (STitle) 1537**] in [**2159**]. PAST MEDICAL HISTORY: Past medical history is also significant for diabetes mellitus and hyperlipidemia. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: The patient was on no medications at the date of admission. SOCIAL HISTORY: The patient has no known history of tobacco or alcohol use or abuse. HOSPITAL COURSE: The patient is transferred from an outside hospital for cardiac catheterization with complaints of chest pain at rest. These were pains that were reportedly similar to the symptoms he experienced with his prior myocardial infarction. He took Aspirin and sublingual Nitroglycerin times one at home without relief. At the outside hospital, he was started on Heparin and intravenous Nitroglycerin and was given intravenous Lopressor times two as well as a standing p.o. dose of 50 mg which made the patient pain free. Cardiac catheterization was performed on [**2165-10-21**], which revealed normal left main coronary artery, 100% proximal disease of the left anterior descending, 90% proximal stenosis of the left circumflex with 90% mid and long 70% OM1, as well as 100% midstenosis of the right coronary artery. The left internal mammary artery to left anterior descending was patent with a small atretic H graft of the gastroepiploic artery connecting the left internal mammary artery to the left anterior descending which had a long 70% lesion at the site of anastomosis. Left ventriculography revealed an ejection fraction of 40%. The patient underwent coronary artery bypass grafting redo times three on [**2165-10-22**], with a Y graft of the left internal mammary artery to left anterior descending and left radial to obtuse marginal as well as a saphenous vein graft to the right coronary artery. Total cross clamp time for the patient was 102 minutes. Total cardiopulmonary bypass time was 121 minutes. The patient was transferred in stable condition, being AV paced at 80 beats per minute to the Cardiac Surgery recovery unit on Nitroglycerin and Neo-Synephrine. Postoperative day one 24 hour events included a successful extubation without complication. The patient with a low grade temperature of 99.9, however, tachycardic in sinus rhythm at 107 beats per minute with an index of 3.26 and a CVP of 5.0, oxygen saturation 96% on five liters nasal cannula. White blood cell count and hematocrit stable as well as the patient's renal function. Aside from the tachycardia, the patient's physical examination was unremarkable. The plan was to continue the patient's Nitroglycerin for the radial artery and to change the Nitroglycerin to Imdur to p.o. today. The plan was to transfer the patient to the floor. On postoperative day two, 24 hour events included transfer to the floor the day prior. On physical examination, the patient only with complaints of mild back pain due to a fall that occurred without injury the day prior. The patient still with a low grade temperature of 99.4 with a temperature maximum of 99.9, oxygen saturation 91% in room air. Physical examination remained unchanged. The plan was to monitor the patient's pain control, to discontinue the patient's chest tube and to continue with the current drug regimen. Postoperative day three, the patient was still in sinus tachycardia in the 90s to 100s, oxygen saturation 93% in room air, with no complaints of pain. The patient was discharged to home in stable condition. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. twice a day. 2. Ranitidine 150 mg p.o. twice a day. 3. Aspirin 325 mg p.o. once daily. 4. Imdur 60 mg p.o. once daily. 5. Metoprolol 25 mg p.o. twice a day. 6. Percocet one to two tablets p.o. q4hours p.r.n. pain. CONDITION ON DISCHARGE: The patient was discharged home in stable condition. DISCHARGE INSTRUCTIONS: The patient is to contact Dr. [**Last Name (STitle) 1537**] for a follow-up visit in four weeks. DISCHARGE DIAGNOSIS: Coronary artery disease, status post redo coronary artery bypass grafting times three. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Doctor Last Name 182**] MEDQUIST36 D: [**2165-11-20**] 14:53 T: [**2165-11-23**] 09:57 JOB#: [**Job Number 18690**]

[ "250.00", "410.71", "414.00", "272.0", "412", "V45.81", "274.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4417, 4780

3950, 4193

685, 746

851, 3924

4297, 4395

181, 497

520, 658

763, 833

4218, 4272

26,638

128,822

26451

Discharge summary

report

Admission Date: [**2159-4-15**] Discharge Date: [**2159-4-20**] Date of Birth: [**2094-3-15**] Sex: F Service: MEDICINE Allergies: Penicillins / Cefepime / Bactrim / Imipenem Attending:[**Last Name (NamePattern1) 13129**] Chief Complaint: STEMI Major Surgical or Invasive Procedure: Cardiac Cathiterization History of Present Illness: 65 year old femal with known 3V CAD s/p stent to LCX in [**2154**] with ischemic cardiomyopathy and EF 25% h/o of cardiogenic [**Year (4 digits) **], 2+MR, PHTN, atrial fibrillation (not anti-coagulated) with multiple medical problems and wheel chair bound who presented with a STEMI. Last night she awoke with bilateral arm pain, and eye pain in the middle of the night. She endoresed, nausea/ phlem production, and diaphoresis, but no other symptoms such as abdominal pain, pleuritis, vision changes, or headache. She report no URI symptoms the remainder of her review of systmes is negative as noted below. . 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. . In the OSH ED: 96.5 84 18 116/64 97 RA. She was given ASA 325 mg PO daily, Heparin 5000 units, Plavix 600 and Integrilin 6.2 ml Past Medical History: -Syncope 3yrs ago . PAST MEDICAL HISTORY: -Coronary Artery Disease (3VD, not a surgical candidate, s/p stent to LCX in [**12/2154**]) -CHF, h/o cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] 20-30% -Severe MR, moderate TR -Atrial fibrillation on amiodarone -Syncope 3yrs ago -Neck pain, eval in 2/99 at [**Hospital1 336**] with some fibromyalgia points, occured after viral syndrome -Iron deficient Anemia -Fibromyalgia -Diverticulosis -Internal Hemorrhoids -Osteopenia -Cluster A personality (schizoid) with question underlying dementia, court order for her to be DNR/DNI -Gastritis -Bursitis -Adrenal adenoma Social History: Patient lives in [**Hospital 11851**] healthcare. She denies any current or past history of smoking. Used to drink alcohol occasionaly, but [**Doctor First Name 1638**] any drink for many years. She denies being sexually active; no inter-personal relationships; no family or friends involved. She is DNR/DNI (per guardian [**Name (NI) **] [**Name (NI) **]). Pt denies ilicit substance use. Family History: n/c Physical Exam: PHYSICAL EXAMINATION: VS: T= 97 BP=117-127/63 HR=80 RR=14 O2 sat= 100 2L GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP above clavicle at 30 degrees. CARDIAC: No carotid bruits. PMI located in 5th intercostal space, midclavicular line. RR, Systolic murmur loudest at LSB, faint at Apex, no thrill. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. Angio seal on R side. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP, PT dopplerable Left: DP, PT dopperlable Pertinent Results: [**2159-4-15**] 09:00AM BLOOD WBC-25.6*# RBC-5.31# Hgb-10.5*# Hct-35.7*# MCV-67* MCH-19.7* MCHC-29.2* RDW-19.6* Plt Ct-524*# [**2159-4-15**] 09:00AM BLOOD Plt Ct-524*# [**2159-4-15**] 09:00AM BLOOD Ret Aut-PND [**2159-4-15**] 09:00AM BLOOD Glucose-252* UreaN-55* Creat-1.7* Na-131* K-4.9 Cl-100 HCO3-17* AnGap-19 ECG: OSH: Inferior ST segment elevations: III> II, Upsloing ST segment ddperssions and flat T waves in V5, V6. ECG: Pre-admission: Demonstrates ST segment elevation in II, III, AvF, with ? ST segment depression in V4, V5, V6. . Post-admission: Resolution of II, III, AvF, with JP elevation in V3 with TWI in the inferior leads. Cath Notes: 170 cc contrast/ SBP 117/64 MAP 84 LMCA: NL LAD: diffuse proximal and mid disease 50-70% LCX: proximal mid stents widely patent RCA: proximal tortuous 80% stenosis, mid total occlusion ASA 325 daily, Plavix > 6 months, Cardiac Echo. ECHO: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with inferior and infero-lateral hypokinesis to akinesis. The apex is not well seen. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-24**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2158-3-15**], the LVEF may have improved. If indicated, a cardiac MRI may better assess LVEF. . RENAL ULTRASOUND: The right kidney measures 8.6 cm. The left kidney measures 9.1 cm. A simple cortical cyst measures 1.6-cm in the left interpolar region. There is no hydronephrosis, hydroureter, renal calculus or suspicious mass. No perinephric fluid collection is noted to suggest abscess. IMPRESSION: 1. A 1.6-cm left simple renal cyst, previously documented in the [**2154**] CT study. 2. No evidence of perinephric abscess. No hydroureteronephrosis or stone. Of note, renal ultrasound is not sensitive to detect pyelonephritis which requires contrast to demonstrate abnormal parenchymal enhancement pattern. . MRI: FINDINGS: THORACIC SPINE: The thoracic vertebral body alignment, heights and marrow signal are maintained. There are scattered foci of endplate irregularities likely representing Schmorl's nodes and degenerative changes. The intervertebral discs are mildly desiccated without significant loss of disc space height. No evidence of disc herniation, spinal canal or neural foraminal narrowing is identified. No large epidural or intradural abnormal fluid collection or mass is identified (contrast could not be given as the patient refused). The thoracic cord is normal in signal and configuration. LUMBAR SPINE: The lumbar vertebral body alignment, heights and marrow signal are maintained. Intervertebral discs demonstrate moderate desiccation with significant loss of height. No large epidural or intradural abnormal fluid collection or mass is identified. The spinal cord and cauda equina are normal in signal and configuration. T12-L1: No disc herniation, spinal canal or neural foraminal narrowing. L1-L2: Mild diffuse disc bulge is present which indents the ventral thecal sac without significant spinal canal narrowing. The neural foramina are not significantly narrowed. L2-L3: A diffuse disc bulge is present with minimal flattening of the ventral thecal sac. Facet arthrosis is present without significant neural foraminal narrowing. L3-L4: A diffuse disc bulge is present with slight asymmetry to the right. Facet arthrosis and ligamentum flavum infolding along with the disc bulge results in mild spinal canal narrowing and mild right neural foraminal narrowing. The left neural foramen is not significantly narrowed. L4-L5: A diffuse disc bulge is present which along with facet arthrosis and ligamentum flavum infolding result in moderate to severe spinal canal narrowing and moderate crowding of the nerve roots. These degenerative changes result in moderate left and mild right neural foraminal narrowing. L5-S1: A broad-based central disc protrusion is present without significant spinal canal narrowing. Facet arthrosis is present but with moderate narrowing of the left neural foramen. The right neural foramen does not demonstrate significant narrowing. Along the posterior margin of the left kidney, there is a 1.6 cm T2 hyperintense structure likely representing a renal cyst. IMPRESSION: 1. The patient refused contrast which limits evaluation although no abnormal epidural fluid collection or mass is identified within the thoracic or lumbar spine on the non-contrast images. If clinically indicated, post-contrast imaging can be repeated with patient co-operation. 2. Degenerative changes of the lumbar spine as described above. There is moderate to severe spinal canal narrowing at L4-L5 due to degenerative changes resulting in crowding of the cauda equina. . MIcrobiology: [**2159-4-15**] 5:01 pm URINE Site: NOT SPECIFIED Source: Catheter. **FINAL REPORT [**2159-4-19**]** URINE CULTURE (Final [**2159-4-19**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: Ms. [**Known lastname 65370**] is a 65 year old female with a history of 3V CAD s/p stent to LCX in [**2154**] with ischemic cardiomyopathy and EF 25% h/o of cardiogenic [**Year (4 digits) **], 2+MR, PHTN, atrial fibrillation (not anti-coagulated) with multiple medical problems and wheel chair bound who presented with a STEMI with subsequent development of Sepsis [**1-24**] UTI complicated by [**Last Name (un) **], non-anion gap acidosis, hematemesis secondary to a presumed stress ulcer, and eosinophilia with marked erythema from a drug rash. She remains clinically stable, but had an episode of back pain without evidence of compression or abscess on MRI. . Transition Issues: - CBC and Chem 7 need to be monitored closely - Anti-hypertensives and diuretics were held at discharge and need to be restarted carefully pending improvement of blood pressure and creatinine . 1) STEMI: She had an Inferior STEMI and was taken urgently to the cath lab where they placed BMS to the proximal and mid portions of the RCA. Upon return from the cath lab she had resolution of ST segment elevation with out ICD, or bradycardia. She remained chest pain free, but slightly tachycardic. She was not initially placed on a beta blocker or ACE due to the development of sepsis from a UTI. She had an echo which demonstrated a preserved EF. She was admitted briefly to the CCU for hypotension secondary to her sepsis, but upon arrival to the floor and volume resuscitation she was started on a beta blocker. She was not started on an ACE due to persistent [**Last Name (un) **]. Prior to discharge she was kept on Metoprolol, ASA 325, Plavix 75 daily and Atorvastatin 40 mg daily (decreased due to amio). . 2) Sepsis [**1-24**] UTI: The patient had profound WBC count on her UA and has a positve Urine culture with gram negative rods. She grew out E. Coli in her urine, but not in her blood. She was empirically started on aztreonam, vanc, and cipro IV. When she spiked a fever on day #2 of admission she was also started on clindamycin. When her cultures returned with the aforementioned speciation, her antibiotics were narrowed to PO cipro. She was give a 2 week course of antibiotics given her history of recurrent UTI. . 3) Hematemesis/Anemia/Fe def: The patient had two episodes of hematemesis after admission which were secondary to a presumed stress ulcer. On the night of admission an NGT could not be placed due to the patient's inability to tolerate the tube an acute desaturation. The patient was placed on a protonix drip and then transitioned to PO protonix [**Hospital1 **]. The case was discussed with the GI fellow who recommended an EGD and [**Last Name (un) **] prior to discharge, or as an outpatient. Because the patient had been started on aspirin and plavix for her STEMI and BMS, and her desire to have only one EGD and one Colonoscopy, it was felt that she should have the procedures as an outpatient when GI could intervene if they found a polyp. Once she is discharged from the hospital she will need follow up regarding her iron deficiency anemia. . 4) [**Last Name (un) **]: The patient has an eosinophilia, and rare eos on her microscopic exam. The differential for her [**Last Name (un) **] includes injury secondary to hypotension, although her urine output remains high and she was never oliguiric, interstitial nephritis, and ATN with contrast induce nephropathy, excess diuretics prior to admission. She had a renal US which did not demonstrate and pyelonephritis or hydronephrosis. Her diuretics were held, and on the day of discharge her Cr was 1.4. She also had repeated urine lytes which were not suggestive of a pre-renal etiology. . 5) Ischemic Cardiomyopathy with h/o cardiogenic [**Last Name (un) **]: Although she became hypotension secondary to sepsis, she was never in cardiogenic [**Last Name (un) **] or volume overloaded. Due to her [**Last Name (un) **] she was not started on her diruetics at the time of discharge but should be readdressed following her discharge. . 6) Mild Elevation in Gap in the setting of ARF with CR 1.7, baseline 1.0. She presented with a mild elevation in her gap that resolved with IVF and treatment of her infection. . 7) Peripherial Eosinophilia/Body Erythema: As mentioned above, she has a peripherial eosinophilia with normal LFT's w/o evidence of DRES. The only new medication added during admission was Iron sulfate, which could percipitate her drug reaction, although she was on lasix and iron sulfate prior to admission. She remained markedly erythematous and warm through out her hospital stay without a clear percipitatn for her drug reaction. She also did not have any cutaneous ulcers. On the day of discharge her erythema was significantly improved. . 9) Hyponatremia: The patient had a low serum NA with a urine osm and serum osm to suggest that she had SIADH, that was secondary to a chronic left sided effusion. However, her hyponatremia resolved after the administration of IV fluids in the setting of her sepsis. . 10) Back pain, Dejenerative Joint Disease without compression: The patients back pain continues to persist despite long acting morhpine, lidocaine patches, and hot packs. Her MRI shows dejenerative changes of the L/T spine, and crowding of the cauda equiana. She did not have evidence of a retroperitoneal bleed or fluid, but her MRI study was limited since she was not given contrast. Of note, she did not have any decrease in perianal sensation, numbness, bowel incontinence. Her strength was intact symmetrically, and her sensation and reflexes were intact. . 11) Fibromyalgia: She was restarted on her long acting morphine after she was admitted to the ICU for sepsis. She was also given lidocaine and warm packs for her pain. . 12) Cluster A personality (schizoid). She responds to questions in yes and no. She was continued on Haldol 1 mg PO qHS. . 13) Code status: Previous records indicate the patient is DNR/DNI by court order. However, the patient wanted to be full code, and after discussing the patient's clinical decision with the health care proxy, [**Name (NI) **] [**Name (NI) **], she was made full code. Please see the chart note regarding this discussion. CODE: FULL Medications on Admission: Aldactone 25 mg PO daily Aspirin 81 mg PO dilay Amiodarone 200 mg PO daily Colace 200 mg PO daily Ferrous Sulfate Oral Elixir 220 (44 Fe) MG/5mL 5 mL PO BID Flonase 50 mcg/dose 1 spray [**Hospital1 **] Lasix 80 mg PO daily Haldol 1 mg qHS Klor-Con 20 meq daily Levoxyl 25 mcg daily Ms Contin 30 mg PO BID Multivitamin daily Plavix 75 mg PO daily Prilosex 40 mg PO dilay Procrit Injection 20,000 MWF Senna 2 tabs PO daily Vitamin C 500 mg PO daily Lisinopril 2.5 mg PO daily Simvastatin 10 mg PO daily Allopurinol 100 mg PO daily Abluterol q4H PRN wheezing/respiratory distress Iprotropium q4H PRN wheezing/respiratory distress Benadryl 12.5 mg PO q8H PRN itch Calcium Caronate 1000 mg PO q4H: PRN Compazine 10 mg PO q8H PRN: nausea Dulcolax REctal Suppository 10 mg PR: PRN constpiation Fleet Enema: daily PRN constipation 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. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath. 8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 10. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). 11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 13. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days: Last dose [**2159-4-28**]. 17. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 19. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 20. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare & Rehabilitation Center - [**Location (un) 620**] Discharge Diagnosis: Primary Diagnosis: STEMI Secondary Diagnosis: Sepsis from UTI Stress Ulcer/Gastritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 65370**] You were admitted to the hospital with a heart attack (STEMI). You were given medicatoins to help thin your blood and you had a stent placed in your coronary arteries. Subsequently you had a infection in your urine that required you to go to the intensive care unit. You also had bleeding from your stomach which was thought to be secondary to stress. You were placed on antibiotics and medications that help prevent your stomach from bleeding. You also developed diffuse redness across your body which may be due to a reaction to a medication you received. The following medication changes were made: ADDED: Protonix, Hydroxyzine, Ciprofloxacin, Metoprolol, Zofran STOPPED: Aldactone, Lisonpril, Lasix, Ferrous Sulfate, Procrit, Vitamin C, Klor-Con, Flonase CHANGED: Aspirin Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please have the rehab call your PCP (Dr. [**Last Name (STitle) **] [**Numeric Identifier 65372**]) to schedule a follow appointment. He should arrange for you to have an EGD and a colonoscopy once you are no longer on plavix therapy. Please have the rehab facility call your cardiologist for a follow up appointment. You should be evaluated by Dr. [**First Name (STitle) **] [**Name8 (MD) 65373**] MD. Completed by:[**2159-4-25**]

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icd9cm

[ [ [] ] ]

[ "36.06", "00.44", "88.56", "00.46", "00.40", "00.66" ]

icd9pcs

[ [ [] ] ]

18916, 19024

10069, 16296

319, 344

19154, 19154

3667, 10046

20237, 20671

2723, 2728

17171, 18893

19045, 19045

16322, 17148

19305, 20214

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2765, 3648

274, 281

372, 1651

19092, 19133

19064, 19071

19169, 19281

1716, 2299

2315, 2707

41,216

109,589

40995+40996

Discharge summary

report+report

Admission Date: [**2165-4-24**] Discharge Date: [**2165-4-27**] Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 8587**] Chief Complaint: fall Major Surgical or Invasive Procedure: ORIF of Lt ulna and radius History of Present Illness: [**Age over 90 **] yo F transferred from ortho clinic today due fracture of distal radius and ulna requiring surgery. Patient fell 3 days ago when cat knocked her down. The exact details of the fall are unclear. [**Name2 (NI) **] did not seem well the next day so she was taken to HV Urgent Care where fracture of wrist was found. At that time she was referred to ortho clinic. Today at clinic her xrays were reviewed by Dr. [**Last Name (STitle) 1024**] and she was sent to the ED for surgery/admission. Past Medical History: PMHx: Idiopathic liver cirrhosis Cataracts Hyponatremia PSx: Cataract surgery Social History: Lives at home alone Has cats at home Non-smoker No alcohol use Family History: NC Physical Exam: AFVSS NAD RRR CTAB S/NT/ND LUE: Sensation intact to light touch. Fingers motor intact. Pertinent Results: [**2165-4-24**] 05:40PM BLOOD WBC-6.0 RBC-2.98* Hgb-10.9* Hct-31.5* MCV-106* MCH-36.5* MCHC-34.5 RDW-13.8 Plt Ct-127* [**2165-4-27**] 01:29AM BLOOD Hct-32.9* [**2165-4-24**] 05:40PM BLOOD Glucose-126* UreaN-36* Creat-1.5* Na-141 K-4.4 Cl-104 HCO3-25 AnGap-16 [**2165-4-27**] 05:40AM BLOOD Glucose-114* UreaN-37* Creat-1.2* Na-139 K-3.5 Cl-104 HCO3-24 AnGap-15 [**2165-4-24**] 05:40PM BLOOD ALT-38 AST-60* AlkPhos-75 TotBili-1.4 [**2165-4-27**] 05:40AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.7 Brief Hospital Course: Mrs.[**Known lastname 89432**] presented to the [**Hospital1 18**] on [**2165-4-24**] after a fall. She was evaluated by the orthopaedic surgery service and found to have a left forearm radius and ulna fracture. She was admitted, consented, and prepped for surgery. On [**2165-4-25**] she was taken to the operating room and underwent an ORIF of her left radius and ulna. She tolerated the procedure well, was extubated,transferred to the recovery room, and then to the floor. On POD 2, she recieved 2 units of PRBCs for postoperative blood loss. Her Hct was stable thereafter. She will be discharged to rehab and follow up with us in 2 weeks. Otherwise, the rest of her hospital stay was uneventful with his lab data and vital signs within normal limits and her pain controlled. She is being discharged today in stable condition. Medications on Admission: Lasix 20mg PO QD Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*60 Tablet(s)* Refills:*0* 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: left distal radius fracture left ulna fracture Discharge Condition: AAO X 3 Regular diet Discharge Instructions: ACTIVITY: Left lower extremity: touch down weight bearing Right lowere xtremity: weight bearing as tolerated Left upper extremity: weight bearing as tolerated Right upper extremity: weight bearing as tolerated General If you have any increased pain, swelling, or numbness, not relieved with rest, elevation, and or pain medication, or if you have a temperature greater than 101.5, please call the office or come to the emergency department. Medications 1) Lovenox is a blood thinner that you should take for 4 weeks. 2)Pain medicine: You have been prescribed a narcotic pain medication. Please take only as directed and do not drive or operate any machinery while taking this medication. There is a 72 hour (Monday through Friday, 9am to 4pm) response time for prescription refil requests. There will be no prescription refils on Saturdays, Sundays, or holidays. Please plan accordingly. Wound Care: - Keep Incision clean and dry. - Do not soak the incision in a bath or pool. - Staples should be removed in rehab on [**2165-5-7**] Physical Therapy: LUE: NWB RUE: WBAT LLE: WBAT RLE: WBAT Treatments Frequency: Left upper extremity cast to stay on until follow up visit Followup Instructions: Please follow-up in [**Hospital 1957**] Clinic in 2 weeks please call [**Telephone/Fax (1) 26936**] for an appointment. Completed by:[**2165-4-27**] Admission Date: [**2165-5-1**] Discharge Date: [**2165-5-4**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1257**] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: EGD [**2165-5-2**] History of Present Illness: Ms. [**Known lastname 89432**] is a [**Age over 90 **] F with a history per notes of cryptogenic cirrhosis and submucosal gastric neoplasm (never biopsied, first noted [**2160**]) who presents to the ED after she was noted to have a hematocrit drop in the setting of dark stool at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] rehab. Of note, she had a mechanical fall on [**2165-4-23**] with resulting displaced fracture of the left radius and ulna and underwent surgical correction on [**2165-4-25**]. She was discharged to rehab on [**2165-4-27**]. Hematocrit check on [**2165-4-28**] was 36, and repeat check today was 29. Patient was noted to have dark/melenotic-appearing stool and was transferred to the ED for further evaluation. Per patient, she has been having [**11-25**] dark stools daily for about the past 1 week. She denies N/V/D/C, abdominal pain, dyspepsia, rectal pain, dizziness/LH or syncope. . In the ED, initial vs were: T 99.3, HR 89, BP 109/75, RR 16, O2 sat 94% RA. Hematocrit on arrival was noted to be 23.8 down from 29 at rehab. She was given 1L IVF with NS. NG lavage was positive for dark, melenotic-appearing fluid; this cleared with 60 cc flush x 4. The patient received 80 mg IV pantoprazole and was started on pantoprazole gtt. The GI team was consulted from the ED (final recs pending) and the liver fellow was alerted given the possibility of variceal bleed with history of cirrhosis and recommended octreotide gtt. LFTs were added on to labs. She remained hemodynamically stable and comfortable in the ED. Vitals on transfer were HR 80s, BP 111/80, O2 sat 95% on RA. . On the floor, she reports feeling tired and wanting to sleep, but denies pain. She does report feeling a sensation of having to urinate, but after it is explained that she has Foley catheter in place she feels this is probably why. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Crptogenic cirrhosis: No known complications - Gastric tumor: Per [**Month/Day (2) 2287**] records, [**2160**] EGD notable for 1.5cm submucosal lesion in the proximal stomach c/w GIST tumor with associated ulceration/bleeding. Bleedings site clipped with endoclips. - Myledysplastic syndrome - Hyponatremia - s/p Cataract surgery - Radial/ulnar fracture s/p surgical repair [**2165-4-25**] Social History: Born in [**State 4565**]. Lives at home alone, though son [**Name (NI) **] and daughter-in-law [**Name (NI) **] live nearby. Never smoker. Does not drink alcohol. No recreational drug use. Family History: Not obtained Physical Exam: Physical Exam on [**Hospital Unit Name 153**] Admission Vitals: T: 96.4 BP: 121/98 P: 78 R: 25 O2: 97% on 2L General: Alert, oriented x 3 ([**Hospital1 **], date [**5-1**]), no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, arcus senilius, pupils reactive Neck: supple, JVP flat, left EJ in place, no LAD Lungs: Diminished BS at right base, 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, liver margin palpable ~2 cm below costal margin GU: Foley in place Ext: Warm, well perfused, 2+ pulses, left forearm in cast, mild left upper extremity edema above cast Pertinent Results: Pertinent labs [**2165-5-1**] 09:20PM BLOOD WBC-9.3 RBC-2.43*# Hgb-8.2*# Hct-23.8*# MCV-99* MCH-33.3* MCHC-33.7 RDW-16.9* Plt Ct-165 [**2165-5-1**] 09:20PM BLOOD Neuts-77.2* Lymphs-14.8* Monos-5.8 Eos-1.7 Baso-0.5 [**2165-5-1**] 09:20PM BLOOD PT-16.3* PTT-30.7 INR(PT)-1.4* [**2165-5-1**] 09:20PM BLOOD Glucose-120* UreaN-69* Creat-1.0 Na-137 K-4.0 Cl-103 HCO3-25 AnGap-13 [**2165-5-1**] 09:20PM BLOOD ALT-13 AST-31 LD(LDH)-248 AlkPhos-103 TotBili-0.9 [**2165-5-1**] 09:20PM BLOOD Albumin-2.6* [**2165-5-2**] 05:25AM BLOOD WBC-11.4* RBC-3.57*# Hgb-11.5*# Hct-34.4*# MCV-96 MCH-32.2* MCHC-33.4 RDW-18.1* Plt Ct-128* Imaging [**2165-5-1**] CXR- Low lung volumes, mild cardiomegaly and moderate alveolar pulmonary edema, increased compared to [**2165-4-24**]. There is a new small-to-moderate right pleural effusion. There is no focal consolidation, and no pneumothorax. Brief Hospital Course: [**Age over 90 **] year old woman with a history of gastric carcinoma and recent radial/ulnar fracture s/p surgical repair on Lovenox who presented with dark stool x 1 week and hematocrit drop. NG lavage was positive for grossly black/melenotic return. # UPPER GI BLEED: Patient presents with hematocrit drop from 35 -> 23 over 3 days in the setting of [**11-25**] dark bowel movements daily. Melenotic fluid was noted on NG lavage but cleared after ~240cc of saline flush. She has been hemodynamically stable and is otherwise asymptomatic. Discharge summary indicates that patient should receive Lovenox, but this medication was not on her med list so it is unclear whether she has been anticoagulated or not, though anticoagulation may have contributed to her current presentation. She has a reported history of gastric neoplasm though details are unknown as the lesion has never been biopsied; this may be the source of her bleed. In addition, she has a history of cryptogenic cirrhosis, which raises the possibility of variceal bleed. However, she has NG lavage that cleared with saline flush is reassuring that this is not brisk/active bleed and BPs have been stable in ED. Patient had EGD on [**5-2**] which showed 3 cord grade 1 esophageal varices, a 2 cm submucosal mass in the stomach, and superficial non-bleeding ulcers at the duodenum. Octreotide was discontinued. She was kept on ceftriaxone and transitioned from pantoprazole gtt to pantoprazole 40 mg po BID. 2 large bore PIV were maintained throughout. # S/P SURGICAL REPAIR OF RADIAL/ULNAR FRACTURE: Patient had mechanical fall with resulting displaced fracture of left radius/ulna, s/p surgical repair on [**2165-4-25**]. Discharge summary instructions state to continue Lovenox for 4 weeks; however, Lovenox is NOT on the discharge medication list. It was later confirmed with ortho that patient did not need to be on Lovenox for fracture of her arm. She continued with calcium and vitamin D. # CRYPTOGENIC CIRRHOSIS: MELD was 15 during prior admission (LFTs pending). She has no known history of variceal bleed but records may be incomplete. LFT was wnl. Octreotide was discontinued after EGD. # GASTRIC NEOPLASM: Details unknown; per [**Date Range 2287**] records, this was a submucosal mass noted on EGD in [**2160**] but in a difficult position for biopsy, so none was undertaken. Per patient and family, it seems she has no history of severe GIB, but EGD report does make note of overlying ulceration with bleeding treated with clips. No further work up of mass has been undertaken and patient has been asymptomatic. EGD confirmed a 2 cm submucosal mass. PCP/GI needs to f/u gastrin level (lab sent on [**5-3**]). # Increased pulmonary interstitial marking. ? baseline LV function. Minimal to no symptoms. BNP was negative. She had echocardiogram in the inpatient setting with pending results. She was discharged on oxygen. . Contact: [**Name (NI) **] [**Name (NI) **] and daughter-in-law [**Name (NI) **] live nearby; she has no official HCP. [**Name (NI) **] [**Name2 (NI) 2287**] records, [**Name (NI) 1569**] [**Name (NI) **] Son [**Telephone/Fax (1) 89433**]. Medications on Admission: Per PCP, [**Name10 (NameIs) 89434**] if patient is taking all of her medications. - furosemide 20 mg Tab Oral 1 Tablet(s) Once Daily - oxycodone 5 mg Tab Oral 0.5 Tablet(s) Every 4 hrs, as needed - senna 8.6 mg Cap Oral 1 Capsule(s) Twice Daily - Colace 100 mg Cap Oral 1 Capsule(s) Twice Daily - Mapap (acetaminophen) 325 mg Tab Oral 2 Tablet(s) Every [**5-1**] hrs, as needed - Caltrate 600 + D 600 mg (1,500 mg)-400 unit Chewable Tab Oral 1 Tablet, Chewable(s) Twice Daily - vhc supplement 60ml Twice Daily between meds Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: Three (3) Tablet, Chewable PO once a day. 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO once a day. 4. 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* 5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: gastrointestinal bleeding gastric ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted because of gastrointestinal bleeding and you had endoscopy and we found an ulcer. You will be on a high dose acid reducer and you have to follow up with our gastrointestinal doctors Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [**2165-5-16**] at 1:20 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 [**2165-5-16**] at 1:40 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: DIV. OF GASTROENTEROLOGY When: THURSDAY [**2165-7-25**] at 2:00 PM With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

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icd9cm

[ [ [] ] ]

[ "45.13", "79.32" ]

icd9pcs

[ [ [] ] ]

14023, 14145

9473, 12631

4901, 4921

14228, 14228

8578, 9450

14627, 15580

7805, 7819

13204, 14000

14166, 14207

12657, 13181

14403, 14604

7834, 8559

4341, 4380

4402, 4462

4847, 4863

6832, 7167

4190, 4323

4949, 6814

14243, 14379

7189, 7583

7599, 7789

43,911

139,067

25589

Discharge summary

report

Admission Date: [**2126-9-7**] Discharge Date: [**2126-9-10**] Date of Birth: [**2064-5-9**] Sex: M Service: CARDIOTHORACIC Allergies: Dilaudid Attending:[**First Name3 (LF) 4679**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: [**2126-9-7**] EGD History of Present Illness: 62M s/p recent minimally invasive esophagectomy on [**2126-7-31**], presents with 3 episodes of hematemesis. The patient describes occasional nausea, sensation of "something stuck" in his esophagus over the past few weeks, with occasional regurgitation of small amounts of mucus-like contents, containing no blood, food, or bile, approximately 2-5 times/week. This morning, he reports feeling similarly nauseous, and after consuming a waffle for breakfast, vomiting approximately "enough to cover [**3-10**] of the water surface in the toilet bowl". The contents were clear mucus with intermixed bright red blood. He was light-headed at the time, but denies syncope/dizziness/chest pain/shortness of breath/abdominal pain. He was advised to visit the Emergency Department. En route to the hospital, he experienced another bout of bright red emesis, measuring approximately 100 cc. In the ED, he experienced yet one more episode of 150 cc of bright red emesis with visible clots, intermixed with clear-colored mucus. In the ED, he reports no lightheadedness, no dizziness, no chest pain, no shortness of breath, no diaphoresis. He does acknowledge feeling palpitations, and a continued sensation of nausea/dysphagia. He denies any recent melena or BRBPR. He has had normal intake of food recently, as well as his regular intake of 4 cans of tube feeds (Replete) daily. Of note, he reports holding his aspirin, plasugrel, and HTN medications this morning. Past Medical History: PMH: GE junction adenocarcinoma, HTN, MI ([**2-/2125**]) s/p drug-eluting stent placement in LAD, GERD, IBS, J tube site infection PSH: J tube insertion ([**2126-6-19**]), minimally invasive esophagectomy ([**2126-7-31**]) Social History: -Tobacco history: [**3-10**] cigars per day -ETOH: previous heavy drinker, cut down significantly 10 yrs ago -Illicit drugs: never -lives with wife -works as trucker . Family History: Parents were healthy into old age. Is unaware of any hx of CAD or SCD. . Physical Exam: Vitals: 98.2 102 118/82 18 100%RA GEN: A&O, in no apparent distress HEENT: No scleral icterus, mucus membranes moist CV: tachycardic, regular rate, no murmurs/rubs/gallops PULM: Clear to auscultation bilaterally, no wheezes/rhonchi/crackles ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses, well healed laparoscopic incisions, J-tube in place with clean/dry/intact insertion site with no surrounding erythema/induration/drainage. Ext: No LE edema, LE warm and well perfused Pertinent Results: EGD [**2126-9-7**] Findings: Esophagus: Excavated Lesions Two ulcers linear ulcers just below the esophageal gastric ulcers were seen ranging in size from 11 mm to 10 mm that started at 26 cm from the incisors were found in the upper third of the esophagus. Clips from the surgery were seen near these ulcers. At the time of the procedure there was no active bleeding. Stomach: Normal stomach. Duodenum: Normal duodenum. [**2126-9-7**] 12:10PM WBC-10.0 RBC-3.29* HGB-10.3* HCT-30.8* MCV-94 MCH-31.2 MCHC-33.3 RDW-14.0 [**2126-9-7**] 05:18PM HCT-27.7* [**2126-9-7**] 12:10PM PT-11.4 PTT-28.9 INR(PT)-1.1 Brief Hospital Course: Mr. [**Known lastname 63878**] was admitted [**2126-9-7**] for hematemsis. His vital signs on admission were stable. He underwent an EGD that showed actively bleeding ulcers and a tear near the anastamosis likely secondary to retching. He was then intubated and repeat EGD showed no active bleeding. He was left intubated to prevent further bleeding from retching. He was maintained on propofol and required phenylephrine. He was also started on a PPI drip. His hct was monitored q6 hours. His Hct slowly dropped over the day on [**9-7**] but was above the transfusion threshold. On [**9-8**] he was extubated and pressors were stopped. He was also transfused 1U PRBC for a hct of 24.7. He had a possible transfusion reaction, was febrile to 102, which came down with tylenol. No evidence of hemolysis was found. His hematocrit has remained stable at 25-26. He was also orthostatic [**2126-9-8**] PM, with HR 130s and BP 80s systolic. He denied chest pain, but the monitor showed some ST changes, and an ECG and troponins were obtained. ECG did not show ST elevations different from baseline. Troponins were negative. He denied chest pain/SOB. He continued to be maintained on PPI gtt and was started on sucralfate. His tube feeds were cycled at night. On [**2126-9-9**], he was feeling well and without nausea. He did endorse some mild midepigastric pain with coughing. We started him on some albuterol nebs, which he says has improved his cough. He was started on a clear liquid diet, which he tolerated well. He was transitioned to a regular soft mechanical diet in the pm, which he tolerated well. On [**2126-9-10**], he continued to tolerate a regular soft diet, had no nausea/vomiting, and was discharged home in good condition. His prasugrel and aspirin were held throughout his hospital course due to his acute GI bleed. His last dose was on Friday [**2126-9-6**]. We contact[**Name (NI) **] his cardiologist Dr. [**Last Name (STitle) **] re: the need for further anti-platelet therapy. She advised discontinuing the prasugrel indefinitely, as it has been over a year since his stent was placed, but recommended resuming his aspirin as soon as possible from a bleeding standpoint. We have advised the patient to resume his aspirin on Wednesday [**2126-9-11**]. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Lorazepam 0.5 mg PO Q6H:PRN anxiety/nausea 3. Atenolol 25 mg PO DAILY 4. Prasugrel 10 mg PO DAILY 5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 6. Nitroglycerin SL 0.4 mg SL PRN chest pain 7. Aspirin 81 mg PO DAILY 8. Fluoxetine 10 mg PO DAILY Discharge Medications: 1. Sucralfate 1 gm PO QID RX *sucralfate 1 gram/10 mL 10 Suspension(s) by mouth four times a day Disp #*600 Milliliter Refills:*1 2. Ondansetron 4 mg PO Q8H RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*20 Tablet Refills:*2 3. Prochlorperazine 10 mg PO Q6H:PRN nausea RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*1 4. Albuterol Inhaler [**1-7**] PUFF IH Q4H:PRN cough 5. Lorazepam 0.5 mg PO Q8H:PRN nausea 6. Aspirin 81 mg PO DAILY Restart Wednesday [**2126-9-11**] 7. Fluoxetine 10 mg PO DAILY 8. Nitroglycerin SL 0.4 mg SL PRN chest pain 9. Atenolol 12.5 mg PO DAILY RX *atenolol 25 mg 0.5 (One half) tablet(s) by mouth once a day Disp #*60 Tablet Refills:*2 10. Lansoprazole Oral Disintegrating Tab 30 mg PO BID RX *lansoprazole 15 mg 2 tablet(s) by mouth twice a day Disp #*100 Tablet Refills:*4 Discharge Disposition: Home Discharge Diagnosis: gastric ulcer, tear at anastomosis acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for an upper GI bleed and bloody vomiting and nausea. Your vomiting has stopped and your blood count is stable. Please continue your pantoprazole for gastric ulcer treatment and zofran for nausea treatment. We have been holding you prasugrel and aspirin since Saturday. You can stop taking the prasugrel indefinitely. Please resume your aspirin on Wednesday [**2126-9-11**]. Please keep your appointment with your cardiologist Friday [**2126-9-13**] to discuss these recent changes. Call Dr[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers greater than 101 or chills -Increased shortness of breath, cough or chest pain -Nausea, vomiting (take anti-nausea medication) -Increased abdominal pain -Incision develops drainage -Recurrence of bloody vomiting Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tub until incision healed -No driving while taking narcotics -No lifting greater than 10 pounds until seen -Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30 minutes daily Diet: Tube feeds: Replete Full Strength 90 x 10 hrs Flush J-tube with water every 8 hours with 10 cc's of water, before and after starting tube feeds and giving medications through tube You may resume your regular diet as tolerated. Eat small frequent meals. Sit up in chair for all meals and remain sitting for 30-45 minutes after meals Daily weights: keep a log bring with you to your appointment NO CARBONATED DRINKS Call if J-tube falls out (save the tube and bring with you to the hospital to be re-placed) or suture breaks Followup Instructions: Department: CARDIAC SERVICES When: FRIDAY [**2126-9-13**] at 2:00 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2126-9-19**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2126-9-19**] at 9:30 AM With: [**First Name8 (NamePattern2) 13018**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2126-9-19**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2348**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please report 30 minutes prior to your appointments on [**2126-9-19**] to the Radiology Department on the [**Location (un) **] of the Dahpiro Clinical Center for a chest xray. Completed by:[**2126-9-10**]

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icd9cm

[ [ [] ] ]

[ "45.13", "96.71", "96.04", "96.6" ]

icd9pcs

[ [ [] ] ]

7143, 7149

3519, 5790

285, 306

7251, 7251

2883, 3496

9066, 10492

2243, 2317

6232, 7120

7170, 7230

5816, 6209

7402, 9043

2332, 2864

234, 247

334, 1792

7266, 7378

1814, 2040

2056, 2227

73,896

116,511

54816

Discharge summary

report

Admission Date: [**2158-7-22**] Discharge Date: [**2158-8-28**] Date of Birth: [**2074-7-15**] Sex: F Service: MEDICINE Allergies: Penicillins / aspirin Attending:[**First Name3 (LF) 3705**] Chief Complaint: Altered mental satus Major Surgical or Invasive Procedure: Left frontal Temporal Craniotomy for Subdural Hematoma History of Present Illness: The patient is an 84 year old female with history of hypertension and GERD who was visiting her daughter and grandson from [**Country 26467**] when she experience a mechanical fall 3 days prior to admission after slipping on wet grass and landing on her right shoulder. She denied hitting her head at the time, denied loss of consciousness, and had no report of neck pain. She was initially brought to the ED at [**Hospital6 2561**] for evaluation of her right shoulder pain and decreased range of motion. She was diagnosed with shoulder dislocation, and the shoulder was re-located with no imaging of the head or torso obtained. The patient was subsequently discharged home from the ED with a sling for the right upper extremity. She initially did well until the night before admission when she began experiencing increasing confusion, altered mental status, and another fall. She returned to [**Hospital6 2561**] where a CT of the head was obtained which demonstrated a significant (1.9cm) left sub-dural hematoma and 7mm midline shift. The patient was then transferred to [**Hospital1 18**] for Neurosurgical intervention. Past Medical History: HTN GERD Social History: Lives in [**Country 26467**], No Tobacco or ETOH. Family History: Non-contributory. Physical Exam: PHYSICAL EXAM ON ADMISSION: O: T: 99.6 BP: 191/100 HR:138 R 14 O2Sats 99 2L Gen: WD/WN, comfortable, NAD. HEENT: NCNT Neck: Hard collar Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake, not following commands or answering questions. Language:Garbled speech Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: UA [**Doctor First Name 81**]: UA. XII: UA. Motor: Right arm in sling, bruised. moving right lower with stim, moves left upper and lower spontaneously. Handedness Right PHYSICAL EXAM ON DISCHARGE: VS: 97.9, 149/87 (130s-140s/70s-80s), 97, 18, 97% RA General- NAD, well-appearing in bed HEENT- Sclera anicteric without injection or erythema, MMM. Recent craniotomy scar, incision c/d/i. Lungs- CTA bilaterally, without wheezes, rales CV- Regular rhythm with tachycardia, normal S1 + S2, no m/r/g Abdomen- soft, non-tender, non-distended, (+)BS, no rebound or guarding GU- diaper, incontinent to urine Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, RUE in sling Neuro- CN II-XII grossly intact, moving all extremities, AOx3 this morning Pertinent Results: ECG [**2158-7-22**] Sinus tachycardia with premature atrial contractions. No previous tracing available for comparison. ECG [**2158-7-22**] Sinus tachycardia. Compared to tracing #1 ectopy is not seen. CT head [**2158-7-22**] 1. Expected postoperative changes, status post left craniotomy and evacuation of the previously large subdural hematoma. Larger than expected quantity of pneumocephalus with displacement of underlying parenchyma - correlate clinically to decide on further mngt. /followup. 2. Significant resolution with persistent small amount of left sided subdural hemorrhage as above. X-ray shoulder [**2158-7-22**] There is again seen a complex fracture involving the right proximal humerus with fracture line predominantly through the surgical neck. There is a displaced greater tuberosity fracture and there is varus angulation at the fracture. There is no glenohumeral joint dislocation. There is generalized demineralization. LENIS [**2158-7-24**] No deep vein thrombus in the left or right lower extremity Right Tib/Fib X-ray [**2158-7-25**] No evidence of bone or soft tissue abnormality. Superior patellar spurring and patellofemoral spurring noted. Vascular calcification is seen posterior to the distal femur [**2158-7-27**] Chest Xray: As compared to the previous radiograph, pre-existing signs of mild fluid overload have improved. There currently is no evidence of pneumonia. Borderline size of the cardiac silhouette. Moderate hiatal hernia. No pleural effusions. A previously visualized right humeral fracture is less evident than on the previous image. [**2158-7-30**]: As compared to the previous radiograph, there is no relevant change. Constant signs of mild fluid overload. No evidence of pneumonia. Borderline size of the cardiac silhouette. No pleural effusions. [**2158-8-1**] CT head: no new hemorrhage. Improving pneumocephalus, improving cerebral edema, improving subdural collections. [**2158-8-1**] LENIS: No lower extremity DVT [**2158-8-4**] U/S Abd: Cholelithiasis in a contracted gallbladder. No intrahepatic or extra-hepatic biliary ductal dilatation. Normal son[**Name (NI) 493**] appearance of the liver without focal lesions. [**2158-8-11**] CT Head: In comparison to [**2158-8-7**] exam, there is no significant change inpostoperative changes related to left parietal craniotomy. Left extra-axial collection is not significantly changed since prior. No new intracranial hemorrhage. [**2158-8-11**] Xray Shoulder: Healing complex fracture involving the right proximal humerus through the surgical neck. No new acute fractures or dislocations. [**2158-8-21**] CT Head: In comparison to the [**2158-8-11**] exam, there is no significant change in the postoperative changes related to left parietal craniotomy. Left extra-axial collection is not significantly changed since prior and likely represents a hygroma. No new intracranial hemorrhage. [**2158-8-22**] V/Q (Lung) Scan: Low probability for a pulmonary embolus. Admission Labs: [**2158-7-22**] 10:20AM BLOOD WBC-15.7* RBC-3.59* Hgb-12.7 Hct-36.6 MCV-102* MCH-35.4* MCHC-34.7 RDW-12.3 Plt Ct-213 [**2158-7-22**] 10:20AM BLOOD Neuts-93.8* Lymphs-3.0* Monos-2.8 Eos-0.1 Baso-0.2 [**2158-7-22**] 10:20AM BLOOD PT-10.8 PTT-25.7 INR(PT)-1.0 [**2158-7-22**] 10:20AM BLOOD Glucose-137* UreaN-16 Creat-0.7 Na-127* K-4.8 Cl-89* HCO3-23 AnGap-20 [**2158-7-24**] 01:00PM BLOOD CK(CPK)-270* [**2158-7-24**] 01:00PM BLOOD CK-MB-5 cTropnT-0.07* [**2158-7-22**] 02:38PM BLOOD Calcium-7.7* Phos-3.1 Mg-1.6 [**2158-7-22**] 01:21PM BLOOD Type-ART Temp-37.4 Rates-/8 Tidal V-630 PEEP-3 FiO2-50 O2 Flow-1.0 pO2-262* pCO2-32* pH-7.47* calTCO2-24 Base XS-1 Intubat-INTUBATED Vent-CONTROLLED Microbiology: URINE CULTURE (Final [**2158-8-13**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 ORGANISMS/ML.. COAG NEG STAPH does NOT require contact precautions, regardless of resistance Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R TETRACYCLINE---------- 2 S VANCOMYCIN------------ 1 S [**2158-8-17**] 7:06 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2158-8-18**]** C. difficile DNA amplification assay (Final [**2158-8-18**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. Discharge Labs: Patient did not have further laboratory results after [**2158-8-16**], attempted to minimize routine/unnecessary lab work in the setting of no concerning complaints, signs, or symptoms [**First Name8 (NamePattern2) **] [**Doctor First Name **] protocol. Brief Hospital Course: The patient is an 84 year old female with history of hypertension and GERD presenting after a mechanical fall with resultant subdural hematoma and evacuation on the neurosurgical service, subsequently transferred to the medical service for management of persistent tachycardia, UTI, and delirium. . ACTIVE ISSUES and HOSPITAL COURSE: On the surgical service: Ms. [**Known lastname **] was evaluated in the ED on [**7-22**]. After review of her outside cranial CT she was taken to the operating room for an emergent left craniotomy for SDH evacuation. . She was followed by Orthopedics for her right upper extremity fracture and a sling was recommended. On [**7-23**] she had a Temp of 101.5 F. Fever work up was initiated, which unrevealing. On [**7-24**] she was tachycardic to 130. EKG demonstrated sinus tachycardia. LENIs to evaluate for DVT were negative. Troponins were obtaine and trended down from 0.07 to 0.05. On [**7-25**] A corrected Dilantin level was 10.2. She had a brief mom[**Name (NI) **] of confusion in the afternoon but this self resolved. . Patient continued to actively work with PT for rehabilitation. As patient is originaly from [**Country 26467**], and her the maximum of her travelers' insurance reached, she was not a candidate for inpatient rehabilitation in the US. The Australian consulate was consulted and stated that they were willing to pay for transportation to [**Country 26467**]. However, the neurosurgery service deemed patient unable to fly for 30 days after her surgery. . On [**7-27**], patient was febrile to 101. The UA was normal and the CXR demonstrated no evidence of pneumonia. . On [**7-28**], patient's continued tachycardia and fevers prompted a medicine consult. The primary service institued their recommendations to obtain orthostatics, obtain blood and urine cultures, bolus the patient 1000 mL of normal saline, place water at the bedside for patient to drink at liberty, and discontinue percocet and replace with standing tyelenol and oxycodone. . Tachycardia continued to persist on [**7-29**], a TSH was obtained to rule out thyroid disease as potential cause, it was normal. Patient's electrolytes were repleted as they were observed to be low. . On [**7-30**], patient suffered increased confusion when examined during morning rounds. Her blood cultures came back came back as normal and her urine cultures from [**7-28**] demonstrated lactobacillus. Levofloxacin was initiated. Repeat urine cultures were obtained for speciation and sensitivities. As part of confusion work-up, CXR, EKG, troponins x1, and orthostatics were obtained. CXR revealed mild fluid overloading; strict ins and outs were instituted and the patient received lasix. All other confusion work-up remained negative. Patient's confusion cleared briefly later in the afternoon. . On [**7-31**] she remained stable and on [**8-1**] she continued to have confusion. Head CT was obtained and was stable, no new findings. . Upon transfer to the medical service: . # Altered mental status: The patient came to the medical service with waxing and [**Doctor Last Name 688**] mental status, concern for infection vs. delirium. CXR from admision and on repeat were negative for a pneumonia. The patient was not experiencing fevers, and no blood cultures were positive. A toxic metabolic workup by LFTs and electrolytes was normal. All sedating medications, including oxycodone, tramadol, and benzos were discontinued. Given head bleed, patient was at high risk for delirium and seizure. Head CT was repeated to rule out any further acute bleeding. Geriatrics was consulted who recommended starting venlafaxine for depression and for its activating effects. Excess lines and tethers were removed at all times to avoid further contribution to delirium. Patient was found to have a positive UTI (coag negative staph) and was treated with nitrofurantoin. Her mental status cleared about one week prior to discharge. . #Subdural Hematoma: Patient is s/p mechanical fall which was complicated by subdural hematoma evacuated by neurosurgery on [**7-30**]. Patient was on levetiracetam 750mg for seizure prophylaxis. Repeat CT scans demonstrated no change. . #Tachycardia: Patient was found to be tachycardic from 95-115 throughout hospital stay. Patient remained asymptomatic. The tachycardia was fluid-responsive, but would reoccur within hours administration. Patient was screened for infections, found not to have pneumonia. The patient did have a UTI, but the tachycardia persisted despite resolution. Concern for PE arose given benign tachycardia. Patient had multiple lower extremity ultrasounds performed which did not reveal DVT. A V/Q lung scan was performed which demonstrated she was low probability for PE. Patient's tachycardia was trended and patient was monitored. . # Rectal bleeding: Patient had one episode of BRBPR while inpatient. She remained normotensive, with no further elevation of her heart rate. Stool found to be guaiac positive, brown. Her hematocrit remained stable, and no further episodes occurred. . TRANSITIONAL ISSUES: Patient had foley catheter inserted prior to discharge for flight to [**Country 26467**]. Foley should be discontinued upon arrival to reduce risk of UTI. Medications on Admission: Nexium BP med-name unknown Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: SDH Humerus fracture Hypokalemia Hypocalcemia Hypophosphatemia UTI Secondary Diagnoses: Hypertension Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair.

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icd9cm

[ [ [] ] ]

[ "38.82", "01.31" ]

icd9pcs

[ [ [] ] ]

13510, 13516

8194, 8511

303, 359

13692, 13692

3059, 4897

1629, 1648

13537, 13624

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1691, 1913

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8,519

197,389

14074

Discharge summary

report

Admission Date: [**2136-1-11**] Discharge Date: [**2136-1-24**] Date of Birth: [**2062-1-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: aflutter Major Surgical or Invasive Procedure: None History of Present Illness: 73 yo male resident of [**Hospital3 **] with h/o VRE and MRSA bacteremia, osteomyelitis, CAD s/p CABG, hypertension, and recent trach placement presents with asymptomatic aflutter and lethargy. His heart rate was not responsive to IV Lopressor 10mg x3 and metop 25 mg po x1. Rate continued to be in the 120's. He was started on a Dilt gtt, with decrease in his SBP to the 110's from 130's. Heart rate minimally responsive with rates in 110-120's. . He received a dose of unasyn (recent urine culture with acinetobacter sensitive to unasyn), linezolid (recent VRE bacteremia). Given PO Flagyl for a recent C diff infection. First set of cardiac enzymes; CK 23, trop 0.04. WBC count 14 with 10% bands. Blood and urine cultures sent in ED. Also given 1L NS bolus. . At baseline pt requires trach mask ~15 L. . Currently denies any f/ch, chest pain/sob, n/v, abd pain, not aware of flutter. No dysuria. Not oriented. Past Medical History: 1. Hyperlipidemia 2. CAD s/p MI s/p CABG in [**2110**] and [**2125**]. last stress was an adenosine stress in [**8-21**] showing fixed mid-lateral wall defect 3. CHF with normal EF (last echo [**2135-8-30**]) 4. Mild aortic stenosis 5. Mild mitral regurgitation 6. Hypertension 7. Chronic Atrial fibrillation/flutter since [**2128**] on Coumadin 8. Right foot cellulitis [**2133-9-24**] 9. Osteoarthritis 10. h/o MRSA epidural infection 11. Parkinson's Disease 12. s/p trach and PEG during last admission for sepsis ([**Date range (1) 41971**]) . Past Surgical History: 1. CABG x2 in [**2110**] and [**2125**] 2. multiple toes right foot amputated from dry gangrene following aneurysm rupture in right leg 3. Right leg aneurysm repair 4. Tonsillectomy 5. Appy Social History: Lives at [**Hospital3 **]. no Tob, no EtOH, no Illicit drug Family History: NC Physical Exam: Physical Exam: Tm 101.8 BP 108/45 HR 115 RR 18 Sat 90 on 15L 40% cool mist. Gen: NAD, lethargic male, arousable, follows commands. HENNT: EOMI, PERRL, anicteric, PERRL, mm dry. Neck: JVD, tacheostomy with thick green sputum. CV: tachy RR, distant heart sounds. unable to appreciate any M/R/G Lungs: rhonchorous breath sounds b/l. no wheezes, crackles at bases. Abd: soft, NT/ND, +BS, No HSM, peg site c/d/i, no erythema. Back: surgical scar appreciated, rectal tube in place, stage one sacral decub ulcer. [**Hospital3 **]: no edema, no clubbing, no cyanosis, DP/PT 1+ b/l. Right lower [**Hospital3 **] with scar in the lower leg/muscle atrophy, amputated toes in right foot, remaining third digit. Neuro: A&Ox1, CNII-XII grosslyt intact, UE/LE muscle strength [**3-21**] in both upper [**Last Name (LF) **], [**First Name3 (LF) **] cogwheel rigidity, [**2-19**] in lower extremities. sensation intact to light touch. . Pertinent Results: Admission Labs: [**2136-1-11**] 05:00AM BLOOD WBC-14.9* RBC-3.85* Hgb-12.6* Hct-33.8* MCV-88 MCH-32.7* MCHC-37.2* RDW-18.5* Plt Ct-440 [**2136-1-11**] 05:00AM BLOOD Neuts-67 Bands-10* Lymphs-14* Monos-6 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2136-1-11**] 05:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL [**2136-1-11**] 05:00AM BLOOD PT-42.5* PTT-38.1* INR(PT)-4.8* [**2136-1-11**] 05:00AM BLOOD Plt Smr-HIGH Plt Ct-440 [**2136-1-11**] 05:00AM BLOOD Glucose-116* UreaN-29* Creat-1.1 Na-136 K-4.5 Cl-104 HCO3-20* AnGap-17 [**2136-1-11**] 05:00AM BLOOD CK(CPK)-23* [**2136-1-11**] 10:30AM BLOOD CK(CPK)-58 [**2136-1-12**] 04:45AM BLOOD CK(CPK)-23* [**2136-1-11**] 05:00AM BLOOD CK-MB-NotDone proBNP-7417* [**2136-1-11**] 05:13AM BLOOD cTropnT-0.04* [**2136-1-11**] 10:30AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2136-1-12**] 04:45AM BLOOD CK-MB-NotDone cTropnT-0.04* [**2136-1-11**] 09:00PM BLOOD Calcium-8.1* Phos-3.4 Mg-1.4* [**2136-1-11**] 05:00AM BLOOD Digoxin-0.8* [**2136-1-11**] 10:44AM BLOOD Type-ART O2 Flow-15 pO2-61* pCO2-33* pH-7.42 calHCO3-22 Base XS--1 Intubat-NOT INTUBA Comment-TRACH [**Last Name (un) **] [**2136-1-11**] 10:44PM BLOOD Type-ART pO2-113* pCO2-36 pH-7.37 calHCO3-22 Base XS--3 Intubat-NOT INTUBA [**2136-1-11**] 05:07AM BLOOD Lactate-1.6 [**2136-1-11**] 10:44AM BLOOD Lactate-1.4 [**2136-1-11**] 10:44PM BLOOD Lactate-0.9 Studies: CXR [**2135-1-11**]: report cut off. ECG: a flutter at 92bpm. . CXR [**2135-1-16**]: New opacities in the right lower lobe and right upper lobe. This may either represent evolving pneumonia or aspiration. Findings communicated to Dr. [**Last Name (STitle) 349**]. . CXR [**2135-1-19**]: No evidence for pneumonia. Brief Hospital Course: (For further details of ICU admission, please see addendum to be completed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) 73 yo male resident of [**Hospital3 **] with h/o VRE and MRSA bacteremia, osteomyelitis, CAD s/p CABG, hypertension, and recent trach placement admitted [**2136-1-11**] to ICU with asymptomatic aflutter and lethargy. He was placed on dilt gtt for rate control, and received a dose of unasyn (recent urine culture with acinetobacter sensitive to unasyn), linezolid (recent VRE bacteremia), and PO Flagyl for a recent C diff infection. Patient was given fluid, including PRBC x 2 units with appropriate improvement in Hct. He was also noted to have had an elevated INR, which did not improve with Vit K, so today he was given a unit of FFP. He improved clinically, Abx were scaled back, and currently on cipro and flagyl, afebrile and with improved WBC count. Pt was in paroxysmal Aflutter, which was adequately rate controlled on PO meds. He was called out to the floor. . The patient was recently admitted for a month, during which time he was treated for VRE line infection with 14 days of linezolid, as well as 5 days of zosyn for acintobacter UTI. He was intubated for hypoxic respiratory distress, and was unable to be extubated, and was trach'd. He was also noted to have been in and out of aflutter during that admission, which prompted starting digoxin for added rate control. On the floor, he was noted to have episodes of atrial flutter into the 120s. His beta blocker was increased, and consideration was made for cardioversion or ablation; EP was curbsided and said that the patient would be a poor candidate for amiodarone or DCCV. His metoprolol was increased and his rate was better controlled in the 80s. On [**1-15**], he developed a fever to 102. Urine and blood were sent for cultures, and he was started empirically on linezolid for possible UTI given his history of VRE. Urine cultures grew out Ecoli sensitive to ciprofloxacin and VRE sensitive to Linezolid. Blood cultures remained NGTD. Stool cultures confirmed the diagnosis of CDiff. Initial CXR had no evidence of pna. Repeat CXR showed patchy area of aspiration vs. pna. A CXR a few days later, did not have any infiltrates. Pt was continued on flagyl for treatment of Cdiff. Pt was given linezolid and cipro for treatment of UTI. Of note, pt was also noted to have some scrotal erythema and edema, first noted on [**1-14**], which did not appear progress. Linezolid would cover cellulitis as well. His foley catheter was removed and he had a condom cath placed. Pt had intermittent episodes of fever and elevated WBC, while on Linezolid, Flagyl, and Cipro. Repeat urine and blood cultures were negative. Pt remained afebrile for several days with a decreasing WBC count prior to discharge. Medications on Admission: 1. Bisacodyl 10 mg PO DAILY as needed 2. Docusate Sodium 150 mg/15 PO BID as needed 3. Simvastatin 80 mg PO DAILY 4. Digoxin 125 mcg PO DAILY 5. Acetaminophen 160 mg/5 mL Solution PO Q4-6H as needed. 6. Metoprolol Tartrate 100 mg PO TID 7. Albuterol 1 puff Inhalation Q2H 8. Ipratropium 1 puff q6H 9. Captopril 25 mg PO TID 10. Miconazole Nitrate 2 % Powder Appl Topical TID as needed. 11. Aspirin 81 mg Chewable PO DAILY 12. Pantoprazole 40 mg daily 13. Heparin 5,000 Injection TID 14. Warfarin 2.5 mg PO DAILY 15. Carbidopa-Levodopa 25-100 mg 0.5 Tablet PO QID 16. Ibuprofen 600 mg PO Q8H as needed. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Carbidopa-Levodopa 25-100 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation QID (4 times a day). 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 21 days. 9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) susp PO DAILY (Daily). 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 11. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 13. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours): please give at 4am, 12pm, 8pm. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnoses VRE/Ecoli UTI Cdiff colitis Atrial flutter with RVR Secondary diagnoses: CAD CHF Aortic stenosis HTN Atrial flutter Parkinson's syndrome UTI CDiff colitis Discharge Condition: Stable Discharge Instructions: Please continue all medications as prescribed. Followup Instructions: Follow up with your primary care physician [**Name Initial (PRE) 176**] 1-2 weeks.

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icd9cm

[ [ [] ] ]

[ "96.6", "99.04", "00.14" ]

icd9pcs

[ [ [] ] ]

9618, 9688

4882, 7713

323, 330

9906, 9915

3136, 3136

10011, 10096

2156, 2160

8366, 9595

9709, 9780

7739, 8343

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2190, 3117

9801, 9885

275, 285

358, 1279

3153, 4859

1301, 1848

2078, 2140

21,312

150,854

4086

Discharge summary

report

Admission Date: [**2181-12-7**] Discharge Date: [**2182-2-1**] Date of Birth: [**2105-5-21**] Sex: F Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 297**] Chief Complaint: Increased drooling, facial twitching Major Surgical or Invasive Procedure: Left Subclavian Central Line Placement History of Present Illness: 76 y/o with PMH significant for HTN, CAD, DM, dementia(baseline A +O x 3, w/ expressive dysphasia [**1-31**] to CVA), [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] [**Male First Name (un) 1291**], L MCA stroke, CHF and other medical problems who presents with w/ two days of right facial twitching, one day of increased drooling (noted at dinner time today), and worsening of normally mild right facial droop and slurred speech while at her nursing home. The nurse noted a concerned look on her face, though she remained alert and aware of the situation. Her words were also unclear. The nurse at the nursing facility called EMS. . Of note, she also experience increased shortness of breath over the past week. This was felt to be CHF. At [**Hospital1 5595**], her MD started to diurese her w/ lasix. Her wt improved from 266 to 253 over the week. Denies CP or n/v/d. Past Medical History: HTN Dyslipidemia DM [**Hospital1 1291**] ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical valve) CAD. S/p cardiac cath in [**6-2**] and has been on plavix since then. Unclear if stent was placed at that time. Diastolic dysfunction EF >55%, 2+TR, moderate PASP CVA Left MCA [**2149**] and [**2151**] with expressive aphasia Dementia, oriented to person, place, time, can read watch recognizes son, has evidence of small vessel infarcts on CT h/o seizures after stroke on dilantin until late 80's PVD with amputations of three toes on right foot h/o R heel osteo H/o esophageal ulcers Depression Gallstones Spinal stenosis H/o pulmonary sarcoid H/o PBC h/o C diff h/o VRE urinary infection h/o decubitus ulcer followed at [**Hospital1 756**] by Dr. [**Last Name (STitle) 17974**] hypothyroidism Social History: Lives at [**Hospital 100**] Rehab, has two son's who are very supportive and involved in her care. Family History: h/o of PE x2 in son, no history of seizures, but son with heart disease Physical Exam: T: 96.2 BP: 138/53 P: 92 RR: 23 O2 sat: mid 90s on 3L NC General: overweight, mild respiratory distress, afebrile During some of exam, . HEENT: Anicteric, MMM without lesions, OP clear Neck: Supple, no LAD, no carotid bruits, no thyromegaly CV: slighty tachy mechanical valve sound Resp: tight diffuse wheezing and crackes Abd: +BS Soft/NT/ND Ext: R foot is in bandages with several toes amputated, +2 edema Skin: No rashes, petechiae Neuro: R face twitching during exam but resolved spontaenously, otherwise CN II-XII intact, R facial droop, dysarhric, motor, sensory and reflexes intact Pertinent Results: Admission Labs: WBC 10.6 with 80% N 0 Bands 11%L HCT 34.6 Plt 184 Chem: D-dimer 435, proBNP 4461 CK 112 MB 5 Trop 0.04 (baseline Creat 1.7 (baseline ), BUN 48 AG = 11 serum tox and urine tox negative TSH 6.6 Free T4 7.8 . EKG [**2181-12-7**] 8:23:34 PM Probable atrial fibrillation Indeterminate frontal QRS axis Intraventricular conduction defect Low R(V2-V4) probably due to right ventricular hypertrophy Inferior T wave changes are nonspecific Repolarization changes may be partly due to rhythm Baseline artifact precludes accurate interpretation of rhythm but suspect accelerated idioventricular rhythm, cannot rule out"regular" atrial fibrillation Since previous tracing of left anterior fascicular block resolved . CXR: Patient is post-median sternotomy. There is cardiomegaly, unchanged. Mediastinal contours are unchanged, with calcification of the aorta. There is persistent elevation of the right hemidiaphragm. No consolidation or pulmonary edema in the lungs. No definite pleural effusion. . NON-CONTRAST HEAD CT: There is no evidence of acute intracranial hemorrhage or shift of normally midline structures. The ventricles and cisterns are normal. There is encephalomalacia of portions of the left frontal, parietal and temporal lobes, consistent with prior infarction. The [**Doctor Last Name 352**]-white differentiation is preserved. Visualized paranasal sinuses and mastoid air cells are clear. Osseous and soft tissue structures are unremarkable. IMPRESSION: No evidence of acute intracranial hemorrhage. Chronic infarction in the left MCA distribution. MRI: Large chronic left middle cerebral artery territory stroke. No enhancing mass lesions or other acute intracranial pathology identified. MICROBIOLOGY: [**2181-12-16**] 12:30 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2181-12-18**]** GRAM STAIN (Final [**2181-12-16**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. IN CHAINS AND. IN CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2181-12-18**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ <=1 S [**2181-12-16**] 12:20 pm BLOOD CULTURE Site: A LINE RADIAL. AEROBIC BOTTLE (Final [**2181-12-19**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Doctor Last Name 17975**] AT 14:20PM ON [**2181-12-17**] - CC6D. STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON REQUEST.. ANAEROBIC BOTTLE (Pending): ... [**Month (only) 404**]: [**2181-1-2**] CT: IMPRESSION: 1. Large left thigh hematoma, involving the sartorius and rectus femoris muscles. . 2. Hazy appearance of the subcutaneous fat possibly also representing a small hematoma along the left lower chest/upper abdominal wall. . 3. Anasarca. . [**2181-1-20**] CT: IMPRESSION: 1. Again seen is a soft tissue fluid collection adjacent to the left hip, consistent with the hematoma noted on prior study. Additionally, there is a new hematoma within the right rectus muscle, measuring 7.7 x 6.2 cm, and a tiny focus of hemorrhage within the left rectus muscle, both at the level of the sacrum. 2. Bilateral pleural effusions, greater on the right, unchanged from prior study. 3. There is asymmetric enlargement of the left psoas muscle. This is of uncertain etiology, though this is unchanged from prior studies dating back to [**2181-12-19**]. Brief Hospital Course: In Brief: 76 year old woman with MMP including old MCA stroke presents with right simple partial seizure and respiratory distress, extensive hospital course complicated by tracheostomy tube, ventilator associated pneumonia and spontaneous bleeds in light of anticoagulation for [**Month/Day/Year 1291**]. . In the ED she was evaluated by Neurology and found to be having multiple brief eposides of facial twitching that lasted about 30 seconds, but she was able to follow commands during this time and her speech was more dysarthric than usual. Between episodes, pt is alert, following commands,with R facial droop, still able to close R eye, and with slightly dysarthric speech. Speech is much more dysarthric during the events. . She was given ativan 2 mg IV and loaded with Dilantin 20mg./kg on tele to watch for hypoptension and arrythmias. She was noted to be in respiratory distress on 5 liters by nasal cannula, and she was initially considered for MICU admission w/ neuro consult but she improved to 3L NC after nebs, lasix 80 x 1 and brief period of nitro gtt, which was stopped b/c of hypotension. She was also given levofloxacin for presumed UTI and urine cx was also sent ; She was reloaded on dilantin with 1500 and again with 500 at 1 pm. Despite this, she continues to seize every 10 minutes. Subsequently, the MICU was called because the patient was desatting and gurgling with worsened mental status. Of note, the patient's BNP was found to be 4461 and her troponin was noted to be 0.05 which is at her baseline considering her renal failure. Patient was subsequently intubated. Of note, at baseline - pt is able to carry on basic conversation, walks with help, feeds self, knows and socializes with the staff at home. . # Simple partial seizures: Per son, patient has not seized in 20 years. She had been treated with dilantin in the past. We initially treated her with dilantin. Depakote and keppra were later added on, but untimately she was treated with a single [**Doctor Last Name 360**] (keppra 1000mg QD), with good control of her seizures. Workup revealed no mass lesion or new stroke. EEG showed no evidence of grand mal seizures. Patient continued to be assymptomatic on Keppra for the duration of her stay until [**1-27**]. Pt did not show any focal neurological deficits. . # Altered mental status: Was off baseline, has baseline aphasia. The possibility of her returning to her baseline mental status is unclear given a two-month ICU stay with multiple psychotropic medicines. It is likely she will require weeks to clear a toxic-metabolic encephalopathy. . # Unresponsiveness: She was slow to regain respnsiveness after sedation weaned down post intubation. Head CT was again negative for new bleed. Toxic metabolic workup unrevealing. Patient slowly regained neurological function untitl she was back to baseline. Patient was subsequently sedated while on the respirator. She remained on fentanyl drip and versed drip as she was visible uncomfortable with grimace during her care at the ICU. During sedation wean periods patient's functional and responsiveness status did not change or increase significantly except for more frequent grimaces that were interpreted to be signs of discomfort. Her sedation was weaned off prior to discharge to rehab. She was treated with a Fentanyl patch of 25 mcg/hr and with Fentanyl boluses prn. Her mental status at the time of transfer to discharge was minimal. She only grimaces to pain no other clear responses. . # Respiratory failure: Initially intubated for airway protection and aspirtation risk. She also has had episodes of apnea. She has evidence of right elevated hemidiaphragm on CXR, perhaps secondary to ligation of phrenic nerve during sternotomy. She was treated with nebulizer combivent for wheeziness. One attempt at extubation on [**2182-12-14**] failed secondary to stridor/worry of laryngeal edema. She was reintubated and started on a short course of prednisone. Patient subsequently underwent tracheostomy. She continued to have great oxygenation while on the ventilator. Patient required persistant AC support, however after aggressive diuresis with CVVH as described below, she is tolerating PS well. Patient eventually was placed back on AC after an episode of tachypnea and aggitation. Patient subsequently had volume overload and PNA complicating her pulmonary issues. She was continued on MDIs to maximize her pulmonary function. She was then weaned to pressure support with a pressure setting of 15 and PEEP of 8 prior to discharge. It would be our plan to continue with PSV weaning. . # CHF exacerbation: She has h/o diastolic dysfunction. Dry weight is 180 per son. Echo [**2-3**] showed EF 55%. Followed previously by Dr. [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) 17976**] at [**Hospital1 756**] but has not been seen by cardiology in a while. Unknown precipitant to the exacerbation but per son, she started wheezing 2 weeks ago. Ruled out for MI. Intermittant diuresis with lasix. Treated with Beta blocker and ACE inh (held during concern for airway edema). Echo on [**2181-12-11**] showed moderately dilated left and right atrium, mild symmetric left ventricular hypertrophy, questionable mildl depressed LV function (estimated ejection fraction ?50%), mild to moderate ([**12-31**]+) mitral regurgitation, Moderate [2+] tricuspid regurgitation, mild pulmonary artery systolic hypertension. Patient continued to be grossly volume overload. Cardiology and Renal service were consulted and patient was started on CVVH with a goal of returning the patient to her dry weight while diuresing 30 L. Patient continued to tolerate the diuresis well. Her edema did improve after CVVH edema (+1 pitting at lower extremities). Patient however by that point was requiring levophed to support her pressures, likely in part secondary to adrenal insufficiency. Her levophed was weaned once the steroids were switched to IV. Her CXR showed only mild improvement in her edema. It was determined that she was no longer a CVVH candidate. She was treated with Lasix and Metalazone prn for fluid overload. At the time of transfer to rehab she was on 200mg Lasix [**Hospital1 **] and Metalazone. . # BP/hypotension: Patient had multiple episodes of hypotension while in the MICU. DDx included acute blood loss into L thigh/rectus abdominus, vs infection/sepsis vs cardiogenic. CVP elevated although patient +30L during her stay, no EKG changes or CE elevations to suggest cardiac etiology. Patient was treated for PNA with ABX. Her hct was also closely followed and her blood products were repleted. Patient had known spontaneous bleeding into R sided rectus abdominus x 2 around the sacral area and also L thigh bleed. Patient was resuscitated with multiple blood products and IVFs to prevent hypotension. Patient also required intermittent doses of Levophed to keep her BP elevated during CVVH. Her BP was monitored through an A-line. Patient continues to require levophed for her BP support. She has been treated on an extensive course of meropenem/levoquin and vanco well past the course originally designated for her known cultures of MRSA sputum on [**1-2**] and Enterobacter in her sputum on [**1-5**]. The antibiotics were continued due to persistant and increasing levophed requirement and leukocytosis. Patient was also treated with several times for adrenal insufficiency and a repeat AM cortisol was only 15.6 on [**1-27**]. Patient was subsequently started on high dose steroids. She was weaned off all pressors. She was placed on Solumedrol for continued steroid support based upon her adrenal insufficiency. On transfer to Rehab she is on Solumedrol 20mg TID which should be weaned slowly over the next several weeks-months. She should be re-evaluated for adrenal insuffiency at that time. . # MRSA and ENTEROBACTER PNA. Patient with persistent leukocytosis and bandemia. RUL PNA on [**1-11**] that persists. MRSA on [**1-2**] Sputum & Enterobacter on [**1-5**] Sputum. Patient initialy scheduled for 2 week Meropenem and Levo [**1-9**] - 14 days) for Enterobacter but continue for persistant leukocytosis. Patient was also continued on empiric Vancomycin for empiric line/HD coveragte. Central lines were resited multiple times. On [**1-29**] the Vancomycin was discontinued after 3 weeks. On tranfer to rehab she will require continued Meropenem and Levo for a full 6 week course. . # CAD: Patient never had active Chest Pain. Troponin mildly elevated upon admision but has been elevated in the past and continued to trend down. Her CK-MB remained flat. Patient was initially continued on her Plavix, Beta blocker, Zocor. Her BB was d/c in light of hypotension. Her plavix was d/c after her second spontaneous bleeding episode involving L thigh bleed. Patient EKG did not show any new ischemic changes. In the meantime patient was continued on heparin gtt for her [**Month/Day (4) 1291**]. . # Rate - Afib with brief intermittent RVR. Etiology: likely sepsis vs. hypovolemia vs. electrolyte abnormalities vs. hypercarbia. Patient's RVR was controlled with amiodarone. In the meantime she was continued on heparin gtt for her [**Month/Day (4) 1291**]. . # [**Month/Day (4) 1291**]: Held coumadin as INR supratherapeutic on admission. Started on Heparin drip for anticoagulation, with plan to transition back to coumadin. After her spontaneous bleeding episodes she was kept on a tight PTT scale of 40-60. . # UTI: H/o levo-resistent UTI in [**2-3**] that required CTX, treated with ceftriaxone until sensitivities showed cipro effective so continued on cipro only for seven day course. Repeat U/A and Urine culture after treatment were negative for infection. . # ARF: Elevated Cr to 1.9 which returned closer to baseline with fluids (1.3), likely prerenal based on her urine lytes. Patient underwent a week long course of CVVH for removal of fluid that she tolerated well with support of levophed. Patient's subsequent baseline appears to be at 1.9-2.0 with hypotension requiring pressors, chronic DM, HTN playing a role. Renal service didn't believe hemodialysis was indicated giving the grim condition of the patient. She is currently on Lasix and Metolazone for continued diuresis. . # DM: We continued her usual regimen of NPH 6qAM and 8qPM with sliding scale, titrated to fingersticks of 80-100, but then put her on an insulin drip on ce prednisone was started. Patient was subsequently transition back to NPH insulin based upon a high insulin drip requirement she was started on NPH 25 [**Hospital1 **] with sliding scale coverage. . # anemia: iron studies normal and B12 and folate WNL. Patient had intermittent blood loss into her spontaneous bleed in rectus abdominus x 2 and also L thigh requiring aggressive PRBC resuscitation. Vascular surgery was involved but since patient was adequately resuscitated with cessation of blood requirements after 24-48 hours, no intervention was awarranted. Patient's Hct was kept >28. . # s/p old stroke: we continued her aspirin and plavix. Plavix was d/c due to persistant spontaneous hemotomas as described above. . # hypothyroidism: We continued her home dose of levothyroxine. . # GERD: She has h/o GIB requiring hospitalization. Treated with lansoprazole per NGT/PO 30 qd. . # h/o primary biliary cirrhosis and gallstones: Stable. We continued ursodiol . # h/o depression and post partum psychosis: - held risperdone and prozac given unresponsiveness and desire to decrease mediaction interactions. . # healthcare decision: MULTIPLE meetings were held with the family with a variety of attendings, the hospitals ethics support service and leagal staff. Some of the care team at times felt the sons hopes of recovery were not realistic and were uncomfortable in providing care that they felt was just hurting the patient. My most recent discussions have focused on explaining Ms. [**Known lastname 17977**] multi-organ system failure and her poor overall prognosis and assuring them that if it was in fact the patients wish to persue continued aggressive care, we would do so. They understand her high risk for nosocomial disease (vent associated pneumonia, UTI, line infection, skin breakdown etc) and still wish to have her sedation lightened so they can communicate with her. I explained that as long as she is not experiencing pain, that is a reasonable goal. # communication: son [**Name (NI) 1193**] [**Telephone/Fax (1) 17978**] who is also her health care proxy . # PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17979**] at [**Hospital 100**] Rehab Medications on Admission: lasix 100 daily (increase from 80 on [**12-7**]) plavix 70 daily fluoxetine 20 daily duoneb risperdal 1 qhs protonix 40 daily metoprolol 12.5 [**Hospital1 **] pantoprazole simvastatin 10 qhs senna ursodial 600 [**Hospital1 **] tylenol prn RISS + NPH 6qAM and 8qPM lisinopril 2.5 daily levothyroxine 50 daily glyburide 2.5 daily maalox prn Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 12. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 14. Metolazone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): give half hour prior to lasix. 15. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. 16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation QID (4 times a day). 17. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane TID (3 times a day) as needed. 18. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty Five (25) units Subcutaneous twice a day: at breakfast and bedtime. 19. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 20. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 1500 (1500) units/hr Intravenous ASDIR (AS DIRECTED): adjust for target PTT 40-60 seconds. Continue until Coumadin therapeutic. 21. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Ten (10) ML Intravenous DAILY (Daily) as needed: to each lumen QD and PRN. 22. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 3 weeks: Continue until [**2-20**] . 23. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 3 weeks: continue until [**2-20**]. 24. Furosemide 10 mg/mL Solution Sig: Two Hundred (200) mg Injection [**Hospital1 **] (2 times a day): please give 30 minutes after Metolazone. 25. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: 25-100 mcg Injection Q2H (every 2 hours) as needed. 26. Methylprednisolone Sodium Succ 1,000 mg/8 mL Recon Soln Sig: Twenty (20) mg Recon Soln Injection Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: 1. Seizures 2. Respiratory failure 3. Shock 4. Adrenal insufficiency 5. Left thigh bleed 6. MRSA and Enterobacter PNA 7. CHF/Volume overload 8. Renal failure 9. [**Hospital6 1291**]/St. Jude's valve 10. Hypothyroidism Discharge Condition: Stable, responsive to pain only, withdraws, does not respond to voice or other stimuli. Discharge Instructions: Continue to monitor BP, CBC, INR, PTT. Will need to have Coumadin restarted and titrated to INR goal [**2-1**]. Continue Lasix prn to keep fluid status even. Continue vent weaning. Titrate insulin to FS 60-120. Continue Meropenem and Levofloxacin for total of 6 week course, complete on [**2-20**]. Titrate down steroids. Followup Instructions: As above

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icd9cm

[ [ [] ] ]

[ "99.04", "31.1", "38.91", "96.72", "44.32", "38.93", "99.07", "96.04", "33.21", "89.19", "97.23" ]

icd9pcs

[ [ [] ] ]

23122, 23195

7334, 9651

306, 346

23456, 23545

2940, 2940

23921, 23932

2241, 2314

20338, 23099

23216, 23435

19974, 20315

23569, 23898

2329, 2921

230, 268

6416, 7311

374, 1263

3967, 6388

2956, 3958

9666, 19948

1285, 2108

2124, 2225

56,110

199,235

47567

Discharge summary

report

Admission Date: [**2111-4-1**] Discharge Date: [**2111-4-5**] Date of Birth: [**2036-5-23**] Sex: M Service: CARDIOTHORACIC Allergies: Prevpac / Tetanus Attending:[**First Name3 (LF) 922**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: aortic valve replacement (27mm [**Company 1543**] Mosaic), coronary artery bypass x 3 (LIMA-LAD, SVG-Dx, SVG-RCA) [**2111-4-1**] History of Present Illness: 74 year old male with known aortic stenosis with bicuspid valve (peak gradient was 54 mmHG, the mean gradient was 32 mmHG and the valve area was 0.9-1.0 cm2, noted for worsening dyspnea on exertion.) Reports worsening dyspnea on exertion relieved with rest, associated with bilateral shoulder pain. This has been occuring for about one year and worsened over the last past four months. Past Medical History: aortic stenosis, coronary artery disease PMH: Sleep apnea-does not use CPAP Hypertension Bicuspid aortic valve/aortic stenosis Hyperlipidemia Vertigo gastroesophageal reflux disease Stage III Kidney disease Appendectomy benign prostatic hyperplasia Social History: Lives with: spouse Occupation: custodian Tobacco: Quit 30 years ago 25 pack year history ETOH: 3 oz scotch [**3-4**] x week Family History: mother ? valve problem Physical Exam: Pulse: 48 Resp: 12 O2 sat: 96% B/P Right: 167/98 Left: 180/93 Height: Weight: General: No acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] decreased range from arthritis - unable to fully evaluate - on bedrest s/p cath Chest: Lungs clear bilaterally [x] anteriorly Heart: RRR [x] Irregular [] Murmur 2/6 systolic ejection Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Alert and oriented x3 non focal Pulses: Femoral Right: cath site Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: no bruit Left: no bruit Pertinent Results: PREBYPASS - No spontaneous echo contrast is seen in the left atrial appendage. - Overall left ventricular systolic function is low normal (LVEF 50-55%). - Right ventricular chamber size and free wall motion are normal. - There are simple atheroma in the descending thoracic aorta. - The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. - There is critical aortic valve stenosis (valve area <0.8cm2). - No aortic regurgitation is seen. - The mitral valve leaflets are mildly thickened. - Mild (1+) mitral regurgitation is seen. - There is no pericardial effusion. - Ascending aorta 3.6cm diameter POSTBYPASS - Prosthetic aortic valve without perivalvular leak or regurgitation - Mean pressure gradient across aortic valve 7-10mmHg - Biventricular systolic function remains preserved with Left ventricular EF 50-55% - Mild mitral regurgitation - Aorta intact [**2111-4-3**] 07:10PM BLOOD WBC-9.8 RBC-3.36* Hgb-10.4* Hct-29.4* MCV-87 MCH-31.0 MCHC-35.5* RDW-13.5 Plt Ct-116* [**2111-4-3**] 07:10PM BLOOD Glucose-122* UreaN-23* Creat-1.4* Na-140 K-4.9 Cl-104 HCO3-30 AnGap-11 [**2111-4-3**] 03:06AM BLOOD Glucose-104* UreaN-22* Creat-1.3* Na-138 K-4.1 Cl-105 HCO3-27 AnGap-10 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2111-4-1**] where the patient underwent aortic valve replacement with a 23-mm [**Company 1543**] Mosaic Ultra valve bioprosthesis as well as coronary artery bypass x 3. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Cefazolin was used for surgical antibiotic prophylaxis. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically were supported with neo-synephrine. Neo was weaned and the patient remained hemodynamically stable. 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. 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 home in good condition with VNA services and appropriate follow up instructions. Medications on Admission: ACETYLCYSTEINE - (Prescribed by Other Provider) - Dosage uncertain AMLODIPINE - (Prescribed by Other Provider) - 2.5 mg Tablet - one Tablet(s) by mouth daily ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - one Tablet(s) by mouth daily CHLORTHALIDONE - (Prescribed by Other Provider) - 50 mg Tablet - one Tablet(s) by mouth daily OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth daily SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - one Tablet(s) by mouth daily Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - one Tablet(s) by mouth daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: aortic stenosis, coronary artery disease PMH: Sleep apnea-does not use CPAP Hypertension Bicuspid aortic valve/aortic stenosis Hyperlipidemia Vertigo gastroesophageal reflux disease Stage III Kidney disease Appendectomy benign prostatic hyperplasia Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with ultram prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) 914**] [**2111-5-5**] 1pm [**Telephone/Fax (1) 170**] Primary Care Dr. [**First Name (STitle) **], [**First Name3 (LF) 4355**] [**Telephone/Fax (1) 2261**] in [**1-31**] weeks Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6512**] in [**1-31**] weeks Completed by:[**2111-4-5**]

[ "272.4", "780.4", "424.1", "427.89", "780.57", "414.01", "285.9", "600.00", "V45.89", "746.4", "458.29", "403.90", "424.0", "530.81", "585.3" ]

icd9cm

[ [ [] ] ]

[ "36.12", "35.22", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

6334, 6385

3381, 4677

301, 432

6678, 6772

2147, 3358

7311, 7696

1280, 1304

5398, 6311

6406, 6657

4703, 5375

6796, 7288

1319, 2128

242, 263

460, 850

872, 1122

1138, 1264

63,226

108,124

40695

Discharge summary

report

Admission Date: [**2104-5-2**] Discharge Date: [**2104-5-8**] Date of Birth: [**2059-2-18**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2290**] Chief Complaint: transfer from OSH for dental abscess Major Surgical or Invasive Procedure: 1. Incision and drainage of submandibular cellulitis [**5-2**] 2. Intubation [**5-2**] 3. Extubation [**5-3**] History of Present Illness: 45 year old male with past medical history of hypertesion and severe obesity who has not seeked regular medical or dental care presents to OSH with 10 day history of right lower tootache, fever and chills. He heard a [**Doctor Last Name **] one day ago with associated pain and progressive swelling which prompted him to go to [**Hospital 1562**] hospital. At [**Hospital **] hospital, CT neck showed soft tissure infection with phlegmon in the right perimandibular region likely originating from dental infection of tooth #7 in the right lower jaw. Labs significant for normal WBC and HgA1c of 12%. He was started on Vancomycin and Unasyn. He was also started on lantus 10 units qam. He was transferred to [**Hospital1 18**] as [**Hospital 1562**] hospital does not have OMFS service on call. On the floor, he reports dysphagia. He also reports having few episodes of unresponsiveness with drooping of face and slurring of his speech over past few years. Last episode one month ago. Past Medical History: 1. New diagnosis of diabetes mellitus 2. Hypertension 3. Severe obesity 4. Likely obstructive sleep apnea Social History: 1 ppd. Over 50 year pack year history of smoking. Social alcohol use. No IVDU. Lives with daughter and her husband. [**Name (NI) **] works as a [**Doctor Last Name **]. Has four dogs at home. Family History: Mother diet of breast cancer. He has 13 siblings of whom four passed away. Physical Exam: Admission Physical Exam 100.2 149/90 92 20 95%RA Gen: Ill appearing obese male with right submandibular swelling HEENT: PERRLA. EOMI. Fundoscopic normal. Poor dentition. Right last molar is partially mandibular and mostly submandibular space tender to palpation without any fluctuation palpable in this area Neck: Submandibular area is tender to palpation and progress towards lateral clavicular area Chest: CTAB. No crackles or wheezing noted Heart: Regular rate and rhythm. No murmurs or gallops appreciated Abdomen: Soft, nontender and nondistended. NABS. External: No edema. R shin 3 cm wound Neuro: Alert and oriented x 3. CN 2-12 intact. [**4-17**] muscle strength. Sensation intact Discharge Physical Exam Objective: 98.4 126-127/70-85 70-76 20 96-100%2LNC 181/184/235 Gen: Obese male NAD. Mild fluctuations noted around right submandibular area HEENT: PERRLA. EOMI. Fundoscopic normal. Poor dentition. Chest: CTAB. No crackles or wheezing noted Heart: Regular rate and rhythm. No murmurs or gallops appreciated Abdomen: Soft, nontender and nondistended. NABS. External: 1+ edema. R shin 3 cm wound Neuro: Alert and oriented x 3. CN 2-12 intact. [**4-17**] muscle strength. Sensation intact Pertinent Results: [**2104-5-3**] 03:43AM BLOOD WBC-14.3* RBC-5.05 Hgb-14.5 Hct-43.6 MCV-86 MCH-28.7 MCHC-33.2 RDW-13.6 Plt Ct-189 [**2104-5-5**] 07:35AM BLOOD WBC-9.6 RBC-4.38* Hgb-12.6* Hct-38.2* MCV-87 MCH-28.7 MCHC-33.0 RDW-13.5 Plt Ct-223 [**2104-5-7**] 08:00AM BLOOD WBC-10.1 RBC-4.56* Hgb-12.9* Hct-38.2* MCV-84 MCH-28.2 MCHC-33.7 RDW-13.4 Plt Ct-343 [**2104-5-7**] 08:00AM BLOOD ESR-100* [**2104-5-3**] 03:43AM BLOOD Glucose-311* UreaN-15 Creat-1.0 Na-131* K-4.8 Cl-95* HCO3-26 AnGap-15 [**2104-5-4**] 04:13AM BLOOD Glucose-289* UreaN-30* Creat-1.2 Na-136 K-4.1 Cl-100 HCO3-26 AnGap-14 [**2104-5-8**] 08:31AM BLOOD Glucose-178* UreaN-10 Creat-0.9 Na-138 K-3.9 Cl-100 HCO3-29 AnGap-13 [**2104-5-3**] 03:43AM BLOOD ALT-120* AST-117* AlkPhos-99 TotBili-1.9* [**2104-5-5**] 07:35AM BLOOD ALT-102* AST-51* AlkPhos-101 [**2104-5-5**] 07:35AM BLOOD Triglyc-382* HDL-33 CHOL/HD-6.4 LDLcalc-101 [**2104-5-5**] 07:35AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.2 Cholest-210* [**2104-5-5**] 07:35AM BLOOD TSH-1.8 [**2104-5-7**] 08:00AM BLOOD CRP-30.7* EKG ([**2104-5-2**]) Sinus tachycardia. Right axis deviation. Non-diagnostic repolarization abnormalities. No previous tracing available for comparison. TTE ([**2104-5-2**]) The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 65%). The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with focal hypokinesis of the apical free wall. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: dilated hypocontractile right ventricle CXR ([**2104-5-5**]) In comparison with the study of [**5-3**], cardiac silhouette is at the upper limits of normal. The pulmonary opacifications have decreased, consistent with improved vascularity. Some of this could reflect the upright position rather than supine. Area of increased opacification at the right base is worrisome for possible pneumonia. Endotracheal tube and nasogastric tubes have been removed. CT Neck ([**2104-5-5**]) Phlegmonous changes in the right submandibular region/floor of mouth without residual drainable fluid collection. [**2104-5-3**] 1:43 am SWAB Site: MANDIBLE RIGHT. GRAM STAIN (Final [**2104-5-3**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. WOUND CULTURE (Preliminary): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES) CONSISTENT WITH OROPHARYNGEAL FLORA. WORK UP REQUESTED PER DR. [**Last Name (STitle) **] #[**Numeric Identifier 21912**] [**2104-5-5**]. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. SECOND MORPHOLOGY. STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. RARE GROWTH. Sensitivity testing performed by Sensititre. CLINDAMYCIN IS SENSITIVE AT 0.12MCG/ML. VIRIDANS STREPTOCOCCI. RARE GROWTH. Sensitivity testing performed by Sensititre. CLINDAMYCIN IS SENSITIVE AT 0.12 MCG/ML . Penicillin IS RESISTANT AT >=8 MCG/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | STREPTOCOCCUS ANGINOSUS (MILLERI) GROU | | VIRIDANS STREPTOCOCCI | | | CLINDAMYCIN-----------<=0.25 S S S ERYTHROMYCIN----------<=0.25 S <=0.25 S 2 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 2 I OXACILLIN-------------<=0.25 S PENICILLIN G---------- <=0.06 S R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S <=1 S <=1 S ANAEROBIC CULTURE (Preliminary): Mixed bacterial flora-culture screened for B. fragilis, C. perfringens, and C. septicum. ID PER DR.[**Last Name (STitle) **] [**2104-5-5**]. PREVOTELLA SPECIES. SPARSE GROWTH. BETA LACTAMASE NEGATIVE. Brief Hospital Course: 45 year old male with past medical history of hypertension and severe obesity without regular medical or dental care presents to OSH with submandibular abscess now status post tooth extraction. 1. Right submandibular osteomyelitis: Likely due to molar infection. He was continued on IV unaysn/vancomcyin. He was taken to the OR the night of admission where he had extra-oral incision and drainage of the right submandibular space that was connected with the right lateral pharyngeal space. Two penrose drains were placed in right lateral pharyngeal space. After Incision and drainage, tooth was removed that was thought to be source. He was continued on IV Unasyn to cover polymicrobial flora. Infectious disease was consulted. Repeat CT neck showed no drainable collection but there was concern for jaw osteomyelitis. Culture from his OR specimen showed polymicrobiol flora with coagulase negative staph, anaerobes and gram negative rods. He was started on IV vancomycin and continued on IV unasyn. After seven days of IV antibiotics, he was discharged home on linezolid, ciprofloxacin and flagyl. 2. Type 2 DM: HgA1c of 12% from OSH. He was treated with insulin lantus 15 units in the morning with sliding scale humalog. He was discharged home on metformin 1000 mg po BID and glyburide 10 mg in the morning and 5 mg in the afternoon. He was started on aspirin and lisinopril. He was risk stratified with lipids which showed dysplipidemia. 3. Hypertension: Untreated in the past per patient. He was started on lisinopril 40 mg po qdaily and chlorthalidone 25 mg po qdaily. 4. Smoking: Kept on nicotine 14 mg patch Follow up for PCP 1. Weekly lab work (CBC with diff, Chem-7, ESR and CRP) to be faxed to Dr. [**Last Name (STitle) 23**] (Fax: [**Telephone/Fax (1) 1419**]) 2. He will need to have his type 2 DM regimen optimized. We were not able to obtain a glucometer for him to monitor his blood sugar levels. 3. Please check creatine and electrolytes at your next visit as we started chlorthalidone and lisinopril during his hospital stay. Medications on Admission: None Discharge Medications: 1. linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 21 days. Disp:*42 Tablet(s)* Refills:*0* 2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 3. glyburide 5 mg Tablet Sig: One (1) Tablet PO qpm . Disp:*30 Tablet(s)* Refills:*2* 4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. chlorthalidone 25 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 once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*2* 9. glyburide 5 mg Tablet Sig: Two (2) Tablet PO qam. Disp:*60 Tablet(s)* Refills:*2* 10. Outpatient Lab Work Please check weekly CBC with differential, chemistry panel, creatinine, ESR and CRP. Please fax it to Dr. [**Last Name (STitle) 23**] (Fax: [**Telephone/Fax (1) 1419**]) Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. R mandibular cellulitis Secondary Diagnosis: 2. Type II Diabetes mellitus 3. Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital 1562**] hospital for an infection in your tooth and jaw. You were transferred to [**Hospital1 827**] for surgery to remove the tooth and the infected tissue. You were intubated during the procedure and remained intubated in the ICU for 24 hours to make sure that your airway was stable. Two drains were placed in your mouth to help drain any infected fluid from your jaw. Both drains were removed prior to your discharge from the hospital. You were then transferred to the medicine floor for antibiotic treatment of your infection. You were treated with IV Vancomycin and Unasyn while in the hospital. You were switched to oral linezolid to be taken at home for 3 weeks and oral ciprofloxacin and flagyl to be taken for 6 weeks. While you were in the hospital, your blood pressure was high and you were treated with lisinopril and chlorthalidone. You were also diagnosed with type II diabetes. You were counseled on how to change your diet and exercise to control your diabetes. You were treated with insulin and metformin while you were in the hospital. You were discharged with metformin and glyburide for treatment of your diabetes at home. Please have weekly labs drawn and faxed to Dr. [**Last Name (STitle) 23**](Fax: [**Telephone/Fax (1) 1419**]). You should have your first week lab drawn at Dr. [**Last Name (STitle) **] office. FOLLOWING CHANGES WERE MADE TO YOUR MEDICATIONS: START: Linezolid 600 mg by mouth twice per day for 3 weeks for jaw infection START: CIPROFLOXACIN 500 mg by mouth twice per day for 6 weeks for jaw infection START: FLAGYL 500 mg by mouth three times a day for 6 weeks for jaw infection START: METFORMIN 1000 mg by mouth twice per day for diabetes START: Glyburide 10 mg by mouth in the morning and 5 mg by mouth in the evening START: Lisinopril 40 mg by mouth once per day for blood pressure START: Chlorthalidone 25 mg by mouth once per day for blood pressure START: Aspirin 81 mg by mouth once per day for prevention of heart disease Followup Instructions: Department: [**Hospital1 7975**] INTERNAL MEDICINE When: TUESDAY [**2104-5-13**] at 4:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site *Dr. [**Last Name (STitle) **] will be your new Primary Care doctor. Department: INFECTIOUS DISEASE When: FRIDAY [**2104-5-23**] at 9:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 88995**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Hospital6 **] [**Location (un) 442**] of Yawkey building [**Last Name (NamePattern1) **]. on [**2104-5-19**] @ 1pm Dr. [**Last Name (STitle) **] (phone: [**Numeric Identifier 88999**])

[ "478.22", "V85.42", "327.23", "584.9", "305.1", "038.9", "507.0", "787.20", "522.5", "250.00", "526.4", "V16.3", "995.91", "401.9", "682.0", "528.3", "458.29", "522.4", "276.1" ]

icd9cm

[ [ [] ] ]

[ "96.71", "27.0", "23.09", "96.04", "38.93", "86.04" ]

icd9pcs

[ [ [] ] ]

11212, 11218

7928, 9989

339, 452

11375, 11375

3134, 5905

13561, 14471

1821, 1897

10044, 11189

11239, 11239

10015, 10021

11526, 13538

1912, 3115

263, 301

5940, 7642

480, 1467

11307, 11354

11258, 11286

7681, 7905

11390, 11502

1489, 1596

1612, 1805