ChanBeDu/relevant_section_length · Datasets at Hugging Face

17,843

120,197

50377

Discharge summary

report

Admission Date: [**2119-10-7**] Discharge Date: [**2119-10-23**] Date of Birth: [**2060-9-23**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5547**] Chief Complaint: Fevers, tachypnea Major Surgical or Invasive Procedure: attempted removal of G tube by scope through ileostomy on [**10-10**] History of Present Illness: 59 yo M with advanced MS, hx of MRSA/VRE, neurogenic bladder, schizoafffective d/o and hypothyroidism presents with fevers and tachypnea. Patient was discharged from the [**Hospital Unit Name 153**] on [**10-6**] on a 7 day course of vancomycin after being treated for sepsis and necrotizing MRSA PNA. During that admission from [**Date range (1) 104997**] the pt was intubated and was extubated on [**10-5**]. His respiratory status was stable on supplemental O2 at discharge and he was afebrile. He was discharged to the MACU at [**Hospital 100**] Rehab. . Pt is nonverbal so hx obtained from notes. On [**10-6**] pt had low grade fever to 100.9 On [**10-7**] his temperature was noted to be 102.4. WBC was checked and was 22.6 and flagyl was added to his regimen in addition to his vancomycin. At noon his temperature spiked to 103.4, his BP was 80/60 and his O2 sat was noted to be 85% on RA and improved to 92% on 5 L NC 02. He was bolused 500 cc of NS without results and was sent to [**Hospital 882**] Hospital. At [**Hospital1 882**] his WBC was 22.3. He was bolused additional fluids. EKG showed sinus tachycardia. He was transferred to the [**Hospital1 **] ED. . Upon arrival to the ED his temp was 104.2, SBP ranged from the 90s to low 100s, HR 120 O2 sat 99% on NRB with RR 40. He had a femoral line placed and received 2L IVFs. He was treated with one dose of vancomycin. CXR showed improved pulmonary edema and a stable right basilar opacity. . Upon arrival to the ICU HR was 122 BP 102/51 and O2 sat was 99% on NRB. Past Medical History: - Multiple sclerosis. - Neurogenic bladder. - Swallowing disorder. - Schizoaffective disorder/Depression. - Hypothyroidism. - s/p colectomy with mucous fistula in [**2106**] secondary to C.diff colitis, course complicated by abscess, has G-tube - h/o aspiration pneumonia - h/o MRSA/VRE in urine [**2107**] - GERD - anxiety Vaccinations: - pneumococcal [**2114**] Social History: The patient is a [**Hospital 100**] Rehab resident. No ETOH, no tobacco, no IV drug use. Family History: unknown Physical Exam: VS: Tc 101 BP 102/51 HR 122 and O2 sat 99% on NRB Gen: contracted, pale, non verbal male, tachypneic with NRB in place Neck: supple, flat JVD Heent: anicteric sclera, dry MM Skin: pale, stage I sacral ulcer with surrounding erythema, dry healing ulcer on left heel, open skin wound in left lower abdomen that appears deeper than at last admission, with no drainage Chest: crackles and rhonchi diffusely, no wheezes CVS: Distant as respiratory sounds were loud Abd: soft, colostomy draining soft brown stool, NT/ND, BS+ Ext: contraction of right foot, no edema, feet cold with 1+ DP pulses Neuro: pupils equal and round Pertinent Results: [**2119-10-23**] 02:42AM BLOOD WBC-11.6* RBC-3.03* Hgb-9.2* Hct-26.7* MCV-88 MCH-30.3 MCHC-34.3 RDW-15.9* Plt Ct-401 [**2119-10-23**] 02:42AM BLOOD WBC-11.6* RBC-3.03* Hgb-9.2* Hct-26.7* MCV-88 MCH-30.3 MCHC-34.3 RDW-15.9* Plt Ct-401 [**2119-10-22**] 04:44AM BLOOD WBC-9.4 RBC-2.95* Hgb-8.9* Hct-25.9* MCV-88 MCH-30.3 MCHC-34.5 RDW-15.9* Plt Ct-406 [**2119-10-21**] 03:40AM BLOOD WBC-9.3 RBC-2.90* Hgb-8.7* Hct-25.7* MCV-89 MCH-30.0 MCHC-33.7 RDW-15.6* Plt Ct-422 [**2119-10-20**] 03:58AM BLOOD WBC-7.9 RBC-2.80* Hgb-8.3* Hct-25.2* MCV-90 MCH-29.6 MCHC-32.8 RDW-15.8* Plt Ct-408 [**2119-10-19**] 05:59PM BLOOD WBC-9.2 RBC-2.91* Hgb-8.4* Hct-25.8* MCV-89 MCH-28.8 MCHC-32.5 RDW-15.7* Plt Ct-468* [**2119-10-19**] 02:30AM BLOOD WBC-9.6 RBC-2.79* Hgb-8.3* Hct-24.4* MCV-88 MCH-29.9 MCHC-34.2 RDW-15.9* Plt Ct-419 [**2119-10-18**] 01:50AM BLOOD WBC-9.8 RBC-3.02* Hgb-8.9* Hct-27.2* MCV-90 MCH-29.3 MCHC-32.5 RDW-15.7* Plt Ct-412 [**2119-10-17**] 01:41AM BLOOD WBC-8.2 RBC-2.94* Hgb-8.9* Hct-25.7* MCV-87 MCH-30.4 MCHC-34.8 RDW-15.9* Plt Ct-388 [**2119-10-16**] 02:34AM BLOOD WBC-9.1 RBC-3.04* Hgb-9.2* Hct-26.4* MCV-87 MCH-30.3 MCHC-34.8 RDW-16.0* Plt Ct-441* Brief Hospital Course: A/P: 59 yo patient with advanced MS,schizoafffective d/o and hypothyroidism, recently discharged after tx for necrotizing MRSA PNA and sepsis who presents with fevers and tachypnea. . * Fevers and leukocytosis: Pt presented with high temps and WBC of 21 with a left shift. The day PTA he was afebrile and WBC was 9. His hypotension suggested early sepsis. Sources for fever included c.diff (likely with rapid rise in WBC and recent abx use), recurrent PNA or aspiration (though pt improving on vanc until [**10-6**] and CXR improved), line infection or wound infection from skin breakdown (multiple areas of breakdown). His urine culture was negative and CXR did not show evidence of new PNA. Sputum showed growth of MRSA and sparse morganella morgani. He did have increased ostomy output, but this is an ileostomy so it was thought that it was less likely this was [**1-19**] to c.diff. -started on vancomycin for coverage of MRSA PNA (course to end on [**10-16**]. -started on flagyl for possible c. diff on [**10-7**]. His c.diff toxin was negative x3. C. diff toxin B is still pending. Flagyl was dc'd on [**10-12**]. -pt was started on ceftazidime for coverage of GNRs and pseudomonas. Course should end on [**10-16**]. Patient had a pneumonia form citobacter and a wound infection with Klebsiela both sensitive to Meropenen. Patient at this point had finished the course of ALL antibiotics Wound should be packek we to dry TID . *Tachypnea and Hypoxia: Pt desatted to 85% on RA on the day of admission. Sats improved to 99% on NRB. He was able to be transitioned to a face mask. The source for increasing tachypnea was unclear. Could have been [**1-19**] to increasing secretions, worsening PNA, or aspiration. Did not appear overloaded, so did not this this was the source. He was continued on a face mask and did not desat during the rest of his admission. His CXR remained stable and he was continued on neb treatments and chest PT. He was continued on vancomycin (end date [**10-16**]) for MRSA and ceftazidime. He will need a repeat chest CT in 6 months for f/u. Patient after GT surgery remained intubated, failure to extubate. On [**2119-10-19**] underwent tracheostomy: PREOPERATIVE DIAGNOSIS: Respiratory failure. POSTOPERATIVE DIAGNOSIS: Respiratory failure. PROCEDURE PERFORMED: Open tracheostomy tube placement. ANESTHESIA: General endotracheal. INDICATION FOR OPERATION: The patient is a 59-year-old gentleman, with a history of multiple sclerosis, who was recently admitted with complications and required prolonged intubation. Due to his persistent need for mechanical ventilation, we have been asked to place a tracheostomy tube to protect his vocal cords and to allow for effective ventilatory weaning and pulmonary care. The patient has had a prior history of tracheostomy tube placement. Therefore, the following procedure was performed. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, and the procedure was performed open due to the history of a prior tracheostomy tube. The operation was performed on the patient's ICU bed. The patient was positioned supine with his neck extended but head not floating. I examined his neck and found that the old tracheostomy scar was overlying the cricoid. The cricoid had a central defect in it and scarring around it, and it appeared that the prior tracheostomy had been placed at least partially through the cricoid. I chose to go for a slightly inferior incision and place the tracheostomy in the proper position through the second and third tracheal rings. We thus made a 2 cm transverse incision approximately 0.5 cm inferior to the old tracheostomy scar and dissected down through the platysma. We split the strap muscles and immediately came upon the cervical trachea. We divided the isthmus and identified the second and third tracheal rings. We then created a trapdoor incision with a lateral anterior incision between the first and second tracheal rings and a vertical anterior incision through the second and third tracheal rings. We then placed a #8 Portex cuffed tracheostomy tube without difficulty. We properly secured it with 3-0 nylon sutures bilaterally and placed trache tape. We had excellent end-tidal CO2 and good volume exchange. The patient tolerated the procedure well. . *Hypotension: Pt was hypotensive with SBPs in the 90s at admission. Had some end organ damage in the setting of this as Cr was elevated to 1.7 and cardiac enzymes were elevated, thought [**1-19**] to demand ischemia. Was thought possibly [**1-19**] to early sepsis, though lactate is 1.4 and SBPs improved with IVFs. Also could have been due to hypovolemia from possible c.diff or inadequate intake. [**Last Name (un) **] stim showed appropriate response at this admission (23->33->44). During his admission he again became transiently hypotensive. Ostomy showed liquid black/dark green stool that was guiac positive (had been in the past) and he had a hct drop of 6 pts (29 to 23) on [**10-11**]. It was thought this was [**1-19**] to GI bleed. He was transfused 4 units of PRBCs and 4 units of FFP (INR 1.6) and given vitamin K prior to transfer to [**Hospital Ward Name 517**] for surgery for removal of PEG tube. . * "Lost" G tube: On [**10-9**], his PEG was noted to be missing. It is unclear how it disloged, but abdominal CT revealed that it was in the distal duodenum. He had serial KUBs with no evidence of obstruction. GI scoped him through the ileostomy but was unable to retrieve it. Surgery was consulted but since the pt was hemodynamically stable with no evidence of obstruction it was initially decided to let it pass. On [**10-11**] hct started dropping and SBPs were lower. Repeat abd ct showed the G tube had not moved so it was decided he should proceed to surgery for removal. He was transferred to the [**Hospital Ward Name **] on [**10-12**]. on [**2119-10-12**] patient underwent surgery: .PREOPERATIVE DIAGNOSIS: 1. Retained foreign body in terminal ileum. 2. Gastrointestinal bleeding POSTOPERATIVE DIAGNOSIS: 1. Retained foreign body in terminal ileum. 2. Gastrointestinal bleeding NAME OF PROCEDURE: 1. Gastroscopy. 2. Ileoscopy. 3. Exploratory laparotomy with lysis of adhesions. 4. Enterotomy with removal of foreign body from terminal ileum. RESIDENT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD ANESTHESIA: General endotracheal. INDICATIONS FOR PROCEDURE: The patient is a 59 year-old gentleman with advanced multiple sclerosis and schizo-affective disorder who is wheelchair-bound and lives in a nursing home. He was admitted to the medical intensive care unit with a significant pneumonia when his long-term feeding gastrostomy tube was noted to have migrated into his gastrointestinal tract. The tube was reportedly a Foley catheter and was visible on an abdominal CT scan having migrated into the terminal ileum. The patient was followed for several days, as he was not obstructed and was clinically stable. However, on the day of surgery ,the patient began to have fairly significant melena via his ileostomy with a transfusion requirement of 3 units of packed red blood cells. It was unclear if this new gastrointestinal bleeding was related to ischemic necrosis secondary to possible intussusception related to the feeding tube. Repeat abdominal CT scan showed no findings concerning for ischemic bowel and the foreign body was still located within the terminal ileum. However, given the failure of the feeding tube to migrate on serial imaging studies and the new onset of gastrointestinal bleeding, I advised operative exploration with removal of the feeding tube from the terminal ileum. The risks and benefits of the procedure were discussed in detail with the patient's sister, who serves as his health care proxy, and permission was granted. OPERATIVE FINDINGS: 1. Gastroscopy via his existing the G-tube site showed no evidence of source of bleeding in the stomach. In addition, there was bile reflux from the pylorus, suggestive of no evidence of bleeding source in the duodenum. 2. Ileoscopy was performed via the ileostomy in the right lower quadrant. There was no evidence of bleeding site in the distal 10-15 cm of ileum, but we had difficulty visualizing beyond this secondary to a large amount of liquid stool. In addition, we could not visualize the feeding tube. 3. After intra-abdominal exploration, a coiled Foley catheter was folded upon itself in the distal ileum with the balloon inflated. There was no evidence of ischemic injury to the bowel or source of GI hemorrhage at this location. PROCEDURE IN DETAIL: The patient was identified in the preoperative holding area and taken to the operating room where he was positioned supine on the operating room table. After the induction of general endotracheal anesthesia, an arterial line and right internal jugular central venous line were placed by the anesthesia team. Gastroscopy was performed via the gastrostomy site in the upper abdomen. This showed no evidence of a source of hemorrhage in the stomach nor in the duodenum, as there was reflux of bile from the pylorus into the stomach. The air was evacuated from the stomach and the same tube was then introduced through the ileostomy in the right lower quadrant. We were able to pass the tube approximately 10-15 cm without evidence of source of GI bleeding nor could we visualize the foreign body. Visualization, however, was limited by a large amount of green liquid stool and so this portion of the procedure was terminated. The right lower quadrant ileostomy was then oversewn with a 2-0 silk suture. The abdomen was widely sterilely prepped and draped in usual fashion. Intravenous antibiotics had been administered in the ICU prior to transfer to the operating room. A generous midline incision was fashioned and carried down through the fascia with the cautery. The abdomen was entered carefully sharply without incident. There was no evidence of ascites. An extensive lysis of adhesions then ensued using [**Doctor Last Name **] clamps to elevate the fascia. This lysis of adhesions was accomplished largely with the Metzenbaum scissors but also with the cautery and no untoward events occurred. The foreign body in the form of a coiled Foley catheter tube with an inflated balloon was easily identified in the distal ileum. There was no evidence of intussusception or ischemic insult to the bowel at this location. There were extensive adhesions of the distal ileum down into the pelvis which explains why this foreign body was unable to pass beyond its current point nor would it likely have done so. We first elected to deflate the Foley catheter balloon with a 22 gauge needle and syringe through the wall of bowel. After this was accomplished, a small enterotomy was made on the antimesenteric border of the small bowel. Secretions and air was aspirated with the Yankauer suction device. The catheter was then grasped with a curved clamp and extracted from the small bowel without incident. The tube was noted to be completely intact. The mucosa of the small bowel appeared normal without evidence of bleeding. The enterotomy was then closed in 2 layers with an interrupted 3-0 Vicryl suture as a full-thickness for the inner layer and then several interrupted 3-0 silk Lembert sutures to invert the closure. The abdomen was then irrigated. We attempted to place a GJ tube via the existing gastrostomy site in the upper abdomen; however, given dense adhesions in the upper abdomen, we could not safely pass this catheter via the duodenum into the jejunum with our hands. Accordingly, we aborted this portion of the procedure. The fascial incision was closed with a running #1 looped PDS suture. Subcutaneous tissues were irrigated and the skin was closed with staples. A sterile dressing was applied and the suture over the ileostomy was cut and an appliance was placed. The patient tolerated the procedure well without complication. He was transferred back to the intensive care unit, intubated and in stable condition. COMPLICATIONS: None. *ARF: Pt's Cr was elevated at 1.7 at admission. Appeared pt was dry at presentation and this was likely pre-renal in nature. Cr improved with IVFs and medications were renally dosed. . *Elevated troponin: Pt's troponin was elevated to 0.12 today, with ck of 269. EKG showed sinus tachycardia with no ST changes. Per report, pt was seen by cardiology who thought this was demand ischemia in the setting of hypotension. Troponins peaked at 0.15. He was started on aspirin. . * Hypernatremia: Pt was hypernatremic at admission. This was initially thought [**1-19**] to hypovolemia and sodium did not improve with IVF hydration. He was given free water fluid boluses through the NGT and started on maintence fluid with LR instead of NS. He was also started on D5W. His water defecit will need to be re-calculated to determine how much D5 he will required. He was given an additional liter of D5 prior to surgery. Free water fluid boluses were stopped when concern for GI bleed. . * Tachycardia: Likely physiologic, response to infection, fever and anemia. No ST-T changes on EKG. Was tachycardic at last admission. . *Elevated LFTs: Slightly elevated at admission,likely [**1-19**] to hypovolemia. Not active. . * Anemia: Hct at admission was stable from last admission. His baseline prior to that was in the low 40s. He was noted to have guiac positive ostomy output at the last admission, but hct was stable. Hct dropped on [**10-11**] and there was concern for GI bleed. Pls see section on hypotension for further information. Pt was continued on PPI. Additionally, per blood bank there was concern for possible delayed transfusion reaction as it was discovered he was Coombs positive. His hemolysis labs were checked on [**10-10**] and were normal. . *Hypothyroidism: Continued on synthroid. . * GERD: PPI, elevated head of bed. . * H/o schizoaffective d/o: continued low dose ativan prn anxiety/agitation and desipramine (TCA) . * Neurogenic bladder: U/A was negative. He had a foley in place. -Continue Foley. - f/u UCx . * PPx: PPI, Heparin SC, . * FEN: Was on TFs but these were held once G tube disappeared (new one placed, but did not want to feed until the tube passed). Currently tube feeds are on hold and he getting d5w. . * Code status: Full Code . * Access: R PICC line . * Comm: Sister [**Name (NI) **] [**Name (NI) 1726**] [**Telephone/Fax (1) 104993**], [**Telephone/Fax (1) 104994**]; Brother [**Name (NI) 4036**] [**Name (NI) 104995**] [**Telephone/Fax (1) 104996**] PCP [**Name Initial (PRE) **] [**Telephone/Fax (1) 608**] PLEASE KEEP IN CONTACT WITH SISTER DAILY. [**Hospital **] rehab [**Telephone/Fax (1) 104300**] Medications on Admission: 1. Desipramine 75 mg PO qPM 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H 3. Albuterol Sulfate 0.083 % solution inhaled q6 hours 4. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO q6 hrs PRN 5. Pepcid 20 mg Tablet qd 6. Multi-Vit 55 Plus Tablet qd 7. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous once a day for 7 days: dose for vancomycin trough goal [**10-6**]. 8. Tube feeds Probalance (or equivalent) goal 65cc/hr to meet ~1800 kcals/day, 75-95 g of protein/day 9. Flagyl x 1 10. Ceftazidime x 1 Discharge Medications: . IV access: Central Line Order date: [**10-19**] @ 1302 10. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date: [**10-19**] @ 1302 2. IV access: Peripheral Order date: [**10-19**] @ 1302 11. Levothyroxine Sodium 100 mcg PO/NG DAILY Order date: [**10-23**] @ 0723 3. 1000 ml LR Continuous at 2 ml/hr KVO Order date: [**10-20**] @ 1737 12. Lorazepam 0.5-1 mg IV Q1-2H:PRN anxiety/agitation Please HOLD for sedation, rr<10 Order date: [**10-19**] @ 1302 4. Acetaminophen 650 mg PO Q4-6H:PRN Order date: [**10-19**] @ 1302 13. Magnesium Sulfate 2 gm / 100 ml NS IV PRN mg < 2.0 Order date: [**10-19**] @ 1302 5. Calcium Gluconate 2 gm / 100 ml NS IV PRN i ca < 1.13 Order date: [**10-19**] @ 1302 14. Metoprolol 50 mg PO/NG [**Hospital1 **] thorugh tube, hold SBP less than 100 or HR less than 60 Order date: [**10-23**] @ 1023 6. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. Order date: [**10-19**] @ 1302 15. Oxycodone-Acetaminophen Elixir [**4-26**] ml PO/NG Q4-6H:PRN pain per G-tube Order date: [**10-23**] @ 1023 7. Heparin 5000 UNIT SC TID Order date: [**10-19**] @ 1302 16. Pantoprazole 30 mg PO Q24H Start: [**2119-10-22**] per peg Order date: [**10-22**] @ 1058 8. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift Order date: [**10-19**] @ 1302 17. Potassium Chloride 40 mEq / 100 ml SW IV PRN k< 4.0 Order date: [**10-19**] @ 1302 9. IV access request: PICC D/C and culture tip Urgency: Routine Order date: [**10-19**] @ 1302 18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Order date: [**10-19**] @ 1302 Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Failure to thrive respiratory failure impacted g tube pneumonia Discharge Condition: good. Tube feeding, tracheostomy with qa2hrs succioning Discharge Instructions: 1. Change dressing wet to dry in the abdomen q 8hours 2. Trach care and succioning q 2hours 3.Tube feeding at goal Followup Instructions: Follow up with Dr [**Last Name (STitle) 1924**] 2 weeks from DC [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1924**], M.D. [**MD Number(1) 104998**] ([**Telephone/Fax (1) 55864**] E/[**Hospital Ward Name 23**] [**Hospital Ward Name 1950**] 9 General [**Doctor First Name **] [**Hospital1 18**] Completed by:[**2119-10-23**]

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2733

Discharge summary

report

Admission Date: [**2159-2-24**] Discharge Date: [**2159-3-1**] Date of Birth: [**2095-10-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: Hypotension per VNA services Major Surgical or Invasive Procedure: Intubated History of Present Illness: 63 yo man with h/o orthotopic liver x-plant in [**2156**], SCLC with mets to bone and liver (recently taken off chemo due to CRI, pancytopenia and liver x-plant) presents with 3 day history of cough, shortness of breath. Has had increased edema with lethargy for past 2 weeks. Pt noted to have BP of 70/40 by VNA services and thus sent to ED. Also c/o orthopnea. Denies any diarrhea, nausea, vomiting. In [**Name (NI) **] pt met criteria for MUST protocol. Pt given vanc, levo, flagyl in ED. Put on levophed. Past Medical History: 1. SCLC metastasis to bone (pelvis) and liver on etoposide and cisplatin treatment. 2. Liver transplant secondary to hepatoma on [**10-21**] from hepatitis C cirhossis 3. DM 4. GERD 5. MR 6. Afib -s/p ablation 7. CHF - preserved EF 8. Home oxygen at 4L NC (normal SaO2 at 96-97%) 9. CRI - baseline cr 1.8 10. h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] esophagitis Social History: Pt is a former construction workers who reported has had some exposure to asbestos. The patient is also a fomer tobacco smoker - more thatn 1ppd x 40+years who quit in [**September 2158**]. The patient also admits to some social alcohol use but quit two years prior to his liver transplant in '[**54**]. The patient denies ever using illicit drugs. Family History: NC, no cancer in family Physical Exam: T 96 BP 100/70 HR 98 RR 16 O2sats 96% on AC w/ FiO2 100% PEEP 5 Gen: Cachectic, ill appearing, intubated male HEENT: intubated, dry mm, perrl, eomi Neck: no jvd Lungs: increased AP dia., bilateral rhonchi, decrease BS at bases b/l l>r Heart: irregularly irregular, no m/r/g Abd: firm, + mid epigastric tenderness Ext: [**3-23**]+ pitting edema in LE b/l Neuro: awake, moving all 4 ext Pertinent Results: [**2159-2-24**] 05:55PM GLUCOSE-234* UREA N-96* CREAT-3.4*# SODIUM-141 POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-34* ANION GAP-18 [**2159-2-24**] 05:55PM WBC-2.6* RBC-2.65* HGB-8.0* HCT-25.4* MCV-96 MCH-30.3 MCHC-31.6 RDW-19.9* [**2159-2-24**] 05:55PM PLT COUNT-125* [**2159-2-24**] 05:55PM PT-13.6 PTT-24.7 INR(PT)-1.2 [**2159-2-24**] 06:07PM LACTATE-4.8* CT TORSO 1. Significant interval increase in the size of the large left upper lobe mass as well as interval worsening of the liver and splenic metastases. 2. Diffuse septal thickening, which may relate to congestive heart failure. Lymphangitic spread of tumor cannot be excluded. 3. Mottled appearance of the iliac bones, which may relate to metastatic lesions. ECHO The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. LV systolic function appears moderately depressed with global hypokinesis. [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. [Intrinsic right ventricular systolic function may be more depressed given the severity of tricuspid regurgitation.] The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. No vegetations seen (cannot exclude). Compared with the report of the prior study (tape unavailable for review) of [**2152-10-12**], biventricular abnormalities are new and mitral regurgitation and tricuspid regurgitation are now significantly worse. Brief Hospital Course: Pt was admitted for sepsis and started on the MUST protocol. Source of infection felt to be from the lungs, as pt with stage 4 lung cancer with rapidly growing tumor. Felt to have post obstructive PNA. He was started on vanco/flagyl/ceftriaxone/levo after being intubated in the ED. He was started on levophed to maintain MAP>65. He was aggressively hydrated to keep CVP 8-12. This was then backed off as CVP was > 15. Held his diuretics and anti-HTN meds. Pt was also in ARF was cr at 3.4 but this quickly improved with fluids. We were able to wean his vent settings to CPAP. He was seen by hepatology in regards to his liver transplant and continued on tacrolimus. Also followed by onc for his cancer. It was felt that his cancer was end stage and no further treatment was available given the extent of his disease. With time pressors were weaned off. As patient improved he was asking that the ETT be removed. He ended up self extubating himself. But only lasted about 30 minutes before he became severely acidotic and required reintubation. He then self extubated himself for a second and asked that he not be re-intubated. Discussion was held with family and patient. Given poor prognosis due to the cancer, pt decided he wanted no further treatment and requested comfort measures only. All meds were stopped except for morphine, ativan. These were titrated to comfort. Pt then expired on [**2159-3-1**] at 1235pm with his family at the bedside. Medications on Admission: prograft, lopressor, lasix, prednisone, fludrocortisone, bactrim, glyburide, amiodarone, protonix, tacrolimus Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Small Cell Lung Cancer Sepsis Acute renal failure Respiratory failure Discharge Condition: Expired [**2159-12-29**] at 1235pm Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "99.04", "96.6" ]

icd9pcs

[ [ [] ] ]

5919, 5928

4261, 5731

344, 355

6042, 6078

2148, 4238

6130, 6136

1703, 1728

5891, 5896

5949, 6021

5757, 5868

6102, 6107

1743, 2129

276, 306

383, 899

921, 1318

1334, 1687

2,967

158,056

18385

Discharge summary

report

[** **] Date: [**2193-11-17**] Discharge Date: [**2193-12-6**] Service: [**Company 191**] MEDICINE HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old woman initially admitted to the [**Hospital1 18**] from [**11-1**] through [**11-6**] on [**Hospital Unit Name 196**] service following transfer from outside hospital for evaluation of chest pain, ST elevation myocardial infarction, and positive troponin. Catheterization on [**11-4**] showed three- vessel coronary artery disease, severe systolic and diastolic dysfunction with an ejection fraction of 27% (global hypokinesis), and mild to moderate mitral regurgitation. CT surgery was consulted at that time. The patient deemed not a surgical candidate secondary to co-morbidities. A repeat cath on [**11-6**] was performed with stenting of RCA. The patient was medically managed and was discharged to [**Hospital **] Rehab on [**11-6**]. The patient did well by report for 10 days after discharge, when she was found dyspneic on day of [**Month (only) **]. She was initially thought to be in failure and received IV lasix, Nitro paste and ativan for agitation. EKG at that time was without changes, and her blood pressure was 200/100. The patient's oxygen saturation was 76% on room air and 85% on a nonrebreather mask. She was intubated in the field for this respiratory distress and hypoxia, and was reported to have aspirated during this intubation. By report, she also had a change in mental status and was unresponsive for 2 hours. Blood pressure following intubation was reported as 40/18 on arrival to the Emergency Department. She was started on a dopa drip and propofol for sedation. The patient was started on treatment for pneumonia, as well, with Levaquin, and was given fluid resuscitation. PAST MEDICAL HISTORY: 1. Old right stroke from [**2176**]. 2. Hypertension. 3. Mild dementia. 4. Anxiety. 5. Pneumonia, [**2193-4-23**]. 6. Diverticulosis. 7. Dyslipidemia. 8. Left subclavian occlusion with collaterals. 9. Coronary artery disease, status post MI. ALLERGIES: No known drug allergies. However, during this [**Year (4 digits) **] the patient had intolerance to benzodiazepines. MEDICATIONS UPON [**Year (4 digits) **]: 1. Captopril 25 mg tid. 2. Metoprolol 25 mg [**Hospital1 **]. 3. Pantoprazole 40 mg qd. 4. Paroxetine 10 mg qd. 5. Atorvastatin 10 mg qd. 6. Aspirin 325 mg qd. 7. Clopidogrel 75 mg qd. 8. Furosemide 40 mg qd. 9. Imdur 30 mg qd. SOCIAL HISTORY: The patient lives in [**Hospital3 **] ([**Doctor First Name **] Terrace) prior to stay at [**Hospital1 **]. No tobacco, alcohol or illicit drug use. Walks with a walker. The patient's children live in [**State 4565**] and are very involved in the patient's care. PHYSICAL EXAM UPON [**State **]: Temperature 102.4, heart rate 89, blood pressure 105/76, respirations 18, oxygen saturation 100%, CVP 1, weight 49.4 kg. Initial vent settings were AC mode, tidal volume 500, respiratory rate 12, PEEP OF 5, FIO2 40%. GENERAL: Patient intubated, sedated, infrequent purposeless movements. HEENT: Pupils equal, round and reactive to light, 3 mm to 2 mm bilaterally, ETT in place. CARDIOVASCULAR: Regular rate and rhythm, normal S1, S2, II/VI systolic ejection murmur at the base, questionable S3. PULMONARY: Left bibasilar crackles, diminished right-sided breath sounds. ABDOMEN: Soft, nontender, normoactive bowel sounds. Liver edge palpable 2 cm below the costal margin. EXTREMITIES: 1+ DP pulses bilaterally, cool diffusely, chronic venous stasis changes. NEURO: Sedated, not responding to verbal or tactile stimuli. SKIN: Stage 2 sacral decubitus ulcer. Superficial laceration to left tibia. LABS UPON [**State **]: White blood cells 9.9. Differential - 92 neutrophils, 0 bands, 3 lymphocytes, 3 monocytes. Hematocrit 38.1, platelets 276. Potassium 3.5, bicarbonate 34, creatinine 1.1, BUN 22. Glucose 111. Rest of chemistries were normal. ALT 104, AST 118, alk phos 126, total bili 0.5, amylase 242, lipase 111. CK 30, troponin 0.27 (On [**11-7**], troponin was 1.65.). Urinalysis showed small blood, positive nitrites, trace protein, trace glucose, trace leukocyte esterase, 0-2 red blood cells, [**7-2**] white blood cells, moderate bacteria, 0-2 epithelial cells. Blood gas on intubation--settings stated above - pH 7.51, PCO2 39, PO2 122, lactate 1.0. Microbiology - urine and blood cultures drawn. Head CT showed age-related atrophy, chronic microvascular infarction, no bleed, or acute changes. Chest x-ray showed diffuse patchy right-sided opacities, loss of right hemidiaphragm, and small left pleural effusion. EKG - normal sinus rhythm at 85 beats per minute, normal axis, right bundle branch block, Q waves in II, AVF and V5/V6. T wave inversions II, III, AVF. No ST segment changes, PVC. These were not significant changes from [**11-7**] EKG. The [**Hospital 228**] hospital course was 20 days long. She was initially admitted to the [**Hospital Ward Name 12573**] Intensive Care Unit on [**11-17**] and was transferred to the medical floor on [**11-20**] with return to the [**Hospital Ward Name 12573**] ICU on [**11-25**], transferred to [**Company 191**] Medicine service on [**12-4**], and discharged on [**12-6**]. HOSPITAL COURSE - 1) RESPIRATORY FAILURE: Etiologies of hypoxia and respiratory failure were thought to be aspiration pneumonitis, pneumonia (community acquired/aspiration), versus flash pulmonary edema. The patient was weaned within 2 days off of the ventilator, and was stabilized on nasal cannula oxygen. Upon transfer to the floor, the patient initially remained stable, however, had intermittent hypoxic episodes with hypercarbia. A blood gas on [**11-24**] showed a pH of 7.32, PCO2 81, PO2 127, and serum bicarbonate in the high-30s. It was unclear why the patient was hypercarbic, and a repeat head CT was obtained with no acute changes. The patient was closely monitored throughout the day, and a repeat blood gas later on [**11-24**] indicated improvement, with a pH of 7.37 and a PCO2 of 65. However, later that evening the patient was found in her room by the RN hypoxic and cyanotic with oxygen saturation in the 50s on nasal cannula. A code blue was called, and the patient was intubated by anesthesia on site, and was transferred to the [**Hospital Ward Name 12573**] Intensive Care Unit. Blood gas at that time showed a pH of 7.13, PCO2 92, PO2 152 with a lactate of 3.9. This was prior to intubation. Postintubation blood gas showed pH 7.34, PCO2 71, PO2 112. Etiology of worsened respiratory status thought to be likely due to recurrent aspiration and hypoventilation. Please see below for pneumonia course. The patient was slowly weaned off of ventilator for this second intubation during this hospitalization, and was extubated on [**12-3**], on day prior to floor transfer. During last days of [**Month (only) **], the patient was stable on 3 liters nasal cannula with good oxygen saturations greater than 95%. 2) PNEUMONIA: The patient thought to initially have presented with community acquired pneumonia with likely aspiration, as reported by EMS team upon arrival. The patient was treated with 21 days of Levofloxacin during this [**Month (only) **]. In addition, she received 10 days of clindamycin for aspiration. On [**11-27**], the patient was started on vancomycin treatment for a sputum that grew out MRSA. On day of discharge, the patient was on day [**11-5**] of vancomycin course. The patient's blood and urine cultures during [**Month/Year (2) **] were persistently negative. Her initial presentation with sepsis and hypotension quickly resolved with the ability to wean pressor support within initial 24 hours of [**Month/Year (2) **]. The patient never required pressors throughout the rest of her hospital stay. The patient is at constant risk for aspiration, as determined by two swallow evaluations performed during this [**Month/Year (2) **]. The patient has a silent aspiration with decreased ability to cough. The patient is at risk for further aspiration pneumonias and precautions should be taken upon discharge. 3) CONGESTIVE HEART FAILURE: Echocardiogram was performed twice during this hospitalization. Ejection fraction was 40-45%. The left and right atria were elongated. The left ventricular cavity size was normal with mild regional left ventricular systolic dysfunction. Resting regional wall motion abnormalities including basal to midinferior and inferolateral hypokinesis. The right ventricular cavity was dilated. There was no aortic stenosis, or regurgitation. The mitral valve leaflets were thickened with moderate 2+ mitral regurgitation noted. The studies performed on [**11-28**] and the initial echo on [**11-22**] were without significant differences. During hospitalization, the patient was intermittently diuresed with furosemide. Her fluid status was very difficult to determine during [**Month (only) **]. Standing furosemide treatment was discontinued, as the patient appeared dry in last days of [**Month (only) **]. Her heart failure has been maximally medically managed with flow titration upward of captopril, and transitioned to qd dosing of lisinopril. The patient is also on beta blocker therapy. 4) CORONARY ARTERY DISEASE: The patient was status post ST elevation MI in [**2193-10-23**] with RCA stenting. The patient was consulted on previous [**Year (4 digits) **] by cardiothoracic surgery who deemed the patient not a CABG candidate. The patient has been maximally medically managed, and is on metoprolol, Atorvastatin, aspirin and Plavix. During [**Year (4 digits) **], the patient had rare chest pain that was not cardiac in origin. Persistent EKG tracings were not consistent with new ischemia. 5) HYPERTENSION: The patient's blood pressure was stabilized after initial pressor support, and she was continued on metoprolol, lisinopril, and amlodipine. 6) NUTRITION: The patient was malnourished during this [**Year (4 digits) **] with albumin ranging from 2.4-2.8 during this hospitalization. Nutrition consult was obtained, as well as speech and swallow evaluation x 2. The patient was initially started on tube feeds during first intubation, and upon transfer to the floor a speech and swallow evaluation reported overt aspiration, profound lethargy, inability to transport purees from front to back of mouth, and inability to take oral medications. At this time, a nasogastric tube was placed, and tube feeds were continued. The patient was given ProBalance tube feeds with a tolerance of maximum goal of 55 cc/h. Upon second extubation, the patient again failed a second swallow study, and tube feeds were resumed. After long discussions with the patient's family, a PEG tube was placed for nutritional supplementation. This PEG was placed on [**12-5**] without complications by interventional radiology. It was discussed with the family that the patient is still at risk for her silent aspiration despite PEG tube placement. The patient will continue feeds with ProBalance as recommended by nutrition consult. The patient started tube feeds at a rate of 10 cc/h, to increase q 2 h as tolerated to reach her goal of 55 cc/h. A q 4 h residual should be checked, and feeds should be held for greater than 200 cc of residual. The patient will be discharged on this nutrition regimen. 7) CHANGE IN MENTAL STATUS: The patient's mental status continued to wax and wane throughout her [**Month (only) **] with paranoid tendencies. This was thought to be due to a delirium superimposed on a baseline mild dementia. The patient had several reasons to be delirious with her hypoxia, pneumonia, and multiple transfers between Intensive Care and regular medical floor. The patient was started on Olanzapine 2.5 mg qd at 4:00 pm with good effect. Haldol was effective for agitation. It was of note that all benzodiazepines should be avoided, as the patient becomes thoroughly sedated with hypoxia. This should be seen as an allergy, and the patient should never receive these medications. The patient was paranoid at times, believing the medical staff was "out to get her." However, these episodes were waxing and [**Doctor Last Name 688**], and the patient was alert and oriented at times, as well. 8) ANEMIA: The patient's hematocrit trended down during her [**Doctor Last Name **]. Her iron studies were consistent with an anemia of chronic disease. She received 2 units of blood during her second Intensive Care course, and never required transfusions otherwise. Her hematocrit was stable on last days of [**Doctor Last Name **] at 33. It was thought that the patient's hematocrit should remain greater than 30, given her severe coronary artery disease. 9) ACCESS: A right internal jugular line was placed on initial presentation to the Intensive Care Unit and was kept in place for 19 days without complications. The site looked clean, dry and intact without erythema or tenderness. Peripheral access was a constant issue for this patient, as she had severe bruising. On the day prior to discharge, a PICC line was placed without complication, and the right internal jugular line was removed. The tip was sent for culture, even though there were no signs of infection, and this culture was pending at the time of this dictation. 10) WOUND: The patient had a stage 3 decubitus ulcer that was followed by the wound nurse [**First Name (Titles) **] [**Last Name (Titles) **]. Instructions on wound care will be sent for this patient. She was given an air mattress during [**Last Name (Titles) **] with frequent change of position q 2 h. The sacral wound should be cleansed with normal saline. A hydrogel should be placed with Telfa over wound. Dressing should be changed [**Hospital1 **]. There was also reddening of the patient's left heel. Multipodus boots were ordered; however, the patient usually refuses them. 11) PROPHYLAXIS: The patient will continue on lansoprazole and heparin subcutaneous injections, as well as a bowel regimen. The patient has MRSA in her sputum and should thus be put on precautions. She should receive no benzodiazepines, as explained above. 12) CODE STATUS: After long discussions with the family regarding code status, the patient was made a DNR/DNI on [**2193-12-4**]. Present at the discussion were the attending, myself and the patient's daughter, [**Name (NI) **], who is her healthcare proxy. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: To [**Hospital6 310**]. DISCHARGE DIAGNOSES: 1. Resolving respiratory failure. 2. Aspiration pneumonia. 3. Methicillin resistant Staphylococcus aureus pneumonia. 4. Likely community acquired pneumonia. 5. Coronary artery disease, status post ST elevation myocardial infarction, [**2193-10-23**], with right coronary artery stenting. 6. Congestive heart failure. 7. Hypertension. 8. Delirium superimposed on dementia. 9. Old right cerebrovascular accident. 10.Malnutrition. 11.Sacral decubitus ulcer. 12.Depression and anxiety. 13.History of diverticulosis. 14.Generalized weakness with severe deconditioning. DISCHARGE MEDICATIONS: 1. Clopidogrel 75 mg qd. 2. Aspirin 325 mg qd. 3. Atorvastatin 10 mg qd. 4. Acetaminophen 325 tablets q 4-6 h prn pain. 5. Albuterol nebs prn wheezing. 6. Ipratropium bromide nebs prn wheezing. 7. Lansoprazole 30 mg po qd. 8. Paroxetine 10 mg po qd. 9. Zinc sulfate 220 mg po qd for wound healing. 10.Ascorbic acid 500 tabs po bid for wound healing. 11.Lidocaine 2% solution 1-2 cc for mucous membranes tid prn. 12.Metoprolol 50 mg tabs po bid. 13.Heparin 5,000 U subcutaneous injection [**Hospital1 **]. 14.Amlodipine 5 mg tablets qd. 15.Haloperidol 0.5 mg q 4 h prn agitation. 16.Olanzapine 2.5 mg po qd at 4:00 pm for agitation. 17.Lisinopril 30 mg po qd. 18.Vancomycin 500 mg IV bid for 5 more days including day of discharge. It is of note that the patient has completed her courses of Levofloxacin and clindamycin before discharge. FOLLOW-UP PLANS: The patient will be discharged to [**Hospital **] Rehabilitation and will be seen by physicians there daily, with changes in medications as needed. The patient's condition, hospital course, as well as her placement were thoroughly discussed with family members, [**Name (NI) **] and [**Name (NI) **], by both case management and the medical team. The patient is DNR/DNI, as reported above. The patient will have aggressive physical therapy upon [**Name (NI) **] to [**Hospital1 **] for her severe deconditioning. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**MD Number(1) 50631**] MEDQUIST36 D: [**2193-12-6**] 13:21 T: [**2193-12-6**] 14:19 JOB#: [**Job Number 50632**]

[ "518.81", "263.9", "507.0", "428.0", "707.0", "799.1", "424.0", "425.4", "996.62" ]

icd9cm

[ [ [] ] ]

[ "43.11", "96.71", "38.93", "33.23", "99.60", "96.04" ]

icd9pcs

[ [ [] ] ]

14540, 15105

15128, 15967

15985, 16734

140, 1790

11400, 14443

1812, 2456

2473, 11384

14468, 14519

11,216

116,130

9757

Discharge summary

report

Admission Date: [**2138-2-1**] Discharge Date: [**2138-2-19**] Date of Birth: [**2066-10-28**] Sex: M Service: MEDICINE Allergies: Morphine / Demerol Attending:[**First Name3 (LF) 613**] Chief Complaint: transferred for OSH with hemothorax Major Surgical or Invasive Procedure: chest tube placement right chest wall intubation hemodialysis placement and removal of left groin hemodialysis catheter History of Present Illness: 71 M admitted to thoracic surgery with right hemothorax likely related to supratherapeutic [**Hospital 31291**] transfered to MICU because of respiratory failure, hypotension, and other comorbidities. . The patient was transferred [**2138-2-1**] from [**Hospital 1562**] hospital with spontaneous hemothorax on right with no prior history of trauma. He had intially complained shortness of breath and dyspnea on exertion for the past 2-4 weeks. He also reports intermittent diarrhea w/ small amount of blood, with INR of >4 the week prior to admission, which was been held 4 days prior to admission(was 1.0 on initial presentation). Denies chest pain or fever or chills. He had a right sided pleural effusion at [**Hospital1 1562**] by CXR, and had right thoracentesis and was diagnosed with hemothorax and transferred to [**Hospital1 18**]. . At [**Hospital1 18**] he was intially scheduled to go to OR and have VATS vs thoracotomy, but deveoped resp failure and hypoxia and was intubated on [**2-3**]/05while on the floor ([**Hospital Ward Name **] 10) with suspected mucous plug. A chest tube was placed instead. He was requiring Levophed temporarily while intubated but this was weaned off, and he was extubated [**2138-2-5**]. The chest tube is scheduled to be pulled on [**2138-2-6**]. . Of note, his hospital course include ongoing HD for ESRD followed by the nephrology service. The patient had thrombosed RUE and LUE AV fistulas which will require fistulogram. He has been getting HD via groin line. He had a TTE to evaluate for CHF showing NL EF. He had required 3U of PRBC's for bloody drainage of hemothorax, but there is no report of bloody stools or hematuria. On [**2138-2-6**] he was noted to spike a temp to 101.0. This temp spike resolved transiently per-HD on [**2-6**]. He was transferred from SICU to MICU for further medical managmeent Past Medical History: 1. type II diabetes mellitus x 25yrs 2. end stage renal disease secondary to DM, s/p RUE brachiocephalic v fistula ([**8-/2133**], revised [**12-17**]), s/p failed renal transplant ([**12-17**]) -> failed, hemodialysis since [**2135**] 3. CAD s/p MI ([**3-16**]), s/p 4v-CABG ([**3-16**])->revised; h/o positive stress and stent of OM2 [**5-/2136**] 4. CHF (but w/ NL EF by TTE [**2138-2-4**]) 5. Sternal dehiscence-> osteomyelitis (coag neg Staph), s/p sternal debridement ([**5-19**]) 6. Hypertension 7. Elevated Cholesterol 8. H/O broken L ankle -> rehab -> RLE DVT ([**4-19**]), s/p IVC filter 9. s/p R cataract extraction 10. Chronic myelogenous leukemia since '[**36**] on Gleevec 11. Osteoporosis 12. DVT [**4-/2136**], was on Coumdin Social History: Lives with his wife [**Name (NI) 622**]. previous Etoh abuse history (quit in '[**31**]) quit tobacco 30 years ago, no current Etoh or tobacco use. Family History: Mom and sister w/ [**Name2 (NI) 499**] Ca, Brother w/ prostate Ca, no family h/o cardiac disease Physical Exam: Tc=99.1 Tm=101.0, BP=(121/51)90s-150s/40's-50s, HR=100-120(102), RR=20, O2=99% on 4L NC; I/O's=357/0(+357) PE: GEN: Patient appears comfortable, lethergic, but in NAD HEENT: nonicteric, mucosa slightly dry CHEST: course exp BS's ant/lat; no wheezes noted CV: RRR, no appreciable abnormal heart sound ABD: good BS's, obese, soft, NT, ND EXT: 2+ pitting LE edema bileraterally NEURO: Oriented to person; patient is generally weak and not cooperative w/ exam; no frank asterixis noted Pertinent Results: [**2138-2-6**] 03:15AM BLOOD WBC-13.7* RBC-2.88* Hgb-8.3* Hct-25.4* MCV-88 MCH-29.0 MCHC-32.9 RDW-14.9 Plt Ct-182 [**2138-2-5**] 03:33AM BLOOD WBC-17.9* RBC-3.15* Hgb-9.4* Hct-27.1* MCV-86 MCH-29.9 MCHC-34.8 RDW-14.8 Plt Ct-238 [**2138-2-4**] 02:46PM BLOOD WBC-22.8*# RBC-3.35* Hgb-9.9* Hct-28.9* MCV-86 MCH-29.6 MCHC-34.3 RDW-14.4 Plt Ct-239 [**2138-2-6**] 04:00AM BLOOD PT-12.9 PTT-29.8 INR(PT)-1.1 [**2138-2-6**] 03:15AM BLOOD Plt Ct-182 [**2138-2-5**] 03:33AM BLOOD Plt Ct-238 [**2138-2-5**] 03:33AM BLOOD PT-12.8 PTT-31.5 INR(PT)-1.0 [**2138-2-6**] 03:15AM BLOOD Glucose-137* UreaN-75* Creat-8.2*# Na-148* K-5.8* Cl-113* HCO3-23 AnGap-18 [**2138-2-5**] 03:33AM BLOOD Glucose-84 UreaN-59* Creat-7.1* Na-146* K-4.7 Cl-110* HCO3-24 AnGap-17 [**2138-2-6**] 03:15AM BLOOD Calcium-8.5 Phos-4.9* Mg-2.2 [**2138-2-5**] 03:33AM BLOOD Calcium-8.1* Phos-4.4 Mg-2.4 [**2138-2-6**] 06:24AM BLOOD Type-ART pO2-126* pCO2-35 pH-7.31* calHCO3-18* Base XS--7 [**2138-2-6**] 06:24AM BLOOD Lactate-0.8 [**2138-2-6**] 06:24AM BLOOD freeCa-1.02* [**2138-2-3**] 10:42PM BLOOD CK(CPK)-65 [**2138-2-3**] 04:49PM BLOOD CK(CPK)-66 [**2138-2-3**] 09:28AM BLOOD CK(CPK)-84 [**2138-2-3**] 10:42PM BLOOD CK-MB-NotDone cTropnT-0.62* [**2138-2-3**] 04:49PM BLOOD CK-MB-5 cTropnT-0.52* [**2138-2-3**] 09:28AM BLOOD CK-MB-NotDone cTropnT-0.43* CXR: [**2-6**]: The right-sided pleural densities are similar to what has been noticed on the preceding study and also the chest tube position is unchanged. No pneumothorax has developed after instrument removal. [**2-3**] - CTA neg for PE, loculated R hydropneumothorax; also w/ large L sided-effusion w/ assoc atelectesis . [**2-4**] - TTE w/ EF>55%(suboptimal, mod LAE, mild [**Last Name (un) **], 1+ AR) . EKG's [**2-1**] - NSR at 88 bpm, 1 mm STD's and TWI's V4-V6, TWI's I & AVL [**2-3**] - NSR at 84 bpm, resolved TWI's and STD's V4-V6; still w/ TWI's I & AVL (ols changes compared to [**5-/2136**]) [**2138-2-7**]: IMPRESSION: 1) AV fistulogram demonstrated complete thrombosis of the brachiocephalic vein fistula. Multiple stenoses are present throughout the outflow cephalic vein. A significant stenosis was identified within the right brachiocephalic vein. 2) Successful lysis of the thrombosed fistula using a total of 10 mg of t-PA. 3) Venoplasty of the outflow cephalic vein stenoses using an 8-mm balloon and of the severe right brachiocephalic stenosis using a 12-mm balloon, all with good angiographic success and restoration of forward flow. [**2138-2-10**] Chest, Abd, Pelvis CT: 1) No evidence of abscess, and no definite evidence of pneumonia. The lung examination is somewhat limited by respiratory motion. There is airspace opacity along the tract of the prior chest tube which may represent contusion vs. consolidation. 2) There are bilateral pleural effusions, loculated, which have increased in the interim since the prior exam. The left effusion is large and the right effusion is moderate, and there is associated atelectasis. [**2138-2-11**] Head CT: IMPRESSION: 1. No evidence of acute intracranial hemorrhage or mass effect. 2. Scattered areas of hypodensity within both thalami and the basal ganglia having an appearance consistent with chronic lacunar infarction. [**2138-2-14**] RUQ U/S: IMPRESSION: Tumefactive sludge within the gallbladder. No ultrasonographic evidence of cholecystitis. Limited visualization of the pancreas due to overlying bowel gas. [**2138-2-15**] CXR: Left-sided PICC line is in distal SVC. There are small bilateral pleural effusions and associated bibasilar atelectases, essentially unchanged since the prior film of [**2138-2-11**]. No new lung lesions. Brief Hospital Course: 71 year old man type II diabetes mellitus, coronary artery disease s/p CABG, congestive heart failure (nml EF), CML, end stage renal disease s/p failed renal transplant on hemodialysis, transferred from outside hospital with hemothorax to Transplant surgery SICU team. Hospitalization complicated by mutiple issues: 1. Hemothorax: The patient was initially transferred for VATS and thoracotomy by the thoracic surgery team. He developed respiratory failure requiring intubation on [**2138-2-3**], and transfer to the MICU. A chest tube was placed. Studies were not done on the initial specimen showing a spun Hct >50%. The cause of the hemothorax was unknown. He was ruled out for PE by negative CTA. There was no history of trauma or previous history of COPD or bled formation. Pleural effusions reaccumulated after removal of the chest tube. A thoracentesis was done which showed an exudative effusion on the right, the side of the hemothorax, and a transudative effusion on the left. Gram stain and culture were negative; however, the patient was on antibiotics (levofloxacin) at the time of the tap for treatment of post-intubation tracheobronchitis. Cytolgy showed no malignant cells. The patient was extubated [**2138-2-5**], and supplemental O2 requirements weaned. By the time of discharge he had stable small bilateral pleural effusions by CXR and was saturating well on room air, not short of breath. The effusions were attributed to CHF and chronic renal failure; the right appearing exudative as a complication of the high blood count. 2. Hypoxia: Postextubation the patient required supplemental O2. He was treated with a 7 days course of levofloxacin 250mg Q48hrs for treatment of tracheobronchitis. The initial decompensation requiring intubation was thought to be due to mucus plugging. CHF status remained stable. He was continued on aspirin, metoprolol, and a statin for secondary prophylaxis. 3. Fevers: postextubation on [**2138-2-6**] he was noted to spike a fever to 101.0. CXR, chest CT, abdominal CT, blood cultures, urinalysis, and urine cultures were nondiagnostic. There was no sign of pneumonia or abscess. He was treated for a day with Zosyn and Vancomycin for concern of hospital acquired or aspiration pneumonia. Sputum grew gram negative rods E. coli and Enterobacter. As no findings were seen on CXR or chest CT, this was attributed to tracheobronchitis and treated with a 7day course of levofloxacin. 4. Delirium: the patient developed a delirium complicated by agitation requiring a 1:1 sitter, Zyprex and Haldol, soft restraints. The delirium resolved with treatment of his multiple medical issues. He was continued on Zyprexa qHS. 5. Nutrition: During his delirium he had an NG tube placed, and he was sustained on tubefeeds. A swallow study was done once the patient was more alert and initially showed risk of aspiration. He was started on a nectar-thickened diet. Two days prior to discharge a repeat swallow study was done. The patient passed. He was discharged on a diabetic, renal, heart healthy, low sodium diet of thin liquids and regular solids. 6. Hypotension: in the ICU the patient became hypotensive and required a small dose of levophed. He was also treated with stress dose steroids. This resolved prior to discharge from the ICU. 7. Pancreatitis: On [**2138-2-12**], after initiating a po diet, the patient developed nausea and epigastric pain. LFTs showed mildly elevated transaminases, normal alk phos and total bilirubin, and moderately elevated lipase and amylase. RUQ ultrasound showed sludging in the gallbladder. It was felt he developed a pancreatitis secondary to gallbladder sludging while on tubefeeds. He was made NPO, treated with gentle ivf's. Nausea and abdominal pain resolved. Diet was advanced slowly, to clears, then to full diet. He was tolerating a full diet as described above prior to discharge. 8. History of DVT: the patient had a DVT diagnosed in [**4-18**]. He completed his course of anticoagulation and has an IVC filter in place. He was treated with DVT prophylaxis with heparin SC. No further anticoagulation was indicated. His dialysis line was noted to have thromboses. This was corrected by interventional radiology procedure. A temporarily groin line was placed for dialysis. This was pulled and the A-v fistula was used 4 times for dialysis prior to discharge. 9. Cardiac: He has known CAD s/p CABG and stent and CHF. Echo was done and showed mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], 1+MR, otherwise normal. He was treated with aspirin, metoprolol and statin. He ruled out for acute MI, and no further acute cardiac issues developed. 10. End stage renal disease: He was continued on M,W,F hemodialysis. 11. Type II diabetes mellitus: he was monitored with QID fingersticks and treated with a regular insulin sliding scale. A standing regimen of insulin was not initiated as the patient's diet fluctuated with tubefeeds, then NPO, then slowly advancing diet. He was continued on prednisone 5mg daily for his failed renal transplant. 12. Chronic myelogenous leukemia: Diagnosed in [**2136**], the patient was previously on Gleevec. This was held in the setting of his acute pulmonary issues. His counts remained stable throughout the hospitalization. Hematoloyg/Oncology was consulted. They recommended holding the patient's Gleevec until he follows up with outpatient Oncology given his persistant state of fluid overload (he still had small pleural effusions), modestly elevated LFTs and recent course of pancreatitis. He will be following up with Dr. [**Last Name (STitle) 410**] in Heme/Onc for further care. He should bring all records regarding his history of CML and iron overload to that appointment. 13. Elevated CK: On [**2138-2-10**] the patient was noted to have an elevated CK to 1300. There was no CK-MB or Trop elevation to suggest a cardiac etiology. It was felt this was likely muscular and resulted from IM haldol injection. Subsequent IM injections were held, and the CK trended down to normal. 14. Dispo: the patient was discharged to rehab. He was evaluated by physical therapy and occupational therapy prior to discharge. He will follow up with his primary care physician Dr [**Last Name (STitle) 15170**]. He should also plan to follow-up with his endocrinologist regarding diabetes care, nephrologist regarding his end stage renal disease, and Dr. [**Last Name (STitle) 410**] regarding his chronic myelogenous leukemia. He is a full code. Communication is with the patient and his wife [**Telephone/Fax (1) 32904**]. Medications on Admission: Meds at Home: Vicodin prn, Neurontin 100 QD, Nephrocaps, Metoprolol 25 [**Hospital1 **], Gleevec 400 [**Hospital1 **], Prednisone 5 QD, Tums prn, Coumadin 7.5/10 alternating, Paxil 10 QD, RISS (+/- NPH?) . Meds on Transfer: Ipratropium Bromide Neb Q6H, Lorazepam 0.5-1 mg IV Q4H:PRN, Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H:PRN, Calcium Acetate 667 mg PO TID W/MEALS, Famotidine 20 mg IV Q24H, Paroxetine HCl 20 mg PO DAILY, Fentanyl Citrate 25-100 mcg IV Q4H:PRN, Phenylephrine HCl 0.5-5 mcg/kg/min IV DRIP TITRATE, Prednisone 5 mg PO DAILY, Insulin SC Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation Q4-6H (every 4 to 6 hours) as needed for shortness of breath or wheezing. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed for constipation. 7. Epoetin Alfa 20,000 unit/2 mL Solution Sig: Five (5) thousand units Injection ASDIR (AS DIRECTED): To be dosed at dialysis. 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) units Injection ASDIR (AS DIRECTED): regular insulin per sliding scale: see attached scale. 11. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a day. 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for to groin. 14. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO HS (at bedtime). 15. Pantoprazole Sodium 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: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: Primary: pleural effusions conjestive heart failure end stage renal disease on hemodialysis type II diabetes mellitus coronary artery disease pressure ulcers pancreatitis chronic myelogenous leukemia respiratory failure Secondary: h/o osteomyelitis/ sternal dehiscence osteoporosis h/o DVT [**4-18**], [**4-19**] s/p cataract surgery hypercholesterolemia hypertension Discharge Condition: stable Discharge Instructions: Please take all medications as prescribed. Please participate in all rehabilitation activities. If you develop fever >101.3, chest pain, shortness of breath, abdominal pain, or persistant nausea, please call your primary care physician [**Name Initial (PRE) **]/or return to the emergency department. Followup Instructions: Please follow-up with Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**] in Hematology/Oncology. [**Telephone/Fax (1) 3760**]. Please bring all records from your oncologist regarding your CML, history of chronic transfusions, and iron overload. Please also plan to follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 15170**]. You can call [**Telephone/Fax (1) 19657**] to make an appointment. You should be seen within the next 1-2 weeks to review your hospital course. You will continue on Mon, Wed, Fri hemodialysis The following appointments have been made for you: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Where: [**Hospital6 29**] HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2138-3-12**] 1:00 Provider: [**Name10 (NameIs) 2502**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 4054**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-3-12**] 1:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "250.40", "403.91", "V45.81", "577.0", "996.73", "205.10", "293.0", "428.0", "466.0", "518.81", "511.8" ]

icd9cm

[ [ [] ] ]

[ "38.95", "38.93", "96.71", "96.6", "34.04", "39.95", "96.04", "99.04", "39.50", "99.10", "34.91" ]

icd9pcs

[ [ [] ] ]

16378, 16490

7571, 14215

314, 436

16903, 16911

3888, 6891

17261, 18421

3271, 3370

14821, 16355

16511, 16882

14241, 14448

16935, 17238

3385, 3869

239, 276

464, 2323

6900, 7548

2345, 3090

3106, 3255

14466, 14798

18,984

188,895

2406

Discharge summary

report

Admission Date: [**2117-12-1**] Discharge Date: [**2118-1-8**] Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: This is an 84-year-old gentleman who was seen at an outside hospital who complained abdominal pain. During that time he also underwent an episode of hypertension and chest pain. It was found that he had a severe myocardial infarction and an elevation in his troponin. His abdominal pain was then evaluated. On admission to that hospital it was found that the patient had a perforated diverticulitis. The patient was transferred to [**Hospital1 **] for further management. The patient had a long hospice care which will be detailed subsequently. PAST MEDICAL HISTORY: Significant for coronary artery disease, atrial fibrillation, hypertension, and high cholesterol. PAST SURGICAL HISTORY: Significant for orthopedic contractures. MEDICATIONS AT HOME: Lipitor, insulin, Lopressor, aspirin, Pravachol. PHYSICAL EXAMINATION ON ADMISSION: He was afebrile. His heart rate was in the 80s. His blood pressure was down approximately 96/43. He was intubated at the time with 100 percent oxygen saturation. His lungs were clear. Heart was regular. The abdomen was soft. It was significantly tender in the bilateral lower quadrants (right greater than left). His rectal examination was guaiac negative. His extremities were warm and well perfused. LABORATORY DATA ON ADMISSION: Unremarkable at the time; however, as noted he had an elevated troponin indicative of a myocardial infarction. SUMMARY OF HOSPITAL COURSE: The patient was transferred to the [**Hospital1 **]. His hospital course was extremely complicated, however. He underwent a percutaneous drainage of his diverticulitis abscess fluid collection on [**12-3**]. On [**12-6**], the patient had complete control of his diverticular episode with the abscess drained. The patient was kept nothing by mouth. After resolution of his symptoms, he was begun on tube feedings. The output from the drains were minimal and were slowly decreasing over the hospital stay. From a cardiac standpoint, his troponin's were elevated and Cardiology was consulted. They felt that medical management was the best option for the patient and that cardiac catheterization would not be a reasonable option due to his overwhelming sepsis. The patient slowly stabilized from a cardiac standpoint; however, he developed gram-negative bacteremia as well as multiple pneumoniae which ultimately caused respiratory failure requiring prolonged intubation and tracheostomy. The patient also underwent a PEG placement at the time of the tracheostomy placement. The patient slowly had a decline in function and again needed fluid resuscitation. It was found that the patient had an episode of severe pancreatitis. Due to his multiple fluid boluses, both from his diverticular episode as well as for his pancreatitis, the patient was ultimately started on CVVH after his creatinine had risen and his BUN had risen greater than 100. However, after prolonged discussions with his family, it was felt that the patient's prognosis was extremely poor. The family decided to make the patient comfort measures only. The patient was extubated on [**2118-1-7**] and was given morphine and Ativan for comfort. The patient expired on [**2118-1-8**] of respiratory failure. The entire family was present during this time as well as a nurse. The patient was pronounced dead at 1:14 p.m. with the family present. The family deferred decision on autopsy at this time. The Medical Examiner was [**Name (NI) 653**], and the case was declined. Dr. [**Last Name (STitle) 6633**] was also notified at that time. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**], M.D. [**MD Number(2) 12418**] Dictated By:[**Doctor Last Name 11225**] MEDQUIST36 D: [**2118-1-8**] 14:12:52 T: [**2118-1-8**] 16:05:25 Job#: [**Job Number 12419**]

[ "599.0", "785.52", "250.00", "562.11", "584.5", "410.71", "577.0", "569.5", "427.31", "398.91", "V58.67", "569.81", "038.3", "396.2", "567.2", "482.41", "995.92", "V09.0", "996.62", "518.5" ]

icd9cm

[ [ [] ] ]

[ "99.15", "99.04", "99.07", "54.91", "88.57", "88.53", "96.6", "89.64", "37.23", "88.56", "39.95", "00.14", "31.1", "97.29", "38.93" ]

icd9pcs

[ [ [] ] ]

897, 968

833, 875

1566, 3954

135, 687

1425, 1537

710, 809

44,506

108,526

35560

Discharge summary

report

Admission Date: [**2120-7-26**] Discharge Date: [**2120-7-31**] Date of Birth: [**2061-5-17**] Sex: F Service: CARDIOTHORACIC Allergies: Morphine Attending:[**First Name3 (LF) 5790**] Chief Complaint: Tracheobronchomalacia Major Surgical or Invasive Procedure: Right thoracotomy, thoracic tracheoplasty w/mesh, Right main stem bronchus/bronchus intermedius bronchoplasty w/mesh, Left main stem bronchus bronchoplasty w/mesh Bronchoscopy with bronchoalveolar lavage History of Present Illness: Ms [**Known lastname 80947**] is a 59 y/o female who has had lifelong respiratory problems given many diagnoses and treatments without true resolution. She was evaluated with bronchoscopy and noted to have tracheobronchomalacia, which was also confirmed on CT. She had a stent placeed with significant improvement of her breathing. The stent was removed 3 weeks later secondary to pneumonia. She was evaluated in clinic for a tracheobronchoplasty. Past Medical History: HTN Hyperlipidemia Fibromalgia Right CEA followed by stenting 13 yrs later Hysterectomy Recurrent pneumonias Cataracts PVD Social History: Ex smoker 33pack year history quit in [**2105**]. No ETOH. Silica exposure: worked in fiber-optics currently retired. Married. Lives with family. Family History: Mother "Breathing problems" Offspring Daughter with "Breathing problem" Physical Exam: VS: 98.1 66 109/53 18 96%RA Gen: Alert and Oriented x 3. NAD. WD/WN female. Cardiac: RRR no m/r/g/c Pulm: CTA Bilaterally (decreased breathsounds in the bases B) Abdomen: +BS, soft, ND/NT Ext: Spider bite on medial aspect of left knee improving. Decreased erythema, no edema, no induration Pertinent Results: [**2120-7-29**] 02:34AM BLOOD WBC-9.2 RBC-3.78* Hgb-11.1* Hct-33.3* MCV-88 MCH-29.3 MCHC-33.2 RDW-14.3 Plt Ct-314 [**2120-7-30**] 09:30AM BLOOD Glucose-134* UreaN-7 Creat-0.8 Na-139 K-3.8 Cl-101 HCO3-30 AnGap-12 [**2120-7-30**] 09:30AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2 Brief Hospital Course: Mrs. [**Known lastname 80947**] was admitted to the hospital and on [**2120-7-26**] she had a R thoracotomy and tracheobronchoplasty. The patient tolerated the procedure well and was extubated immediately postoperatively. She was taken to the ICU for observation of her respiratory status postoperatively. Her CT and epidural were d/ced on POD 2 and her pain was well controlled with PO pain medications and toradol. Her diet was advanced to regular. However her BP was sensitive to narcotics so she was kept in the ICU until her pain was adequately controlled with an acceptable BP. She did not require pressors. She was transfered to the floor on POD 3 and her home medications were started. She continued to do well on the floor, her saturations were within normal limits on oxygenation, she ambulated without breathing issues. She was discharged home on POD 6. Medications on Admission: Atenolol 50', Benzonatate 100'''prn, Cilostazol 100'', Cyclobenzaprine 10HS, Lisinopril 20', Ativan 1'', Zantac 150'', Zoloft 100', Zocor 10', Guaifenesin Discharge Medications: Atenolol 50mg', Cyclobenzaprine 10mg qhs, Lisinopril 20mg', Lorazepam 0.5mg qhs prn insomnia, Pletal 100mg'', Ranitidine 150mg'', Sertraline 100mg', Zocor 10mg', Keflex 500mg qid (Stop on [**8-3**]), Dilaudid 2-4mg PO q3hrs PRN pain Discharge Disposition: Home Discharge Diagnosis: tracheo-broncho malacia Discharge Condition: Stable Discharge Instructions: Please Call Dr. [**Last Name (STitle) **] with any questions or concerns [**Telephone/Fax (1) 3020**]. Call with fevers greater than 101.5 Call with increased cough or secretions call with increased shortness of breath and or chest pain. You may shower today. Do not soak/swim x 6 weeks. Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) **] on [**2120-8-20**] 10:30am CDC [**Location (un) **] Far Building Please make an appointment with your primary care physician [**Name Initial (PRE) 176**] 2 weeks of your discharge.

[ "729.1", "780.52", "519.19", "366.9", "916.5", "401.9", "272.4", "530.81", "E906.4", "443.9", "V45.89" ]

icd9cm

[ [ [] ] ]

[ "33.48", "31.79", "33.24" ]

icd9pcs

[ [ [] ] ]

3331, 3337

2000, 2868

297, 503

3405, 3414

1706, 1977

3751, 4004

1307, 1381

3074, 3308

3358, 3384

2894, 3051

3438, 3728

1396, 1687

236, 259

531, 982

1004, 1128

1144, 1291

11,369

103,786

226

Discharge summary

report

Admission Date: [**2203-11-3**] Discharge Date: [**2203-11-12**] Date of Birth: [**2161-11-27**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 348**] Chief Complaint: Shortness of breath, chest pain Major Surgical or Invasive Procedure: Pericardiocentesis EGD with biopsy History of Present Illness: 41 y/o M w/ h/o HIV/AIDS (HIV dx 83, AIDS 92, last CD4 132, VL >100K [**10/2203**], RF IVDU), not currently on HAART, previous right sided bacterial endocarditis with residual 4+ TR, h/o prior MI in [**2193**], who presents from [**Hospital **] Hospital for emergent evaluation of pericardial tamponade. Patient was recently hospitalized at [**Hospital1 18**] for osteomyelitis of his L-ankle s/p prior fall. Presented to ED with fevers and ankle pain. Taken to OR by ortho and found to have neg brefringent crystals c/w gout. Tissue/Bone cultures grew MSSA. Patient started on cefazolin. F/U MRI could not rule out osteomyelitis and the patient was discharged to [**Hospital **] hospital for 6 weeks of IV cefazolin (to end [**2203-12-5**]). While at [**Hospital1 **], patient had uneventful course until night prior to admission when he developed low grade temp to 100.2. The morning of admission patient felt short of breath, lethargic with some chest pain. Noted to be tachycardic by vitals, and with decreased O2 sat to 90% on RA -> 96% 2L NC. Chest CT performed showing massively enlarged cardiac silhouette. Transfered to [**Hospital1 18**] for emergent pericardiocentesis. On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. In the ED, T98.8, HR 122, BP 147/87, RR 19, O2 97%. Patient noted to be uncomfortable, and w/ rub on exam. Pulsus not performed. Otherwise exam unremarkable. Transferred to cath lab for emergent peridcardiocentesis. In cath lab, pericardial pressure 35, RA and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1934**] each 30, RV systolic 55. 1.2 L of sanguinous fluid drained from the pericardium. Pericardial pressure decreased to 5mm Hg, and RA to 18mm Hg s/p drain. Patient admitted to CCU for further management. Past Medical History: - HIV/AIDS: HIV dignosed in '[**79**], AIDS diagnosed in '[**88**], last CD4 count 132, VL 100K [**2202-7-26**]. Perscribed HAART but pt reports noncompliance for past 5 months (followed by Dr [**Last Name (STitle) 2219**] at [**Hospital1 2177**] and NP [**Doctor Last Name **] [**Telephone/Fax (1) 2218**]) -- ONLY FATHER KNOWS DIAGNOSIS. - Hep C - Hep B cleared - Myocardial infarction in [**2193**] - h/o endocarditits with grade 4 TR - approximately 12 years ago - Recurrent epididimitis - h/o IVDU on methadone 80 mg QD (followed at Baycove [**Telephone/Fax (1) 2217**]) - Asthma - osteomyelitis (MSSA) on cefazolin Social History: Pt was most recently living at [**Hospital1 **]. He has a girlfriend. [**Name (NI) **] denies tobacco, EtOH, and current drug use/abuse. He is in a methadone program because of past IVDU. Family History: NC Physical Exam: ON ADMISSION: VS: T 99.3, BP 132/72 , HR 105 , RR 20, O2 99% 2l NC Gen: Caucasion male w/ mild bitemporal wasting resting comfortably in bed. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple. Unable to appreciate JVD as prominent carotid pulses b/l. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. +2/6 SEM at LUSB. Chest: Pericardial drain in place, clean, dry, intact, No scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Sparse basilar crackles right > left. Abd: +BS, softly distended, non-tender, liver edge palpable below the costal margin. No abdominial bruits. Ext: R-AKA. Left ankle in cast, 2+ DP pulse. No c/c/e. No femoral bruits. +line in L-groin, no bleeding, no hematoma. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit ON DISCHARGE: VS: 98.1 117/89 118 20 95% RA Exam was largely unchanged. Abdomen was mildly distended, not tender, normoactive bowel sounds. His cardiac exam was unchanged, the pericardial drain was pulled on day 2 of admission. Lungs were clear to auscultation bilaterally. Wound vac was in place, with minimal drainage. Pertinent Results: [**2203-11-3**] 05:00PM OTHER BODY FLUID TOT PROT-6.1 GLUCOSE-69 LD(LDH)-650 AMYLASE-56 ALBUMIN-1.9 [**2203-11-3**] 05:00PM OTHER BODY FLUID WBC-2122* HCT-11* POLYS-56* LYMPHS-27* MONOS-13* EOS-2* METAS-2* [**2203-11-3**] 03:58PM LACTATE-3.2* [**2203-11-3**] 03:50PM GLUCOSE-126* UREA N-38* CREAT-1.8* SODIUM-132* POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-25 ANION GAP-14 [**2203-11-3**] 03:50PM estGFR-Using this [**2203-11-3**] 03:50PM CK(CPK)-29* [**2203-11-3**] 03:50PM cTropnT-<0.01 [**2203-11-3**] 03:50PM CK-MB-NotDone [**2203-11-3**] 03:50PM WBC-6.2 RBC-3.09* HGB-9.2* HCT-28.6* MCV-93 MCH-29.6 MCHC-32.0 RDW-19.5* [**2203-11-3**] 03:50PM NEUTS-77.3* LYMPHS-17.1* MONOS-5.3 EOS-0.1 BASOS-0.2 [**2203-11-3**] 03:50PM PLT COUNT-295# [**2203-11-3**] 03:50PM PT-15.1* PTT-38.2* INR(PT)-1.4* Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS. . ECHO ([**2203-11-3**]) Pre-pericardiocentesis: The left atrium is elongated. The estimated right atrial pressure is >20 mmHg. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is moderately dilated. There is a large circumferential pericardial effusion. Stranding is visualized within the pericardial space c/w some organization. There is left atrial diastolic collapse. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Compared with the prior study (images reviewed) of [**2203-10-20**], large pericardial effusion with echocardiographic signs of tamponade is new. . ECHO ([**2203-11-3**]) Post pericardiocentesis: The left atrium is elongated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). The right ventricular cavity is markedly dilated. Right ventricular systolic function is normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is partial flail of a tricuspid valve leaflet. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2203-11-3**], the residue pericardial effusion is minimal. . Cardiac catherization ([**2203-11-3**]): 1. Large circumferential pericardial effusion with tamponade physiology. 2. Successful pericardiocentesis with drainage of 1500mls of blood stained fluid. Patient left cathlab in stable condition FINAL DIAGNOSIS: 1. Severe pericardial tamponade. 2. Mild primary pulmonary hypertension. 3. Successful pericardiocentesis with drainage of 1500ml of blood stained fluid. . ECHO ([**2203-11-4**]): The left atrium is mildly dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal [intrinsic function is likely depressed given the severity of tricuspid regurgitation.]. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened and appear shortened/remnants that do not fully coapt. A small echodensity is seen on the right atrial side of the septal leaflet - ?vegetation ?old vs. partial flail of leaflet segment. Severe [4+] tricuspid regurgitation is seen. There is a small (<1cm), circumferential, partially echo filled pericardial effusion without evidence of hemodynamic compromise. Compared with the prior study (post-pericardiocentesis, images reviewed) of [**2203-11-3**], the findings are similar. . ECHO ([**2203-11-5**]): The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened and appear shortened/remnants and fail to fully coapt. A small echodensity is again seen on the right atrial side of the septal leaflet which could be either a vegeateion or a partial leaflet segment. Severe [4+] tricuspid regurgitation is seen. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2203-11-4**], the pericardial effusion is slightly smaller and may be more echo dense. The left ventricular cavity size is probably slightly larger (reflecting better filling). The small echodensity on the tricuspid leaflet has not changed in size. . ECHO ([**2203-11-8**]): The left atrium is mildly dilated. The right atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated. Right ventricular systolic function is normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2203-11-5**], pericardial effusion now appears slightly smaller. . ECHO ([**2203-11-11**]): The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal. The mitral valve leaflets are structurally normal. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. There is a very small, partially echo filled pericardial effusion. Compared with the prior study (images reviewed) of [**2203-11-8**], the findings are similar. Brief Hospital Course: 41 year old male with HIV/AIDS, previous R-sided endocarditis and severe TR, presented in cardiac tamponade from rehabilitation. CARDIAC TAMPONADE: On admission, he was transferred to the cardiac catherization lab, where over one liter of fluid was drained from his pericardial space. The fluid was sent for gram stain, culture, AFB, [**Doctor First Name **], TB PCR as well as viral studies and cytology. A pericardial drain was initially left in place, but given minimal drainage over 24 hours, was pulled prior to his transfer to the floor. The etiology of the pericardial effusion is unknown. He was followed by Cardiology on the floor and the initial plan was for a pericardial window, for both tissue and to prevent reaccumulation of fluid. The patient refused the procedure at this time. He will follow up as an outpatient to re-evaluate for the procedure. The effusion was followed by serial ECHO while the patient was in the hospital. There was no evidence of re-accumulation. He is scheduled for an outpatient ECHO in several weeks to evaluate the pericardial space for reaccumlation of effusion. ATRIAL FIBRILLATION/FLUTTER: Per multiple EKGs, the patient appears to have developed new a fib/flutter. Given his guaiac positive stools, it is not advisable to start anticoagulation at this time. The patient is being rate controlled on a low dose of beta-blocker, which appears to be effective. He will be followed by outpatient Cardiology. ANEMIA: The patient had a hematocrit drop during this admission. His lab studies are consistent with anemia of chronic disease, however, the patient was found to have guaiac positive stools. GI was consulted and recommeded colonoscopy and EGD. The patient was unable to tolerate the prep and thus the colonoscopy was cancelled. His EGD demonstrated gastritis and thrush. He was started on fluconazole to treat the thrush. He was also transfused two units of packed red blood cells with an appropriate hematocrit response. HIV/AIDS: The patient had a CD4 count checked during his last admission, it was found to be 132 with a viral load >100K. Given his past noncompliance with HAART therapy and the risk of developing drug resistant HIV, HAART was not restarted. Pt is willing to restart HARRT, and the plan remains to restart medications at rehabilitation. Bactrim was continued for PCP [**Name Initial (PRE) 1102**]. OSTEOMYELITIS: The patient was previously admitted for left ankle pain. He was followed previously by both the orthopedic and ID services. Both services continued to follow the patient on this admission. The patient was continued on 6 weeks of IV antibiotics (last day of cefazolin [**2203-12-5**]), although the dose was decreased to 1g q6 because of a low white blood count. SEVERE TRICUSPID REGURGITATION: Pt with known grade 4 TR and flail leaflet which he deveoped after acute bacterial endocarditis roughly 10 years ago. We restarted his lasix and spironolactone on this admission. HCV: HCV viral load checked, and found to be 1.5 million. No further therapy initiated. ANXIETY: Pt with history of anxiety and on Klonapin at home. His home regimen was continued. ESOPHAGEAL CANDIDIASIS: Patient was found to have thrush on EGD. He was started on a course of fluconazole given his immunosupressed state. He is being discharged to complete a two week course of anti-fungal medication. Medications on Admission: cefazolin 2g IV q8 methadone 80mg PO qd (confirmed on prior admit) prednisone 10mg qd lovenox 40mg SQ prilosec 20mg PO qd ASA 81mg PO daily colace 100mg PO daily clonazepam 1mg qAM, 1mg qNoon, 2mg qhs prn sennekot 2 tabs PO BID PRN morphine sulfate IR 15mg PO q4 PRN promethazine 12.5mg PO q4h PRN Discharge Medications: 1. Methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q 12 NOON (). 7. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 14 days. 17. 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. 18. Cefazolin 1 gram Recon Soln Sig: One (1) Intravenous every six (6) hours for until [**2203-12-5**] weeks: please continue until [**2203-12-5**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary diagnosis: Cardiac tamponade GI Bleeding Atrial flutter [**Female First Name (un) 564**] esophagitis Secondary diagnosis: Pancytopenia HIV/AIDS Hepatitis B and C Endocarditits with flail tricuspic valve Right heart failure. Recurrent epididymitis IVDU on methadone 80 mg QD (followed at Baycove [**Telephone/Fax (1) 2217**]) ?Myocardial infarction in [**2193**] Asthma LLE medial MSSA foot abscess/osteomyelitis. Gout Traumatic Right AKA PCP Anxiety and depression. PPD (+) treated with 6 months INH Discharge Condition: Stable without fluid reaccumulation per ECHO Discharge Instructions: You were admitted with shortness of breath. You were found to have fluid around your heart. The fluid was removed but no specific cause was identified. If you have any chest pain or shortness of breath, please alert your doctors [**Name5 (PTitle) 2227**]. You will need weekly labs (specifically CBC, LFTs, BUN, and Cr) faxed to Dr. [**Known firstname **] [**Last Name (NamePattern1) 1075**] in the Infectious [**Hospital 2228**] clinic at [**Hospital1 18**] (fax [**Telephone/Fax (1) 432**]). You have a wound VAC on your ankle to help with healing of the tissue. This should be changed every 3 days by the nurses at your facility. You will need to be seen in the [**Hospital 1957**] clinic to determine how long you will need to have this in place. If you have any symptoms of worsening foot pain, foot redness, fevers, chest pain, nausea, vomiting, or any other concerning symptoms you are to go to the emergency room. Medication changes: 1. Lasix and spironalactone were restarted during this admission. 2. You HAART medication was held during this admission. These can be restarted by your ID doctors [**Name5 (PTitle) 1028**] [**Name5 (PTitle) **] are at rehab. 3. You are being treated with an antibiotics called cefazolin. You need to continue this medication until [**2203-12-5**]. Followup Instructions: Please arrive at ORTHO XRAY (SCC 2) on [**2203-11-15**] at 7:40 AM for x-ray *(Phone:[**Telephone/Fax (1) 1228**]). . Please follow up with your orthopedic doctor, [**Name6 (MD) **] [**Name8 (MD) 2229**], MD on [**2203-11-15**] at 8:00 AM (Phone:[**Telephone/Fax (1) 1228**]) . Please follow up with [**Known firstname **] [**Name8 (MD) **], MD on [**2203-11-25**] 11:00AM (Phone:[**Telephone/Fax (1) 457**]) . You are scheduled for an ECHO on [**2203-11-21**] at 8 AM. Please come to the [**Hospital Ward Name 23**] building, [**Location (un) 436**] for your appointment. Please follow up with Dr. [**Last Name (STitle) 2230**], CT surgery on Monday, [**11-21**] at 1:15 pm. This appointment is at [**Hospital Unit Name 2231**]. You are also scheduled for a Cardiology appointment with Dr. [**Last Name (STitle) 2232**] on Monday, [**2203-11-28**] at 9:40 AM. This appointment is in the [**Hospital Ward Name 23**] building on the [**Location (un) 436**]. Please follow up with the gastroenterologists for a colonoscopy. You can call to schedule the appointment at ([**Telephone/Fax (1) 2233**].

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icd9cm

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5118+55632

Discharge summary

report+addendum

Admission Date: [**2158-4-27**] Discharge Date: [**2158-6-1**] Date of Birth: [**2103-6-1**] Sex: F Service: SURGERY Allergies: Dilaudid / Codeine Attending:[**First Name3 (LF) 668**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: percutaneous tracheostomy Extended left hemicolectomy with takedown of splenic flexure and ileostomy History of Present Illness: Ms. [**Known lastname **] is a 54-year female with a history of diabetes, coronary artery disease, hypertension, renal transplant and significant peripheral [**Known lastname 1106**] disease who presented with a several day history of abdominal discomfort and worsened over the past 24 hours. She was seen in the emergency room and was found to be in relative extremis condition. Although hemodynamically stable, she had extensive peritonitis. She underwent a CTA of the abdomen which demonstrated what appeared to be a thrombosis of the SMA and thickening of the left and right colon. She was taken to the operating room urgently for exploration. Past Medical History: MI x2, CABG x2, DM1 with retinopathy/neuropathy/nephropathy. CRT '[**43**] (Dr. [**Last Name (STitle) 15473**], PVD, LBKA [**6-/2147**], fem-[**Doctor Last Name **] '[**48**] w/ [**Doctor Last Name **]-DP bypass, ^chol, L eye prosth, b/l breast ca, chr anemia, CRI (baseline Cr 2.0) Physical Exam: on discharge: Afebrile, BP 11/79-166/65, 74, 14, 100% Trach Mask AOx3 CTA B/L Trache in position Abd soft, NT, ND Resolving erythema over R knee - edema Pertinent Results: [**2158-4-27**] 05:30AM BLOOD WBC-5.7 RBC-4.01*# Hgb-13.8# Hct-40.1# MCV-100* MCH-34.5* MCHC-34.5 RDW-18.5* Plt Ct-240 [**2158-4-30**] 02:54AM BLOOD WBC-18.1* RBC-3.18* Hgb-10.6* Hct-32.1* MCV-101* MCH-33.4* MCHC-33.0 RDW-19.1* Plt Ct-178 [**2158-5-5**] 03:00AM BLOOD WBC-20.9* RBC-2.45* Hgb-8.2* Hct-24.2* MCV-99* MCH-33.4* MCHC-33.8 RDW-19.3* Plt Ct-235 [**2158-5-8**] 03:13AM BLOOD WBC-8.7 RBC-2.46* Hgb-8.2* Hct-24.1* MCV-98 MCH-33.1* MCHC-33.8 RDW-19.3* Plt Ct-162 [**2158-5-16**] 01:47AM BLOOD WBC-7.1 RBC-2.28* Hgb-7.4* Hct-21.9* MCV-96 MCH-32.7* MCHC-34.1 RDW-18.6* Plt Ct-196 [**2158-5-20**] 03:20AM BLOOD WBC-7.3 RBC-3.10* Hgb-9.8* Hct-29.1* MCV-94 MCH-31.7 MCHC-33.8 RDW-17.2* Plt Ct-262 [**2158-5-31**] 03:09AM BLOOD WBC-7.4 RBC-3.13* Hgb-10.0* Hct-29.3* MCV-94 MCH-32.0 MCHC-34.2 RDW-16.9* Plt Ct-261 [**2158-5-26**] 04:08AM BLOOD PT-12.6 PTT-25.6 INR(PT)-1.1 [**2158-4-28**] 02:48AM BLOOD PT-17.9* PTT-34.7 INR(PT)-1.7* [**2158-5-31**] 03:09AM BLOOD Glucose-205* UreaN-72* Creat-1.4* Na-140 K-4.1 Cl-112* HCO3-20* AnGap-12 [**2158-5-24**] 03:01AM BLOOD Glucose-117* UreaN-93* Creat-1.8* Na-146* K-3.9 Cl-109* HCO3-27 AnGap-14 [**2158-5-19**] 02:25AM BLOOD Glucose-76 UreaN-94* Creat-1.9* Na-139 K-3.7 Cl-100 HCO3-27 AnGap-16 [**2158-5-12**] 05:11AM BLOOD Glucose-125* UreaN-90* Creat-2.0* Na-140 K-3.9 Cl-104 HCO3-23 AnGap-17 [**2158-5-4**] 05:09PM BLOOD Glucose-195* UreaN-86* Creat-2.6*# Na-135 K-3.8 Cl-105 HCO3-19* AnGap-15 [**2158-4-27**] 05:25PM BLOOD Glucose-219* UreaN-88* Creat-3.0* Na-143 K-3.6 Cl-110* HCO3-16* AnGap-21* [**2158-5-29**] 02:34AM BLOOD ALT-32 AST-37 AlkPhos-214* Amylase-37 TotBili-0.8 [**2158-5-13**] 12:09PM BLOOD ALT-54* AST-50* CK(CPK)-25* AlkPhos-179* Amylase-64 TotBili-0.5 [**2158-5-3**] 03:02AM BLOOD ALT-16 AST-26 LD(LDH)-348* AlkPhos-78 Amylase-148* TotBili-0.2 [**2158-5-3**] 05:43PM BLOOD Lipase-102* [**2158-4-27**] 01:35PM BLOOD Lipase-113* [**2158-5-31**] 03:09AM BLOOD Calcium-11.4* Phos-3.0 Mg-1.8 [**2158-5-28**] 02:27AM BLOOD Calcium-12.5* Phos-2.8 Mg-2.1 [**2158-5-25**] 03:00PM BLOOD Calcium-11.7* Phos-3.6 Mg-2.2 [**2158-5-18**] 02:34AM BLOOD Albumin-2.4* Calcium-9.2 Phos-4.2 Mg-1.9 [**2158-5-29**] 02:34AM BLOOD calTIBC-168* TRF-129* [**2158-5-30**] 03:17AM BLOOD Ferritn-880* [**2158-4-29**] 02:41AM BLOOD Triglyc-156* HDL-15 CHOL/HD-6.7 LDLcalc-55 [**2158-5-3**] 05:43PM BLOOD TSH-1.9 [**2158-5-28**] 02:27AM BLOOD PTH-21 [**2158-5-5**] 12:10PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2158-5-30**] 06:49AM BLOOD FK506-6.3 [**2158-5-29**] 06:54AM BLOOD FK506-5.9 [**2158-4-27**] 01:59PM BLOOD Glucose-459* Lactate-4.7* [**2158-4-27**] 03:20PM BLOOD Glucose-352* Lactate-5.6* Na-140 K-3.7 Cl-108 [**2158-4-27**] 05:42PM BLOOD Glucose-203* Lactate-6.3* [**2158-4-28**] 01:06PM BLOOD Glucose-147* [**2158-4-28**] 06:37PM BLOOD Glucose-133* Lactate-1.2 [**2158-5-28**] 09:08AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013 [**2158-5-28**] 09:08AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2158-5-28**] 09:08AM URINE RBC-0-2 WBC-21-50* Bacteri-FEW Yeast-NONE Epi-<1 [**2158-5-23**] 11:08AM URINE RBC->50 WBC-21-50* Bacteri-FEW Yeast-OCC Epi-0 TransE-0-2 [**2158-5-23**] 11:08AM URINE CastHy-[**11-13**]* [**2158-5-8**] 11:45 am URINE **FINAL REPORT [**2158-5-9**]** URINE CULTURE (Final [**2158-5-9**]): YEAST. >100,000 ORGANISMS/ML.. [**2158-5-28**] 9:08 am URINE **FINAL REPORT [**2158-5-30**]** URINE CULTURE (Final [**2158-5-30**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R CTA PELVIS W&W/O C & RECONS [**2158-4-27**] 8:01 AM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Reason: NO IV CONTRAST, eval for divertic, aortic dz, mesenteric isc Contrast: VISAPAQUE [**Hospital 93**] MEDICAL CONDITION: 54 year old woman with severe ab pain REASON FOR THIS EXAMINATION: NO IV CONTRAST, eval for divertic, aortic dz, mesenteric ischemia CONTRAINDICATIONS for IV CONTRAST: Cr 3.3 today, renal transplant pt HISTORY: 54-year-old woman with severe abdominal pain. The patient has history of end-stage renal disease, status post renal transplant. TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained without contrast. A mesenteric CTA was then performed with 80 cc of Visipaque followed by delayed venous sequence. CT ABDOMEN: There is bibasilar atelectasis. The liver, gallbladder, spleen, and adrenal glands are unremarkable. The pancreas and native kidneys are atrophic. Stomach and small bowel loops are unremarkable. There appears to be inflammatory stranding and slight wall thickening of the transverse colon and hepatic flexure. A small amount of free fluid is identified tracking around the liver. There is no free air. No mesenteric or retroperitoneal lymphadenopathy is identified. The ventral hernia is noted in the epigastrium. CT PELVIS: Foley catheter is noted in the bladder. The uterus, adnexa, sigmoid colon, and rectum are unremarkable. There is a small amount of pelvic free fluid. Moderate hydronephrosis is again identified in the transplant kidney. This is not significantly changed from the most recent renal ultrasound of [**2156-11-27**]. A small cyst is noted in the transplant kidney as well. There are no suspicious lytic or sclerotic osseous lesions. CTA IMAGES: There is severe atherosclerotic disease. Bilateral iliac stents are noted. The mesenteric vessels are highly calcified and there is significant amount of plaque within the superior mesenteric artery. However, the mesenteric vessels appear patent, and no [**Year (4 digits) 1106**] occlusion is identified. The 3D reformats demonstrate patency and flow to the segments of abnormal- appearing colon. IMPRESSION: 1. Severe atherosclerotic disease especially involving the superior mesenteric artery, but patent mesenteric vasculature. 2. Inflammatory stranding and slight wall thickening of the transverse colon and splenic flexure consistent with colitis, most likely infectious or related to a low flow state. 3. Small amount of free fluid in the abdomen and pelvis. 4. Moderate hydronephrosis in the transplant kidney which is not significantly changed compared to [**2156-11-27**]. RENAL TRANSPLANT U.S. [**2158-5-2**] 10:07 AM RENAL TRANSPLANT U.S. Reason: assess cadaveric renal transplant for clot/occlusion [**Hospital 93**] MEDICAL CONDITION: 54 year old woman with h/o cadaveric renal transplant, now admitted w/ SMA occlusion s/p OR w/ R colectomy, now worsening renal function REASON FOR THIS EXAMINATION: assess cadaveric renal transplant for clot/occlusion INDICATION: History of cadaveric renal transplant, admitted with SMA occlusion, status post colectomy, now with worsening renal function. Please assess for clot or occlusion. COMPARISON: [**2156-11-27**]. TECHNIQUE: Renal transplant ultrasound. FINDINGS: A transplant kidney is again identified within the left lower quadrant, measuring 11.6 cm in length. Moderate hydronephrosis of the transplant kidney appears approximately unchanged in degree since [**2156-11-27**]. There is ascites throughout the abdomen, including within the left lower quadrant adjacent to the transplant. Doppler examination of the transplant kidney demonstrates visibly less venous flow in the periphery of the renal cortex in comparison with the previous examination. The diastolic flow on pulse Doppler waveforms appears diminished. Resistive indices range from 0.63 to an estimated upper value of 0.8. The main renal vein appears patent and demonstrates a normal waveform. There is no echogenic thrombus within the main renal artery or vein. IMPRESSION: 1. Stable hydronephrosis of the transplant kidney. 2. Continued slight increase in resistive indices and visual decrease in venous flow within the transplant kidney. No evidence of thrombosis of the main renal artery or vein. Conclusions: 1. The left atrium is moderately dilated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5.The estimated pulmonary artery systolic pressure is normal. 6. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of [**2156-5-13**], the EF is slightly more vigorous then. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2158-5-5**] 17:14. [**Location (un) **] PHYSICIAN: [**Known lastname **],[**Known firstname 21022**] [**2103-6-1**] 54 Female [**Numeric Identifier 21023**] [**Numeric Identifier 21024**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 21025**]/dif SPECIMEN SUBMITTED: COLON (1). Procedure date Tissue received Report Date Diagnosed by [**2158-4-27**] [**2158-4-27**] [**2158-5-3**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma?????? Previous biopsies: [**Numeric Identifier 21026**] COMMON FEM ART. PLAQUE (RT.) [**Numeric Identifier 21027**] EMC/jh/mf. [**Numeric Identifier 21028**] SENTINEL, RT BREAST RE-EXC./bb. [**Numeric Identifier 21029**] RT BREAST MICROCALCS/lb. (and more) DIAGNOSIS Colon (A-Q): 1. Colon with transmural infarction with ulceration and serositis. 2. Mucosal infarction present at distal resection margin. 3. Proximal resection margin viable. 4. Mesenteric vessels with mild focal medial calcification. 5. Ileum, cecum, ileocecal valve, and appendix, no diagnostic abnormalities recognized.. 7. One lymph node, no malignancy identified. Brief Hospital Course: From the ED patient was taken to the SICU fairly quickly, intubated, and then taken to the OR for a R extended colectomy & ileostomy/[**Doctor Last Name **] for gangrenous R colon due to SMA thrombus. #Neuro/Psych: when the patient was tolearting PO medications, her home antidepressants were restarted. Ativan PRN was used to tx her anxiety. Morphine was given for tracheostomy site pain. #Pulm: Patient was intubated fairly immediately after being admitted to the SICU from the ED and remained so after the OR. She failed extubation multiple times. She was oringinally extubated POD2 and remained extubated for over a week. She was reintubated on [**5-14**] with NGT and swanz-ganz catheter placement after being brought to unit the day before for shortness of breath and a negative V/Q scan. Extubation was attempted a few days later and she failed within minutes. Thoracic surgery performed a fiberoptic bronchoscopy which did not show any abnormalities. She continued to have a good cuff leak and stayed on low ventilatory support. Extubation was again attempted on [**5-23**] and the second time she failed within hours. A percutaneous trachesotomy was eventually performed on [**5-26**] at the bedside, and she has done well weaning to a trach mask since that time. It is still unknown why patient continued to fail extubation. #CV: cardiology was involved. Patient was in fluid overload with pulmonary edema and cardiomegaly, underwent diuresis and altering of blood pressure medications as her pressures were running on the high end for a significant period of time. ECHO showed mod [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **],LVEF 40-50%,3+MR,2+TR, mod PA HTN and on [**5-11**] was WORSE vs [**5-5**]. She is discharged with stable BP controlled on oral agents. #GI: patient's ostomy has functioned well since the surgery without any problems. She has been followed by the osteomy nurses. Patient had multiple instances of repeat abdominal pain with elevated white counts in the setting of immunosuppression so KUBs and a few CTs were performed to rule out any obstruciton, abscesses, or acute surgical complications. Diet was advanced from sips to clears on POD4. She then went back and forth from from cleras to NPO for the next week during intermittent episodes of abdominal pain. Was eventually on a regular diet for a few days before having to be reintubated gain for respiratory failure. Elemental tube feeds were started slow only [**5-27**], they were advanced on [**6-1**] when she had no abdominal pain. On [**6-1**] her feeding tube became dislodged during a coughing spell. It was replaced by interventional radiology. #Renal/Electrolytes: Patient had post-op ATN in the setting of a previous kidney transplant. A renal consult was obtained. Had renal US which showed stable hydronephrosis of the transplant kidney. Continued slight increase in resistive indices and visual decrease in venous flow within the transplant kidney. No evidence of thrombosis of the main renal artery or veinHad HD at one point. Later developed hyponatremia and hypercalcemia. Was started on calcitonin [**Hospital1 **] and diuresed and hydrated with some normal saline. Her sodium normalized, though her calcium remained elevated.On [**6-1**] the calcitonin was discontinued and pamidronate was given (30mg IV x 1); it may be repeated in [**1-27**] weeks. Patient continues on her immunosuppression for her transplant. #Endo: was followd by [**Last Name (un) 387**] for her DM-I. required an insulin drip intermittently. Is discharged with stable blood glucose, controlled with insulin. #heme: Throughout her admission, patient received a total of 8 units of red cells for falling hematocrits. #ID: was given a few doses of vancomycin peri- and post-op as well as zosyn for 2 weeks post-op. She also received a course of levo toward the end of her stay for E Coli in her urine which will complete on [**2158-6-3**]. #Nutrition: Patient was maintained on TPN throughout her stay and later was started on trophic TF via a dobhoff. Tube feeds should be advanced and TPN decreased over time. #Rheum: Early [**Month (only) **] patient complained of R knee pain - had a gout flair with suprapatellar bursitis. Was started on cochicine taper and calcitonin [**Hospital1 **]. Medications on Admission: Allopurinol 100', ASA 81', Ativan 0.5 q8prn, CaCO3cVIT D 600-200", CATAPRES-TTS 2 0.2MG/24HR 2 patches qwk, Doxazosin 2', Lisinopril 2.5', Fluoxetine 30', Lasix 40", Lantus 26hs, Novolog SS, Imuran 25', Isosorbide mono 90qAM/30qPM, Lipitor 10', Lopressor 75", Nifedipine 90', NTG 0.4' SL prn, Prednisone 7, Prograf [**1-26**], Procrit 6000 qSu/W, Ranitidine 150" Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO once a day. 4. Azathioprine 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Isosorbide Dinitrate 20 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 12. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 14. Nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours). 15. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 18. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheeze/sob. 19. Paroxetine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 20. Pantoprazole 40 mg IV Q24H 21. Lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection Q6H (every 6 hours) as needed for anxiety. 22. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q2H (every 2 hours) as needed for tracheostomy pain . 23. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours). 24. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous Q4-6H (every 4 to 6 hours) as needed: for sbp>150. 25. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 26. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding scale Subcutaneous ASDIR (AS DIRECTED): per provided sliding scale. 27. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. 28. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: Two Hundred Fifty (250) mg Intravenous Q24H (every 24 hours): through doses on [**6-3**]. 29. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 30. Tacrolimus 1 mg Capsule Sig: as directed Capsule PO twice a 31. Alendronate 5 mg Tablet Sig: One (1) Tablet PO QTHUR (every Thursday). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] TCU - [**Location (un) 701**] Discharge Diagnosis: 1. mesenteric ischemia 2. pancreatitis 3. respiratory failure 4. acute renal failure 5. R prepatellar bursitis 6. HTN 7. DM-I 8. anemia of chronic renal disease and chronic disease 9. hypercalcemia 10. hypernatremia Discharge Condition: Good Discharge Instructions: please seek medical attention if you experience fever > 101.5, severe nausea, vomitting, pain, shortness of breath please take medications as directed Followup Instructions: 1. Please call the transplant clinic [**Telephone/Fax (1) 673**] to schedule appointments with both Dr. [**Last Name (STitle) **] and with one of the transplant surgeons 2. Follow up with your Cardiologist within one month to have your Lisinopril restarted. 3. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2158-6-6**] 11:00 [**Month/Day/Year **] NON-INVAS [**Month/Day/Year 3628**] [**Month/Day/Year **] [**Month/Day/Year 3628**] (NHB) Date/Time:[**2158-7-10**] 10:00Provider: [**Month/Day/Year **] NON-INVAS [**Month/Day/Year 3628**] [**Month/Day/Year **] [**Month/Day/Year 3628**] (NHB) Date/Time:[**2158-7-10**] 10:00 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] (NHB) Date/Time:[**2158-7-10**] 10:30 Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2158-7-10**] 11:00 Name: [**Known lastname **],[**Known firstname 3473**] C Unit No: [**Numeric Identifier 3474**] Admission Date: [**2158-4-27**] Discharge Date: [**2158-6-1**] Date of Birth: [**2103-6-1**] Sex: F Service: SURGERY Allergies: Dilaudid / Codeine Attending:[**First Name3 (LF) 2800**] Addendum: please see tacrolimus dose addendum Discharge Medications: 31. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 49**] TCU - [**Location (un) 50**] [**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**] Completed by:[**2158-6-1**]

[ "274.9", "518.81", "996.81", "250.51", "V10.3", "557.1", "250.61", "599.0", "443.9", "275.42", "401.9", "410.71", "726.69", "486", "997.1", "276.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "46.21", "39.95", "99.15", "31.1", "33.22", "96.72", "45.95", "99.04", "96.6", "45.73", "96.04", "38.95" ]

icd9pcs

[ [ [] ] ]

21851, 22083

12343, 16638

290, 392

20076, 20083

1564, 6148

20284, 21731

21754, 21828

8754, 8891

19837, 20055

16664, 17028

20108, 20261

1391, 1391

1405, 1545

236, 252

8920, 11057

420, 1070

11089, 12320

1092, 1376

30,504

103,679

29099

Discharge summary

report

Admission Date: [**2175-6-10**] Discharge Date: [**2175-6-20**] Date of Birth: [**2100-10-16**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: Trauma admission s/p motor vehicle accident. Major Surgical or Invasive Procedure: None, pelvic fractures were deemed non-operative by orthopedic surgery, as were diffuse subarachnoid hemorrhage by neurosurgery History of Present Illness: 75 year old male admitted to trauma SICU after motor vehicle accident in which he was the driver and was t-boned by another vehicle. Had positive loss of consciousness at the scene, airbag had deployed, and had prolonged extraction. Was intubated in the ED for combative behavior. Past Medical History: Atrial fibrillation, hypertension, diabetes, gout, chronic kidney disease Stage IV, peripheral vascular disease Social History: Widowed, good family support, has children in the area Family History: Non-contributory Physical Exam: At admission: Gen: Intubated and sedated CV: Atrial fibrillation Resp: Clear to ausculation bilaterally Abd: Soft, non-distended, unable to assess pain due to sedation Pertinent Results: [**2175-6-10**] 11:22PM TYPE-ART TEMP-37.1 RATES-/16 TIDAL VOL-600 PEEP-5 O2-50 PO2-188* PCO2-43 PH-7.39 TOTAL CO2-27 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED [**2175-6-10**] 11:22PM LACTATE-2.1* K+-3.6 [**2175-6-10**] 11:22PM freeCa-1.17 [**2175-6-10**] 11:09PM GLUCOSE-247* UREA N-27* CREAT-1.3* SODIUM-141 POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-23 ANION GAP-11 [**2175-6-10**] 11:09PM LD(LDH)-356* CK(CPK)-739* [**2175-6-10**] 11:09PM CK-MB-12* MB INDX-1.6 cTropnT-0.03* [**2175-6-10**] 11:09PM CALCIUM-8.3* PHOSPHATE-2.3* MAGNESIUM-1.6 [**2175-6-10**] 11:09PM WBC-13.9* RBC-3.40* HGB-9.4* HCT-26.9* MCV-79* MCH-27.6 MCHC-35.0 RDW-16.0* [**2175-6-10**] 11:09PM PT-16.0* PTT-33.3 INR(PT)-1.4* [**2175-6-10**] 04:29PM TYPE-ART PO2-361* PCO2-39 PH-7.37 TOTAL CO2-23 BASE XS--2 [**2175-6-10**] 04:29PM LACTATE-3.3* [**2175-6-10**] 04:15PM GLUCOSE-475* UREA N-31* CREAT-1.4* SODIUM-139 POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-21* ANION GAP-13 [**2175-6-10**] 04:15PM CK(CPK)-372* [**2175-6-10**] 04:15PM CK-MB-8 cTropnT-0.01 [**2175-6-10**] 04:15PM CALCIUM-7.5* PHOSPHATE-3.4 MAGNESIUM-1.4* [**2175-6-10**] 04:15PM TRIGLYCER-140 [**2175-6-10**] 04:15PM WBC-16.7* RBC-3.02*# HGB-8.0*# HCT-24.0*# MCV-79* MCH-26.3* MCHC-33.2 RDW-15.2 [**2175-6-10**] 04:15PM NEUTS-91.3* BANDS-0 LYMPHS-5.9* MONOS-2.5 EOS-0.1 BASOS-0.1 [**2175-6-10**] 04:15PM PT-18.8* PTT-36.0* INR(PT)-1.7* [**2175-6-10**] 04:15PM PLT SMR-LOW PLT COUNT-78*# [**2175-6-10**] 02:14PM PH-7.62* [**2175-6-10**] 02:14PM GLUCOSE-402* LACTATE-4.0* NA+-154* K+-4.9 CL--103 [**2175-6-10**] 02:14PM freeCa-0.80* [**2175-6-10**] 02:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2175-6-10**] 02:10PM URINE COLOR-Red APPEAR-Hazy SP [**Last Name (un) 155**]-1.012 [**2175-6-10**] 02:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2175-6-10**] 02:10PM URINE RBC->50 WBC-[**5-2**]* BACTERIA-NONE YEAST-NONE EPI-[**5-2**] [**2175-6-10**] 02:10PM URINE AMORPH-RARE [**2175-6-10**] 01:50PM UREA N-33* CREAT-1.7* [**2175-6-10**] 01:50PM estGFR-Using this [**2175-6-10**] 01:50PM AMYLASE-66 [**2175-6-10**] 01:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2175-6-10**] 01:50PM WBC-18.0* RBC-4.53* HGB-11.7* HCT-36.1* MCV-80* MCH-25.9* MCHC-32.5 RDW-15.0 [**2175-6-10**] 01:50PM PT-21.9* PTT-32.8 INR(PT)-2.1* [**2175-6-10**] 01:50PM PLT COUNT-169 [**2175-6-10**] 01:50PM FIBRINOGE-316 Imaging: [**6-10**] Head CT: diffuse SAH [**6-10**] C-spine CT: no fractures [**6-10**] CT torso: Left pubic rami, sacral ala, and acetabular fx with associated hematoma in the pelvis. Rounded hyperenhancing structure in the spleen with small amount of perisplenic blood, suspicious for post-traumatic pseudoaneurysm. 7/19 L femur film: no fx 7/19 L hand film: no fx, ?FB [**6-10**] CT Head and CTA Head: No obvious aneurysm. Stable SAH. [**6-10**] repeat Abd CT: Stable splenic injury [**6-11**] MRA/MRI brain: Diffuse vasospasm of L>R MCA Abnl restricted diffusion of cortex - R sylvian fissure concerning for acute infarction [**6-12**] ECHO: poor quality - LVEF 60%, no effusion, can't r/o wall motion abnormality Brief Hospital Course: [**6-10**]: Patient was admitted to TSICU with diagnoses of pelvic fractures and subarachnoid hemorrhage. He was intubated and sedated at the time. He was given IV fluids for resuscitation and had a Foley catheter in place. Dilantin was given for seizure prophylaxis, and a phenylephrine drip was initiated to keep SBP above 110. Electrolytes were repleted as necessary (magnesium, potassium, calcium). Blood gases were followed. [**6-11**]: He was transfused 4 units PRBCs after labs revealed a following hematocrit and acute anemia related to blood loss. Isotonic fluid administration was continued as was mechanical ventilation. Serial hematocrit checks were followed. MRA/MRI of brain were obtained which revealed diffuse vasospasm and abnormal restriction of cortex concerning for acute infarction. Sodium bicarbonate was administered. [**2089-6-10**]: Lasix was begun for diuresis. Vancomycin, Zosyn, and ciprofloxacin were started after pt developed a fever. Blood cultures were sent; bronchioalveolar lavage was performed and sputum sample was sent for culture. Arterial line was removed and tip was sent for culture. Blood gases were followed. [**2094-6-12**]: Tube feeds were initiated via NG tube. Antibiotics were discontinued after cultures came back negative. Source of fever was thought to be either active gout or central (related to brain infarct). [**6-19**]: After 10 days on ventilator and in light of brain infarct and patient's complete lack of responsiveness to stimulation when off all sedating medications, decision was made by family to discontinue life support. Patient's respiratory rate gradually declined and heart rate rose throughout the night and into the next day. [**6-20**]: Pt expired with family at bedside. Medications on Admission: Coumadin, Lasix, glyburide, lopressor, aspirin, allopurinol, digoxin, lipitor, amitriptyline, verapamil, prilosec, levemir Discharge Medications: Pt expired. Discharge Disposition: Expired Discharge Diagnosis: Diffuse subarachnoid hemorrhage and subsquent brain infarction secondary to motor vehicle accident, pelvic fractures with associated pelvic hematoma, small stable splenic injury Discontinuation of ventilatory support at family's request leading to respiratory arrest and death. Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None

[ "274.9", "327.23", "427.31", "V58.67", "403.90", "865.00", "801.26", "434.91", "808.0", "V66.7", "867.8", "285.1", "808.2", "250.00", "805.6", "E812.0", "585.4", "272.4" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "38.7", "96.6", "99.05", "96.72" ]

icd9pcs

[ [ [] ] ]

6488, 6497

4531, 6279

360, 489

6818, 6827

1244, 3807

6880, 6887

1022, 1040

6452, 6465

6518, 6797

6305, 6429

6851, 6857

1055, 1225

276, 322

517, 799

3816, 4508

821, 934

950, 1006

27,210

139,728

27253

Discharge summary

report

Admission Date: [**2165-3-23**] Discharge Date: [**2165-3-24**] Date of Birth: [**2142-10-11**] Sex: F Service: MEDICINE Allergies: Haldol / Oxycodone / Demerol / Ms Contin / Penicillins / Fentanyl Attending:[**First Name3 (LF) 338**] Chief Complaint: Mild DKA Major Surgical or Invasive Procedure: none History of Present Illness: This a 22 year old woman with h/o IDDM, chronic pancreatitis from pancreas divisum, chronic abdominal pain on narcotics, and borderline personality disorder with history of multiple hospital admissions who is admitted with hyperglycemia x 4 days. Patient reports compliance with insulin. She called her [**Name8 (MD) **] MD yesterday who increased her NPH dosage but sugars continued to be elevated today so she reported to the ED. Patient reports +depression for the past week since she has been fired from the [**Company 191**] practice. Her narcotics contract was stopped. She has been on chronic dilaudid 6mg q3h for many months. This was stopped and she was given a prescription for Clonidine 0.1mg [**Hospital1 **] along with Fentanyl patch 25mg q72h. She reported to the ED yesterday for itching with Fentanyl patch, she reports ithcing over her entire body. She was prescribed Benadryl for itching and the Fentanyl was placed on her allergy list, however, she remains with the fentanyl patch today. She denies any recent fevers, but +chills. No cough, or vomiting but does report +nausea x 1 day and +diarrhea for the past few days, non-bloody. She also reports slight increase in her usual epigastric pain. She denies urinary frequency or dysuria. . Of note, patient was recently discharged on [**2165-3-16**] for abdominal pain. During that admission the patient was verbally abusive to the staff and attempted to physically assault the intern, Dr. [**First Name (STitle) 66832**] [**Name (STitle) 66833**]. Patient was then seen in [**Company 191**] on [**2165-3-19**] and was subsequently fired from [**Company 191**] [**3-11**] violation of behavioral and narcotics contract. Past Medical History: 1. Type I DM (since age 12, c/b severe gastroparesis) 2. Chronic pancreatitis (pancreas divisum) 3. Chronic abdominal pain (unclear etiology likely multifactorial [**3-11**] chr pancreatitis, gastroparesis and psychological factors; on narcotics contract) 4. H/o PUD secondary to H. pylori 5. Gastritis 6. Iron deficiency anemia 7. Right adnexal cyst 8. Status post cholecystectomy ([**1-11**]) 9. Asthma 10. Urinary retention (worsened by dephenhydramine) 11. H/o line infections 12. Depression & borderline personality disorder; h/o cutting behavior and suicide attempts. Social History: Patient was born and raised in the [**Country 13622**] Republic. She was sent to the US at age 11-12 years due to onset of medical problems (i.e. diabetes). She used to live with father until she was kicked out of the house prior to third psychiatric hospitalization. Homeless off and on. Currently lives in group home. - Smokes one ppd - Denies EtOH or illicit drug use - Legal/[**Doctor Last Name **] guardian - [**Name (NI) 919**] [**Last Name (NamePattern1) **] Office [**Telephone/Fax (1) 66830**], Cell [**Telephone/Fax (1) 66831**] Family History: Noncontributory Physical Exam: VS: Temp 98.9, BP 151/87, HR 82, RR 16 100% RA Gen: NAD, lying in bed comfortably HEENT: NCAT, EOMI, PERRL. Anicteric, no conjunctival pallor. OP clear, MMM. Neck: Supple, no LAD CVS: +S1/S2, no M/R/G, RRR LUNGS: CTAB, no wheezes, crackles or ronchi ABD: soft +BS, NT/ND, No HSM. Has a G-J tube in place. EXT: no c/c/e, +2 pulses Pertinent Results: [**2165-3-23**] 12:10PM WBC-11.4* RBC-4.70 HGB-14.9 HCT-41.3 MCV-88 MCH-31.6 MCHC-36.0* RDW-13.8 [**2165-3-23**] 12:10PM NEUTS-80.9* LYMPHS-16.0* MONOS-2.1 EOS-0.6 BASOS-0.3 [**2165-3-23**] 12:10PM PLT COUNT-288 [**2165-3-23**] 12:10PM GLUCOSE-446* UREA N-13 CREAT-0.7 SODIUM-136 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-17* ANION GAP-22* [**2165-3-23**] 05:23PM GLUCOSE-223* UREA N-9 CREAT-0.6 SODIUM-140 POTASSIUM-3.9 CHLORIDE-112* TOTAL CO2-16* ANION GAP-16 [**2165-3-23**] 10:20PM GLUCOSE-178* UREA N-8 CREAT-0.5 SODIUM-139 POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-18* ANION GAP-14 Brief Hospital Course: 22yo woman with h/o DM I who presents with DKA. . # DKA: Ms. [**Known lastname **] presents with serum glucose > 400 along with anion gap of 18 consistent with mild DKA. Exacerbation possibly related to opiod withdrawal as she was just fired from [**Company 191**] and had her narcotic contract terminated. AG currently normal with FSBG in 200s and patient did not require insulin gtt. We continued with RISS SQ and home NPH 28uqAM and 38uqPM on the floor and her gap remained closed. On the morning of discharge, the patient began to refuse all care, including her tubefeeds and potassium repletion. She was given half dose of her NPH for a glucose of 200. She was advised to initiate her tubefeeds upon returning to her group home and she understood the risk of not doing so. . # Pruritis: Patient reported to ED yesterday with ?Fentanyl allergy. This allergy was inserted by the ED physician into [**Name9 (PRE) **] yesterday. Given this concern, the Fentanyl patch was discontinued. The patient has a new PCP appointment at [**Name9 (PRE) 336**] on [**4-3**]. Plan is to start lower dose dilaudid at 2mg q6h to bridge her until her next appointment as she does not tolerate Fentanyl. She was discharged with an Rx for 84 tabs of Dilaudid 2mg PO q6h PRN to carry her over until her new PCP [**Name Initial (PRE) 648**]. . # Borderline personality disorder: Patient has history of attempted physical abuse to nursing staff and house staff and has just been terminated from [**Company 191**] for violating behavioral contract. Patient has contracted for safety and stated she will not abuse on housestaff or nursing staff. We continued diazepam, quetiapine according to home regimen. . # Chronic Abdominal Pain: Patient has just been fired from [**Company 191**] for violating behavioral contract. She has been instructed to find primary care elsewhere. Plan is to cont her usual outpatient regimen of Dilaudid. will not increase unless clinically indicated. . # Asthma: continued albuterol and advair . Medications on Admission: Albuterol 90 mcg/Actuation Aerosol 2 puffs q4h:PRN Albuterol (0.083 %) Neb 1 INH Q4H (every 4 hours) PRN Diazepam 5 mg PO Q6H Clotrimazole 1 % Cream Topical [**Hospital1 **] Fluticasone-Salmeterol 250-50 mcg/Dose Disk [**Hospital1 **] Gabapentin 250mL PO qHS Hydromorphone 6 mg PO Q3H Lactulose 10 gram/15 mL Syrup(45) ML PO Q8H PRN Pantoprazole 40 mg daily Prochlorperazine 25 mg PR q12h:PRN as needed. Acetaminophen 160 mg/5 mL Solution Sig: Ten (10) ml PO Q6H PRN MVI Daily Insulin NPH 27u qam, 24u qpm. Discharge Medications: 1. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for 3 weeks. Disp:*84 Tablet(s)* Refills:*0* 4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Gabapentin 250 mg/5 mL Solution Sig: Two [**Age over 90 1230**]y (250) ML PO qHS (). 8. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO Q8H (every 8 hours) as needed. 9. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal Q12H (every 12 hours) as needed. 10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Eight (28) units Subcutaneous QAM. 11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty Eight (38) units Subcutaneous at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary: Mild DKA Possible opiate withdrawal . Secondary: Chronic Pancreatitis Discharge Condition: stable, AG closed Discharge Instructions: You were admitted with mild DKA. This morning, your gap was closed. You will be discharged with enough dilaudid to last you until your appointment with your new PCP. Followup Instructions: Please be sure to keep your appointment with your new PCP.

[ "536.3", "V58.67", "338.29", "577.1", "250.63", "250.13", "304.01", "301.83", "493.90" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7893, 7899

4230, 6239

335, 342

8022, 8042

3615, 4207

8257, 8319

3232, 3249

6797, 7870

7920, 8001

6265, 6774

8066, 8234

3264, 3596

287, 297

370, 2061

2083, 2659

2675, 3216

58,296

135,938

2032

Discharge summary

report

Admission Date: [**2184-8-13**] Discharge Date: [**2184-8-24**] Service: SURGERY Allergies: Lisinopril / Plaquenil / Haldol Attending:[**First Name3 (LF) 695**] Chief Complaint: Lethargy and abdominal pain Major Surgical or Invasive Procedure: [**2184-8-16**]: retroperitoneal mass biopsy [**2184-8-23**]: Exploratory Lap ( Unresectable) History of Present Illness: 89F mild dementia at baseline, RA, HTN, anemia, CRI from nursing home for evaluation of lethargy. Per report, her baseline is awake, alert and fully oriented. This morning she was reportedly arousable to verbal stimuli but lethargic. Abdominal tenderness was also noted. . In the ED, initial vs were: 8 100.1 100 114/73 18 95%. Exam was significant for AAOx3, marked abdominal tenderness with guarding, and guiaic positive brown stool. Labs significant for lactate 5.5, clean UA with granular and hylanine casts, Cr 1.9 (baseline 1.1), HCO3 21, Glc 135 with small AG, ALT 122, AST 226, ALP 130, WBC 23.3 with 73% N and 11 % Band, Hgb 7.8 (baseline ~ 9), INR 2.2. Blood and urine cultures were obtained. Imaging including abdominal US, CT Abd and Plevis without contrast were suggestive of gangrenous cholecystitis with wall thickening and probable hemorrhage with no frank perforation. CT showed dilated gallbladder with pericholecystics stranding and irregular wall contour again raising concern for gangrenous cholecystitis less likely [**Hospital3 **] surgery was consulted with initial impression of gangrenous cholecystitis with suggestion of perc chole but further review may suggest a gallbladder mass with secondary infection. She was given vancomycin and zosyn in addition to APAP for fever. She also received 3 L of NS. VS on transfer: 96 110/98 25 100% 3L with access consisting of 2 18G PIV. On the floor, the patient was smiling, non-toxic, and complained mostly of arthritis. Past Medical History: 1. Erosive RA - previously on plaquenil (off >10 years). Also h/o chronic NSAID use. No DMARDs or biologics in the past per rheum note 04/[**2183**]. On prednisone 10mg daily (likely started 04/[**2183**]). 2. Aortic insufficiency (1+ on echo in [**2176**]) 3. HTN 4. Anemia - previous labs c/w anemia of chronic inflammation, also h/o B12 deficiency 5. CRI (baseline Cr around 1.4-1.5) 6. Hyperlipidemia 7. Vitiligo (secondary to plaquenil use) 8. Hx of esophageal tear [**2178**] 9. Positive PPD in past, per PCP no [**Name Initial (PRE) **]/o INH treatment Social History: Originally from [**Country **]. Currently in nursing home facility ([**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]). Has one sister, who lives out of state. No children. Tobacco: no smoking history per medical records. No EtOH or illicit drug use. Family History: none relavent to this presentation Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ABDOMINAL CT [**8-13**]:IMPRESSION: 1. Abnormal dilated gallbladder with an irregular margin and a small amount of pericholecystic stranding. Central density is intermediate but increased from normal. No pericholecystic fluid is seen. The findings raise concern for gangrenous cholecystitis versus GB mass. Ultrasound is recommended for further evaluation of the gallbladder. 2. Mild intrahepatic biliary ductal dilatation as seen on MRI [**2178**]. 3. No small-bowel obstruction. 4. Indeterminant left adrenal nodule is stable from [**2179-1-8**]. NCHCT [**8-13**]: IMPRESSION: No acute intracranial process. ABDOMINAL ULTRASOUND [**8-13**]: IMPRESSION: Abnormal GB with irregular mass-like wall thickening. The appearance is atypical for acute cholecystitis, although the clinical picture suggests infection. The possiblity of gallbladder neoplasm with micro-perforation should be considered. If clinically indicated, MRCP could be performed for further evaluation. Blood Cx [**8-13**]: GRAM NEGATIVE ROD(S). [**2184-8-13**] 8:00 am BLOOD CULTURE #1. **FINAL REPORT [**2184-8-15**]** Blood Culture, Routine (Final [**2184-8-15**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing confirmed 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----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [**2184-8-13**]): Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 11131**] @ 2209 ON [**8-13**] - CC6D. GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final [**2184-8-13**]): GRAM NEGATIVE ROD(S). [**8-18**] CT chest abd and pelvis: MPRESSION: 1. Gallbladder enlargement with mural thickening and hyperenhancement in keeping with a gallbladder carcinoma. The mass is closely related to the first and second parts of duodenum, transverse colon and right lobe of the liver. However, there is no evidence of frank invasion of these structures. 2. No enlarged adjacent lymph nodes. No liver metastasis. 3. Stable scarring and parenchymal calcification in the right upper lobe likely secondary to prior granulomatous disease. The staff radiologist has reviewed the images and the report. [**2184-8-13**] CT head: No acute intracranial process. Gallbladder biopsy: The specimen consists predominantly of fragments of necrotic tissue, but a few well preserved markedly atypical glands are present in a fibrotic stroma consistent with adenocarcinoma. Brief Hospital Course: 89F multiple medication issues presenting with gram negative bacteremia from a biliary source thought to represent a gallbladder mass with probable superinfection. # Sepsis: Patient presented with SIRS criteria and GNR bacteria from a likely billiary source. She was treated initially with broad spectrum antibiotics but narrowed to zosyn only for the GNR bacteremia. Her lactate cleared (5.2 --> 5.5 --> 1.9) with fluid resuscitation. Blood pressures were stable without need for pressor support. Her bacteremia grew E coli pansensitive and she was given ceftriaxone. Pt's last positive blood cx was positive on [**8-13**]. Surveilance cultures since then have been negative. Bactrim will be continued as outpatient to complete a 14 day course # Gallbladder mass- Adenocarcinoma: Abdominal CT and US was notable for a markedly dialated and tortuous gallbaldder. Imaging was initially concerning for a gangernous cholangtitis, but upon further review suggested a billiary mass (carcinoma) with overlaying super infection. Pt had mass biopsy which showed adenocarcinoma. Surgery and Oncology services were consulted for palliative care. Pt went to OR on [**2184-8-24**] but decision was made not to remove gallbladder given extent of her disease. # ARF: Patient presented with a Cr of 1.9 from a base line of 1.1. In the setting of her sepsis this was felt to be pre-renal versus ATN given the pressence of granular and hyaline casts. Her Creatinine began trending down after fluid resuscitation and was stable at the time of transfer (1.1). # Transaminitis: Felt to be secondary to gallbladder pathology (adenocarcinoma) versus a primary hepatic issue. Trended down over the course of her hospital stay. Alk phos remained in the 120s and AST and ALT in the 30s at time of discharge. # Anemia/Thalassemia: Patient's baseline HgB was 30 on admission her Hct feel to 20 in the setting of blood streaked stool. She was transfused a total of 4 units pRBC while in the MICU and her HCT went to 28 and was stable at the time of transfer. Heme/Onc evaluated her smear and noticed she had signs on her smear of thalassemia. # History of PE: The patient suffered a significant PE in [**2183-11-24**]. Was on warfarin at home. Switched to heparin here given bleed. She went home on no anticoagulation as the PE was > 6 months ago. Oncology did not recommend continuing the anticoagulation due to tumor thrombus concerns. # Dementia: Patient appeared to be AAOx3 and appropriate to situation. # Rheumatoid Arthritis: continued prednisone Medications on Admission: - norvasc 5 mg PO qD - caltrate 600 and Vit D 200 units PO daily - colace - senna - lidoderm patch prn knee pain - mirtazapine 15 mg PO qHS - prednisone 10 mg PO qD - tramadol 25 mg PO qD - coumadin 4.5 mg PO qD - cipro HC otic 2 drops to L ear twice daily Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. 3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 4. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day. 5. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 7. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. 8. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital1 **] senior living Discharge Diagnosis: Adenocarcinoma of gallbladder: unresectable E coli bacteremia Thalassemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Mostly Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, increased abdominal pain, incisional redness, drainage or bleeding or other concerning symptoms. Coumadin was stopped during this hospitalization asn patient is > 6 months out from PE, oncology does not recommend anticoagulation in this patient due to tumor. Please consult with patients PCP regarding [**Name9 (PRE) 11132**] this medication, not continued due to fall risk. Patient is unresectable and will have oncology follow up Followup Instructions: Provider: [**Name10 (NameIs) 3150**],[**Name11 (NameIs) **] MD Phone:[**Telephone/Fax (1) 11133**] Date/Time:[**2184-8-30**] 11:00 Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2184-8-30**] 11:00 Dr [**Last Name (STitle) 4727**] office ([**Telephone/Fax (1) 673**]) does not need to see patient in follow up, please have PCP see patient in next 2 weeks [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2184-8-24**]

[ "585.9", "038.42", "285.21", "785.52", "294.8", "575.0", "403.90", "584.9", "714.0", "V12.51", "V58.61", "V12.42", "790.4", "282.49", "156.0", "995.92", "716.90" ]

icd9cm

[ [ [] ] ]

[ "54.21", "54.24" ]

icd9pcs

[ [ [] ] ]

9959, 10016

6447, 8999

265, 361

10134, 10134

3320, 6177

10902, 11526

2767, 2803

9307, 9936

10037, 10113

9025, 9284

10326, 10879

2818, 3301

198, 227

389, 1883

6186, 6424

10149, 10302

1905, 2466

2482, 2751

21,970

189,133

23370

Discharge summary

report

Admission Date: [**2127-10-8**] Discharge Date: [**2127-10-21**] Date of Birth: [**2051-3-6**] Sex: F Service: SURGERY Allergies: Codeine / Sulfa (Sulfonamides) / Zestril Attending:[**First Name3 (LF) 148**] Chief Complaint: Painless Jaundice Major Surgical or Invasive Procedure: Whipple Pancreatic Resection History of Present Illness: Patient started with Painless Jaundice in [**2127-8-1**], evaluated by ERCP and CT showing a Pancreatic Head Mass Past Medical History: Migrane, Reflux, Bladder Cancer Social History: No alcohol Family History: Non pertinent to this admission Physical Exam: Patient alert, oriented x3. Non appearent distress. CV: RRR. Resp: CTA Bilateral. Abdomne soft, non tender, non distended. Motor full, Extrem: no edemas Pertinent Results: [**2127-10-8**] 10:14PM TYPE-ART PO2-202* PCO2-36 PH-7.47* TOTAL CO2-27 BASE XS-3 [**2127-10-8**] 06:33PM GLUCOSE-165* UREA N-7 CREAT-0.4 SODIUM-134 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-24 ANION GAP-13 [**2127-10-8**] 06:33PM CALCIUM-8.4 PHOSPHATE-3.2 MAGNESIUM-1.9 [**2127-10-8**] 06:33PM WBC-10.4 RBC-3.58* HGB-10.5* HCT-30.0* MCV-84 MCH-29.3 MCHC-34.9 RDW-13.4 [**2127-10-8**] 06:33PM PLT COUNT-221 [**2127-10-8**] 05:00PM WBC-12.3*# RBC-3.60* HGB-10.4* HCT-30.2* MCV-84 MCH-29.0 MCHC-34.6 RDW-13.4 [**2127-10-8**] 05:00PM PT-13.5* PTT-28.5 INR(PT)-1.2 [**2127-10-8**] 04:26PM GLUCOSE-169* LACTATE-2.5* NA+-132* K+-3.9 CL--100 [**2127-10-8**] 04:26PM HGB-10.9* calcHCT-33 [**2127-10-8**] 04:26PM freeCa-1.16 [**2127-10-8**] 03:04PM TYPE-ART PO2-233* PCO2-35 PH-7.48* TOTAL CO2-27 BASE XS-3 INTUBATED-INTUBATED VENT-CONTROLLED [**2127-10-8**] 03:04PM GLUCOSE-151* LACTATE-2.5* NA+-133* K+-3.6 CL--101 [**2127-10-8**] 03:04PM HGB-10.5* calcHCT-32 [**2127-10-8**] 03:04PM freeCa-1.19 [**2127-10-8**] 11:11AM TYPE-ART PO2-433* PCO2-40 PH-7.43 TOTAL CO2-27 BASE XS-2 INTUBATED-INTUBATED VENT-CONTROLLED [**2127-10-8**] 11:11AM GLUCOSE-139* LACTATE-1.8 NA+-136 K+-4.1 CL--101 [**2127-10-8**] 11:11AM HGB-12.0 calcHCT-36 [**2127-10-8**] 11:11AM freeCa-1.24 US INTR-OP 60 MINS [**2127-10-8**] 7:23 AM CONCLUSION: Ill-defined mass in the pancreatic neck anteriorly with dilatation of the pancreatic duct and CBD stenting. No definite evidence by laparoscopic ultrasound of unresectability. Bile duct thickening noted, although most likely due to a inflammatory thickening from the indwelling stent. SPECIMEN SUBMITTED: GALLBLADDER, JEJUNUM, AND WHIPPLE. Procedure date Tissue received [**2127-10-8**] DIAGNOSIS: I. Pancreas and duodenum, pancreaticoduodenectomy (A-IA 1. Adenocarcinoma of the pancreatic head, see synoptic report. 2. Focal atrophy of the pancreas, extending to the uncinate margin. 3. Dilation and chronic active inflammation of the common bile duct and pancreatic duct. 4. Segment of duodenum, within normal limits. II. Jejunum, ([**Female First Name (un) **]-LA) Segment of small intestine, within normal limits. III. Gallbladder, (MA-OA) 1. Chronic cholecystitis. 2. No calculi. 3. Marked hyperplasia of the cholecystic duct lymph node. 4. No tumor. Pancreas (Exocrine): Resection Synopsis MACROSCOPIC Specimen Type: Pylorus sparing pancreaticoduodenectomy, partial pancreatectomy. MICROSCOPIC Histologic Type: Ductal adenocarcinoma. Histologic Grade: G2: Moderately differentiated. EXTENT OF INVASION Primary Tumor: pT3: Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery. Regional Lymph Nodes: pN0: No regional lymph node metastasis. Lymph Nodes Number examined: 13. Number involved: 0. The tumor abuts on an adjacent lymph node, without invasion. Distant metastasis: pMX: Cannot be assessed. Margins: Margins uninvolved by invasive carcinoma: Distance from closest margin: 20 mm. Specified margin: Bile duct. Margins involved: The tumor extends very close to the peripancreatic adipose tissue margins. Venous/Lymphatic vessel invasion: Absent. Perineural invasion: Present. Clinical: Pancreatic mass. Gross: The specmen is received fresh in three containers, all labeled with "[**Known lastname 59976**], [**Known firstname 17765**]" and the medical record number. Part 1 is additionally labeled "Whipple specimen" and consists of duodenum with attached pancreatic head. The segment of duodenum measures 12.5 cm in length and 3.5 cm in diameter. It is stapled at both margins, one measuring 2.3 cm and the other 2.9 cm. The pancreatic head measures 7.5 x 4.5 x 3.0 cm. The duodenum, common bile duct and pancreatic duct are opened. The common bile duct measures 3.8 cm in length with a diameter measuring between 0.6 and 1.2 cm. There is a 1.0 x 0.6 cm ulcerated lesion in the common bile duct, 2.0 cm from the resection margin. It has heaped up edges and the adjacent common bile duct between the ulcerated area and the resection margin appears moderately dilated. The duodenum and the 1.2 x 0.4 x 0.2 cm ampulla have unremarkable mucosa. The pancreatic duct measures 3.0 cm in length and between 0.5 and 0.8 cm in diameter. The junction between the common bile duct and the pancreatic duct has normal mucosa. The common bile duct margin is inked in yellow and the uncinate pancreatic margin is inked in [**Location (un) 2452**]. The pancreatic parenchyma is sectioned to reveal the tan lobular cut surface with patchy firmness. There is periductal firmness that measures up to 3 cm. The specimen is represented as follows: A = uncinate pancreatic margin, B = bile duct margin, C = 2.9 cm stapled margin bile duct, D = 2.3 cm shaved staple margin (distal), E = unremarkable duodenal mucosa, F-H = ampulla, I-N = ulcer, O-U = firmness area, V-W = pancreatic duct, X-Y = unremarkable pancreatic parenchyma, Z-AA = pancreatic duct with adjacent fat, BA-IA = surrounding pancreatic fat with possible lymph nodes. Part 2 is additionally labeled "jejunum" and consists of a 6.5 cm long segment of small bowel with a diameter of 2.5 cm. It is stapled at both ends, one staple margin measures 2.6 cm and the other measures 2.8 cm. It is opened to reveal an unremarkable small bowel mucosa. It is represented as follows: [**Female First Name (un) **] = shaved 2.6 cm stapled margin, KA = shaved 2.8 cm stapled margin, LA = sections through unremarkable jejunum. Part 3 is additionally labeled "gallbladder" and consists of a 10 x 3.2 x 0.9 cm cholecystectomy specimen with a pink glistening serosal surface. The serosal surface is also remarkable for a 3.0 x 0.4 cm yellow linear scar. The gallbladder is opened to reveal a green-tan velvety mucosa and less than 10 cc of yellow -green bile. No stones are seen. There is a 1.6 x 0.9 x 0.2 cm lymph node adjacent to it. No stones are seen. The specimen is represented as follows: MA = bisected cystic duct node, NA = sections through cystic duct, OA = sections through gallbladder wall. CT RECONSTRUCTION [**2127-10-18**] 6:17 PM IMPRESSION: 1. Tiny bilateral effusions and patchy air-space disease at the right base, possibly representing pneumonia. 2. Large abscess collection within the pancreatic bed, as described above. A second smaller fluid collection to the right of the abscess also suspicious for early abscess formation. 3. Dilated and thickened afferent loop of duodenum. 4. Mild thickening of the rectum, a nonspecific finding. This can be seen in infectious colitis. Clinical correlation is suggested. 5. Air within the bladder without evidence for Foley catheter. Clinical correlation is suggested. Brief Hospital Course: Patient was transfered to the regular floor and follow the Whipple Protocol with out complications initially. She was then able to tolerate PO and ambulate. She had postop fever and Enterococo was isolated from Urine (UTI), she recieved antibiotics with a good response. She persisted with isolated episodes of vomiting and was found to have (by CT scan) a little colection peripancreatic (see reports). At this time, a broad spectum antibiotics was administer. She was able to tolerate PO, ambulate. With comunication with her PCP (Dr [**Last Name (STitle) 59977**], the patient was agreed to D/C to Rehab and follow up with Dr [**Last Name (STitle) **] in the outpatient clinic with a follow up CT scan. Medications on Admission: Lopresor, Provastatin, Protonix, Remipril Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection Q12H (every 12 hours). 2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO Q 12H (Every 12 Hours) as needed for hold for SBP < 100, HR < 60. 7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. 11. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 2 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 **] TCU Discharge Diagnosis: Pancreatic Cancer (T3N0M) Discharge Condition: Good. Discharge Instructions: -If any Fever, nauseas or Vomit, please call Dr [**Last Name (STitle) **]. -Please call Dr [**Last Name (STitle) **] office ([**Telephone/Fax (1) 2363**] to set up a CT Scan the [**Last Name (un) 44550**] before seen him in the Clinic on [**11-11**] Followup Instructions: With Dr [**Last Name (STitle) **] on [**11-11**] (Tuesday). Need a CT scan in the AM before meeting with Dr [**Last Name (STitle) **] Completed by:[**2127-10-21**]

[ "576.2", "575.11", "280.0", "041.04", "424.1", "157.0", "212.6", "599.0", "V10.51" ]

icd9cm

[ [ [] ] ]

[ "99.04", "51.22", "38.93", "52.7" ]

icd9pcs

[ [ [] ] ]

9390, 9437

7584, 8291

317, 348

9506, 9514

811, 7561

9813, 9979

590, 623

8383, 9367

9458, 9485

8317, 8360

9538, 9790

638, 792

260, 279

376, 491

513, 546

562, 574

27,251

106,302

45439

Discharge summary

report

Admission Date: [**2152-9-21**] Discharge Date: [**2152-9-26**] Service: MEDICINE Allergies: Penicillins / Codeine / Sulfonamides / Aspirin / Valium / Erythromycin Base / Ciprofloxacin / Biaxin / Acyclovir / Zestril / Egg / Oxycontin Attending:[**First Name3 (LF) 3151**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] yo F w/ ipf, chf, cad, sjogren's syndrome presenting c/o severe shortness of breath for "many days." Pt reports that she has shortnes of breath at baseline (no home O2). She was in her usual state of health, which consists of chronic shortness of breath and Left sided nonradiating chest pain, for which she uses NTG 1-2 times a day. Pt is status post RCA stenting three years ago, since then with recurrent chest pains but negative nuclear tests, thus suggesting noncardiac origin of the chest pains. Pt went to her cardiologist ([**Doctor Last Name **]) for routine f/u today. She reported worsening shortness of breath, and on exam she "appeared uncomfortable, shivering and tachypneic. The respiratory rate is 40 per minute. Her blood pressure is 95/70 in both arms seated, pulse is 60 and regular." She was sent to ER for respiratory distress and lower than normal pressure. She reports 2 episodes of left sided nonradiating non-pleuritic sharp chest pain with no diaphosesis at rest each lasting 10 minutes and resolving without intervention (once while in the cardiologist's office and once while in the ED). She reports that this chest pain is consistent with recurrent chest pain that she has had at basline. ROS positive for chills and rhinorhea and 2 pillow orthopnea; but no PND or leg edema, no fevers, denies nausea/vommitting/diarrhea, no cough, no dysuria. Per ED discussion with pcp- [**Name10 (NameIs) **] has had multiple episodes of dyspnea with CP which is attributed to anxiety and then resolves after r/o MI. . In the ED: T 97.0 HR 58 BP 106/69 RR 25 SzO2 95%2L. Pt given ativan and rountine labs with CE, EKG, and CXR. EKG with no change, first set of CE negative, and admitted to medicine. Past Medical History: -- CAD: s/p MI x2; s/p Cypher stent to RCA in [**2148**]; [**12-12**] P-MIBI: Normal pharmacologic stress myocardial perfusion with normal left ventricular cavity size and wall motion. -- CHF: Echo [**2151-3-4**] EF >55%, 1+MR, 1+ TR, mild PA systolic pressure -- Hypertension -- Diabetes mellitus -- Atrial fibrillation - per history but currently in sinus. Not on coumadin -- Sjogren's syndrome / scleroderma. -- squamous cell carcinoma -- Interstitial lung disease -- osteoporosis, with vertebral compression fractures. -- GERD / esophageal dysmotility / peptic ulcer disease. -- Macular degeneration -- h/o DVT -- s/p colectomy -- s/p CVA x4 -- s/p TAH/RSO -- s/p post appendectomy -- h/o femoral hernia repair Social History: [**Hospital1 18**] employee x 36 years, widowed for 38 years, 2 children (58 and 67). Pt does not see family often as live in [**State **] and [**State 4565**] Smoked for about 5 years 3 packs per day. Gave up about 65 yrs ago. Her husband was a heavy smoker, no alcohol. Walks with a cane, reports not leaving the house often (can walk to [**Location (un) **] Corner, about [**12-7**] mile). Lives alone w/ VNA 2x per week. Family History: One child died at age 60 of CAD/cancer. Father died at 52 of MI. Physical Exam: Vitals - T 98.4 BP 144/68 HR 64 RR 26 SaO2 100% on 3.5L NC General - pt is elderly female in moderate distress, shivering, and tachypnic HEENT - Brige of nose with scabed over lesion, [**Name (NI) 3899**], Pt blind, MMM, OP clear Neck - no thyromegaly, no lad, jvp flat CV - nml s1 s2 rrr no m/r/g Lungs - cta bil no rales/rhonchi/wheeze Abdomen - +bs, soft, ntnd, no hsm Ext - no c/c/e neuro: a&ox3, moving all extremities, nonfocal Pertinent Results: [**2152-9-21**] 02:34PM TYPE-[**Last Name (un) **] PO2-38* PCO2-23* PH-7.64* TOTAL CO2-26 BASE XS-4 COMMENTS-GREEN TOP [**2152-9-21**] 02:34PM LACTATE-3.4* [**2152-9-21**] 02:30PM GLUCOSE-100 UREA N-18 CREAT-1.2* SODIUM-137 POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-23 ANION GAP-17 [**2152-9-21**] 02:30PM estGFR-Using this [**2152-9-21**] 02:30PM CK(CPK)-75 [**2152-9-21**] 02:30PM cTropnT-<0.01 [**2152-9-21**] 02:30PM CK-MB-NotDone proBNP-4429* [**2152-9-21**] 02:30PM WBC-14.2* RBC-4.23 HGB-13.7 HCT-38.0 MCV-90 MCH-32.4* MCHC-36.1* RDW-15.0 [**2152-9-21**] 02:30PM NEUTS-62.6 LYMPHS-27.3 MONOS-8.5 EOS-0.8 BASOS-0.6 [**2152-9-21**] 02:30PM PLT COUNT-195 [**2152-9-21**] 02:30PM PT-11.3 PTT-23.8 INR(PT)-1.0 . . Imaging: [**2152-9-21**] CXR - 1. Evidence of pulmonary fibrosis, unchanged. 2. Stable cardiomegaly. 3. Overall no change since [**2152-8-14**]. Brief Hospital Course: [**Age over 90 **] yo F w/ Sjogren's syndrome/Scleroderma, esophageal dysmotility, CAD s/p MI X 2 and s/p RCA stent, "chest pain syndrome" resulting in numerous admisssions and extensive negative work-up, who presents with SOB. . # Shortness of breath/chest pain - Pt has presented with similar symptoms multiple times in the past. Pt does have a hx of coronary artery disease and is status post RCA stenting 3 years ago, but has had recurrent chest pains on multipls occasions since which have been worked up with negative nuclear tests, thus suggesting noncardiac origin of the chest pains. She was ruled out for MI w/ serial EKG's and cardiac enzymes. While on the medical floor the patient became extremely anxious and developed a respiratory alkalosis to 7.84 and transferred to the MICU for observation. Anti-anxiolytics were used with good effect. Geriatrics was consulted to assist in anxiety control and recommended clonazepam 0.25 mg [**Hospital1 **] w/ lorazepam rescue. She was also instructed in the use of a brown paper bag to control anxiety -related SOB. . #Gout Patient experienced an acute episode of gout in her right big toe. This was treated w/ 2 days of PO prednisone 40 mg. She will continue 3 more courses to complete 5 total days of 40 mg daily prednisone. . # CAD Patient was ruled out for MI as stated above. Her home dose of beta blocker, statin, and aspirin were continued. . # HTN Well controlled on home BP meds (valsartan, nifedipine, metoprolol). . # DM Patient is currently diet controlled. However, w/ prednisone will continue sliding scale until she completes prednisone. . # Sjogrens/Scleroderma Pt has history of IPF associated with connective tissue disease. On no current therapy. Medications on Admission: Albuterol 1-2 Puffs Q6H PRN Aspirin 81 mg daily Calcium Carbonate 500 mg TID Valsartan 160 mg daily Nitroglycerin 0.3 mg PRN Nifedipine 60 mg SR daily Hexavitamin daily Metoprolol 100mg [**Hospital1 **] Atorvastatin 80 mg daily Isosorbide Mononitrate 60 mg SR TID Ipratropium inhalations QID Fosamax 70 mg weekly Protonix 20 mg daily Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO TID (3 times a day). 11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 12. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO at bedtime. 13. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED) for 3 days: See sliding scale. 15. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 3 days. 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 21. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Primary: Non-cardiac Chest Pain, Gout . Sencondary: - Coronary Artery Disease - Anxiety disorder, NOS - Congestive Heart Failure -- Hypertension -- Diabetes mellitus -- Atrial fibrillation - Not on coumadin -- Sjogren's syndrome / scleroderma. -- squamous cell carcinoma -- Interstitial lung disease -- osteoporosis, with vertebral compression fractures. -- GERD / esophageal dysmotility / peptic ulcer disease. -- Macular degeneration -- h/o Deep Venous Thrombosis -- status post colectomy -- status post CVA x4 -- status post Total Abdominal Hysterectomy /Right Salpingo Ooporectomy -- status post post appendectomy -- status post femoral hernia repair Discharge Condition: Stable, chest pain resolved, SaO2 95% on RA Discharge Instructions: You were admitted to the hospital with shortness of breath and chest pain. You were monitored in the Medical Intensive Care Unit because of your breathing. We think that your breathing difficulty may be related to external stressors. . You also had a gout flare which was treated with prednisone. Please continue to take this for the full course. If you have continued fevers, worse pain in the toe or elsewhere, please let your caretakers know or call your doctor. . If you have any symptoms of worsening shortness of breath, chest pain, abdominal pain, nausea, vommiting, or any other concerning symptoms please go to the emergency room. Followup Instructions: Provider PULMONARY BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2152-9-27**] 1:30 Provider [**Name9 (PRE) 1570**],INTERPRET [**Name Initial (PRE) **]/LAB NO CHECK-IN PFT INTEPRETATION BILLING Date/Time:[**2152-9-27**] 1:30 Provider [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2152-9-27**] 2:00 Provider [**Name9 (PRE) **],[**First Name3 (LF) 251**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 250**] [**2152-10-3**] @ 12:20

[ "V45.82", "414.01", "300.00", "733.00", "362.50", "530.81", "274.9", "786.59", "710.1", "401.9", "515", "428.32", "250.00", "786.05", "276.3", "428.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8805, 8877

4790, 6524

368, 374

9576, 9622

3887, 4767

10313, 10867

3350, 3417

6908, 8782

8898, 9555

6550, 6885

9646, 10290

3432, 3868

309, 330

402, 2150

2172, 2890

2906, 3334

73,460

188,469

42498

Discharge summary

report

Admission Date: [**2185-1-3**] Discharge Date: [**2185-1-16**] Date of Birth: [**2098-7-1**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 983**] Chief Complaint: vomiting blood, bright red blood per rectum Major Surgical or Invasive Procedure: esophagogastroduodenoscopy (EGD) [**2185-1-3**], [**2185-1-5**], [**2185-1-8**], and [**2185-1-11**]. flexible sigmoidoscopy [**2185-1-5**] History of Present Illness: 86 year old woman with AF on coumadin (INR of 2.4), distant hx of PUD with upper GI bleed, s/p recent oral surgery taking motrin for pain who presents to the ED at [**Hospital 4199**] Hospital today vomiting bright red blood and having BRBP. The history was obtained from her son and records since pt is currently sedated and intubated. Her son found her today at home disoriented in a pool blood, she was vomiting and passing bright red bloody stools. She initially taken to [**Hospital 4199**] Hospital where her SBP was in the 70s. She was given 5L of IV fluids, 3u pRBCs and a dose of protonix and sent to [**Hospital1 18**]. She had right femoral CVL placed as well as 2x 18 gauge IVs. En route, she vomited large amount of blood and required initiation of a pressor. On arrival, to our ED her vitals were temp 96.6, HR was 70s, BP 85/76, 17, 100% on N/c. NG lavage revealed BRB which did not clear with 500cc. She was noted to have BRBPR, her SBP dropped to the 60s. Her Hct was also noted to have dropped from 30 to 23 even with 3 units of PRBCs. She was then given additional 2 units of PRBCs and 2 FFP. She had the massive transfusion protocol activated. She was started on PPI drip and given erythromycin. She was then intubated for airway protection and for EGD which was done in the ED. As per GI report, she had multiple ulcers in the antrum and pylorus (endoclip, injection). Her abdomen was noted to be distended prior to the EGD and she had CT-abd done which the prelim report did not show any pneumoperitoneal or acute process. Final read still pnd. She had a total of 10 units of PRBCs, 6 FFP, 1 plalets. On arrival to the MICU, pt was HD stable off pressors. She is intubated and minimally responsive on fentanyl and midazolan drip. The patient was scoped by GI and found to have a bleeding ulcer which was clipped. She extubated, transferred to the floor. On the floor, she had hemetemesis on the day of discharged and was transferred back to the unit for repeat endoscopy which showed another bleeding ulcer. She was re-intubated and subsequently extubated once she was stable. Her hematocrits were monitored in the ICU and were stable. She was hemodynamically stable with no further evidence of bleeding and was transferred back to the floor. Past Medical History: - PUD with upper GI bleed 8 years ago - A-fib on coumadin and metoprolol Social History: she is married and has 1 son who lives on upper level of their 2 family home. Her husband is [**Name2 (NI) 11345**] and she is the main care taker for him. She has worked as a bookeper and house wife. Does not drink or smoke Family History: noncontributory Physical Exam: ON ADMISSION: GEN: pale, cool to touch female intubated on vent, in NAD HEENT: PERLA, non-icteric CV: irregular rate, no murmurs LUNGS: CTA bil, no crackles or wheezing ABD: distended, soft, appears non-tender, + hyperactive BS, no masses EXT: + pulses, trace bil UE and LE edema, cool to touch Neuro: sedated, not responding to verbal stimuli, withdrawing to painful stimuli . AT DISCHARGE: AF 98.9 122/72 90 18 95% RA GEN: well appearing female, hard of hearing, resting quietly NAD HEENT: PERLA, non-icteric, conjunctiva slightly pale but still pink CV: irregular rate, no murmurs LUNGS: CTA bil, no crackles or wheezing ABD: soft, non-tender, non-tender, + BS, no masses EXT: + pulses, trace bil UE and LE edema R>L (pt states this is chronic since R leg injury in past) Neuro: A&Ox3, no tremor, strength 4/5 throughout, EOMI, sensation intact Pertinent Results: EGD ON [**2185-1-3**]: Impression: Normal mucosa in the esophagus Blood in the stomach. Ulcers in the antrum and pylorus (endoclip, injection). Blood in the duodenum. Otherwise normal EGD to third part of the duodenum . EGD [**2185-1-5**] Normal mucosa in the esophagusUlcers in the antrum - here were no high risk stigmata for bleeding and there was no blood in the lumen. Friability, erythema and congestion in the first part of the duodenum compatible with duodenitis. Otherwise normal EGD to third part of the duodenum . EGD [**2185-1-8**]: Ulcer in the pylorus (endoclip, injection) Ulcer in the pylorus Blood in the fundus Blood in the duodenum Otherwise normal EGD to third part of the duodenum . EGD [**2185-1-11**] Mild distal esophagitis Erythema and healing erosions in the stomach body Healing ulcer in prepyloric region Mild duodenitis Otherwise normal EGD to third part of the duodenum . Sigmoidoscopy [**2185-1-5**] Black blood filled the rectum and could not be washed away. Impression: Blood in the colon Otherwise normal sigmoidoscopy to rectum . ECG [**2185-1-3**] Baseline artifact. Underlying rhythm is likely atrial fibrillation with moderate ventricular response. Delayed R wave progression. Diffusely low QRS voltage. Compared to the previous tracing of [**2185-1-3**] atrial fibrillation is new. Cannot exclude prior inferior myocardial infarction of indeterminate age. Delayed R wave progression and low QRS voltage are new. Clinical correlation is suggested. . CXR [**2185-1-4**] FINDINGS: Endotracheal tube ends approximately 4.8 cm above the carina and is adequately positioned. Orogastric tube is seen to course below the diaphragm; however, the distal end is off the radiographic view. Left lower lung opacity, new since yesterday likely from aspiration or atelectasis. Small bilateral pleural effusions are unchanged. Pulmonary vascular congestion has improved over the last 24 hours. Mildly enlarged heart size, mediastinal and hilar contours are stable in appearance. . ADMISSION LABS: [**2185-1-3**] 09:15PM BLOOD WBC-7.7 RBC-2.48* Hgb-8.3* Hct-23.4* MCV-95 MCH-33.6* MCHC-35.5* RDW-13.0 Plt Ct-97* [**2185-1-4**] 03:34AM BLOOD Neuts-80.3* Lymphs-13.1* Monos-6.0 Eos-0.4 Baso-0.1 [**2185-1-3**] 09:15PM BLOOD PT-25.2* PTT-35.9 INR(PT)-2.4* [**2185-1-3**] 09:15PM BLOOD Fibrino-155* [**2185-1-4**] 03:34AM BLOOD Glucose-114* UreaN-40* Creat-0.9 Na-144 K-4.1 Cl-112* HCO3-24 AnGap-12 [**2185-1-4**] 03:34AM BLOOD ALT-22 AST-26 AlkPhos-40 TotBili-1.0 [**2185-1-4**] 03:34AM BLOOD Albumin-3.1* Calcium-7.1* Phos-4.4 Mg-1.5* [**2185-1-4**] 01:56AM BLOOD Type-ART pO2-374* pCO2-39 pH-7.38 calTCO2-24 Base XS--1 [**2185-1-3**] 09:23PM BLOOD Glucose-158* Lactate-1.2 Na-139 K-4.6 Cl-116* calHCO3-22 . DISCHARGE LABS: [**2185-1-16**] 07:05AM BLOOD Glucose-109* UreaN-8 Creat-0.8 Na-138 K-4.1 Cl-103 HCO3-27 AnGap-12 [**2185-1-16**] 07:05AM BLOOD WBC-8.1 RBC-3.60* Hgb-10.7* Hct-32.9* MCV-91 MCH-29.7 MCHC-32.5 RDW-14.1 Plt Ct-352 [**2185-1-16**] 01:30PM BLOOD Hct-34.6* Brief Hospital Course: 86 y/o F on coumadin for Afib, h/o PUD in past transferred to [**Hospital1 18**] with upper GIB. . # GI Bleed - Pt just had oral surgery for gums and has been on motrin. Presented to [**Hospital 91974**] hosp initially after vomiting bright red blood and with BRBPR - found by son in pool of blood and passed out. On arrival to OSH hypotensive to the 70s fluids, given 3u prbc protonix and transferred to [**Hospital1 **]. R fem line was placed. Pt was scoped in ED, ng lavage didn't clear with 500s ccs, continued with BRBPR and bp in 60s. Hct drop from 30 to 23 even after receiving 3u RBCs at OSH. On admission put on massive transfusion protocol, got 2uPRBCs and 2u FFP, PPI drip started, given erythromycin, intubated for airway protection. EGD performed in ED, multiple ulcers in antrum/pylorus which endoclipped and injected. Had CTabdomen for distension but no evidence of perforations. Received a total of 10uRBC, 6ffp, and 1plt and was admitted to MICU. From that point forward pt was HDS never on pressors, the following morning was extubated. Hct remained stable around 27. no further transfusions. Re-scoped [**2185-1-5**], found same ulcers still in stomach and duodenitis but with significant healing. It was difficult to clear the rectum on sigmoidoscopy of black dark blood felt they couldnt r/o other source of bleed so pt went back to MICU temporarily. Hcts stable at 27 and was transferred to floor that evening. Some melena while being turned likely old blood. HDS. Pt was transitioned to [**Hospital1 **] PPI. on [**2185-1-6**] pt had 30ccs frank blood per rectum, no stool. Felt dizzy, HCT was stable and this was thought due to dehydration as pt had not been able to hydrate herself adequately on liquid diet. Pt was advanced to regular diet, remained stable overnight and was olanned to be discharged to rehab. H pylori serologies negative, and GIB felt to be NSAID induced. However, on [**1-9**], the patient had dark stools with hematemesis with large clots. She had NG lavage with 50cc bright red blood. The patient was intubated and transferred back to the MICU. She received 3U PRBCs and was extubated successfully. Her Hct remained stable, but she started to have melanotic stools. So she was taking for EGD and colonoscopy which showed no active bleeding from upper GI and blood on colon which was difficult to see. She was sent back to the MICU for obs, since she was doing well she was then transferred to the floor. She was noted to have an episode of dark slick stool (minimal) and she was re-scoped by GI on [**2185-1-11**], at which time they saw no evidence of active bleeding. Pt remained on the floor, diet was advanced and HCT remained stable. . #Afib - pt on warfarin and metoprolol at home. On admission INR was 2.4 in setting of GI bleed. Warfarin was discontinued. Warfarin was held throughout this admission and given the significance of her bleed she was sent home on aspirin for primary stroke prevention (CHADS score only 2 for afib and age). This decision was communicated to the PCP. . #hypocalcemia - pt with low ionized ca in setting of massive transfusions, Ca was followed and was slighly low but only marginally. Repleted as needed. . #UTI - pt with equivocal UTI (large leuks, small blood, posiitve bacteria but no WBCs) Pt noted to have odorous cloudy stool s/p foley in MICU and was given 3 day course of cipro. . TRANSITIONAL ISSUES: We have stopped pt's warfarin in setting of massive GI bleed. CHADs score only 2 for Afib and age, we have started aspirin for primary stroke prevention. GI does not feel that they need to follow, but pt needs to have a repeat EGD in [**2184-2-3**]. If PCP would like GI to follow along, can schedule an appointment with [**First Name8 (NamePattern2) 3095**] [**Last Name (NamePattern1) **], [**Hospital1 18**] gastroenterology. Also, pt will need lifelong high dose PPI. Medications on Admission: metoprolol 50mg [**Hospital1 **] warfarin (dose unknown) motrin prn for pain s/p oral surgery 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:*0* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 **] Senior Healthcare of [**Location (un) **] Discharge Diagnosis: PRIMARY gastrointestinal bleed peptic ulcer disease . SECONDARY atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you during your recent hospitalization. You were admitted with bleeding from your GI tract. You lost a significant amount of blood. We found a bleeding vessel in an ulcer in your stomach. This vessel was clipped and bleeding appeared to stop. Your blood levels remained stable, but you did have another episode of vomiting blood and a bloody bowel movement, so endoscopy was repeated. Another bleeding vessel was found and was clipped. After this there was a repeat endoscopy which showed things were healing and no further areas of bleeding. After this you had no further vomiting of blood, you had some dried blood in your stool which was the old blood passing through. We advanced your diet which you tolerated well. You will go to a rehab facility for physical therapy. . We made the following changes to your medications: STOPPED ibuprofen STOPPED warfarin STARTED aspirin 81mg daily STARTED pantoprazole 40mg twice a day CHANGED metoprolol to lower dose. You were taking 50mg twice a day. Now take 12.5 mg twice a day. You can adjust this dose with your PCP. Followup Instructions: Department: GI-WEST PROCEDURAL CENTER When: THURSDAY [**2185-3-3**] at 12:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: WEST PROCEDURAL CENTER When: THURSDAY [**2185-3-3**] at 12:30 PM With: WPC ROOM THREE [**Telephone/Fax (1) 5072**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Please make an appointment to see your PCP in the next [**12-6**] weeks.

[ "785.59", "427.31", "V12.71", "531.40", "518.81", "E935.9", "285.1", "V58.61", "599.0", "275.41" ]

icd9cm

[ [ [] ] ]

[ "96.71", "45.13", "44.43", "48.23", "96.04" ]

icd9pcs

[ [ [] ] ]

11486, 11571

7062, 10437

345, 487

11699, 11699

4041, 6045

12972, 13715

3137, 3154

11075, 11463

11592, 11678

10957, 11052

11850, 12681

6785, 7039

3169, 3169

3561, 4022

10458, 10931

12710, 12949

262, 307

515, 2783

6061, 6769

3183, 3547

11714, 11826

2805, 2879

2895, 3121

49,604

189,276

42094

Discharge summary

report

Admission Date: [**2161-8-9**] Discharge Date: [**2161-8-24**] Date of Birth: [**2110-3-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4095**] Chief Complaint: C. perfringens bacteremia Major Surgical or Invasive Procedure: Intubation/Extubation History of Present Illness: 51yo M PMHx polysubstance abuse, strep viridans endocarditis s/p St. [**Male First Name (un) 1525**] MVR on coumadin, EtoH and HCV Cirhosis c/b ascites, prior GI bleeds (without known varices) initially presenting to OSH from Addiction [**Hospital6 91328**] for pancytopenia (WBC 1.1, Hct 26, platelets 54), was found to be hypotensive (SBP80s) with strongly guaiac positive stools; he was started on octreotide and famotidine gtts with stabilization of Hct in the upper 20, low 30s; also found to have low grade fevers, with blood cultures growing out GPRs (clostridium perfringens, one of two bottles), for which he was treated with ciprofloxacin, clindamycin; source of bacteremia was felt to be cholecystitis based on exam and CT imaging that demontrated pericholestatic fluid, gallbladder wall thickening; patient was trasferred to [**Hospital1 18**] for further surgical management on [**2161-8-9**]. Patient was admitted to [**Hospital1 18**] SICU. On further questioning patient endorsed ~3wks melena and nosebleeds prior to admission, also reported sharp, constant periumbilical pain, withut nausea/vomiting/constipation/diarrhea. Regarding concern for cholecystitis, patient abx changed to vanco/zosyn per ID recommendations, but then had HIDA scan w/o evidence of cholecystitis, edematous gallbladder attributed to ascites; given bacteremia had TTE that did not demonstrate any signs of acute valvular pathology, but did demonstrate severe AS. Patient had heparin drip initiated for subtherapeutic INR. Hepatology service was consulted given patient's cirrhosis. . Remainder of SICU course was remarkable for continued fevers, hypotension requiring levophed drip and development of acute respiratory distress [**2161-8-12**], O2sat high 80s, low 90s on NRB. Patient was intubated for hypoxic respiratory failure (ABG 7.30/53/63). CXR demonstrated bibasilar opacities, concerning for aspiration PNA. As source of fevers/hypotension remained uncertain, patient's abx were broadened to meropenem and vancomycin. On day of transfer, patient underwent bronch without clear findings (no cultures sent). . On transfer to MICU, the patient remained intubated and sedated, with PIV, triple lumen [**Last Name (LF) 14938**], [**First Name3 (LF) **], Flexiseal, Foley in place. Given patient intubated, unable to perform perform review of systems. Past Medical History: - Hepatitis C and alcohol cirrhosis complicated by ascites, GI bleeds, unknown varices history - Mitral Valve Repair (St. Jude's Valve) in [**2157**] for strep viridans bacterial endocarditis - Cocaine abuse (clean for 8 years) - Hepatitis C - Positive ANCA/[**Doctor First Name **] - GERD - Hypertension Social History: Works in construction. Denies unprotected sex or for money/drugs. Last HIV 6 months ago. Currently homeless and living with his sisters, "[**Name2 (NI) 24667**] to [**Name2 (NI) 24667**]." Stays on the streets during the days, sisters at night. - Tobacco: 1ppd > 25 years - Alcohol: Abuse in the last six months - Illicits: Cocaise use 8 years ago, no current IVDU Family History: Mother deceased at unknown age, father deceased at 73yo of MI, 7 sisters with one recently deceased from ?CVA at age 45yrs. Physical Exam: ON TRANSFER TO MICU Vitals: T 100.7 BP 122/62 HR 74 RR 26 Sat 98%/vent FiO2 40% General: Intubated, sedated. Not following. HEENT: Sclera anicteric, MMM. Neck: JVP not elevated. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, II/VI midsystolic murmur at RUSB. Abdomen: Bowel sounds absent, distended, cannot assess tenderness in setting of sedation, +diffuse guarding GU: Foley in place. +Rectal. Ext: warm, well perfused, 2+ pulses . Discharge Exam: AVSS NAD, No longer jaundice RRR 2/6 SEM Abd mild distended, non-tender Extr: 1+ pretibial edema Pertinent Results: BCx [**8-9**] X2 NGTD BCx [**8-10**] X2 NGTD BCx [**8-11**] X2 NGTD BCx [**8-12**] X2 NGTD BCx [**8-12**] Fungal and AFB cultures NGTD Stool [**8-12**] CDiff tox and fecal cultures negative Catheter tip [**8-10**] negative Urine [**8-10**], 16, 17 negative Sputum [**8-12**] gram stain and cultures negative . RUQ: 1. Essentially no significant change in comparison to prior study from [**2161-8-10**]. Markedly thickened gallbladder wall with gallstones within the gallbladder lumen. Given the patient's history of cirrhosis, the GB wall thickening is likely related to patient's underlying liver disease. 2. Moderate ascites. 3. Stable right pleural effusion. 4. Splenomegaly. . CXR: Cardiac size is normal. The aorta is tortuous. Small bilateral pleural effusions, larger on the right side, are grossly unchanged with associated left greater than right lower lobe atelectasis. Left PICC tip is at the cavoatrial junction. There is no pneumothorax. Cardiac size is normal. Brief Hospital Course: HOSPITAL COURSE 51yo M PMHx strep viridans endocarditis s/p St. [**Male First Name (un) 1525**] MVR, cirhosis p/w GIB, admitted with bacteremia, hypotension, course complicated by respiratory failure and intubation, who was subsequently extubated and transferred to general medicine floor. # C. perfringens bacteremia: Per ID, likely GI source, although no signs biliary obstruction on CT scan, and no evidence cholecyctitis on HIDA. Diagnostic paracentesis was negative for SBP and TTE neg for endocarditis. Pt remained stable on meropenem/vanco but spiked fever once to 100.9 on general medicine floor. repeat blood cultures at that time were negative, repeat RUQ u/s was unchanged, and attempt to repeat paracentesis was unsuccessful due to lack of tappable pocket. No further fever spikes were recorded and pt reported feeling well and denied subjective fevers. He remained stable and afebrile after this and received a 14d total course of vanc and meropenem, which was discontinued the morning of [**2161-8-23**]. # Aspiration / HCAP: Pt w aspiration event in ICU resulting in hypoxic respiratory failure leading to intubation; patient had initially been covered w zosyn/vanco for above bacteremia, then broadened with respiratory distress / fever episodes. He was extubated without issues and was weaned to room air on the general medicine floor. He continued to have a productive [**Date Range **], but had no oxygen requirement on the general medicine floor. He was placed on nebs for a short course due to mild wheezing on exam, but denied shortness of breath throughout the rest of his hospital stay. He spiked one fever to 100.9 while on the floor but no cause was identified (see above). He finished a 14d total course of vancomycin/meropenem and reported significant improvement in breathing and [**Date Range **] by the time of discharge. #Pancytopenia: Chronic process per OSH records, likely [**1-28**] chronic cirrhosis; received 1 dose neupogen in SICU w rise in ANC >1000. Started on multivitamin and folate daily for anemia. Arranged for outpatient follow up with liver specialist. #s/p MVR: Pt has a mechanical [**Hospital3 **] valve with INR goal 2.5-3.5. He was started on a heparin drip to bridge coumadin. INR became supratherapeutic and coumadin was held until INR reached 1.7, after which coumadin was restarted at 2mg po daily. He will require outpatient follow up at coumadin clinic to follow up steady state levels on [**2161-8-26**]. #Aortic stenosis: Present on OSH TTE [**3-/2161**], now [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 109**] 0.8. Pt was initially euvolemic but began to develop pitting edema in LE bilaterally around [**2161-8-20**], so spironolactone was started, as process was thought most likely secondary to liver disease. LE edema continued to worsen and pt continued to have [**Last Name (LF) **], [**First Name3 (LF) **] a repeat CXR on [**2161-8-23**] was done which showed stable pleural effusions and no pulm edema. Pt denied chest pain and was able to ambulate well on floor, so no further action was taken to address AS and pt was arranged for outpatient follow up with cardiologist. #HCV/EtOH cirrhosis: Pt w cirrhosis c/b ascites. He was continued on thiamine, folate, MVI, and lactulose while in house. Ascites was tapped at time of fever on admission and was negative for SBP. Ascites remained stable throughout admission and had improved mildly at the time of discharge. Pt began to develop pitting edema in the LE bilaterally on [**2161-8-20**] and was started on spironolactone 100mg po daily with good diuresis. LE edema initially worsened, then improved once patient started ambulating and mobilizing peripheral fluid. # Guaiac Pos stool - Pt w guaiac pos brown stool on admission. Hct remained stable throughout admission. He was continued on protonix, with plans to follow up with GI as an outpatient for EGD and colonoscopy. ***NOTE: Patient departed from hospital before being given prescriptions, discharge instructions and follow up appointment dates, despite being instructed multiple times that he needed to wait for this before leaving. He could not be reached by phone. We faxed his prescriptions to his pharmacy, informed his PCP, [**Name10 (NameIs) **] faxed copies of his discharge summary to his PCP and cardiologist.*** TRANSITIONAL ISSUES - studies pending on discharge: blood cultures (from [**2161-8-21**]) - will need labs (CBC with diff, coags, electrolytes) drawn on [**2161-8-27**] - cardiologist should determine when to restart Lisinopril - recommend GI appointment for EGD and colonoscopy to follow up on guiac+ stool [[pulmonary nodule, requires follow-up, see CT scan [**2161-8-12**]: . 1cm nodule within the right middle lobe, this may be infectious. Would recomend follow up in 3 months or when current clinical situtation resolves.]] Medications on Admission: Lisinopril 10mg daily Omeprazole 20mg daily Folic acid 1mg daily Lisinopril 10mg daily Warfarin 6mg daily Trazodone 150mg qHS Iron 65mg 2 tabs daily Magnesium oxide 400mg [**Hospital1 **] Vitamin C Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for vitamins. Disp:*30 Tablet(s)* Refills:*0* 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). Disp:*30 Tablet(s)* Refills:*2* 4. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain,fever. 5. trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 6. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2 times a day) as needed for constipation: take as needed to have [**2-27**] BM per day. Disp:*1 bottle* Refills:*2* 7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: apply for 12 hours a day, then remove for 12 hours. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0* 8. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for itching: apply to neck rash as needed for itching. 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 10. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 11. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*0* 13. hydrocortisone 0.5 % Cream Sig: One (1) application Topical TID PRN (as needed) as needed for neck itching: apply topically as needed 3 times a day for neck rash itching. Disp:*1 tube* Refills:*2* 14. Outpatient Lab Work Please draw CBC with differential, coagulation panel (PT, INR, PTT) and chem 10 on Thursday, [**8-27**] and fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3003**] (fax # [**Telephone/Fax (1) 91329**]) Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Clostridial bacteremia Aspiration Pneumonia / Healthcare-associated pneumonia Aortic stenosis Secondary Diagnoses: HCV/alcoholic cirrhosis Mechanical mitral valve 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: Thank you for letting us take part in your care at [**Hospital1 771**]. You were transferred to our hospital because you had bacteremia, which is an infection in your blood. You also had pneumonia and required a short period of intubation due to respiratory distress. You were extubated when your breathing was stable and treated with antibiotics for both the bacteremia and pneumonia. An echocardiogram was done on your heart because to ensure your mechanical valve had not become infected by the bacteria in your blood (endocarditis). It did not show endocarditis, but did show that your aortic valve was very narrow (stenosed). You should follow up with your cardiologist to further evaluate this. You should continue your coumadin at 3mg daily for now and have your levels checked on Wednesday. Your doctor will adjust the dose according to the level. While you were here, you developed swelling in your legs and had fluid in your abdomen called ascites. This is common in patients with liver disease. We have arranged an appointment with a liver specialist for you to help you manage the swelling and discuss treatment options for liver disease. You may also need an EGD, which is a test requiring a camera to look into your esophagus, to look for any bleeding because your blood counts were low. You were seen by physical therapy who recommended that you use a rolling walker until you are feeling stronger. We encourage you to use the walker and take short walks with it 3 times per day. The following changes were made to your medications: STARTED: --multivitamin 1 tab by mouth daily --thiamine 100mg by mouth daily --spironolactone 25 mg by mouth daily --Hydrocortisone Cream 0.5% apply topically three times a day as needed for neck rash for itching --Lactulose 15 mL by mouth twice a day as needed for constipation (take as needed to have [**2-27**] bowel movements per day) CHANGED: --warfarin 3mg by mouth daily (your dose may be adjusted according to your INR level; please continue to have your level monitored as you have been doing previously) STOPPED: --lisinopril 10mg by mouth daily Please discuss with your cardiologist (Dr. [**Last Name (STitle) 19944**] when you should start taking Lisinopril again. Please have your blood drawn on Wednesday, [**2161-8-26**] (CBC with differential, coagulation panel (PT, INR, PTT), liver function tests (AST, ALT, bilirubin) and chem 10) and have the lab fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3003**] (fax # [**Telephone/Fax (1) 91329**]) Please attend the follow up appointments listed below to follow up on your hospitalization. Your primary care doctor will also make you an appointment with a liver doctor for the near future. Followup Instructions: Name: PRIOR,[**Doctor First Name **] S. Location: COMMUNITY HEALTH CENTER OF [**Hospital3 **] Address: [**Doctor Last Name 91330**], [**Hospital1 **],[**Numeric Identifier 27861**] Phone: [**Telephone/Fax (1) 14916**] Appt: [**8-25**] at 4:20pm ***Its recommended you see a Liver Doctor for your Cirrhosis issues within 2 weeks of discharge. Please discuss with Dr [**Last Name (STitle) 3003**] setting up an appt with one in your area. Name: [**Last Name (LF) **],[**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Address: [**Street Address(2) 91331**], [**Hospital1 **],[**Numeric Identifier 19665**] Phone: [**Telephone/Fax (1) 19666**] Appt: Thursday, [**8-27**] at 12:45pm

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icd9cm

[ [ [] ] ]

[ "33.23", "38.91", "96.71", "38.97", "96.04" ]

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34270

Discharge summary

report

Admission Date: [**2136-6-5**] Discharge Date: [**2136-6-8**] Date of Birth: [**2089-7-20**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 348**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Esophageal Duodenoscopy with Esophageal Variceal Banding History of Present Illness: Pt is a 46 y.o male with a h.o HCV, ETOH who presented to [**Hospital 1562**] Hospital this AM after vomiting ~[**2-1**] cup of BRB x4 this AM. At OSH HCT was 34, HR 140's, NG had 200cc coffee grounds per report. Pt was given 2L of IVF, 1 unit of PRBcs, octreotide/protonix gtt. PT denies prior h.o hematemesis, melena, brbpr, but reports that he has had episodes of vomiting in the past that were blood tinged. Pt reports that he felt a slight discomfort/cramping in his left periumbilical area for a few weeks. Pt otherwise denies fever/chills/headache/LH, CP, palpitations, SOB, current abd pain/n/v/d, dysuria/hematuria, joint pains. PT reports that he usually drinks 3 "nips" of whiskey daily, last drink was yesterday afternoon. Past Medical History: Hep C-never treated S/P hernia repair Social History: Lives on [**Location (un) **] with his wife, has 2 children. Smokes [**2-1**] ppd, drinks ~3 nips of Whiskey a few times per week. Reports he has been in rehab for ETOH before and has experienced symptoms of ETOH withdrawal. Reports remote history of marijuana use. Denies IVDU. Family History: DM, stroke, cardiac disease. Physical Exam: gen: thin male, appears slightly anxious/tremulous vitals: T. 99.7, BP 151/97, HR 115, RR 13, 100%RA, VT 75.5 HEENT: PERRLA, L.eye slightly bloodshot, +nares with dried blood secondary to NGT placement. No blood visible in oropharynx. neck: no JVD chest: b/l ae no w/c/r heart: s1s2 tachycardic, no m/r/g abd: +bs, soft, NT, ND, no palpable HSM ext: no c/c/e 2+pulses neuro: non-focal. Pertinent Results: DISCHARGE LABS: [**2136-6-8**] 07:15AM BLOOD WBC-6.8 RBC-3.10* Hgb-10.5* Hct-31.7* MCV-102* MCH-33.9* MCHC-33.1 RDW-16.0* Plt Ct-106* [**2136-6-8**] 07:15AM BLOOD PT-15.7* INR(PT)-1.4* [**2136-6-8**] 07:15AM BLOOD Glucose-103 UreaN-12 Creat-0.7 Na-140 K-3.8 Cl-104 HCO3-29 AnGap-11 [**2136-6-8**] 07:15AM BLOOD ALT-43* AST-91* TotBili-1.3 [**2136-6-6**] 04:34AM BLOOD AFP-11.9* [**2136-6-5**] 05:03PM BLOOD HCV Ab-POSITIVE [**2136-6-5**] 05:03PM BLOOD HEPATITIS C - RIBA-PND [**2136-6-5**] 05:03PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV Ab-POSITIVE [**2136-6-5**] 5:03 pm IMMUNOLOGY Source: Line-PIV. **FINAL REPORT [**2136-6-6**]** HCV VIRAL LOAD (Final [**2136-6-6**]): 325,000 IU/mL. Performed by real-time PCR. Detection Range: 30 - 55,000,000 IU/mL. This test was developed and its performance characteristics were determined by the [**Hospital1 18**] Clinical Microbiology Laboratory. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research.. If HCV genotype on patient's sample is desired, please contact laboratory at ext. [**7-/3146**] within two weeks. Log-In Date/Time: [**2136-6-7**] 9:40 am IMMUNOLOGY CHEM# [**Serial Number 78891**]M ( REQUEST FOR ENDPOINT DETERMINATION ). HCV VIRAL LOAD (Pending): HCV GENOTYPE (Pending): ABDOMEN U.S. (COMPLETE STUDY) [**2136-6-6**] 8:36 AM ABDOMEN U.S. (COMPLETE STUDY) Reason: please eval for signs of cirrhosis, mass, ascites [**Hospital 93**] MEDICAL CONDITION: 46 year old man with HCV, newly found esophageal varices, please eval for signs of cirrhosis, mass, ascites REASON FOR THIS EXAMINATION: please eval for signs of cirrhosis, mass, ascites ABDOMINAL ULTRASOUND: CLINICAL HISTORY: 46-year-old man with HCV, esophageal varices, evaluate for signs of cirrhosis, mass, or ascites. COMPARISONS: No prior ultrasound studies are available for comparison. Evaluation of the liver demonstrates mildly coarsened echotexture throughout, compatible with underlying cirrhosis/fibrosis. There is no intrahepatic or extrahepatic biliary dilatation. No focal mass lesions are identified. The portal vein is patent and forward. The gallbladder is unremarkable without evidence of cholelithiasis or gallbladder wall thickening. There is a 1.1-cm simple cyst in the left hepatic lobe. Small amount of ascites is seen around the liver. The spleen is not enlarged and measures only 11 cm in length. The left kidney is unremarkable and measures 12 cm in length. The right kidney is unremarkable and measures 11.7 cm in length. The body of the pancreas is unremarkable. The head and tail of the pancreas are not well seen due to artifact from adjacent gas-filled loops of bowel. IMPRESSION: 1. Mildly coarsened hepatic echotexture throughout, suggestive of underlying cirrhosis. No focal mass lesions are identified. 2. Small amount of ascites. No evidence of splenomegaly or intra-abdominal varices. Date: Tuesday, [**2136-6-5**] Endoscopist(s): [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 78892**], MD [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Patient: [**Known firstname **] [**Known lastname 78893**] Ref.Phys.: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Birth Date: [**2089-7-20**] (46 years) Instrument: ID#: [**Numeric Identifier 78894**] Medications: See anesthesia record Indications: GI Bleeding Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. The patient was administered conscious sedation. A physical exam was performed prior to administering anesthesia. The patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the second part of the duodenum was reached. Careful visualization of the upper GI tract was performed. The vocal cords were visualized. The procedure was not difficult. The patient tolerated the procedure well. There were no complications. Findings: Esophagus: Protruding Lesions 4 cords of grade [**3-4**] varices were seen in the esophagus. There were stigmata of recent bleeding. 4 bands were successfully placed. Stomach: Contents: Melena was seen in the stomach. Duodenum: Mucosa: Normal mucosa was noted. Other findings: No gastric varices were seen Impression: Esophageal varices (ligation) Blood in the stomach Normal mucosa in the duodenum No gastric varices were seen Recommendations: follow up per Liver service Continue PPI, octreotide, antibiotics, serial hcts Repeat EGD if acutely rebleeds Additional notes: The attending was present for the entire procedure. Routine post-procedure orders The patient??????s reconciled home medication list is appended to this report Brief Hospital Course: 46 y.o male with h.o Hep C, ETOH who presents with first episode of hematemesis 1. Acute Blood Loss Anemia/Esophageal Varicies: He was started on octreotide and pantoprazole gtt. Pt had an EGD that showed 4 cords of grade [**3-4**] esophageal varices with stigmata of recent bleeding. 4 bands were successfully placed, and octreotide was discontinued. He was started on cipro [**Hospital1 **] for banding prophylaxis and sucralfate 1g qid. Stable Hct over three days prior to discharge. Last HCT 31.7. Discharged on 40 mg Daily nadolol. 2. Hepatits C/Alcoholic Cirrhosis: Hep C VL and genotype, Hep B serologies, Hep A included in report. Iron studies were sent, but in the setting of transfusion before theses labs, they are uninterpretable. RUQ U/S suggests cirrhosis without mass. AFP was elevated at 11.9. Will follow up on [**2136-6-18**] at 1:15PM with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] at [**Hospital1 18**]. 3. Alcoholism: Treated with CIWA scale for withdrawl. No complications. Plan for outpatient rehab made between social worker and patient. Started on MVA, thiamine, foalte supplementation. 4. Tobacco ABuse: Nicotine patch prescribed for six weeks, then will need taper. 5. Thrombocytopenia: No splenmegaly on US. Please follow. 6. Coagulopathy: Due ot liver disease. Did not normalized with 5mg PO vit K. Medications on Admission: Occasional OTC pain relief meds Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day for 2 weeks. Disp:*28 Capsule(s)* Refills:*0* 2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 6 weeks: then begin taper. please speak to pharmacist or doctor about how to do this. Disp:*42 Patch 24 hr(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:*2* 4. Nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:*8 Tablet(s)* Refills:*0* 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 9. Maalox 200-200-20 mg/5 mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for heartburn for 2 weeks. Disp:*QS ML(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Blood Loss Anemia Esophageal Varices with Bleeding Alcohol and Hepatitis C Cirrhosis Alcoholism Thrombocytopenia Discharge Condition: Stable Hct. No signs of withdrawl. Discharge Instructions: You had bleeding form the blood vessels in your esophagus becuase of severe liver disease called cirrhosis. Please take the nadolol and the protonix as prescribed. You will also be on ciprofloxacin, an antibiotic , for 4 more days because you had banding of the blood vessels in your esophagus. Please follow up with Dr. [**First Name (STitle) 679**] on Monday [**2136-6-18**] at 1:15PM. Followup Instructions: Please follow up with Dr. [**First Name (STitle) 679**] on Monday [**2136-6-18**] at 1:15PM. Completed by:[**2136-6-8**]

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icd9cm

[ [ [] ] ]

[ "96.07", "99.04", "42.33", "94.62" ]

icd9pcs

[ [ [] ] ]

9693, 9699

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1943, 3634

1519, 1907

226, 239

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364, 1100

1122, 1162

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1,197

104,739

43904

Discharge summary

report

Admission Date: [**2197-9-4**] Discharge Date: [**2197-9-7**] Date of Birth: [**2124-12-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 72F with a PMH s/f ESRD on HD MWF, CVA's, seizure disorder with a declined mental status (A+Ox1), who is presenting to the MICU with hypotension after dialysis. Today during dialysis the patient became unresponsive 45 minutes into the session with a systolic blood pressure in the 60s. She was given 2.5L of fluids and BP responded immediately as did her mental status. She was sent to the ED for further work-up. . In the ED, the patients initial vitals were 97.7, 145/59, 66, 100% on 2L NC. A finger stick blood glucose was 133. She did not have any fevers, leukocytosis, or elevated lactate. A CXR showed a right pleural effusion. She has a history of traumatic cardiac tamonade during a dialysis line placement in [**7-/2197**], so a bedside echo was performed, which did not show any signs of tamponade. She continued to have episodes of hypotension with systolic BP's in the 70s, which would resolve spontaneously without fluids. Past Medical History: 1. ESRD on HD since [**2189**] 2. Diabetes mellitus II: [**8-13**] A1C of 5.2% 3. Hypertension 4. Hyperlipidemia: [**4-11**] LDL of 49 5. Peripheral [**Month/Year (2) 1106**] disease 6. Diastolic CHF, EF 70% 7. Chronic upper extremities DVTs 8. CVA x2 9. Seizure d/o s/p CVA [**99**]. h/o MRSA line sepsis/klebsiella bacteremia, coag neg staph bacteremia 11. h/o Osteomyletis (L3-L4 vertabrae) '[**92**] 12. h/o Pelvic fx 13. h/o psoas abscess PAST SURGICAL HISTORY: 1. s/p Right BKA Social History: Lives at [**Hospital3 **] Home in [**Location (un) 583**], MA. Daughter is next of [**Doctor First Name **]: [**First Name8 (NamePattern2) **] [**Known lastname **] [**Telephone/Fax (1) 94263**]. No tobacco, EtOH, drug use. Family History: Non-contributory Physical Exam: T=97.2... BP=132/54... HR=70... RR=15... O2=100% 2L . . PHYSICAL EXAM GENERAL: elderly african american female, lying on her right side, refusing to be examined, un-cooperative with history or physical. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. Small reactive pupils bilaterally. Neck supple. Cardiac: RRR, no murmurs, will not allow me to auscultate or take a blood pressure LUNGS: Refusing exam, only able to listen over left lung, no abnormalities ABDOMEN: NABS. Soft, NT, ND. EXTREMITIES: R BKA, Left aKA, stump c/d/i SKIN: ~5cm superficial sacral decubitus ulcer NEURO: Unable to tell me her name, place or year. Follows simple commands intermittently. Moving all four extremities. Not cooperative with neuro exam. Pertinent Results: ADMISSION LABS [**2197-9-4**] 02:25PM BLOOD WBC-5.2 RBC-3.65* Hgb-12.3 Hct-38.4 MCV-105* MCH-33.6* MCHC-31.9 RDW-19.0* Plt Ct-259 [**2197-9-4**] 02:25PM BLOOD Neuts-62 Bands-0 Lymphs-24 Monos-10 Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2197-9-4**] 12:50PM BLOOD PT-23.0* INR(PT)-2.2* [**2197-9-4**] 02:25PM BLOOD Glucose-110* UreaN-30* Creat-4.6* Na-137 K-5.0 Cl-102 HCO3-25 AnGap-15 [**2197-9-4**] 02:25PM BLOOD cTropnT-0.07* [**2197-9-4**] 02:25PM BLOOD Albumin-3.2* Calcium-7.9* Phos-3.6 Mg-2.3 [**2197-9-4**] 02:31PM BLOOD Glucose-102 Lactate-1.3 K-6.1* CHEST X-RAY ([**2197-9-6**]) AP BEDSIDE CHEST. The heart is upper limits of normal. There is central [**Month/Day/Year 1106**] congestion and interstitial edema. Small right and probably left effusions layering in semi-erect position with possible superimposed right pleural thickening. Sternal wire sutures. Left subclavian line with tip in mid SVC. Allowing for technical differences there is no change from similar exam two days ago ([**2197-9-4**]). IMPRESSION: No short interval change. CHF and/or fluid overload. Brief Hospital Course: Ms. [**Known lastname **] is a 72F with a PMH s/f ESRD on HD, CVA with seizure disorder and declining mental status who presented with hypotension. . #. Hypotension: Occured transiently after dialysis, and immediately responded to fluids. No fevers, leukocytosis, lactate, tamponade physiology on echo, or signs of bleeding. Likely a result of hypovolemia after dialysis combined with autonomic dysreflexia. All antihypertensives were held and midodrine was started with good response. Patient has remained normotensive and will be discharged with this regimen. She will need close follow up with primary renal team per D/C instructions . #. Right pleural effusion: Appears chronic based on past CXRs. Patient remained afebrile and without supplementa oxygen requirement. . #. Pericardial effusion: Although prior history of this, currently there is no tamponade physiology on bedside echocardiogram done in the ED. No further intervention is required. . #. Sacral decubitus ulcer: Chronic, noted at admission. Wound care consult was called. . #. Mental status: Based on prior neuro notes, this appears to be her baseline. Recent head CT with old strokes, and nothing acute on [**8-30**]. . #. ESRD: Patient tolerated HD on above regimen, defer further management to outpatient renal team. . #. DM: continue home insulin regimen . #. CVA: Continue coumadin per outpatient regimen. . #. HTN: Not active as above . #. Seizures: continue home regimen of keppra Medications on Admission: ISS Remeron 15mg daily Bisacodyl NGT transdermal ointment 1" q6H prn SBP>150 Dilaudid prn Aluberol prn Cinacalcet 30mg every other day Ranitidine 150mg daily [**Month/Year (2) **] 81mg daily Lactulose [**Hospital1 **] Coumadin: unclear dose, was not discharged on this Metoprolol tartrate 37.5mg TID Keppra 500mg daily, give after dialysis if possible Discharge Medications: 1. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): Hold for SBP >130. 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 9. Insulin Regular Human 100 unit/mL Solution Sig: As directed per insulin sliding scale units Injection ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital 94271**] nursing home [**Location (un) **] Discharge Diagnosis: Hypotension Discharge Condition: Stable Alert and oriented to self only Intermittently responds to questions BP 130-160/50-60 HR in the 60s Satting well on room air Discharge Instructions: You were admitted with low blood pressure, which we think is due to autonomic dysreflexia. We started a new medication called midrodine to help keep your blood pressure normal, and stopped your antihypertensives. . Please take all of your medications as directed . Please return to the emergency room if you experience any loss of consciouness or abnormally elevated blood pressures. Followup Instructions: Provider: [**Last Name (NamePattern5) 9155**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2197-11-15**] 2:00

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

6641, 6722

4014, 5061

326, 333

6778, 6912

2908, 3991

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2097, 2115

5877, 6618

6743, 6757

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2130, 2889

275, 288

361, 1330

5076, 5474

1352, 1797

1855, 2081

13,906

114,183

18403

Discharge summary

report

Admission Date: [**2101-10-9**] Discharge Date: [**2101-11-1**] Date of Birth: [**2020-8-24**] Sex: F Service: SURGERY Allergies: Allopurinol / Dyazide Attending:[**First Name3 (LF) 974**] Chief Complaint: Acute Lower GI Bleed Major Surgical or Invasive Procedure: Left hemicolectomy with coloproctostomy History of Present Illness: 81F with multiple recent admissions over the last several months for LGIB with refusual of surgical intervention. Two admissions in [**8-26**] notable for normal EGD and +blood in left colon with massive diverticulosis and an equivocal tagged cell scan. On [**2101-10-7**] she had melena/hematachezia and was evaluated at CHA with recommendation for colectomy. Evaluation by the surgical service deemed her too high a surgical risk. She was transfused 4 units PRBCs and 2 FFP on [**10-9**]. After continuing to have multiple bloody bowel movements she was transferred to [**Hospital1 18**] for possible embolization. Past Medical History: - LGIB w/ [**Month (only) **] HCT [**7-/2099**] - Diverticulosis - diagnosed after 1st GIB - HTN - on Lisinopril, Procardia, metoprolol - CVA - in the [**2054**] - Ulcer operation ? in the [**2054**]. Apparently surgery was done on a part of her stomach. - S/P TAH-BSO - gastritis - s/p trt for duodenitis, PUD and H Pylori [**2098**], tx w/ Prevpack - Subarachnoid hemorrhage - per OSH report Social History: Lives alone. 32 pack yr history smoking. Social EtOH use. Closest relatives are a son and a sister. Family History: Noncontributory Physical Exam: Admission Physical Exam - [**2101-10-9**] 98.5 104 176/49 16 98%RA NAD, AxOx3, conversant Decreased breath sounds bilateral bases, CTA o/w Tachy, regular; [**1-24**] HSM @ LLSB to axilla; 2/6 SEM @ RUSB soft/ND/NT; No tympany; multiple incisional scars Rectal deferred Ext: 2+ fem, 1+ [**Doctor Last Name **]; 1+ DP, non-palp PT pulses bilaterally mild pedal edema; warm and well-perfused Pertinent Results: Admission Labs [**2101-10-9**] 09:21PM BLOOD WBC-10.5 RBC-2.74*# Hgb-8.4*# Hct-23.8*# MCV-87 MCH-30.6 MCHC-35.2* RDW-15.4 Plt Ct-137*# [**2101-10-9**] 09:21PM BLOOD Neuts-91* Bands-0 Lymphs-6* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2101-10-9**] 09:21PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2101-10-9**] 09:21PM BLOOD PT-11.6 PTT-25.0 INR(PT)-1.0 [**2101-10-9**] 09:21PM BLOOD Fibrino-161 [**2101-10-9**] 09:21PM BLOOD Glucose-140* UreaN-49* Creat-2.2* Na-145 K-4.2 Cl-116* HCO3-18* AnGap-15 [**2101-10-9**] 09:21PM BLOOD Calcium-8.0* Phos-6.0*# Mg-1.8 [**2101-10-10**] 06:00AM BLOOD Type-ART pO2-73* pCO2-40 pH-7.30* calTCO2-20* Base XS--5 GI BLEEDING STUDY Reason: ACTIVE SIGMOID COLON BLEEDING. IDENTIFY AND LOCALIZE LGIB RADIOPHARMECEUTICAL DATA: 15.0 mCi Tc-[**Age over 90 **]m RBC ([**2101-10-9**]); HISTORY: 81 year old female with active sigmoid colon bleeding seen on bleeding study at outside hospital this morning. INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the abdomen for minutes were obtained. A left lateral view of the pelvis was also obtained. Blood flow images are normal. Dynamic blood pool images show increased tracer uptake in the left lower quadrant at approximately 15 minutes and increasing in this location throughout the duration of the examination (approx 60 minutes). IMPRESSION: Active GI bleed in the left lower quadrant at 15 minutes, consistent with a bleed in the sigmoid colon. These findings were discussed at the immediate identification of hemorrhage with the ordering physician [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **], and the Interventional Radiology resident, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] arranged for a mesenteric angiogram and possible embolization. Attempted Embolization PROCEDURE: This procedure was performed by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 4686**]. Dr. [**Last Name (STitle) 4686**], the attending radiologist, was present during the entire procedure supervising. The risks and benefits of the procedure were discussed with the patient and informed consent was obtained. The patient was brought to the angiography table and placed in supine position. A preprocedure timeout was performed and proper identification of the patient and the procedure was performed. The right groin was then prepped and draped in standard sterile fashion. The right common femoral artery was then accessed and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was introduced into the aorta. The needle was then exchanged for a 5 French sheath. Using a C2 Cobra catheter, we were able to cannulate the SMA. Selective angiogram of the SMA demonstrated a patent artery with no evidence of acute hemorrhage or hemodynamically significant stenosis. There was a 9-mm aneurysm in a proximal jejunal branch. We then attempted to cannulate the [**Female First Name (un) 899**] several times with using the C2 catheter as well as the Mickaelson and [**Doctor Last Name **] catheters without success. We then decided to perform an aortogram to determine the origin of the [**Female First Name (un) 899**]. An infrarenal PA and lateral aortogram demonstrated extensive atherosclerotic disease of the abdominal aorta and iliacs without hemodynamically significant stenosis. The aorta was of normal caliber. Specifically, the inferior mesenteric artery was identified and was opacified. No acute hemorrhage was identified on the aortogram. We then attempted several times to cannulate selectively the inferior mesenteric artery, without success. Multiple catheters were used. The catheter wire and sheath were then removed and pressure was held at the right groin for 20 minutes and hemostasis was achieved. The patient tolerated the procedure well and there were no complications. IV CONSCIOUS SEDATION: Moderate sedation was provided by administering divided doses of Versed and fentanyl throughout the total intraservice time of 120 minutes during which the patient's hemodynamic parameters were continuously monitored. IMPRESSION: 1. No acute hemorrhage was identified. Inability to selectively cannulate the inferior mesenteric artery. 2. Moderate atherosclerotic disease of the aorta and iliacs without hemodynamically significant stenosis. 3. 9-mm aneurysm in a jejunal branch of the SMA. Admission CXR IMPRESSION: AP chest compared to [**2101-9-1**]: Moderate cardiomegaly has progressed, vascular engorgement of the hila is stable, lungs are clear. Thoracic aorta is generally large and heavily calcified. Small regions of aneurysmal dilatation cannot be excluded, particularly in the region of the aortic arch. Mediastinal widening and tracheal narrowing at and above the thoracic inlet are most likely due to a large thyroid gland. Small right pleural effusion may be present. Operative Note PREOPERATIVE DIAGNOSES: Lower gastrointestinal hemorrhage. POSTOPERATIVE DIAGNOSES: Lower gastrointestinal hemorrhage. PROCEDURE: Left hemicolectomy with coloproctostomy. ASSISTANT: [**Doctor First Name **] [**Doctor Last Name **], RES [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD HISTORY: This 81-year-old female was transferred from [**Hospital 8**] hospital because of uncontrollable bleeding after 5 units of transfusion, at which point her hematocrit was only 22. She was sent here because of need for interventional radiology. The surgeon's there felt she was too hazardous for operation. She underwent efforts at interventional control of her bleeding and they were unable to enter the artery on the left side of the colon. She had 2 previous bleeding scans on 2 previous bleeding episodes over the last 2 years which revealed this to be confined to the left colon and specifically the sigmoid region. She had a confirmation of that same scan at [**Hospital1 8**]. Prior to the interventional people doing their attempt at embolization last night, she was required to have another bleeding scan which again localized this as the sigmoid. Therefore, faced with an 81- year-old lady with chronic renal insufficiency and multiple other comorbidities with the possibility of a subtotal colectomy for bleeding, we decided to do a left colectomy because of all the previous localizations. The patient also would not consent to a stoma but did agreed to having a coloproctostomy. Therefore, she had a formal left colectomy at the level of the left branch of the middle colic artery. We had excellent arcades into the distal colon. This came down easily into the pelvis and there was an anastomoses without any tension with an EEA. No other unusual abdominal findings were noted. She had a previous gastrectomy for ulcer disease and had a lot of adhesions of the duodenum and stomach to the underwall of the liver. These did not need to be taken down. The left colon, of course, was totally mobilized for removal but the transverse easily reached down into the pelvis for the anastomoses. PROCEDURE: Under adequate general anesthesia, the patient was prepped and draped in the usual fashion. Midline incision was opened and carried down through the subcutaneous tissue and the fascia. The abdomen was entered. There were multiple adhesions which were taken down. The above-noted findings were observed. Therefore, the sigmoid colon which was fairly densely adherent from previous diverticulitis was mobilized up off the left sidewall. This was mobilized along the line of Toldt. The splenic flexure was brought down and over to the level of the left branch of the middle colic as noted above. At this point with full mobilization, the mesentery was taken down sequentially at the major vascular arcades with 2-0 silk ligatures in continuity and then 2-0 silk suture ligature on the proximal component. At this point then, with the mesentery gently mobilized in the superior aspect, the transverse colon and distal transverse colon was divided with a TIA and was oversewn in its end to be resected. Additionally at this point, the patient had the remainder of the mesentery taken down. Both the right and left ureters were identified as we entered the pelvis and the inferior mesenteric artery was taken down as well as the superior hemorrhoidal. The lateral mesorectal arcades were taken down to the first level to allow good rectal stump as the bleeding appeared to be in the distal sigmoid At this point the specimen was passed off the field. The patient was having a lot of diffuse oozing. There was a question whether this might be because of dilutional factors, therefore, fibrinogens and platelets were sent and ultimately fibrinogens returned low and the patient was transfused with some fibrinogen. Additionally, we used an argon beam to control any surfaces that were having difficulty with oozing. There was no pumping, bleeding but just a fair amount of oozing. This was all controlled with the argon beam. Having the field in the pelvis particularly dry, attention was then turned to the EEA anastomoses. The distal rectum had been transected after firing a reticulating TA-55. At this point then, the EEA was brought up through the post that had been placed in the distal transverse colon after a pursestring had been placed and this was then oriented with the mesentery in the appropriate location and the EEA was brought together and fired for a good anastomoses. The donuts were totally intact. The anastomoses were without any tension and there was excellent appearance of both the rectum and the distal transverse colon with no evidence of any vascular compromise. At this point then, it appeared that there did not require any particular control of the mesentery as it draped so nicely over the sacral promontory. It was tacked ever so slightly with some silks but the packs in the upper abdomen were removed and it was noted at this point that there was some oozing at the area of the liver where we had taken down some adhesions from the omentum to get the colon to come down into the pelvis. This was controlled with the argon beam. The left gutter was controlled completely with the argon beam. The spleen was carefully inspected. There was no evidence of any bleeding from the spleen or any of the splenic pedicles and as the packs were removed, it appeared that everything was fine. Sponge, needle and instrument count then being correct, the peritoneum and fascia were closed with a double looped #1 running PDS. Skin was closed with skin staples. Prior to this, however, we had flooded the pelvis with saline and, with a rigid sigmoidoscope, had visualized and then insufflated the anastomoses. There was no evidence of any leak. With the abdomen closed, sterile dressing was applied. Sponge, needle and instrument count were correct x2. The patient reversed from anesthesia and returned to the ICU for further resuscitation of her ongoing bleeding and for assessment of her coagulopathy. Family was advised of her guarded condition. Brief Hospital Course: [**Known firstname **] [**Known lastname **] was admitted to the ICU at [**Hospital1 18**] on [**2101-10-9**] under the care of trauma surgery. A bleeding scan was completed which showed an active GI bleed in the left lower quadrant at 15 minutes,consistent with a bleed in the sigmoid colon. Embolization was attempted on HD 2 without success. Because she was still requiring transfusion to maintain her hematocrit the patient agreed to undergo surgery. On HD 2 she was taken tot he operating room where she underwent a left hemicolectomy with transverse [**Last Name (un) **]-proctostomy. She tolerated the procedure well and was returned to the SICU. At POD 1 she required fluid resuscitation for low urine output. Hematocrit was stable. A chest xray was performed to access for edema or infiltrates which showed a small right pleural effusion and borderline interstitial edema. Levoquin was started. Albumin was provided in attempt to reduce edema. At POD 2 her urine output was improved. Her blood pressure was elevated and lopressor was started. Her NGT was discontinued. Levoquin was stopped and Lasix was started for generalized edema. Physical therapy was started. Creatinine was 1.4. At POD 3 her blood pressure remained elevated and her home blood pressure medications were provided. WBC count was elevated from 13.9 to 17.4. Urine and blood cultures were sent. There was question of lung infiltrate. Vancomycin/Levoquin were started. At POD 4 a bedside swallow evaluation was completed due to concerns of aspiration and was WNL. Her diet was advanced. Tube feeds were attempted via post-op NGT with high residuals and were stopped. Reglan was started. Blood pressure continued to be elevated and Nifedipine was increased. WBC count had trended down to 12.3. At POD 5 the NG tube was removed and a Dobhoff was placed which was coiled in the stomach. She was edematous and received Lasix IV diuresis dependent upon creatinine. A RUE ultrasound for edema was performed which was negative for clot. Blood pressure continued to be elevated and lisinopril/lopressor were increased. Geriatrics was consulted to follow patient course. At POD 6 the Dobhoff was discontinued. She was not eating well and had emesis. She was made NPO and an NGT was placed for medications/potential feeding until a Dobhoff could be placed in IR. Her blood pressure was elevated at 190/100. Nitropaste was provided. EKG was negative for acute event. Blood glucose was elevated and was being monitored and control with sliding scale insulin. [**Last Name (un) **] was consulted. NGT continued with elevated residuals with attempted low volume feedings and were stopped. At POD 8 there was return of bowel function. Blood pressure was under better control. Nausea was improved. The NGT was removed and she was started on clears with supplements. Vancomycin was discontinued. Levoquin remained. At POD 9 TPN was started for nutritional support. 1unit PRBCs were given for low hematocrit. Lopressor was adjusted for continued hypertension. She was advanced to a regular diet and calorie counts were started. Her abdomen was distended and a KUB was performed showing unchanged moderate distention of the remnant ascending and transverse colon. At POD 10 WBC count was elevated at 19.0. The central line was discontinued and sent for culture. Urine and blood cultures were sent. At POD 12 CT scan showed partial small bowel obstruction and distended stomach. The NGT was replaced. Central line was placed and TPN was continued. Blood pressure continued to be elevated despite increases in blood pressure medications. EKG and cardiac enzymes were completed and were negative. At POD 15 the surgical wound was opened and drained 20ml purulent fluid. Culture was sent. Wound was dressed with wet-to-dry twice daily. At POD 16 urine culture and wound cultures showed resistant e. coli. Zosyn was started per sensitivities. Levoquin was discontinued. Diuresis continued with Lasix. Creatinine was 1.2. Central line tip culture was negative. At POD 17 she was afebrile. WBC count was 10.6. TPN continued. One unit PRBCs were given for low hematocrit. RUE ultrasound was repeated for continued swelling with no evidence of clot. Support stocking at arms were provided. At POD 21 1 unit PRBCs were given for low hematocrit at 25.4. At POD 22 she was doing better. She was tolerating a regular diet and was taking in adequate calories with supplements. Her wound was healing nicely. Wet-to-dry wound dressings were continued twice daily. She was discharged to [**Hospital1 **] Acute Rehabiliation. Her primary care physician was [**Name (NI) 653**] and her hospital course was breifly discussed. It was decided that we should start Glyburide for elevated blood glucose and discontinue the Lantus. SSI was continued. Blood pressure medications significantly changed from home medications to accomodate for continued elevated blood pressure and heart rate. These issues were discussed with Dr. [**Last Name (STitle) 9834**] and a copy of the discharge summary was sent to her office. At discharge the central line was discontinued. Upon discharge, she was afebrile and in good condition. Blood pressure continued to be elevated and was being treated with a new increased dose of Toprol. Her vital signs were to be monitored every 4-6 hours in order to evaluate response to blood pressure medications. Medications on Admission: Lopressor 100 [**Hospital1 **] Procardia XL 60 QD Lasix 40 [**Hospital1 **] Lipitor 40 QD Protonix 40 [**Hospital1 **] Hydralazine 50 QID KDur 20 [**Hospital1 **] Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 7. Humulin R 100 unit/mL Solution Sig: Per Sliding Scale Injection Per Sliding Scale: Insulin SC Sliding Scale QACHS (Before Meals and at Bedtime) Regular Glucose Insulin Dose 0-65 mg/dL [**11-22**] amp D50 66-120 mg/dL 0 Units 121-160 mg/dL 2 Units 161-200 mg/dL 4 Units 201-240 mg/dL 6 Units 241-280 mg/dL 8 Units 281-320 mg/dL 10 Units > 320 mg/dL Notify M.D. . 8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Nifedipine 20 mg Capsule Sig: Three (3) Capsule PO every eight (8) hours. 10. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Lower gastrointestinal hemorrhage Postoperative Ileus Postoperative Wound Infection Postoperative Anemia Diabetes Type II Uncontrolled Discharge Condition: Good Discharge Instructions: Please contact or return: * Fever (> 101 F) or chills * Abdominal pain * Inability to pass gas or stool * Nausea or vomiting * Increased redness or drainage from wound * Inability to urinate or dark urine * Chest Pain * Shortness of Breath * Elevated Blood Pressure * Any other concerns Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) **] in clinic on [**2100-11-22**] at 10:30am. The clinic is located in the [**Location (un) 470**] of the [**Hospital Unit Name 3269**]. The number is [**Telephone/Fax (1) 2359**] for any questions or concerns. Completed by:[**2101-11-1**]

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icd9cm

[ [ [] ] ]

[ "99.15", "88.42", "99.07", "99.04", "45.75" ]

icd9pcs

[ [ [] ] ]

19932, 20011

13137, 18546

301, 342

20190, 20197

1990, 13114

20532, 20829

1543, 1560

18759, 19909

20032, 20169

18572, 18736

20221, 20509

1575, 1971

241, 263

370, 991

1013, 1409

1425, 1527

50,028

128,313

35093+57976

Discharge summary

report+addendum

Admission Date: [**2109-8-16**] Discharge Date: [**2109-8-24**] Date of Birth: [**2030-12-18**] Sex: M Service: MEDICINE Allergies: Atenolol / Penicillins Attending:[**First Name3 (LF) 4071**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: This is a 78 year-old male with PMH significant for AS, pafib, and COPD who presented to OSH with wheezing, cough and changes in mental status. He was transfered from [**Hospital6 28728**] Center for evaluation and management of his tracheomalacia on [**8-16**]. The patient had an episode of hypercarbic respiratory failure on his initial day of admission to the OSH requiring BiPAP. He was treated with antibiotics and steroids. His troponin rose to 0.8 x2 as well at that time. He also had an elevated ddimer at that time, 1.06 (range of 0-0.49). When SBPs high, would require bipap, when normotensive was tolerating 1L NC. Ruled out for PE and pneumonia. Was treated for COPD exaccerbation at [**Location (un) 1121**]. . Upon arrival to [**Hospital1 18**], patient was seen by IP to evaluate his tracehobronchomalacia. It was believed his respiratory failure was multifactorial from TBM, AS, COPD, CHF, poor lung reserve. While on the floor, he had flash pulmonary edema in setting of SBPs in 200s and was transferred to the SICU. He required bipap and was able to be weaned off when his blood pressures normalized. . Past Medical History: - CAD, LAD-DES in [**2104**], subsequent cath in [**2105**] showing patent stent - PVD with claudication - Chronic diastolic heart failure, last EF >55% - Type II DM - COPD - CKD - Pafib, not anticoagulated prior Social History: married, lives with wife. [**Name (NI) **] etoh, tobacco or drug use Family History: noncontributroy Physical Exam: VS - T 96.6, BP 117/62, P P81, R 22, 99% on 1L Gen - in bed, sitting up [**Location (un) 1131**] a book, NAD HEENT - ATNC, EOMI, supple neck, no JVD noted, no bruits, no lymphadenopahty CV - 2/6 systolic murmur, regular rate, no rubs or gallops Lungs - coarse rhonchi throughout with diffuse expiratory wheezes Abd - soft, NT, ND, no hsm or masses, normoactive BS Ext - warm, no edema Neuro - CN intact, no focal deficits, moving all 4 limbs Pertinent Results: CT Trachea: Multiple respiratory movements limit the evaluation of the lung parenchyma. Mild centrilobular emphysema is mostly in upper lobes. 2-mm right upper lobe lung nodules are present (4:106 and 5:109). Right upper lobe subpleural ill- defined opacity is present. Expiration images are very suboptimal. Collapse of bronchus intermedius down to 2 mm (9:132) suggests bronchomalacia. There is no significant collapse of the trachea, accounting for a suboptimal study. Bilateral bronchial wall thickening is more prominent in both lower lobes. Biapical scarring is present. Left fissural thickening is present and associated with lingular and bibasilar atelectasis. Bilateral pleural effusion are small. Right pulmonary artery enlargement up to 29 mm suggests pulmonary hypertension. Severe calcifications of the aortic valve are present. Calcifications of the mitral annulus, coronary arteries, and aorta are also present. A stent is in the LAD. Multiple calcified mediastinal and bilateral hilar lymph nodes are present but not enlarged using CT criteria. Incidentally, lipomatous hypertrophy of the interatrial septum is present. Bones are normal except to note old left seventh and eighth rib fracture. Although this study was not tailored for subdiaphragmatic evaluation, the upper abdomen is unremarkable. IMPRESSION: 1. Suboptimal study with multiple respiratory movements. 2. Mild centrilobular emphysema. 3. Collapse of the bronchus intermedius suggests bronchomalacia. No air trapping in expiration. 4. Sub-3-mm lung nodules do not warrant further followup if there is no risk factor for neoplasia. If the patient is a smoker, followup in one year is recommended. 5. Diffuse bronchial wall thickening, more prominent in lower lobes suggests peribronchial inflammation. 6. Small bilateral pleural effusion. Left fissural thickening with lingular and dependent atelectasis. 7. Severe calcifications of the aortic valve are of unknown hemodynamic significance. 8. Multiple calcified mediastinal and bihilar lymph nodes suggest prior granulomatous disease. 9. Coronary artery calcifications and stent, aortic calcifications, and mitral annulus calcifications. 10. Lipomatous hypertrophy of the interatrial septum. . . Cardiac Catheterization: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed non-obstructive and branch vessel disease. The LMCA had no angiographically apparent disease. The LAD revealed a patent stent in the proximal vessel and a 90% stenosis in the D1 branch, which was small to moderate in size. The LCx had a 60% lesion in the mid-vessel. The RCA had a 30% stenosis in the mid-vessel. 2. Resting hemodynamics revealed mildly elevated right and left heart pressures with a mean RA of 9mmHg and mean PCWP of 13mmHg. The cardiac index was preserved at 3.2 l/min/m2. There was mild systemic arterial hypertension with a central aortic systolic pressure of 144mmHg. 3. There was moderate aortic stenosis with a peak gradient of 36mmHg and a calculated valve area of 0.94cm2. 4. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Coronary arteries revealed non-obstructive disease. 2. Moderate aortic stenosis with a calculated [**Location (un) 109**] of 0.94cm2. 3. Mildly elevated right and left heart filling pressures. . . Echo: The left atrium is normal in size. The estimated right atrial pressure is 0-10mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>70%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area 0.8cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. IMPRESSION: Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. . . Labs: [**2109-8-16**] 07:30PM BLOOD WBC-15.3* RBC-3.45* Hgb-10.4* Hct-31.5* MCV-91 MCH-30.0 MCHC-32.9 RDW-14.8 Plt Ct-281 [**2109-8-17**] 11:28PM BLOOD WBC-37.3*# RBC-4.30* Hgb-13.1*# Hct-39.8*# MCV-93 MCH-30.6 MCHC-33.0 RDW-14.9 Plt Ct-533*# [**2109-8-20**] 07:00AM BLOOD WBC-15.8* RBC-3.50* Hgb-10.5* Hct-32.2* MCV-92 MCH-30.0 MCHC-32.6 RDW-14.4 Plt Ct-197 [**2109-8-22**] 06:35AM BLOOD WBC-21.4* RBC-3.78* Hgb-11.6* Hct-34.0* MCV-90 MCH-30.8 MCHC-34.2 RDW-14.7 Plt Ct-194 [**2109-8-23**] 09:50AM BLOOD WBC-26.6* RBC-4.25* Hgb-13.0* Hct-39.1* MCV-92 MCH-30.7 MCHC-33.4 RDW-14.6 Plt Ct-222 . [**2109-8-16**] 07:30PM BLOOD Glucose-216* UreaN-62* Creat-1.7* Na-140 K-4.9 Cl-105 HCO3-27 AnGap-13 [**2109-8-17**] 11:28PM BLOOD Glucose-146* UreaN-57* Creat-1.5* Na-141 K-6.5* Cl-103 HCO3-29 AnGap-16 [**2109-8-19**] 02:16AM BLOOD Glucose-193* UreaN-57* Creat-1.5* Na-138 K-5.1 Cl-98 HCO3-31 AnGap-14 [**2109-8-23**] 09:50AM BLOOD Glucose-95 UreaN-46* Creat-1.4* Na-138 K-4.9 Cl-99 HCO3-30 AnGap-14 . [**2109-8-17**] 06:25AM BLOOD CK-MB-NotDone cTropnT-0.13* [**2109-8-17**] 11:28PM BLOOD CK-MB-NotDone cTropnT-0.16* [**2109-8-18**] 08:16AM BLOOD CK-MB-NotDone cTropnT-0.13* . [**2109-8-17**] 11:13PM BLOOD Type-ART Rates-/44 FiO2-100 pO2-349* pCO2-116* pH-7.09* calTCO2-37* Base XS-1 AADO2-277 REQ O2-51 Intubat-NOT INTUBA [**2109-8-18**] 12:36AM BLOOD Type-ART pO2-81* pCO2-66* pH-7.29* calTCO2-33* Base XS-2 [**2109-8-18**] 01:33AM BLOOD Type-ART pO2-97 pCO2-62* pH-7.31* calTCO2-33* Base XS-2 [**2109-8-22**] 11:22AM BLOOD Type-ART pO2-106* pCO2-47* pH-7.43 calTCO2-32* Base XS-5 . . [**8-23**] CXR: Heart size is normal. Calcified lymph nodes are present in the mediastinal and hilar regions. Lungs are grossly clear except for focal linear scar in the periphery of the left mid lung. Pleural effusions have resolved. Focal opacity overlying lower spine on lateral view appears to correspond to a large lateral osteophyte on recent CT of [**2109-8-19**]. IMPRESSION: No evidence of pneumonia. Brief Hospital Course: 78 y/o M with hx of CAD, COPD, CHF, AS, bronchotracheomalacia who was transferred from outside hospital for workup of BTM, but then had acute pulmonary edema before bronch was able to be done. Acute diastolic heart failure results in acute pulmonary edema in setting of hypertension. Transferred to SICU where he was treated with IV lasix, IV hydralazine and bipap. He did not require intubation, but was in severe respiratory distress. He was then transferred to [**Hospital1 1516**] (the cardiology service) for workup of flash pulmonary edema. Had cath [**8-22**] showing non obstructive CAD and mod-severe AS. It was thought that medical management of hypertension would be required to prevent future acute decompensation. Patient has had well controlled BPs since transfer, increased losartan on with goal of SBPs in 110s. Will continue with his current regimen as an outpatient. The only less than ideal medicine is the use of a calcium channel blocker instead of a beta blocker. This was used because he has known bronchospasm when given atenolol in the past. Otherwise he is medically optimized from a cardiac standpoint. . For COPD exaccerbation that likely contributed to respiratory distress, he was started on high dose steroids that are to be tapered over the next two weeks after discharge. He was also started on doxycycline and will complete a 10 day course. He does have a history of MRSA in his sputum from prior hospitalizations at an OSH, but MRSA screen was negative x2 here. Will also complete a steroid taper, and continue his home inhalers of advair and spiriva, as well as albuterol nebs as needed. . Patient did have increasing leukocytosis, probably due to steroids, but might have an infection. He had yeast in groin, and yeast is growing in urine. CXR was negative and has pending blood cultures to r/o yeast in the blood. He remained afebrile. . Patient has a hx of afib and should be anticoagulated. He was on a heparin drip throughout his stay, and coumadin was restarted prior to d/c. . He has been medically stabilized and the bronch could be completed with the interventional pulmonologists as an outpatient in 2 weeks. He can be anticoagulated for the procedure. Based on the CT scan findings, his tracheobronchomalacia is likely mild and will not require stenting, but a bronchoscopy is warranted. . He was discharged to rehab for pulmonary therapy and physical therapy. He walks with a walker at baseline. Medications on Admission: HOME MEDICATIONS: Advair diskus 500/50 [**Hospital1 **] Amiodarone 200 mg daily Cozaar 50 mg daily Diltiazem CD 180 mg dailiy Ferrous Sulfate 325 mg daily Flomax 0.4 mg daily Ompeprazole 20 mg daily K+ 20 meq daily Plavix 75 mg daily Prednisone 5 mg daily Spiriva 18 mcg daily Spironolactone 25 mg daily Zoloft 100 mg daily . MEDS ON TRANSFER: Senna/Bisacodyl ASA 81 mg daily Simvastatin 40 mg daily Heparin gtt Insulin SC Protonix 40 mg daily Cipro 500 mg q12 hr Tiotroprium 1 cap daily Methylprednisolone 60 mg IV q12 hr Doxy 100 mg q12 hr Spironolactone 25 mg daily Diltiazem XR 180 mg daily Losartan 50 mg daily Advair 500/50 1 puff [**Hospital1 **] Amiodarone 200 mg daily Ipratropium 1 neb q6 hr Albuterol 1 neb q2 hr PRN Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (): Take one puff twice daily. 6. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 15. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Prednisone 10 mg Tablet Sig: Steroid Taper; will start with 5 tabs daily for two days; 4 tabs daily for 3 days; 3 tabs daily for 3 days; 2 tabs daily for 2 days; 1 tab daily for two days; half tab daily for 2 days, then stop. Tablet PO once a day for 14 days. 18. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 2 days: Please take two more days of doxycycline and then stop. 19. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Please take one more day of cipro to complete course. 20. Lantus 100 unit/mL Solution Sig: Six (6) units Subcutaneous at bedtime. 21. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) unit Subcutaneous as directed by sliding scale below; give 4 times daily: Please give 1 unit for FS btw 150-200, 3 units for 201-250, 5 units for 251-300, 7 units for 301-350. . Discharge Disposition: Extended Care Facility: Life Care Center of the [**Location (un) 1121**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: 1. Aortic Stenosis 2. Flash pulmonary edema 3. HTN 4. Tracheobronchomalacia . Secondary diagnosis: 1. Diabetes 2. COPD exaccerbation 3. CHF Discharge Condition: vital signs stable, afebrile, yeast infection in his groin, ambulating with the help of a walker, normal mentation Discharge Instructions: You were admitted to the hospital for difficulty breathing. It was thought that it was due to tracheobronchomalacia, which is a narrowing of your airways. You were transferred to [**Hospital1 18**] to have a bronchoscopy, but while you were waiting for the procedure, you had an episode of flash pulmonary edema. This was likely multifactorial in nature. You heart failure, severe aortic stenosis, and COPD all contributed to your difficulty breathing. You were placed on bipap and diuresed with lasix. You did much better. When your blood pressure is controlled, you are able to continue to breath well without problems. . Due to this edema, though, a bronchoscopy was not done. You were transferred to the cardiology service where you had a catheterization to evaluate you aortic valve and your coronary arteries. There were no major finds to suggest a specific cause for your flash pulmonary edema, and surgery would not be a good idea at this time. So, by controlling your blood pressure very tightly, we are able to help you breath well. . The pulmonologists will see you in two weeks to do a flexible bronchoscopy and evaluate your airways. Until then, continue on your medicines and spent time working on your strength at rehab. . Please return to the hospital with any chest pain, shortness of breath, abdominal pain, nausea, vomitting, fevers, chills or any other worries. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Followup Instructions: Follow up with your primary care doctor once you have been discharged from rehab. His name is [**Name (NI) 13277**] [**Name (NI) **] at [**Telephone/Fax (1) 2634**]. . You are to follow up in about 2 weeks with the interventional pulmonologists to have a bronchoscopy. They will call you to let you know the day and time. It has not been scheduled yet, but they want to pick the time. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**] Completed by:[**2109-8-24**] Name: [**Known lastname 12890**],[**Known firstname 4794**] Unit No: [**Numeric Identifier 12891**] Admission Date: [**2109-8-16**] Discharge Date: [**2109-8-24**] Date of Birth: [**2030-12-18**] Sex: M Service: MEDICINE Allergies: Atenolol / Penicillins Attending:[**First Name3 (LF) 2604**] Addendum: Please see list below for actual discharge medications. Amlodipine 5 mg daily was added to his anti-hypertensive regimen just prior to discharge. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (): Take one puff twice daily. 6. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 15. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Prednisone 10 mg Tablet Sig: Steroid Taper; will start with 5 tabs daily for two days; 4 tabs daily for 3 days; 3 tabs daily for 3 days; 2 tabs daily for 2 days; 1 tab daily for two days; half tab daily for 2 days, then stop. Tablet PO once a day for 14 days. 18. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 2 days: Please take two more days of doxycycline and then stop. 19. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Please take one more day of cipro to complete course. 20. Lantus 100 unit/mL Solution Sig: Six (6) units Subcutaneous at bedtime. 21. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) unit Subcutaneous as directed by sliding scale below; give 4 times daily: Please give 1 unit for FS btw 150-200, 3 units for 201-250, 5 units for 251-300, 7 units for 301-350. . 22. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Life Care Center of the [**Location (un) 95**] - [**Location (un) 102**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2605**] Completed by:[**2109-8-24**]

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Discharge summary

report+addendum

Admission Date: [**2164-3-16**] Discharge Date: [**2164-3-18**] Date of Birth: Sex: Service: MEDICAL INTENSIVE CARE UNIT [**Location (un) **] SERVICE REASON FOR ADMISSION: Fevers and chills with decreased urine output. HISTORY OF PRESENT ILLNESS: This is an 88 year old, nursing home resident, with a history of recurrent Clostridium difficile colitis, urinary retention with an indwelling Foley, history of hypotension, who presents with two days of fevers, rigors, hypotension and decreased urine output, over one to two days prior to admission. The patient was noted to have decreased urinary output and hematuria at the nursing home. The Foley catheter was changed at the nursing home but did not result in increased urine output. The patient was also noted to have a cough productive of a large amount of brown sputum. He also reported one day of fevers, chills and some mild nausea with one episode of vomiting two days prior to admission. Of note, he also noted profound dysuria, despite changing the Foley catheter. The patient was transferred to [**Hospital1 69**] where vital signs demonstrated a temperature of 103.2; heart rate in the 160's; blood pressure of 70/40. The sepsis protocol was initiated. He initially received Vancomycin, Ceftazidime and Flagyl. He was given a total of 7 liters of normal saline. A right internal jugular sepsis catheter was placed and the patient was transferred to the Medical Intensive Care Unit for sepsis protocol monitoring. Of note, he denied abdominal pain, light headedness, diarrhea, bright red blood per rectum, chest pressure, shortness of breath, cough, peripheral edema or palpitations. PAST MEDICAL HISTORY: 1. The patient received most of his medical care at [**University/College 18328**]Medical Center and, in [**2163-10-12**], was hospitalized in their Intensive Care Unit with an episode of sepsis, secondary to a gangrenous cholecystitis with accompanying pancreatitis. At that time, he underwent an open cholecystectomy with a liver biopsy and was transferred to the Surgical Intensive Care Unit for monitoring. He also had a biliary stent placed for residual drainage of infected fluid collection. This was performed via endoscopic retrograde cholangiopancreatography. 2. He also has had multiple episodes of Clostridium difficile colitis. 3. [**Last Name (un) 3671**]-[**Doctor Last Name **] macroglobulinemia. 4. History of benign prostatic hypertrophy with chronic indwelling Foley catheter, which is changed once per month, at the discretion of his outpatient urologist at [**Hospital1 2177**]. 5. Glucose intolerance. 6. Tachyarrhythmia, not otherwise specified, with known history of paroxysmal atrial fibrillation, not on Coumadin. 7. Hypotension, with a systolic blood pressure at baseline in the 90's. 8. Major depressive disorder. 9. History of splenectomy, status post trauma in [**2155**]. 10. History of upper gastrointestinal bleed, not otherwise specified. MEDICATIONS ON ADMISSION: 1. ProMod 2 q. day. 2. Celexa 30 mg q. day. 3. ASA 81 q. day. 4. Vitamin B-12 1 mg q. day. 5. Multi-vitamin one q. day. 6. Flomax 0.4 q. day. 7. Megace 400 mg q. day. 8. KCl 40 mg q. day. 9. Protonix 40 mg q. day. 10. Advair one puff twice a day. 11. Cholestyramine 2 grams twice a day. 12. Os-Cal one twice a day. 13. Neutra-Phos one three times a day. 14. Remeron 7.5 q h.s. 15. Tylenol prn. 16. Proscar 5 mg q. day. SOCIAL HISTORY: 35 pack year tobacco history. Quit five years ago. History of alcohol abuse. Has been sober for the past five years. No history of drug use. He lives at the [**Hospital3 2558**]. PHYSICAL EXAMINATION: Temperature 101.7; heart rate 133; blood pressure 95/55; respiratory rate 20; breathing 95% on 100% non rebreather face mask. General: Frail appearing, labored breathing. Positive use of accessory muscles. HEAD, EYES, EARS, NOSE AND THROAT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Dry mucous membranes. No lymphadenopathy. Neck supple. Chest: Minimal crackles at the bases bilaterally. Cardiovascular: Tachycardia, regular rhythm, no murmurs. Abdomen: Positive bowel sounds, firm in the suprapubic region but nontender. No organomegaly. Guaiac positive brown stool. Extremities: No edema. Dermatology: No rashes. The patient was sitting in a large pile of stool. LABORATORY DATA: White blood cell count of 17.7 with 76% neutrophils, 22% bands and 2% lymphocytes. Hematocrit of 37. Platelets 48. Chemistry 7: 138, 4.7, 108, 13, 62, 2.7, 156. Lactate of 5.7. ALT 8. AST 14. Amylase 58. Alkaline phosphatase 205. Total bilirubin 0.3. Albumin 2.9. CK 40. INR of 1.1. Troponin of 0.04. Initial arterial blood gas: 7.33, PC02 of 22, P02 of 89. Electrocardiogram showed sinus tachycardia at 147 with a normal axis; no ST or T wave changes; normal intervals. No prior available for comparison. Urinalysis showed large blood; greater than 50 red cells; greater than 50 white cells; many bacteria; less than 1 epithelial cell; negative nitrite; moderate leukoesterase. Chest x-ray significant for a left lower lobe infiltrate. HOSPITAL COURSE: 1. Sepsis. The patient was initiated on the sepsis protocol and was placed on Vancomycin, Ceftazidime and Flagyl for empiric coverage of most likely urosepsis with the Ceftazidime, especially given the patient's asplenic status and susceptibility to encapsulated organisms. He was also placed on Flagyl for a question of Clostridium difficile colitis given his history. Xigris was considered; however, it was not instituted, given the patient's history of gastrointestinal bleed. He was started on Levophed for blood pressure support. He was bolused with normal saline as needed. A cortisol stimulation test was performed and showed no evidence of hypoadrenal state. The patient was eventually weaned off of Levophed on [**2164-3-17**]. 2. Respiratory failure. The patient had an underlying metabolic gap acidosis, secondary to lactic acid production. He had an appropriate compensatory respiratory alkalosis; however, he was unable to breathe down his C02 and required intubation on [**2164-3-17**], secondary to labored breathing and acute hypoxemia. This was thought to be most likely secondary to volume overload, status post aggressive fluid resuscitation. The patient was quickly weaned off of the ventilator on [**2164-3-17**]. The patient was transferred to the medical team on [**2164-3-18**] and was oxygenating well on nasal cannula. 3. Genitourinary: On [**2164-3-16**], the patient was noted to have a markedly distended bladder. A bladder ultrasound was performed at the bedside, which demonstrated approximately one liter of fluid in the urinary bladder. The urology consult was obtained and after replacing the patient's Foley catheter, 900 cc of dark red urine was drained from the urinary bladder. He was maintained on Proscar and Flomax per his outpatient regimen. It was recommended that he follow-up with his urologist for urodynamic study and possible transurethral resection of prostate. 4. Gastrointestinal bleed: Given his guaiac positive stool, he was continued on Protonix. Stools were guaiac negative subsequent to the initial stool on admission. 5. Diarrhea: The patient was tested negative for Clostridium difficile colitis times three. 6. Glucose control: He was maintained euglycemic on insulin sliding scale. 7. Acute renal failure: The patient initially had a creatinine greater than 2. This was felt to be secondary to post obstructive nephropathy and his creatinine decreased to 1.5 status post drainage of the urinary bladder. The patient was transferred to the medical floor team on [**2164-3-18**]. Given the fact that he was extubated off of pressors, maintaining adequate oxygenation on nasal cannula and maintaining adequate blood pressure without the need for frequent bolusing. A discharge addendum will be dictated separately. 8. Infectious disease: Of note, the patient grew out Klebsiella, pansensitive from his urine on [**2164-3-16**]. He grew out 4 out of 4 bottles of gram negative rods, with Klebsiella and Enterococcus on [**3-15**] from his blood cultures. He was negative for Clostridium difficile times three. Please note that his antibiotic coverage was changed to Levofloxacin and p.o. Vancomycin for targeted treatment for gram negative rods as well as Clostridium difficile prophylaxis. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AIY Dictated By:[**Last Name (NamePattern1) 1811**] MEDQUIST36 D: [**2164-3-18**] 11:28 T: [**2164-3-19**] 04:39 JOB#: [**Job Number 102631**] Name: [**Known lastname 16572**], [**Known firstname **] Unit No: [**Numeric Identifier 16573**] Admission Date: [**2164-3-16**] Discharge Date: [**2164-3-23**] Date of Birth: [**2075-5-13**] Sex: M Service: [**Location (un) 571**] ADDENDUM: From [**2164-3-19**], through the day of discharge which was [**2164-3-23**]. HOSPITAL COURSE: 1. Sepsis/Klebsiella bacteremia - Prior to being transferred out of the Intensive Care Unit, the patient's antibiotics were pared down to more specifically cover gram negative bacteremia. He was maintained on Levaquin. He remained afebrile and had gradually decreasing white blood cell counts until it was within the normal range prior to discharge. Repeat blood cultures were negative. His Levaquin dose was adjusted for renal function and eventually increased from 250 mg once daily to 500 mg once daily once his renal function improved. On the day of discharge, the patient is day seven of a planned fourteen day course for Levaquin. 2. Respiratory failure - The patient did well after being extubated. His oxygen requirement varied from room air to three liters by nasal cannula, however, his baseline oxygen requirement was two to four liters per nasal cannula so he was felt to be at his baseline. There was no evidence of ongoing infectious pulmonary process. 3. Genitourinary - The patient was maintained on Proscar for the continued treatment of his benign prostatic hypertrophy. There were no further complications and the patient will follow-up with his urologist as an outpatient for further treatment of the benign prostatic hypertrophy including possible transurethral resection of prostate. 4. Gastrointestinal bleed - There was concern for gastrointestinal bleeding in the Intensive Care Unit because the patient had guaiac positive stool on admission. However, subsequently his stools remained guaiac negative for the rest of the hospital admission. His hematocrit was also stable and there were no further signs of gastrointestinal bleeding. The patient should receive a colonoscopy as an outpatient. 5. Diarrhea - The patient was begun on empiric therapy for Clostridium difficile colitis with p.o. Vancomycin because he was having diarrhea and had an elevated white blood cell count above 30.0. However, Clostridium difficile toxin was negative times three effectively rule out active Clostridium difficile colitis. In addition, the patient's white blood cell count gradually decreased. Though he continued to have some loose stool, there was no concern for Clostridium difficile colitis and his p.o. Vancomycin was discontinued. 6. Glucose control - The patient was maintained on sliding scale insulin for glucose control and had effective control on this regimen. 7. Acute renal failure - The patient presented with acute renal failure which was thought to be secondary to postobstructive nephropathy. After replacement of his Foley and adequate drainage of urinary bladder, the patient's creatinine gradually decreased over the rest of the hospital admission. It was within normal limits by discharge. 8. Neurology - After leaving the Intensive Care Unit, the patient was noticed to have a left sided tongue deviation along with what was thought to be apparently new swallowing impairment which was thought to be neurological in etiology by the swallowing evaluation service. Neurology was consulted for the evaluation of possible stroke. A MRI/MRA was obtained which showed several areas of infarct, some old and some possibly new. Neurology had recommended beginning the patient on Coumadin and/or Aggrenox and Aspirin for anticoagulation to prevent the possibility of stroke. However, it was felt that the patient would be at more risk for Coumadin then benefit. This was due to the fact that he had a question of gastrointestinal bleeding as well as the fact that he had had recent percutaneous endoscopic gastrostomy tube placed and that he is a high fall risk. Therefore, he was not started on Coumadin and was only started on Aspirin. His neurological symptoms remained stable and there were no further deficits. 9. Dysphagia - After extubation and being transferred out of the Intensive Care Unit, the patient was noticed to have a significant swallowing impairment. A video swallowing study showed significant impairment in initiation of the swallowing reflex and recurrent aspiration of thin liquids. Therefore, the patient was made completely NPO and gastroenterology was consulted for the placement of a percutaneous endoscopic gastrostomy tube. Percutaneous endoscopic gastrostomy tube was placed without complication and the patient was begun on tube feeds for nutrition. It is not clear what the exact etiology of the patient's swallowing impairment was. It may have been secondary to what was apparently a new stroke or secondary to the fact that he was recently intubated. He will need to be continually evaluated for improvement in swallowing function, however, if he does not show any improvement, will need to be fed through the percutaneous endoscopic gastrostomy tube and remain NPO. 10. Waldenstrom's macroglobulinemia - The patient has a history of this disease and had been followed by hematologist from [**Hospital6 592**] up until [**Month (only) 5298**]. There is a concern that hyperviscosity resulting from this syndrome could have led to the patient's stroke. Therefore, the hematology service was consulted. They suggested checking a serum viscosity which was done and which was found to be normal. With this normal serum viscosity, there is no need for urgent treatment such as plasmapheresis. A SPEP and UPEP were also sent for further workup of his Waldenstrom's and these studies would be followed up with the patient by hematology at an outpatient appointment which was set up for the patient prior to discharge. 11. Code Status - The patient is full code on admission and at discharge. DISCHARGE STATUS: The patient is to be discharged to [**Hospital **] Rehabilitation. CONDITION ON DISCHARGE: The patient is in good condition. He is afebrile, hemodynamically stable and tolerating tube feeds. DISCHARGE DIAGNOSES: 1. Klebsiella urosepsis and Klebsiella bacteremia. 2. Stroke. 3. Benign prostatic hypertrophy. MEDICATIONS ON DISCHARGE: 1. Finasteride 5 mg p.o. once daily. 2. Aspirin 325 mg p.o. once daily. 3. Sliding scale Regular insulin. 4. Levaquin 500 mg once daily for seven days after discharge. 5. Lansoprazole 30 mg p.o. once daily. 6. Remeron 7.5 mg p.o. q.h.s. 7. Albuterol inhaler one to two puffs four times a day as needed. 8. Advair Discus 100/50 mcg one inhalation once daily. RECOMMENDED FOLLOW-UP AND DISCHARGE INSTRUCTIONS: 1. The patient will receive physical therapy and occupational therapy at the rehabilitation facility. 2. He will also require close monitoring of his electrolytes as he has been requiring potassium, phosphate, and magnesium repletion due to poor p.o. intake. 3. He should also be continued on his tube feeds. 4. In terms of follow-up, the patient will follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1786**], after discharge. 5. He also has an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of hematology for further management of his Waldenstrom's macroglobulinemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1789**], M.D. [**MD Number(1) 1790**] Dictated By:[**Name8 (MD) 3520**] MEDQUIST36 D: [**2164-3-27**] 16:01 T: [**2164-3-27**] 17:50 JOB#: [**Job Number 16574**]

[ "276.5", "788.20", "584.9", "436", "038.0", "599.0", "273.3", "276.2", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.91", "99.04", "43.11", "96.6", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

14937, 15036

15062, 15455

3017, 3453

9108, 14790

15479, 16407

3677, 5185

281, 1685

1707, 2991

3470, 3654

14815, 14916

8,555

139,314

20276

Discharge summary

report

Admission Date: [**2200-10-29**] Discharge Date: [**2200-12-26**] Date of Birth: [**2200-10-29**] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] is the former 1.19 kg product of a 28 [**1-7**] week gestation pregnancy born to a 33 year old gravida 1 now para 0 woman. Prenatal screens, blood type A positive, antibody negative, RPR nonreactive, Rubella immune, Hepatitis B surface antigen negative, Group B Streptococcus status unknown. The prenatal course was significant for preterm labor initiated on [**2200-10-27**], treated with magnesium sulfate. The mother also received two doses of Betamethasone. She presented with vaginal bleeding and was felt to have a chronic abruption. On the date of delivery, the mother developed a fever to 101 degrees F without other signs of chorioamnionitis. She was treated with Ampicillin and Erythromycin prior to delivery. The infant was born by spontaneous vaginal delivery. Apgars were 8 at one minute and 9 at five minutes. He received blow-by oxygen for central cyanosis that resolved. He was admitted to the Neonatal Intensive Care Unit for treatment of prematurity. PHYSICAL EXAMINATION: Physical examination upon admission to the Neonatal Intensive Care Unit revealed weight 1.19 kg, length 38 cm, head circumference 25.5 cm, all at the 50th percentile for gestational age of 28 weeks. Oxygen saturation 90% on a CPAP of 5 cm of water pressure. General: Nondysmorphic preterm male. Head, eyes, ears, nose and throat: Anterior fontanelle open and flat, palate intact, positive red reflex bilaterally. Chest, breath sounds slightly decreased but equal, mild to moderate intercostal, subcostal retraction. Cardiovascular, regular rate and rhythm, normal S1 and S2, no murmur. Abdomen was soft, nontender, nondistended. Extremities, warm and well perfused. Genitourinary: Normal preterm male, testes undescended. Anus patent. Spine, intact with normal sacrum. Hips stable. HOSPITAL COURSE: (By systems including pertinent laboratory data) 1. Respiratory - [**Known lastname **] was treated with continuous positive airway pressure for the first four days of life. He was then in nasal cannula oxygen through day of life #21 when he had increasing work with breathing and was restarted on the continuous positive airway pressure. He continued for five minutes. On day of life #26 he was changed back to nasal cannula oxygen and remained in nasal cannula oxygen through day of life #43, [**2200-12-11**]. He was treated for apnea of prematurity with caffeine. The caffeine was discontinued on [**2200-12-7**]. His last episode of spontaneous apnea and bradycardia occurred on [**2200-11-29**]. Recently he has had some cyanosis associated with feeding which is quickly self-resolving. 2. Cardiovascular - [**Known lastname **] has maintained normal heart rates and blood pressures during admission. A soft murmur has been noted intermittently during admission and is felt to be consistent with peripheral pulmonic stenosis. 3. Fluids, electrolytes and nutrition - [**Known lastname **] was initially NPO and maintained on intravenous fluids. Enteral feeds were started on the day of life #2 and gradually advanced to full volume. On day of life #22 he presented with guaiac positive stools and abdominal distention. There was high suspicion for necrotizing enterocolitis, and he received 14 days of bowel rest. Feedings were again initiated on day of life #37 and he was gradually advanced and feedings were well tolerated. During his course of bowel rest, he was maintained on total parenteral nutrition via a peripherally placed central line. At the time of discharge, he is breastfeeding or taking expressed mother's milk fortified to 26 kg/oz, 4 calories by Enfamil powder and 2 calories by corn oil. Serum electrolytes were checked in the first week of life and then again with the onset of his gastrointestinal illness and were within normal limits. Weight at the time of discharge is 2.535 kg with a head circumference of 30.5 cm and a length of 48 cm. 4. Infectious disease - Due to the mother's significant fever and prematurity, [**Known lastname **] was evaluated for sepsis. The white blood cell count was 5000 with a differential of 58% polys, 3% bands. A blood culture was obtained and intravenous Ampicillin and Gentamicin were started. On day of life #4 he had a lumbar puncture that showed 0 red cells and 23 white cells with an elevated protein and a low glucose. These findings were with concern for possible meningitis and he received a 14 day course of ampicillin and gentamicin. On day of life #18 he presented with lethargy and increased apnea and bradycardia. A repeat complete blood count was obtained and had a white count of 15, 600 with a differential of 27% polys, 9% bands, 2 metacytes, 1 myelocyte and 1 promyelocyte with an immature to total ratio of 0.32. A blood culture was obtained and intravenous antibiotics of Vancomycin and Gentamicin were started. A repeat lumbar puncture was performed with 1 red blood cells and 20 white blood cells but with normal glucose and protein. With the onset of his guaiac positive stools and abdominal distention his antibiotic coverage was changed to Ampicillin and Gentamicin, and he received a 14 day course in concordance with his bowel rest. 5. Hematology - Hematocrit at birth was 51%. On [**2200-11-20**], along with his workup for suspicion for necrotizing enterocolitis, his hematocrit was noted to be 24.5%. He received one red blood cell transfusion, that was his only transfusion during admission. He is blood type A positive. He was treated with supplemental iron, once his feedings were restarted. His most recent hematocrit was [**2200-12-25**] and is 25.4% with a reticulocyte count of 2.8%. He is being discharged on 4 mg/kg/day of supplemental iron. 6. Gastrointestinal - [**Known lastname **] required treatment for unconjugated hyperbilirubinemia with phototherapy. His peak serum bilirubin occurred on day of life #1 with a total of 6.6/0.3, direct mg/dl. Phototherapy was continued for 72 hours and a rebound bilirubin was 4.6 total/0.3 direct. As previously mentioned, [**Known lastname **] presented with high suspicion for necrotizing enterocolitis with abdominal x-rays showing an abnormal gas pattern at the same time that he presented with guaiac positive stools. He was treated with 14 days of bowel rest and antibiotics. A recent serum bilirubin was obtained on [**2200-12-13**], due to some clinical jaundice and was a total of 3.8/1.3 direct. This is consistent with total parenteral nutrition-associated cholestasis. 7. Neurology - [**Known lastname **] had had two normal head ultrasounds on [**11-6**] and [**2200-11-26**]. He has maintained a normal neurological examination during admission and there were no neurological concerns at the time of discharge. 8. Sensory - Audiology, hearing screening was performed with automated auditory brainstem responses, [**Known lastname **] passed in both ears. Ophthalmology, [**Known lastname 12626**] eyes were most recently examined on [**2200-12-22**]. He has Stage 1, zone 2, 3 clock hours of retinopathy of prematurity in the right eye. His retina is immature to zone 2 on the left. Recommended follow up examination, in two weeks. The follow up examination is recommended the week of [**1-5**]. The ophthalmologist is Dr.[**First Name9 (NamePattern2) 50073**] [**Name (STitle) **] with offices at the [**Hospital3 1810**] at [**Location (un) **], [**Hospital1 54437**], [**Location (un) **] MA, phone [**Telephone/Fax (1) 50314**] CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To home with parents. PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 54438**], [**Location (un) 54439**], [**Location (un) 1887**] [**Numeric Identifier 54440**], phone [**Telephone/Fax (1) 37518**]. Fax [**Telephone/Fax (1) 37519**]. CARE/RECOMMENDATIONS: Feedings - Expressed mother's milk fortified to 26 cal/oz, 4 calories by Enfamil powder, 2 calories by corn oil. Medications - Vi-Day-[**Doctor First Name **] 1 cc p.o. q. day, Ferrous Sulfate 25 mg/ml dilution 0.4 cc p.o. q.d. Carseat position screening - Performed and was observed for 90 minutes in the carseat without episodes of apnea, bradycardia or oxygen desaturation. State newborn screen - Sent on [**11-3**], [**11-25**], and [**2200-12-10**], all results within normal limits. Immunizations received - Hepatitis B on [**2200-12-3**], Synagis [**2200-12-23**]. Immunizations recommended - Synagis respiratory syncytial virus prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: 1. Born at less than 32 weeks; 2. Born between 32 and 35 weeks with two of the three of the following: Daycare during respiratory syncytial virus season, with a smoker in the household, neuromuscular disease, airway abnormalities or school-age siblings; or 3. With chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age the family and other caregivers should be considered for immunization against influenza to protect the infant. Follow up appointments recommended - 1. With primary pediatrician, Dr. [**Last Name (STitle) 54438**] within three days of discharge. 2. Dr.[**First Name9 (NamePattern2) 50073**] [**Name (STitle) **] of Ophthalmology the week of [**1-5**]. DISCHARGE DIAGNOSIS: 1. Prematurity at 28 1/7 weeks gestation 2. Respiratory distress syndrome 3. Suspicion for sepsis 4. Suspicion for meningitis 5. Presumed necrotizing enterocolitis 6. Apnea of prematurity 7. Anemia of prematurity 8. Retinopathy of prematurity 9. Unconjugated hyperbilirubinemia [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**] Dictated By:[**Last Name (Titles) 37548**] MEDQUIST36 D: [**2200-12-26**] 06:55 T: [**2200-12-26**] 07:17 JOB#: [**Job Number 54441**]

[ "038.9", "776.6", "V30.00", "769", "322.9", "765.14", "774.2", "765.24", "557.0" ]

icd9cm

[ [ [] ] ]

[ "99.83", "96.6", "03.31", "96.72", "99.04", "99.55", "38.93", "93.90" ]

icd9pcs

[ [ [] ] ]

7742, 9639

9660, 10225

2036, 7686

1223, 2018

176, 1200

7711, 7718

73,124

125,056

48659

Discharge summary

report

Admission Date: [**2115-8-28**] Discharge Date: [**2115-9-3**] Date of Birth: [**2054-6-23**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 695**] Chief Complaint: HCV/ETOH cirrhosis Major Surgical or Invasive Procedure: liver [**First Name3 (LF) **] [**2115-8-29**] History of Present Illness: Mr. [**Known lastname **] is a 61M who presents to the hospital today to receive a liver [**Known lastname **]. In his interim history he does not report any new medical issues. More recently he has had some nausea, and decrease of appetite over the last few days, but denies any emesis/fever/chills/rigors. He denies having any pain, and reports that he has had no change in his bowel function. He does report some episodes of dysphagia, and trouble with solids more than liquids that has been occuring over the last month. ROS: Denies headaches/chest pain/SOB/cough Past Medical History: - HCV/ETOH cirrhosis (diagnosed [**2102**]) - CT on [**2114-7-7**] showed 2.2cm mass in segment VII of the liver c/w HCC. AFP 49. - History of alcoholism. - Hypertension. - Thrombocytopenia - History of two surgeries on the right knee. Social History: The patient lives with his wife and has two children who are in good health. He has a history of alcoholism, but quit in [**2092**]. Prior to that, he was drinking two to three pints of vodka daily for over 20 years. The patient has been smoking for 40 years and currently smokes one pack of cigarettes daily. The patient has no history of IV drug use. He has multiple tattoos, which he got in the [**2064**] and has a history of blood transfusions in the late [**2074**] after a right arm laceration. Family History: The patient's father and uncle died of liver cirrhosis secondary to alcoholism. The patient's mother had heart disease. Physical Exam: Vitals: T 97.6 P82 BP 124/78 R 20 97%RA GEN: A&O, NAD, Appears Stated Age, Pleasant Affect HEENT: EOMI, mucous membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, distended, nttp, large ventral hernia that is reducible Ext: LE edema +2 bilaterally, venous stasis ulcers present bilaterally Laboratory: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2115-8-28**] 12:40 4.4 4.60 14.4 42.0 91 31.2 34.2 16.0* 43* (Other labs pending) Imaging/Studies: CT C/A/P with Contrast [**2115-8-15**] 1. Two small foci of arterial hyper-enhancement and early washout in hepatic segments VII and III concerning for new areas of focal hepatocellular carcinoma. 2. Increase in volume of ascites since the prior study. 3. Unchanged stigmata of chronic liver disease including splenomegaly,gynaecomastia, recanalized paraumbilical vein, and gastrohepatic ligament varices. EKG [**2115-7-12**] Sinus rhythm. Non-specific ST-T wave changs. Borderline prolonged QTc interval. Echo [**2114-8-13**] The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Pertinent Results: [**2115-8-28**] 12:40PM BLOOD WBC-4.4 RBC-4.60 Hgb-14.4 Hct-42.0 MCV-91 MCH-31.2 MCHC-34.2 RDW-16.0* Plt Ct-43* [**2115-9-3**] 04:30AM BLOOD WBC-5.5 RBC-3.29* Hgb-10.6* Hct-28.8* MCV-88 MCH-32.4* MCHC-36.9* RDW-16.5* Plt Ct-61* [**2115-9-2**] 04:25AM BLOOD PT-13.3 PTT-24.9 INR(PT)-1.1 [**2115-9-3**] 04:30AM BLOOD Glucose-65* UreaN-39* Creat-1.0 Na-139 K-4.2 Cl-107 HCO3-28 AnGap-8 [**2115-8-28**] 12:40PM BLOOD ALT-50* AST-87* AlkPhos-87 TotBili-2.3* [**2115-9-3**] 04:30AM BLOOD ALT-63* AST-26 AlkPhos-60 TotBili-0.6 [**2115-9-2**] 04:25AM BLOOD Albumin-2.5* Calcium-7.6* Phos-3.4 Mg-2.0 [**2115-9-3**] 04:30AM BLOOD tacroFK-10.4 Brief Hospital Course: On [**2115-8-28**], he underwent orthotopic deceased donor liver [**Date Range **], portal vein to portal vein anastomosis, branch patch (recipient) to celiac patch (donor) common bile duct(no T tube), piggyback for end-stage liver disease secondary to Hepatitis C virus (HCV), hepatocellular carcinoma. Two JP drains were placed. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please refer to operative note for further details. Patient was transferred to the SICU postop intubated. He required blood products, but remained hemodynamically stable and was extubated on postop day 1. LFTs initially trended up as expected and liver duplex demonstrated patent vasculature. There was increased flow velocity in the main portal vein with slightly increased flow in the intrahepatic portal vein branches. JP outputs were non-bilious. LFTs trended down. Immunosuppression consisted of steroid taper, cellcept and prograf was initiated. Prograf dosing was adjusted per trough levels. He was transferred out of the SICU and continued to do well. An insulin drip was initially started in the SICU for hyperglycemia from steroids. [**Last Name (un) **] was consulted and converted drip to NPH and Humalog sliding scale. Diet was advanced and tolerated. He was passing flatus and had BMs. JP drainage decreased. Both JPs were removed and sites sutured. The medial drain site required re-suturing for ascites fluid. Abdominal incision was intact and was without redness or drainage. Generalized edema was treated with lasix. He was given a script for Lasix with instructions to call should he experience resolution of edema, wt loss, thirst or dizziness. PT cleared him for home. He was ambulating independently. Medication/insulin teaching went well. VNA services were arranged to assist him at home. He was ready for discharge to home on postop day 6. Vitals were stable. Medications on Admission: Medications - Prescription FUROSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth once a day LACTULOSE - 10 gram/15 mL Solution - 15 ml(s) by mouth b.i.d. to t.i.d. Titrate for 3 bowel movements a day METHYLPHENIDATE [METHYLIN] - 10 mg Tablet - 1 Tablet(s) by mouth three times a day OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - [**1-20**] Tablet(s) by mouth every 4-6 hours as needed for post-procedure pain RIFAXIMIN [XIFAXAN] - 550 mg Tablet - 1 Tablet(s) by mouth twice a day SPIRONOLACTONE - 50 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC ACETAMINOPHEN - (OTC) - 325 mg Tablet - 2 Tablet(s) by mouth every six (6) hours as needed for fever, pain MULTIVITAMIN [[**Last Name (un) **] MULTIVITAMIN] - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day --------------- --------------- --------------- --------------- Allergies: NKDA Discharge Medications: 1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): follow taper schedule. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 8. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol: if blood sugar low and you are unresponsive or unable to drink/eat. Disp:*5 doses* Refills:*2* 9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. insulin lispro 100 unit/mL Solution Sig: follow printed sliding scale units Subcutaneous four times a day. Disp:*1 bottle* Refills:*2* 12. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty Five (25) units Subcutaneous once a day. Disp:*1 bottle* Refills:*2* 13. NPH insulin human recomb 100 unit/mL Suspension Sig: Five (5) units Subcutaneous at bedtime. 14. One Touch Ultra 2 Kit Sig: One (1) Miscellaneous once a day. Disp:*1 kit* Refills:*1* 15. One Touch UltraSoft Lancets Misc Sig: One (1) Miscellaneous four times a day: prior to meals and bedtime. record all glucoses. Disp:*1 box* Refills:*2* 16. One Touch Ultra Test Strip Sig: One (1) Miscellaneous four times a day: follow sliding scale. Disp:*1 box* Refills:*2* 17. Insulin syringes Low dose U 100 needle 25-26 inch suppy 1 box refills: 4 18. tacrolimus 1 mg Capsule Sig: Seven (7) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: HBV HCC Hyperglycemia from steroids Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the [**First Name3 (LF) 1326**] Office [**Telephone/Fax (1) 673**] if you have any of the following: temperature of 101 or greater, jaundice, increased incisional pain, incision or old drain sites appear red or have bleeding/drainage, constipation/diarrhea or any concerns. You may shower. Do not apply powder/lotion/ointment to incisions. No tub baths or swimming. Do not get direct sunlight on incision. You will need to have blood drawn for labs every Monday and Thursday at Quest in Stratham N.H. No driving while taking pain medication. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2115-9-11**] 2:20 Provider: [**Name10 (NameIs) **] SOCIAL WORKER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-9-19**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2115-9-19**] 11:40 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2115-9-4**]

[ "401.9", "790.29", "305.1", "789.59", "E932.0", "790.01", "070.54", "303.93", "459.81", "572.3", "155.0", "287.5", "572.8", "707.19", "571.2" ]

icd9cm

[ [ [] ] ]

[ "50.51", "00.93" ]

icd9pcs

[ [ [] ] ]

9152, 9235

4364, 6300

320, 368

9315, 9315

3707, 4341

10045, 10658

1762, 1883

7227, 9129

9256, 9294

6326, 7204

9466, 10022

1898, 3688

262, 282

396, 967

9330, 9442

989, 1226

1242, 1746

13,443

131,844

15193+56622

Discharge summary

report+addendum

Admission Date: [**2194-9-29**] Discharge Date: [**2194-10-8**] Date of Birth: [**2128-9-18**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This 66 year old male presented to an outside hospital with midsternal chest pain. Electrocardiogram was taken and showed ST changes. He underwent cardiac catheterization which showed multivessel disease with an ejection fraction of 45%. He was transferred to [**Hospital1 69**] for coronary artery bypass graft. PAST MEDICAL HISTORY: Significant for: 1. Myocardial infarction in [**2185**]. 2. Perforated diverticulitis with colostomy and closure. 3. Status post incisional hernia. 4. Rheumatoid arthritis. MEDICATIONS ON ADMISSION: 1. Lisinopril 7.5 mg p.o. once daily. 2. Heparin drip. 3. Protonix 40 mg p.o. once daily. 4. Lipitor 20 mg p.o. once daily. 5. Folic Acid. 6. Plavix 75 mg p.o. once daily. 7. Aspirin 325 mg p.o. once daily. ALLERGIES: He had no known drug allergies. PHYSICAL EXAMINATION: He was afebrile and vital signs were stable. His extraocular movements were intact. His neck was supple. His lungs were clear. The heart was regular rate and rhythm, no murmurs, rubs or gallops. The extremities were warm and well perfused. HOSPITAL COURSE: He was taken to the operating room on [**2194-10-1**], where coronary artery bypass graft times three was performed, left internal mammary artery to left anterior descending, saphenous vein graft to OM1, saphenous vein graft to OM2 was performed. The patient was transferred to the CSRU postoperatively and was able to be quickly weaned and extubated. The patient did well in the CSRU and his oxygen was weaned. He was transfused two units. Chest tube was left in for high output. The patient was transferred to the floor postoperatively and nearly postoperative he was complaining of abdominal pain. He was given Morphine for this abdominal pain. A KUB was taken which showed no small bowel obstruction, no dilated loops, however, he continued to have difficulty passing stool. However, he continued to have positive flatus. Postoperatively, he began to become nauseous and nasogastric tube was placed with high output. He continued to pass flatus and had bowel movements. The nasogastric tube was clamped and residual was checked which was low and the nasogastric tube was removed. The patient was continued on NPO status and intravenous fluids. General surgery was consulted at that time and suggested continuing management with repeat KUB which continued to improve. His abnormal examination continued to improve throughout this time. Postoperatively, physical therapy was consulted to evaluate his ambulation and his endurance and he continued to do well with physical therapy and planned for possible discharge to home. His Lopressor was increased postoperatively for better rate control and furthermore, he had episodes of rapid atrial fibrillation which were unable to be converted with intravenous Lopressor. He was started on Amiodarone with intravenous bolus and then to 400 mg p.o. Amiodarone. Amiodarone was held during the episodes of nausea and vomiting with nasogastric tube placement. The patient was converted to sinus rhythm during that time, however, Amiodarone was continued for prophylaxis. The patient continued to improved and his nasogastric tube was removed. He continued to ambulate with physical therapy. At the time of dictation, the patient was planned to be discharged to home with home services and continues to be in sinus rhythm. MEDICATIONS ON DISCHARGE: (at this time) 1. Amiodarone 400 mg p.o. once daily. 2. Lasix 20 mg p.o. twice a day. 3. Aspirin 325 mg p.o. once daily. 4. Protonix 40 mg p.o. once daily. 5. Lopressor 100 mg p.o. twice a day. 6. Potassium Chloride 20 meq p.o. twice a day. 7. Atorvastatin 20 mg p.o. once daily. 8. Percocet one to two tablets p.o. q4hours p.r.n. for pain. 9. Colace 100 mg p.o. twice a day. The current plan is for the patient to be discharged home in stable condition with VNA services. He was instructed to follow-up with Dr. [**Last Name (STitle) 70**] in four weeks as well as his primary care physician in one to two weeks and follow-up with cardiology in two to four weeks. The patient was discharged home in stable condition. Please refer to addendum for any changes and discharge date. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2194-10-6**] 18:22 T: [**2194-10-6**] 19:20 JOB#: [**Job Number 44244**] Name: [**Known lastname 8097**], [**Known firstname 1019**] H Unit No: [**Numeric Identifier 8098**] Admission Date: [**2194-9-29**] Discharge Date: [**2194-10-8**] Date of Birth: [**2128-9-18**] Sex: M Service: Patient is discharged on [**2194-10-8**] to home with services. DISCHARGE MEDICATIONS: Amiodarone 400 mg po q day, EC-ASA 325 po q day, Lasix 20 mg po bid, Lopressor 100 mg po bid, Lipitor 20 mg po q day, Percocet 1-2 tablets po q4 hours prn, Colace 100 mg po bid, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 3112**] 20 mEq po bid. DISCHARGE DIAGNOSES: Coronary artery disease, status post coronary artery bypass graft, perforated diverticulitis, status post colostomy and then takedown, status post incisional hernia, and then rheumatoid arthritis. His discharge medications are as listed above. The patient is instructed to followup in [**1-22**] weeks with his primary care physician, 2-4 weeks with his cardiologist and four weeks with Dr. [**Last Name (STitle) 71**]. The patient is discharged home in stable condition with VNA services. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**] Dictated By:[**First Name (STitle) 1589**] MEDQUIST36 D: [**2194-10-8**] 17:31 T: [**2194-10-9**] 06:19 JOB#: [**Job Number **]

[ "401.9", "412", "414.01", "411.1", "E878.2", "997.4", "427.31", "997.1", "560.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.12", "36.15", "42.23", "88.72" ]

icd9pcs

[ [ [] ] ]

5236, 6027

4950, 5214

3558, 4926

702, 962

1249, 3532

985, 1231

159, 475

498, 676

5,544

171,299

487

Discharge summary

report

Admission Date: [**2117-2-15**] Discharge Date: [**2117-2-21**] Date of Birth: [**2047-10-15**] Sex: M Service: MEDICINE Allergies: Tetracyclines / Niacin Attending:[**Location (un) 1279**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: THis is a 69yo M with h/o CAD, DM2 and HTN who presented to the ED with chest pain. He woke up at 4am on the day of admission with left sided sharp 10/10 chest pain that radiates down his left arm. He took nitro with minimal relief.On route to [**Hospital1 18**] on the ambulance, he recieved multiple [**Last Name (un) 4070**] spray which brought the pain down. He complained of nausea but denies SOB/palpitation/dizziness. On arrival to ED, his SBP is 180 with HR 90. He recieved ASA, lopressor, morphine, nitro gtt, integrillin and plavix. Concerning with in stent thrombosis Past Medical History: 1. coronary artery disease-CABG [**2113**]; stent in native OM [**2117-2-10**] 2. NIDDM with neuropathy 3. hypertension Social History: He lives with his wife in [**Name (NI) 620**]. Rare alcohol use and denies any cigarette smoking. He is a retired consultant (pharmacist). Family History: Coronary artery disease Physical Exam: T97 P83 BP137/69 R18 SpO2 99% Gen-very pleasant gentleman in NAD, A+O x3 HEENT-anicteric, mmm CV-RRR, 2/6 SEM loudest in right 2ICS, no heaves resp-CTAB(anteriro exam) [**Last Name (un) 103**]-soft, active BS, NT/ND skin-no rashes extremities-left groin site no hematoma, DP 1+ bilaterally Pertinent Results: PROCEDURE DATE: [**2117-2-10**] INDICATIONS FOR CATHETERIZATION: Angina FINAL DIAGNOSIS: 1. Multi-vessel native coronary disease. 2. Atretic LIMA-LAD 3. Patent SVG-OM and Radial graft to RI 4. Successful stenting of native OM with 2.0 x 18mm Pixel stent. COMMENTS: 1. Selective coronary angiography of this right dominant system revealed multi-vessel coronary disease. The LMCA was without angiographically apparent disease. The LAD had a mild, 30% ISRS but was otherwise without flow-limiting disease. A D1 branch had a mild 40% lesion. The LCX had a tight, 99% origin lesion, but the distal and AV groove vessel filled well. The RCA had a 50% ostial lesion but was otherwise without flow limiting disease. 2. Graft angiography revealed an atretic LIMA-LAD. The SVG-OM had patent stents but a 90% lesion just beyond the most distal stent in a small native OM vessel. The Radial graft was without flow limiting disease. 3. Limited resting hemodynamics revealed a mildly elevated central aortic pressure 148/71. 4. Successful placement of 2.0 x 18 mm Pixel stent in the native OM distal to the SVG-OM bypass graft with significant effort. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow PROCEDURE DATE: [**2117-2-15**] INDICATIONS FOR CATHETERIZATION: Known CAD, prior CABG, recent PCI, rest pain with concern for stent thrombosis. FINAL DIAGNOSIS: 1. Native three vessel coronary artery disease. 2. Severely diseased SVG-OM bypass graft. 3. Central hypertension. 4. Unsuccessful treatment of SVG-OM bypass graft disease. 5. Unsuccessful treatment of chronically, totally occluded OM. COMMENTS: 1. Coronary angiography of this right dominant system demonstrated native three vessel coronary artery disease. The LMCA had no flow-limiting coronary disease. The LAD had a 40% in-stent restenosis (ISR) of a previously placed midvessel stent without other significant flow-limiting disease. The LCx was subtotally occluded proimximally with a totally occluded OM1. The ramus intermedius was totally occluded ostially. 2. Graft angigoraphy demonstrated a SVG-OM with thrombotic occlusion as well as TIMI 1 flow. The previously stented distal native vessel after the touchdown of this graft did not fill. The SVG-RI was without flow-limiting disease. The LIMA was not selectively engaged as shown to be atretic at the last catheterization. 3. Limited resting hemodynamics revealed central hypertension with blood pressure 177/83 mmHg. 4. Unsuccessful treatment of thrombotic SVG-OM with TIMI 1 flow despite attempts to remove the thrombus burden mechanically, administration of intra-coronary medications, and balloon angioplasty of the previously placed distal stents. Final angiography demonstrated continued thrombus burden, no angiographically apparent dissection, and slow flow (See PTCA Comments). 5. Unsuccessful treatment of native chronically, totally occluded OM due to inability to cross despite aggressive guide position and aggressive wire choices. [**2117-2-15**] 11:30AM PLT COUNT-322 [**2117-2-15**] 07:02AM PT-14.1* PTT-111.8* INR(PT)-1.3 [**2117-2-15**] 06:14AM GLUCOSE-252* NA+-141 K+-4.1 CL--101 [**2117-2-15**] 06:14AM freeCa-1.15 [**2117-2-15**] 06:05AM GLUCOSE-249* UREA N-25* CREAT-1.0 SODIUM-136 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-24 ANION GAP-16 [**2117-2-15**] 06:05AM CK(CPK)-197* [**2117-2-15**] 06:05AM CK-MB-3 cTropnT-0.10* [**2117-2-15**] 06:05AM CALCIUM-9.5 MAGNESIUM-1.6 [**2117-2-15**] 06:05AM WBC-8.2 RBC-4.15* HGB-11.9* HCT-34.7* MCV-84 MCH-28.8 MCHC-34.4 RDW-12.2 [**2117-2-15**] 06:05AM NEUTS-76* BANDS-0 LYMPHS-13* MONOS-7 EOS-3 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 Brief Hospital Course: 69yo M with severe CAD, HTN, hypercholesterlemia presented with OM thrombosis and SVG-OM thrombosis unintervenable. He underwent cardiac catheterization in [**2117-2-10**] which shows: graft: patent SVG-OM, patent radial-R1, atretic LIMA-LAD native:LMCA OK, LAD 30%ISR, D1 40%, LCx 99% origin, RCA 50%, OM 90% after graft touchdown On admission [**2-15**] cath shows: graft:thrombotic occlusion with TIMI 1 flow in SVG-OM not intervenable; TO stented native OM not intervenable native: 40% ISR with no flow limit Multiple attempt was unsuccesful in opening graft to OM or native OM. Patient was allowed to infarct and was supported with morphine. He was continued on plavix lifelong, lipitor and aspirin. Aggressive BP control was done with restarted lopressor, imdur and zestril. Medications on Admission: 1. glucophage 2. lopressor 100 [**Hospital1 **] 3. amitryptilline 4. isosorbide 60 5. lipitor 20 6. neurontin 8. aspirin 9. plavix 10. lisinopril 10 13. metformin 100 [**Hospital1 **] 14. humalog SS Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Amitriptyline HCl 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 5. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*1* 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO BID (2 times a day). Disp:*180 Tablet Sustained Release 24HR(s)* Refills:*0* 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO twice a day. Disp:*180 Tablet Sustained Release 24HR(s)* Refills:*1* 11. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*0* 12. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO once a day. Disp:*15 Tablet(s)* Refills:*1* 13. Insulin Glargine 100 unit/mL Cartridge Sig: 0.5 ml Subcutaneous at bedtime. Disp:*15 ml* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: coronary artery disease Diabetes Mellitus Tyep 2 hypertension Discharge Condition: stable Discharge Instructions: please return to the hospital or call your doctor if you have fever/chills/chest pian or if there are any concerns at all. PLease take all your prescribed medication Followup Instructions: Please Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Where: [**Known lastname 273**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2117-2-24**] 2:30 Completed by:[**2117-3-11**]

[ "401.9", "414.01", "V58.67", "357.2", "999.8", "250.60", "272.0", "E849.7", "244.9", "414.02", "410.71", "996.72", "285.9", "E878.1", "E879.8", "427.31", "493.90" ]

icd9cm

[ [ [] ] ]

[ "88.56", "99.61", "36.05", "99.04", "37.22", "99.20" ]

icd9pcs

[ [ [] ] ]

7877, 7883

5299, 6083

292, 317

7989, 7997

1593, 1625

8212, 8454

1242, 1267

6333, 7854

7904, 7968

6109, 6310

3004, 5276

8021, 8189

1282, 1574

2907, 2987

242, 254

345, 925

947, 1069

1085, 1226

30,023

102,381

32563

Discharge summary

report

Admission Date: [**2160-1-6**] Discharge Date: [**2160-1-8**] Date of Birth: [**2099-11-6**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Pt awoke with c/o the worst headache. Major Surgical or Invasive Procedure: External Ventricular Drain placed [**2160-1-6**] Cerebral Angiogram [**2160-1-6**] History of Present Illness: This nonsmoking Right handed 60yo male awoke this am with c/o the worst headache of his life behind R.eye. Shortly after began vomiting. Pt without headache relief, became diaphoretic around 4pm with continued headache extending from behind his right eye posteriorly down his neck, nausea and vomiting x4-5. Pt called his wife and 911. Pt brought to OSH, head CT obtained, which showed diffuse SAH involving sylvian fissure and basal cisterns with hydrocephalus. Received Nimodipine at OSH without any other medication given. Transferred to [**Hospital1 18**]. He became increasingly lethargic while he was in the ER. Ancef 1gram was given and a ventriculostomy was placed prior to taking him for an angiogram. Past Medical History: Legally blind with Macular degeneration [**2132**]'s, 4vessel CABG [**2132**], Type II diabetes, hypercholesterolemia, HTN Social History: Lives with his wife, social [**Name (NI) 75920**] weekend, tobacco quit 19yrs ago Family History: unknown Physical Exam: Gen: WD/WN, c/o posterior headache radiating down neck, restless. HEENT: Pupils: [**6-1**] bilat, brisk rxn EOMs: intact with conjugated lateral nystagmus, + Left homonomous hemianopsia Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, lethargic, difficulty keeping eyes open during conversation, 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, 5to4 mm bilaterally. Left homonomous hemianopsia, III, IV, VI: Extraocular movements intact bilaterally, bilateral conjugate lateral nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-2**] throughout.Minimal left pronator drift. Decreased finger to nose coordination. Sensation: Intact to light touch, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 5----------> Left 5----------> Toes downgoing bilaterally Pertinent Results: COMPLETE [**Month/Day (1) 3143**] COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2160-1-8**] 02:48AM 10.8 3.85* 12.2* 34.6* 90 31.8 35.3* 12.8 212 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2160-1-6**] 11:16PM 93.5* 0 3.7* 2.6 0.2 0.1 [**2160-1-6**] 06:07PM 93.0* 0 4.1* 2.9 0.1 0 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr [**2160-1-6**] 11:16PM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL [**2160-1-6**] 06:07PM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2160-1-8**] 02:48AM 212 [**2160-1-8**] 02:48AM 12.61 25.2 1.1 1 NOTE NEW REFERENCE RANGE AS OF [**2159-12-12**] 12:00A [**2160-1-6**] CT/CTA HEAD W/W-O CONTRAST: 1. Large amount of subarachnoid hemorrhage with diffuse distribution in basilar cisterns and throughout bilateral fronto-temporal lobes and falx. Slight asymmetry with predominance on the right. 2. CTA source and MIP images do not demonstrate aneurysm or vascular malformation. [**2160-1-6**] CEREBRAL ANGIOGRAM TECHNIQUE: After obtaining written informed consent, the patient was brought to the interventional neuroradiology suite and placed on the fluoroscopy table in the supine position. Moderate sedation was obtained using 15 mcg of fentanyl and 4 mg of Versed. Both groins were prepped and draped in the usual sterile fashion. Using local anesthesia with 1% lidocaine mixed with sodium bicarbonate and aseptic precautions, access was obtained into the right common femoral artery using a 6 French vascular sheath. The sheath was connected to a continuous saline infusion. A 5 French [**Doctor Last Name **] catheter was advanced coaxially over a 0.038 hydrophilic glidewire into the aortic arch. Under fluoroscopy, the following vessels were selectively catheterized and arteriograms were performed in AP and lateral projections: The right common carotid artery, the right internal carotid artery, the left vertebral artery, and the left common carotid artery. After review of the films, the catheter and sheath were withdrawn and pressure was applied on the groin until hemostasis was obtained. The patient was sent to the CT scanner for a post- angiogram head CT. Then, the patient was sent to the surgical ICU for further management. The study is slightly limited due to patient motion. Arteriogram of the right common carotid artery demonstrates prompt flow of contrast into the internal and external carotid artery including their main branches. There is no high-grade stenosis or occlusion at the origin of either the internal and external carotid artery. Arteriogram of the right internal carotid artery demonstrates prompt flow of contrast into the right anterior and right middle cerebral arteries. There is no aneurysm identified in the anterior communicating artery or the bifurcation of the right middle cerebral artery. There is no high-grade stenosis or occlusion present.Mild irregularity of the supraclinoid artery Upon arteriogram of the left vertebral artery, there was prompt flow of contrast into both posterior cerebral arteries. The basilar artery appears to be within normal limits. Both anterior inferior cerebellar arteries as well as the left posterior inferior cerebellar artery was obtained. There was no reflux of contrast into the right vertebral artery to evaluate the right PICA. Arteriogram of the left common carotid artery demonstrates prompt visualization and flow into the right internal and external carotid arteries showing normal caliber vessels. Visualization of the left anterior and middle cerebral artery was also obtained, which shows no aneurysm. There is also no high-grade stenosis or vessel occlusion. There is no vascular malformation. Catheterization of the right vertebral artery was going to be attempted for evaluation of right PICA. However, due to patient motion, the study had to be terminated. IMPRESSION: Limited study due to patient motion. Evaluation of the right vertebral artery and right PICA was not done due to significant patient motion. No aneurysm was identified. No vascular malformation or AV fistula present.Irregularity of right supraclinoid artery likely to be atherosclerotic. [**2160-1-6**] POST CEREBRAL ANGIOGRAM CT 11PM There is a new subdural [**Month/Day/Year **] collection along the right cerebral convexity, measuring 8 mm in the maximal thickness. There is a small amount of [**Month/Day/Year **] in the occipital [**Doctor Last Name 534**] of the left lateral ventricle. The extent of large amount of subarachnoid hemorrhage with diffuse distribution in basilar cisterns and along bilateral frontotemporal lobes and falx has increased with more hemorrhage along the cerebellar tentorium. There has been interval placement of the intraventricular catheter with decompression of the lateral ventricles. [**Doctor Last Name **]- white matter differentiation is preserved. Density values of brain parenchyma are within normal limits. There is a tiny focus of pneumocephalus along the left frontal lobe, consistent with recent intervention. Imaged paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Interval development of subdural hematoma and intraventricular hemorrhage; marginal increase in extent of extensive subarachnoid hemorrhage. Interval placement of intraventricular catheter with decompression of the lateral ventricles. [**2160-1-7**] REPEAT CT 5AM HEAD CT WITHOUT CONTRAST. INDICATION: Evaluate progression of intracranial hemorrhage. COMPARISON: [**2160-1-6**] at 11:00 p.m. FINDINGS: There has been interval increase in intraventricular hemorrhage, with small amount of [**Year (4 digits) **] now layering in the occipital [**Doctor Last Name 534**] of the lateral ventricles bilaterally. Additionally, there is a 6-mm focus of hyperdensity in the right frontal lobe, that may represent an intraparenchymal hemorrhage. The appearance of subdural hematoma overlying the right cerebral convexity is not appreciably changed. The extent of subarachnoid hemorrhage has slightly increased, with slightly more hemorrhage now noted on the left. Ventriculostomy catheter is in place. The ventricles have enlarged since the prior study, raising a concern of catheter obstruction. The patient is intubated. IMPRESSION: Interval progression of intraventricular as well as subarachnoid component of the hemorrhage. Enlargement of the lateral ventricles. Probable focus of intraparenchymal hemorrhage in the right frontal lobe. Unchanged right subdural hematoma. No new mass effect or shift of normally midline structures. [**2160-1-8**] CT/CTA/CTP: TECHNIQUE: Five-mm axial images of the head were obtained without IV contrast. 1.25 mm axial images of the head were obtained after the administration of 111 cc of Optiray IV contrast. Curved reformat, volume rendered, and multiplanar reformats were also obtained. Utilizing a second smaller bolus of contrast, CT perfusion was performed with mean transit time, relative cerebral [**Name2 (NI) **] flow, and relative cerebral [**Name2 (NI) **] volume maps generated on an independent workstation. FINDINGS: Comparison is made to a head CT dated [**2160-1-7**] and cerebral angiogram from [**2160-1-6**]. CT: Again seen is a large extensive subarachnoid hemorrhage filling the basal cisterns extending down into the prepontine cistern. Subarachnoid hemorrhage is also seen within the sylvian fissures and along the frontoparietal sulci bilaterally. The left frontal ventricular shunt is seen with the tip at the left foramen of [**Last Name (un) 2044**]. Intraventricular [**Last Name (un) **] is seen. The ventricles have not significantly changed in size. There is a newly apparent hypodensity involving the anterior and medial right temporal lobe consistent with infarct. Adjacent subdural hematoma is also seen. CTP: There is a limited mean transit time, decreased CVS and _____, corresponding to the infarct of the right temporal lobe. CTA HEAD: There is a fusiform aneurysm involving the distal right internal carotid artery just proximal to the bifurcation. This aneurysm measures approximately 8 x 5 mm in size. Along the lateral aspect of the right cavernous internal carotid artery is a small outpouching which may represent an infundibulum of the inferolateral trunk versus an aneurysm. This measures approximately a mm in size. The caliber of the vertebrobasilar system and the internal carotid arteries, middle cerebral arteries, and anterior cerebral arteries are otherwise normal with no evidence of vasospasm. No vascular malformations are seen. IMPRESSION: 1. Eight x 5 mm fusiform aneurysm of the distal right internal carotid artery just before the bifurcation. 2. Tiny, approximately 1 mm outpouching along the lateral aspect of the right cavernous ICA which may represent an infundibulum of the inferolateral trunk versus a tiny aneurysm. 3. Extensive subarachnoid hemorrhage, intraventricular hemorrhage, and right subdural hematoma as described above. 4. New infarct involving the anterior and medial right temporal lobe [**2160-1-7**] ECG: Sinus rhythm. Compared to tracing #1 the findings are similar. Intervals Axes Rate PR QRS QT/QTc P QRS T 92 134 94 338/394 57 42 88 [**2160-1-7**] CXR: FINDINGS: The lungs are well expanded and clear. The mediastinum is unremarkable. There has been prior median sternotomy. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is evident. The visualized osseous structures are otherwise unremarkable. IMPRESSION: No acute pulmonary process. Brief Hospital Course: 60yo male presented to [**Hospital1 18**] with diffuse SAH as reported from OSH transfer. On admission CT/CTA performed. Pt became increasingly somnolent, external ventricular drain placed in the ED, and immediately brought for a cerebral angiogram. Post angio CT obtained revealing new SDH, increased hemorrhage. Pt then transferred to and remained in Surgical ICU. SBP maintained <140, EVD open at 15, loaded with Dilantin and continued with 100mg TID, Nimodipine 60mg given Q4hrs. Repeat CT obtained in AM revealing extension of hemorrhage. Neurological exam significant for increased somnolence. [**1-8**] CT/CTA/CTP (perfusion) obtained revealing Right ICA aneurysm Case discussed with Dr.[**Last Name (STitle) 70160**]. It was decided that due to the complexity of the R.Supraclinoid carotid artery fusiform dilatation, a possible bypass surgery may be required to treat the aneurysm. Considering Dr.[**Last Name (STitle) **] at [**Hospital6 13185**] is the only surgeon available to perform bypass surgery, the patient will be transferred immediately to [**Hospital1 **] for further care. Medications on Admission: Zetia 10mg QD, Lipitor 80mg QD, Lisinopril 5mg QD, Actos 45mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 32mg QD, MVI, Metformin 1000mg QD Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours). 7. Nicardipine 2.5 mg/mL Solution Sig: One (1) Intravenous INFUSION (continuous infusion). 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Insulin Regular Human 100 unit/mL Solution Sig: Five (5) Injection TITRATE TO (titrate to desired clinical effect (please specify)). 12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day) as needed for HTN. 13. CefazoLIN 1 gm IV Q8H 14. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN 15. Midazolam 1-2 mg IV Q4H:PRN agitation 16. Metoprolol 5 mg IV Q4H:PRN PRN SPB > 130 Start: [**2160-1-7**] hold for HR < 65 17. Phenytoin 100 mg IV Q8H 18. Phenytoin 300 mg IV ONCE Duration: 1 Doses 19. HydrALAzine 20 mg IV Q6H:PRN PRN SBP>130 Start: [**2160-1-8**] Discharge Disposition: Extended Care Discharge Diagnosis: SAH Potential for bypass for R. supraclinoid carotid artery fusiform dilatation. Discharge Condition: Stable Discharge Instructions: PATIENT TRANSFERRED TO [**Hospital6 **], [**Doctor First Name **], [**Location (un) **]. Followup Instructions: Per receiving institution Completed by:[**2160-1-8**]

[ "V45.81", "432.1", "401.9", "414.01", "272.0", "430", "331.4", "250.00" ]

icd9cm

[ [ [] ] ]

[ "88.41", "02.2" ]

icd9pcs

[ [ [] ] ]

15157, 15172

12463, 13566

353, 438

15296, 15304

2842, 12440

15441, 15497

1444, 1453

13763, 15134

15193, 15275

13592, 13740

15328, 15418

1468, 1694

276, 315

466, 1181

2007, 2822

1709, 1991

1203, 1328

1344, 1428

32,359

185,346

52761

Discharge summary

report

Admission Date: [**2175-5-12**] Discharge Date: [**2175-5-17**] Date of Birth: [**2094-6-21**] Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending:[**First Name3 (LF) 458**] Chief Complaint: STEMI, acute stent thrombosis Major Surgical or Invasive Procedure: Cardiac catheterization with thrombectomy History of Present Illness: 80yoF with DM, hypercholesterolemia, HTN who had 2 DES to the proximal and mid-LAD placed [**5-8**] in the setting of NSTEMI with positive CEs and 80% LAD stenosis, presented with substernal chest pain and SOB since the morning of admission, found to have an STEMI with stent thrombosis on cath, s/p thrombectomy. On [**5-7**], pt presented with lower extremity weakness without chest pain, ruled in for NSTEMI, EKG showed twi in V3-V5, loaded with plavix, cath showed 60% stenosis LAD with 2 overlapping drug eluting stents placed; ECHO showed ef 40-45%, dc'ed on asa/plavix on [**5-9**]. Pt reports that she was confused about her medications, and although she filled all prescriptions, she is not sure that she took all of her medications correctly. Day of admission ([**5-12**]) she awoke at 9am with chest pain/pressure, [**5-9**], and when it did not subside, she had her husband call 911, and she was brought to [**Last Name (un) 108819**] ER. She was found to have ST-elevations anteriorly (EKG not available for review currently), heparin was started, and she was transferred to [**Hospital1 18**]. At [**Hospital1 18**], EKG showed NSR, HR 92, nl PR and QRS intervals, ST elevations in V2-V3, late transition, poor R wave progression, TWI in v4-v5. Plavix was loaded, and she was given integrillin bolus--> gtt. Cath showed subacute stent thrombosis, successful PTCA with thrombectomy. She was transferred in stable condition to the CCU. . On ROS, patient notes that FSGs have been running higher in last day than baseline (160s vs. 130s). She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, or red stools (she has black stools at baseline from iron supplementation). She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for intermittent palpitations for the past 2-3 years, absence of DOE, PND, orthopnea, ankle edema, syncope or presyncope. Of note, prior to recent hospitalization, she had not received health care for two years following her husband's diagnosis with bladder CA/nephrolithiasis. . Past Medical History: cad - [**5-8**] cath with 2 DES placed - 80% stenosis of LAD. EF 40-45%. parotid tumor cholecystectomy anxiety DMII obesity hyperchol HTN nephrotic syndrome chronic rales (per [**2168**] d/c summary chronic anemia- extensive w/u 6 years ago including BMB was non-diagnostic, she was started on Fe supplementation . Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension Social History: Social history is significant for 45 pack-year smoking history, quit 12 years ago. Occasional alcohol use, denies hx of heavy usage. Lives with husband. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 98.4, BP 126/60, HR 97, RR 17, O2 100% on 3L nc Gen: WDWN middle aged female in NAD, resp or otherwise. Oriented x3. Lying flat. Tangentiality on giving history. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pale, mucous membranes moist. Neck: Could not assess JVP as patient required to lie flat. ?R thyroid nodule, rubbery, mobile. CV: RRR, normal S1, S2. ?? S3. No murmurs, rubs, or gallops. Chest: Exam limited by pt position. Clear vesicular breath sounds with few bibasilar crackles. Abd: Bowel sounds present. Soft, NT, ND, No HSM. No bruits. Ext: 1+ BL pitting edema in LEs. DP/PT pulses 2+ BL. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: EKG demonstrated NSR, nl intervals, late transition, ST-elevations V2-V3. . 2D-ECHOCARDIOGRAM performed on [**5-8**] demonstrated: There is regional left ventricular systolic dysfunction with distal LV and apical hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. EF 40-45%. . PCI, [**5-8**] anatomy as follows: Selective coronary angiography of this right dominant system demonstrated single vessel coronary artery disease. The LMCA was without apparent coronary artery disease. The LAD had a 60% proximal and an 80% mid vessel stenoses. The LCX was patent as was RCA. 2. Limited resting hemodynamics were performed. The systemic arterial pressures were elevated measuring 171/72mmHg. 3. Successful PTCa and stenting of the proximal and mid LAD with overlapping 2.5 x 23 mm (mid) and 3.0 x 23 mm (proximal) cypher DES. the stents were post dilated to 3.0 and then 3.5 with a NC [**Male First Name (un) **] balloon. Final angiography revealed no residual stenosis in the stent, no dissection and TIMI III flow (See PTCA comments). FINAL DIAGNOSIS: 1. Single vessel coronary artery disease. 2. Elevated systemic arterial pressures. 3. Successful stenting of the LAD. . LABORATORY DATA - Plts 457 OSH labs: Na 134, K 3.9, Cl 97, HCO3 27, BUN 16, Cr 1.2, glu 189 WBC 13K, HCT 26, PLT 451 Trop I 0.16 . [**2175-5-16**] 07:00AM BLOOD WBC-7.8 RBC-3.01* Hgb-9.0* Hct-27.8* MCV-92 MCH-29.8 MCHC-32.3 RDW-15.2 Plt Ct-566* [**2175-5-16**] 07:00AM BLOOD PT-22.2* PTT-64.7* INR(PT)-2.1* [**2175-5-13**] 05:30AM BLOOD Fibrino-655* [**2175-5-13**] 05:48AM BLOOD Ret Aut-3.4* [**2175-5-16**] 07:00AM BLOOD Glucose-200* UreaN-23* Creat-1.2* Na-136 K-4.3 Cl-99 HCO3-27 AnGap-14 [**2175-5-13**] 05:48AM BLOOD ALT-45* AST-136* LD(LDH)-748* CK(CPK)-1647* AlkPhos-44 TotBili-0.2 [**2175-5-15**] 04:05AM BLOOD ALT-36 AST-32 LD(LDH)-542* AlkPhos-63 TotBili-0.3 [**2175-5-12**] 05:50PM BLOOD CK-MB-138* MB Indx-5.4 cTropnT-9.53* [**2175-5-12**] 11:55PM BLOOD CK-MB-79* MB Indx-3.4 cTropnT-8.21* [**2175-5-13**] 05:48AM BLOOD CK-MB-43* MB Indx-2.6 cTropnT-5.75* [**2175-5-14**] 03:55AM BLOOD CK-MB-10 MB Indx-1.8 [**2175-5-16**] 07:00AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.9 [**2175-5-13**] 05:30AM BLOOD Hapto-426* [**2175-5-13**] 05:48AM BLOOD TSH-0.32 Brief Hospital Course: # CAD/Ischemia - CAD risk factors DM, HTN, hyperchol, s/p cath 2 DES to LAD on [**5-8**], subacute stent thrombosis, now s/p thrombectomy ([**5-12**]). Per history, pt thinks she had been taking plavix upon discharge, but not entirely sure due to confusion. Pill count by daughter c/w having taken all meds. Possibly hypercoagulable in setting of thrombocytosis. Attempted to perform platelet inhibition studies, but not routinely available. TSH wnl. Transfused 1 u pRBCs on [**5-13**] to improve 02 delivery. Started on plavix 150 qd to continue for minimum 1yr, aspirin 325mg qd, BB, ACE inhibitor. . # Pump - ECHO performed [**5-8**] peri-NSTEMI, showing EF 40-45%. Outpatient regimen lasix 40 [**Hospital1 **]. CXR shows no signs of failure/edema. Echo post thrombosis shows 25% EF, severe hypokinesis of anterior and apical walls, no thrombus, moderate pulmonary hypertension. Anticoagulated on heparin/coumadin for intraventricular thrombus risk, goal INR of [**1-1**]. Restarted lasix at 40 mg PO BID, with significant diuresis in setting of pulmonary rales. Should have a repeat Echo to assess for interval improvement. . # Rhythm - no evidence of arrythmia prior to arrival or on EKG here, or on telemetry. Daily EKGs showed resolution of lateral ST/T changes. Mg kept >2, K>4. . # HTN - Treated with an ACE inhibitor, and beta blocker. Home amlodipine held, given pump dysfunction. Pressures initially low, but stable at 100-140 systolic prior to discharge. . # DM - Started on insulin sliding scale, Lantus added for poor control, continued to have high finger sticks. Restarted home PO regimen prior to discharge. . # Anemia: Chronic condition since [**2168**] with extensive negative work-up, except for slightly hypocellular marrow, normal iron stores, low serum iron/ferritin, nl B12, folate. Appeared pale during hospital stay. Also appears to have more acute HCT drop from baseline in 30s. Notes also show that she had had an acute drop in HCT in [**2168**] prompting work-up, and thought to be possible viral suppression. On B12 supplementation, MCV of 95. Received 1 U pRBCs on [**5-13**] with apprpriate bump. Retics 3.4, no evidence of hemolysis based on haptoglobin, fibrinogen. Guaiacs negative. Started on PPI [**Hospital1 **], scheduled for upper and lower scope in three months. . Medications on Admission: 1. Clopidogrel 75 qd 2. Atorvastatin 80 qd 3. Aspirin 325 mg qd 4. Lisinopril 40 qd 5. Amlodipine 10 qd 6. Glucophage 1,000 [**Hospital1 **] 7. Glucophage 500 mg qd 8. Atenolol 100 qd 9. Actos 45 qd 10. Lasix 40 [**Hospital1 **] 11. Alprazolam 1 tid prn 12. Iron 325 mg 13. Multivitamin 14. Vitamin B-12 1,000 . Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM: Start with 1.5 tablets and adjust as instructed by your PCP. . Disp:*45 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): Vitamin B12. 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): 40mg daily. 6. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 10. Alprazolam 0.5 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed. 11. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Take two pill. Disp:*60 Tablet(s)* Refills:*2* 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. 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* 15. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 16. Pioglitazone 15 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 17. Glimepiride 4 mg Tablet Sig: One (1) Tablet PO daily (). 18. Metformin 500 mg Tablet Sig: One (1) Tablet PO NOON (At Noon). Discharge Disposition: Home Discharge Diagnosis: Primary: ST elevation myocardial infarction, early stent thrombosis . Secondary: anemia, anxiety, hypercholesterolemia, hypertension Discharge Condition: Stable Discharge Instructions: You have an appointment with Dr. [**Last Name (STitle) 2987**] for a colonoscopy and upper endoscopy on [**8-15**] at 10 am at [**Location (un) **]., [**Hospital Ward Name 1950**] Building, [**Location (un) 470**]. The office phone number is ([**Telephone/Fax (1) 451**]. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: -You were noted to have continued low blood count (anemia). This needs to be evaluated with a colonoscopy. This is scheduled for you with Dr. [**Last Name (STitle) 2987**] on [**2175-8-15**]. You were started on a new medication called Coumadin (also called Warfarin). This is a blood thinning medication that needs to be monitored regularly with a blood test called the "INR." Your PCP's office should be contacting you regarding having your INR checked If you do not hear from them Thursday morning, please give them a call. This should be checked within two days. - Your dose of Plavix (the medication to help keep your stent open) was doubled to 150mg daily. Please take this every day unless instructed to do otherwise by you Cardiologist. Missed doses may result in a heart attack or death. -Your atenolol was stopped and you were started on metoprolol succinate (a similiar drug) for your heart rate and blood pressure control. -Your dose of amlodipine was decreased to 2.5mg (from 10mg). Please take this lower dose for now. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 6197**] Date/Time:[**2175-5-18**] 10:00 Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 6197**]. Please call to reschedule the appointment that was originally made for [**2175-5-18**]. . A followup appointment has been scheduled for you with your PCP: [**First Name11 (Name Pattern1) 1569**] [**Last Name (NamePattern1) **], MD. Phone: [**Telephone/Fax (1) 10011**]. Time/Date: [**2178-5-22**]:30 AM. Location: [**Location (un) 108820**] 109. . Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2175-8-15**] 11:00 -- for a colonoscopy. Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 1246**] (ST-3) GI ROOMS Date/Time:[**2175-8-15**] 11:00

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icd9cm

[ [ [] ] ]

[ "99.04", "00.24", "88.56", "00.40", "99.20", "37.22", "00.66" ]

icd9pcs

[ [ [] ] ]

11164, 11170

6632, 8955

307, 350

11346, 11354

4010, 5412

12838, 13785

3211, 3293

9318, 11141

11191, 11325

8981, 9295

5429, 6609

11378, 12815

3308, 3991

238, 269

378, 2627

2649, 3025

3041, 3195

10,127

182,839

27685

Discharge summary

report

Admission Date: [**2198-6-28**] Discharge Date: [**2198-7-20**] Date of Birth: [**2181-4-19**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: s/p Motor vehicle crash vs. tree Major Surgical or Invasive Procedure: Occiput-C4 fusion [**6-29**] (Dr. [**Last Name (STitle) 739**], neurosurgery) Ex-fix R femur [**6-29**] (Dr. [**Last Name (STitle) **], orthopedics) Tracheostomy/PEG [**7-2**] (Dr. [**Last Name (STitle) **], trauma surgery) IM rod R femur [**7-4**] (Dr. [**Last Name (STitle) **], orthopedics) R PICC [**7-4**] (Dr. [**Last Name (STitle) 19420**], interventional radiology) IVC filter placement [**7-9**] (Dr. [**Last Name (STitle) **], vascular surgery) History of Present Illness: Ms. [**Known lastname 67614**] is a 17-year-old female who was an unrestrained back seat passenger in a motor vehicle crash versus a tree. She was unresponsive at the scene and had respiratory and cardiac arrest requiring CPR. She was intubated and transported to an outside hospital from which she was subsequently transferred to [**Hospital1 18**]. She was found to have a C1 vertebral fracture, and spinal cord hemorrhage and edema from C2-C4. Past Medical History: None Family History: Noncontributory Physical Exam: VS upon admission to trauma bay: BP 90/palp HR 76 GCS 3 Gen: Intubated HEENT: 5cm head laceration; lip abrasion Neck: cervical collar in place Chest: equal breath sounds, no crepitus Back/Spine: no stepoffs Abd: FAST negative Pelvis: stable Rectum: +rectal tone, guaiac negative Extr: RLE deformity with abrasion over shin region Current exam: T 99 HR 95 Sinus BP 103/53 RR 12 vented Assist Control Ventilation FiO2: 40% TV: 500 RR: 12 PEEP: 5 Alert & oriented, answers questions, moves everything above the neck Course breath sounds bilaterally, moving air well. Tracheostomy site clean. Regular rate & rhythm, normal S1 & S2 Abdomen soft, non-tender, non-distended. G-tube in place, site clean. Mild peripheral edema, 2+ DP pulses bilaterally Pertinent Results: Labs upon admission: [**2198-6-28**] 08:35PM LACTATE-1.0 [**2198-6-28**] 08:22PM GLUCOSE-150* UREA N-11 CREAT-0.6 SODIUM-142 POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-24 ANION GAP-13 [**2198-6-28**] 08:22PM WBC-18.5* RBC-3.20* HGB-10.0* HCT-28.1* MCV-88 MCH-31.3 MCHC-35.6* RDW-12.3 [**2198-6-28**] 08:22PM WBC-18.5* RBC-3.20* HGB-10.0* HCT-28.1* MCV-88 MCH-31.3 MCHC-35.6* RDW-12.3 [**2198-6-28**] 08:22PM PLT COUNT-226 [**2198-6-28**] 04:43AM GLUCOSE-133* LACTATE-5.7* NA+-142 K+-3.2* CL--111 TCO2-15* [**2198-6-28**] 04:40AM UREA N-11 CREAT-0.7 MR CERVICAL SPINE Reason: eval for cord/ligament injury [**Hospital 93**] MEDICAL CONDITION: 17 year old woman with known C1 & C2 fx REASON FOR THIS EXAMINATION: eval for cord/ligament injury INDICATION: 17-year-old unrestrained back seat passenger in a motor vehicle accident with known C1 and C2 fracture. Assess for spinal cord/ligamentous injury. TECHNIQUE: Multiplanar T1- and T2-weighted images of the cervical spine without IV contrast. Comparison is made to CT of the cervical spine performed seven hours earlier. FINDINGS: The images are slightly limited in quality due to motion artifact. Again seen is the transverse fracture through the dens, better appreciated on the prior CT scan. Increased T2 and STIR signal intensity is seen in the spinal cord extending from the level of the tip of the dens to the superior endplate of the C4 vertebral body. There is mild expansion of the cord at the level of the body of C2. Axial gradient echo images demonstrate susceptibility artifact centrally in the cord at the level of C2. At the C2-3 and C3-4 levels, there is mild left paracentral disc bulging with mild narrowing of the left neural foramina at these levels. There is no central canal stenosis. Vertebral body and intervertebral disc signal elsewhere in the cervical spine is normal. Mild edema is seen in the prevertebral soft tissues. The patient is intubated, however. Increased T2 and STIR signal intensity is also seen in the interspinous area posterior to C2. IMPRESSION: 1. Signal abnormalities in the spinal cord indicate focal areas of hemorrhage in the central cord posterior to C2, and cord edema from C2-C4 as described above. There is also mild expansion of the cord at the C2 level. 2. Probable ligamentous injury of the interspinous ligaments at the level of C2-3. 3. Mild left paracentral disc bulges at C2-3 and C3-4 with mild left neural foraminal narrowing. Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the completion of the examination. FEMUR (AP & LAT) SOFT TISSUE R Reason: eval fx [**Hospital 93**] MEDICAL CONDITION: 17 year old woman with MVC and likely R femur fx REASON FOR THIS EXAMINATION: eval fx HISTORY: Fracture. Two radiographs of the right femur demonstrate a displaced fracture through the mid diaphysis of the right femur. Limited assessment of the knee and hip joints is unremarkable. Ionated contrast is present within urinary bladder as is a Foley catheter balloon. IMPRESSION: Displaced right femoral diaphyseal fracture. These findings were reported to the ED dashboard at the time of image interpretation. MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: Eval. for vertebral artery dissection Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 17 year old woman s/p C2-C4 cord contusion and C1 fx, now paraplegic with fevers and new onset vertical nystagmus concerning for new brainstem lesion. REASON FOR THIS EXAMINATION: Eval. for vertebral artery dissection MRI/MRA OF THE BRAIN HISTORY: 17-year-old female status post C2 through C4 cord contusion with C1 and C2 fractures, now with fevers. MRI BRAIN: TECHNIQUE: Multiplanar, multisequence MR images of the brain with triplanar post-gadolinium images were obtained. FINDINGS: There are areas of susceptibility artifact of the posterior upper neck and skull base consistent with artifacts from surgical fusion. The upper spinal cord and the adjacent medulla are expanded and have increased T2 signal. There are also areas of enhancement, both within and at the periphery of these regions. There are no signal changes indicative of blood within the spinal cord or medulla. No epidural fluid collections or abscesses are seen, although evaluation is somewhat limited by adjacent artifact. The above findings may represent changes of cord and brainstem contusion vs. infection, with no evidence of abscess formation. A type 2 dens fracture is present. No extra-axial fluid collections are seen. The [**Doctor Last Name 352**]/white matter differentiation is maintained. There is no shift of the normally midline structures. The ventricles, sulci, and basal cisterns are normal. The orbits and paranasal sinuses are normal. Soft tissue changes of the mastoid air cells bilaterally are seen. MRA: TECHNIQUE: 3D TOF of the intracranial arteries and 2D TOF of the cervical arteries were obtained with MIP reconstructions. Post-gadolinium coronal FAME of the cervical and intracranial vessels were also obtained. Axial T1 fat sat images of the neck were also obtained. FINDINGS: The V4 segment of the right vertebral artery is hypoplastic but patent. No occlusions, dissections, or aneurysms are seen. IMPRESSION: No vertebral artery dissections. Enhancement, expansion, and T2 hyperintensity involving the upper cervical cord and medulla which likely represents changes of contusion Vs. infection without abscess formation. Posterior cervical spinal fusion with a type 2 dens fracture still visible. MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: Eval. for vertebral artery dissection Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 17 year old woman s/p C2-C4 cord contusion and C1 fx, now paraplegic with fevers and new onset vertical nystagmus concerning for new brainstem lesion. REASON FOR THIS EXAMINATION: Eval. for vertebral artery dissection MRI/MRA OF THE BRAIN HISTORY: 17-year-old female status post C2 through C4 cord contusion with C1 and C2 fractures, now with fevers. MRI BRAIN: TECHNIQUE: Multiplanar, multisequence MR images of the brain with triplanar post-gadolinium images were obtained. FINDINGS: There are areas of susceptibility artifact of the posterior upper neck and skull base consistent with artifacts from surgical fusion. The upper spinal cord and the adjacent medulla are expanded and have increased T2 signal. There are also areas of enhancement, both within and at the periphery of these regions. There are no signal changes indicative of blood within the spinal cord or medulla. No epidural fluid collections or abscesses are seen, although evaluation is somewhat limited by adjacent artifact. The above findings may represent changes of cord and brainstem contusion vs. infection, with no evidence of abscess formation. A type 2 dens fracture is present. No extra-axial fluid collections are seen. The [**Doctor Last Name 352**]/white matter differentiation is maintained. There is no shift of the normally midline structures. The ventricles, sulci, and basal cisterns are normal. The orbits and paranasal sinuses are normal. Soft tissue changes of the mastoid air cells bilaterally are seen. MRA: TECHNIQUE: 3D TOF of the intracranial arteries and 2D TOF of the cervical arteries were obtained with MIP reconstructions. Post-gadolinium coronal FAME of the cervical and intracranial vessels were also obtained. Axial T1 fat sat images of the neck were also obtained. FINDINGS: The V4 segment of the right vertebral artery is hypoplastic but patent. No occlusions, dissections, or aneurysms are seen. IMPRESSION: No vertebral artery dissections. Enhancement, expansion, and T2 hyperintensity involving the upper cervical cord and medulla which likely represents changes of contusion Vs. infection without abscess formation. Posterior cervical spinal fusion with a type 2 dens fracture still visible. UNILAT LOWER EXT VEINS RIGHT P Reason: SWELLING AND FEVER IN QUADEPLEGIC [**Hospital 93**] MEDICAL CONDITION: 17 year old woman with quadriplegia and incg size of RLE and fever REASON FOR THIS EXAMINATION: eval DVT c doppler INDICATION: 17-year-old female with quadriplegia, increasing size of right lower extremity and fever. Evaluate for DVT. RIGHT UNILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal veins were performed. Normal compressibility, augmentation, flow, and waveforms are demonstrated. No evidence of intraluminal thrombus. IMPRESSION: No evidence of DVT. Date: [**2198-7-17**] Signed by [**Name6 (MD) 7495**] [**Last Name (NamePattern4) 59896**], MD on [**2198-7-17**] Affiliation: HMFP Title: NEUROLOGY STAFF NEUROLOGY STAFF ATTENDING I saw and examined Ms. [**Known lastname 67614**] this afternoon, confirming pertinent parts of her history and examination as detailed in Dr.[**Last Name (un) 67615**] note on OMR. I agree with her assessment and plan of action and would add the following: Her parents were present during my visit today. [**Known firstname **] was able to mouth "yes" and "no" appropriately. She demonstrates upbeat nystagmus in all positions today, though it is maximal with upgaze. This suggests a lesion in the brainstem connections with the anterior semicircular canals; this tends to occur in the pontomedullary junction, and this localization is consistent with the known enhancing lesion seen on the overnight MRI from yesterday. Because her ocular findings developed over the past couple of days, which her parents confirm, it argues against the lesion being ischemic and directly related to her original trauma as that event was over two weeks ago and would be beyond the period of maximal swelling. I understand the lesion is felt to be an abscess, which would be more in line with the development of her symptoms and findings. The trauma team is already consulting the infectious disease consultants to confirm appropriateness of her current antimicrobial regimen. We have nothing further to offer her at this time, particularly as our neurosurgical colleagues are already seeing her and have rendered an opinion re: the likelihood of being able to remove or drain this lesion if it continues to expand. Please let us know if we can be of further assistance in the future. Brief Hospital Course: Ms. [**Known lastname 67614**] was admitted to the trauma surgical ICU at [**Hospital1 18**] on [**2198-6-28**] as a transfer from an outside hospital with a C1 fracture, C2-C4 spinal cord hemorrhage/edema, facial bone fractures, and right femur fracture following a car vs. tree motor vehical crash. Steroid protocol was initiated with intravenous solumedrol and the right femur was externally fixed. On hospital day #2, she underwent posterior occipito-cervical fusion laminectomy for cervical spine stabilization. She tolerated the procedure well and returned to the ICU. On hospital day #4, she had two episodes of bradycardia which were self-limited and self-resolved. She returned to the operating room on hospital day #5 and underwent uncomplicated open tracheostomy and percutaneous gastrostomy tube placement. Tube feeds were started and she steadily improved tolerating her diet. Ms. [**Known lastname 67614**] was taken back to the operating room on hospital day #7 ([**2198-7-4**]) where the external fixator was removed from the right upper leg and an intermedullary rod was placed to definitively repair the right femur. She returned to the operating room on [**2198-7-9**] for placement of an inferior vena cava filter for DVT prophylaxis. She intermittently had fever spikes; see below: [**7-9**]: LENI neg, IVC filter placed; Spiked--> pancx [**7-10**]: Spiked again, started Vanco (this was eventually stopped) in case MRSA PNA. [**7-11**]: Fever spiked, started on ceftiaxone for GNR coverage in sputum [**7-12**]: Fever, stopped ctx given Stenotr and started empiric PO flagyl (discontinued on [**7-19**]) [**7-13**]: spiked again, pancx., lost PICC [**7-14**]: Bronched, minimal mucus; foley changed/irrigated with ampho [**7-16**]: Started having upbeat nystagmus, Neurology consulted (see Pertinent results for note), then MRA head and neck. Has likely brainstem abscess & ?R vert artery CVA/dissection. Was started on ASA 325 qd; this has been discontinued secondary no dissection was identified. Broadened abx. & called nsurg. [**7-17**]: LP performed, ID c/s, staples out of thigh [**7-18**]: ID c/s- CT RLE, US RLE; Ortho not concerned; HypoT to sBP 80s--> responsive to IVF x 2 [**7-19**] fever spike during night, T 101.5. On Zosyn and Vancomycin for empiric coverage. [**7-20**] WBC 8.0 temp down to 99. ID following along and have recommended continuing Zosyn and Vanco for a total of 2 week course (start and restart date on [**2198-7-16**]). It is recommended that she have ID consulted once at rehab for continued management of these issues. Medications on Admission: None Discharge Medications: 1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-1**] Drops Ophthalmic PRN (as needed). 4. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO TID (3 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day) as needed for prophylaxis. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs Miscell. Q4-6H (every 4 to 6 hours) as needed. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Ibuprofen 100 mg/5 mL Suspension Sig: [**10-19**] mL PO Q8H (every 8 hours) as needed. 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. 13. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nasal congestion. 14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 18. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 19. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed for nausea. 20. Piperacillin-Tazobactam Na 4.5 gm IV Q8H 21. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every eight (8) hours for 10 days. 22. Zosyn 4.5 g Recon Soln Sig: One (1) Intravenous every eight (8) hours for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: s/p Motor vehicle crash vs. tree Quadriplegia s/p C1 & C2 fractures Right femur fracture Respiratory failure Discharge Condition: Hemodynamically stable with tracheostomy (full vent support), PEG (tolerating tube feeding at goal), IVC filter in place. C-collar to be worn for 12 weeks after fusion. Discharge Instructions: Continue to wear your cervical collar for a total of 12 weeks from your surgery ([**2198-6-29**]) at which time you will follow up with Neurosurgery to determine discontinuing the collar. Followup Instructions: Neurosurgery--Dr. [**Last Name (STitle) 739**] [**Telephone/Fax (1) 1669**]; follow-up with Dr. [**Last Name (STitle) 4696**], in [**Hospital 4695**] clinic 12 weeks from surgery ([**2198-6-29**]); please inform the office that AP/Lat films of neck will be needed for thia appointment.. Orthopedics--Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1228**]; follow up in [**2-2**] weeks Trauma [**Hospital 67616**] Clinic [**Telephone/Fax (1) 6439**]; follow-up in [**3-3**] weeks as needed Completed by:[**2198-7-20**]

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icd9cm

[ [ [] ] ]

[ "79.05", "33.24", "78.15", "79.35", "43.11", "81.01", "81.03", "86.59", "93.44", "78.65", "81.62", "38.7", "03.31", "96.6", "31.1", "03.53", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

17222, 17292

12569, 15155

347, 804

17445, 17616

2136, 2143

17852, 18376

1326, 1343

15210, 17199

10184, 10251

17313, 17424

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17640, 17829

1358, 2117

275, 309

10280, 12546

832, 1282

2158, 2754

1304, 1310

461

185,084

13327

Discharge summary

report

Admission Date: [**2122-1-9**] Discharge Date: [**2122-1-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 297**] Chief Complaint: 82yo M w/ a PMHx significant for RUL Stage 3a vs 3b NSCLC s/p chemo/xrt with good response found to have a 2nd primary in the RLL after wedge resection 1/'[**20**] represented with a persistent right pleural effusion and suspicious cytology from prior pleurocentesis. He was referred to the Interventional Pulmonology service for Pleuroscopy, Biopsy, Evacuation of a Probable Malignant Pleural Effusion, and talc Pleurodesis [**2122-1-9**]. Major Surgical or Invasive Procedure: 1- S/p Right Chest thoracoscopy, Pleurodesis([**2122-1-9**]) History of Present Illness: 82yo M who typically lives with his wife in [**Name (NI) 108**], well known to the Thoracic oncology group after treatment for a previous RUL Stage 3a, possibly Stage 3b NSCLCa (?SCCa) with almost complete response 4 years ago. His functional status did not allow for surgical management of his disease previously. He was being followed serially by Dr. [**Last Name (STitle) 3274**] in the multidisciplinary Thoracic [**Hospital **] clinic and serial imaging revealed a persistent, and possibly enlarging right pleural effusion. Additionally, the patient was known to have a moderately differentiated adenocarcinoma of the RLL and was s/p VATS/wedge resection of this lesion with Dr. [**Last Name (STitle) 952**] in 1/'[**20**]. After serial pleural cytologic analysis was persistently suspicious for malignancy but no definitive pathologic diagnosis could be rendered, he was referred for pleuroscopy, pleurodesis and biopsy with Dr. [**Name (NI) **]. Past Medical History: Hypertension Gout s/p Cholecystectomy Lung Cancer (likely 2 primaries, see HPI) Social History: He has three children, 8 grandchildren and no great grandchildren. He smoked one pack a day for 20 years, he quit 36 years ago. Family History: Father-- coronary artery disease Mother- breast cancer Physical Exam: VS T= 98.2 HR= 78 (regular) BP = 132/76 RR = 20 SpO2 = 96%RA HEENT- elderly male, NAD, AAOx3, anicteric, no cervical/supraclavicular adenopathy, no bruit Cor- Regular, no murmur Pulm- decreased BS on R-lung with dullness to percussion half way up the right posterior hemithorax, Left lung is clear Abd- soft, non-tender, no hernia/mass, no HSM Ext- cool, dry, distal pulses dopplerable only, calves soft Pertinent Results: [**2122-1-9**] 11:48AM PLEURAL TOT PROT-4.5 LD(LDH)-194 ALBUMIN-2.5 [**2122-1-9**] 04:15PM PT-11.8 PTT-28.5 INR(PT)-1.0 [**2122-1-9**] 04:15PM PLT COUNT-226 [**2122-1-9**] 04:15PM WBC-9.3 RBC-5.27 HGB-15.6 HCT-45.7 MCV-87 MCH-29.6 MCHC-34.2 RDW-15.8* [**2122-1-9**] 04:15PM OSMOLAL-271* [**2122-1-9**] 04:15PM CALCIUM-8.5 PHOSPHATE-3.4 MAGNESIUM-2.1 [**2122-1-9**] 04:15PM GLUCOSE-123* UREA N-12 CREAT-0.8 SODIUM-126* POTASSIUM-5.0 CHLORIDE-91* TOTAL CO2-24 ANION GAP-16 [**2122-1-9**] 08:55PM CALCIUM-8.3* PHOSPHATE-4.2 MAGNESIUM-2.0 [**2122-1-9**] 08:55PM GLUCOSE-156* UREA N-17 CREAT-1.0 SODIUM-128* POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-23 ANION GAP-15 Brief Hospital Course: Mr. [**Known lastname **] was admitted to the IP service on [**2122-1-9**] after undergoing a Right Chest Pleuroscopy, Biopsy, Pleurodesis, and placement of a right chest tube thoracostomy. Initially post-operatively, his chest tube outputs were serosanguinous with no evidence of airleak on suction. Interval fimls confirmed improved aeration of the right hemithorax after evacuation/pleurodesis of the right chest. By POD#1, the patient had an symptomatic bout of Afib with a RVR necessitating transfer to the CSRU. He was not cardioverted, however, amiodarone IV load with transition to an oral regimen was utilized in conjunction with beta blockade. A surface echo revealed no tamponade physiology and a stable peri-cardial effusion. No significant decrement in EF or wall motion abnormalities were noted on this study as well. Over the ensuing days, he did have a change in character of his CT outputs and serial H/H revealed a 15 point Hct drop. A CT chest done on [**2122-1-12**] revealed a moderate to large hemothorax (as described by Houdsfiled signature of the complex right pleural effusion in the background of bloody chest tube outputs). He was managed conservatively and no transfusion requirement occured. He did have eventual transfer to the floor (Far 2.Thoracic floor). Intermittently, the patient had burst of Afib that converted to SR necessitating advancement of his lopressor medication. He was continued on diltiazem and after clearance with PT was cleared for disposition to rehabilitation. Medications on Admission: allopurinol 300mg qD, protonix 40mg qD, cardura 0.4mg qD Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed. 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for tachycardia. 8. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: 1- Right pleural effusion (malignant)s/p thoracoscopy with talc pleurodesis 2- Post-operative atrial fibrillation 3- Hypertension (controlled) 4- Gout (controlled) 5- prior history of right upper lobe (?SCCA/Stage 3a vs3b w/ complete response to chemoxrt) and right lower lobe non-small cell lung cancer (moderately differentiated adenocarcinoma) s/p chemotherapy and radiation Discharge Condition: Stable, afebrile, sinus rhythm, with adequate pain control with good room air saturations, wounds healing well Discharge Instructions: Please resume your pre-admission medications as directed. Some changes have been made to your heart medications to help control your heart rate after the procedure. No heavy lifting greater than 15-20lbs for 2-3 weeks. You may shower and pat your wound dry but no bath-tub/swimming/whirlpool for 2 weeks. Followup Instructions: See Dr. [**Name (NI) **] in the pulmonary clinic within 2 weeks of dismissal. You should follow-up with Dr. [**Last Name (STitle) 3274**] of the Heme-onc service as well by making an appointment in the next 2 weeks. Completed by:[**2122-1-15**]

[ "274.9", "V10.11", "997.1", "427.31", "998.11", "197.2", "276.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "34.04", "34.92", "34.09" ]

icd9pcs

[ [ [] ] ]

5606, 5677

3212, 4741

702, 765

6099, 6212

2515, 3189

6568, 6816

2019, 2075

4848, 5583

5698, 6078

4767, 4825

6236, 6545

2090, 2496

221, 664

793, 1750

1772, 1853

1869, 2003

75,663

188,481

39502

Discharge summary

report

Admission Date: [**2119-8-31**] Discharge Date: [**2119-9-6**] Date of Birth: [**2064-3-13**] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 2751**] Chief Complaint: lung cancer obstructing right mainstem bronchus Major Surgical or Invasive Procedure: 1. Rigid bronchoscopy. 2. Flexible bronchoscopy. 3. Mechanical debridement of the endobronchial tumor. 4. Mycoplasma coagulation. History of Present Illness: This is a 55 yo M with a 30 pack year history of tobacco smoking who was transferred from [**Hospital 1562**] Hospital to [**Hospital1 18**] on [**8-31**] for endobronchial mechanical debridement of newly-diagnosed NSCLC, which was obstructing the right mainstem bronchus. . Four weeks prior to admission the patient complained of productive cough and dyspnea on exertion. The patient was thought to have bronchitis, and was treated with Azithromycin with no improvement. Subsequent CXR showed RML consolidation and was concerning for pneumonia. After 8 days of Moxifloxacin, patient was still dyspneic, and complained of night sweats, worsening cough, and fever. He presented to the ED, and CT chest on [**8-30**] showed a large hilar mass 4.2cm x 6cm invading and partially occluding R mainstem bronchus and tracheal carina, with metastases to the trachea. Bronchoscopy and biopsy was performed on [**8-31**] that confirmed non-small cell lung ca. CXR on [**8-31**] showed a small right apical pneumothorax, at most 10%, and complete occlusion of right mainstem bronchus since [**8-30**]. Patient was transferred to [**Hospital1 18**] for consideration of IP procedure to relieve airway obstruction and debulking. Past Medical History: -Non-small cell lung cancer -Depression/Bipolar -Tobacco use Social History: Tobacco use, reduced to [**12-12**] ppd over last 2 years, quit 1 month ago. Previously had a 30 pack year smoking history. No EtOH. Worked in past as a cook. Lives with mother. Family History: Mother with [**Name2 (NI) 64650**] Father with CHF Physical Exam: Vitals: 97.6 108/68 118 24 94% 15L high flow oxygen General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx some erythema Neck: supple, JVP not elevated, no LAD Lungs: decreased breath sounds on right lung, left lung clear CV: Regular rate and rhythm, normal S1 + S2, no murmurs Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: [**2119-9-1**] 06:18AM BLOOD WBC-10.2 RBC-3.97* Hgb-11.1* Hct-33.5* MCV-84 MCH-27.8 MCHC-33.0 RDW-14.1 Plt Ct-420 [**2119-9-1**] 06:18AM BLOOD PT-16.2* PTT-36.4* INR(PT)-1.4* [**2119-9-1**] 06:18AM BLOOD Glucose-115* UreaN-9 Creat-0.7 Na-135 K-4.0 Cl-99 HCO3-27 AnGap-13 [**2119-9-1**] 08:55PM BLOOD ALT-61* AST-42* LD(LDH)-127 AlkPhos-122 TotBili-0.5 [**2119-9-1**] 06:18AM BLOOD Calcium-8.2* Phos-4.2 Mg-2.0 [**2119-9-2**] 03:40AM BLOOD calTIBC-129* Ferritn-1261* TRF-99* . Discharge labs: [**2119-9-5**] 06:50AM BLOOD WBC-10.6 RBC-3.94* Hgb-10.6* Hct-33.2* MCV-85 MCH-27.0 MCHC-31.9 RDW-14.7 Plt Ct-472* [**2119-9-5**] 06:50AM BLOOD Glucose-99 UreaN-7 Creat-0.6 Na-138 K-5.1 Cl-102 HCO3-29 AnGap-12 [**2119-9-4**] 07:20AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.0 . Urinalysis: [**2119-9-1**] 08:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2119-9-1**] 08:55PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2119-9-1**] 08:55PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 . Microbiology: [**2119-9-1**] MRSA screen: negative [**2119-9-1**] Blood culture: no growth [**2119-9-1**] Urine culture: no growth [**2119-9-2**] Blood culture: pending . Imaging: . CXR PA and lateral [**2119-9-1**]: The current study demonstrates right mediastinal shift in combination with abrupt termination of the right main bronchus as well as irregularity in tracheal column. In addition, there is a small right pneumothorax. Findings are consistent with known history of extensive right lung cancer with right main stem obstruction and subsequent complete collapse of the right lung. The left lung is essentially clear. There is no pleural effusion or pneumothorax. Comparison with outside studies as well as cross-sectional imaging is highly recommended. . CT chest with contrast [**2119-9-2**]: 1. In comparison to [**2119-8-30**], there has been interval development of complete opacification of the right upper lobe. 2. Large right hilar mass encasing right main and upper lobe bronchi in addition to bronchus intermedius. There is pretrachial adenopathy and a subcarinal mass which may represent contiguous tumor or adenopathy. The assessment of the local extent of the mass is somewhat limited by extent of adjacent pulmonary opacity and volume loss. 3. Right chest tube in adequate position. A small residual anterior pneumothorax is noted. 4. Opacification with air bronchograms in the right lower lobe, which may represent infection, hemorrhage, or atelectasis. 5. Enlarged pretracheal and subcarinal lymph nodes. No prevascular, left mediastinal or left hilar nodes are identified. . MRI head with and without contrast [**2119-9-3**]: 1. No evidence of intracranial metastatic disease. 2. A small lipoma is present within the right frontal scalp and a small fat deposit/hemangioma in the right side of the anterior arch of atlas. . Bone scan [**2119-9-3**]: Focus of increased uptake in the right manubrium, concerning for isolated metastasis. . Pathology: . Right mainstem bronchus [**2119-9-1**]: Invasive squamous cell carcinoma, moderately to poorly differentiated. Brief Hospital Course: 55 yo M with new diagnosis of NSCLC and large R hilar mass compressing mainstem bronchus, transferred to [**Hospital1 18**] for endobronchial debridement of the obstructing mass. The debridement was complicated by perforation of the bronchus intermedius and pneumothorax, requiring a chest tube. The chest tube was removed prior to discharge. . # Non small-cell lung cancer: The patient was diagnosed at an outside hospital and transferred to [**Hospital1 18**] for ridid bronchoscopy and endobronchial debridement of the tumor, which was obstructing the right mainstem bronchus. The procedure succeeded in permitting aeration of the right upper and middle lobes, but the right upper lobe remained collapsed. The debridement was complicated by perforation of the bronchus intermedius and pneumothorax, which was treated with a chest tube. Given this complication and the fragile nature of the patient's airways, the interventional pulmology team felt that the patient was not currently a candidate for chemoradiation. A bone scan and head MRI were done for staging purposes and were notable for a focus of increased uptake in the right manubrium, concerning for metastasis. Palliative care and hematology-oncology were consulted, and the patient was given the telephone number for the oncology practice at [**Hospital3 **] Hospital. Primary care and pulmonology follow-up were arranged. The patient will need repeat bronchoscopy and chest x-ray at the time of his pulmonology follow-up. . # Airway perforation: The endobronchial debridement procedure was complicated by perforation of the bronchus intermedius due to the friable nature of the patient's airways. A chest tube was placed, but was removed prior to discharge. A dressing will need to remain over the site of the chest tube until [**2119-9-8**]. The stiches will be removed at the time of the patient's pulmonology follow-up on [**2119-9-20**]. . # Respiratory Failure: The patient was intubated with a rigid bronch for mechanical debridement of his airway and attempted placement of Y stent. The procedure was complicated by airway perforation and PTX. Chest tube was placed, and the patient was transferred to the ICU. He was extubated on [**2119-9-2**]. At the time of discharge, the patient was satting well on 4 liters of oxygen. Arrangements were made for home oxygen. . # Post-obstructive pneumonia: The patient was treated for post-obstructive pneumonia with clindamycin and levofloxacin. These antibiotics should be continued until [**2119-9-16**]. . # Coffee ground nasogastric tube output: While in the ICU, the patient had some bloody/coffee ground aspirates from his NG tube. His hematocrit remained stable. He was started on [**Hospital1 **] pantoprazole. There was no further evidence of bleeding. . # Hypotension: The patient was hypotensive peri-intubation. This was thorugh to be due to sedation. He briefly required neosynepherine for blood pressure support. Pressors were quickly weaned off, and the patient remained hemodynamically stable throughout the remainder of his hospitalization. . # Chest wall pain: The patient's chest wall pain, related to the procedures that he underwent, including the chest tube, was treated with oxycodone. The patient was discharged with a prescription for oxycodone. He was also instructed to take acetaminophen 650 mg TID. . # Normocytic anemia: Iron studies were consistent with anemia of chronic disease. The patient had some coffee ground nasogastric output in the ICU, but this quickly resolved and did not result in hemodynamic instability or a significant hematocrit drop. . # Depression: Continued paroxetine. . # Insomnia: Continued trazodone. . # Thrush: The patient was noted to have oral thrush and was started on Nystatin. . # Goals of Care: The interventional pulmonology team discussed goals of care with the patient and his family. This discuss was also repeated with the patient by the palliative care and medical teams. The patient decided to change his code status to DNR/DNI. . # Communication: Healthcare proxy is patient's brother [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 87249**], [**Telephone/Fax (1) 87250**]. . # Pending labs at time of discharge: There is a pending blood culture from [**2119-9-2**]. All other culture has shown no growth. . # Transitional care issues: The patient had no primary care doctor, so a new primary care doctor (Dr. [**First Name (STitle) 15425**] [**Name (STitle) 87251**] of the Community Health Center of [**Hospital3 **]) was arranged. The patient will follow up with Dr. [**Last Name (STitle) 87251**], with Dr. [**Last Name (STitle) **] in interventional pulmonology, and with oncology. The patient stated that he would like to receive his oncology care at [**Location (un) 21541**] Hospital. We were unable to arrange an oncology appointment prior to discharge, but we spoke with the cancer center at Cape Code, and they told us that they would contact the patient to schedule an appointment once they had received records from us. The patient was discharged home with home oxygen and VNA. Medications on Admission: MEDICATIONS ON TRANSFER: Clindamycin IV Levaquin IV Lovenox 40 mg daily (ppx), last dose 9/22 PM Trazodone 50 mg QHS (home med) Paxil 30 mg daily (home med) Nicotine patch 14mg Duonebs Maalox prn Saline tears prn Tylenol #3 1 tab Q4H prn cough Tyelnol prn Lidocaine 2ml 2%solu neb Q4H prn cough Zofran prn HOME MEDICATIONS: Paxil 30mg po qhs Trazadone 50mg po qhs Discharge Medications: 1. home oxygen 4L continuous. Please evaluate for pulse dose for portability. MH# [**Telephone/Fax (5) 87252**]. At rest room air sat 86%. Patient needs portability for doctor's appointments and activities [**3-16**] hours/week. Non-small cell lung cancer. 2. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 4. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*10 Tablet(s)* Refills:*0* 5. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every six (6) hours. Disp:*40 Capsule(s)* Refills:*0* 6. 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* 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:*2 inhalers* Refills:*5* 8. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*2 inhalers* Refills:*5* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 11. Polyethylene Glycol 3350 17 gram Powder in Packet Sig: Seventeen (17) grams PO once a day as needed for constipation. Disp:*30 packets* Refills:*0* 12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: Do not drive or participate in hazardous activities while on oxycodone. Disp:*75 Tablet(s)* Refills:*0* 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush: Swish and swallow. Disp:*250 ML(s)* Refills:*0* 14. Tylenol 325 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: Primary: 1. Non-small cell lung cancer. 2. Airway perforation. 3. Upper GI bleeding Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 **] because the main airway to your right lung was occluded by lung cancer. You had a procedure to open the airway, which was complicated by an airway perforation. You had a chest tube in place to remove air from your chest. The chest tube was removed prior to discharge. You will need to have the dressing removed by your visiting nurse in 2 days (on [**2119-9-8**]). The stitch will remain in place until the time of your follow-up appointment with Dr. [**Last Name (STitle) **] in pulmonary clinic. . While you were in the intensive care unit, you had some bloody output from a tube that was in your stomach. You had no further bleeding and your blood counts remained stable. You were started on a medication called pantoprazole in order to decrease the risk of bleeding. . We have arranged for your to follow up with Dr. [**Last Name (STitle) **] in interventional pulmonology. At the time of your follow-up with Dr. [**Last Name (STitle) **], you will have a repeat bronchoscopy and chest x-ray. We have also made you an appointment with a new primary care doctor and with a new oncologist. . During your hospitalization, you had an MRI of your head and a bone scan in order to look for metastatic disease. The MRI was negative, but the bone scan showed an area of increased uptake in the right side of your breast bone. You should discuss this finding with your oncologist. . You are being discharged on home oxygen. We have arranged for an oxygen company to provide you with the necessary supplies. . There are some changes to your medications. START levofloxacin and clindamycin to treat pneumonia. Continue this for 10 more days. START pantoprazole to reduce the risk of stomach ulcers and GI bleeding START albuterol and ipratropium inhalers as needed for shortness of breath. START oxycodone as needed for pain. This is a sedating medication, and you should not drive or participate in other hazardous activities while on oxycodone. START nystatin swish and swallow for yeast infection in mouth You have been given presciptions for a stool softener called Colace and laxatives called senna and Miralax. You can use these as needed for constipation, which tends to happen with oxycodone. . Follow up as indicated below. If any issue comes up before your new primary care appointment, you can call can call the main number of the Community Health Center of [**Hospital3 **] ([**Telephone/Fax (1) 14916**]) and ask for Ext #125 to speak to triage nurse, [**Last Name (un) 6129**]. Followup Instructions: Department: WEST PROCEDURAL CENTER When: WEDNESDAY [**2119-9-20**] at 8:30am AM [**Telephone/Fax (1) 5072**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage ****NOTE: NOTHING TO EAT OR DRINK FROM MIDNIGHT THE NIGHT BEFORE UNTIL AFTER YOUR APPT.****** . Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2119-9-20**] at 9:00 AM With: [**First Name8 (NamePattern2) 828**] [**Name8 (MD) 829**], MD [**Telephone/Fax (1) 3020**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage . Department: WEST PROCEDURAL CENTER When: WEDNESDAY [**2119-9-20**] at 9:30 AM With: [**First Name8 (NamePattern2) 828**] [**Name8 (MD) 829**], MD [**Telephone/Fax (1) 5072**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage . Name: Dr [**First Name (STitle) 15425**] [**Name (STitle) 87251**] Location: COMMUNITY HEALTH CENTER OF [**Hospital3 **] Address: [**Street Address(2) 87253**], [**Location (un) 9188**], [**Numeric Identifier 84441**] Phone: [**Telephone/Fax (1) 14916**] Appt: [**9-22**] at 10am . We will fax your discharge summary and radiology reports to the [**Location (un) 73424**] Cancer Center at [**Hospital3 **] Hospital. The cancer center will call you to schedule an appointment. If you do not hear from them by the end of the week, please call them at [**Telephone/Fax (1) 56014**]. The address of [**Hospital3 **] Hospital is [**Street Address(2) 87254**], [**Location (un) 9101**], MA.

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icd9cm

[ [ [] ] ]

[ "96.05", "32.01", "96.71", "34.04", "33.22", "33.78" ]

icd9pcs

[ [ [] ] ]

13196, 13257

5750, 10054

315, 447

13385, 13385

2565, 2565

16084, 17845

1987, 2039

11251, 13173

13278, 13364

10862, 10862

13536, 16061

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2054, 2546

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228, 277

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475, 1692

2581, 3057

13400, 13512

10887, 11169

1714, 1776

1792, 1971

4,899

147,326

25569+57456

Discharge summary

report+addendum

Admission Date: [**2153-6-27**] Discharge Date: [**2153-6-29**] Date of Birth: [**2075-9-17**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 2485**] Chief Complaint: Obstructed CBD requiring ERCP Major Surgical or Invasive Procedure: ERCP on [**2153-6-28**]: Moderate diffuse dilation in common bile duct. Unable to visualize specific filling defect or stone. Stent placed, with patent flow. History of Present Illness: 77 yo M with ESRD on HD, COPD, CHF, DM, pna with tracheostomy in place who is transferred from [**Hospital 8**] Hospital ICU for ERCP. After protracted hospital course [**1-10**] bacteremia/pna/uti, pt developed RUQ tenderness on [**6-11**]. At that time, LFTs elevated. RUQ U/S showed sludge in gallbladder. Pt underwent cholecystostomy tube placement for gallbladder decompression. Subsequent HIDA scan showed no flow into duodenum indicating obstruction. Cholangiogram through cholecystostomy showed obstructed common bile duct. CT scan showed no tumor but possible worsening common bile duct dilation. T Bili 11.6, D Bili 7.4, Alk Phos 300 ([**6-26**]), AST and ALT normal at 53 and 12 day of transfer to [**Hospital1 18**] ([**6-27**]), trending up. . Of note, pt admitted to [**Hospital 8**] Hospital on [**2153-5-13**] and was eventually diagnosed with Klebsiella + MRSA pneumonia, Klebs UTI + Klebs bacteremia. Coded [**5-17**] (hypotensive, bradycardic) - was rescusitated and intubated, placed on neosynephrine. Was found to have cecal volvulus . [**5-30**] found to have blood cx+ for Klebsiella, [**Female First Name (un) **], pseudomonas. Also with VRE in bile (cholecystostomy tube). With episodes of tachycardia + hypotensions, controlled on Diltiazem gtt. Past Medical History: ESRD on HD - 3x/week - last on [**6-25**] (monday) COPD (?FEV1) CHF ([**2153-5-28**] - cor pulmonale, poor RV fxn, ?EF) DM CAD s/p CABG paroxysmal A-fib hypercholesterolemia Chronic lower GI bleed Sz d/o (beginning [**2153-6-4**]) Social History: Unknown. Patient speaks mostly Arabic. No hx provided in OSH notes. Family History: Unknown. Physical Exam: Vitals - T 97.5, HR 100 (irregularly irregular), BP 90/60, RR 20, O2 sat 99% on AC/550x20/0.4/5 General - Trached, slightly agitated w/ ?baseline tremor in UE b/l SKin - jaundiced, anasarcic HEENT - icteric sclera, PERRL, petechiae/purpura noted on mucosa of lips and underside of tongue Neck - supple, difficult to assess [**1-10**] trach CVS - distant heart sounds [**1-10**] vented breath sounds, no M/R/G Lungs - vented breath sounds b/l, no noted crackles/wheezes/rhonci Abd - distended, tender to palpation diffusely - greatest in RUQ (assessed by wincing of patient), hypoactive bowel sounds Ext - [**1-11**]+ pitting edema in UE and LE b/l Neuro - Awake - looks at you when speak to him, does not understand english, so difficult to assess ?follow commands, withdraws/reacts to pain Lines - Left IJ C/D/I, R subclavian dialysis cath C/D/I Pertinent Results: WBC 28.4, Hct 29.2, Plt 253, MCV 77 diff: 93% neutrophils, 1% bands, 3% lymphs, 3% monos PT 14.3, PTT 28.5, INR 1.4 . Na 132, K 4.1, Cl 95, CO2 18, BUN 82, Cr 3.2, Glu 81 Ca 7.9, Ph 3.7, Mg 1.3, Uric acid 7.4 . ALT 15, AST 57, Alk Phos 569, Tbili 14.9, Amylase 226, Lipase 106 . Lactate 1.3 Brief Hospital Course: A/P: 77yo man w/ PMH ESRD on HD, COPD, CHF, DM, bacteremia, pna w/ trach, transferred from [**Hospital 8**] Hospital with evidence of obstruction in CBD for ERCP to be performed [**6-28**]. . 1.) CBD Dilatation: Pt transferred from [**Hospital 8**] Hospital for ERCP on [**6-28**]. There was evidence of CBD obstruction via HIDA scan and cholangiogram through his cholecystostomy tube, and he also had clinical evidence of cholangitis and rising LFTs in obstructive pattern @ OSH. No evidence of mass on CT. He was kept NPO over night and had an ERCP in the [**Hospital Unit Name 153**] on [**6-28**] which found moderate diffuse dilation in the common bile duct, but not definitive stones or filling defects were seen. A 10Fx9cm Cotton [**Doctor Last Name **] plast stent was placed. The pancreatic duct was not cannulated. He tolerated the procedure well and remained in the [**Hospital Unit Name 153**] overnight for observation. He was transferred back to [**Hospital 8**] Hospital in the morning of [**6-29**]. . 2.) Bacteremia/pneumonia/UTI/cholangitis: Pt was continued on the broad spectrum antibiotics he was on at [**Hospital 8**] Hospital (Zosyn and Linezolid). No further dose of amikacin was given as he had received one dose prior to arrival in the [**Hospital Unit Name 153**]. Plans for amikacin re-dose after dialysis @ [**Hospital 8**] Hospital on [**6-29**]. . 3.) Hypotension: He continued to require neosynephrine for BP support, with the goal being to keep MAP >60. SBPs were maintained in the 100-120s. He was also continued on dexamethasone 2mg [**Hospital1 **] for suspected underlying adrenal insufficiency. Fluid boluses were not given [**1-10**] oliguric state. . 4.) Respiratory failure: Pt remained on the same vent settings AC/550x20/0.4/5. O2 sats remained between 96-100% while in the [**Hospital Unit Name 153**]. . 5.) ESRD on HD: Nephrocaps and renagel were held [**First Name8 (NamePattern2) **] [**Hospital 8**] Hospital requests. Pt's last HD was on [**6-27**] prior to transfer and will receive his next scheduled HD on [**6-29**] upon his return to [**Hospital 8**] Hospital. . 6.) DM: On RISS, with FS 86-154. . 7.) Seizure disorder: His PO dose of dilantin was given IV as patient was NPO for the ERCP. . 8.) CHF: Pt had no issues with CHF while admitted here. His O2 sats remained stable and there were no signs/sxs of pulmonary congestion/fluid overload . 9.) CAD: Continued to hold his betablocker, ASA, and stain [**1-10**] to his current medical problems (hypotension, GI bleed, and elevated LFTs). . 10.) A Fib: He was continued on Diltiazem gtt for HR control, with a goal HR of <120. He was not anticoagulated [**1-10**] heparin allergy. . 11.) COPD: He was continued on Albuterol/Atrovent nebs (for vent) and dexamethasone IV (for suspected adrenal insufficiency). . 12.) Chronic Lower GI Bleed: During his stay, there were no signs/sx of acute blood loss and no evidence of blood in his stool. . 13.) FEN: TPN held as patient was only here for one day and there were not enough ports available to deliver TPN and his medications/gtt. His electrolytes were monitored and were stable compared to his labs from the OSH. . 14.) PPX: On PPI [**Hospital1 **] (for GI bleed, steroids) and pneumoboots (not on heparin [**1-10**] to heparin allergy). . 15.) Access: No further lines placed here. Pt had L IJ, R subclavian dialysis cath, and cholecystostomy tube placed at OSH. . 16.) Code status: Full . 17.) Dispo: Returning to [**Hospital 8**] Hospital ICU. Medications on Admission: Zosyn 2.25gm q12hr Zosyn 750mg IV post HD Lactinex 1tab per NG [**Hospital1 **] Rocatrol Pravachol 30mg qhs RISS Atrovent 2puffs q 6hr Albuterol 2 puffs q6hr Actigall 300mg [**Hospital1 **] Dilantin 100mg TID Linezolid 600mg [**Hospital1 **] Ditiazem gtt 2-10mg (7.5mg) Ferrous Sulfate 325mg TID Protonix 40mg IV BID Neosynephrine gtt Dexamethasone 2mg [**Hospital1 **] Fentanyl 25mcg q 2hr PRN Zofran 4mg q6hr PRN Desatin ointment to scrotum TID PRN Dulcolax 10mg qd PRN Tyelenol Annusol 1 PR qhs PRN Natural tears 1 drop both eyes PRN Amikacin 600mg IV x 1 dose ([**6-26**]) Discharge Medications: 1. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Pravastatin Sodium 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale unita Injection ASDIR (AS DIRECTED). 4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Pantoprazole Sodium 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 10. Diltiazem HCl 5 mg/mL Solution Sig: 2-10 mg Intravenous INFUSION (continuous infusion). 11. Linezolid 600 mg/300 mL Parenteral Solution Sig: One (1) injection Intravenous Q12H (every 12 hours). 12. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) tablet PO TID (3 times a day). 13. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Two (2) mg Injection Q12H (every 12 hours). 14. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: Twenty Five (25) mcg Injection Q2H (every 2 hours) as needed. 15. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 16. Phenytoin Sodium 50 mg/mL Solution Sig: One Hundred (100) mg Injection Q8H (every 8 hours). 17. Phenylephrine HCl 10 mg/mL Solution Sig: drip mg Injection TITRATE TO (titrate to desired clinical effect (please specify)) as needed for sedation. Discharge Disposition: Extended Care Discharge Diagnosis: Common Bile Duct Dilatation. Discharge Condition: Fair. Patient with significant jaundice. On ventilator via tracheostomy tube. Discharge Instructions: Please continue care at [**Hospital1 8**] ICU per team physicians. Followup Instructions: Patient should have regular dialysis today [**2153-6-29**] on return to [**Hospital 8**] Hospital. Patient should receive dose of Amikacin post dialysis. Patient will need repeat ERCP in 2 months by Dr. [**Last Name (STitle) **] if patient is stable for removal of potential stones and for stent exchange. Name: [**Known lastname 11346**],[**Known firstname 11347**] Unit No: [**Numeric Identifier 11348**] Admission Date: [**2153-6-27**] Discharge Date: [**2153-6-29**] Date of Birth: [**2075-9-17**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 1015**] Addendum: Pt with hyponatremia 131->128 during hospital stay. CVP checked [**6-29**] = 7. Therefore given 500cc NS bolus, with instructions to monitor on transfer to OSH. Discharge Disposition: Extended Care [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1016**] MD [**MD Number(2) 1017**] Completed by:[**2153-6-29**]

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icd9cm

[ [ [] ] ]

[ "51.87", "96.71", "00.14" ]

icd9pcs

[ [ [] ] ]

10303, 10475

3336, 6846

305, 465

9257, 9336

3021, 3313

9451, 10280

2129, 2139

7473, 9146

9205, 9236

6872, 7450

9360, 9428

2154, 3002

236, 267

493, 1774

1796, 2028

2044, 2113

28,277

143,113

3909

Discharge summary

report

Admission Date: [**2163-9-6**] Discharge Date: [**2163-9-27**] Date of Birth: [**2085-12-1**] Sex: F Service: SURGERY Allergies: Bacitracin / Keflex / Plavix Attending:[**First Name3 (LF) 4748**] Chief Complaint: Progressive lower extremity claudication and lower extremity ulcerations bilaterally Major Surgical or Invasive Procedure: PICC line placement [**2163-9-11**] Rt. femoral gamma nail fixation [**2163-9-12**] Abdominal aortogram with proximal study of bilateral lower extremities [**2163-9-15**] Bilateral femoral endartectomies and iliac stenting [**2163-9-16**] History of Present Illness: 77 yo female presented with progressive left toe pain after trama by "high heel shoes" and lt.. toe ulcerations with multiple debridments and rt. toe ulcerations with progression of toe pain requiring narcotics for relieve . She has been incompacitated by pain and not able to ambulate as she use to do. [**Last Name (un) **] admitted for vascluar evaluation and IV antibiotics for toe ulcerations. Past Medical History: histroy of Dm2 histroy of hypothyroidism histroy of hypertension history of urinary incontinence histroy of carotid disease s/p left cea '[**64**] ,multiple TIA and syncople episode over the last eight years. current U/s of carotids occluded [**Country **], left ICA patent, Social History: lives with daughter Family History: noncontributory Physical Exam: Gen: AAOx3 Heart; RRR holosysltoic with percordial transmission Lungs:clear to ausculatation ABD: benging, tuberant. wearing diaper EXT: toes exquisetly tender and erythematous bilaterally with ulcerations of left ist toe and rt. #2 toe Pulses absent bilaterally. Neuro: nonfocal Pertinent Results: [**2163-9-6**] 11:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2163-9-6**] 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2163-9-6**] 11:00PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2163-9-6**] 08:30PM GLUCOSE-196* UREA N-13 CREAT-0.6 SODIUM-133 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-23 ANION GAP-15 [**2163-9-6**] 08:30PM estGFR-Using this [**2163-9-6**] 08:30PM ALT(SGPT)-23 AST(SGOT)-23 ALK PHOS-109 TOT BILI-0.1 [**2163-9-6**] 08:30PM WBC-7.0 RBC-3.86* HGB-12.3 HCT-34.4* MCV-89 MCH-32.0 MCHC-35.8* RDW-12.1 8 08:30PM PLT COUNT-284 [**2163-9-6**] 08:30PM PT-11.8 PTT-22.7 INR(PT)-1.0 EKG [**9-12**] 1Low atrial rhythm, likely sinus with atrial premature beat. Diffuse T wave flattening. No significant difference compared with prior tracing. SUN [**2163-9-11**] 3:08 PM PFI: Left PICC tip is not clearly visualized. The tip can be followed to the brachiocephalic confluence. The lungs are clear. There is no pneumothorax or pleural effusion. Cardiac size is top normal. ECHO: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are 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). 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. An eccentric, posteriorly directed jet of mild to moderate ([**1-19**]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. Stress test: [**2163-9-12**] 1. Normal myocardial perfusion, apart from the inferior wall which could not be assessed. Reimaging was not performed due to concerning EKG changes. 2. Normal LV cavity size and systolic function (EF 74%). CT abd/pelvis [**9-12**] 08 1. No evidence of solid organ injury. 2. Porcelain gallbladder. 3. Right femoral fracture, previously described on recent pelvic CT. U/scarotids [**9-9**] FINDINGS: Duplex evaluation was performed of bilateral carotid arteries. On the right there is a heterogeneous plaque with heavy calcification in the proximal ICA. There is minimal flow seen in the right ICA with a peak velocity of 17 and end-diastolic velocity of 0. CCA and ECA are patent with peak velocities of 44 and 147 cm/s respectively. This is consistent with near-occlusive stenosis or recanalization. On the left there is mild plaque in the proximal ICA. Peak velocities are 103, 81 and 172 cm/s in the ICA, CCA and ECA respectively. This is consistent with less than 40% stenosis. CTA [**2163-9-8**] IMPRESSION: 1. Severe atherosclerotic disease of the aorta and its distal branches. Some of the vessels demonstrate a focal noncalcified occlusion but with reconstitution of collaterals distally.Please refer to the body of the report 2. Calcified gallbladder stone versus porcelin gallbladder. A CT abdomen non-contrast or ultrasound examination is recommended. 3. Colonic diverticulosis without evidence of diverticulitis. The report has been placed on the radiology dashboard for it to be relayed to the referring doctor. Brief Hospital Course: [**2163-9-6**] admitted . IV antibiotics started Vanco,cipro,flagyl. [**2163-9-7**] carotid ultra sounds cardiology consult for ? hx NSTEMI in last months [**2163-9-8**] CTA of aorta,iliacs and femoral severe diseased calcified aorta iliac and femorals [**2163-9-9**] Stress, negative for ischemia. fall, RT. hip FX Ortho consulted [**Date range (1) 17433**] /08 awaiting cardiology evaluation to proceed with Ortho procedure. poor venous access PICC line placed. RT. gamma nail fixation [**Date range (1) 15151**] /08 Iv antibiotics continued. Social service consulted for family support. Angio diagnostic completed.[**Last Name (un) **] consult for DM management. [**2163-9-16**] DOS: bilateral iliac stenting with femoral endartectomies.CVL placed(RT. IJ) [**Doctor Last Name 10219**];enc reversed with Narcan. Patient in respiratory failure re intubated. Transferred to ICU .Hypotension treated with neo gtt.Low urinary ;output treated with fluid resustation.Beta blockers held. cardiac enzymes . troponin 0.03-0.05 .Intraoperative Af.converted to NSR. [**2163-9-17**] POD#1 remains intubated and on neo gtt.antibiotic of Vanco and Cipro continued. [**2163-9-18**] POD#2 Extubated and re intubated for respiratory failure. Transfused for HCT. 26.6(30.0) CT scan of ABD done was negative for retroperitoneal bleed. [**2163-9-19**] POD#3 remain intubated and on propofol gtt. neo weaned. post transfusion HCT. 31.9 requiring IV NTG gtt for systolic HTN. sacral coccyx stage 1 decubitus: DuoDerm. [**2163-9-20**] POD#4 off NTG gtt. hypertension controlled. remains intubated on CPAP/ps successfully weaned and extubated later in Pm/.Pt continues to follow. [**2163-9-21**] POD#5 transferred to VICU.coumadin began, lovenox continued. [**2163-9-22**] POD#6 Swallowing evaluation. sings/SX of aspiration of thin liquids and pharyngeal residue of solids .recommendation nectar thickened clear liquids. po meds crushed in spoon fulls. Video study scheduled for conformation of ? prandial aspiration and safest diet.Aztreonam started for PNA. [**2163-9-23**] POD# 7 videoswallow done, mild orophargeal dysphagia without aspiration. recommended ground solids and thin liquits. med in purees. 1:1 supervision with meals with standard aspiration precautions.Nutrition consulted. supplements ar meals. [**2163-9-24**] POD# 8 glycemic control continues to improve. Rehab screening in place. [**Date range (1) 17434**] POD's # [**2166-9-27**] stable. pulmonary status stable. tolerating po's. d/c to rehab. Medications on Admission: levothyroxin 75mcg daily glyburide 2.5mg daily simvistatin 10mgm daily norvasc 5mgm daily Vicodan [**1-19**] tab @ HS lisinopril 10mgm qpm tylenol prn asa 81mgm daily Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 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. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. Haloperidol Lactate 5 mg/mL Solution Sig: as directed Injection HS (at bedtime) as needed for agitation: 0.125-0.25mg IM. 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 11. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous Q12H (every 12 hours). 12. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 16. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 18. Insulin sliding scale Insulin SC Fixed Dose Orders Bedtime Glargine 8 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-60 mg/dL [**1-19**] amp D50 61-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-160 mg/dL 2 Units 2 Units 2 Units 0 Units 161-200 mg/dL 3 Units 3 Units 3 Units 0 Units 201-240 mg/dL 4 Units 4 Units 4 Units 2 Units 241-280 mg/dL 5 Units 5 Units 5 Units 4 Units 281-320 mg/dL 6 Units 6 Units 6 Units 5 Units > 320 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital 17435**] Rehab @ [**Hospital 17436**] Hospital Discharge Diagnosis: postoperative PNA Bilateral aorto-ilia-femoral disease with lower extremity ulcerations and claudication History of hypertension History of DM2,controlled History of carotid disease with multiple TIA and syncopal episode over last eight years,s/p left CEA '97now with occluded [**Country **] by U?S, [**Doctor First Name 3098**] patent Right femoral neck fx History of urinary incontinance History of hypothyroidism Post angio confusion secondary to concous sedation,resolved Postoperative somulance with respiratory failure, reintubated Postoperative acute blood loss anemia,transfused-corrected Postoperative hypotension, treated with neo gtt,resolved Postoperative hypertension, resolved with Ngt. gtt. Postoperative oliguria, fluid resustated Postoperative dysphagia Postoperative sacral decub stage 1 Postoperative lymphatic drainage, treated with wound vac Discharge Condition: stable Discharge Instructions: Incision Care: Keep clean and dry. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. -Your staples will be removed during at your follow up appointment. Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([**11-2**] lbs) until your follow up appointment. * Continue wound vac care. Followup Instructions: 2 weeks Dr. [**Last Name (STitle) 1391**], call [**Telephone/Fax (1) 1393**] for an appointment. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1005**] (Orthopedic surgeon), call [**Telephone/Fax (1) 1228**] for an appointment. Follow-up with primary care physician [**Name Initial (PRE) 176**] 1 week. Pt needs to have INR checked with followup on [**2163-9-29**]. Please check electrolytes (chem-10) every other day for next week until electrolytes normalize. Replete electrolytes as necessary with po supplements. Completed by:[**2163-9-28**]

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icd9cm

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icd9pcs

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10276, 10361

5318, 7817

372, 613

11268, 11277

1726, 5295

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1393, 1410

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11301, 11301

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1356, 1377

27,463

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33962

Discharge summary

report

Admission Date: [**2119-8-18**] Discharge Date: [**2119-9-1**] Date of Birth: [**2051-4-21**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 603**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: Removal of tunneled hemodialysis catheter and placement of another. Insertion and removal of left internal jugular central venous line. Insertion and removal of femoral central venous line. History of Present Illness: 68 yo F with history of afib on coumadin, systolic CHF with EF 15%, CAD, DM2 on insulin, s/p L AKA, p/w fall out of bed this morning. Pt fell two feet out of bed onto wooden floor onto her R side. Happened early this morning while she was sleeping. C/O R sided rib pain, headache (though denies head trauma or LOC), and pain at L AKA stump (which is chronic). Denies any LH/dizziness or other prodromal symptoms. Of note, pt had 3 admissions over the past month for SOB and volume overload, was treated with HD. . In the ED vitals notable for SBP 79-94, HR 79. She was given a 500ml bolus of fluid and her SBP went up to 99. She was given morphine 4mg IV x1 and percocet 5/325mg x2 for pain as well as nebs. She had CXR, CT head, C spine and abdomen/pelvis for trauma work up, all of which was negative. She was admitted to the floor for pain control and placement. . On arrival to the floor, she trigerred for hypotension with BP 78/doppler. Satting mid-high 90s on RA. EKG was v-paced. Currently, she complains of headache and R-sided rib pain and upper sternal pain. Denies LH/dizziness, chest pain, SOB, abdominal pain. A 500cc bolus was started and BP improved quickly to 90/doppler and remained stable. . ROS: As above, otherwise denies fever, chest pain, abdominal pain, diarrhea, constipation. No nausea/vomiting. No arthralgias, numbness/tingling in extremities. Past Medical History: 1. CHF with EF of 15% s/p BiV pacer on coumadin, recently admitted for CHF exacerbation in [**7-23**] 2. ESRD - on HD since [**2119-8-1**], *EDW 64.4 kg* 3. CAD s/p MI & CABG x 2 ([**2108**] and revised in [**2118**]) 4. DMII x 4yrs on insulin 5. s/p L AKA 6. Hypothyroidism 7. a-fib Social History: Lives at home with daughter. Remote smoking history less than 2-3yrs total, pt has not smoked in over 30yrs. There is no history of alcohol abuse. Family History: non-contributory Physical Exam: VITAL: T 98.4, BP 78/dop-->90/dop (s/p IVF), HR 81, RR 22, 100% 2L--> 99% RA GEN: fatigued obese female lying in bed, spanish-speaking, A+Ox3, NAD HEENT: PERRL, EOMI, OP clear, MMM NECK: supple CV: distant heart sounds, RRR, II/VI holosys murmur at LSB, no M/G/R PULM: mild bibasilar rales, no wheeze ABD: Soft, NT, ND, +BS, obese EXT: s/p L AKA, trace RLE edema, 2+ R DP pulse by doppler Pertinent Results: [**2119-8-18**] 01:40PM GLUCOSE-206* UREA N-28* CREAT-3.1* SODIUM-135 POTASSIUM-5.7* CHLORIDE-93* TOTAL CO2-32 ANION GAP-16 [**2119-8-18**] 01:40PM WBC-7.3 RBC-3.70* HGB-9.9* HCT-33.8* MCV-91 MCH-26.8* MCHC-29.3* RDW-17.4* [**2119-8-18**] 01:40PM PT-16.0* PTT-24.9 INR(PT)-1.4* MICRO: [**8-28**] BCx: NGTD [**8-27**] BCx: NGTD [**8-26**] Fem line tip: Klebsiella Pn., pan R (I to gent) [**8-26**] HD line: no signif growth [**8-24**] BCx: coag neg staph [**8-23**] Bcx: NGTD [**8-22**] BCx: NGTD [**8-21**] UCx: no growth [**8-21**] BCx: NGTD [**8-21**] Stool O+P: + for strongyloides [**Date range (1) 67624**] BCx: + for coag neg staph (MRSE)x3 . STUDIES: . [**2119-8-18**] EKG: v-paced at 71 bpm, unchanged from prior . [**2119-8-18**] CT head without contrast: no acute process . [**2119-8-18**] CT C spine without contrast: no cervical spine fx or malalignment, though slightly limited by pt motion. probable small tracheal diverticulum at level of C7. irregular soft tissue density material at level of C6 most likely represents thickened secretions or mucous. . [**2119-8-18**] CT abdomen/pelvis: IMPRESSION: 1. No acute traumatic injury in the abdomen or pelvis. 2. Moderate-sized simple right pleural effusion and adjacent compressive atelectasis. 3. Trace ascites. 4. Extensive vascular calcification. . [**8-22**] TTE: IMPRESSION: Mild ventricular hypertrophy with severe global systolic dysfunction and severe diastolic dysfunction. No echocardiographic evidence of endocarditis. Mild mitral regurgitation. Moderate pulmonary hypertension. . [**8-25**] CXR A right dual lumen internal jugular central venous line and left pacemaker leads are in unchanged position. Moderate cardiac enlargement is stable. Increased interstitial markings consistent with mild interstitial edema are unchanged, however, a small right-sided pleural effusion has mildly increased in size. . [**8-27**] UE DOPPLERS: IMPRESSION: Partially occlusive thrombus in the right internal jugular vein. . [**8-30**] CT Chest: 1. Moderate cardiac decompensation as evidenced by interstitial and alveolar edema, moderate-sized right pleural effusion, and cardiomegaly. No acute consolidative process. 2. No evidence of tracheobronchomalacia. 3. No evidence of pulmonary embolism. Brief Hospital Course: Pt is a 68 yo female with afib, systolic CHF with EF 15%, CAD, DM2 on insulin, s/p L AKA admitted following mechanical fall. 1.MRSE Bacteremia: On admission, pt was hypotensive in ED and on floor, found to have GPCs (grew MRSE) in blood on [**6-13**], [**8-24**], transferred to MICU on [**8-21**], started on Vanco which should be continued for 14 days after last positive culture which was [**2119-8-26**] (a fem line tip). This fem line tip from [**8-26**] also grew pan-resistant Klebsiella which was thought to be a contaminant. TTE this admission was negative. Pt had a left IJ placed after cultures cleared which was removed at D/C. Pt briefly required levophed in MICU. On arrival to the floors, her pressures continued to improve and she was restarted on home doses of lisinopril and carvedilol with SBP on day of d/c in 110s. Pt discharged to continue vanco dosed at HD on Tues, Thurs, Sat to end [**9-9**]. . 2. Chronic ischemic CM: EF 15% s/p [**Hospital1 **] V pacer also s/p MI and CABGX2 IN [**2108**] AND [**2118**]. Hypotension resolved at discharge, was likely from bacteremia. Pt discharged on home regimen of Lisinopril, Carvedilol, ASA. . 3. RUE DVT: Discovered [**8-27**] after tunneled HD catheter taken out [**8-26**]. Pt was on heparin gtt until d/c. Pt restarted on coumadin 2 days prior to discharge. Given Coumadin 5mg Daily at d/c with INR to be repeated Tues [**9-5**] at dialysis. INR at discharge 1.9. . 4. [**Name (NI) 39621**] Pt on heparin gtt here, discharged on coumadin. . 5. DM2: Pt continued on home dose Glargine 12 units Daily here with Humalog SS and discharged on same. . 6. CKD: ESRD, presumed [**3-18**] DM on HD x 1 month prior to admission T/Th/Sa. HD continued in house and pt discharged on same home schedule. Continued Sevelamer. . 7 Anemia: HCT stable and 31.5 at discharge. . 8. Hypothyroidism: Pt continued on Levothyroxine. . 9. Strongyloides: Diagnosed by stool O and P in MICU after eosinophilia was noticed. Pt given ivermectin x 2 doses (full course for uncomplicated infxn). . 10. FULL CODE, confirmed on MICU admission Medications on Admission: Levothyroxine 125 mcg Tablet PO DAILY Aspirin 325 mg Tablet PO DAILY Docusate Sodium 100 mg Capsule Capsule PO BID Sevelamer HCl 400 mg Tablet PO TID W/MEALS Carvedilol 3.125 mg Tablet PO BID Warfarin 9 mg Tablet PO once a day. Lisinopril 2.5 mg Tablet PO DAILY Lantus 12u qHS. Humalog sliding scale Albuterol neb Q6H as needed for wheezing. Tramadol 50 mg PO Q6H as needed for pain. Zolpidem 5 mg Tablet PO HS as needed for for sleep. Lorazepam 0.5 mg Tablet PO HS as needed for anxiety. Guaifenesin [**6-24**] mL PO Q6H PRN as needed for cough. Senna 8.6 mg Tablet PO BID as needed for constipation. Bisacodyl 10 PO Q24 PRN as needed. Lactulose 15 mL PO Q4H PRN as needed Discharge Medications: 1. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet(s)* Refills:*2* 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(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. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*1* 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. Disp:*30 neb* Refills:*2* 9. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. Disp:*200 units* Refills:*2* 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. Disp:*80 Tablet(s)* Refills:*2* 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) ML PO Q6H (every 6 hours) as needed. Disp:*100 ML(s)* Refills:*2* 13. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. Disp:*20 Tablet(s)* Refills:*1* 14. Humalog 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous three times a day: see attached sliding scale. Disp:*1 bottle* Refills:*2* 15. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO every four (4) hours as needed for constipation: For severe constipation. Disp:*90 mL* Refills:*1* 16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. Disp:*20 Adhesive Patch, Medicated(s)* Refills:*0* 18. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 19. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. Disp:*80 nebulizations* Refills:*2* 20. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours) as needed. Disp:*30 Tablet Sustained Release(s)* Refills:*1* 21. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 22. Outpatient Lab Work INR check Tues [**2119-9-5**] at Hemodialysis. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: MRSE bacteremia Secondary diagnoses: s/p fall RUE DVT CHF with EF 15% Atrial fibrillation DM type 2 ESRD on HD Hypothyroidism Anemia Strongyloides Discharge Condition: Stable. O2 sat 100% on RA. Discharge Instructions: You were admitted after a fall at home. While you were here, you were found to have low blood pressures which required your transfer to the ICU. For the last few days, your blood pressures have been good and we have been able to restart you on your home doses of Lisinopril and Carvedilol. We think that your low blood pressures were caused by an infection in your blood which is being treated with antibiotics until [**9-9**]. You will get your antibiotics when you go to dialysis on Tuesday, Thursday and Saturday. Please do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 1988**] dialysis sessions. You will also have your INR checked at hemodialysis on Tuesday [**9-5**]. This is a mark of your coumadin level. Weigh yourself every morning, [**Name8 (MD) 138**] MD if you have a weight change > 3 lbs. Adhere to 2 gm sodium diet. Please call your doctor or return to the ED if you have any chest pain, increasing shortness of breath, fever, chills, swelling in your legs, loss of consciousness, confusion, diarrhea or any other concerning symptoms. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] (cardiology) Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2119-9-4**] 10:00 Provider: [**Name10 (NameIs) 16244**] [**Last Name (NamePattern4) 16245**], MD (endocrinology) Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2119-9-4**] 3:40 Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in the next 2 weeks. The office number is [**Telephone/Fax (1) 12473**]. Please continue Hemodialysis Tues, Thurs, Sat and have your INR checked at dialysis Tues [**2119-9-5**]. Completed by:[**2119-9-1**]

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icd9cm

[ [ [] ] ]

[ "39.95", "38.93", "38.95", "97.49" ]

icd9pcs

[ [ [] ] ]

10737, 10743

5138, 7231

322, 514

10953, 10982

2848, 5115

12102, 12759

2404, 2423

7955, 10714

10764, 10764

7257, 7932

11006, 12079

2438, 2829

10820, 10932

274, 284

542, 1916

10783, 10799

1938, 2223

2239, 2388

3,482

192,399

50031

Discharge summary

report

Admission Date: [**2152-11-15**] Discharge Date: [**2152-11-29**] Date of Birth: [**2097-4-20**] Sex: M Service: MEDICINE Allergies: Penicillins / Codeine / Pork Derived (Porcine) Attending:[**First Name3 (LF) 2195**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: Endotrachial intubation PICC line placement History of Present Illness: Mr. [**Known firstname **] [**Known lastname 17204**] is a 55-year-old man with CAD s/p CABG, hypertension, COPD on 2L of home oxygen and multiple recent hospital admissions who presented one day prior to admission with worsening shortness of breath. He is now transferred to the ICU for worsening hypercarbia and initiation of BiPAP. Notably, the patient has had 4 admissions in the past 2 weeks for similar symptoms and he has been treated for COPD exacerbations. He reports that on discharge from the hospital about four days ago, he was feeling well. At 1 am on the morning of admission he experienced an episode of shortness of breath while watching TV. He turned his oxygen up, used his nebulizers and inhalers and had no relief. He waited until the morning hours and then went to the ED. He reports using all medications as prescribed and using oxygen regularly. He smokes 1 ppd but states he is quitting today. In the ED, initial vs were: T 97.8, 102, 152/111, 20, 96% on 2L. Patient was given nebs, prednisone 30 mg (total dose on day of admission 60 mg), and azithromycin. He was given morphine 4 mg IV for pain and Toradol. Labs showed leukocytosis of 14.4 and otherwise unremarkable. BNP was 1163 and troponin was negative. ECG showed sinus tach without ST changes. On the floor, patient was continued on prednisone 60 mg and azithromycin. On day of transfer to the ICU, patient was noted to become increasingly confused and an ABG was performed that showed respiratory acidosis with 7.19/93/96 (no previous for comparison during this admission). It is noteworthy that the patient had received 0.5 mg Ativan x2 and morphine earlier in the afternoon, and there is concern that this may have contributed to his altered mental status. He is transferred to the ICU for worsening respiratory acidosis. Vital signs at time of transfer are O2 sat mid 90s on 3L oxygen, HR 70, BP 127/57, RR 26. Notably, on the day of transfer his metoprolol was stopped and changed from amlodipine. Otherwise most of his home medications have been continued. ROS: currently, patient endorses shortness of breath and chest tightness. Review of systems is otherwise limited as patient is currently on Bipap for ventilation. Past Medical History: 1) CAD s/p MI and CABG PCI [**5-/2150**]: patent LIMA to the LAD, RIMA to the RCA, BMS placed in the RCA just distal to his RIMA touchdown, Cath [**12/2150**]: widely patent LIMA and RIMA grafts; patent distal RCA stent and known occluded native LAD and RCA. Nuclear Stress [**1-/2151**] Nuclear Perfusion Stress: no anginal symptoms or ischemic ST segment changes. 2) Tobacco abuse- 1ppd/3 days since age 21 3) Hypercholesterolemia 4) Hypertension 5) COPD on 2L home O2 overnight 6) History of head trauma in [**2118**] from MVA with post-traumatic grand mal seizure, now off antiepileptics 7) Thoracic aortic anuerysm s/p repair [**2148**] 8) neurogenic claudication 9) s/p spinal stenosis surgery [**1-/2152**] Social History: Patient lives with his sister in law and her children. -Tobacco history: 30 pk/year hx, recently increased from [**12-4**] ppd to 1 ppd, currently smokes 1 ppd but quit on admission -ETOH: previous hx of 16-30 beers/day, cut back a year ago, now occasional 1-2 beers. -Drug: denies hx of IVDU Family History: Mother died of MI at 59. Father died at 61 of "MI and cancer." Cousin with MI at 41. Paternal uncle died with MI at 41. Sister with borderline diabetes. Brother died of throat cancer. Physical Exam: Exam on Admission: Vitals: T: 97.7 BP: 112/66 P: 98 R: 26 O2: 95% 4L General: Alert, oriented, breathing somewhat labored HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP difficult to assess due to neck muscle contraction, no LAD Lungs: Diffuse wheezes throughout lung fields, no rales or crackles, barrel-chested CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2152-11-15**] WBC-14.4*# RBC-5.15 Hgb-13.0* Hct-39.1* MCV-76* MCH-25.2* MCHC-33.2 RDW-16.4* Plt Ct-246 UreaN-13 Creat-0.5 Na-137 K-4.8 Cl-95* HCO3-27 AnGap-20 proBNP-1163* CXR [**2152-11-15**]: 1. No acute pulmonary process with no evidence of pulmonary edema. 2. Hyperexpanded lungs due to underlying obstructive lung disease. Discharge Labs: [**2152-11-28**] WBC-9.7 Hct-30.9* [**2152-11-29**] Glucose-87 UreaN-20 Creat-0.4* Na-139 K-4.1 Cl-94* HCO3-42* Brief Hospital Course: 1. COPD with severe exacerbation: At presentation patient was treated with prednisone 60mg On [**2152-11-16**] he became acutely confused, took off his oxygen, with desats to 60s on room air; ABG showed 7.19/93/96. Soon afterwards he was transferred to the ICU for NIV with subsequent endotrachial intubation and mechanical ventilation. After tranfer and intubation he was covered with vancomycin and levofloxacin for possible hospital-aquired respiratory infection with increase in steroids to 60mg IV solumedrol. Sputum subsequently grew MRSA and Serratia Marsecens. After three days on mechanical ventilation he was extubated and soon thereafter discharged to the medical floor. He completed his course of Vancomycin/Levofloxacin with no further respiratory issues and tolerated a Prednisone taper. 2. Coronary artery disease and hypertension: Continued home regimen of [**Date Range 42297**], aspirin. Held lisinopril and amlodipine initially given hypotension surrounding intubation. Restarted Amlodipine and Lisinopril in the ICU, and then metoprolol and furosemide on the medical floor, which the patient tolerated well. 3. Lower extremity edema: Mild LE edema starting on [**11-27**], R>L. No pulmonary edema. Patient had mild response to PO lasix at increased dosing (40mg daily) with stable Cr. Thought to be secondary to steroids; bilateral lower extremity dopplers negative for DVT on the day of discharge. If lower extremity edema persists after cessation of steroids would also consider possible contribution of Amlodipine and consider a trial discontinuation. Electrolytes to be checked by VNA on [**2152-12-1**] with results faxed to Dr.[**Last Name (STitle) **]. 4. Anemia: Hct decreased from 39 on admission to 26-27, but remained stable at that level. Iron studies consistant with iron deficiencies. Stools were guaiac negative. Placed on ferrous sulfate supplementation. Defer further work-up to the outpatient setting. 5. Chronic Back Pain: Continued 5/325mg Percocets 1-2 Tabs q6hr prn pain and encouraged patient to discuss pain regimen with his PCP. 6. Goals of care: Given frequent admission related to symptoms control, palliative care was consulted and confirmed DNR but OK to intubate. He also prefers to be at home with his sister-in-law and HCP, [**Name (NI) **]. 7. Medication compliance: Extended conversations with the patient and his sister-in-law brought to light that the patient has not been taking his medications as prescribed between admissions. He confirmed this, during a family meeting on [**11-28**], and is now agreeable to having his sister-in-law administer his medications. VNA will be arranged to assist with medication reconciliation. Based on a review of his medications at home, with his sister-in-law [**Name (NI) **], many of his cardiac medications have not been filled since [**2151-12-3**]. He is aware of the importance of medication compliance in reducing readmissions. An adequate supply will be provided to the patient, to reach his planned appointment with his PCP. Medications on Admission: Medications, per last d/c summary, confirmed with patient: Advair 2 disks [**Hospital1 **] Omeprazole 40mg PO daily Ipratropium nebs q6H PRN Albuterol 1 neb q4H PRN Fluticasone 50mcg 2 sprays nasal [**Hospital1 **] Lidocaine patch for back (patient was unable to get this as an outpatient) Iron 300mg PO daily Prednisone 30mg PO daily (empty bottle at home, presumably taking) Percocet 1-2 tabs PO q6H PRN pain (pt states he takes 2 tablets 3 times per day) Medications with bottle [**2151-12-3**] date at home (empty or nearly empty bottles, unclear if taken recently per sister-in-law reviewing medications over the phone): Aspirin 325mg PO daily Simvastatin 20mg PO daily Lisinopril 20mg PO daily Metoprolol Tartrate 100mg PO BID Lasix 20mg PO daily Ranitidine 150mg [**Hospital1 **] Calcium +D 600mg [**Hospital1 **] Discharge Medications: 1. Outpatient Physical Therapy PULMONARY REHAB 2. Nicoderm CQ 14 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day. Disp:*30 patches* Refills:*0* 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): please apply to both feet up to the ankles twice daily, after showering. Disp:*qs tube* Refills:*0* 6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 8. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* 10. nicotine (polacrilex) 2 mg Gum Sig: [**12-4**] Gums Buccal Q1H (every hour) as needed for nicotine craving. Disp:*120 Gum(s)* Refills:*0* 11. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day): Please rinse out your mouth after using this medication. Disp:*qs qs* Refills:*0* 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for wheezing. 13. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain for 10 days: 10 day supply only. Need to discuss with PCP about this medication at followup appointment. Disp:*80 Tablet(s)* Refills:*0* 14. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days: Please take for 2 more days, then stop on [**2152-12-1**]. Disp:*2 Tablet(s)* Refills:*0* 15. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). Disp:*60 Disk with Device(s)* Refills:*0* 16. 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* 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* 18. furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day: Please take this every day. Call your doctor if you have leg swelling and they can talk to you about adjusting your dose. Disp:*60 Tablet(s)* Refills:*0* 19. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: COPD, with severe exacerbation Respiratory failure with intubation MRSA pneumonia CAD, s/p CABG, stable Episodic hypotension Hypertension Anemia, multifactorial Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [**Known lastname 17204**], It was a pleasure to care for you during this admission. As you know, you were admitted for an exacerbation of your COPD and pneumonia with MRSA. This was so severe you required intubation and placement on mechanical ventilation. You will need to slowly come down on your prednisone dose in an attempt to keep your symptoms controlled, but we have been able to decrease it to 10mg during your stay. We hope you will be able to remain off cigarettes after discharge. To that end, we have given you a prescription for nicotine gum. Please use this when you have a craving to smoke. We want to ensure you know that you should never use your oxygen when you are smoking, as this can cause an explosion. We have confirmed which medications you have at home with your sister-in-law, at your suggestion. We want to reinforce how important it is that you take oyur medications as prescribed, and regularly. Followup with Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) **] is particularly important, as they may need to adjust your medications. Followup Instructions: Department: [**Hospital3 249**] When: THURSDAY [**2152-12-7**] at 2:10 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11917**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: MONDAY [**2152-12-11**] at 3:00 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "441.2", "V12.04", "401.9", "786.50", "309.24", "724.2", "272.0", "V45.81", "482.83", "V58.65", "E935.2", "V49.86", "110.4", "428.33", "276.4", "280.9", "428.0", "292.81", "288.60", "424.1", "491.22", "V46.2", "305.1", "482.42", "719.43", "518.81" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "96.71", "38.91", "96.6" ]

icd9pcs

[ [ [] ] ]

11541, 11599

5002, 8045

331, 376

11803, 11803

4498, 4498

13062, 13706

3686, 3871

8917, 11518

11620, 11782

8071, 8894

11953, 13039

4866, 4979

3886, 3891

270, 293

404, 2619

4514, 4850

3905, 4479

11818, 11929

2641, 3357

3373, 3670

60,403

153,507

5741

Discharge summary

report

Admission Date: [**2142-4-1**] Discharge Date: [**2142-4-6**] Date of Birth: [**2065-10-7**] Sex: F Service: CARDIOTHORACIC Allergies: Darvon / Cardizem / Shellfish / Methyldopa, Methyldopate Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**4-1**] Cardiac cath [**4-2**] Coronary artery bypass grafting x3: Left internal mammary artery to left anterior descending artery and saphenous vein grafts to the obtuse marginal and posterior descending arteries History of Present Illness: This 76 year old female who presented to an OSH after developing chest pain at 9 AM this morning. She reports a 2 month history of pain under her left arm radiating across chest which she attributed to indigestion and was relieved with Maalox. This morning she awoke with similar pain, rate 7/10, radiating across chest, associated with diaphoresis, not relieved with Maalox. She was taken to OSH and found to have ST elevation on EKG, was Plavix loaded and transferred to [**Hospital1 18**] for cath. Catheterization revealed 70% Left main disease, 95% LCX, RCA 100% with left->right collaterals. An IABP was inserted via the right femoral with ongoing chest pain. She is currently chest pain free on NTG and Heparin gtts. Cardiac surgery was consulted for evaluation. Past Medical History: Breast cancer [**2137**] (s/p partial left mastectomy,s/p radiotherapy,Arimidex therapy) peripheral vascular disease- s/p L SFA stent [**3-/2139**] Hyperlipidemia Osteoporosis hypertension Lower limb edema rheumatoid arthritis/ Kyphosis h/o Premalignant lesion of left leg -- treated with cryotherapy --> nonhealing ulcer --> Left BKA [**2139**] s/p Appendectomy s/p Carpal tunnel release Social History: Retired nurse - Tobacco history: Stopped in [**2119**], 40 pack yr history - ETOH: 1 glass wine, 1 scotch daily - Illicit drugs: None Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: MI in 60s; several siblings with CAD - Father: Passed away from COPD Husband passed away 2 years ago Physical Exam: Pulse: 67 Resp: 16 O2 sat: 96% RA IABP1:1 B/P Right: 120/48 Left: Height: 5"0" Weight:120# General: AAOx 3 in NAD Skin: Dry [x] intact [x] Ecchymosis of RLE HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] IABP [**Last Name (un) 22881**] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Well healed mid line incision scar Extremities: Warm [x], well-perfused [] Edema trace RLE edema, Left BKA Varicosities: Right lower extremities Neuro: Grossly intact [x] Pulses: Femoral Right:IABP Left:2+ DP Right:none Left: BKA Dopleraable popliteal pulse PT [**Name (NI) 167**]:dopplersble Left:BKA Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: [**4-1**] Cath: 1. Selective coronary angiography in this right dominant system severe left main and 2 vessel coronary artery disease. The LMCA had a 70% diffuse complex calcified lesion. The LAD had a 60% stenosis at the origin and 60% in the proximal region. The LCX had a 95% stenosis at the origin and an 80% ramus stenosis. The RCA had a 100% mid-vessel occlusion with left to right collaterals. 2. Limited resting hemodynamics revealed a central aortic pressure of 150/70mm Hg. . [**4-2**] Carotid U/S: 1. Less than 40% stenosis of the right internal carotid artery. 2. 60 to 69% stenosis of the left internal carotid artery. . [**4-2**] Echo: PRE-BYPASS: The left atrium is elongated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There is an intra-aortic balloon pump with the tip about 1 to 1.5 cm distal to the aortic arch. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time of surgery. POST-BYPASS: The patient is A paced. The patient is on no inotropes. Biventricular function is unchanged. Mitral regurgitation is unchanged. The intra-aortic balloon pump remains in position 1.5 cm distal to the aortic arch. The aorta is intact post-decannulation. . [**2142-4-6**] 04:58AM BLOOD WBC-8.7 RBC-3.52*# Hgb-11.5*# Hct-31.9*# MCV-91 MCH-32.7* MCHC-36.1* RDW-14.5 Plt Ct-104* [**2142-4-1**] 04:12PM BLOOD WBC-7.8 RBC-3.11* Hgb-10.7* Hct-28.4* MCV-91 MCH-34.4*# MCHC-37.7* RDW-12.6 Plt Ct-218# [**2142-4-6**] 04:58AM BLOOD Glucose-121* UreaN-33* Creat-1.3* Na-139 K-3.9 Cl-102 HCO3-30 AnGap-11 [**2142-4-1**] 04:12PM BLOOD Glucose-129* UreaN-23* Creat-0.8 Na-135 K-4.2 Cl-101 HCO3-21* AnGap-17 Brief Hospital Course: As stated in the HPI, Ms. [**Known lastname 4223**] presented with an STEMI and underwent a cardiac cath which showed severe two vessel coronary artery disease. An IABP was placed for refractory angina and she was worked up for bypass surgery. On [**4-2**] she was brought to the Operating Room where she underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one she was started on beta-blockers and diuretics and gently diuresed towards her pre-op weight. On post-op day two she was transferred to the step-down floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. On post-op day three she required a blood transfusion for low hematocrit (23). The following day her hematocrit was 31.9. She continued to make good progress while working with Physical Therapy for strength and mobility. She developed serosanguinous drainage, without leukocytosis or fever. The wound remained well approximated and dry sterile dressings were continued. She was still edematous and 5kg above her preoperative weight so diuresis was continued at discahrge for a week. This may be necessary for a longer period of time. The wound continued to drain a moderate amount and a dry dressing will continue as required. On post-op day 4 she was discharged to [**Hospital 20605**] in [**Location (un) 246**]. Medications on Admission: Anastrozole 1 mg PO QD Atenolol 50 mg PO QD Celecoxib 200 mg PO BID Gabapentin 300 mg PO/NG TID Hydrochlorothiazide 25 mg PO/NG DAILY Hold for SBP<90 Ketorolac tromethamine 0.4% Opth drops 1 drop QID Atorvastatin 80 mg PO/NG DAILY Plavix 75 mg daily PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QID Ezetimibe 10 mg PO DAILY Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Spironolactone 25 mg PO/NG DAILY Start: In am Hold for SBP<90 Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 2. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). 10. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day. 13. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. 15. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO twice a day for 7 days. 16. Combivent 18-103 mcg/actuation Aerosol Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. 17. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day): discontinue when mobile. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass grafts Peripheral vascular disease h/o breast cancer(s/p partial mastectomy,chemotherapy,radiation therapy) Hyperlipidemia Hypertension Gastroesophageal reflux s/p left below knee amputation 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. Edema-[**1-29**]+ 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. [**First Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2142-5-8**] at 1:30pm Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]([**Location (un) 620**]) on [**2142-4-19**] at 10:30am Please call to schedule appointments with: Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22882**]([**Telephone/Fax (1) 5294**]in [**5-3**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2142-4-6**]

[ "V49.75", "V15.82", "443.9", "V70.7", "401.9", "714.0", "733.00", "250.00", "272.4", "410.91", "414.01", "412", "737.10", "356.9", "V10.3" ]

icd9cm

[ [ [] ] ]

[ "36.15", "88.56", "37.61", "39.61", "36.12" ]

icd9pcs

[ [ [] ] ]

9035, 9107

5345, 6912

331, 548

9392, 9610

3027, 5322

10533, 11283

1933, 2163

7414, 9012

9128, 9371

6938, 7389

9634, 10510

2178, 3008

281, 293

576, 1350

1372, 1763

1779, 1917

5,728

192,039

15905

Discharge summary

report

Admission Date: [**2132-3-19**] Discharge Date: [**2132-3-26**] Date of Birth: [**2065-9-8**] Sex: M Service: ADMISSION DIAGNOSIS: Unstable angina. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Severe mitral regurgitation. 3. Status post coronary artery bypass graft times four. 4. Mitral valve repair. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old male with known coronary artery disease, status post percutaneous transluminal coronary angioplasty in [**2131-10-7**] and in [**2132-2-6**], who presented to an outside hospital with 10/10 chest pain with electrocardiogram changes of ST depressions in leads V3, V4, and V5 with T wave inversions. The patient reportedly continued to have unstable angina despite being on an heparin and nitroglycerin drips. The patient did recently have a cardiac catheterization and stent in [**Month (only) 404**] but did not undergo operative management at that time secondary to improvement of his symptoms. The patient is now transferred to the [**Hospital1 190**] for management in the Coronary Care Unit setting and possible revascularization procedure. The patient currently denies chest pain and shortness of breath. PAST MEDICAL HISTORY: 1. Inferior myocardial infarction. 2. Anxiety. 3. Bilateral leg neuropathy. 4. Coronary artery disease; status post stenting in [**2131-11-6**] and [**2132-2-6**]. 5. Mitral regurgitation of 3 to 4+. 6. Transient ischemic attack. MEDICATIONS ON ADMISSION: 1. Lisinopril 40 mg p.o. q.d. 2. Isosorbide dinitrate 5 mg p.o. q.i.d. 3. Nitroglycerin patch 0.4 mg q.d. 4. Omega 1000 mg p.o. q.d. 5. Ibuprofen 400 mg p.o. b.i.d. 6. Folic acid 400 mcg p.o. q.d. 7. Aspirin 162 mg p.o. q.d. 8. Atenolol 50 mg p.o. q.d. 9. Zocor 20 mg p.o. q.d. 10. Paxil 10 mg p.o. q.d. 11. Serax 10 mg p.o. b.i.d. and 20 mg p.o. q.h.s. 12 Plavix 75 mg p.o. q.d. ALLERGIES: Allergy to NORTRIPTYLINE. PHYSICAL EXAMINATION ON PRESENTATION: General physical examination revealed the patient was an elderly male who was quite anxious and in no acute distress. Vital signs were stable, afebrile. Oxygen saturation was 96% on room air. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Pupils were equal, round, and reactive to light. Extraocular movements were intact. Sclerae were anicteric. The throat was clear. The neck was supple, midline. No masses or lymphadenopathy. The chest was clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm without appreciable murmur. The abdomen was soft, nontender, and nondistended and without masses or organomegaly. Extremities were warm. No cyanosis and no edema times four. Neurologic examination was grossly intact. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission revealed complete blood count with a white blood cell count of 9.1, hematocrit was 40.5, and platelets were 204. Chemistry-7 revealed sodium was 137, potassium was 3.9, chloride was 103, bicarbonate was 24, blood urea nitrogen was 21, creatinine was 1.1, and blood glucose was 96; 8.8, 2, 4.5. Prothrombin time was 13.8, INR was 1.3, partial thromboplastin time was 88.4. HOSPITAL COURSE: The patient was initially admitted for management of his unstable angina and coronary artery disease. The patient was transferred directly the Coronary Care Unit on heparin and nitroglycerin drips. Revascularization was initially planned for the day of transfer (on [**2132-3-19**]) but because of a recent infusion of Integrilin with Plavix, the decision was made to delay the surgery until [**3-21**]. The patient remained hemodynamically stable and without events until his surgery was performed on [**2132-3-21**]. At that time, the patient was to the operating room and underwent coronary artery bypass graft times four with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the obtuse marginal, diagonal, and descending right coronary artery. The patient also had a 28-mm mitral ring placed for his failing mitral valve. Postoperatively, the patient was taken to the Cardiothoracic Surgery Recovery Unit for closer monitoring. On postoperative day one, the patient was extubated. He remained AV paced in the 90s with an underlying rhythm in the 50s. Otherwise, the patient had an uneventful stay in the Intensive Care Unit. On postoperative day three, the patient was transferred to the floor without event. His floor stay was unremarkable, and the patient continued to work with Physical Therapy in order to regain his strength. DISCHARGE DISPOSITION: Ultimately, the patient was discharged to home on postoperative day five; tolerating a regular diet, in adequate pain control on oral pain medications, and having no further anginal symptoms. The patient was cleared for home by Physical Therapy. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: Discharge status was to home. DISCHARGE DIET: Cardiac diet. MEDICATIONS ON DISCHARGE: 1. Lopressor 12.5 mg p.o. b.i.d. 2. Lasix 20 mg p.o. b.i.d. (times seven days). 3. Potassium chloride 20 mEq p.o. b.i.d. (times seven days). 4. Aspirin 325 mg p.o. q.d. 5. Colace 100 mg p.o. b.i.d. 6. Percocet 5/325 one to two tablets p.o. q.4h. as needed. 7. Prozac 10 mg p.o. q.d. 8. Captopril 25 mg p.o. t.i.d. 9. Serax 10 mg p.o. t.i.d. and 20 mg p.o. q.h.s. 10. Ibuprofen 800 mg p.o. q.8h. DI[**Last Name (STitle) 408**]E INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Cardiology in one to two weeks to address the need for diuresis as well as for adjustment of cardiac medications at that time. 2. The patient was to follow up with Dr. [**Last Name (Prefixes) **] in four weeks' time. 3. The patient was encouraged to continue ambulation as well as incentive spirometry. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 5745**] MEDQUIST36 D: [**2132-3-27**] 14:51 T: [**2132-3-27**] 15:02 JOB#: [**Job Number **]

[ "414.01", "300.00", "424.0", "411.1", "V45.82", "412" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.13", "35.12", "36.15" ]

icd9pcs

[ [ [] ] ]

4665, 4923

191, 336

5082, 6156

1495, 3233

3251, 4641

152, 170

4938, 5055

365, 1209

1231, 1468

67,967

161,197

49430

Discharge summary

report

Admission Date: [**2180-9-13**] Discharge Date: [**2180-9-20**] Date of Birth: [**2122-10-3**] Sex: F Service: NEUROSURGERY Allergies: Penicillins / Morphine Attending:[**First Name3 (LF) 3227**] Chief Complaint: Vertigo, gait disturbance, headaches and short term memory loss. Major Surgical or Invasive Procedure: Right Occipital Craniotomy for Tumor History of Present Illness: HPI: Pt is a 57 y/o with one-two weeks of vertigo and ataxia. She is left handed and has had changes in her handwriting and her writing often doe snot make sense. She also has been damaging her car while driving. She has had short term memory problems as well as spatial orientation issues. She has had several falls. She has had daily headaches after waking from sleep. She has had associated nausea for several days. Her right arm "feels heavy". She presented to [**Hospital3 **] ED and underwent CT imaging with revealed a right occipital mass. She was given Decadron and transferred to [**Hospital1 18**]. Past Medical History: DM, HTN, anxiety Social History: Social Hx: she reports rare ETOH use. She stopped smoking 5 years ago and smoked 1-1.5 packs per day prior to this time. She is a part time chef. She is left handed. Family History: non-contributory Physical Exam: On Admission: O: T:99.3 BP: 174/96 HR 79: R 16 O2Sats 97% Gen: WD/WN, comfortable, NAD. Obese HEENT: Pupils: 3.5-3mm B EOMs Full Extremities: congenital shortening of 2-3rd digits B. Neuro: Mental status: Awake and alert, cooperative with exam 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, 3.5 to 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-9**] throughout. No pronator drift Sensation: Intact to light touch. Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin slightly impaired on Left secondary to restricted knee ROM s/p surgery. Pertinent Results: Labs On Admission: [**2180-9-13**] 09:30PM BLOOD WBC-10.8 RBC-4.53 Hgb-12.4 Hct-39.0 MCV-86 MCH-27.4 MCHC-31.8 RDW-13.2 Plt Ct-294 [**2180-9-13**] 09:30PM BLOOD Neuts-92.6* Lymphs-6.3* Monos-0.6* Eos-0.3 Baso-0.3 [**2180-9-13**] 09:30PM BLOOD PT-11.8 PTT-20.9* INR(PT)-1.0 [**2180-9-13**] 09:30PM BLOOD Glucose-186* UreaN-20 Creat-0.7 Na-137 K-4.4 Cl-99 HCO3-26 AnGap-16 [**2180-9-13**] 09:30PM BLOOD Albumin-4.3 Calcium-10.0 Mg-2.1 [**2180-9-13**] 09:30PM BLOOD T4-9.0 [**2180-9-14**] 04:30AM BLOOD Phenyto-7.5* Labs on Discharge: [**2180-9-19**] 05:15AM BLOOD WBC-8.8 RBC-4.25 Hgb-12.0 Hct-36.8 MCV-87 MCH-28.2 MCHC-32.6 RDW-13.4 Plt Ct-306 [**2180-9-19**] 05:15AM BLOOD PT-11.1 PTT-18.0* INR(PT)-1.0 [**2180-9-19**] 05:15AM BLOOD Plt Ct-306 [**2180-9-19**] 05:15AM BLOOD Glucose-184* UreaN-24* Creat-0.6 Na-138 K-3.8 HCO3-29 [**2180-9-19**] 05:15AM BLOOD Albumin-3.6 Calcium-8.8 Phos-3.6 Mg-1.8 [**2180-9-19**] 05:15AM BLOOD Phenyto-10.4 Imaging: Head CT [**9-14**]: HEAD CT WITHOUT IV CONTRAST: A mass is noted in the right parietal lobe measuring approximately 4.8 x 3.0 cm mass. There is surrounding vasogenic edema resulting in local sulcal effacement as well as effacement of the occipirtal [**Doctor Last Name 534**] of the right lateral ventricle. The mass has a dense rim and is centrally hypodense aside from a hyperdense central focus (series 2, image 21) concerning for intralesional hemorrhage. There is no significant shift of midline structures. Basilar cisterns are patent. There are no additional masses identified on this noncontrast CT. The visualized paranasal sinuses and soft tissues appear unremarkable. IMPRESSION: Right parietal lobe mass with central hyperdense focus concerning for hemorrhage. MRI is recommended for further evaluation. MRI Head [**9-14**]: A large necrotic right frontoparietal mass is unchanged measuring approximately 3.1 x 4.6 cm in size with mass effect on the ipsilateral ventricle and surrounding edema. The edema extends into the splenium of the corpus callosum. No other lesions are seen. There is approximately 5 mm of midline shift to the left. IMPRESSION: Large necrotic mass in the right parietal lobe. This most likely represents a glial neoplasm. Differential would include metastatic disease or abscess. Clinical correlation is advised. MRI Head [**9-15**]: FINDINGS: There has been no significant change in appearance of the heterogeneously enhancing mass within the right parietal lobe. Central areas of non-enhancement likely reflect gliosis. There is signal abnormality within the adjacent white matter may reflect vasogenic edema versus tumor infiltration. There is a similar degree of associated mass effect. No additional lesions are seen. IMPRESSION: Limited post-contrast examination demonstrates no significant interval change in the appearance of the heterogeneously enhancing mass centered within the right parietal lobe. Head CT [**9-15**]: FINDINGS: Patient is status post right posterior craniotomy with underlying pneumocephalus and pneumocephalus layering non-dependently along the right frontal vertex. Below the craniotomy site at the site of prior tumor is surgical packing material containing multiple locules of air. In the right posterior vertex (2:25) is a 7 x 5 mm focus of hyperdensity and a trace linear region of hyperdensity (2:11). No other foci of hemorrhage are present. The prior tumor resection site has persistent white matter hypodensity reflecting edema which appears stable since the preoperative examination. Otherwise, the [**Doctor Last Name 352**]-white matter differentiation remains well preserved. There is no midline shift or herniation. No evidence for acute vascular territorial infarction. The visualized paranasal sinuses, ethmoid, and mastoid air cells appear clear. Apart from the right posterior craniotomy, osseous structures are intact. IMPRESSION: 1. Status post right posterior parietal mass resection with 5 x 7 mm foci of hyperdensity due to blood products. Otherwise, the surgical resection site contains multiple locules of air likely secondary surgical packing material. There is persistent edema of the white matter, unchanged. 2. Pneumocephalus underlying the craniotomy site and layering along the right frontal convexity. 3. Stable ventricular size. No herniation or midline shift. MRI Head [**9-17**]: FINDINGS: There are changes from a right parietal craniotomy with extensive blood products in the operative bed. There does appear to be a small amount of enhancement noted in the anterior aspect of the operative bed image 15, series 13 which could represent residual neoplasm. Recommend attention on short-term followup imaging. There is new restricted diffusion in the superior right parietal lobe medially and surrounding the operative bed which could represent cytotoxic edema versus ischemia relating to surgery. Intracranial flow voids are maintained. IMPRESSION: Post-op changes in the right parietal lobe with evaluation limited due to blood products. Nonetheless, there does appear to be small amount of residual neoplasm along the anterior aspect of the operative bed. Restricted diffusion in the medial superior parietal lobe and surrounding the operative cavity which could represent post-op cytotoxic edema versus ischemia. Brief Hospital Course: Patient was admitted to the hospital on [**2180-9-13**] following an episode of headache and clumsiness, and increased falls. At CT scan of the head was done revealing a right sided parietal mass. She was started on decadron and Keppra. The patient underwent surgical resection of the mass with the goal of palliative mass effect and tissue diagnosis. Her operative course was unremarkable. She was observed the ICU on POD0. On POD#1 she was transferred to the neurosurgical floor. Her post-operative MRI revealed a gross total resection of the parietal mass. Her neurologic status remained similar to pre-op. She was seen and evaluated by physical therapy who determined she would be appropriate for discharge to home with services. She was given instructions to call and schedule an appointment to be seen in the brain tumor clinic within 4 weeks. She was also discharged on a decadron taper, and transition to keppra from dilantin. Medications on Admission: Cozaar 100 mg po QD, Effexor 37.5 mg po QD, Actos 40mg po QHS, Protonix 30 mg po QD, Hydrocodone prn, Glipizide 10 po BID Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever,pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for fungal infection. Disp:*1 bottle* Refills:*0* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO as directed in discharge paperwork. Disp:*50 Capsule(s)* Refills:*0* 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 7. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 8. Outpatient Physical Therapy 9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO as directed in discharge paperwork. Disp:*100 Tablet(s)* Refills:*0* 10. Keppra 500 mg Tablet Sig: One (1) Tablet PO as directed in discharge paperwork. Disp:*120 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Right occipital Brain Tumor Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions/Information ?????? 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. ?????? Your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. *******YOU ARE BEING TRANSITIONED FROM DILANTIN TO KEPPRA FOR ANTISEIZURE PROPHYLAXSIS; DIRECTIONS ARE AS FOLLOWS: [**2180-9-19**] & [**2180-9-20**]:Take Dilantin 200mg twice daily AND Keppra 500mg twice daily [**2180-9-21**] & [**2180-9-22**]: Take Dilantin 100mg twice daily AND Keppra 1gm twice daily(you will continue indefinitely at this dose) [**2180-9-23**]: Dilantin 100mg daily until [**2180-9-25**]; then discontinue dilantin. ****YOU ARE ALSO BEING DISCHARGED ON DECADRON TAPER; TAKE THIS MEDICATION WITH FOOD/MILK AS FOLLOWS: [**Date range (3) 103473**]: Decadron 6mg daily(in the morning) [**Date range (1) 103474**]: Decadron 3mg daily(in the morning) [**9-25**] and thereafter: Decadron 2mg daily Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**7-14**] days (from your date of surgery) for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You will be scheduled for an appointment in the Brain [**Hospital 341**] Clinic. They should be contacting you at home within the next two days with this date and time. If you do not hear from them within this time frame, please call [**Telephone/Fax (1) 1844**], and request an appointment to be seen within 4 weeks. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. ??????You will not need an MRI as this was done during your acute hospitalization Completed by:[**2180-9-19**]

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icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

10137, 10186

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352, 391

10258, 10282

2543, 2548

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1272, 1290

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10207, 10237

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419, 1032

1738, 2524

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1088, 1256

29,961

166,089

6581

Discharge summary

report

Admission Date: [**2115-10-6**] Discharge Date: [**2115-10-18**] Date of Birth: [**2043-2-28**] Sex: M Service: MEDICINE Allergies: Demerol / Actos Attending:[**First Name3 (LF) 1436**] Chief Complaint: elevated LFTs Major Surgical or Invasive Procedure: AICD cardioversion on [**10-8**] History of Present Illness: 72-year-old gentleman with a past medical history significant for VF arrest s/p AICD placement in [**2102**], CHF with EF of 15-20%, afib, DM, COPD, HTN, ischemic hepatitis, and recent admissions to ICU first for syncope in setting of AFIB with RVR in [**Month (only) 216**] then for altered mental status in early [**Month (only) **] (D/C [**2115-7-26**]), now tranfered from [**Hospital 100**] Rehab because feeling ill for the past few weeks found to have AST 1733, ALT 1164 in the ED without obstructive picture on LFTs. . Pt reports he has not felt well over the past few weeks. In particular, he reports he went to rehab 4 weeks ago from his last stay at [**Hospital1 18**]. He says he was regaining strength for the first two weeks but then in the last two weeks has lost all that strength again and feels like he is back to when he was admitted to rehab. He says his weakness is particularly prominent in his legs. He reports occasional SOB when walking that has also worsened somewhat in the last 2 weeks. He denies chest pain, diaphoresis, or nausea this these sx. He started having a prominent itching sensation around the time he was admitted to rehab, mostly on his arms. He has been itching his arms a lot in the last 4 weeks and has created multiple scabs on his arms from the itching. He denies thinking that his skin is more yellow. He denies nausea although told ED he had some. He says he hasn't had much of an appetitie recently and hasn't eaten anything by mouth but also reports he has been feed daily through his G-tube while at rehab. He is not able to clearly articulate why he has a G-tube. He isn't sure why the rehab sent him to the hospital today, but is able to articulate that they found his liver to be inflammed on the labs from the ED here. . In the ED, initial VS: 98.1 90 102/67 25 96% RA. AST/ALT markedly elevated with only mild AP elevation and normal Tbili but with significantly elevated INR. WBC WNL and RUQ U/S showed mild abnormalities but no evidence of cholecystitis. Surgery was consulted re gallbladder and said no evidence of cholecystitis or surgical need. CXR showed "stable" R pleural efffusion with no evidence of PNA. ED concerned that UA consistent with a UTI. Pt was given IV Cipro/Flagyl as well as zofran. Having intermittent nose bleeds in ED. Gtube patent. Pt with episodic desats to 80s but O2 sat probe unreliable. Most Recent Vitals: 2235: T 97.7 HR 92 BP 92/53 RR 20. Past Medical History: - sCHF- TTE 15-20%, dry weight 198 lbs. - Paroxysmal atrial fibrillation - on Coumadin - CAD - Cath showed [**2-22**] showed single vessel LCx disease (70% occlusion distally and the OM branch had 90% at mid vessel) - ACID after VF arrest in [**2102**], [**Company 1543**] [**Last Name (un) 24119**] VR 7232Cx - Diabetes (last A1C 8.5 [**4-/2115**]) - Dyslipidemia - Hypertension - COPD - Barrett's esophagus with high grade dysplasia - Right sided pleural effusion which had been present on chest x rays since [**2114-9-17**] - Post-cryotherapy x 3, BARRx [**2-23**] - S/p GI bleed- UGIB from a gastric ulcer [**12/2102**] - S/p Appendectomy [**2063**] - S/p Bone tumor excision from shoulder [**2057**] - Portal vein thrombosis - G-tube Social History: Occupation: Retired from [**Location (un) 86**] police force and security service at [**Location (un) 745**] [**Hospital 3678**] Hospital Housing: Lives independently at Blakes Estate senior center (a retirement community), but found to be in squalor in [**6-27**]. Family: Closest family is cousin [**First Name5 (NamePattern1) **] [**Name (NI) 23636**]), lives down the street from him. HCP is [**Name (NI) **] [**Name (NI) 25176**]. Adopted. Never married, no children. Tobacco: 45 year 1-2ppd history, quit 11 years ago. Alcohol: None Drugs: None Family History: Adopted. Does not know his family history. Physical Exam: ADMISSION EXAM: VS - Temp 96.3 F, BP 96/64, HR 71, R 22, O2-sat 98% RA GENERAL - sick appearing M with thin ext, difficult to tell if mild yellowish tinge to face is baseline skin color HEENT - PERRLA, EOMI, sclerae anicteric but very pale, MMM, OP clear but with poor dentention NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - Decreased breath sounds halfway up on R, otherwise clear HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - Distended, no fluid wave, no HSM, NT to palp, Norm BS, [**Name (NI) 282**] tube in place in epigastrium is normal appearing without surround swelling, erythema, or discharge EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), pt with multiple UE excoriations and scabs at various stages of healing (some appear to be fairly recent), none on legs Skin: Scratch lesions on arms as noted above, no spider angiomas or palmar erythema, no prominent skin yellowing except for question of this vs baseline color on face LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**3-21**] throughout, sensation grossly intact throughout, no asterixis Discharge Exam: VS: 97.6, 110/58, 59, 18, 98RA GENERAL: Cachectic, ill appearing male. AAOx2, Tachypnic with accessory muscle. Comfortable appearing HEENT:Area of right neck with subcutaneous echymosis. No pulsatile mass, small excoriation of the right lateral area underneath the dressing. CARDIAC: RR, [**1-20**] holosystolic mumur heard best at the LLSB and in the apex, no appreciable S3 or S4. LUNGS: Moving air bilaterally in upper lung fields. Small crackles in the R anterior chest. ABDOMEN: Thin, Soft, NTND. No HSM or tenderness. EXTREMITIES: Cool lower extremities- cyanotic, but able to move them, slowed capillary refill biltarelly. No pitting edema. SKIN: No peripehral edema Pertinent Results: [**2115-10-6**] LIVER ULTRASOUND Son[**Name (NI) 493**] images of the right upper quadrant demonstrate normal liver echogenicity, without focal lesions. The midline structures including the pancreas are not well seen due to overlying gastrostomy tube. Normal hepatopetal flow is seen within the main portal vein. There are pleural effusions, right greater than left, a small amount of perihepatic ascites. The gallbladder is collapsed with an abnormally thickened wall - likely reflecting liver disease. There is no pericholecystic fluid. The common bile duct is normal in caliber measuring 4 mm. IMPRESSION: 1. Decompressed gallbladder with thick wall, likely reflecting liver disease. 2. Bilateral pleural effusions, right greater than left with small amount of perihepatic ascites. [**2115-10-7**] ECHO The left and right atria are moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated with severe global hypokinesis (LVEF = 20 %). Systolic function of apical segments is relatively preserved. No masses or thrombi are seen in the left ventricle. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-18**]+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension.There is no pericardial effusion. IMPRESSION: Biventricular cavity enlargement with severe global left ventricular hyopkinesis and right ventricular free wall hypokinesis. Moderate to severe tricuspid regurgitation. Mild-moderate mitral regurgitation. Pulmonary artery hypertension. ADMISSION LABS [**2115-10-6**] 05:12PM BLOOD WBC-10.2 RBC-3.58* Hgb-7.5* Hct-25.6* MCV-72* MCH-21.0* MCHC-29.4* RDW-17.4* Plt Ct-363# [**2115-10-6**] 05:12PM BLOOD PT-36.7* PTT-37.2* INR(PT)-3.7* [**2115-10-6**] 05:12PM BLOOD Glucose-318* UreaN-82* Creat-1.0 Na-129* K-4.4 Cl-88* HCO3-30 AnGap-15 [**2115-10-6**] 05:12PM BLOOD ALT-1164* AST-1733* LD(LDH)-954* CK(CPK)-41* AlkPhos-233* TotBili-1.3 [**2115-10-6**] 05:12PM BLOOD TotProt-6.6 Albumin-3.5 Globuln-3.1 Calcium-9.2 Phos-2.2* Mg-2.2 [**2115-10-6**] 08:11PM BLOOD Lactate-2.0 Discharge Labs: [**2115-10-17**] 07:55AM BLOOD WBC-8.4 RBC-4.00* Hgb-8.1* Hct-29.7* MCV-74* MCH-20.2* MCHC-27.2* RDW-18.1* Plt Ct-293 [**2115-10-17**] 07:55AM BLOOD PT-37.9* PTT-39.1* INR(PT)-3.7* [**2115-10-17**] 07:55AM BLOOD Glucose-218* UreaN-73* Creat-1.6* Na-136 K-5.1 Cl-95* HCO3-33* AnGap-13 [**2115-10-17**] 07:55AM BLOOD ALT-192* AST-75* AlkPhos-224* TotBili-1.4 [**2115-10-17**] 07:55AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.9* [**2115-10-14**] 04:18AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 [**2115-10-14**] 04:18AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2115-10-14**] 4:18 am URINE CULTURE (Final [**2115-10-15**]): NO GROWTH. Brief Hospital Course: MICU Course: 72 year old male transferred from rehba to the MICU for congestive hepatopathy and encephalopathy due to Afib with RVR whose heart condition continued to decompensate and it was determined that given his poor perfusion and recent studies that he has end stage heart dieseae and changed his goals of care to comfort measures only. # Goals of Care: Goals of care discussion occured on this admission with both Mr. [**Known lastname **] and with the 2 healthcare proxys. Decision was made to be CMO, focus on comfort. Pt was given morphine elixir as needed for SOB. He may also get lasix 40-80mg IV prn for SOB. He is on lactulose for bowel movements, but has not had a bm in a few days. This should continue to be address at his rehab. HCP and pt request that patient is not re-hospitalized. Pt is eating [**Known lastname 16429**] and ice cream by mouth and is aware of aspiration risks. His ICD was turned off prior to discharge. # Acute hepatitis- patient was originally admitted with transaminitits and this was felt to be int he setting of poor forward flow of the heart given his Afib with RVR. His workup for other causes was negative. His LFTs continued to downtrend after his heart rate improved. # A. fib with RVR: Pt with a known history of atrial fibrillation with BiV ICD. It was unclear if this was actually pacing him at the time that he came in. The ICD was used to cardiovert him into regular rate. He then went into afib to the 130s on additional occasion however responded well to metoprolol. His pacer was interogated and felt to be working properly. His warfarin was d/c'd due to his changes in goals of care to CMO. # End stage heart failure- Patient has history of both systolic and diastolic heart failure with an EF of 15-20%. A repeat TTE did not demonstrate any significant changes. The patient originally required dobutamine in the ICU. His medical management was optimized however due to his low blood presures and EF. It was then felt that his heart failure with worsening renal function was end stage, and his goals of care were changed to CMO. . # Acute renal failure- Patient had intermittently elevated Cr in the setting of oliguria likely due to decreased perfusion of his kidneys from his poor cardiac output. . #Cystitis: Patient had a positive urine culture for E. coli. patient was given 3 days of ceftriaxone. No associated complications. Transitional Issues: Patient was discharged to Rehab for palliative care/hospice care, with the goal to NOT be rehospitalized. his ICD was turned off prior to being discharged. Medications on Admission: - Levofloxacin 750mg Qd day 1 [**10-6**] - Metronidazole 500mg TID day 1 [**10-6**] - Digoxin 0.125 mg EOD - Metoprolol 6.25 mg [**Hospital1 **] - Aldactone 12.5 mg Qd - Lasix 40mg [**Hospital1 **] - Metolazone 5mg Qd - ASA 81mg Qd - Lantus 15units [**Hospital1 **] and ISS - Vit D + Calcium - Ranitidine 150mg [**Hospital1 **] - Tylenol PRN - ducolax PRN - MIralax PRN - Warfarin Discharge Medications: 1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 2. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO TID (3 times a day). 3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: One (1) PO Q1H (every hour) as needed for shortness of breath or wheezing. 5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 8. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous qAM. 9. insulin lispro 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: per sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Primary Diagnoses End stage heart failure Acute Renal Failure Congestive Hepatopathy Atrial Fibrillation with rapid ventricular rate Secondary diagnoses: Insulin dependent type II diabetes Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you while you were here at [**Hospital1 18**]. You were brought to the hospital from rehab because you weren't feeling well and blood tests from rehab showed that your liver wasn't working properly. From testing performed here, it was determined that this was due to your heart not pumping properly and had bakced up the blood in the liver. Because your heart wasn't pumping very well you were in the ICU and on IV medications to keep your blood pressure up for a short time. After they put your heart back a slower speed (by using your AICD to shock the heart), you were transfered out of the ICU to the cardiology floor. Your heart continued to not pump very well despite giving you medications to try to help it pump better. We discussed with you and your health care proxy that the long term prognosis for the heart not pumping well were not good, and that you have end stage heart failure. During these discussions you decided to focus your care on comfort, and we will be transferring you back to a rehab facility with this goal of making you comfortable. Transitional Issues: You are being transfered to rehab for palliative care. Followup Instructions: You should follow-up with your primary care doctor

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icd9cm

[ [ [] ] ]

[ "96.6", "99.62", "38.93" ]

icd9pcs

[ [ [] ] ]

13260, 13325

9345, 11745

292, 327

13559, 13559

6060, 8588

14969, 15023

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12356, 13237

13346, 13480

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5365, 6041

14890, 14946

238, 254

355, 2789

13574, 13715

2811, 3552

3568, 4121

13,933

194,891

9834

Discharge summary

report

Admission Date: [**2107-12-7**] Discharge Date: [**2107-12-14**] Date of Birth: Sex: Service: ADMITTING DIAGNOSIS: Pneumonia. DISCHARGE DIAGNOSIS: Pneumonia. HISTORY OF THE PRESENT ILLNESS: The patient is a 28-year-old female who underwent a laparoscopic appendectomy on [**2107-11-30**] for acute appendicitis. The patient tolerated the procedure well. The patient was discharged home in stable condition. The patient presents to the emergency room with fever and left upper quadrant pain on [**2107-12-8**], postoperative day #8. She stated that the pain started approximately one to two days postoperatively and it was getting progressively worse. It was exacerbated by deep breaths. It radiated to the left shoulder and arm. She complained of nausea, but she did not have any emesis. She also had anorexia and poor p.o. intake. She had a fever of 101 at home. She complained of chills, sweats, as well as shortness of breath. On the morning of admission she developed diffuse maculopapular rash on her face, upper extremities, back and lower extremities. The patient felt that this was related to her Percocet. The patient went to her primary care physician and she was told to stop her Percocet. With the increase in temperature, as well as one episode of vomiting and loose stools, the patient presented to the emergency room for evaluation. PAST MEDICAL HISTORY: 1. Asthma. 2. Hypertension. PAST SURGICAL HISTORY: History revealed laparoscopic appendectomy on [**2107-11-30**]. MEDICATIONS: 1. Albuterol. 2. Percocet. ALLERGIES: The patient is allergic to SULFA. FAMILY HISTORY: History revealed a grandmother with a history of PE. SOCIAL HISTORY: The patient has no smoking habit, occasional alcohol. PHYSICAL EXAMINATION: On examination, the patient had a temperature of 101.2, pulse 120, blood pressure 180/95, respiratory rate 22, and saturation 94 on room air. She was awake, alert, and oriented times three. She follows commands. She appears uncomfortable. PERRLA. Sclerae are anicteric. HEART: Heart revealed regular, but tachycardiac. LUNGS: Lungs were clear to auscultation bilaterally with decreased breath sounds. ABDOMEN: Soft, obese, nondistended, but tender in the left subcostal region. No peritoneal signs. EXTREMITIES: Extremities are warm, well perfused, no edema, but with a maculopapular rash. SKIN: Maculopapular rash on the face, upper extremity, left upper extremity as well as the lower extremities and back. LABORATORY DATA: Labs on admission revealed the white count of 16.7, hematocrit of 35.3 and platelet count 385,000. The SMA 7 revealed the sodium of 129, potassium 3.6. The amylase was 375, alkaline phosphatase 190. Chest x-ray revealed left pleural effusion and a question of left lower lobe infiltrate. CT scan revealed positive left lower lobe consolidation. CTA negative for PE. HOSPITAL COURSE: The patient was admitted on [**2107-12-8**] with a diagnosis of postoperative pneumonia. She was started on Levofloxacin and Vancomycin. She remained febrile with decreased breath sounds at the bases of her lungs bilaterally. On [**2107-12-9**] the patient spiked a temperature to 104. She became tachypneic into the 40s. She felt short of breath and somnolent. She was started on Tylenol and she was transferred to a monitored setting. She was started on Tylenol and she was bolused with fluid and transferred to a more monitored unit setting. In the unit, ....................consultation was obtained as well as Infectious Disease consultation. Sputum cultures were sent. It was decided that the Vancomycin should be discontinued. She was continued on Levofloxacin and Clindamycin was added for anaerobic coverage. Angiography was done, which was negative. Diet was advanced. Given her bump in amylase and lipase, these labs were followed, which alkaline phosphatase decreased to 95. The amylase and lipase decreased to 129 and 152. The patient continued to have a left lower lobe consolidation. It was thought that the patient would be transferred to the floor on hospital day #4. The patient had ruled out for a PE and the vital signs had stabilized. Of note, the abdominal CT was negative for evidence of pancreatitis or gallstones. The amylase and lipase continued to improve. She tolerated p.o. diet. It was felt that her symptoms was consistent with a drug eruption by her examination. She was started on Triamcinolone cream, as well as Sarna. The rash improved. On [**2107-12-14**], the patient was discharged home in stable condition. It was found that the amylase and lipase elevations were not pancreatitis, as clinically, the patient did not have pancreatitis. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-331 Dictated By:[**Last Name (NamePattern1) 4985**] MEDQUIST36 D: [**2108-3-13**] 13:09 T: [**2108-3-13**] 13:22 JOB#: [**Job Number 33071**]

[ "493.90", "486", "427.89", "794.6", "997.3", "693.0", "518.81", "276.1" ]

icd9cm

[ [ [] ] ]

[ "99.21" ]

icd9pcs

[ [ [] ] ]

1647, 1701

180, 1398

2928, 4960

1475, 1630

1796, 2910

146, 158

1420, 1451

1718, 1773

79,939

194,897

35902

Discharge summary

report

Admission Date: [**2174-1-27**] Discharge Date: [**2174-1-31**] Date of Birth: [**2106-3-26**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: s/p Coronary artery bypass graft surgery (Left internal mammary artery>left anterior descending, saphenous vein graft>diagonal, saphenous venin graft>obtuse marginal1, saphenous vein graft>obtuse marginal2, saphenous vein graft>right coronary artery) [**2174-1-27**] History of Present Illness: 69 year old male with six months of chest heaviness and dyspnea on exertion. Referred for cardiac catherization that revealed coronary artery disease and was referred for surgical intervention. Past Medical History: Coronary artery disease Sleep apnea on CPAP [**Doctor Last Name **] [**Location (un) 2452**] exposure in [**Country **] Hiatal Hernia Social History: Works in shipping packaging company Lives alone Alcohol 1 glass wine occassionally Tobacco quit thirty years ago Family History: Non contributory Physical Exam: General No acute distress Skin unremarkable HEENT unremarkable Neck supple Full ROM Chest Lung CTA bilateral Heart RRR Abdomen soft, nontender, nondistended, +bowel sounds Extremeties warm well perfused edema +1, slight varicosities Neuro grossly intact Pertinent Results: [**2174-1-31**] 07:05AM BLOOD WBC-8.6 RBC-2.81* Hgb-8.7* Hct-25.5* MCV-91 MCH-30.9 MCHC-34.0 RDW-14.5 Plt Ct-260 [**2174-1-27**] 04:45PM BLOOD WBC-16.0*# RBC-3.62* Hgb-11.4* Hct-32.3* MCV-89 MCH-31.6 MCHC-35.4* RDW-14.0 Plt Ct-201 [**2174-1-31**] 07:05AM BLOOD Plt Ct-260 [**2174-1-28**] 03:48AM BLOOD PT-14.2* PTT-30.0 INR(PT)-1.2* [**2174-1-27**] 04:45PM BLOOD Plt Ct-201 [**2174-1-27**] 04:45PM BLOOD PT-15.9* PTT-28.8 INR(PT)-1.4* [**2174-1-31**] 07:05AM BLOOD Glucose-104 UreaN-12 Creat-0.6 Na-137 K-4.1 Cl-100 HCO3-28 AnGap-13 [**2174-1-27**] 06:07PM BLOOD UreaN-14 Creat-0.6 Cl-110* HCO3-26 [**2174-1-31**] 07:05AM BLOOD Mg-2.1 CXR [**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2174-1-30**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 81565**] Reason: r/o ptx s/p chest tube removal [**Hospital 93**] MEDICAL CONDITION: 67 year old man with s/p cabg REASON FOR THIS EXAMINATION: r/o ptx s/p chest tube removal Final Report PA AND LATERAL CHEST, [**1-30**] HISTORY: Status post CABG. Chest tube removed. IMPRESSION: PA and lateral chest compared to [**1-27**]: Moderately severe left basal atelectasis and small left pleural effusion are unchanged. Postoperative widening of the cardiomediastinal silhouette has improved. Right lung is clear aside from mild basal atelectasis. No pneumothorax. Suspect mild pneumomediastinum is a common and is present, postoperative finding. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: [**First Name8 (NamePattern2) **] [**2174-1-30**] 4:46 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 81566**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81567**] (Complete) Done [**2174-1-27**] at 1:31:08 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: [**2106-3-26**] Age (years): 67 M Hgt (in): 73 BP (mm Hg): / Wgt (lb): 230 HR (bpm): BSA (m2): 2.29 m2 Indication: Intraop CABG ICD-9 Codes: 440.0, 424.0 Test Information Date/Time: [**2174-1-27**] at 13:31 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW1-: Machine: aw5 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Annulus: 3.0 cm <= 3.0 cm Aorta - Sinus Level: 2.5 cm <= 3.6 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Arch: 2.8 cm <= 3.0 cm Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm Findings LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild to moderate ([**1-7**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma 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. Mild to moderate ([**1-7**]+) central mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**Known firstname 565**] [**Known lastname **] before CPB Post_Bypass: Normal RV systolic function. Overall LVEF 55% Previously hypokinetic areas look normal. Intact thoracic aorta.. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2174-1-27**] 16:33 Brief Hospital Course: Same day admission and was brought to the operating room and underwent coronary artery bypass graft surgery. See operative report for further details. He received cefazolin for periop antibiotics. He was transferred to the intensive care unit for hemodynamic monitoring. In the first twenty four hours was weaned from sedation, awoke neurologically intact and was extubated without complications. He continued to use CPAP as prior to admission at night time. On post op day one he was started on beta blockers and diuretics. He was transferred to the floor for the remained of his care. Physical therapy worked with him on strength and mobility. He was ready for discharge home on post op day four with VNA services. Medications on Admission: Plavix 75 mg daily Aspirin 325mg daily Folic Acid 0.4mg daily Multivitamin Glucosamine [**Doctor First Name **] 180mg daily Fluticasone 50mcg daily Advair 250/50 twice a day Toprol XL 25 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 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 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*0* 10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Nasal once a day as needed for allergy symptoms. Disp:*qs qs* Refills:*0* 11. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Coronary artery disease s/p CABG Hiatal hernia Sleep apnea on CPAP Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule all appointments Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27542**] in 1 week ([**Telephone/Fax (1) 27541**]) Dr [**Last Name (STitle) **] [**Name (STitle) 1911**] in [**2-8**] weeks Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3071**]) Completed by:[**2174-2-1**]

[ "414.01", "V87.2", "553.3", "327.23", "V46.2" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9697, 9765

7165, 7889

341, 610

9876, 9883

1444, 2339

10394, 10836

1137, 1155

8135, 9674

2379, 2409

9786, 9855

7915, 8112

9907, 10371

5734, 7142

1170, 1425

281, 303

2441, 5685

638, 834

856, 991

1007, 1121

24,573

132,386

1134

Discharge summary

report

Admission Date: [**2132-11-4**] Discharge Date: [**2132-11-7**] Date of Birth: [**2070-7-15**] Sex: M Service: MEDICINE Allergies: Cefepime / Percocet / Codeine / Ciprofloxacin / Tramadol Attending:[**First Name3 (LF) 1711**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Endotracheal intubation Hemodialysis History of Present Illness: 62 yo M with a history of CAD s/p CABG [**2125**], multiple PCIs, ESRD on HD, DM, PVD, recent admission for enterococcal bacteremia, s/p PPM removal, and tunneled line removal, presents with chest pain, bradycardia, with subsequent PEA arrest in the ED. . Per ED history, patient experienced left anterior chest pain at home and called 911. When he was picked up by EMS, he was noted to be bradycardic to the 40s. . On arrival to the ED, he was awake, with nausea and vomiting, complaining of chest pain. Initial VS were: HR 49 RR 26 SpO2 96/RA BP 111/34. The patient was given Zofran IV for nausea. As he was bradycardic, and he had missed dialysis, he was treated with IV calcium, insulin and glucose for presumed hyperkalemia. As preparation were made to obtain central access, patient suffered a PEA arrest, and was treated with one cycle of chest compressions and atropin, for approximately 3 minutes. He returned to a sinus rhythm. He was paralyzed with etomidate and rocuronium, sedated with fentanyl and Versed, intubated and placed on mechanical ventilation. The patient was further given an amp of bicarb and an amp of D50. Vancomycin and gentamicin started IV. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: CABG: [**2-/2126**] (SVG-OM1, SVG->RCA/PDA, LIMA->LAD) PERCUTANEOUS CORONARY INTERVENTIONS: - [**9-2**] - 2.5x 13 mm Cypher Des to LM/LCx - [**10-2**] - s/p Cypher DES to prox LAD - [**2131-1-1**] - Taxus DES to the LMCA-LAD with PTCA rescue of the origin of LAD on [**2131-1-1**] . -PACING/ICD: 2 Lead pacer of unknown model implanted last year at [**Hospital3 **] . - CHF with intact EF (LVEF 55%, 1+ MR (eccentric), [**12-29**]+ TR, Mod PA HTN) . 3. OTHER PAST MEDICAL HISTORY: - PVD, s/p bilateral common iliac artery stents with atherectomy in [**2125**], s/p overlapping stents to his left external iliac artery in [**3-/2130**], s/p 3 self expanding stents to the left SFA in [**6-/2130**] - ESRD [**1-29**] diabetic nephropathy on hemodialysis - Depression - Carotid artery disease - H/O C-diff colitis - H/O + PPD - h/o UGI bleed : EGD ([**2-3**]) showed non-bleeding [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear, gastropathy, and gastritis - Pulmonary Fibrosis: PET scan [**2129-4-27**], no areas of abnormal FDG uptake . Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension Social History: Patient is originally from [**Location (un) 7225**], [**Country 7192**]. His wife and family are still there. Patient currently lives alone, but his brother is nearby. He is on disability. His sister-in law works @ [**Hospital1 18**] in housekeeping. -Tobacco history: Former smoker, smoked from 13-45 x10 cigs daily, but no smoking since [**31**] years ago. -ETOH: Ethanol remote use, not current -Illicit drugs: No hx IVDU Family History: Father died of CAD Mother and brother with DM2 Physical Exam: Admission Exam Gen: middle aged male in NAD, getting HD, AAOx3. HEENT: Pupils fixed, non-reactive Neck: JVP elevated to jaw while lying flat for HD Chest: R chest, pacer pocket with stitches, non fluctuant. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 3/6 systolic murmur at LLSB. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. bibasiler crackles, no wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. + DP/PT pulses b/l. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Discharge exam: T 98.4, BP 154/59, HR 54-77, RR 18, 100% RA Gen: NAD, walking around room HEENT: NC/AT CV: holosystolic murmur that effaces S1 and S2 RESP: CTA bilaterally ABD: Soft, non-tender, BS + EXTR: RUE mild swelling, non-pitting edema of right hand NEURO: AAO, answers questions and follows commands Pertinent Results: Admission labs: [**2132-11-4**] 01:54AM WBC-12.5*# RBC-2.95* HGB-9.1* HCT-28.0* MCV-95 MCH-30.9 MCHC-32.6 RDW-17.4* [**2132-11-4**] 01:54AM NEUTS-80.4* LYMPHS-12.8* MONOS-4.6 EOS-1.5 BASOS-0.7 [**2132-11-4**] 01:54AM GLUCOSE-284* UREA N-48* CREAT-7.7*# SODIUM-131* POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-20* ANION GAP-18 [**2132-11-4**] 01:54AM CALCIUM-9.1 PHOSPHATE-6.0* MAGNESIUM-2.6 [**2132-11-4**] 01:54AM cTropnT-0.07* . Discharge labs: [**2132-11-6**] 06:10AM BLOOD WBC-7.2 RBC-3.03* Hgb-9.3* Hct-27.3* MCV-90 MCH-30.7 MCHC-34.1 RDW-18.1* Plt Ct-190 [**2132-11-6**] 06:10AM BLOOD Glucose-77 UreaN-19 Creat-4.3* Na-138 K-4.0 Cl-94* HCO3-34* AnGap-14 [**2132-11-4**] 02:10PM BLOOD CK-MB-4 cTropnT-0.17* [**2132-11-6**] 06:10AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.0 . Unilateral Upper Extremity Ultrasound: No DVT. . CTA chest: IMPRESSION: 1. No evidence of pulmonary embolism to the subsegmental level. 2. Mild septal thickening, trace effusions, and reflux of contrast into the IVC that can be seen in cardiac decompensation. [**11-5**] Upper Ext Doppler right side: no DVT [**11-4**] Echo: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis (LVEF = 50 %). The right ventricular cavity is mildly dilated with impairedfree wall contractility. 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. Mild to moderate ([**12-29**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2132-10-20**], findings are similar. 3. Pacer pocket in the anterior right chest wall. No adjacent focal fluid collections. 4. Bibasilar atelectasis. Brief Hospital Course: 59 yo M hx CAD s/p CABG, PCI, DM, ESRD on HD p/w bradycardia and leukocytosis and episode of PEA arrest in the ED. . # PEA arrest: Unclear etiology. Thought likely due to increased vagal tone during central line placement which resulted in hypotension and bradycardia and resultant brief PEA arrest. Negative CTA for PE, dissection. No pulmonary edema, no pneumothorax. Bedside U/S in ED showed no evidence of tamponade. Not hyperkalemic or hypercalcemic. Echo unchanged from prior. Pt recovered with atropine and only 1 cycle of chest compressions. No further episodes of PEA arrest. . # Bradycardia. Initially with irregular bradycardia rhythm on presentation, possibly atrial fibrillation with slow ventricular response. Held metoprolol, amlopdipine, and isosorbide. Was given atropine once in the ED and once in the CCU then started on dopamine drip and HD. On hospital day 1, dopamine drip was stopped and pt's HR in the 60s and normotensive. Metoprolol 25mg [**Hospital1 **] restarted in hospital after patient's systolic BP to 150s-160s. Patient can restart his other antihypertensives as outpatient. . # Coronaries: He has a strong history of CAD and numerous risk factors. Elevated trop (max 0.17) but neg CK and CK-MB. Elevated trop was at baseline and likely secondary to his underlying renal disease. Continued his medical management of CAD with [**Hospital1 **], [**Hospital1 4532**], statin. His metoprolol succ was resumed to 50mg daily whcih is decreased from his outpatient 100mg daily. Pt should follow up with outpatient cardiologist to discuss when to increase it back up to 100mg daily. . # Fever/Leukocytosis: Pt had recent enterococcus bactermia ([**2132-10-17**]) episode resulting in vegetations of his pacer leads after explantation on [**2132-10-23**]. Pt had leukocytosis and fever on admission and continued his outpatient coverage of Vancomycin, Gentamicin. Fever subsided on hospital day 1, and WBC has normalized. Patient should complete the six weeks of vancomycin and gentamicin therapy. Last doses given on [**2132-11-6**]. Pt will continue until [**2132-12-5**]. He will get weekly labs checking Cr, Bun, CBC with diff, ESR and CRP at [**Hospital **] clinic faxed to ID. . # ESRD: Continued his HD T/H/S throughout hospitalization. Also continued his sevelamer therapy. His last HD was on the thursday before discharge. . # Altered Mental Status: On admission to the CCU, patient has fixed, unreactive pupils (likely from atropine), not responding to commands, not withdrawing from pain, off all sedation. Following both extubation and dialysis, the patient's mental status completely recovered. AMS thought most likely to uremia or altered lytes that was improved after dialysis. . # Respiratory: Patient initially intubated and on mechanical ventilation to protect airway. He was extubated at 10am on [**11-4**] after he was following commands. Patient saturating in high 90s on room air. . # Hyperlipidemia: Continued statin therapy. . # HTN: Initially held amlodipine, metoprolol, and isosorbide dinitrate. Metoprolol and amlodipine restarted in hospital. Pt can resume his home BP meds at discharge. . # DM: Diet-controlled at home. ISS while inpatient. . # Nausea: Patient reports continued nausea. He says that he regularly has nausea, sometimes associated with hemodialysis, sometimes associated with activity. Patient responded to Zofran therapy. Patient's nausea may be secondary to recent constipation. Patient's diabetes makes gastroparesis higher on differential. Zofran will be provided on discharge; cause of nausea can be investigated as outpatient. . # Chest pain, likely secondary to trauma caused by compressions during resuscitation. Along with patient's back pain, chest pain has made him uncomfortable. Patient received hydrocodone-acetaminophen with no allergic reaction and acceptable pain relief. Will provide hydrocdone-acetaminophen until patient's follow-up appointment with his primary care physician. . #RUE Swelling: Pt had swelling of his right arm. Negative doppler/ultrasound. Sweling was attributed to blood pressure cuff. It improved during the hospitalization. At discharge, pt had mild swelling of right upper extremity. Medications on Admission: - amlodipine 5 mg daily - clopidogrel 75 mg daily - aspirin 325 mg daily - atorvastatin 80 mg daily - B complex-vitamin C-folic acid 1 mg daily - collagenase clostridium hist. apply topical [**Hospital1 **] - sevelamer carbonate 1600 mg tid - ranolazine 500 mg [**Hospital1 **] - ranitidine HCl 75 mg PO bid - pregabalin 25 mg PO bid - pramipexole 0.125 mg qhs prn - nitroglycerin 0.3 mg Tablet prn Chest Pain - metoprolol succinate sustained release 100mg PO daily - isosorbide dinitrate 120 mg daily - Humalog sliding scale - Insulin glargine 8 units qhs - silver sulfadiazine cream - lorazepam 0.5 mg tid prn back pain. - vancomycin 1g & gentamicin 40 mg IV daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol). 7. gentamicin 40 mg/mL Solution Sig: One (1) Injection HD PROTOCOL (HD Protochol). 8. ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO BID (2 times a day) as needed for angina. 9. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qhs () as needed for restless leg. 12. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO twice a day as needed for nausea. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 13. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for chest pain or back pain. Disp:*60 Tablet(s)* Refills:*0* 14. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet Sublingual once a day as needed for chest pain. 15. isosorbide dinitrate 40 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO once a day. 16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 17. silver sulfadiazine 1 % Cream Sig: One (1) Topical once a day. 18. insulin glargine 100 unit/mL Cartridge Sig: 8 units Units Subcutaneous at bedtime. 19. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*3* 20. Outpatient Lab Work Please check weekly with dialysis: ESR, CRP, Cr, BUN, CBC with Diff. Fax results to: [**Hospital **] clinic [**Telephone/Fax (1) 1419**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Episode of pulseless electric arrest Episode of bradycardia Chest pain, likely secondary to compressions during resuscitation End-stage renal disease Enterococcus faecalis bacteremia Hyperlipidemia Hypertension Diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 7203**], You were admitted to the hospital because you had a dangerous heart rhythm. We are not sure why you had this dangerous rhythm. You were also sleepy with low blood pressures and heart rate. We gave you dialysis which improved your symptoms. Please make sure to continue your antibiotics for the total 6 week course. You received your last dose of Vancomycin and Gentamicin on [**2132-11-6**]. Once you have completed your antibiotics, you may benefit from having your pacemaker replaced. Please be sure to see your cardiologist, Dr. [**First Name (STitle) **]. We are providing you with some medications to help with your nausea and pain. The nausea will be treated with Zofran. The pain will be treated with hydrocodone-acetaminophen. Otherwise, you should continue your medications as you had before you came to the hospital. You should follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on Monday, [**2132-11-24**]. Your metoprolol dose was changed from 100mg daily to 50mg daily because your heart rate was a little slow. Please follow up with your cardiologist to decide when to increase it back up to 100mg daily. You need to continue your anitbiotics (vancomycin and gentamicin) until you have completed six weeks of antibiotic therapy (last date is [**2132-12-5**]. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: TRANSPLANT CENTER When: FRIDAY [**2132-11-14**] at 2:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: MONDAY [**2132-11-24**] at 8:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: OTOLARYNGOLOGY (ENT) When: FRIDAY [**2132-11-28**] at 10:30 AM With: [**Last Name (un) 6410**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], AU.D. [**Telephone/Fax (1) 6411**] Building: LM [**Hospital Unit Name **] [**Location (un) 895**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE [**2132-12-4**], at 9:50am appt with Infectious Disease with Dr. [**Last Name (STitle) 438**].

[ "443.9", "V45.11", "V58.67", "311", "515", "403.91", "V45.81", "427.89", "V45.82", "416.8", "564.00", "414.00", "786.50", "427.31", "428.32", "428.0", "585.6", "427.5", "250.40" ]

icd9cm

[ [ [] ] ]

[ "39.95", "96.04", "38.93", "96.71", "99.60" ]

icd9pcs

[ [ [] ] ]

13354, 13412

6365, 8734

328, 367

13685, 13685

4358, 4358

15309, 16350

3259, 3308

11280, 13331

13433, 13664

10588, 11257

13836, 15286

4807, 6342

3323, 4029

1673, 2123

4045, 4339

278, 290

395, 1569

4374, 4791

13700, 13812

2154, 2800

1591, 1653

2816, 3243

76,253

197,508

38128

Discharge summary

report

Admission Date: [**2133-10-12**] Discharge Date: [**2133-10-20**] Date of Birth: [**2079-4-13**] Sex: F Service: CARDIOTHORACIC Allergies: Morphine Attending:[**First Name3 (LF) 4679**] Chief Complaint: esophageal cancer Major Surgical or Invasive Procedure: minimally invasive esophagectomy History of Present Illness: 54F w/locally advanced esophageal cancer. She underwent chemo (only a partial course b/c she could not tolerate a full course) and RT, completed in [**2133-5-28**]. She presented this admission for minimally invasive esophagectomy. Past Medical History: Diabetes Mellitus Coronary Artery Disease Hypercholesterolemia Anxiety Hard of hearing, h/o hip fracture Social History: Single. Tobacco: 135 pack-year. ETOH none Family History: Mother [**Name (NI) 85075**] lymphoma in mother Father CAD s/p MI Siblings DM2 Physical Exam: Gen: alert and oriented x3, NAD HEENT: no cervical or supraclavicular LAD CV: RRR, no murmur LUNGS: CTA bilaterally ABD: soft, NT, ND, +BS EXTR: warm, well-perfused, 2+ pulses Pertinent Results: Pathology Report [**2133-10-12**]: I. Level 7 lymph nodes (A-J): Twenty four lymph nodes with no carcinoma seen (0/24). II. Esophagogastrectomy (K-AK):Poorly differentiated invasive adenocarcinoma, arising in the proximal fundus/distal gastroesophageal junction, most consistent with a gastric origin; see synoptic report and comments. III. Lesser curvature gastric lymph nodes ([**Doctor Last Name **]-AN):One of two lymph nodes, positive for metastatic carcinoma ([**11-29**]). IV. Gastric fundus (AO-AR):Segment of gastric fundus/corpus with no carcinoma seen. V. "Esophageal donuts" (AS-AY):Esophageal and gastric fundic fragments with no carcinoma seen. Barium Esophagogram [**2133-10-18**]: Small leak at esophago-gastric anastomosis, possibly contained. Brief Hospital Course: The patient was taken to the operating room on [**2133-10-12**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] where she had an [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy. She was extubated in the OR, then brought to the ICU for initial monitoring, with epidural, JP, right Chest tube and NGT, and was kept NPO, with IV fluids. She had pain on arrival to the SICU, and was bolused w/dilaudid then split epidural. She also had high blood sugars, with a history of poorly controlled DM at home, and was seen by [**Last Name (un) **] post-op. She was recovering well and transferred to the floor on the evening of POD 3. She had pain issues, which improved when her epidural was replaced on POD 4. She was doing well on the floor POD 4 and 5. She had a mild cough but was otherwise asymptomatic. On POD 6 her JP output changed from serous to brown fluid and she was started on zosyn, cipro, and flagyl. A barium swallow was obtained at that time, which showed a small leak at the anastomosis, which appeared to be contained. On POD 7 she developed copious, foul-smelling respiratory secretions, as well as air output into her JP drain with respiration and coughing. Her cough worsened and she required increased nasal cannula oxygen. Her WBC count rose to 13 and her antibiotics were broadened to vanc, zosyn, and diflucan. She remained hemodynamically stable. She was taken to the OR for EGD and bronchoscopy, which revealed a large fistula between her trachea and her gastric conduit, as well as necrosis of the proximal 5-6cm of her conduit. She was kept intubated after procedures and taken to the ICU. On POD 8 she remained intubated and sedated. After discussion of the high morbidity associated with any further operations and the prognosis and quality of life after surgery, her family elected to make her comfort measures only. She remained in the ICU and expired at 5:15pm on [**2133-10-20**]. Medications on Admission: Actos 45', wellbutrin 300', lipitor 20', lisinopril 10", meclizine 25 PRN, metformin 1000", zofran 4" PRN, promethazine 25''', sertraline 100"", sprionolactone 25', phenadoz 50" PRN, metclopramide 10', prochlorphenazine 10''' PRN, levemir 160" Discharge Disposition: Expired Discharge Diagnosis: esophageal cancer Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2133-10-23**]

[ "E878.2", "V66.7", "151.0", "250.00", "389.9", "518.81", "272.0", "530.84", "496", "414.01", "272.4", "997.4", "V16.7", "E849.7", "V15.3" ]

icd9cm

[ [ [] ] ]

[ "46.39", "42.23", "96.71", "45.13", "33.24", "96.6", "42.41", "40.3", "03.90", "96.04" ]

icd9pcs

[ [ [] ] ]

4149, 4158

1882, 3855

295, 330

4220, 4230

1091, 1859

4283, 4320

800, 880

4179, 4199

3881, 4126

4254, 4260

895, 1072

238, 257

358, 593

615, 722

738, 784

9,791

128,033

22983

Discharge summary

report

Admission Date: [**2186-2-23**] Discharge Date: [**2186-3-10**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Sternal drainage. Major Surgical or Invasive Procedure: Sternal debridement and sternal flaps [**2186-2-24**] History of Present Illness: Mr. [**Known lastname **] is s/p CABG x 3 on [**2186-1-30**]. He was discharged to rehabilitation on [**2186-2-6**] and was readmitted here [**2-24**] with cough and 4 day history of sternal drainage. His sternum was not stable with a click and chect CT showing malalignment of sternum without evidence of medistinitis. Past Medical History: BPH s/p TURP - postoperative course complicated by a-fib w/ non-ST elevation MI HTN Hyperlipidemia TIA Hypothyroidism Renal insufficiency Social History: no ETOH, no tobacco, lives w/ daughter, wife Family History: father w/ MI at 68 Pertinent Results: [**2186-3-6**] 04:15AM BLOOD WBC-11.2* RBC-3.48* Hgb-10.8* Hct-30.7* MCV-88 MCH-31.0 MCHC-35.1* RDW-14.4 Plt Ct-696* [**2186-3-9**] 05:13AM BLOOD PT-16.4* INR(PT)-1.7 [**2186-3-6**] 04:15AM BLOOD Glucose-91 UreaN-11 Creat-0.6 Na-132* K-4.0 Cl-99 HCO3-27 AnGap-10 [**2186-3-7**] 05:38AM BLOOD Vanco-23.1* Brief Hospital Course: Mr [**Known lastname **] was admitted [**2186-2-23**] with sternal wound infection. He was started on Vancomycin intravenously for MRSA and he was taken to the operating room on [**2-24**] for sternal debridement by Dr. [**Last Name (STitle) **] and flap closure by Dr. [**First Name (STitle) **] of plastic surgery. Please see OR notes for details. On post-operative day one he was successfully weened and extubated and remained in the ICU for hemodynamic monitoring. On POD two he was tranferred to the inpatient floor for ongoing recovery and rehabilitation and care of his JP drains. On POD three a PICC was placed for long-term antibiotic administration. Vanco levels were monoitored and on POD four, his dose was increased to 1250 mg [**Hospital1 **] for appropriate levels. On post-operative days five through thirteen, Mr. [**Known lastname **] continued with physical therapy. He was also followed closely by the Plastic surgery team for monitoring of his mediastinal JP drain and, with decreased drainage to less than 30 cc for a 24 hour period, on [**2186-3-9**] his last drain was discontinued. He also continued throughout this time with a scant amount of sero-sang drainage from the lower aspect of his sternal incision. On [**2186-3-9**] it was decided that Mr. [**Known lastname **] was stable for transfer. Medications on Admission: Lopressor 25 mg PO bid. Colace 100 mg PO bid. Zantac 150 mg PO bid. Amiodarone 200 mg PO daily. Aspirin 81 mg PO daily. Synthroid 100 mcg PO dialy. Lexapro 10mg PO daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Warfarin Sodium 1 mg Tablet Sig: Two(2) Tablet PO today [**3-10**] for 1 days: Please dose according to INR for goal INR of 1.5-2/0. 13. Vancomycin HCl 1,250 mg Sig: One (1) 1250 mg Intravenous twice a day for 4 weeks: Total of 6 weeks. Start date [**2186-2-23**]. Discharge Disposition: Extended Care Facility: [**Location (un) **] Discharge Diagnosis: Coronary artery disease, s/p coronary artery bypass graft x 3 and MAZE on [**2186-1-30**]. Sternal wound infection, s/p sternal debridement and sternal flaps [**2186-2-24**]. Discharge Condition: Stable. Discharge Instructions: Wash incisions daily. Betadine paint incision and place DSD at all times until d/c by plastic surgery. No swimming or bathing in a tub. No heavy lifting greater than 5 pounds. Strict sternal precations. Followup Instructions: Make appointment to follow-up with Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 25063**]. Make appointment to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Plastic surgery) in 2 weeks [**Telephone/Fax (1) 15527**]. Follow-up with Dr. [**Last Name (STitle) 11250**]. Completed by:[**2186-3-10**]

[ "412", "998.59", "V58.61", "593.9", "244.9", "733.00", "V09.0", "998.32", "E878.2", "272.0", "401.9", "730.08", "482.41", "427.31", "E849.7", "V45.81", "414.00" ]

icd9cm

[ [ [] ] ]

[ "38.93", "77.61", "99.04", "83.82" ]

icd9pcs

[ [ [] ] ]

3998, 4045

1299, 2628

286, 342

4263, 4272

971, 1276

4524, 4879

932, 952

2848, 3975

4066, 4242

2654, 2825

4296, 4501

229, 248

370, 693

715, 854

870, 916

57,745

110,899

45295

Discharge summary

report

Admission Date: [**2129-3-14**] Discharge Date: [**2129-3-23**] Date of Birth: [**2067-3-29**] Sex: M Service: SURGERY Allergies: E-Mycin Attending:[**First Name3 (LF) 1234**] Chief Complaint: Disabling left leg claudication, status post prior ligation of popliteal artery aneurysm Major Surgical or Invasive Procedure: [**2129-3-14**] Left superficial femoral artery to posterior tibial artery bypass graft using 6 mm ringed Propaten [**2129-3-15**] Cardiac Catheterization with PTCA [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 96769**] stents(x3) to the mid to ostial RCA History of Present Illness: The patient is a male who had an arm vein bypass femoral-popliteal done approximately 17 years ago for a large popliteal aneurysm. It lasted for that number of years and then occluded approximately 5 minutes before presentation. This was even with a previously normal graft study before that. Angiogram showed occlusion of the graft. There was no way to open up the graft since it was months after symptoms. In addition, there would be no percutaneous measure because the aneurysm was ligated. The patient has no veins whatsoever and did not have this similar anomaly in his left arm with essentially 2 brachial arteries. After a long discussion with the patient and the family he is not capable of staying at his current level. In other words he was so debilitated by this that he felt he needed surgery. He understands that his only option other than PTFE would be either an arterial construct which would be very difficult to harvest or thigh femoral vein which would also be very challenging. He understands the risk of graft failure either acutely or shorter long-term as well as graft infection and consents to go forward with the procedure. Past Medical History: PMH: PVD, Hyperlipidemia, H/O thyroid CA, colon polyps Social History: Smoking: none Alcohol: infrequent Family History: n/c Physical Exam: vss A&O x 3 in NAD Lungs:cta bilat Card: rrr, no m/r/g Abd: soft +bs, no m/t/o Extrem: warm bilat, LLE incision c/d/i, slight errythema at distal incision DP PT L P P R D P Pertinent Results: [**2129-3-23**] 06:37AM BLOOD Hct-29.5* [**2129-3-23**] 06:37AM BLOOD PT-24.9* INR(PT)-2.4* [**2129-3-21**] 06:15AM BLOOD Glucose-100 UreaN-13 Creat-1.0 Na-138 K-3.8 Cl-101 HCO3-31 AnGap-10 [**2129-3-18**] 03:36AM BLOOD CK(CPK)-408* [**2129-3-17**] 08:24AM BLOOD CK(CPK)-628* [**2129-3-16**] 05:16PM BLOOD CK(CPK)-1116* [**2129-3-16**] 04:39AM BLOOD CK(CPK)-1071* [**2129-3-15**] 07:41PM BLOOD CK(CPK)-590* [**2129-3-15**] 01:45PM BLOOD CK(CPK)-645* [**2129-3-15**] 06:00AM BLOOD CK(CPK)-483* [**2129-3-14**] 09:50PM BLOOD CK(CPK)-213 [**2129-3-18**] 03:36AM BLOOD CK-MB-7 cTropnT-2.31* [**2129-3-17**] 08:24AM BLOOD CK-MB-16* MB Indx-2.5 cTropnT-2.01* [**2129-3-16**] 04:39AM BLOOD CK-MB-102* MB Indx-9.5* cTropnT-1.75* [**2129-3-15**] 07:41PM BLOOD CK-MB-40* MB Indx-6.8* cTropnT-0.76* [**2129-3-15**] 01:45PM BLOOD CK-MB-55* MB Indx-8.5* cTropnT-0.97* [**2129-3-15**] 06:00AM BLOOD CK-MB-38* MB Indx-7.9* cTropnT-0.30* [**2129-3-14**] 09:50PM BLOOD CK-MB-9 cTropnT-<0.01 [**2129-3-16**] 04:39AM BLOOD %HbA1c-7.2* eAG-160* Cardiology Report ECG Study Date of [**2129-3-14**] 4:23:54 PM Probable sinus rhythm. Low amplitude P waves. Cannot rule out ST-T wave abnormalities. Baseline artifact. Since the previous tracing of [**2129-3-9**] the rate is faster. Further comparison cannot be made. Portable TTE (Focused views) Done [**2129-3-15**] at 7:23:31 PM FINAL Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: *5.4 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.4 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% to 60% >= 55% The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. There is mild regional left ventricular systolic dysfunction with distal inferoseptal and apical hypokinesis. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Limited emergency echo. Mild regional left ventricular systolic dysfunction with overall normal systolic function. Portable TTE (Complete) Done [**2129-3-16**] at 11:50:08 AM FINAL The left atrium is normal in size. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with distal inferoseptum, inferior wall hypokinesis. 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 arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2129-3-15**], the region of hypokinesis in the distal inferoseptum has decreased. Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2129-3-14**] and underwent Left superficial femoral artery to posterior tibial artery bypass graft using 6 mm ringed Propaten. He tolerated the procedure well and was taken to the PACU for recovery. He was found to have a low h/h and was hypertensive post operatively. He received 1u prbcs, and was placed on a nitro gtt. A heparin gtt was also initiated post op given his arterial disease. Once hemodynamically stable he was transferred to the VICU where he continued to be monitored closely. On POD 1 he was weaned off the nitro. His hct was still low and he was transfused another unit of prbcs. On [**3-15**], pod 1 the pt experienced some chest pain and a cardiac work up was started. His ekg st elevation in S II,III and his cardiac enzymes were positive, and trending upwards. Dr. [**Last Name (STitle) **] (cardiology) was consulted to see the pt and felt the pt was having an acute MI. Mr. [**Known lastname **] was taken urgently for a cardiac cath with the following findings: LMCA was calcified with minimal disease. The LAD had an ostial 60-70% lesion. The LCx had minimal disease. The RCA had an ostial 90% lesion, and a mid 60% calcified tubular lesion. 3 drug eluding stents were placed in the RCA and the pt tolerated the procedure well. He remained hemodynamically stable and was transferred back to the CCU. He remained in the CCU for 1 day, where he remained hemodynamically stable. He was started on plavix for the DES, and continued on iv heparin, and started on coumadin for PAD. He was transferred back to the vascular team and the VICU on the afternoon of [**3-16**]. His A1C was found to be >7 and the [**Last Name (un) **] diabetes team was asked to consult on his case. They monitored him closely and had him on a humalog sliding scale while in the hospital. Throughout the remainder of his hospital stay, his cardiac status was monitored closely. He was started on the appropriate medications s/p MI. He worked with physical therapy throughout his post operative course and was found to be stable to go home without services. His hct remained slightly decreased and on [**3-21**] it was recommended to transfuse 1 unit of prbcs. However, the pt had no IV access and refused to allow the team to place an EJ line. On [**3-22**] his hct had trended down to approximately 24 and we strongly encouraged him to be transfused. Given difficulty with piv and ej placement, an IJ was placed by a surgical resident at the bedside. Mr. [**Known lastname **] was transfused 2u prbcs with an appropriate rise in his hct. He remained hemodynamically stable and his hct was stable on [**3-22**]. He was tolerating a po diet, ambulating without assistance and voiding without difficulty. He was deemed stable for discharge home on [**2129-3-22**]. He will need cardiology follow up and will inevitably need CABG for his LAD disease at some point in the future. After his follow up with cardiology, he may start a cardiac rehabilitation program. His PT/INR will be followed by his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 131**] and he will see the [**Last Name (un) **] diabetes team for further evaluation of his diabetes in the next few weeks. Medications on Admission: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)). 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): otc - use if taking narcotics. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain . 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for GERD: otc - . 9. Alprazolam 0.25 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed for anxiety: home medication. 10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: call pcp for refills. Disp:*30 Tablet(s)* Refills:*2* 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 14 days. Disp:*14 Tablet(s)* Refills:*0* 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 weeks. Disp:*56 Capsule(s)* Refills:*0* 15. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 16. glucometer check blood sugars multiple times per day as recommened by the diabetes team Discharge Disposition: Home With Service Facility: [**Hospital **] Homecare Discharge Diagnosis: Primary: Disabling left leg claudication (long standing PVD) Secondary: Post op MI Diabetes Hyperlipidemia H/O thyroid CA H/O colon polyps Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. 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 [**1-5**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 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 You also experienced a post operative myocardial infarction (heart attack) and underwent a cardiac catheterization with stenting of your Right Coronary Artery. It is important that you follow up with your cardiologist in the next few weeks and get set up with a cardiac rehab center as soon as you are cleared by Dr. [**Last Name (STitle) **] (he will give you a persciprtion for cardiac rehab) You have been started on several new medications including coumadin (warfarin). It is very important that you have your PT/INR values monitored by your PCP , [**Last Name (NamePattern4) **]. [**Last Name (STitle) 131**]. He will let you know if you need to adjust your coumadin dose. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2129-4-1**] 9:15 Dr. [**Last Name (STitle) 131**] will follow your PT/INR (coumadin lab values). The VNA will draw your INR friday, and at least twice a week after that and send the results to : DR. [**Last Name (STitle) **],[**First Name3 (LF) 132**] C. [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL GROUP Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 133**] Fax: [**Telephone/Fax (1) 445**] Dr. [**Last Name (STitle) 9671**] 2 weeks (diabetes)([**Telephone/Fax (1) 17484**] Call for appt. Dr. [**Last Name (STitle) **] (cardiology) [**Telephone/Fax (1) 7960**]. His office will call you with f/u appt (2-3 weeks) Cardiac Rehab - to start when cleared by Dr. [**Last Name (STitle) **] Completed by:[**2129-3-23**]

[ "300.00", "244.0", "443.9", "250.00", "790.01", "440.31", "410.41", "414.01", "272.4", "V10.87" ]

icd9cm

[ [ [] ] ]

[ "39.29", "36.07", "99.04", "37.22", "88.53", "00.66", "00.40", "88.56", "00.47" ]

icd9pcs

[ [ [] ] ]

11244, 11299

5737, 8967

356, 623

11483, 11483

2183, 5714

15135, 16076

1950, 1955

9550, 11221

11320, 11462

8994, 9527

11634, 14020

14046, 15112

1970, 2164

228, 318

652, 1801

11498, 11610

1823, 1880

1896, 1934

62,186

185,078

47879

Discharge summary

report

Admission Date: [**2160-6-26**] Discharge Date: [**2160-7-22**] Date of Birth: [**2097-8-21**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 668**] Chief Complaint: Abdominal Wound dehiscence Major Surgical or Invasive Procedure: VAC placment with white sponge under black sponge History of Present Illness: Mr. [**Known lastname **] is a 62 year old male who was recently admitted after gastrocutaneous fistula takedown on [**2160-6-11**] that was complicated by small medial fascial dehiscence treated with wound vac. He was discharged to rehab on [**6-21**] and returned to clinic today for post-operative checkup and was noted to have increase in size of the dehiscence and was directly admitted to the surgical service for observation. He reports mild pain over wound site that has been improving. His appetite is improving. He denies any fever/chills, nausea, vomiting, or change in ostomy output/character. He last received [**Month/Year (2) 2286**] yesterday via his left radiocephalic fistula without complications. Past Medical History: (Per record & patient) ESRD on HD (secondary to post-streptococcal glomerulonephritis, Renal transplant '[**37**] failed, transplant nephrectomy in [**2143**]), Hyperparathyroidism, Hypertension, Atrial fibrillation (started on warfarin [**Date range (1) 101024**]), CAD, Diastolic CHF with remote history of systolic CHF [**Date range (1) 8974**], Endocarditis w/ Aortic and Mitral valve involvement, Repeated episodes of pneumonia, VRE septic arthritis, L wrist [**Date range (1) 8974**] infective arthritis, Right hip fracture s/p Right hip hemiarthroplasty, [**2157-1-11**], Right Prosthetic Hip infection s/p explantation [**2-18**], Ischemic colitis/ileitis s/p subtotal colectomy and terminal ileal resection, followed by ileocolonic anastomosis with diverting loop ileostomy and gastrostomy tube placement [**2156**] . PAST SURGICAL HISTORY: (Per record or patient) [**2158-11-7**]: Aortic valve replacement(21 mm ON-X, Mitral valve replacement 25/33 On-X Conform-X mechanical valve) [**2158-10-5**]: Right heart catheterization [**2158-10-3**]: Paracentesis [**2158-7-13**]: Fistulogram, 6-mm balloon angioplasty of juxta-anastomotic segment [**2157-6-16**]: Washout and drainage right hip wound infection. [**2157-6-14**]: Revision left radiocephalic arteriovenous fistula, endarterectomy radial artery. [**2157-2-22**]: Evacuation drainage of right hip deep hematoma-abscess. [**2157-2-18**]: Removal right hip hemiarthroplasty. [**2157-2-3**]: Irrigation, debridement and evacuation of hematoma of right septic hemiarthroplasty. [**2157-1-26**]: Right hip revision of hemi arthroplasty due to dislocation. [**2157-1-15**]: Exploratory laparotomy, gastrostomy tube, ileocolonic anastomosis and diverting loop ileostomy. [**2157-1-14**]: Exploratory laparoscopy, subtotal colectomy. [**2157-1-13**]: Exploratory laparotomy, Subtotal colectomy, Resection of terminal ileum, Temporary abdominal closure. [**2157-1-11**]: Right hip hemiarthroplasty. [**2156-12-10**]: Left wrist incision and drainage. [**2156-2-17**]: Right ring finger closed reduction percutaneous pinning for mallet finger. Left index and long ring finger PIP joint manipulation under anesthesia. [**2155-12-16**]: Left carpal tunnel release and left index, long and ring finger trigger releases Social History: SH: H/o ~3 p-y tob, occ etoh. Family History: Father with prostate CA. Physical Exam: admission Physical Exam: Vitals: T 98.8, HR 65, BP 132/71, RR 18, O2 99%RA Gen: A&O, NAD CV: irregularly irregular, no m/r/g Pulm: CTAB Abd: soft, non-distended, mild TTP over incision site. Ostomy intact with stool/gas. Incision open in LUQ with fibrinous material at base. Approximately 3-4cm dehiscence over medial aspect. Ext: w/d, trace BLE edema Labs: pending Pertinent Results: [**2160-7-1**] 05:50AM BLOOD PT-40.5* INR(PT)-4.0* [**2160-6-30**] 05:35AM BLOOD PT-43.9* INR(PT)-4.3* [**2160-6-29**] 05:20AM BLOOD PT-37.4* INR(PT)-3.7* [**2160-6-28**] 05:30AM BLOOD PT-26.2* INR(PT)-2.5* [**2160-6-27**] 05:45AM BLOOD PT-28.8* INR(PT)-2.8* [**2160-6-26**] 07:50PM BLOOD PT-29.9* PTT-39.9* INR(PT)-2.9* [**2160-7-1**] 05:50AM BLOOD WBC-5.3 RBC-2.93* Hgb-8.5* Hct-28.9* MCV-99* MCH-29.0 MCHC-29.4* RDW-16.5* Plt Ct-181 [**2160-7-3**] 4:24 pm URINE Source: CVS. **FINAL REPORT [**2160-7-6**]** URINE CULTURE (Final [**2160-7-6**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. CEFEPIME sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: 62M admitted after gastrocutaneous fistula takedown on [**2160-6-11**] that was complicated by small medial fascial dehiscence treated with wound vac. He was now admitted for wound management. Wound vac was changed on Mondays and Thursdays only with white sponge placed first to cover small area of exposed cauterized liver then black sponge. Coumadin was continued. Hemodialysis per home HD schedule (M-W-F). INR was noted to be rising up to 3.7 and warfarin was held. This value continued to rise and the warfarin was held for 7 days before being restarted on home dose. He experienced bladder spasms with penile pain with sense of urinary urgency (doesn't make urine)that persisted. He then had purulent/bloody appearing drainage from his penis. Urology was consulted and oxybutinin was suggested for spasm control. This was started with some relief of symptoms, however he started became confused with occasional hallucinations. Oxybutinin was stopped. A full ID evaluation of potential causes including GC/Chlamydia (negative) and HSV (negative) were performed. Culture on the discharge revealed E coli, and a cystoscopy was done on [**7-8**] showing Vesiculoenteric fistula between the bladder dome and small bowel in the right hemipelvis and also a Coloenteric fistula extending between the small bowel and the distal colon/rectum. Unasyn was started on [**7-6**], CT done on [**7-10**] also showed a fistulous tract from the anterior abscess to the ileocolic anastomosis in the right lower quadrant. Air was noted within the bladder, likely demonstrating a connection to the bladder resulting in a vesicoenteric fistula at this level. GI was consulted and an ileoscopy and rectal scope was performed on [**7-11**] after FFP and Vit K for reversal of INR. Several biopsies were taken with results as follows: Ileum, biopsy: Intestinal mucosa with surface denudation, tissue distortion precludes full interpretation. Anastomosis, biopsy: Colonic mucosa, within normal limits. Rectum, biopsy: Colonic mucosa with focal lamina propria hyalinization, otherwise unremarkable. Given these findings, Unasyn continued for a total of 15 days. The cultures obtained from the bladder at the time of the cystoscopy isolated E coli. All blood cultures have been negative and he has been afebrile. Penile/bladder pain abated. During this time period he was also noted to have subtherapeutic INR, as he required FFP so that biopsies could be obtained. He was started on a heparin drip for sub-therapeutic INR. INR was 3.0 on [**7-20**] and heparin gtt was stopped. Coumadin continued. On [**7-12**] the patient received one unit of RBCs in hemodialysis for blood noted in both ostomy and rectally. A CT was done, and patient had evidence of hematoma near the biopsy site The patient was transferred to the SICU and underwent an Ileoscopy/Sigmoidoscopy. A large blood clot was noted upon insertion of the scope into the rectum. There were multiple excoriated areas as well as friable tissues. It was felt that source of bleeding was in the efferent ileal loop. A total of four units of pRBCs were given. Hcts were stable, a heparin drip was started, and the hematocrit remained stable. He was again started on coumadin once the drip was therapeutic, and on [**7-21**], the heparin drip was discontinued, and warfarin therapy monitored with daily INRs. The patient complained of intermittent bladder/suprapubic pain, although this seems better managed using oxycodone. The abdominal wound has been healing well with healthy granulation tissue, the VAC continues to be changed twice weekly (Monday and Thursday)with a white sponge directly to wound then black sponge (as there was small area of exposed cauterized liver tissue on Left side of wound). This has been healing nicely and has been free of any bleeding. Hemodialysis has been continued on routine MWF schedule. The dietician followed him noting insufficient Kcals (800-1100kcal/day). Recommendations were to place a feeding tube. Several unsuccessful attempts were made to place a nasogastric feeding tube. He tried hard to eat and increased his supplement intake. Friends brought food from home which has helped his caloric intake. He refused further attempts to place a nasogastric feeding tube. PT evaluated and recommended rehab admission. The patient uses a wheelchair at baseline. A bed was available at [**Hospital **] HealthCare on [**7-22**]. He will transfer there today with f/u in 1 week with Dr.[**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **] and urologist, Dr. [**Last Name (STitle) 770**]. He will also continue on Augmentin 3x/wk after HD for UTI prophylaxis given vesicoenteric fistula. Medications on Admission: pantoprazole 40'', Oxycodone 5 q4 PRN, Acetaminophen 325-650 q6H PRN, digoxin 125 q T/Th, sevelamer 800''', Vit B-Vit C-folic acid', lorazepam 0.5 q4H PRN, Coumadin 5.5', Ciprofloxacin 500', lisinopril 2.5 q T/Th/Sat/Sun, ASA 81' Discharge Medications: 1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 2X/WEEK (TU,TH). 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: 2.5-3.5 goal. 4. Outpatient Lab Work daily INR (goal 3-3.5) 5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. [**Last Name (STitle) 101026**] 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR): after [**Last Name (STitle) 2286**] for prophylaxis UTI given vesiculoenteric fistula. 9. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA). 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) **] Discharge Diagnosis: gastrocutaneous fistula Fascial dehiscence testicular mass vesiculoenteric/coloenteric fistula E coli UTI h/o AVR/MVR afib 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: Please call Dr[**Name (NI) 17175**] office at [**Telephone/Fax (1) 673**] if patient develops fever, chills, nausea, vomiting, increased abdominal pain, there are changes noted in the volume or nature of the VAC drainage (becomes bloody or develops a foul odor) ot other concerning symptoms. Please only change the VAC dressing on Monday and Thursday of each week. Continue Hemodialysis Monday-Wed-Friday per routine outpatient schedule Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2160-7-31**] 3:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 5727**] Date/Time:[**2160-8-4**] 3:20 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2160-8-18**] 9:00 f/u with urology in [**5-16**] weeks Completed by:[**2160-7-22**]

[ "E945.1", "V02.53", "569.41", "596.1", "292.81", "V45.87", "V45.11", "305.1", "428.42", "608.89", "599.0", "V45.73", "998.12", "583.89", "V45.72", "V43.3", "588.81", "041.49", "555.0", "V55.3", "788.30", "V58.61", "404.91", "585.6", "V46.3", "E934.2", "414.01", "285.21", "428.0", "998.31", "E879.8", "567.22", "427.31", "569.81", "V43.64", "790.92", "E878.0" ]

icd9cm

[ [ [] ] ]

[ "45.24", "45.12", "99.15", "45.14", "39.95", "38.93", "57.32", "48.24" ]

icd9pcs

[ [ [] ] ]

11334, 11417

5380, 10075

329, 381

11584, 11584

3927, 5357

12221, 12736

3498, 3524

10356, 11311

11438, 11563

10101, 10333

11760, 12198

2005, 3434

3564, 3908

263, 291

409, 1128

11599, 11736

1150, 1980

3450, 3482

788

139,716

52749+59464

Discharge summary

report+addendum

Admission Date: [**2194-1-13**] Discharge Date: [**2194-1-16**] Date of Birth: [**2122-7-19**] Sex: F Service: CHIEF COMPLAINT: Fever and chest pain. HISTORY OF PRESENT ILLNESS: Seventy-one year old female with recent history of upper respiratory infection symptoms, who presents to the Emergency Department with cough, fevers, and fatigue. The patient presented to her PCP on the [**2194-1-9**] complaining of two days of rhinorrhea, cough with yellow sputum, right sided pleuritic chest pain, and reported fever and chills. Given her normal physical exam, she was treated for a bilateral upper respiratory infection with symptomatic treatment. However, the patient's symptoms persisted and she presented to the [**Hospital1 69**] Emergency Department on the [**2194-1-13**] complaining of increased weakness, right sided lateral chest pain, persistent cough (nonproductive), rhinorrhea, and reported fevers and chills. REVIEW OF SYSTEMS: The patient denies headache, neck stiffness, sore throat, palpitations, chest pressure, abdominal pain, nausea, vomiting, diarrhea, bright red blood per rectum, dysuria, vaginal discharge, and lower extremity edema. In the Emergency Department, the patient was treated with levofloxacin and ceftriaxone, and received IV fluids. She was treated according to the sepsis protocol for presumed pneumonia/sepsis and central line was placed. PAST MEDICAL HISTORY: 1. Hyperlipidemia. 2. Anxiety disorder. 3. Nephrolithiasis. 4. Gastroesophageal reflux disease. 5. Pyelonephritis [**2193-9-30**]. 6. Hypertension. 7. COPD. ALLERGIES: Patient is allergic to codeine which causes chest pain, and to Macrobid (nitrofurantoin/nitrofuran), which causes fever, chills, arthralgias, and arthritis. MEDICATIONS: 1. Atenolol 50 q.d. 2. Aspirin 325 q.d. 3. Lipitor 5 q.d. 4. Xanax prn. 5. Aleve/Naproxen prn. 6. The patient reports that her hydrochlorothiazide is being discontinued. SOCIAL HISTORY: The patient denies tobacco and alcohol use. She lives by herself in an apartment above her children. FAMILY HISTORY: Diabetes, coronary artery disease, cancer of the stomach and lungs. PHYSICAL EXAMINATION: Vital signs: Temperature 95.3, pulse 62, blood pressure 79/48, O2 saturation 95% on room air. In general, this is a well appearing, cooperative, elderly female. HEENT: PERRL. Anicteric sclerae. Oropharynx: Moderate pupils dry, but clear. Neck is supple without lymphadenopathy. Cardiovascular: S1, S2, regular, rate, and rhythm, no murmurs, rubs, or gallops. Lungs: Rhonchi and wheezing on the right side. Abdomen: Soft, nontender, nondistended with normoactive bowel sounds. Back without CVA tenderness. Extremities without edema. Pulses 1+, no rash. Neurologic: Alert and oriented times three. Cranial nerves II through XII intact. LABORATORIES: White blood cell count 17.4, hematocrit 31.9, platelet count 198. Sodium 137, potassium 3.7, chloride 99, bicarb 20, BUN 22, creatinine 1.2, glucose 281. Lactate was 6.7. Chest x-ray showed right middle lobe consolidation consistent with pneumonia. HOSPITALIZATION COURSE: Given her picture of sepsis, the patient was enrolled in the sepsis protocol and admitted to the Medical ICU for treatment of her pneumonia. 1. Pneumonia: The patient was diagnosed with community acquired pneumonia and treated with levofloxacin and ceftriaxone. This led to a rapid improvement in her lung examination with resolution of the rhonchi and wheezing within 48 hours. The patient continued to complain of pleuritic type chest pain, for which she was treated very gently with Tylenol and Motrin unsuccessfully, and then successfully with Darvocet (codeine was avoided because the patient is allergic). 2. Hypertension/sepsis: Most likely secondary to pneumonia. In addition to her antibiotic treatment, the patient was aggressively hydrated according to the sepsis protocol. This resulted in an improvement in her blood pressure. At the same time, her antihypertensive medications were held. 3. Hyperglycemia: During hospitalization, the patient's glucose was found to be elevated. The patient reports no history of diabetes. Obviously given her acute illness, the diagnosis of glucose intolerance cannot be made at this time. However, the patient was found to have a hemoglobin A1C of 6.3, indicating possibly glucose intolerance. It is recommended that the patient follows up with her PCP to evaluate this finding. MEDICATIONS ON DISCHARGE: 1. Levofloxacin 500 mg p.o. q.d. for 10 days. 2. Cefpodoxime proxetil 200 mg b.i.d. for 10 days. 3. Acetaminophen 325 mg 1-2 tablets p.o. q.4-6h. prn. 4. Docusate sodium 100 mg b.i.d. 5. Lipitor 5 mg q.d. 6. Dextromethorphan guaifenesin 10/100 mg/5 mL syrup take every six hours as needed. 7. Atrovent inhalers and Albuterol inhalers. 8. Darvocet one tablet p.o. q.6h. for seven days. 9. Atenolol 50 mg one tablet p.o. q.d. DISCHARGE STATUS: Home. DISCHARGE CONDITION: Good. DISCHARGE INSTRUCTIONS: The patient was advised to followup with her PCP within one week (Dr. [**Last Name (STitle) **], phone number [**Telephone/Fax (1) 1144**]. Also she was advised to contact her PCP or come back to the Emergency Department if she continues to have fever, chills do not resolve or if she experiences any nausea and vomiting. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Sepsis. 3. Hypertension. 4. Possible glucose intolerance. As of [**2194-1-15**], the patient is still in the Medical ICU, but expected to be discharged on the following day to home. At this time, sputum cultures and blood cultures are pending. An addendum will follow. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-207 Dictated By:[**Last Name (NamePattern1) 5233**] MEDQUIST36 D: [**2194-1-15**] 17:50 T: [**2194-1-20**] 07:36 JOB#: [**Job Number 108798**] Name: [**Known lastname 17828**], [**Known firstname 2770**] Unit No: [**Numeric Identifier 17829**] Admission Date: [**2194-1-13**] Discharge Date: [**2194-1-18**] Date of Birth: [**2122-7-19**] Sex: F Service: [**Hospital1 248**] ADDENDUM: HOSPITAL COURSE (continued): 1. PNEUMONIA: The patient was transferred to the Floor and continued on Levaquin and ceftriaxone. She was afebrile but continued to have mild oxygen desaturation on room air with ambulation. Her respiratory status improved with mild diuresis. Ceftriaxone was discontinued on hospital day three. On hospital day four, the patient continues to have oxygen saturations in the low 90s while ambulating on room air. She was in no apparent distress, however, was able to walk without becoming short of breath. She was diuresed further, and on hospital day five, was stable for discharge home. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Sepsis. 3. Hypotension. CONDITION ON DISCHARGE: Good. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg p.o. q. day times ten days. 2. Tylenol p.r.n. 3. Colace p.r.n. 4. Lipitor 5 mg p.o. q. day. 5. Dextromethorphan - guaifenesin p.r.n. 6. Atrovent two puffs q. six to eight hours. 7. Albuterol two puffs q. four to six hours. 8. Atenolol 50 mg p.o. q. day. 9. Hydrochlorothiazide 25 mg p.o. q. day. DISCHARGE INSTRUCTIONS: 1. The patient was instructed to call her primary care physician or return if she experienced fever and chills or was unable to eat or drink. 2. She was also instructed to follow-up with her primary care physician in one week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**], M.D. [**MD Number(1) 225**] Dictated By:[**Last Name (NamePattern1) 629**] MEDQUIST36 D: [**2194-2-1**] 17:42 T: [**2194-2-1**] 17:46 JOB#: [**Job Number 17830**]

[ "272.0", "401.9", "038.9", "285.9", "486", "530.81", "995.91", "300.00" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

4948, 4955

2073, 2142

6797, 6842

6898, 7227

4475, 4926

7251, 7752

2165, 4449

964, 1403

145, 168

197, 944

1425, 1937

1954, 2056

6868, 6875

69,131

107,225

36015+58054

Discharge summary

report+addendum

Admission Date: [**2127-1-12**] Discharge Date: [**2127-2-7**] Date of Birth: [**2082-5-16**] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5667**] Chief Complaint: Necrotizing fasciitis Major Surgical or Invasive Procedure: [**2127-1-12**]: Incision and drainage of deep neck abscess of the neck with extensive debridement of the skin and muscle, as well as fascia of both sides of the neck and the anterior upper chest wall. [**2127-1-17**]: 1. Left pectoralis myofascial flap. 2. Split-thickness skin grafting measuring an area of 30 cm x 20 cm, meshed at 1.5:1. History of Present Illness: 44M with HIV (per report, unknown CD4. no HARRT) who had dental abscess 10 days ago in [**State 4565**]. He underwent L inferior tooth extraction, and was placed on oral Abx. During the next 2 days, he began feeling L neck swelling, and while on a plane flight, the neck wound opened and started draining purulence. He was seen by an OSH in [**State 108**], and the neck abscess continued to spread, and he started draining copious amounts of fluid. He was started on IV abx, but was ultimately brought to [**Hospital1 18**] ED by his father. Today he reports [**6-8**] pain, no fevers or chills. No difficulty breathing. He was diagnosed with HIV 7 yrs ago and stopped f/u due to financial reasons. Denies any infections until now. Also c/o diarrhea for past 4 weeks, and 30 lb weight loss over past 6 weeks. No night sweats. No dyspnea, cough. Past Medical History: -HIV, diagnosed [**2119**], never on ARV, no Hx infections -Hx hemorrhoids, s/p "day surgery" x 3 Social History: Up until last week lived in basement of friend's home in LA. Moved to LA from [**Location (un) 86**] 20 yrs ago. No tobacco, rare ETOH. Cocaine (nasal) [**2098**]'s. Intermittent methamphetamine (last 1 yr ago), marijuana recently. Family History: NC Physical Exam: On admission: Vitals: 34.6C 75 112/61 18 98%RA Gen: Alert & oriented x3, in [**6-8**] pain, but breathing and speaking comfortably OC: s/p extraction L lower molar Neck: submental and L neck skin necrotic and open area ~5x6cm - draining purulence. Portion of straps anteriorly eroded. skin overlying T2-3 appears necrotic, leathery, erythematous, blanches with palpation. fluctuant down to ~T2-3 bilat across chest. very tender to palpation. HP/LX: deferred to OR Pertinent Results: Labs on admission: [**2127-1-12**] 10:40AM BLOOD WBC-10.5 RBC-4.00* Hgb-9.3* Hct-29.0* MCV-73* MCH-23.4* MCHC-32.2 RDW-20.0* Plt Ct-377 [**2127-1-12**] 10:40AM BLOOD Neuts-86.4* Bands-0 Lymphs-6.7* Monos-6.5 Eos-0.3 Baso-0.1 Atyps-0 Metas-0 Myelos-0 [**2127-1-12**] 10:40AM BLOOD PT-17.9* PTT-34.3 INR(PT)-1.6* [**2127-1-13**] 11:02AM BLOOD WBC-7.3 Lymph-13* Abs [**Last Name (un) **]-949 CD3%-93 Abs CD3-886 CD4%-15 Abs CD4-146* CD8%-76 Abs CD8-724* CD4/CD8-0.2* [**2127-1-12**] 10:40AM BLOOD Glucose-58* UreaN-18 Creat-0.4* Na-127* K-4.0 Cl-97 HCO3-25 AnGap-9 [**2127-1-12**] 10:40AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.0 [**2127-1-12**] 11:09AM BLOOD Lactate-1.8 K-3.8 Imaging: CT neck/chest with contrast [**2127-1-12**]: 1. Necrotizing fasciitis involving the soft tissues of the anterior chest wall, incompletely visualized. No definite intrathoracic/mediastinal extension. 2. 5-mm right pulmonary nodule. Followup chest CT in 12 months is recommended. Postop CTA head/neck [**2127-1-13**]: 1. No evidence of intracranial hemorrhage. The carotid and vertebral arteries and their major branches are patent without evidence of stenosis or aneurysm formation. 2. Interval surgical drainage of the left cervical abscess with extensive post-surgical changes as described above. 3. Sinus disease as described above. TTE [**2127-1-13**]: Left ventricular wall thickness, cavity size and regional/global systolic function appear to be normal (LVEF >55%). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: Patient was diagnosed with nectrotizing fascitiis of the neck. Broad spectrum antibiotics were started in the ED with zosyn, vancomycin, and gentamycin under ID consultation. He was immediately taken to the operating room for washout and debridement. There was gross pus draining from the neck in multiple areas with soupy muscle visible throughout the open wound. The open wound measured, in medial to lateral direction about 8 cm, and in a superior to inferior direction about 6 cm. Please see Dr.[**Name (NI) 18353**] operative note for details. Patient tolerated the procedure well and was then transferred to the TICU intubated. ENT performed daily dressing changes until he returned to the OR for wound coverage on [**2127-1-17**] by plastics for left pectoralis myofascial flap and STSG. Please see Dr. [**Name (NI) 73208**] operative note for detailes. Post-operatively, he did well and was transferred out of the ICU on [**1-21**]. During his course on the floor he continued to improve. He spiked a fever a couple days into his stay on the floor and infectious work-up was significant for likely candidal esophagitis and was started on a 14d course of fluconazole. A CT scan of his neck to evaluated for source of infection suggested osteomyelitis of the left side of the mandible. OMFS was consulted and he was subsequently taken to the operating room on [**2127-2-3**] where a debridement of the right and left mandible, placement of rigid fixation, and extraction of 7 teeth, numbers 18, 21, 22, 23, 24, 25 and 26 was performed. He was subsequently changed from Augmentin to Zosyn with ID following for likely Osteomyelitis of the mandible. His entire postoperative course is outlined below by systems. . Neuro: Immediately postoperatively patient was noted to have anisacoria not noted preoperatively. Neurology was consulted given the concern for an acute CVA. A CTA of the head and neck was obtained which was negative for an acute stroke. Neurology concluded that this was not consistent with a CVA or TIA, and recommended an opthalmology consult for a formal ophthalmologic exam. Neuro-optho concluded that his left pupil appears fixed secondary to synechiae (prior infection). No further treatment or workup was recommended. Pain was well-controlled with fentanyl. Versed/fentanyl drips were used for sedation while intubated. Patient was given ketamine for daily dressing changes. No episodes of delirium. Cardiovascular: No active issues. On [**1-13**] (POD1) his pressors were successfully weaned. His BPs and HR were stable for the rest of his TICU stay. On [**1-15**] and [**1-18**] he was volume overloaded on exam and was effectively diuresed with lasix. Pulmonary: Patient was successfully extubated on [**2127-1-20**] (POD3 s/p wound closure by plastics). No active issues. . GI: Diarrhea likely from tube feed regimen. Stool cultures and O&P were negative. C.diff have consistently been negative. . Nutrition: Continous tube feeds (via a dobhoff tube placed intraoperatively) was started on [**2127-1-13**]. His albumin on admission was 1.6. He has remained on tube feeds with nutrition following. At the time of transfer he is currently on a full liquid diet with continuous tube feeds. . Renal: No active issues - UOP adequate, with appropriate GFR. . Hematology: On [**2127-1-15**] he was transfused 2uPRBC for a HCT of 19. On [**1-17**] he was again given 2uPRBC before going to the OR for wound closure by plastics. His HCT remained stable post-operatively after the plastics closure but did level out in the low 20's and he was subsequently given 3u PRBC during the OMFS mandible debridement at which point his HCT has remained stable at 30. . Endocrine: No active issues - his sugars were well-controlled with a RISS. . Infectious Disease: ID was immediately consulted and follows daily. Patient was immediately started on vanc, zosyn, and gentamycin. Vanc and gent serum drug levels were closely monitored, with drug dosing adjusted accordingly. There was no evidence of active TB (no isolation cautions initiated). Intraoperative OR cultures from [**2127-1-12**] ultimately grew polymicrobes, staph aureus, and peptococcus. Staph sensitivies showed MSSA. Prior wound cultures from an OSH grew pan-sensitive e. coli and MSSA. Gentamycin was discontinued on [**2127-1-18**]. Currently, he remains on zosyn for osteomyelitis of the mandible. Consider stopping vanc once staph aureus sensitivies return. Serology for toxo, CMV, and syphilis were negative. He is currently on Zosyn for osteomyelitis of the mandible, bactrim prophylaxis and fluconcazole for candidal esophagitis. Surgical wound: Debrided wound was followed by ENT with daily dressing changes and packing of the left superior neck dead space. General and thoracic surgery were consulted for possible redebridement. All services were in agreement that a repeat debridement was not indicated. Plastic surgery was consulted for wound closure management. Patient underwent left pectoralis myofascial flap and STSG from bilateral thighs on [**2127-1-17**]. His skin graft sites over his neck were continued with daily dressing changes with xeroform and kerlex gauze wrapped around his upper chest and neck. The skin graft site on the R did not take as well as on the left but it remained clean and has continued to heal well. The coverage has continued to heal without infection. Dispo: Will be transferred to [**Hospital **] rehab Medications on Admission: Ibuprofen prn Immodium prn Discharge Medications: 1. Senna 8.6 mg Tablet [**Hospital **]: One (1) Tablet PO BID (2 times a day) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital **]: One (1) ml Injection TID (3 times a day). 4. Lorazepam 0.5 mg Tablet [**Hospital **]: 1-4 Tablets PO Q4H (every 4 hours) as needed. 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 7. Ascorbic Acid 90 mg/mL Drops [**Last Name (STitle) **]: Five (5) ml PO DAILY (Daily). 8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily) as needed for PCP [**Name Initial (PRE) 1102**]. 9. Docusate Sodium 100 mg Capsule [**Name Initial (PRE) **]: One (1) Capsule PO BID (2 times a day). 10. Oxycodone 5 mg Tablet [**Name Initial (PRE) **]: 1-3 Tablets PO Q4H (every 4 hours) as needed for pain. 11. Acetaminophen 500 mg Tablet [**Name Initial (PRE) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed. 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Name Initial (PRE) **]: One (1) Tablet PO TID (3 times a day). 13. Folic Acid 1 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO DAILY (Daily). 14. Nystatin 100,000 unit/mL Suspension [**Name Initial (PRE) **]: Five (5) ml PO Q8H (every 8 hours). 15. Menthol-Cetylpyridinium 3 mg Lozenge [**Name Initial (PRE) **]: One (1) Lozenge Mucous membrane PRN (as needed). 16. Fluconazole 100 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO Q24H (every 24 hours): Started [**2127-1-31**] for 14 day course. Stop date [**2127-2-14**]. 17. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day/Year **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 18. Heparin, Porcine (PF) 10 unit/mL Syringe [**Hospital1 **]: Two (2) ML Intravenous PRN (as needed) 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. . 19. HYDROmorphone (Dilaudid) 0.25-1.0 mg IV Q3H:PRN 20. Piperacillin-Tazobactam Na 2.25 g IV Q8H 21. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 22. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain 23. Alteplase (Catheter Clearance) 1 mg IV PRN catheter clearance, no more than q8 Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Necrotizing fasciitis Discharge Condition: Good, Stable Discharge Instructions: Continue daily dressing changes to your neck skin graft sites with xeroform gauze with kerlex dressing as has been done daily in the hospital. You should continue to keep your skin graft donor sites on your legs dry and open to air. Allow the dried dressing to peel off on its own. You will continue on your tube feeds and antibiotics. You should continue to ambulate as tolerated. Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] in the next week after discharge. Call his office at ([**Telephone/Fax (1) 9144**] for an appointment Follow-up with Dr. [**First Name (STitle) **] of OMFS in the next week after discharge. Call ([**Telephone/Fax (1) 37579**] for an appointment. Follow-up with the Infectious Disease clinic with Dr. [**Last Name (STitle) 81746**] on [**2127-2-28**] 11:00. His office number is Phone:[**Telephone/Fax (1) 457**] Name: [**Known lastname 13109**],[**Known firstname **] Unit No: [**Numeric Identifier 13110**] Admission Date: [**2127-1-12**] Discharge Date: [**2127-2-7**] Date of Birth: [**2082-5-16**] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1165**] Addendum: Final ID recommendations are to continue zosyn for six weeks from the OMFS operation date of [**2127-2-3**] and to draw weekly CBC, Chem panel, LFT's, ESR/CRP Discharge Disposition: Extended Care Facility: [**Hospital6 4356**] - [**Location (un) 164**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1167**] MD [**MD Number(2) 1168**] Completed by:[**2127-2-7**]

[ "728.86", "526.89", "785.52", "528.3", "364.70", "038.9", "041.11", "042", "707.03", "995.92", "707.22", "112.0", "785.4", "262", "379.41" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.04", "86.69", "86.74", "76.99", "76.2", "23.19", "83.45", "96.72" ]

icd9pcs

[ [ [] ] ]

14883, 15112

4297, 9775

335, 678

12617, 12631

2464, 2469

13850, 14860

1947, 1951

9853, 12455

12572, 12596

9801, 9830

12655, 13827

1966, 1966

274, 297

706, 1558

2483, 4274

1580, 1680

1696, 1931

51,337

142,756

40155

Discharge summary

report

Admission Date: [**2183-10-22**] Discharge Date: [**2183-10-25**] Date of Birth: [**2130-12-14**] Sex: F Service: MEDICINE Allergies: Lisinopril / Ampicillin Attending:[**First Name3 (LF) 1711**] Chief Complaint: Cardiac Arrest Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: Ms. [**Known lastname **] is a 52 y/o schoolteacher w/ HTN admitted to CCU s/p cardiac arrest while walking into school this AM. Per report, CPR was initiated by her co-workers. When EMS arrived she was found pulseless and apneic and one shock was delivered. She was then found to be breathing at a RR of 10 with a rapid pulse, but was still unresponsive. She was bolused 100 mg of lidocaine IO. Cardiac monitor per EMS report showed sinus tach at rate of 140 with a BP of 150/100. Patient then became responsive. Lidocaine infusion at 1 mg/min was started. She was transferred to [**Hospital1 18**] ED for further management. In the ED, intial VS: Temp: 98.6 HR: 115 BP:147/92. The lidocaine gtt was stopped. She was given 50 mg of fentanyl and 4 mg of zofran for chest pain and nausea. The patient states she felt herself "blackout" immediately before the arrest and remembered nothing else. She denies pre-syncope, syncope, palpitations, chest pain or sob. She has had atypical exertional chest pain since [**Month (only) 116**] of this year, having severe neck pain radiating to shoulders in the morning during light exertion, lasting less than 5 minutes. She had a stress test which was equivical and subsequently had a cardiac cath at [**Hospital1 2025**] which was normal per patient. She admits to the sensation this morning, prior to her arrest. . In the ED she was seen by the EP service who placed ICD for secondary prevention. She was then transferred to CCU for further monitoring. Past Medical History: . PAST MEDICAL HISTORY: Hypertension . PAST SURGICAL HISTORY: 3 C-Sections Appendectomy Social History: 4th grade teacher, remote smoking history. Quit 25 years ago, smoking [**12-14**] ppd for 5-10 years. Drinks [**12-14**] glasses of wine per week. Denies drug use. Family History: Mother: Died of heart failure at age of 52 secondary to a "virus". No history of arrythmias, syncope, or sudden death in the family. Physical Exam: ADmission Exam: Gen: Pleasant, calm HEENT: No conjunctival pallor. No icterus. MMM. OP clear. Flushed face. NECK: Supple, No LAD. JVP low. CV: PMI in 5th intercostal space, mid clavicular line. Regular and tachycardic. normal S1,S2. No murmurs, rubs, clicks, or [**Last Name (un) 549**] LUNGS: CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. No HSM. EXT: WWP, NO CCE. Full distal pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. Normal coordination. Gait assessment deferred Pertinent Results: [**2183-10-22**] 08:50AM cTropnT-<0.01 [**2183-10-22**] 11:15PM CK-MB-5 [**2183-10-22**] 11:15PM CK(CPK)-221* [**10-22**] echo: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 52 yo Female with h/o HTN, who is admitted for cardiac arrest. #. Cardiac Arrest: Pt received one shock in the field suggestive of VF or VT rhythm. Cardiac cath showed 80% LAD occlusion which was the culprit lesion, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **]. Echo revealed preserved cardiac function. EP followed patient, decision was made not to place ICD since the LAD occlusion was the source of the cardiac arrest. . #. CAD: Pt with 80% occlusions of LAD s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **]. This LAD lesion was 20% in [**5-/2183**] at [**Hospital1 2025**] cardiac cath. Pt was started on medical management for CAD. Metoprolol, atorvastatin, ASA 325mg, plavix, [**Last Name (un) **] was started in lieu of ACE-I secondary to allergy. Her lipid panel revealed TAG 154, HDL 50, LDL 104. Started on atorvastatin 80mg daily Her HbA1c was pending at time of discharge. . # HTN: Held home dilt. Started metoprolol 25mg [**Hospital1 **] and will go home on metoprolol. . #LFTs: Pts LFTs were found to be elevated (400s ALT, 200s AST). They trended down mildly. Differential included components of shock liver in setting of cardiac arrest versus underlying chronic transaminits (possible NASH). Patient should follow this up outpatient. . #Chest Pain: Pt had chest pain from chest compressions and likely underlying rib fx. CXR was neg for obvious fractures. Pt was treated with narcotics and tramadol for pain which controlled symtoms. Pt will go home with VNA services Medications on Admission: Diltiazem ER 240 mg Daily (did not take this AM) Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*3* 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 3. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*3* 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 6 days. Disp:*36 Tablet(s)* Refills:*0* 7. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 8. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Cardiac Arrest Left Anterior Descending Artery occlusion status post Drug eluting stent Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to take care of you during this hospitalization. You were admitted to the hospital for cardiac arrest. Essentially, your heart was beating in a bad rhythm and not pumping blood forward. You were found to have a clogged artery going to your heart which explained why you went into cardiac arrest. The artery was opened with a stent. You were started on several new medications to protect your heart. It is very important to take these medications every day. You also had chest pain which was attributed to rib fractures from chest compressions during CPR. This is treated with rest and pain medications. Please follow up with your primary care doctor at the appointment below. It is also important to follow up with a cardiologist. Please refrain from strenuous activity for one week. Follow up with your cardiologist. The following changes were made to your medications: STOP Diltiazem START: Atorvastatin 80mg daily Clopidogrel 75 mg daily Metoprolol Succinate 50mg daily Valsartan 80mg daily Ultram 50mg every 6 hours as needed for pain Ibuprofen 400mg every 8 hours as needed for pain Followup Instructions: Primary care doctor Appointment- Monday, [**2183-10-27**] at 8:45 AM Name: [**Last Name (LF) **],[**First Name3 (LF) 640**] A Location: [**Hospital3 **] PRIMARY CARE Address: [**2183**] STE 441WHITE, NEWON,[**Numeric Identifier 42001**] Phone: [**Telephone/Fax (1) 9386**] Cardiologist appointment: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], [**11-4**] at 2:40pm. [**Location (un) 830**], Sharpio 7 [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 62**]

[ "570", "285.9", "571.8", "401.9", "786.59", "414.01", "427.5", "427.41", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "00.66", "36.07", "88.48", "00.40", "00.45", "88.56" ]

icd9pcs

[ [ [] ] ]

6317, 6388

3634, 5214

302, 327

6544, 6544

2924, 3611

7832, 8339

2162, 2296

5313, 6294

6409, 6523

5240, 5290

6695, 7809

1936, 1964

2311, 2905

248, 264

355, 1852

6559, 6671

1898, 1913

1980, 2145

51,424

136,986

54842

Discharge summary

report

Admission Date: [**2134-5-31**] Discharge Date: [**2134-6-4**] Date of Birth: [**2084-1-1**] Sex: F Service: MEDICINE Allergies: iodine dye / Penicillin V / Isovue-128 / Salicylate Attending:[**First Name3 (LF) 4891**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: This is a 50 year old lady with T2DM, hypothyroidism who presented with fever, fatigue, diffuse myalgias and left back pain in the setting of known ecoli uti. In brief her sx reportably began several weeks ago with myalgias, chills and fevers up to 103F. With supportive measures she did not improved and soon developed dysuria. A urine culture from [**5-27**] at her PCPs office grew > 100,000 E. coli which was pansensitive. She was started on cipro and when her sx did not improved was admitted to [**Hospital1 18**] ED on [**5-29**] where cipro was changed to cefpodoxime because of concern that her UTI was not adequately treated with Cipro and she was discharged back home. She re-presented yesterday to the ED with persistent symptoms with initial vitals of 98.2 83 105/45 18 100%. She received morphine for pain as well as Zofran for nausea. Labs were notable for absence of leukocytosis and mildly elevated lactate to 2.3. A renal ultrasound revealed no evidence of abscess. Overnight her blood pressures continued to trend down to the 70s and were minimally responsive to 3L of NS with systolics maintained in the 80s. She was noted to have a fever of 101.8 at 10PM. A repeat lactate was 1.2 at 3AM. Her antibiotics were changed from cefpodoxime to ceftriaxone q24 hrs. Her PM trazadone was held. A chest xray demonstrated no acute cardiopulmonary process. A CBC with diff, cortisol and chem 7 were drawn in the morning. A cdiff was sent when the patient endorsed 6 episodes of diarrhea in the last 36 hours. A second IV was placed in addition to a foley catheter. The patient was ultimately transferred to the MICU for persistent hypotension despite fluid rescussitation and marked nursing concern. Two triggers were called for hypotension overnight. . On arrival to the ICU, intial vitals were: 98.0 100/58 90% RA RR 27. She was comfortable, still tired complaining of fatigue. She also endorsed headache, which has been present since her symptoms began. She also reported some left calf pain. . Review of systems: (+) Per HPI (-) Denies cough, shortness of breath, or wheezing. Denies chest pain, palpitations, or weakness. Denies vomiting, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: HISTORY HYSTERECTOMY INCLUDING CERVIX ANXIETY STATES, UNSPEC IRRITABLE BOWEL SYNDROME PAIN SYNDROME - CHRONIC OBESITY UNSPEC DM - TYPE 2 DIABETES MELLITUS FATTY LIVER GANGLION - JOINT HYPOTHYROIDISM VERTIGO HEADACHE Social History: Works in the [**Location (un) 86**] Public School system as a teaching aid for students with autism. She is married with 4 kids at home. She is sexually active and monogamous with her husband. -Tobacco: denies -EtOH: None -Drugs: None Family History: Father Diabetes - Type II Sister [**Name (NI) 3730**]; Diabetes; Fibromyalgia, Hypertension; Irritable Bowel Syndrome; Psych - Depression; cirrohsis; cva Physical Exam: Admission exam: VS - Temp 99.7F BP 116/69 HR 89 RR 20 SpO2 100/RA FS=122 GENERAL - well-appearing woman in NAD, comfortable, appropriate HEENT - NC/AT, EOMI, erythema and swelling of tonsils, L>R, no exudates visualized NECK - supple, mild swelling but no discrete lymphadenopathy LUNGS - CTA bilat, no r/rh/wh HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/obese. Palpable spleen tip on exam BACK - minimal CVA tenderness (similar pain with palpation of her thigh muscles) EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, no focal defecits Discharge exam - unchanged from above, except as below: ABDOMEN - +BS, soft, ND, mild TTP in RUQ and LUQ, palpable spleen tip Pertinent Results: Admission labs: [**2134-5-31**] 01:30PM BLOOD WBC-6.6 RBC-4.09* Hgb-12.0 Hct-36.8 MCV-90 MCH-29.3 MCHC-32.6 RDW-14.1 Plt Ct-264 [**2134-5-31**] 01:30PM BLOOD Neuts-44* Bands-3 Lymphs-35 Monos-4 Eos-4 Baso-1 Atyps-8* Metas-1* Myelos-0 [**2134-5-31**] 01:30PM BLOOD Glucose-102* UreaN-12 Creat-0.7 Na-142 K-3.4 Cl-105 HCO3-26 AnGap-14 [**2134-6-1**] 05:40AM BLOOD Calcium-7.9* Phos-3.6 Mg-1.8 [**2134-5-31**] 01:46PM BLOOD Lactate-2.3* [**2134-6-2**] 05:04AM BLOOD Lipase-20 [**2134-6-1**] 05:40AM BLOOD ALT-51* AST-46* LD(LDH)-327* AlkPhos-84 TotBili-0.3 [**2134-6-1**] 05:40AM BLOOD Cortsol-17.3 [**2134-5-31**] 01:45PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020 [**2134-5-31**] 01:45PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2134-5-31**] 01:45PM URINE RBC-2 WBC-4 Bacteri-FEW Yeast-NONE Epi-1 Discharge labs: [**2134-6-4**] 05:30AM BLOOD WBC-7.0 RBC-3.19* Hgb-9.5* Hct-29.1* MCV-91 MCH-30.0 MCHC-32.8 RDW-14.8 Plt Ct-271 [**2134-6-4**] 05:30AM BLOOD Glucose-119* UreaN-7 Creat-0.6 Na-138 K-3.4 Cl-107 HCO3-25 AnGap-9 [**2134-6-4**] 05:30AM BLOOD Albumin-2.9* Calcium-7.6* Phos-2.5* Mg-1.7 Micro: -BCx ([**2134-5-31**], [**2134-6-1**], [**2134-6-3**]): NGTD -UCx ([**2134-5-31**]): No growth - final -Monospot ([**2134-5-31**]): Negative -C. diff ([**2134-6-1**]): **FINAL REPORT [**2134-6-2**]** C. difficile DNA amplification assay (Final [**2134-6-2**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). -CMV ([**2134-5-31**]): **FINAL REPORT [**2134-6-1**]** CMV IgG ANTIBODY (Final [**2134-6-1**]): NEGATIVE FOR CMV IgG ANTIBODY BY EIA. <4 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final [**2134-6-1**]): POSITIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: SUGGESTIVE OF PRIMARY INFECTION. IgM antibody may persist for 6 months or longer after primary infection and may reappear during reactivation. Greatly elevated serum protein with IgG levels >[**2121**] mg/dl may cause interference with CMV IgM results. Submit follow-up serum in [**1-29**] weeks. -EBV ([**2134-5-31**]): **FINAL REPORT [**2134-6-3**]** [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2134-6-3**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2134-6-3**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2134-6-3**]): NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. In most populations, 90% of adults have been infected at sometime with EBV and will have measurable VCA IgG and EBNA antibodies. Antibodies to EBNA develop 6-8 weeks after primary infection and remain present for life. Presence of VCA IgM antibodies indicates recent primary infection. Imaging: -Renal US ([**2134-5-31**]): The right kidney measures 10.7 cm and the left 11 cm. There is no evidence of masses, hydronephrosis, abscess, or stones. The visualized bladder is unremarkable. The spleen is enlarged measuring 14.6 cm. IMPRESSION: No evidence of renal abscess. Splenomegaly. -CT abd/pelvis w/o contrast ([**2134-6-1**]): 1. Cholelithiasis or biliary sludge within the gallbladder. Further evaluation for cholecystitis is limited without intravenous contrast. If clinical concern for cholecystitis exists, a followup right upper quadrant ultrasound could be considered. 2. Right adnexal hypodense lesion incompletely characterized on unenhanced CT. 3. Hepatic steatosis. 4. Enlarged spleen. -CXR ([**2134-6-1**]): Lung volumes are low. Borderline size of the cardiac silhouette. The presence of minimal fluid overload cannot be excluded. However, there is no overt pulmonary edema. No pleural effusions. -RUQ US ([**2134-6-2**]): 1. Normal examination of the gallbladder. No evidence for stones or sludge. No evidence for cholecystitis. 2. Increased echogenicity of the liver consistent with fatty infiltration. Please note that other forms of liver disease including significant fibrosis/cirrhosis cannot be excluded on the basis of this study. 3. Splenomegaly of 15 cm. -Pelvis US ([**2134-6-2**]): 1. Two hemorrhagic cysts on the right ovary. 2. Status post hysterectomy. Brief Hospital Course: 50 year old woman with a history of T2DM and hypothyroidism admitted with fever, fatigue and myalgias, course complicated by hypotension, found to have acute CMV infection. # Acute cytomegalovirus infection: Her initial presentation with a fever, fatigue, diarrhea and diffuse myalgias was initially thought to be consistent with mononucleosis or a similar viral illness. Supporting this was 8% atypical cells on her admission CBC/diff and splenomegaly to 15cm on imaging. At admission, monospot was negative and CMV IgM was positive with a negative IgG which is consistent with acute CMV infection. EBV IgG was positive with negative IgM suggesting prior exposure. She was treated conservatively with IV fluids and tylenol/NSAIDs for pain control and fevers. A renal US and CT abd/pelvis (without contrast because of prior adverse reaction to IV contrast) did not show any evidence of renal or preinephric abscess or other causes to explain her fevers. She had a RUQ US because of concern for stones/sludge in the gallbladder on her CT abdomen. This US was unremarkable and did not show cholecyctitis or CBD dilation. She also had a pelvic US which was unremarkable aside from two ovarian cysts. She continued to have fevers up to 101.9F during this admission. At discharge, she was off IV fluids and taking adequate PO. She has been instructed that CMV infection can take weeks to resolve and that she will likely continue to have these symptoms along with fevers during this time. We considered sending a HIV test, but this was deferred to her PCP given that her CMV infection is a better explaiantion for her symptoms and she has no high risk behaviors for HIV infection. This was communicated to her PCP by email prior to discharge. #Hypotension: In the setting of high fevers and poor PO intake, she was briefly hypotensive to the high 70 to low 80s systolic on her first night of admission. She was transferred to the MICU for closer monitoring where she received IV fluids and did not require pressors. At discharge, she was taking good PO and not requiring IV fluids with systolic BP in the 90-120s. #Hypoxia: O2 sats briefly in the 88-92% range on room air while in the MICU. She was asymptomatic and CXR was unremarkable. Likely cause was atelectasis and she was given an incentive spirometer on the floor. She was quickly weaned to room air after transfer to the floor. #Transaminitis: LFTs mildly elevated this admission to the 40-50s, which is consistent with her acute CMV infection. RUQ US was unremarkable with no cholecystitis, stones or CBD dilation. Should have repeat LFTs 4-6 weeks after discharge to ensure resolution. #UTI: She had pansensitive E. coli at an outpatient visit prior to admission, no perinephric abscess or hydro on renal US or on CT abd/pelvis. Prior to admission, she was on Cipro which was subsequently changed to cefpodox and was continued on CTX for 3 days this admission. She had no urinary symptoms and urine culture was negative at admission. --Inactive issues-- #T2DM: Appears well controlled, last A1c in Atrius records was 6.9% in [**2-/2134**] and has been <7 for the past 2 years. She was not on medications for her diabetes at admission and blood sugar remained well controlled. #Hypothyroidism: Continued on home dose of levothyroxine 100mcg daily #Code status this admission: Full (confirmed) #Transitional issues: -Should have an HIV test as an outpatient given her recent acute CMV infection -Will need repeat LFTs in [**4-2**] weeks to assess for resolution of her transaminitis -Has been instructed to continue to consume plenty of fluids (including juice and sport drinks) while she is having diarrhea and high fevers. -Has been advised that she may continue to have fatigue, myalgias and high fevers for a few weeks while her CMV infection resolves Medications on Admission: Medications: (home) -Ciprofloxacin 500 mg Oral q12h for 7 days (D1=[**2134-5-27**], stopped [**2134-5-29**]) -Cefpodoxime 100mg [**Hospital1 **] (started [**2134-5-29**], still taking) -Sertraline 50 mg Oral daily -Gabapentin 300 mg Oral Capsule 1 capsule nightly -Ibuprofen 200 mg Oral Tablet 3 tablets with food twice a day as needed for pain -Pravastatin 20 mg Oral Tablet Take 1 tablet every evening for cholesterol -Levothyroxine 100 mcg Oral Tablet take 1 tablet by mouth a day -MELATONIN ORAL 1 to 3 mg daily -GINSENG ORAL take daily - available over the counter -BLOOD SUGAR DIAGNOSTIC TEST STRIPS (ONE TOUCH ULTRA TEST STRIPS) InVt Strp use as directed twice daily -LANCETS (ONE TOUCH ULTRASOFT LANCETS) Misc Misc USE AS DIRECTED to test blood sugar twice daily -CINNAMON ORAL pt reports she takes 1 capsule every pm -MULTIVITAMIN CAPSULE PO (MULTIVITAMINS) 1 po qd -CALCIUM CARBONATE TABLET 650MG PO as . Medications: (Transfer) 1. Heparin 5000 UNIT SC TID 2. Insulin SC 3. Levothyroxine Sodium 100 mcg PO/NG DAILY 4. Acetaminophen 325-650 mg PO/NG Q4H:PRN pain 5. Multivitamins 1 TAB PO/NG DAILY 6. Calcium Carbonate 500 mg PO/NG DAILY 7. Ondansetron 4 mg IV Q8H:PRN nausea 8. Cefpodoxime Proxetil 200 mg PO/NG Q12H 9. Pravastatin 20 mg PO DAILY 9. CeftriaXONE 1 gm IV ONCE 11. Docusate Sodium 100 mg PO/NG [**Hospital1 **] 12. Sertraline 50 mg PO/NG DAILY 13. Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation 12. Gabapentin 300 mg PO/NG HS Discharge Medications: 1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. ibuprofen 200 mg Tablet Sig: Three (3) Tablet PO every eight (8) hours as needed for pain for 2 weeks. 4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. melatonin 1 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. 7. ginseng Oral 8. Cinnamon Oral 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. calcium carbonate 650 mg calcium (1,625 mg) Tablet Sig: One (1) Tablet PO once a day. 11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for fever or pain. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Acute cytomegalovirus infection Secondary diagnoses: Type 2 diabetes Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 112064**], It was a pleasure taking care of you during your admission to [**Hospital1 18**] for fever and muscle aches. You were found to have a viral infection called CMV (cytomegalovirus). This will likely take a few weeks to resolve and is thought to be the cause of your weakness, fevers, fatigue and muscle aches. You can be expected to continue to have fevers for at least a couple of weeks while this infection resolves. Your blood pressure was low and you were transferred to the ICU briefly where you received IV fluids. You blood pressure improved prior to discharge. The following changes were made to your medications: START Tylenol (acetaminophen) 325-650mg every 6 hours as needed for pain or fever START ibuprofen 600mg every 8 hours as needed for fever or muscle aches Followup Instructions: Name: [**Last Name (LF) 54468**],[**First Name3 (LF) 54469**] B. Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 3530**] Appointment: Monday [**2134-6-7**] 10:50am

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14852, 14858

8727, 12107

323, 330

15004, 15004

4166, 4166

15998, 16257

3186, 3342

14076, 14829

14879, 14931

12595, 14053

15155, 15975

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2389, 2678

271, 285

359, 2370

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15019, 15131

2700, 2918

2934, 3170

22,815

181,523

49344

Discharge summary

report

Admission Date: [**2196-2-1**] Discharge Date: [**2196-2-12**] Date of Birth: [**2143-5-24**] Sex: M Service: MEDICINE Allergies: Compazine / Methotrexate / Ceftazidime Attending:[**First Name3 (LF) 10370**] Chief Complaint: Fevers Major Surgical or Invasive Procedure: Intubation Tunneled Catheter Placement History of Present Illness: 52M w/Crohn's s/p multiple bowel resections c/b short gut syndrome, s/p ostomy, on chronic TPN with Hickman (placed [**9-23**] by IR), who presents with fevers to 102 x 3 days. Pt reports minimal non productive cough, worsening SOB, orthopnea. Has some nasal congestion; Denies no sinus pain, neck stiffness, sore throat. No new abd pain, nausea/vomiting. No change in ostomy output. No dysuria/urgency/frequency. No new sexual encounters/penile discharge. No sick contacts. [**Name (NI) **] site unchanged/no pain. No CP. Past Medical History: 1. Crohn's/FEN Related - Crohn's Disease (S/P Multiple Surgeries, Ileostomy, Swith Short Gut Syndrome, On Chronic TPN, Chronic Nausea), Chronic Hypocalcemia, Vitamin D Deficiency, Recurrent Dehydration. . 2. [**Name (NI) **] - Staph epidermidis C4-C5 Osteomyelitis (On Chronic Vancomycin), Mitral Valve [**Name (NI) **], Recurrent Polymicrobial Line Sepsis, Recent RLL PNA, LE Cellulits ([**2193**]) . 3. Respiratory - COPD (Baseline PaCO2 of 48), H/O ARDS with Intubations/Tracheostomy ([**2192**] and [**2193**]). . 4. Severe MR 5. CKD (Baseline Cr 1.3 to 1.4) 6. Anemia of Chronic Inflammation (on EPO) 7. Mild Dementia 8. Chronic Pain (Fentanyl 50 mcg Patch) 9. Restless Leg Syndrome 10. Steroid-Induced Osteoporosis 11. Multiple Spinal Compression Fx 12. Peripheral Neuropathy 13. UGIB/Duodenal Ulcer ([**2193**]) 14. Depression 15. Bilateral SVC Thrombi. Social History: Lives alone; 24[**Hospital 8018**] nursing care with multiple nurses; fully intact ADLs; ambulates without assistance; never married; has no children; has worked many odd jobs; he has five brothers and one sister that are very supportive. His three brothers, [**Name (NI) **], [**Name (NI) **], and [**First Name8 (NamePattern2) **] [**Name (NI) **], are all his health care proxies. He smokes one to one and a half packs per day; has a 60-pack-year history of smoking. He reports minimal alcohol use and nouse of illicit substances. Full code. Family History: Non-contributory Physical Exam: PE: T 99.4 BP 108/47 P 84 R 27 Vent: AC 500 x 18, FiO2 0.60, PEEP 8--->7.39/35/101 General: middle aged male appearing above his stated age, comfortable on the ventilator HEENT: Scleral icterus; no sinus tenderness with palpation Neck: Soft, supple, no cervical adenopathy Heart: RRR, normal S1/S2, III/VI SEM radiating to axilla Lungs: Coarse [**Name (NI) 1440**] sounds with prominent rhonchi and scattered wheezes diffusely, no crackles anteriorly. Abd: Soft, mildly tender diffusely, non-distended, multiple surgical scars; ostomy in place with moderate output. Ext: Warm, trace BLE pitting edema; 2+ DP pulses. No Osler's nodes, [**Last Name (un) 1003**] lesions, or splinter hemorrhages. Skin: line in R subclavian; no tenderness, no erythema around line site; no other areas of skin breakdown noted. Pertinent Results: [**2196-2-2**] 06:01AM BLOOD WBC-9.3 RBC-3.41* Hgb-10.6* Hct-32.1* MCV-94 MCH-31.2 MCHC-33.2 RDW-16.0* Plt Ct-112* [**2196-2-2**] 06:01AM BLOOD Plt Ct-112* [**2196-2-2**] 06:01AM BLOOD Glucose-78 UreaN-19 Creat-1.6* Na-141 K-3.9 Cl-110* HCO3-21* AnGap-14 [**2196-2-2**] 06:01AM BLOOD ALT-31 AST-23 AlkPhos-500* TotBili-7.8* [**2196-2-2**] 06:01AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.5* [**2196-2-2**] 06:01AM BLOOD Vanco-21.3* [**2196-2-1**] 04:18PM BLOOD Lactate-1.1 Micro: Bld [**2-1**]- GNR CXR ([**2-1**])Marked interval worsening of congestive heart failure when compared with prior exam of one day earlier. ECHO: ([**1-23**]) :Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60-70%). Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are mildly focally thickened. There is moderate focal thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 52M with Crohn's c/b short gut syndrome, s/p ileostomy, on chronic TPN with multiple line infections in the past admitted with GNR bacteremia with hospital course c/b ARDS/intubation. Once admitted, he was found to have [**2-22**] blood cultures (+) for GNR; presumed source unclear but possibilities included in-dwelling line vs. pneumonia vs. translocation of bacteria from gut. On admission had been hypoxic in the low 90s. ABG showed pH 7.43 pCO2 29 pO2 59 HCO3 20. Hypoxia was initially thought to be due to mild CHF (by hx, exam, CXR); he received lasix 20 mg IV x 1 with mild improvement of symptoms. Despite improvement in sx, pt continued to remain hypoxic/tachypneic throughout the day, with O2 sats falling into the 80s on 40% face mask. Patient was put on a NRB and f/u ABG showed pH 7.43 pCO2 33 pO2 91 HCO3 23. Portable CXR showed worsening diffuse pulmonary infiltrates suggestive of ARDS. Intubated in the [**Hospital Unit Name 153**] with vent settings initially on AC TV500/rate16/PEEP5/FIO2 100%, sedated with propofol gtt. He was intubated for possible ARDS on [**2-1**]. Bld cultures grew enterobacter. The source was unclear but possibilities included line infection or bacterial gut translocation. He is being treated with Levofloxacin for Enterobacter Sepsis. His Hickman was removed and a temp line placed on [**2196-2-4**]. He was successfully extubated [**2-8**]. He was continued on nebulizers (given his underlying COPD). He had a bump in his chronic elevation of cholestatic liver enzymes and RUQ was normal. 1. Enterobacter bacteremia: Source thought to be line sepsis, as per past h/o polymicrobial line infections, although translocation of bacteria from gut was also entertained given patient's history of Crohn's with friable mucosa. The enterobacter from his blood cultures was pan-sensitive. He was treated with a 10 day course of levofloxacin. Given patient's past history of mitral valve [**Month/Year (2) **], he underwent a TEE in setting of bacteremia to r/o seeding of his valve, which was negative. Patient's Hickman was removed, and catheter tip did not grow any bugs in culture. He had a new line placed by IR on [**2196-2-12**]. 2. Chronic vertebral osteomyelitis: Pt was continued on vancomycin for chronic Staph epi osteo of the c-spine at C4-C5. 3. ARDS-Patient developed progressive respiratory distress and hypoxia in the setting of his GNR bacteremia, with CXR c/w ARDS. Pt has had a h/o ARDS in the setting of infection in the past. He was intubated for one week and was weaned without difficulty, with no further complications (pulmonary infection/long term ventilation requiring tracheostomy as in the past). 4. Crohn's disease: Patient is s/p multiple surgeries with short gut and an ileostomy on chronic TPN. His TPN was restarted after his Hickman was removed and a temporary line was placed. He was continued on his home regimen of loperamide/DTO. 5. Acute on CRF: Patient initially had an elevated creatinine to 2.1, up from 1.3 to 1.4 at baseline. Etiology was thought ? toxicity from gentamicin given in the ED for GNR bacteremia versus a pre-renal state from volume depletion in setting of fevers/infection and increased insensible losses. His renal function returned to baseline by the end of his hospitalization. 6. Diastolic CHF: TTE performed [**2-2**] shows impaired relaxation consistent with diastolic dysfunction. Also noted was mitral regurgitation, although this was 4+ in the past, and is now 2+ with an eccentric jet (TTE [**2-2**]). EF unchanged. Pt may benefit from afterload reduction in the setting of his MR, although his MR [**First Name (Titles) **] [**Last Name (Titles) 84485**] improved from his last echo. This can be discussed with his PCP as an outpatient. 7. Anemia: Likely due to chronic inflammation. Patient apparently on epogen at home, but did not receive it in the hospital. He will restart this regimen once he is d/c to home. Continue on niferex. 8. Chronic nausea: Continued on drabinol and alprazolam as per home regimen. 9. COPD: Patient had not had PFTs since [**2184**], but has extensive smoking history, with baseline PaCO2 of 48. Was given nebulizer treatments as needed. 10. Restless leg syndrome: Continue clonazepam as per home regimen. 11. Osteoporosis: Seemingly due to prior chronic steroids; patient has h/o compression fractures. Patient was continued on calcitriol, vitamin D and calcium. 12. Depression: Continue risperidone 0.25 mg po bid 13. Chronic pain: Continue fentanyl patch per home regimen 14. Cholestasis: Patient with chronically elevated LFTs [**12-23**] duodenal obstruction of biliary tract now herniating from stoma. Patient is followed closely by his GI doctor Dr. [**Last Name (STitle) 8494**]. Likely chronic TPN also contributes to cholestasis. Medications on Admission: 1. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 2. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 5. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 6. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 8. Opium 10 % Tincture Sig: Five (5) Drop PO Q8 H PRN (). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln Intravenous Q48H (every 48 hours). 11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. TPN 13. Epo 14. Octreotide Discharge Medications: 1. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 2. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 5. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 6. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 8. Opium 10 % Tincture Sig: Five (5) Drop PO Q8 H PRN (). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln Intravenous Q48H (every 48 hours). 11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. TPN Please resume home TPN orders. 13. Epo Please resume home dose. 14. Octreotide Please resume home dose. Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Therapies Discharge Diagnosis: Enterobacter Sepsis Acute on chronic renal failure Respiratory failure Discharge Condition: Good Discharge Instructions: Please call your primary care physician or return to the hospital if you experience worsening shortness of [**Location (un) 1440**], chest pain, fever > 101.4, or any other conerns. Please take all your medications as before you where hospitalized. Followup Instructions: 1. Please follow up with Dr. [**Last Name (STitle) 5717**] in the next 3-5 days. [**Telephone/Fax (1) 250**] 2. Please follow up with Dr. [**Last Name (STitle) 79**] in the next week. ([**Telephone/Fax (1) 21747**] You have the following appointments scheduled: 1. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2196-3-10**] 11:00 2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 4451**] Date/Time:[**2196-4-27**] 11:00

[ "584.9", "428.30", "579.3", "276.5", "585", "733.00", "995.92", "733.13", "996.62", "038.49", "496", "V44.2", "730.18", "428.0", "518.81", "424.0", "285.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "96.72", "86.05", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

11459, 11528

4535, 9355

306, 347

11642, 11648

3235, 4512

11946, 12612

2375, 2393

10379, 11436

11549, 11621

9381, 10356

11672, 11923

2408, 3216

260, 268

375, 909

931, 1793

1809, 2359

14,836

142,095

51183

Discharge summary

report

Admission Date: [**2132-2-11**] Discharge Date: [**2132-2-24**] Date of Birth: [**2090-10-15**] Sex: M Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: This is a 41 year-old gentelman who underwent an aortic valve replacement in [**2120**] for endocarditis. Following that procedure the patient had a repeat bout of endocarditis and had to have the replacement valve removed and a new one inserted. The patient's first aortic valve replacement was done with a bioprosthetic valve. Then in [**2128-3-2**] the patient's repeat AVR was done with a Carbomedics valve. Over the last couple of years the patient has been followed by serial echocardiograms where it has been noticed that his aortic root has gradually been dilating. Currently his aortic root is approximately dilated at 5.8 cm with 1+ mitral regurgitation and 3+ tricuspid regurgitation, and mild pulmonary hypertension. The patient was admitted for a repeat aortic valve replacement. The patient was admitted and underwent an aortic valve replacement surgery on [**2132-2-11**]. A #23 St. Jude valve was placed and a graft was placed on the ascending aorta. The cross clamp time was 144 minutes. The procedure was performed by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] and he was assisted by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 16398**]. There were no complications during the case and the patient tolerated the procedure well. Following a brief stay in the PACU the patient was transferred to the CSRU still sedated on a Propofol drip. The patient was also on a nitroglycerin drip, which was titrated to maintain his systolic blood pressure between 100 and 110. The nitroglycerin drip was weaned as tolerated. Postoperative day number one the patient had three chest tubes in place. On postoperative day number one the patient had his TA line and A line removed. The nitroglycerin drip was continued to be weaned as tolerated. The patient was extubated without difficulty and was able to maintain his O2 saturations greater then 95% on nasal cannula. The patient's postoperative course was complicated by development of compartment syndrome following the surgery. Vascular surgery was consulted and it was determined that the patient needed to be returned to the Operating Room to open up the patient's left calf. The patient underwent a fasciotomy on [**2132-2-12**] by vascular surgery Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. There were no complications during the surgery and the patient tolerated this without difficulty. The final procedure was a left lower extremity anterior, posterior, lateral compartment fasciotomies. The patient was continued to be weaned off all of his pressors and he was able to maintain his blood pressure. The patient still had his AV wires attached, but was able to remain in normal sinus rhythm without any ectopy. On postoperative day number two the patient had his DC pacing wires removed and the patient was started on Coumadin for anticoagulation. The patient's left lower extremity continued to decrease in size and no longer complained of any pain at that site. The patient was seen by renal consult for an increase in creatinine. The patient's creatinine had risen range of motion 1.0 to 1.5 over the course of one day. It was determined that the patient was most likely experiencing some rhabdomyolysis, which caused the creatinine to increase. Recommendations from renal included transfusion if the patient's hematocrit dropped to less then 30 and to hold off on any aggressive intravenous fluid or bicarb replacement. By postoperative day number three it was determined that the patient was well enough to be transferred out of the CSRU to the surgical floor. When the patient reached the floor he continued to have a relatively uneventful recovery. The patient was seen and evaluated by physical therapy who determined that the patient would be able to be discharged to home following a few sessions with the physical therapist. The patient's postoperative course on the floor was complicated only by increase in his white blood cells. The patient's white blood cell count increased from approximately 13 to 20. The patient was seen and evaluated by infectious disease. Multiple blood cultures, urine cultures, chest x-rays were performed. All of these came back negative. The patient never spiked a fever nor had any clinical indication of any infection. The patient underwent a ultrasound of the cannulation site in his left groin, which demonstrated a small hematoma. As there was no fluctuance, erythema or pain surrounding the site this was determined not to be the course of the patient's elevated white blood cell count. The patient was continued to be followed for several days and his white blood cells were monitored. The patient continued to not exhibit any indications of a systemic illness and the patient's white count decreased to 13. At this point as the patient had been cleared by physical therapy and no obvious source of infection had been discovered it was determined that the patient was well enough to be discharged to home. DI[**Last Name (STitle) 408**]E DISPOSITION: The patient will be discharged to home and asked to follow up with Dr. [**Last Name (Prefixes) **] in four weeks. In addition, the patient was instructed to follow up with the clinic for which he follows his INR levels. The patient was also instructed to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1461**] in one to two weeks and his cardiologist in two to three weeks. The patient was asked to please schedule these appointments. DISCHARGE DIAGNOSES: 1. Status post aortic valve replacement with a St. Jude valve. 2. Status post AVR times two. 3. Status post fasciotomy left lower extremity. 4. Status post ascending aortic graft replacement. 5. Hypertension. DISCHARGE MEDICATIONS: 1. Metoprolol 100 mg po b.i.d. 2. Colace 100 mg po b.i.d. 3. Lasix 20 mg po b.i.d. for seven days. 4. Potassium chloride 20 milliequivalents po b.i.d. for seven days. 5. Coumadin 10 mg tablets one tablet po Monday through Friday. 6. Coumadin 7.5 mg tablets one tablet po Saturday and Sunday. 7. Oxycodone 20 mg tablets po b.i.d. for ten days. 8. Dilaudid 2 mg tablets one to three tablets po q 3 to 4 hours prn pain. 9. Lorazepam 0.5 mg tablets one to two tablets po q.h.s. prn. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 846**] MEDQUIST36 D: [**2132-2-27**] 08:48 T: [**2132-2-27**] 08:47 JOB#: [**Job Number 106223**] cc:[**Last Name (NamePattern4) 16198**]

[ "729.9", "728.88", "996.02", "396.3", "288.8", "997.2", "401.9", "416.8", "441.2" ]

icd9cm

[ [ [] ] ]

[ "88.72", "83.09", "39.61", "35.22", "38.45" ]

icd9pcs

[ [ [] ] ]

5742, 5957

5980, 6761

177, 5721

82,377

134,854

37064

Discharge summary

report

Admission Date: [**2176-1-18**] Discharge Date: [**2176-1-26**] Date of Birth: [**2107-3-27**] Sex: M Service: SURGERY Allergies: Morphine / Iodine Containing Agents Classifier Attending:[**First Name3 (LF) 4691**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: 1. Exploration of abdomen and anterior mediastinum. 2. Small-bowel resection. 3. Repair of thoracoabdominal defect with polypropylene mesh interposition 20x25 cm. 4. CVL placement. History of Present Illness: HISTORY OF PRESENTING ILLNESS This patient is a 68 year old male who complains of ABD PAIN. The patient is a 68-year-old gentleman with a long-standing ventral hernia who developed pain at the hernia site today. Timing: Sudden Onset Quality: Dull Severity: Moderate Duration: Hours Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: [**2153**] -PERCUTANEOUS CORONARY INTERVENTIONS: five caths since CABG, ATRIUS records attached. -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: -DMII -CKD stage III -GOUT -hypothyroidism -S/P staph infection of sternum requiring complete excision of sternum -chronic lung dz attributed to restrictive physiology after removal of sternum -BPH -Depression Social History: -Tobacco history: distant, none x over 25 years -ETOH: none currently -Illicit drugs: denies -lives with partner -disabled, uses wheelchair for ambulation Family History: Father MI at age 49, mother CAD alive at 83 Physical Exam: PHYSICAL EXAMINATION: upon admission [**2176-1-17**] Temp:97.7 HR:77 BP:124/52 Resp:16 O(2)Sat:99 Constitutional: Mild to moderate discomfort initially Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Large ventral hernia, firm, tender, woody and erythematous Neuro: Speech fluent Psych: Normal mood, Normal mentation Pertinent Results: [**2176-1-26**] 05:11AM BLOOD WBC-7.6 RBC-3.14* Hgb-9.1* Hct-27.4* MCV-87 MCH-29.0 MCHC-33.2 RDW-16.0* Plt Ct-289 [**2176-1-25**] 04:56PM BLOOD WBC-7.2 RBC-3.15* Hgb-8.8* Hct-28.0* MCV-89 MCH-28.0 MCHC-31.5 RDW-16.3* Plt Ct-289 [**2176-1-24**] 05:38AM BLOOD WBC-7.6 RBC-2.92* Hgb-8.3* Hct-25.4* MCV-87 MCH-28.5 MCHC-32.8 RDW-15.3 Plt Ct-221 [**2176-1-23**] 01:49AM BLOOD WBC-8.5 RBC-2.87* Hgb-8.2* Hct-25.4* MCV-88 MCH-28.7 MCHC-32.4 RDW-15.2 Plt Ct-197 [**2176-1-20**] 01:56AM BLOOD WBC-14.3* RBC-3.42* Hgb-9.9* Hct-29.4* MCV-86 MCH-29.0 MCHC-33.8 RDW-16.0* Plt Ct-173 [**2176-1-18**] 08:07PM BLOOD WBC-14.0* RBC-3.79* Hgb-10.9* Hct-31.9* MCV-84 MCH-28.7 MCHC-34.1 RDW-15.6* Plt Ct-220 [**2176-1-18**] 12:01AM BLOOD WBC-18.5*# RBC-4.76# Hgb-13.9*# Hct-39.6*# MCV-83# MCH-29.1 MCHC-35.0 RDW-15.5 Plt Ct-245 [**2176-1-18**] 08:07PM BLOOD Neuts-70 Bands-12* Lymphs-9* Monos-7 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 [**2176-1-18**] 03:56AM BLOOD Neuts-89.8* Lymphs-7.2* Monos-2.7 Eos-0.1 Baso-0.1 [**2176-1-26**] 05:11AM BLOOD Plt Ct-289 [**2176-1-25**] 04:56PM BLOOD Plt Ct-289 [**2176-1-26**] 11:42AM BLOOD Glucose-136* UreaN-22* Creat-1.2 Na-140 K-4.3 Cl-100 HCO3-29 AnGap-15 [**2176-1-26**] 05:11AM BLOOD Glucose-99 UreaN-22* Creat-1.2 Na-142 K-3.4 Cl-101 HCO3-29 AnGap-15 [**2176-1-25**] 03:42PM BLOOD Glucose-112* UreaN-24* Creat-1.2 Na-142 K-3.5 Cl-97 HCO3-30 AnGap-19 [**2176-1-25**] 06:08AM BLOOD Glucose-105* UreaN-25* Creat-1.1 Na-143 K-3.2* Cl-101 HCO3-31 AnGap-14 [**2176-1-18**] 08:07PM BLOOD Glucose-125* UreaN-48* Creat-1.6* Na-144 K-3.3 Cl-104 HCO3-29 AnGap-14 [**2176-1-18**] 12:01AM BLOOD Glucose-156* UreaN-59* Creat-2.0* Na-139 K-2.9* Cl-90* HCO3-33* AnGap-19 [**2176-1-20**] 08:48AM BLOOD CK(CPK)-175 [**2176-1-19**] 11:11PM BLOOD CK(CPK)-203 [**2176-1-21**] 05:31PM BLOOD CK-MB-2 cTropnT-0.07* [**2176-1-21**] 10:45AM BLOOD CK-MB-2 cTropnT-0.07* [**2176-1-20**] 08:48AM BLOOD CK-MB-2 cTropnT-0.04* [**2176-1-19**] 11:11PM BLOOD CK-MB-3 cTropnT-0.05* [**2176-1-26**] 11:42AM BLOOD Calcium-8.6 Phos-2.2* Mg-2.0 [**2176-1-26**] 05:11AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.0 [**2176-1-19**] 09:22AM BLOOD Type-ART pO2-161* pCO2-58* pH-7.36 calTCO2-34* Base XS-5 [**2176-1-18**] 08:19PM BLOOD Type-ART pO2-134* pCO2-47* pH-7.46* calTCO2-34* Base XS-9 [**2176-1-18**] 06:44PM BLOOD freeCa-1.05* Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2176-1-18**] to the acute care service with an incarcerated abdominal hernia. He was put on telemetry, NPO on IVF He was started on his home medications and put on an insulin sliding scale with dilaudid for pain control. After a preoperative workup, he was transferred to the OR for a ventral hernia repair. Please see the operative note for full details. Post operatively he was transferred to the ICU for recovery. He had drains in place, had an NGT, was on IV antibiotics perioperatively, he was intubated, had a foley for urine output monitoring, as well as heparin SQ and pneumatic boots for prophylaxis. On [**1-19**] he was transfused two units of pRBC. His CHF was managed with close fluid status monitoring, cardiology consultation, and beta blockers. On [**1-19**] he was extubated. On [**1-20**] he was transferred to the floor with PPI and HSQ for prophylaxis, NPO on IVF, on telemetry. He had a foley for urine output monitoring. He had an NGT as well as two JP drains. He was started on a subset of his home medicaitons through his NGT. On [**1-21**], he was transferred back to the ICU for closer monitoring. He was started on his plavix and aspirin. His cardiac status was monitored with EKGs and cardiac enzyme tests. On [**1-22**], his IV PPI was switched to [**Hospital1 **] PO famotidine. He was transferred back to the floor on [**1-23**] on his home medications. his NGT was d/ced and he was started on sips of clear liquids. His foley was d/ced and he voided. Later that day he was advanced to full liquids. At this point more aggressive diuresis was necessary and he was started on lasix 20 mg [**Hospital1 **]. On [**1-24**] he was advanced to a regular diet and restarted on his bumetanide after contacting his cardiologist. On [**1-25**], a physical therapy consult was initiated. He was given a bowel regimen to help facilitate a bowel movement. On [**1-26**], his bumetanide dose was increased to 4 mg PO TID. He was discharged home with services on [**1-26**] with close follow up with his surgeon, and VNA for drain care. Medications on Admission: emazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for insomnia. 2. isosorbide mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for angina. 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. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for stress ulcer ppx. 9. bumetanide 2 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO q 6 hours () as needed for anti-anginal. 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours) as needed for angina. 14. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 15. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Three (3) Tab Sust.Rel. Particle/Crystal PO QID (4 times a day). Import Discharge Medications Discharge Medications: Discharge Medications: 1. temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for insomnia. 2. isosorbide mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for angina. 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. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for stress ulcer ppx. 9. bumetanide 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO q 6 hours () as needed for anti-anginal. 12. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*50 Tablet(s)* Refills:*0* 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 14. nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours) as needed for angina. 15. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 16. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Three (3) Tab Sust.Rel. Particle/Crystal PO QID (4 times a day). Discharge Disposition: Home With Service Facility: [**Hospital1 3894**] Health VNA Discharge Diagnosis: Incarcerated strangulated hernia with necrotic small bowel in anterior mediastinum. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-30**] 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. 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. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow up with Acute care surgery in one to weeks to have your sutures removed and for a check up. Please call [**Telephone/Fax (1) 600**] to make this appointment.

[ "551.3", "274.9", "244.9", "272.4", "V45.85", "428.0", "428.22", "496", "276.8", "585.3", "276.2", "250.00", "V45.81", "403.90", "412" ]

icd9cm

[ [ [] ] ]

[ "45.62", "53.80", "45.91" ]

icd9pcs

[ [ [] ] ]

9731, 9793

4366, 6473

321, 504

9921, 9921

2037, 4343

13014, 13189

1566, 1611

8091, 9708

9814, 9900

6499, 8035

10072, 11053

11680, 12991

1626, 1626

1012, 1134

1648, 2018

11085, 11665

267, 283

532, 904

9936, 10048

1165, 1377

926, 992

1393, 1550

63,253

119,137

32082

Discharge summary

report

Admission Date: [**2131-12-31**] Discharge Date: [**2132-2-11**] Date of Birth: [**2075-11-11**] Sex: F Service: MEDICINE Allergies: Cefepime / Aztreonam Attending:[**First Name3 (LF) 3913**] Chief Complaint: Hemodynamic instability s/p VATS Major Surgical or Invasive Procedure: VATS, thoracotomy, chest tubes, BAL, intubation History of Present Illness: 56-year-old woman with a history of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5622**] chromosome ALL s/p allogeneic transplant, s/p DLI with subsequent severe GVHD (diagnosed via transjugular liver biopsy) originally admitted on [**12-30**] for failure to thrive and fall, now with prolonged loculated hemothorax s/p R VATS converted to open thoracotomy, evacuation and decortication. . Prior to this hospitalization, patient discharged on [**12-16**] for suspected graft versus host disease that was diagnosed with transjugular liver biopsy. Hospital course on that admission was complicated by a tension pneumothorax following biopsy which required a pigtail catheter on [**2131-12-4**] which did not resolve pneumothorax and a surgical chest tube was placed [**12-4**]. Following this pt developed a hemothorax and a significant drop in hematocrit however pneumothorax did not improve and an adidtional Due chest tube was placed [**12-5**]. Chest tube was eventually d/c'd on [**2131-12-16**] and a CXR prior to discharge was notable only for a tiny residual right apical pneumothorax and stable small right-sided loculated pleural effusion. . During her follow-up visit with her Oncologist pt was noted to have weight loss (lost approx 40lbs over the past 3 months) that was attributed to her GVHD. Pt was admitted to BMT service on [**12-30**] for failure to thrive and initiation of TPN. On chest x-ray pt was noted to have a pleural effusion on the right, a follow up CT chest was notable for multi loculated right pleural effusion. IP and CT surgery were consulted, and decided at that time to undergo VATs due to the possibility of hemothorax. Pt received 1u PRBC, 2u plts prior to going to the OR on [**1-1**]; during VATs right lower lobe was notable for patchy parts of necrosis, and there was copious bleeding. VATs was converted to open posterolateral thoracotomy, pt was transfused 5u PRBC, 2u plt, 4u plasma, 1u Cryoprecipitate and then taken to the TICU. Tissue samples demonstrated Gram negative rods and Gram Positive Cocci. Patient was started on Vancomycin, Zosyn, and Flagyl on [**1-2**]. A BAL was performed which demonstrated gram Positive Cocci, Gram Positive Rods, Gram Negative Rods. Pt noted to be hypotensive with systolic BP to 78. Patient was started on pressor therapy with Phenylephrine. . On [**1-3**] AM she was weaned off of pressors. However that afternoon while she was being repositioned she developed atrial fibrillation with vent rates to 180s and hypotension to 80s. She received adenosine push 6 mg IV. She had approx 4 sec asystolic pause and then afib to 150-170s. She was shocked with 200J. Her blood pressure transiently improved however her HR was still in 120s. She was given amiodarone 150 mg IV bolus followed by loading drip. She also received lopressor 5mg x2, neosynephrine drip, and IV fluid bolus. Cardiology consult was obtained and they recommened completion of amio IV loading and possible elective DCCV. Given patients' multiple medical issues and complicated picture patient was transferred from the thoracic ICU to the medical ICU on [**1-4**]. On arrival to MICU pt was afebrile with HR 136 AFRVR, BP 123/85 CMV/AC 450x18, FiO2 40%, PEEP 5. She was able to communicate that she did not have any shortness of breath, chest pain, abdominal pain. She nodded yes to back pain. Her husband stated that patient experienced decreased apetite and generalized weakness prior to hospitalization but did not experience fevers, chills, SOB, chest pain. . In the MICU patient was continued on antibiotics. ID was consulted. Hemodynamic improved and patient was extubated on [**2132-1-9**]. Patient was transferred back to the primary BMT service for furthur care. Past Medical History: PAST ONCOLOGICAL HISTORY: [**Location (un) 5622**] chromosome positive ALL, status post allogeneic transplant with evidence of disease recurrence. Her last dose of cyclosporine was on [**2131-7-28**] and last dose of prednisone was on [**2131-7-24**]. She has not had any clear evidence of GVH since tapering off her immunosuppression. The patient's bone marrow biopsy in the setting revealed areas of extensive confluent necrosis and immature mononuclear cell infiltrates, consistent with relapsed acute lymphoblastic leukemia. By immunohistochemistry, the neoplastic cells were strongly reactive for CD10. Chimerism studies revealed that she was approximately 99% donor. She still was noted to have the normal abnormal gene rearrangement 922 and two out of 100 nuclei were examined. She was ultimately admitted on [**2131-8-10**] for part A of hyper-CVAD regimen (without CNS treatment) with Gleevec. She is still recovering from her treatment. She does have some mild progression of her peripheral neuropathy in the setting of vincristine that she received with her most recent cycle of hyper-CVAD. . - GVHD Social History: She has been married for 33 years. Does not smoke or drink alcohol. She has three grown children. She has three siblings. Family History: Her father was recently diagnosed with an unknown blood disorder. Physical Exam: On admission Vitals: T 97.2 BP 123/85 HR 136 AF, 99% CMV/AC 450x18, FiO2 0.40, PEEP 5 Gen: cachectic, ill appearing, able to follow commands, [**Year (4 digits) 4459**]: Dry mucus membranes, JVP not elevated. Heart: Tachy. Normal S1 and S2. No appreciable MRG. Lungs: Diffuse rhonchi in anterior lung fields Abdomen: Soft, nontender. No appreciable mass Ext: [**1-18**]+ bilateral lower extremity edema. Warm to touch. Tenderness to touch bilateral lower extremities. Neuro: Following commands, able to grip BLE. Able to wiggle toes slightly in bilateral lower extremities Pertinent Results: [**12-31**] - CT chest - IMPRESSION: Increase of right-sided pleural effusion and subsequent atelectasis. Complete resolution of the left-sided pleural effusion. No evidence of infection. No evidence of lung nodules or of hilar and mediastinal lymphadenopathy. . [**1-4**]- EKG - Sinus tachycardia. Otherwise, no diagnostic abnormality. Compared to the previous tracing of [**2132-1-3**] no major change. . [**1-6**] Echo - IMPRESSION: No endocarditis or abscess seen. Normal biventricular systolic function. Moderate mitral regurgitation. . [**1-8**] - hepatic ultrasound - IMPRESSION: 1. No biliary ductal dilatation. 2. No evidence of cholecystitis. . [**1-10**] - portable chest x-ray - right apical pneumothorax now showing signs of tension pneumothorax with shifting of the mediastinum . [**2132-2-9**] CXR: FINDINGS: In comparison with study of [**2-7**], there is a small residual apical pneumothorax. Chest tube remains in place and post-surgical changes are again seen in the right hemithorax. . [**2132-2-9**] CTA: MPRESSION: 1. Gas in the intracranial venous sinuses and cortical veins, as well as in the right internal jugular vein just above the venous catheter entry site. While the large intracranial venous sinuses and large deep basal veins are patent, some of the small cortical veins may be occluded. 2. Extensive multifocal cerebral edema and enhancement, right greater than left, which may be related to venous ischemia. The CT perfusion study supports the presence of ischemia. 3. Focus of gas in the proximal right internal carotid artery, origin uncertain. 4. No evidence of arterial stenoses in the head and neck. No evidence of intracranial arterial aneurysms. 5. Moderate compression deformity of the T3 vertebral body. . [**2132-2-9**] MR head: IMPRESSION: 1. Extensive multifocal cortical swelling, right greater than left, with ishemia and possible infarction, likely related to cortical venous air embolism which is demonstrated on the concurrent head CTA. 2. Small foci of increased susceptibility in the affected cortex may correspond to the air emboli or to microhemorrhages. 3. No occlusion of the large venous sinuses. . [**2132-2-10**] Echo: The left atrium and right atrium are normal in cavity size. There is mild symmetric hypokinesis of the anterior septum and mild hypokinesis of the remaining segments (LVEF = 40 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without evidence for hemodynamic compromise. If there is a suspicion for a paradoxical embolism, a follow-up study by laboratory son[**Name (NI) 16272**] with agitated saline contrast is suggested. . [**2132-2-10**] CT head: IMPRESSION: Progression of extensive multifocal infarctions with dramatic increase in cerebral edema. New herniation of the cerebellar tonsils and leftward subfalcine herniation. . [**2132-2-11**] EEG: IMPRESSION: This telemetry captured no epileptiform activity. The background activity was very slow and of low voltage suggestive of a severe encephalopathy. Brief Hospital Course: 56-year-old woman with a history of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5622**] chromosome ALL s/p allogeneic transplant s/p DLI in remission with subsequent severe GVHD who on this admission underwent thoracotomy for empyema. . DEATH SUMMARY: Pt was initially admitted for complicated empyema for which she was treated with 3 chest tubes and antibiotics by the SICU team prior to transfer to the medical floor. Her empyema was complicated by gram negative rod bacteremia and gram negatives found on BAL. Both her empyema and bacteremia were treated with meropenem. Meropenem was kept on long after finishing treatment for empyema & bacteremia because of concern for infection given that she still had 3 chest tubes in place. Thoracics was removing her chest tubes over time and her second tube was removed 2 days prior to her transfer to the ICU. CXRs were obtained after every adjustment of her chest tubes. Her pain was controlled with IV morphine sulfate with a continuous basal amount through a PCA and PO morphine sulfate for breakthrough pain. . From an infectious point of view, meropenem was ultimately stopped because the patient developed c diff which resolved quickly on oral vancomycin. She was later started on levofloxacin for treatment of a UTI. Because she had ALL and was in remission she was continued on her acyclovir, inhaled pentamidine, and micofungin (she had previously been on caspofungin but this was discontinued in the setting of rising LFTs). Her GVHD was likely repsponsible for her rising LFTs and her steroid dose was adjusted during her hospital stay. Her cellcept dose was also increased. Concern for fungal infection in he setting of her LFTs prompted an MRI of the abdomen which showed no fungal infection. . She was transfused both blood and platelets during her hospital course. Her metoprolol dose was adjusted to treat her worsening HTN in the setting of her increased dose of cellcept. Her diet was slowly advanced since she had severe dysphagia and a hoarse voice after her intubation. She was seen regularly by both physical therapy and speech/swallow. . The patient was improving markedly and the plan was for her final chest tube to be pulled, her diet to be advanced, and to soon be discharged. Earlier in the day of her event the patient was walking with her walker accompanied by her husband. After sitting down for a while she suddenly complained of shortness of breath and the nurse placed her on 2L nasal canula for comfort despite a normal oxygen saturation. The nurse then turned around to find her slumped over and leaning towards the left. At this time the patient was complaining of a headache. Upon entering the room the medicine intern noted her head to be slumped over to the left. The patient was communicating normally and reported a headache. Mrs. [**Known lastname 52383**] was found to have left sided hemiparesis and left sided loss of sensation on very brief physical exam. A stat CXR was ordered due to concern of worsening PTX given the patient reported tachypnea (this CXR was read as not changed from prior). A code stroke was called and the attending physician was immediately informed and at the patient's bedside. She was rushed to the CT scanner where she required Ativan due to starting to seize. . A CTA of the head was obtained that ultimately showed gas within the intracranial venous sinuses and cortical veins, the right internal jugular vein just above the venous catheter entry site, and the right internal carotid artery. The CT perfusion study also showed extensive multifocal cerebral edema and enhancement. After confirmation in the [**Hospital Unit Name 153**] that the patient had stopped seizing, an MRI and MRV were also obtained. They showed extensive multifocal cortical swelling (right greater than left) with ishemia and possible infarction which was likely related to cortical venous air embolism which is demonstrated on the concurrent head CTA. . In the [**Hospital Unit Name 153**], neurology was consulted to follow the pt with the ICU team. On the morning prior to her passing she was noted to have 4cm and fixed pupils that were non-reactive, roving eye movements, and Cheynne-[**Doctor Last Name **] breathing. Following the presence of increased Cheynne-[**Doctor Last Name **] and apneic episodes concerns for airway protection prompted an intubation. Several hours following intubation she was noted to have fully dilated and fixed bilateral pupils. Due to concern of tonsillar herniation she was rushed for a CT head. The CT of the head showed extensive multifocal infarctions with dramatic increase in cerebral edema, new herniation of the cerebellar tonsils, and leftward subfalcine herniation. A family meeting was held with Dr. [**Last Name (STitle) **], ICU team, and Neurology. Given her situation, the decision was made by family for comfort measures only. The family decided to keep the patient intubated in order to allow time for her son to fly in to [**Name (NI) 86**]. The patient died with her family at her bedside. Medications on Admission: Pyridoxine 100 mg PO DAILY Folic Acid 1 mg PO DAILY Acyclovir 400 mg PO Q8H Lorazepam 0.5 mg PO Q8H PRN Pantoprazole 40 mg PO Q24H Zolpidem 5 mg PO HS PRN Gabapentin 300 mg PO Q12H Budesonide 3 mg PO Q 8H Loperamide 2 mg PO QID Methylprednisolone 15mg IV qam and 10mg IV qpm Mycophenolate Mofetil 1000mg po bid Senna 8.6 mg PO BID PRN Oxycodone 20 mg SR PO q12H Docusate Sodium 100 mg [**Hospital1 **] Oxycodone 5-10 mg q6hours PRN Ursodiol 300 mg PO TID Atenolol 25mg po daily Potassium Chloride 20mg daily Caspofungin 35mg IV daily . Meds on transfer from floor: Fentanyl 25-100 mcg IV q4h prn Midazolam 1-2 mg IV q2h prn Lidocaine patch Hydrocortisone 100 mg IV q8h Linezolid 600 mg IV q12h Amiodarone drip Esmolol drip at 100 mcg/kg/min Mycophenolate Mofetil 500 mg IV bid Tobramycin 100 mg IV q8h Meropenem 500 mg IV q6h Phenylphrine 1 mcg/kg/min Vasopressin 1.2 units/hr Potassium sliding scale Calcium gluconate sliding scale Chlorhexidine Pantoprazole 40 mg IV q24h Acyclovir 400 mg IV q8h Caspofungin 35 mg IV q24h Insulin sliding scale . Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased Completed by:[**2132-2-18**]

[ "707.22", "799.4", "599.0", "038.49", "996.85", "923.10", "921.2", "E933.1", "783.7", "348.5", "E888.9", "E878.0", "204.00", "357.6", "427.31", "513.0", "707.03", "338.12", "V85.0", "434.11", "510.0", "572.8", "518.81", "V64.42", "008.45", "511.89", "348.4", "785.52", "780.39", "279.52", "286.6", "995.92", "996.74" ]

icd9cm

[ [ [] ] ]

[ "88.72", "99.04", "00.14", "33.24", "99.61", "38.93", "96.04", "99.05", "96.6", "99.15", "96.72", "34.51", "96.71" ]

icd9pcs

[ [ [] ] ]

15785, 15794

9568, 14653

316, 365

15846, 15856

6104, 9175

15913, 15952

5428, 5495

15752, 15762

15815, 15825

14679, 15729

15880, 15890

5510, 6085

244, 278

393, 4128

9184, 9545

4150, 5271

5287, 5412

24,740

160,828

54203

Discharge summary

report

Admission Date: [**2163-7-13**] Discharge Date: [**2163-7-16**] Date of Birth: [**2092-7-25**] Sex: M Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: Anterior MI Major Surgical or Invasive Procedure: Cardiac Cath on [**2163-7-13**] with placement of 3 stents Mechanical Ventilation [**2163-7-13**] History of Present Illness: 70 yo man with h/o end-stage COPD (Combivent Inh 2 puffs [**8-1**] Xs/day & home 02 2LNC) w/ severe midsternal CP at 1 am. At OSH, EKG was noted to have anterior ST elevations (2 mm in V1-V4) and old poor r-wave progression. Made pain-free with NTG and had resolution of ST elevations. Patient had recurrent symptoms and was transfered to [**Hospital1 18**] for management. Underwent Left and Right Heart Cath that showed 1VD with 80% proximal LAD stenosis and 80% hazy proximal D1 stenosis. Placement of 1 stent in D1 and 2 overlapping stents in the mid-LAD. Patient's course complicated by V-fib arrest during 1st of 2 stents placed in mid-LAD. Patient underwent CPR, defibrillation X 5, emergent intubation, and transient pressor support with dopamine Past Medical History: Severe COPD (FEV1 = .5L; 19% of normal on [**9-25**]) h/o hyperplastic polyp h/o hypothyroid in the past Social History: Long tobacco history currently smokes 1 puff per day, No alcohol use, Lives at home with wife, [**Name (NI) **] children, Retired (used to work in investments) Family History: non-contributory Physical Exam: BP 107/66, HR 82, RR 18 Gen - thin elderly man in NAD HEENT - ETT in place, anicteric NECK - no JVD CHEST - decreased BS throughout, mild exp wheezes, no rales CV - reg rate, distant heart sounds, [**1-28**] SM ABD - soft, NT/ND, +BS, no HSM EXT - intact peripheral pulses, no edema Pertinent Results: EKG: Rate 86 Sinus rhythm. Tall peaked P waves and rightward P wave axis. QS deflections in leads V1-V2 consistent with prior anteroseptal myocardial infarction. The T waves are now biphasic to inverted in leads V1-V3 and there are ST segment depressions in leads II, III and aVF and variation in the left precordial lead placement cardiac cath: 90%LAD stenosis s/p drug eluting stent x2, 80% D1 stenosis s/p bare metal stent x1 w/ 30% residual stenosis; modest disease in RCA, LCx. Normal LMCA, elevated right and left sided pressures (RV 41/18, RA mean 13, PA mean 32, PCWP mean 19). CXR: Severe changes of emphysema, without evidence of pneumonia or congestive heart failure. Asymmetric pleural thickening in the lung apices, right greater than left. Echo: LVEF>55%, trivial mitral regurgitation, pulmonary artery systolic hypertension TR Gradient (+ RA = PASP): *30 to 35 mm Hg (nl <= 25 mm Hg) [**2163-7-13**] 12:54PM TSH-10* [**2163-7-13**] 12:54PM TRIGLYCER-53 HDL CHOL-62 CHOL/HDL-2.4 LDL(CALC)-74 [**2163-7-13**] 12:54PM ALT(SGPT)-16 AST(SGOT)-25 LD(LDH)-224 CK(CPK)-144 ALK PHOS-45 TOT BILI-0.3 [**2163-7-13**] 12:54PM CK-MB-6 cTropnT-<0.01 [**2163-7-13**] 07:38PM CK-MB-17* MB INDX-2.0 cTropnT-0.03* [**2163-7-13**] 07:38PM CK(CPK)-861* [**2163-7-13**] 12:54PM WBC-19.0* RBC-4.45* HGB-13.1* HCT-40.5 MCV-91 MCH-29.6 MCHC-32.4 RDW-13.0 Brief Hospital Course: Impression: 70 yo with end stage COPD, still smoking, who presents with acute anterior STEMI. Hospital Course: 1. CAD - taken to cath on arrival to [**Hospital1 18**] where cath showed results above. He had DE stent and PCTA to prox LAD and D1. Cath c/b VFib arrest. Patient was cardioverted x5, intubated, placed on pressors and taken to the CCU. His cardiac enzymes peaked around 24-36 hours after cardioversion. He was started on ASA, plavix, lipitor, and Lisinopril. A Bblocker was not started given severe COPD. His lipitor dose was decreased to 10mg QD given his persistent elevation in CKs. He will need to have these followed up as an outpatient to ensure they normalize. Given that his troponin remained <0.1 and his MBI never was positive, it was felt that he did not have a plaque rupture but subacute coronary stenosis. 2. COPD - end stage, on home O2 and severely limited in ADLs. Pt only taking combivent and theodur at home. He was extubated without event shortly after arrival to the CCU. His initial lab work did not show signs of chronic CO2 retention. Pulmonary was consulted to assist in optimization of his COPD medication regimen. They recommended starting tiotropium and using atrovent for rescue therapy. Albuterol use to be minimized given CAD. He was felt to be a candidate for pulmonary rehab and will f/u with Dr. [**Last Name (STitle) **]. 3. CHF - noted to have PCWP of 28 with elevated PAP on Right heart cath. He was diuresed with good results. No evidence of decompensated CHF on exam. TTE performed which showed EF 70% with no evidence of WMA (poor windows given COPD). 4. Aspiration - initally felt to have aspiration PNA given emergent intubation and he was started on levaquin and flagyl. As he remained afebrile with gradually decreasing WBC, his abx were d/c'd on HD#2. 5. Deconditioning - given his MI and his poor pulmonary reserve, he was evaluated by PT and OT and felt to benefit from short term rehab. 6. Follow up - patient has no PCP and was referred to [**Company 191**] to establish primary care. He will also f/u with Dr. [**Last Name (STitle) **] in pulmonary and Dr. [**Last Name (STitle) 911**] in Cardiology. Medications on Admission: 1. Theodur 300 [**Hospital1 **] 2. combivent 3-4puffs QID 3. Supplemental O2 at 2L NC Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). Tablet, Delayed Release (E.C.)(s) 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 3. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation QID (4 times a day). Disp:*1 inh* Refills:*2* 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. Disp:*1 inh* Refills:*0* 6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. Disp:*30 capsules* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Acute Anterior Myocardial Infarction Emphysema Discharge Condition: No chest pain. Continues to have dyspnea requiring frequent inhalers, nebs, O2 @ 2LNC. Not able to move very often due to SOB. This is the patient's baseline. Discharge Instructions: Please return to the emergency department if you experience any chest pain, severe shortness of breath. No heavy lifting for the next 2 weeks. You will be discharged on a number of medications. Please take those medications as advised. An appointment has been made for you with your Pulmonologist Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] on Thursday, [**2163-7-21**] at 4PM. His office is located in [**Hospital Ward Name 23**] 7. Please call to make appointments with the following doctors: Cardiology: Drs. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] [**Name5 (PTitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] - please see within 2 weeks ([**Telephone/Fax (1) 920**]). Pulmonary: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] for management of COPD ([**Telephone/Fax (1) 5091**]). Primary Care: Followup Instructions: Appointment made with Pulmonologist Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] on Thursday, [**2163-7-21**] at 4PM. Patient advised to call and make appointments with the following physicians: Cardiology: Drs. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] [**Name5 (PTitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] in 2 weeks ([**Telephone/Fax (1) 920**]). Primary Care: [**Hospital3 **] Medical Center ([**Telephone/Fax (1) 250**]) [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2163-7-16**]

[ "E879.0", "427.5", "507.0", "458.29", "276.4", "428.0", "496", "427.41", "410.71" ]

icd9cm

[ [ [] ] ]

[ "99.60", "96.04", "99.20", "36.06", "96.71", "36.07", "99.62", "36.05" ]

icd9pcs

[ [ [] ] ]

6569, 6640

3277, 3372

347, 447

6731, 6891

1889, 3254

7861, 8543

1552, 1570

5600, 6546

6661, 6710

5490, 5577

3389, 5464

6915, 7838

1585, 1870

296, 309

475, 1231

1253, 1359

1375, 1536

30,278

124,925

53245

Discharge summary

report

Admission Date: [**2161-9-7**] Discharge Date: [**2161-9-18**] Date of Birth: [**2081-10-8**] Sex: M Service: MEDICINE Allergies: Lidocaine / Shellfish Attending:[**First Name3 (LF) 458**] Chief Complaint: Dyspnea, Syncope on exertion Major Surgical or Invasive Procedure: Intubation [**9-8**] and [**9-14**] Trach tube placement on [**9-15**] History of Present Illness: This is a 79 year-old male with a history of hypertension, hyperlipidemia who presents for evaluation of dyspnea and syncope on exertion. Per team on the floor, the dyspnea on exertion and syncope have been getting progressively worse over the course of the last 2 months. Pt's functional capacity is extremely limited; he is now only able to go from the bed to the bathroom and even this makes him presyncopal and dyspnic. Pt has been having syncopal espisodes with prodrome for 2 years. On day of admission, pt was rushing to the bathroom when he had a syncopal episode. It is unclear if he syncopized while running to the bathroom or on the toliet. His son called the ambulance. The chest pain occured while the patient was recovering from syncope. The patient describes pain as [**4-30**], L shoulder tapping pressure, not radiating, not a/w nausea diaphoresis or shortness of breath. It resolved after about 10 minutes. Patient denies symptoms at rest. . In the ED, initial vitals were T: 97.4 HR:82 BP:127/78 RR: 28. EKG showed a fib, PVCs. Pt. was admitted for further evaluation and management. . On the floor, VS were: T98.8, BP 128/55, P 59, R20, O2 sat 98% on 2L. Pt was also noted to be orthostatic. BB and ACEI were decreased. Pt was planned for cardiac cath to evaulate coronary anatomy as cause of DOE and initiation of sotalol afterwards for PAF and possible contribution to dyspnea. Pt has been on heparin gtt for subtherapeutic INR while in A fib with possible planned cardioversion. Of note, PTT has been >150. . At 8:40 AM on [**2161-9-8**], pt was found unresponsive, slumped to the right, by nursing. He did slightly lift his head but would not follow commands. On examination by house officers, he was found slumped to the right. He lifted his head to sternal rub. Pupils were equal and reactive, though sluggish. His right arm was noted to be flexed and rigid. Code stroke/blue was called. BP was 155/114. HR was 114. Throughout the code, pt maintained a blood pressure and pulse of 80-100. Pt did desat to 80s. Pt was found to have copious oral secretions and after suctioning O2 sats improved to 100%. A blood gas showed 7.19/109/254 during the code; it is unclear what the O2 sat was at the time. He was intubated for airway protection. Of note, he was noted to have vomit on his [**Doctor First Name **]. Head imaging including CT and CTA head showed no acute event preliminarily. Neuro evaluated the pt and found no focal neurologic deficits. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism. 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, paroxysmal nocturnal dyspnea, ankle edema, palpitations. Past Medical History: PAST MEDICAL HISTORY: Pacemaker for symptomatic bradycardia Dilated cardiomyopathy Atrial flutter, s/p ablation [**5-27**] Arrhythmia in [**2113**]??????s requiring shock, ? Afib Hypertension Hyperlipidemia [**2151**] Cyst removed from chest s/p Pacemaker placement in [**6-27**] Social History: Social history is significant for the absence of tobacco use. There is no history of alcohol abuse. Lives at home with several of his children. Family History: There is no family history of premature coronary artery disease or sudden death. Family history of DM. Physical Exam: VS - T99.8, P61, BP119/77, RR18, O2 sat 99 Gen: Intubated, sedated. HEENT: NCAT. Sclera anicteric. Pupils constricted and reactive bilaterally. Neck: Supple. No JVD. No carotid bruits. CV: Irregularly irreglular, no murmurs. Chest: No chest wall deformities, scoliosis or kyphosis. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. No abdominial bruits. Ext: Trace pedal edema bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: PERRL, Dolls eyes negative, Babinski downgoing bilaterally, DTRs intact, moving all 4 extremities, no rigidity. . Pulses: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: [**2161-9-7**] 04:28AM BLOOD WBC-6.5 RBC-4.12* Hgb-12.3* Hct-39.7* MCV-96 MCH-29.9 MCHC-31.1 RDW-15.0 Plt Ct-186 [**2161-9-7**] 04:28AM BLOOD Neuts-77.1* Lymphs-17.4* Monos-5.0 Eos-0.5 Baso-0.1 [**2161-9-7**] 04:28AM BLOOD PT-15.8* PTT-28.0 INR(PT)-1.4* [**2161-9-7**] 04:28AM BLOOD Plt Ct-186 [**2161-9-7**] 04:28AM BLOOD Glucose-101 UreaN-23* Creat-1.1 Na-139 K-4.3 Cl-96 HCO3-39* AnGap-8 [**2161-9-7**] 04:28AM BLOOD CK(CPK)-266* [**2161-9-7**] 04:28AM BLOOD CK-MB-8 [**2161-9-7**] 04:28AM BLOOD cTropnT-0.09* [**2161-9-8**] 11:34AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.2 [**2161-9-7**] 05:05PM BLOOD TSH-12* [**2161-9-8**] 07:10AM BLOOD T4-2.1* [**2161-9-8**] 09:24AM BLOOD Type-ART pO2-254* pCO2-109* pH-7.19* calTCO2-44* Base XS-9 [**2161-9-8**] 09:24AM BLOOD Glucose-135* Lactate-0.7 Na-140 K-4.7 Cl-90* calHCO3-41* [**2161-9-8**] 10:23PM BLOOD O2 Sat-91 [**2161-9-8**] 09:24AM BLOOD freeCa-1.14 . . PERTINENT LABS: . MEDICAL DECISION MAKING EKG demonstrated a. fib with PVCs, unchanged from [**2160-5-21**]. . TELEMETRY demonstrated: a fib with frequent PVCs, short period of pacing. . 2D-[**Month/Day/Year **] performed [**2160-5-20**] demonstrated: on Mild left atrial/atrial appendage spontaneous echo contrast without intracardiac or atrial/atrial appendage thrombus. Biventricular cardiomyopathy. Mild mitral regurgitation. Mild aortic regurgitation. Mild-moderate tricuspid regurgitation. Simple aortic atheroma. . [**2161-9-7**] CXR: Bibasilar atelectasis, however, no evidence of pneumonia. . [**12-27**]: Excercise Mibi: 1. The left ventricle appears to be more enlarged when compared with the prior study. 2. The myocardial perfusion appears normal at the level of exercise attained. 3. We could not perform a gated study due to multiple ectopics. . [**12-27**] Excercise ECG stress: In reviewing the stress test's EKG component, it was difficult to interpret secondary to his AV pacing. Throughout the stress test, the patient demonstrated a rhythm that was paced with frequent polymorphic ventricular premature beats and several ventricular couplets. Of note, however, the patient had to discontinue the study after 5 minutes with 3.2 METS representing limited functional capacity study for his age. Also of note, the patient had a drop in systolic blood pressure from 152/90 to 130/64. . LABORATORY DATA: See below. . . DISCHARGE LABS: [**2161-9-17**] 05:26AM BLOOD WBC-5.9 RBC-3.23* Hgb-10.0* Hct-30.7* MCV-95 MCH-30.9 MCHC-32.5 RDW-15.6* Plt Ct-207 [**2161-9-8**] 11:34AM BLOOD Neuts-92.5* Bands-0 Lymphs-4.5* Monos-2.8 Eos-0.1 Baso-0.1 [**2161-9-8**] 11:34AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-1+ [**2161-9-17**] 05:26AM BLOOD Plt Ct-207 [**2161-9-16**] 06:08AM BLOOD ESR-11 [**2161-9-17**] 05:26AM BLOOD Glucose-96 UreaN-15 Creat-1.0 Na-140 K-3.8 Cl-113* HCO3-23 AnGap-8 [**2161-9-8**] 09:38PM BLOOD CK(CPK)-312* [**2161-9-8**] 09:38PM BLOOD CK-MB-7 [**2161-9-17**] 05:26AM BLOOD Calcium-7.8* Phos-2.1* Mg-2.1 [**2161-9-17**] 05:26AM BLOOD Theophy-3.3* [**2161-9-17**] 05:59AM BLOOD Type-ART Temp-37.1 Rates-15/1 Tidal V-500 PEEP-5 FiO2-40 pO2-111* pCO2-38 pH-7.38 calTCO2-23 Base XS--1 Vent-IMV [**2161-9-15**] 04:42PM BLOOD Glucose-85 [**2161-9-16**] 12:34AM BLOOD O2 Sat-96 [**2161-9-17**] 05:59AM BLOOD freeCa-1.13 Brief Hospital Course: Patient is a 79 yo man with a past medical history pacemaker placement for symptomatic bradycardia, diastolic cardiomyopathy, and atrial fibrillation who presented with syncope and dyspena on exertion on [**9-7**]. Patient was found unresponsive on [**2161-9-8**] with hypercarbic respiratory failure and he was then transferred to the CCU. . #) Hypercarbic respiratory failure: Patient was found to be in hypercarbic respiratory failure on [**9-8**]. He was intubated in the CCU on [**9-9**]. He remained intubated until the 23rd. After extubation, patient had multiple episodes of apnea overnight. An EEG was performed which showed "mild encephalopathy or marked drowsiness. There were no focal lateralized or epileptiform features seen." Patient was unable to have MRI performed because of his his pacemaker. It appeared that he was experiencing symptoms of central sleep apena. Patient was started on Diamox for this process, which caused little to no improvement in his condition. On [**9-13**], an ABG was drawn which showed a pH of 7.18, CO2 of 74, O2 of 112. Patient previous to this time had declared that he was DNR/DNI, so he was encouraged to increase his own tidal volume. Respiratory status and ABG improved. On [**9-14**], patient reversed his code status and had an ABG of 7.14, CO2 81 and O2 of 93. Patient was intubated and remained as such until [**9-15**]. Due to the patient's central sleep apnea, it was decided that the patient would undergo a tracheostomy placement, which was performed on [**9-15**]. Patient tolerated this procedure without complications. Patient was placed on Theophylline 80 mg PO q6h, which he has tolerated well. . #)Coronary Artery Disease: Patient has a h/o biventricular hypokinesis, but he has no known CAD. Patient was continued on his home dose of aspirin, and his Atorvastatin was increased to 80 mg PO daily during this hospital admission. Patient had no acute events relating to his coronary artery disease during this admission. . #)Hypotension: Patient had multiple episodes of hypotension unrelated to apnea during this hospitalization. Patient's SBP would decrease to 60-80. The patient was asymptomatic during this episodes, and each responded to 250 cc NS fluid bolus. Etiology of this hypotension remains unclear, but it could represent autonomic instability, disregulation of centeral BP control. Patient's metoprolol was discontinued and his fluid balance was regulated in the setting of increased fluid boluses. Patient was started on Florinef 0.1 mg daily. This dose was gradually increased to 0.4 mg daily, and the patient only had two episodes of hypotension in the 24 hours prior to discharge. . #) Abdominal Pain: Patient had some abdominal pain subsequent to the placement of his PEG tube; however these episodes resolved the next day. The tube was placed to suction, which seemed to help relieve his symptoms. On the day of discharge, the patient was receiving tube feeds comfortably, and was no longer experiencing any abdominal pain or distension. . #)Diastolic Congestive Heart Failure: Patient has known history of diastolic cardiomyopathy w/ EF 40%. A TTE was performed on this admission, and it was unchanged from prior studies. Patient did not have any acute episodes in regards to his CHF during this hospital stay. . #) Hypothyroidism: Patient's TSH on admission was elevated. However, patient's dose of levothyroxine had been increased two weeks prior to admission. Patient was continued on this increased dose of levothyroxine. These studies should be repeated two weeks after discharge with the prospect of increasing his current dose of levothyroxine. . #. Anticoagulation: Patient was placed on a heparin gtt during this hospital stay. He was restarted on his home dose of Coumadin three days prior to discharge. Patient should be continued on his heparin gtt until his INR is within a therapeutic range ([**2-22**]). Patient should have daily INRs followed until he is stabalized on his home regimen. #. Code: Full Medications on Admission: Atorvastatin 20mg QD Furosemide 20mg Qd Levothyroxine 112mcg daily Lisinopril 30mg daily Metoprolol succinate 100mg QD Warfarin 5mg QD ASA 325mg QD Discharge Medications: 1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fludrocortisone 0.1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. Theophylline 80 mg/15 mL Elixir Sig: Eighty (80) mg PO Q6H (every 6 hours). 5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO once a day. 6. Heparin continuous drip Sig: 1050 (1050) units/hour Intravenous Continuous: Until INR > 2.0. 7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 10. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. 11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 14. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 15. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Primary: Central sleep apnea Coronary Artery Disease Syncope Secondary: Diastolic Congestive Heart Failure Hypothyroidism Discharge Condition: Stable. Patient's vital signs are stable. Patient is asymptomatic with SBP in the 80s. Discharge Instructions: You were admitted to the hospital because you were experiencing shortness of breath and syncope on exertion. While you were here, you had two episodes of respiratory distress and you were subsequently intubated each time. You were found to have central sleep apnea, and thus you received a trach tube to help you breathe at night. While you were here, we made the following changes to your medications: 1. We increased your Lipitor to 80 mg daily 2. We stopped your Lasix 3. We discontinued your Lisinopril 4. We discontinued your Metoprolol Please keep all previously scheduled appointments. Please take all medications as prescribed. Please return to the ED or your healthcare provider immediately if you experience shortness of breath, chest pain, loss of consciousness, dizziness, chills, fevers, or any other concerning symptoms. Please weigh yourself every morning, and call your healthcare provider if you gain > 3 lbs in one week. Please adhere to a low sodium (2 gm) diet. Followup Instructions: Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2161-9-30**] 11:00 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2161-10-15**] 8:30 Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2161-10-15**] 9:20 Completed by:[**2161-9-27**]

[ "425.4", "434.91", "518.81", "780.2", "427.32", "V45.01", "428.32", "427.89", "327.21", "428.0", "276.2", "244.9" ]

icd9cm

[ [ [] ] ]

[ "43.11", "96.72", "38.93", "96.04", "33.24", "96.6", "45.13", "31.1" ]

icd9pcs

[ [ [] ] ]

13439, 13494

7854, 11894

309, 382

13661, 13752

4523, 4523

14790, 15237

3715, 3821

12092, 13416

13515, 13640

11920, 12069

13776, 14767

6898, 7831

3836, 4504

241, 271

410, 3233

4540, 5442

5459, 6881

3277, 3537

3553, 3699

30,475

147,999

32073+32074

Discharge summary

report+report

Admission Date: [**2173-1-2**] Discharge Date: [**2173-1-8**] Date of Birth: [**2097-6-23**] Sex: M Service: TRA ADMISSION DIAGNOSES: 1. Status post motor vehicle accident. 2. Left pelvic fracture. 3. Left femoral dislocation. 4. Grade 1 splenic laceration. 5. Atrial fibrillation. 6. Hypertension. 7. Coronary artery disease status post coronary artery bypass graft. 8. Prostatic cancer. DISCHARGE DIAGNOSES: 1. As above. 2. Status post open reduction, internal fixation of acetabular posterior wall, posterior column fracture, status post exploration of sciatic nerve and neuroplasty. 3. Status post insertion of inferior vena cava filter. 4. Blood loss anemia. DICTATION ENDED [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 33889**] Dictated By:[**Doctor Last Name 3763**] MEDQUIST36 D: [**2173-1-8**] 11:50:46 T: [**2173-1-8**] 12:05:00 Job#: [**Job Number 75095**] Admission Date: [**2173-1-2**] Discharge Date: [**2173-1-8**] Date of Birth: [**2097-6-23**] Sex: M Service: TRA ADMISSION DIAGNOSES: 1. Status post motor vehicle accident. 2. Left pelvic fracture. 3. Left femoral dislocation. 4. Grade 1 splenic laceration. 5. Atrial fibrillation. 6. Hypertension. 7. Coronary artery disease status post coronary artery bypass grafting. 8. Prostate cancer. 9. Right fibular fracture. DISCHARGE DIAGNOSES: 1. Status post motor vehicle accident. 2. Left pelvic fracture. 3. Left femoral dislocation. 4. Grade 1 splenic laceration. 5. Atrial fibrillation. 6. Hypertension. 7. Coronary artery disease status post coronary artery bypass grafting. 8. Prostate cancer. 9. Right fibular fracture. 10.Blood loss anemia. 11.Status post insertion of inferior vena cava filter. 12.Status post open reduction, internal fixation of left acetabular posterior wall posterior column fracture, status post exploration of sciatic nerve and neuroplasty. ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname **] is a 75-year- old gentleman on Coumadin for atrial fibrillation who was a restrained driver involved in a motor vehicle collision at about 30-35 miles per hour. He did lose consciousness during the accident, but otherwise had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale score of 13 at the scene. Notably, his INR was therapeutic and there was additional concern given his significant mechanism of injury and his coagulopathy. He was hemodynamically stable in the field and brought to the emergency room at the [**Hospital1 1444**]. Upon arrival the patient's hemodynamics were normal and his GCS score was 14. The patient was stabilized in the trauma bay and underwent immediate imaging, which included a CT of the head which found no acute intracranial hemorrhage. Additionally, he underwent a CT of the C spine which demonstrated no abnormality. A CT of the torso was notable for grade 1 splenic laceration, but otherwise comminuted fractures in the posterior wall and column of the left acetabulum with complete separation of the posterior wall. The patient's hematocrit on presentation was 30, but this was felt to be hemo concentrated as after fluid resuscitation this had dropped to 24. His INR at the time of presentation was 1.9. He was successfully resuscitated with crystalloid and in addition he was given vitamin K, fresh frozen plasma and packed red blood cells. After initial stabilization he was monitored in the intensive care unit until he was able to undergo operative repair of his lower extremity fractures on [**2173-1-4**]. At the time of this repair, he also underwent insertion of an IVC filter as it was felt he would be immobile for some time and he had a relative contraindication to using heparin given the fact that he had a small splenic laceration. The patient was extubated subsequent to operative repair of his fractures and placement of his inferior vena caval filter. He did well, he remained afebrile with normal hemodynamics. His diet was advanced without difficulty and we were able to wean his oxygen requirement slowly. His hematocrit had stabilized by hospital day 2 and he did not require further blood transfusions. Otherwise, his renal function remained stable at his baseline creatinine of [**2-3**].1. Physical therapy began to work with the patient on hospital day 4 and felt that he would benefit from rehab, therefore, he was screened and discharged to rehab on [**2173-1-8**]. At the time of his discharge his hematocrit was 30.7 and his BUN and creatinine were 30 and 1. His chest x-ray showed mild pulmonary edema which was significantly improving on a daily basis with no large effusions visible. He was to be discharged on the following medications: Colace 100 mg p.o. b.i.d. p.r.n., regular insulin sliding scale, betamethasone dipropionate 0.05 ointment 1 application topically q.[**5-8**] h. as needed for a rash, hydrocortisone 1% ointment 1 topical application q.i.d. p.r.n. rash, metoprolol 50 mg p.o. b.i.d., Percocet 5/325 1-2 tabs every 4-6 hours as needed for pain, Pepcid 20 mg p.o. once daily, bisacodyl p.r.n., senna p.r.n. The patient's Coumadin was being held given his recent bleeding, as was his aspirin. His aspirin is okay to resume in 1 week. He is discharged to rehab with touch down weightbearing status of the left lower extremity, posterior hip precautions and the patient is to wear a knee immobilizer at all times. The patient has a followup appointment with Dr. [**Last Name (STitle) 2719**] of orthopedic surgery in 2 weeks and he should followup with Dr. [**Last Name (STitle) **] of general surgery in 10 days. He is discharged. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 33889**] Dictated By:[**Doctor Last Name 3763**] MEDQUIST36 D: [**2173-1-8**] 12:00:07 T: [**2173-1-8**] 12:42:57 Job#: [**Job Number 75096**]

[ "808.0", "414.00", "280.0", "E815.0", "185", "823.81", "V45.81", "780.09", "835.00", "401.9", "427.31", "865.09" ]

icd9cm

[ [ [] ] ]

[ "79.39", "04.79", "38.7", "04.04" ]

icd9pcs

[ [ [] ] ]

1477, 6026

1167, 1456

7,681

172,880

17127

Discharge summary

report

Admission Date: [**2166-6-8**] Discharge Date: [**2166-6-13**] Date of Birth: [**2117-1-14**] Sex: M Service: Medicine, [**Location (un) **] Firm HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old gentleman with a history of alcoholic cirrhosis, hepatitis C, gastritis, duodenitis, and upper gastrointestinal bleed times three. He was previously admitted to the [**Hospital1 190**] from [**5-21**] to [**5-24**] with a gastrointestinal bleed after transfer from an outside hospital. The patient was treated with octreotide and subsequently was discharged to home. The patient then presented via ambulance on [**5-27**] with vomiting and melena. The patient was admitted to the Intensive Care Unit and while awaiting transfer sent out against medical advice and presented to the [**Hospital1 346**] Emergency Department. The patient received 6 units of packed red blood cells at the outside hospital. The patient was admitted to the Intensive Care Unit and underwent transjugular intrahepatic portosystemic shunt on [**5-31**] without complications initially. However, the next day the patient became febrile with a temperature maximum of 103. The patient's liver function tests continued to rise, and a computerized axial tomography a right hepatic lobe infarction. The patient was subsequently discharged home after doing well on [**6-6**]. Over the next two days, the patient developed lethargy and fatigue and stated that he did take all his medications. He also noted that he had melanotic stools and subsequently presented to the Emergency Department. In the Emergency Department, his vital signs revealed temperature was 97.2, blood pressure was 119/60, heart rate was 100, and his oxygen saturation was 98% on room air. His hematocrit dropped to 23.4. The patient was subsequently admitted to the Medical Intensive Care Unit for esophagogastroduodenoscopy and observation. PAST MEDICAL HISTORY: 1. Alcoholic cirrhosis; hepatitis C induced. 2. The patient has a history of portal hypertension. 3. Numerous admissions with upper gastrointestinal bleeds. 4. As mentioned previously, the patient was admitted on [**2166-5-27**] and underwent transjugular intrahepatic portosystemic shunt on [**5-31**] which was complicated by localized hepatic infarction and was subsequently admitted on [**6-8**]. 5. The patient has a history of hepatitis C virus. The patient failed pegylated interferon. At the outside hospital the patient was also treated with ribavirin. 6. The patient has a history of gastritis and duodenitis by esophagogastroduodenoscopy in [**2165-7-28**]. 7. Type 2 diabetes mellitus. 8. Lumbar disk herniation. 9. Echocardiogram with a normal ejection fraction of 60% and 1+ mitral regurgitation. MEDICATIONS ON ADMISSION: 1. Multivitamin. 2. Lactulose 30 mL by mouth three times per day. 3. Protonix 40 mg by mouth once per day. 4. Oxycodone 5 mg by mouth four times per day as needed. 5. Tylenol 325 mg by mouth as needed. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: Family history was noncontributory. SOCIAL HISTORY: The patient has a history of heavy alcohol use. He quit nine months prior to presentation. He has a history of cocaine and marijuana use. The patient has a 20-year history of tobacco use. The patient is unemployed and lives with his mother. [**Name (NI) **] has a history of arrests and [**Last Name (un) 20934**]. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed vital signs with a temperature of 97.2, blood pressure was 119/60, heart rate was 100, respiratory rate was 18, and oxygen saturation was 985 on room air. In general, the patient was lying in bed in no apparent distress. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light and accommodation. Extraocular muscles were intact. Sclerae were icteric. The mucous membranes were dry. Neck examination revealed no jugular venous distention. No carotid bruits. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. The lungs were clear to auscultation bilaterally. The abdomen was distended. Soft and nontender with good bowel sounds. Extremities revealed 1+ lower extremity edema bilaterally. Dorsalis pedis pulses were 1+ bilaterally. Neurologically, the patient was alert and oriented times three. The patient had somewhat slurred speech. The patient was tired-appearing. The patient had positive asterixis. Deep tendon reflexes were 2+ bilaterally. The toes were downgoing. PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's laboratory values on admission revealed white blood cell count was 5.6, hematocrit was 23.4, and platelets were 105. Sodium was 133, potassium was 4.5, chloride was 114, bicarbonate was 25, blood urea nitrogen was 13, creatinine was 0.6, and blood glucose was 194. ALT was 146, AST was 113, alkaline phosphatase was 199, lactate dehydrogenase was 281, and total protein was 3.1. INR was 1.6. HOSPITAL COURSE BY ISSUE/SYSTEM: As mentioned above, the patient was readmitted on [**6-8**] with melena, a drop in hematocrit, and lethargy. 1. GASTROINTESTINAL ISSUES: The patient had an esophagogastroduodenoscopy that showed a nonbleeding ulcer. The patient had a Doppler ultrasound showing reversible flow in the left portal vein, and decreased transjugular intrahepatic portosystemic shunt velocities, and worsening ascites; consistent with decreased transjugular intrahepatic portosystemic shunt patency. The patient subsequently underwent a transjugular intrahepatic portosystemic shunt revision on [**2166-6-10**] during which the patient was found to have a spontaneous splenorenal shunt stealing blood flow from the transjugular intrahepatic portosystemic shunt. The shunt was coiled and the transjugular intrahepatic portosystemic shunt was angioplastied. Subsequently, the patient was doing well. However, an ultrasound from [**6-11**] showed slowed flow through the transjugular intrahepatic portosystemic shunt. Therefore, the patient was started on heparin 600 units per hour. An ultrasound was repeated the following morning. The repeat ultrasound showed patent forward flow and increased transjugular intrahepatic portosystemic shunt velocity; consistent with a patent transjugular intrahepatic portosystemic shunt. Heparin was discontinued. The patient was subsequently transferred to the general nursing floor for further observation where the patient did extremely well. The patient did not show any signs of return of encephalopathy or fluid overload. The patient's regimen consisted of Aldactone 100 mg by mouth once per day, Lasix 40 mg by mouth once per day, as well as fluid restriction, lactulose, and multivitamins. From a cirrhosis point of view, the patient had a successful transjugular intrahepatic portosystemic shunt revision; status post angioplasty of transjugular intrahepatic portosystemic shunt and coiling of spontaneous splenorenal shunt. Liver function tests were followed daily. The patient was followed by the Liver Service. 2. HEMATOLOGIC ISSUES: Anemia and thrombocytopenia were stable. The patient did not show any evidence of active bleed. The thrombocytopenia was likely secondary to splenic sequestration and was stable. 3. INFECTIOUS DISEASE ISSUES: The patient was placed on ciprofloxacin 500 mg by mouth every day for spontaneous bacterial peritonitis prophylaxis. 4. RENAL ISSUES: Hyponatremia was stable; most likely secondary to end-stage liver disease/ascites/total body sodium overload. A stable level for the patient. Normal renal function with good urine output. 5. PULMONARY ISSUES: The patient was stable with normal oxygen saturations. 6. DIABETES ISSUES: The patient was managed with a regular insulin sliding-scale. 7. PROPHYLAXIS ISSUES: For prophylaxis the patient was put on a proton pump inhibitor, pneumo boots, as well as ciprofloxacin for spontaneous bacterial peritonitis prophylaxis. DISCHARGE DISPOSITION: On [**2166-6-13**] the patient had a repeat renal ultrasound which showed good flow through the transjugular intrahepatic portosystemic shunt. The patient was discussed with the Liver Service and was discharged to home with close followup in the Liver Clinic two weeks status post discharge. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: Discharge status was to home. DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed. 2. Thrombocytopenia. 3. Alcoholic liver cirrhosis. 4. Portal hypertension. 5. Encephalopathy. 6. Anemia. 7. Decreased patency of original transjugular intrahepatic portosystemic shunt; status post revision with good flow. MEDICATIONS ON DISCHARGE: 1. Pantoprazole 40 mg by mouth once per day. 2. Multivitamin. 3. Thiamine. 4. Folic acid 1 mg by mouth once per day. 5. Lactulose 30 mL by mouth three times per day (titrate to three bowel movements once per day). 6. Spironolactone 100 mg by mouth once per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up in the Liver Clinic in one to two weeks after discharge. The patient was to call and make this appointment. [**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**] Dictated By:[**Name8 (MD) 4937**] MEDQUIST36 D: [**2166-6-13**] 15:07 T: [**2166-6-21**] 09:35 JOB#: [**Job Number 48097**]

[ "285.1", "287.5", "996.1", "789.5", "571.2", "578.9", "572.2", "070.54", "303.90" ]

icd9cm

[ [ [] ] ]

[ "39.50", "39.79", "45.13" ]

icd9pcs

[ [ [] ] ]

8140, 8444

3070, 3107

8564, 8821

8847, 9116

2790, 3052

9150, 9567

5151, 8116

8459, 8543

192, 1919

1941, 2764

3124, 5117

8,984

165,279

28545

Discharge summary

report

Admission Date: [**2126-10-25**] Discharge Date: [**2126-11-5**] Date of Birth: [**2087-8-22**] Sex: F Service: MEDICINE Allergies: Dilantin Attending:[**First Name3 (LF) 1377**] Chief Complaint: RP Bleed Major Surgical or Invasive Procedure: Angiography with embolectomy History of Present Illness: 39 F w/ ETOH cirrhosis, Child's C w/ recent admission ([**Date range (1) **]) from a massive UGI bleed sp TIPS [**8-6**] and epi injection of a bleeding gastric ulcer, known esophageal varices, portal gastropathy, portal hypertension with ascites, splenomegaly/thrombocytopenia trasnferred from OSH with several falls, abd pain and Hct 20. Has been drinking since admission and fell down 7 steps 2 days prior to admission without seeking medical attention. On Thursday she was intoxicated and standing up in kitchen and slipped and fell on water, she remembers little else although has had abdominal pain since. She denies fevers but tachycardic, lactate 3.5 and has a history of recent pneumonia at [**Hospital1 **] and h/o MRSA PNA in [**8-7**] so was given Vanc/levo/flagyl in ED. Blood pressure stable 130's in ED. She is coagulopathic from intrinsic liver disease. . Surgery was consulted in the ED for RP bleed seen on CT and possible active bleeding but given extent of liver disease and area of bleed felt that she was an undesirable candidate and that she should be monitored in the MICU with possible need for serial scans. In the ED she received 1 unit pRBCs at OSH, 4 units FFP, and Vit K 10 sc x 1 at [**Hospital1 18**] ED. Hepatology aware of patient. Past Medical History: ETOH cirrhosis, Child's class B to C esophageal varices/portal hypertension portal gastropathy ascites splenomegaly/thrombocytopenia Esophagitis Bipolar Disorder PTSD PUD Chronic Diarrhea Social History: Lives with a friend, divorced, [**Name2 (NI) 69144**] mother of two. 2 L Vodka/day, occasional tobacco. Family History: Father died age 50 of MI. Mother alive and well. No fam hx of ETOH or liver disease. Physical Exam: Vitals: HR 166 BP 121/53 RR 18 95%/2L n.c. Gen: awake, oriented, tremulous, mild discomfort HEENT: Pupils equal, round, dilated, reactive, icteric sclera, OP clear, MM dry Neck: prominent carotid pulse, JVP ?8cm CV: Regular, tachycardic, systolic murmur Pulm: bibasilar crackles L>R Abd: Normoactive bowel sounds, firm area on right side of abdomen otherwise soft, distended, palpable spleen tip, voluntary guarding right sided, no rebound Ext: WWP, no edema skin: mult spider angiomas on chest, no caput medusa guaiac: negative in ED Pertinent Results: [**2126-10-25**] 05:14PM GLUCOSE-127* UREA N-5* CREAT-0.4 SODIUM-136 POTASSIUM-3.1* CHLORIDE-95* TOTAL CO2-34* ANION GAP-10 [**2126-10-25**] 05:14PM CALCIUM-7.6* PHOSPHATE-2.8 MAGNESIUM-2.3 [**2126-10-25**] 05:14PM HCT-21.8* [**2126-10-25**] 05:14PM PLT COUNT-30* [**2126-10-25**] 05:14PM PT-19.8* INR(PT)-1.9* [**2126-10-25**] 05:14PM FIBRINOGE-122* [**2126-10-25**] 04:30AM GLUCOSE-153* UREA N-5* CREAT-0.6 SODIUM-136 POTASSIUM-3.0* CHLORIDE-92* TOTAL CO2-35* ANION GAP-12 [**2126-10-25**] 04:30AM ALT(SGPT)-25 AST(SGOT)-79* ALK PHOS-89 TOT BILI-11.6* [**2126-10-25**] 04:30AM CALCIUM-8.1* PHOSPHATE-2.8 MAGNESIUM-1.6 [**2126-10-25**] 04:30AM WBC-5.5 RBC-2.06* HGB-7.5* HCT-20.2* MCV-98# MCH-36.2* MCHC-37.0* RDW-24.0* [**2126-10-25**] 04:30AM PLT COUNT-60* [**2126-10-25**] 04:30AM PT-18.6* PTT-34.2 INR(PT)-1.8* [**2126-10-25**] 12:35AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.032 [**2126-10-25**] 12:35AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-12* PH-6.5 LEUK-NEG [**2126-10-25**] 12:35AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [**2126-10-24**] 11:17PM LACTATE-3.5* [**2126-10-24**] 10:55PM GLUCOSE-131* UREA N-4* CREAT-0.5 SODIUM-136 POTASSIUM-3.3 CHLORIDE-92* TOTAL CO2-32 ANION GAP-15 [**2126-10-24**] 10:55PM estGFR-Using this [**2126-10-24**] 10:55PM ALT(SGPT)-34 AST(SGOT)-115* CK(CPK)-118 ALK PHOS-104 AMYLASE-50 TOT BILI-12.6* DIR BILI-4.0* INDIR BIL-8.6 [**2126-10-24**] 10:55PM LIPASE-21 [**2126-10-24**] 10:55PM CK-MB-4 [**2126-10-24**] 10:55PM ALBUMIN-3.2* [**2126-10-24**] 10:55PM WBC-8.0 RBC-2.00*# HGB-7.7* HCT-21.2* MCV-106*# MCH-38.7*# MCHC-36.4* RDW-22.1* [**2126-10-24**] 10:55PM WBC-8.0 RBC-2.00*# HGB-7.7* HCT-21.2* MCV-106*# MCH-38.7*# MCHC-36.4* RDW-22.1* [**2126-10-24**] 10:55PM NEUTS-70.6* LYMPHS-21.7 MONOS-5.0 EOS-1.8 BASOS-0.8 [**2126-10-24**] 10:55PM ANISOCYT-3+ POIKILOCY-1+ MACROCYT-3+ [**2126-10-24**] 10:55PM PLT COUNT-69* [**2126-10-24**] 10:55PM PT-19.5* PTT-37.1* INR(PT)-1.9* . CT Abd/Pelv [**10-25**]: Very large acute retroperitoneal hemorrhage 23 x 10 x 10 cm. There may be active bleeding vs acute blood products. Very distended gallbladder without signs of cholecystitis. . CT Abd/Pelv [**10-28**]: IMPRESSION: 1. Slight decrease in size in retroperitoneal hematoma. No new hematoma identified. 2. Worsening diffuse anasarca. Worsening bilateral effusions and findings consistent with congestive heart failure. 3. Multifocal patchy areas of ground glass opacity in both lungs, most likely representing infection. Differential diagnosis includes asymmetric pulmonary edema. 4. Bilateral lower lobe atelectasis or consolidation. . CT Head [**10-25**]: No evidence for hemorrhage or fracture. . CT C spine [**10-25**]: No evidence for cervical spine fracture or malalignment. A 2-mm right upper lobe lung nodule. A dedicated chest CT is recommended to evaluate for other nodules. . CXR [**10-27**]: Bibasilar atelectasis Brief Hospital Course: Pt was admitted to the MICU for care. RP Bleed: A repeat CTA was peformed and continuing bleed was identified. The patient went to angiography with IR and had two lumbar arteries (L1, L3) embolized. Her hematocrits stablized after embolization. Received a total of 10 U pRBC and 6 bags of platelets during hospital course. Repeat CT of abdomen showed stable size of RP hematoma. Hct remained stable and pt transferred to medical floor where Hct continued to remain stable, not requiring additional transfusions of pRBCs. The pt did have fevers during this time and underwent infectious work-up which was negative (see below). It was thought that the fevers were secondary to the resolving large RP hematoma. Placed on prn oxycodone for pain around site of hematoma with good effect. Fevers: During the hospitalization, the patient had intermittent fevers. She was started on vancomycin and flagyl for presumed aspiration pneumonia in the MICU. Cultures for sputum were sent and grew MRSA. The patient was treated for MRSA in sputum with 7 day course of vancomycin. However, CXR was negative for pneumonic process. The flagyl was discontinued and was placed on levaquin for SBP prophylaxis. Upon transfer to the floor, the pt continued to have intermittent fevers. CT abdomen did not reveal enough ascites to be tappable. Urine and blood cultures were all negative. Did not suspect meningitis given lack of other clinical symptoms that would suggest meningitis. On review of pt's most recent discharge summary, it was noted that the patient had intermittent fevers upon her most recent hospitalization in which a source was never identified. There was a question of drug fever on the prior admission. The pt continued to have occasional low grade fevers by the time of discharge, however her fever curve had trended down. It was thought that the major contributor to the fevers was likely the result of her large resolving retroperitoneal hematoma. Hyponatremia: During the MICU course, the patient's sodium fell from normal limits to a nadar of 123. Free water fluids were held and urine lytes were sent. Spironolactone and other diuretics were also held. Urine lytes were consistent with a cirrhotic cause to her hypervolumic hypernatremia. On transfer to the medical floor, diuretics were continued to be held and patient was placed on a 1L free water restriction with improvement in sodium. The pt never exihibited any neurologic compromise [**1-3**] hyponatremia. . ETOH cirrhosis: Child's Class C, MELD score 24. History of esophageal varices, portal gastropathy, portal HTN with ascites, s/p TIPS [**8-6**]. Is not a liver transplant candidate because of continued ETOH use. - Ascites: Held lasix and spirinolactone given hyponatremia. - Esophageal varices: Propranolol 20 TID. - Encephalopathy: Lactulose 30 [**Hospital1 **] - Nutrition: Folate, Thiamine, Iron. Performed nutrition calorie counts which showed intake of approximately 1000 kcal per day that were recorded. As suspected that pt's total intake was not accurately recorded, was not initiated on tube feeds. Continued to encourage po intake during hospitalization. - Withdrawal: Placed on CIWA scale without any development of withdrawal seizures or DTs. . Thrombocytopenia: Chronic, likely etiology is splenomegaly from liver disease and subsequent thrombocytopenia. While in the MICU, the patient had downward trending platlet counts despite aggressive therapy with platelet transfusions. Hematology was consulted and recommended Winrho. Pt received one dose. Platlet count was stable at 25 prior to leaving the MICU. During stay on medical floor, did not require further platelet transfusions and platelet count recovered to pt's prior baseline. . Depression: Followed by psychiatry service. Per psych, pt does not have a history of bipolar disorder despite prior notes documenting this. Celexa was switched to remeron 7.5 mg qhs and risperdal 0.5 mg [**Hospital1 **] was continued. The pt did have one episode of visual hallucinations during hospital course that was not felt to be related to alcohol withdrawal as pt was already more than 10 days out from her last drink at this point. Per pt, has had auditory hallucinations in the past as well off of risperdal. Risperdal was continued and pt did not have further episodes of visual or auditory hallucinations. . Of note, during the hospital course, the patient attempted to signout AMA while she was still deemed medically unstable (Hct had not stabilized, having intermittent fevers). Seen by psychiatry who deemed pt not competant to make this decision given her lack of insight and judgement. . The patient was followed closely by the SW and CM services while on the medical floor. The pt does have an outside CM through Mass Health. Due to insurance reasons, the patient was unable to qualify for an inpatient alcohol recovery program. The patient was advised to participate in an intensive outpatient 30 day alcohol program; however refused to go directly from hospitalization to the program. Was reevaluated by psychiatry who felt that patient was compentent to make this decision. The patient subsequently signed out AMA. She did express a desire to participate in an outpatient alcohol recovery program that would be arranged in the future with her CM through Mass Health. Medications on Admission: lasix 20mg po qday spironolactone 50mg po qday risperdal 5mg po bid magnesium oxide 900mg po bid celexa 20mg po qday trazodone 150mg po qhs propranolol 20 mg po qday omeprazole 20mg po qday lactulose [**Hospital1 **] (pt holdinf for diarrhea) piroxicam tid levofloxacin (from d/c summary, but pt not taking daily --> completed levoflox treatment for PNA last week, though) Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). Disp:*1800 ML(s)* Refills:*2* 2. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 4. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. 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* 8. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:*15 Tablet(s)* Refills:*2* 9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for R flank pain. Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Retroperitopneal bleed s/p embolization of lumbar artery Alcoholic Intoxication Alcoholic Cirrhosis . Secondary Diagnosis: Depression Thrombocytopenia Coagulopathy Gastric ulcer PTSD Discharge Condition: Stable. Eating regular diet. Breathing well on room air. Discharge Instructions: You were admitted with alcohol intoxication and a very low blood count secondary to a large retroperitoneal bleed. You had 2 arteries in your back embolized. You also were detoxed from alcohol. You were discharged from the hospital against medical advice. You will need to follow closely with your Mass Health case manager to make arrangements for placement in a alcoholic day program. Please take all of your medications as prescribed. It is very important that you continue to abstain from alcohol to prevent further damage to your liver and other organs. If you do not do this, the risks include further liver damage, liver failure, and possibly death. Please call your doctor or return to the emergency room if you experience any of the following: fever > 101, chills, night sweats, increased abdominal pain, lightheadedness. Followup Instructions: Please follow-up with your primary care doctor within 1 week of discharge. Please follow-up with your MassHealth case manager within [**1-4**] days of discharge. It is very important that you participate in AA mtgs and an outpatient alcoholic day program. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**] Completed by:[**2126-11-6**]

[ "868.04", "572.2", "311", "572.3", "284.8", "E885.9", "537.89", "303.01", "571.2", "309.81", "V09.0", "456.21", "780.6", "291.81", "789.5", "507.0", "276.1", "785.0", "571.1" ]

icd9cm

[ [ [] ] ]

[ "99.05", "99.07", "38.93", "39.79", "99.04" ]

icd9pcs

[ [ [] ] ]

12536, 12542

5650, 10978

279, 309

12788, 12847

2623, 5627

13730, 14141

1964, 2051

11402, 12513

12563, 12563

11004, 11379

12871, 13707

2066, 2604

231, 241

337, 1612

12705, 12767

12582, 12684

1634, 1824

1841, 1947

59,807

152,977

2666

Discharge summary

report

Admission Date: [**2114-8-1**] Discharge Date: [**2114-8-21**] Service: MEDICINE Allergies: Lipitor / Bactrim Attending:[**First Name3 (LF) 1515**] Chief Complaint: bradycardia Major Surgical or Invasive Procedure: [**2114-8-3**] - Implantation of permanent pacemaker [**2114-8-7**] - CoreValve (aortic valve) placement History of Present Illness: This is a 89 year-old Female with a PMH significant for CAD (with 2-VD on cardia cath without PCI, s/p NSTEMI in [**2111**]), history of systolic CHF (now EF 60%), HTN, HLD, severe aortic stenosis (AV gradient 44 mmHg, [**Location (un) 109**] 0.56 cm^2 with valvuloplasty performed [**1-/2114**]), MR, dementia, hypothyroidism who was recently scheduled for CoreValve placement (on [**2114-7-31**]) but this was post-poned given that she experienced a mechanical fall from her wheelchair on presentation to the hospital. Her walker slipped backward and her head hit the floor. A CT head was negative. Her procedure was re-scheduled for [**2114-8-7**], but she presented to [**Hospital 10478**] [**Hospital3 **]'s ER on [**2114-8-1**] for a syncopal episode and she was found to be in sinus bradycardia with HR in the 50s. . This AM the patient's VNA noted that the patient had some abdominal discomfort. She started to feel better and went to move her bowels at 11AM and during Valsalva she developed lightheadedness and pre-syncopal concerns without LOC or head injury. EMS responded and the patient was evaluated at [**Hospital3 13313**] ED where her labs were reassuring, but she had episodes of sinus bradycardia to the 50s. She was without further lightheadedness, dizziness or chest pain. . Of note, she was initially thought to be too fragile and her dementia too severe for her to unfergo CoreValve placement, but by her [**2114-7-6**] appointment with Dr. [**Last Name (STitle) 914**], she had markedly improved and was reconsidered for the CoreValve procedure. . The patient's most recent hospital admission was on [**2114-6-27**] to the [**Hospital1 18**] ED for chest pain attributed to demand ischemia from her severe aortic stenosis. She was discharged on [**2114-6-29**] with her previous cardiac medications and the addition of Lasix 20 mg PO twice daily. . On arrival to the floor, the patient is without chest pain or trouble breathin. She has no nausea or vomiting, no abdominal complaints. She denies lightheadedness or dizziness. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or pre-syncope. . ROS: The patient denies a history of prior stroke/TIA, deep venous thrombosis or pulmonary embolus. They deny bleeding at the time of prior procedures or surgeries. Denies headaches or vision changes. No cough or upper respiratory symptoms. Denies chest pain, dizziness or lightheadedness; no palpitations. Denies shortness of breath. No nausea or vomiting, denies abdominal pain. No dysuria or hematuria. No change in bowel movements or bloody stools. Denies muscle weakness, myalgias or neurologic complaints. No exertional buttock or calf pain. Past Medical History: CARDIAC HISTORY: CAD, Hyperlipidemia, Hypertension * CABG: None * PERCUTANEOUS CORONARY INTERVENTIONS: s/p several cardiac caths in the past without PCI (2-VD disease on [**2113-11-2**]) * PACING/ICD: None . PAST MEDICAL & SURGICAL HISTORY: 1. Coronary artery disease (s/p several cardiac caths - most recent [**2113-11-2**]); s/p NSTEMI ([**1-/2112**]) 2. Severe aortic stenosis (AV gradient 44 mmHg, [**Location (un) 109**] 0.56 cm^2 with valvuloplasty performed [**1-/2114**]; 2D-Echo showing [**Location (un) 109**] < 0.8 cm^2 ([**3-/2114**]) 2. Hyperlipidemia 3. Hypertension 4. Moderate mitral regurgitation (on 2D-Echo [**3-/2114**]) 5. (?) Chronic systolic congestive heart failure (2D-Echo [**3-/2114**] showing improved EF 60%) 6. Chronic iron deficiency anemia (baseline HCT 28-30%) 7. Chronic renal insufficiency (baseline creatinine 1.8) 8. Recurrent urinary tract infections (on suppressive therapy) 9. Hypothyroidism 10. Hepatitis C infection (inactive, contracted from prior blood transfusions; normal LFTs with preserved hepatic function) 11. Dementia 12. h/o back and neck surgeries 13. h/p right shoulder reconstruction 14. h/o TIA (not clear if TIA vs. stroke occurred; periventricular white matter disease) 15. GERD, reflux esophagitis Social History: Patient lives at home by herself; and recently had moved from an [**Hospital3 **] facility. Denies tobacco use (never smoker) or alcohol use; no recreational substance use. Ambulates with a walker. Cooks for herself and has four children. Support from her two daughters. [**Name (NI) **] a life line at home. Family History: Denies family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM VITALS: 97.8 195/66 54 18 96%RA GENERAL: Appears in no acute distress. Alert and interactive. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. No xanthalesma. NECK: supple without lymphadenopathy. JVD at low-neck while at 30-degrees. CVS: PMI located in the 5th intercostal space, mid-clavicular line. Regular rate and rhythm, 4/6 systolic ejection murmur peaking early with radiation to the carotids; no rubs or gallops. S1 and S2 normal. No S3 or S4. RESP: Respirations unlabored, no accessory muscle use. Clear to auscultation bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. Stable inspiratory effort. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses DERM: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs 2+ throughout, strength 5/5 bilaterally, sensation grossly intact. Gait deferred. PULSE EXAM: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE PHYSICAL EXAM Vitals - Tm/Tc:98.1/98.1 HR: 59-60 BP: 133-172/69-71 RR: 18 02 sat: 97% 2L NC In/Out: 1540/inc Weight: 61.4 (63.2) GENERAL: 89 yo F in no acute distress, lying in bed HEENT: Right IJ line in place. OP clear. CHEST: Poor air movement bilaterally. Crackles 1/2 up on left, unable to assess right, no wheezes or cough. CV: S1 S2 Normal in quality and intensity RRR, 2/6 systolic soft murmur at LSB. ABD: soft, slight TTP in b/l lower quadrants, non-distended, BS normoactive. no rebound/guarding. EXT: wwp, no edema. DPs, PTs 2+. Neuro: left side slighly stronger, [**1-20**] from [**12-23**]. Speech garbled at times but can blurt out coherant sentence. Cleared for PO's by speech therapy. Pertinent Results: ADMISSION LABS [**2114-8-2**] 06:30AM BLOOD WBC-7.2 RBC-3.01* Hgb-9.5* Hct-27.6* MCV-92 MCH-31.5 MCHC-34.3 RDW-13.8 Plt Ct-161 [**2114-8-4**] 06:45AM BLOOD WBC-6.8 RBC-3.01* Hgb-9.6* Hct-26.8* MCV-89 MCH-32.0 MCHC-35.9* RDW-14.2 Plt Ct-154 [**2114-8-4**] 06:45AM BLOOD Neuts-68.7 Lymphs-20.2 Monos-6.4 Eos-4.4* Baso-0.3 [**2114-8-2**] 06:30AM BLOOD PT-13.4 PTT-27.2 INR(PT)-1.1 [**2114-8-7**] 10:28AM BLOOD Fibrino-266 [**2114-8-2**] 06:30AM BLOOD Glucose-102* UreaN-40* Creat-1.6* Na-137 K-3.6 Cl-103 HCO3-25 AnGap-13 [**2114-8-6**] 09:00AM BLOOD ALT-9 AST-16 CK(CPK)-24* AlkPhos-50 TotBili-0.3 [**2114-8-2**] 06:30AM BLOOD CK-MB-2 cTropnT-0.02* [**2114-8-6**] 09:00AM BLOOD CK-MB-2 proBNP-3184* [**2114-8-2**] 06:30AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.4 [**2114-8-10**] 04:23AM BLOOD %HbA1c-5.4 eAG-108 [**2114-8-10**] 04:23AM BLOOD Triglyc-95 HDL-35 CHOL/HD-3.6 LDLcalc-73 LDLmeas-71 [**2114-8-2**] 06:30AM BLOOD TSH-8.1* [**2114-8-2**] 06:30AM BLOOD Free T4-1.1 . DISCHARGE LABS: [**2114-8-21**] 09:28AM BLOOD WBC-9.0 RBC-3.10* Hgb-9.6* Hct-29.8* MCV-96 MCH-30.9 MCHC-32.2 RDW-15.4 Plt Ct-189 [**2114-8-21**] 09:28AM BLOOD Glucose-125* UreaN-40* Creat-2.1* Na-145 K-3.4 Cl-113* HCO3-20* AnGap-15 . MICROBIOLOGY [**2114-8-13**] URINE CX (final): NO GROWTH [**2114-8-13**], [**2114-8-15**] BLOOD CX (final): NO GROWTH . EKG ([**2114-8-1**]): sinus bradycardia to 50s, NI/LAD, no ST-changes . 2D-ECHO ([**2114-7-6**]): The left atrium is moderately dilated. The right atrium is moderately dilated. Moderate symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function (LVEF > 55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP > 18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta and aortic arch are mildly dilated. The aortic valve leaflets (3) are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-19**]+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . CARDIAC CATH ([**2114-2-8**]): There was severe pulmonary hypertension with a PCWP = 30 mmHg. Using rapid ventricular pacing at 180 bpm tow inflations were performed using a 22 x 6-cm balloon. This resulted in an improvement of the aortic valve area from 0.56 cm^2 to 0.86 cm^2 and a reduction of the mean gradient from 44 mmHg to 27 mmHg. Echocardiography showed 1+ AI with valvular excursion improved from the baseline images. Estimated blood loss < 100cc. The procedure was performed from the right femoral artery using [**Month/Day/Year 1106**] ultrasound guidance and a Preclose technique with a single Perclose device. . IMAGING: [**2114-7-30**] CT HEAD W/O CONTRAST - There is no evidence of hemorrhage, edema, or shift of the midline structures. There is small vessel ischemic disease as evidenced by periventricular and right thalamic hypodensities. Prominence of the ventricles and sulci is normal for age. Carotid [**Month/Day/Year 1106**] calcifications are noted. The mastoid air cells are well pneumatized. The imaged paranasal sinuses are normal. No suspicious osseous lesions or fractures. . [**2114-8-3**] CXR - New left chest wall pacer with transsubclavian leads extending to expected locations in RA and RV. However, there is a new 2-cm left apical PTX. No pulmonary edema or new focal consolidations. No effusion. Stable cardiomegaly. . [**2114-8-4**] CXR - Roughly 3-cm apical left PTX noted to the level of the 5th rib (or 4th intercostal space); preliminary report pending . [**2114-8-8**] CHEST (PORTABLE AP): The left chest tube has been removed. There is no evidence of residual pneumothorax. No other changes as compared to the previous examination. . [**2114-8-16**] CAROTID LMTD/ DPP: The patient was moving and central lines only on the left side were evaluated. The left carotid artery shows velocities 73, 71, 134 in the ICA, CCA, ECA respectively. The ICA/CCA ratio is 1. This is consistent with less than 40% stenosis. Antegrade flow in the left vertebral artery. . [**2114-8-18**] CT HEAD W/O CONTRAST: There is no acute intracranial hemorrhage, edema, mass effect, or acute territorial infarction. There are chronic lacunar infarcts in the basal ganglia, left greater than right. Moderate confluent centrum semiovale and periventricular hypodensities consistent with sequela of chronic small vessel disease. There are only mild age-related involutional changes. Paranasal sinuses are clear. The mastoid air cells are underdeveloped on the left side. No mastoid opacification. . [**2114-8-18**] CHEST (PA & LAT): The patient is after recent transarterial aortic valve replacement. The replaced valve appears to be in expected position. Cardiomediastinal silhouette is unchanged. Patient is in mild interstitial pulmonary edema that appears to be improved since the prior study. There is also slight interval improvement in bibasal atelectasis and pleural effusion. Right internal jugular line tip is at the proximal right atrium and might be pulled back for approximately 1.5/2 cm to secure its position above the cavoatrial junction. Brief Hospital Course: 89F with a PMH significant for CAD (with 2-VD on cardia cath without PCI, s/p NSTEMI in [**2111**]), history of systolic CHF (now EF 60%), HTN, HLD, severe aortic stenosis (AV gradient 44 mmHg, [**Location (un) 109**] 0.56 cm^2 with valvuloplasty performed [**1-/2114**]), MR, dementia, hypothyroidism with complicated hospital course prior to and after CoreValve placement on [**2114-8-7**]. # SEVERE AORTIC STENOSIS s/p CoreValve placement - She had severe/critical aortic stenosis with her most recent valvuloplasty procedure ([**2114-2-8**]) showing improvement of the aortic valve area from 0.56 cm^2 to 0.86 cm^2 and a reduction of the mean gradient from 44 mmHg to 27 mmHg following valvuloplasty. However, she remained symptomatic for some time from her critical aortic stenosis with progression to congestive heart failure. She underwent successful placement of CoreValve on [**2114-8-7**]. Her CoreValve procedure on [**2114-8-7**] was complicated by a CVA (see below). . # CORONARIES - The patient presents with known 2-vessel disease with her last coronary angiography showing LMCA with minimal irregularities, LAD with 50% origin stenosis and 40% mid-vessel stenosis, LCx showing minor irregularities and her RCA showing 90% mid-PDA stenosis (but small). She was also noted to have severe pulmonary artery hypertension with a PASP of 75 mmHg. There was critical aortic stenosis with a mean gradient of 54 mmHg and a calculated [**Location (un) 109**] of 0.5 cm^2 (12/[**2112**]). The patient had prior valvuloplasty at the time of her last cardiac catheterization. The patient was admitted without chest pain or dyspnea. On admission, her EKG was stable showing sinus bradycardia, NI/LAD, and no ST-changes. Troponin was negative, per the outside hospital report. We continued her medical optimization with Aspirin 81 mg PO daily and Pravastatin 40 mg PO daily. She was monitored via telemetry. # Chronic diastolic heart failure - Her carvedilol was increased and her lasix dose was changed to 20mg daily. Most recent ECHO from [**2114-8-14**] showed mild symmetric left ventricular hypertrophy with normal left ventricular cavity size and normal regional left ventricular wall motion. LVEF>55%. Right ventricular chamber size and free wall motion was normal. An aortic CoreValve prosthesis was visualized with normal transaortic gradient for this prosthesis. . # Sinus bradycardia s/p pacemaker placement complicated by pneumothorax and hematoma- The patient's syncopal episode was attributed to symptomatic sinus bradycardia (new onset) versus a vasovagal response. On [**8-3**] she underwent pacemaker placement (mode: DDD) that was complicated a minimal amount of local hematoma which resolved with a compression dressing. This was achieved via a left subclavian approach and the patient was noted to develop a new oxygen requirement following the procedure with CXR showing a small apical pneumothorax. She eventually required revision of her pacer pocket procedure on [**8-6**] which was successful, given some concerns for pacer pocket hematoma and bleeding. She did require placement of a left pigtail catheter (chest tube) for decompression of her apical PTX on [**8-6**] prior to her CoreValve procedure. She had no further rhythm issues after this. . # CEREBROVASCULAR ACCIDENT: The patient's CoreValve procedure on [**2114-8-7**] was complicated by a CVA, resulting in left sided UMN pattern facial droop and and UMN pattern of left arm weakness, and difficulty swallowing. On [**8-15**], she was noted to have new left-sided hemianopia, with a non-contrast head CT showing no evidence of acute intracranial processes. Carotid ultrasound was done, but was a difficult study, showing 40% stenosis on the left, and unable to assess on the right. The patient was initially given nutrition through an NG tube until she passed speech and swallow. . # PNEUMONIA: Following her CoreValve procedure and CVA, the patient was noted to be febrile with evidence of a left lower lobe pneumonia on chest x-ray. She was treated with intravenous metronidazole, cefepime and vancomycin for an 8-day course for a hospital-acquired pneumonia, likely secondary to aspiration. . # HYPOTHYROIDISM - Prior to admission, the patient's last TSH was 4.5 (slightly elevated) and she has been on Levothyroxine 50 mcg PO daily. She presented with no overt symptoms of inappropriate replacement. She was continued on her home dose. Given her bradycardia, her TSH as rechecked and was elevated at 8.1. We increased her Levothyroxine dose to 75 mcg PO daily. She will need her TFTs rechecked in [**2-21**] weeks following her surgery. . # CHRONIC RENAL INSUFFICIENCY - The patient presented with a baseline creatinine in the 1.6-1.7 range; her admission creatinine was stable at 1.6 and was trended closely. We renally dosed her medications and avoided nephrotoxins. . # NORMOCYTIC ANEMIA - The patient presented with evidence of a chronic, normocytic anemia, with baseline hemoglobin in the range of 8.3-10 g/dL. Given her recent Left sublavian access site with oozing where her pacer was placed, her hematocrits were serially monitored and she required 2 units of packed RBCs this admission (see above), until her pacer pocket revision procedure on [**2114-8-6**]. Hemoglobin 9.6 on the day of discharge. . # HYPERLIPIDEMIA - We continued her Pravastatin 40 mg PO daily. . # DEMENTIA - Per her daughters, her baseline mental status was stable with no changes reported, per her daughters. She remained alert and oriented to time, place and self. We continued her home dosing of Respirdone and Donepezil. . # GERD - We initially continued her Omeprazole 20 mg PO daily and then discontinued secondary to plavix therapy. . TRANSITION OF CARE ISSUES: 1. Recheck TSH in [**2-21**] weeks, following dose increase from Levothyroxine 50 to 75 mcg PO daily given her elevated TSH of 8.1 and bradycardia. Medications on Admission: 1. Donepezil 10 mg PO QHS 2. Levothyroxine 50 mcg PO daily 3. Omeprazole 20 mg EC PO daily 4. Aspirin 81 mg PO daily 5. Ferrous sulfate 300 mg (60 mg iron) PO daily 6. Carvedilol 6.25 mg PO BID 7. Respirdone 0.25 mg PO QHS 8. Calcium carbonate 200 mg calcium (500 mg) 1 tab PO TID PRN dyspepsia 9. Senna 8.6 mg PO BID 10. Pravastatin 40 mg PO daily 11. Vitamin D 1,000 unit capsule PO daily 12. Cranberry Concentrate capsule PO daily 13. Lasix 20 mg PO BID Discharge Medications: 1. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: Five (5) mL PO DAILY (Daily). 5. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed for dyspepsia. 7. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. Disp:*60 Tablet(s)* Refills:*0* 8. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Cranberry Concentrate Capsule Sig: One (1) Capsule PO once a day. 11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day: Hold if SBP<100. Disp:*30 Tablet(s)* Refills:*0* 12. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day: Hold if SBP<100. Disp:*60 Tablet(s)* Refills:*0* 13. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 14. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Hold if SBP<100. Disp:*60 Tablet(s)* Refills:*0* 15. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for fever or pain: Not to exceed 10 tablets/day. Disp:*30 Tablet(s)* Refills:*0* 17. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 18. Outpatient Lab Work Please checked chemistry panel of labs on Thursday, [**8-22**]. Have results faxed to Dr. [**Last Name (STitle) 713**] (fax: [**Telephone/Fax (1) 716**], phone: [**Telephone/Fax (1) 719**]), who will adjust medications as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Primary Diagnoses: 1. Severe, symptomatic aortic stenosis, now status-post CoreValve Placement on [**2114-8-7**]. 2. Coronary artery disease 3. Hypertension 4. Sinus bradycardia 5. Left apical pneumothorax 6. Aspiration Pneumonia, now status-post 8-day treatment with broad-spectrum antibiotics. . Secondary Diagnoses: 1. Hyperlipidemia 2. Moderate mitral regurgitation 3. Chronic renal insufficiency Discharge Condition: Mental Status: Clear and coherent, though waxes and wanes (baseline). Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Patient Discharge Instructions: Ms. [**Known lastname 5700**], You were admitted to the [**Hospital1 1516**] Cardiology-Internal Medicine service at [**Hospital1 69**] on [**Hospital Ward Name 121**] 3 regarding management of your heart issues. You were transferred from [**Hospital3 13313**] given your concerns of fainting as well as a resting heart rate that was in the low 40-50 range. You remained asymptomatic since this transfer. . While hospitalized here, your cardiac medications, including blood pressure therapy, were optimized. You had a pacemaker placed [**2114-8-3**] without issues or complications, and this was functioning well at the time of discharge. . You also underwent CoreValve placement for severe aortic stenosis on [**2114-8-7**]. You were transferred to the Cardiac Critical Care service for observation after the procedure. As a complication of this procedure, you may have suffered an embolic stroke, which is when something like a clot or calcification travels up your arteries and restricts blood flow to parts of your brain. However, consultation with the stroke specialists and imaging of your brain showed no acute findings for which we would have intervened. . Also during this hospitalization, you developed some trouble with swallowing food and liquids, possibly related to the stroke signs and symptoms described above. We had to insert a plastic tube through your nose into your stomach multiple times, in order to feed you and give you your medications. We believe that this difficulty swallowing may have led to some food or gastric fluid dropping into your lung, causing a pneumonia for which we treated you with strong antibiotics for 8 days. After you passed an evaluation by our speech and swallow team, your feeding tube was removed, and you were able to take an oral diet. . At discharge, you were in stable condition, with no fever or new signs/symptoms. . Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * Worsening swelling in your legs or a weight gain of 3 lbs or more, fatigue or excessive weakness. * 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 the following medications: You should START: Amlodipine 10mg daily (for blood pressure) You should START: Carvedilol 25mg PO twice-daily (for blood pressure) You should START: Clopidogrel 75mg daily (to prevent complications of CoreValve). **THIS MEDICATION SHOULD BE CONTINUED FOR THREE MONTHS.** You should START: Furosemide(Lasix) 20mg daily (for blood pressure) . * The following medications were DISCONTINUED on admission and you should NOT resume: DISCONTINUE: Carvedilol 6.25mg twice daily (changed to increased dose above) DISCONTINUE: Furosemide(Lasix) 20mg twice daily (changed to decreased dose above) . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Thank you for allowing us to participate in the care of your medical needs during this time. Followup Instructions: Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2114-9-12**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage . Department: GERONTOLOGY When: TUESDAY [**2114-9-18**] at 12:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2114-8-30**] 10:30 . Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2114-8-30**] 11:15 . Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2114-9-7**] 9:00 . Department: CARDIAC SERVICES When: FRIDAY [**2114-9-7**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2136-10-16**] Discharge Date: [**2136-11-1**] Date of Birth: [**2063-8-19**] Sex: M Service: MEDICINE Allergies: Cephalosporins / Clindamycin / Iodine-Iodine Containing Attending:[**First Name3 (LF) 1377**] Chief Complaint: Lethargy. Major Surgical or Invasive Procedure: Central venous line placement [**2136-10-16**]. PICC placement [**2136-10-20**]. History of Present Illness: Mr. [**Known lastname **] is a 73-year-old male with a history of obesity and metabolic syndrome with cryptogenic cirrhosis s/p TIPS [**2136-10-12**] who now presents with few dasy of lethargy. Pt reports sudden onset of chills and shakes when he awoke suddenly this am. He was then unable to lift himself off the toilet requiring EMS to be called. He denies feeling febrile or any n/v/d. He also denies any CP or SOB. He has had a mild dry cough and has noticed some mild lower abd distension. . He was recently hospitalized from [**10-12**] - [**2136-10-13**], during which he had a 6L paracentesis and 50g of 5% albumin was given. TIPS was placed on [**10-12**] for GI bleeding and ascites given patient is not a transplant candidate; he had been requiring Q2-4 weeks transfusions. Baseline SBP is in the 90's. . In ED VS were T 99.1 BP: 87/34 HR: 65 RR: 16 O2Sat: 98% RA. He was transferred from an OSH ED where he was started on unasyn/flagyl for presumed sepsis. In the [**Hospital1 18**] ED BP 70-80's systolic. A central line was placed and he was started on levophed and given 2-3L NS boluses. Spiked to 102.6. ABX broadended to include Vanc and Zosyn. TIPS found to be patent on u/s. Labs notable for lactate 2.7 with normal WBC ct. CXR with low lung volumes, prominent perihilar vasculature and R pleural effusion. Past Medical History: -cryptogenic cirrhosis; c/f NASH -TIPS placed [**2136-10-12**] -obesity -type 2 diabetes -dyslipidemia -hypertension -chronic leg edema -history of carcinoma in situ of the anal canal s/p resection at [**Hospital1 112**] 10-12 years ago, no recurrence -peptic ulcer disease/H pylor -spinal stenosis -E. coli urinary tract infection -previous seizures secondary to hypoglycemia -colorectal polyps: last colonoscopy in [**2135**], pt states no polyps -Cdiff colitis -lower extremity cellulitis -profound iron deficiency anemia -2 melanomas s/p resection >10 years ago, no recurrence -s/p laparoscopic cholecystectomy> 12 years ago. Social History: He lives in [**Location 620**] with his wife. [**Name (NI) **] is a retired biology teacher. They spend their summers in their house in Oak Bluff on [**Hospital3 4298**]. They do not have any children. He has a 25-pack year smoking history but quit 35 years ago. He has always had rare alcohol and has not had any alcohol at all since he was diagnosed with cirrhosis. He has had extensive travel abroad to [**Female First Name (un) 8489**], [**Country 480**] and Europe as well as to various other countries. Family History: His father died of old age at 94. A brother had [**Name2 (NI) 499**] cancer and alcoholic cirrhosis. His mother had 2 strokes and died at age 67. A great uncle had diabetes. Physical Exam: Upon admission: VS in the ED: T 99.1 BP: 87/34 HR: 65 RR: 16 O2Sat: 98% RA GA: alert and oriented to [**Hospital1 18**], summer and year. NAD HEENT: PERRLA. MM very dry. no LAD. no JVD. neck supple. RIJ in place. Cards: PMI palpable at 5/6th IC space. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: scattered crackles bilaterally Abd: +BS, soft, NT-ND, no fluid wave, [**3-14**]+ bilateral flank edema Extremities: 3+ bilat LE edema Skin: senile purpura ob upper ext bilaterally Neuro/Psych: AOx3. CNs II-XII intact. 5/5 strength in U/L extremities. Stool: guiac positive per ED At discharge: VS: afeb 102/52 67 16 96 %on RA Gen: elderly male in NAD HEENT: anicteric, EOMI, PERRLA, MMM Neck: JVD elevated at 3cm above sternum, supple, no LAD CV: RRR, no m/r/g Lungs: diffuse crackles bilaterally to mid-upper lung, decreased breath sounds at bases Abdomen: obese, +BS, soft, nontender, nondistended, unable to palpate liver edge, fluid wave not present Ext: wwp, 3+ lower extremity edema bilaterally to mid thigh, dp 2+ bilaterally, multiple areas of skin breakdown and fluid filled vesicles on the calves Neuro: A&Ox3, CN 2-12 intact, moving all five extremities, upper extremities 4/5 strength, lower extremities 3/5 strength, fingert nose intact, no asterixis Pertinent Results: ADMISSION LABS: [**2136-10-16**] 08:10AM BLOOD WBC-7.7# RBC-2.22* Hgb-7.3* Hct-22.8* MCV-103* MCH-32.7* MCHC-31.8 RDW-20.4* Plt Ct-113* [**2136-10-16**] 08:10AM BLOOD Neuts-89* Bands-6* Lymphs-2* Monos-2 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2136-10-16**] 08:10AM BLOOD PT-20.0* PTT-34.8 INR(PT)-1.8* [**2136-10-16**] 08:10AM BLOOD Glucose-58* UreaN-30* Creat-1.0 Na-134 K-4.9 Cl-104 HCO3-21* AnGap-14 [**2136-10-16**] 06:35PM BLOOD ALT-38 AST-75* LD(LDH)-234 CK(CPK)-172 AlkPhos-179* TotBili-4.4* [**2136-10-16**] 06:35PM BLOOD Albumin-2.2* Calcium-7.4* Phos-2.6* Mg-1.8 MICROBIOLOGY: [**2136-10-16**] Blood Cultures x 2: negative [**2136-10-16**] Urine Cultures: negative IMAGING: [**2136-10-17**] TTE: The left atrium is mildly dilated. The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta 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. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. Compared with the prior report (images unavailable for review) of [**2136-6-27**], the findings are similar. [**2136-10-17**] ABD DOPPLER US to assess to TIPS patency: The study was significantly limited due to patient condition and compliance. The patient could not hold breath or follow other commands for the Doppler interrogation. Limited imaging did reveal a patent TIPS. The proximal, mid and distal velocities were 77.4 cm/sec, 146.7 cm/sec, 137.5 cm/sec, respectively. The main portal vein was patent with hepatopetal flow. Branches of the portal vein, however, could not be adequately interrogated again due to patient compliance. The hepatic veins were all widely patent and demonstrated appropriate flow. Though limited, no large volume ascites was detected in the right upper quadrant. At discharge: [**2136-11-1**] 06:43AM BLOOD WBC-2.6* RBC-2.70* Hgb-8.7* Hct-26.9* MCV-100* MCH-32.3* MCHC-32.4 RDW-20.6* Plt Ct-74* [**2136-11-1**] 06:43AM BLOOD Glucose-78 UreaN-25* Creat-1.3* Na-135 K-4.9 Cl-104 HCO3-28 AnGap-8 [**2136-11-1**] 06:43AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.9 Brief Hospital Course: Mr. [**Known lastname **] is a 73 year old male with cryptogenic cirrhosis s/p TIPS placement on [**2136-10-12**] presented with hypotension and fever suggestive of sepsis, received 14 day course of vancomycin. Subsequently he was diuresed for volume overload, but diuresis was limited by acute renal failure and hypotension. Sepsis. Mr. [**Known lastname **] was started on vancomycin, cefepime and flagyl empirically. Blood cultures returned negative, but it was suspected that his sepsis may be due to an infected TIPS placed percutaneously on [**2136-10-12**]. He was on norepinephrine from [**2136-10-16**] to [**2136-10-18**]. BP, fever curve and WBC improved with this empiric antibiotic regimen. As his sepsis was resolving, he was started on lasix drip and then 20 mg IV boluses for diuresis. He was transfused 2 units RBC om [**2136-10-18**] for Hct 22.1, likely due to his prior oozing portal gastropathy. Doppler ultrasound showed a patent TIPS, though it was a limited study. Culture data returned from the outside hospital, growing a contaminant. He received a 14 day course of vancomycin given his sepsis syndrome. A PICC was placed for this antiobiotic and was subsequently removed. Volume overload. This was secondary to cirrhosis with associated large volume ascites plus fluid resuscitation from sepsis. He was started on his home doses of lasix and spironolactone. He tolerated these well and they were initially titrated up. However, his creatinine increased and peaked at 1.5. Diuresis was held to prevent hepatorenal physiology, and his creatinine slowly trended down to 1.2. He was started back on his home dose of lasix 40mg and a decreased dose of spironolactone 100mg with a stable creatinine at 1.3. He was monitored throughout with strict I's and O's via a Foley. Hypotension. Resolved, now at his baseline of low 100's systolic. On the floor, his lowest SBP was 75, after one dose of nadolol the prior night. He was asymptomatic and mentating appropriately. His nadolol was permanently discontinued, and midodrine was started to help support his pressures. This was uptitrated to midodrine 10mg TID. He was also given concurrent colloid with two doses of 50 grams of albumin on subsequent days, and 2 units of packed RBC's on subsequent days. Acute renal failure. This was most likely secondary to increasing diuretics. The creatinine recovered to 1.3 after diuretics were decreased as above, colloid was given, and midodrine was added. The patient was not given any intravenous fluids after the initial MICU course. Anemia. The hematocrit was stable at 25 for most of the admission. However, at times the hematocrit would drop to 21-22, which was most likely secondary to his oozing portal gastropathy. He was continued on his PPI and sucralfate twice daily. He was transfused four units total over the course of the admission. He had previously received transfusions as an outpatient, and will most likely require transfusions in the future. Rash. A new rash resembling drug reaction appeared in the last few days prior to admission. The only new change in the patient's regimen was two 50g doses of albumin. It is possible that there was an allergy to a product in the albumin delivery or the vancomycin that he had received the week prior, however, the etiology of the rash remains unclear. [**Name2 (NI) **] was started on triamcinolone 0.1%, with instructions to avoid the face, hands, and genitals. Type 2 Diabetes. The patient was maintained on NPH 14 units in the morning, and 7 units at night with excellent glycemic control. He was covered by a Humalog according to a sliding scale. Lower extremity edema. Most likely secondary to volume overload from cirrhosis. The patient used waffle boots to keep his heels elevated off the bed, and to cushion his calves. His calves were wrapped by wound care or nursing daily. Deconditioning. The patient has been primarily in bed for the past three weeks. His albumin is 1.9. He was encouraged to move about as much as possible, with daily out of bed to chair. Physical therapy worked with him intermittently. He will need aggressive physical therapy at rehab to return him to his baseline functional status. Cough. This would occur primarily after eating, making it most likely secondary to small aspiration events. Speech and swallow reevaluation determined that the risk of aspiration with nectar thick liquids and thin liquids is relatively similar. The patient wanted to take this small increased risk with thin liquids, and we agreed that this would be better tolerated. He was instructed to use chin tucks while drinking liquids and small bites with slow rate of intake. He was also instructed to use incentive spirometry as much as possible. Depression. The patient exhibited symptoms of depression including early morning awakenings, depressed mood, lack of motivation, and anhedonia. This should be followed by his PCP, [**Name10 (NameIs) 151**] consideration given to adding an [**Doctor Last Name 360**] in addition to citalopram. Prophylaxis. The patient has been bed bound and therefore was continued on prophylactic subcutaneous heparin until he is more mobile. Medications on Admission: HOME MEDICATIONS (per recent DCS): 1. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Insulin NPH & Regular Human Subcutaneous 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 7. Spironolactone 50 mg Tablet Sig: Three (3) Tablet PO once a day. 8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times a day): Take 2 hours after and before other meds. 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Fourteen (14) units Subcutaneous qAM. 3. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Seven (7) units Subcutaneous at bedtime. 4. Humalog 100 unit/mL Solution Sig: 2-10 units Subcutaneous qidachs as needed for hyperglycemia: Per sliding scale. 5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 13. Rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical TID (3 times a day). 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**] Discharge Diagnosis: 1. Bacteremia with Sepsis 2. Volume overload 3. Acute renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you during your stay here at [**Hospital1 18**]. You were treated with antibiotics for staphylococcus bacteremia and sepsis. You required intravenous fluids and medications to support your blood pressure. A PICC line was placed and you received IV antibiotics. You received diuretics for volume overload and lower extremity swelling. You received albumin and a blood transfusion to replete your intravascular volume. The following medications were added to your home regimen: Start: Rifaximin Start: Midodrine Decrease: Spironolactone Followup Instructions: The following appointments have been made for you: Department: TRANSPLANT CENTER When: FRIDAY [**2136-11-9**] at 1:20 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

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icd9cm

[ [ [] ] ]

[ "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

14858, 14993

7183, 12402

327, 409

15105, 15105

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2436, 2947

31,994

130,132

33155

Discharge summary

report

Admission Date: [**2149-2-4**] Discharge Date: [**2149-2-10**] Date of Birth: [**2082-11-30**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Keflex / Diovan / Ciprofloxacin / Ace Inhibitors / Quinine / Levaquin / Novocain Attending:[**First Name3 (LF) 134**] Chief Complaint: transfer for cath Major Surgical or Invasive Procedure: 1. Hemo-dialysis 2. Cardiac catheterization 3. Coronary angioplasty with bare metal stent placement History of Present Illness: 66-year-old female with a history of IDDM, ESRD on HD, s/p pacemaker, PVD s/p right BKA, and CAD s/p CABG and stent to LAD who is transferred from OSH after hypotension and presyncope at HD and chest pain with positive cardiac enzymes. She was at HD on Saturday and 1/2 hour into the run she became hypotensive and presyncopal. She was transferred to [**Hospital 5871**] Hospital ED and from there to [**Location (un) **]. During her ambulance ride to [**Location (un) **] she developed chest pain and she was given nitro in the [**Location (un) **] ED. She was admited to telemetry after her initial cardiac enzymes were negative. She underwent dialysis on Sunday but again became hypotensive and developed chest pain. She had ST depressions and cardiac enzymes were positive with a peak troponin of 7.07; she was also noted to have ST depressions during dialysis. CXR was negative. On transfer from the OSH, she was reportedly pain free on a heparin drip. . On arrival to [**Hospital1 18**], she went directly to the cath lab. Cath revealed distal edge 80% re-stenosis of LAD stent -> received 2 Taxus stents. Transferred to CCU for dialysis post cath. . On admission to the CCU, the patient denied chest pain, SOB, abdominal pain, palpitations, abdominal discomfort, headache or any other problems. She noted feeling tired. Past Medical History: IDDM CAD, s/p CABG CHF ESRD on hemodialysis Tues, Thurs and Sat Anemia PVD, s/p right BKA Irritable bowel syndrome Diverticulitis Social History: She does not smoke cigarettes or drink EtOH. Family History: Mother died of colon ca; she also had diabetes. Father died of heart disease. Physical Exam: Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of [**7-22**] cm. CV: RR normal rate, 3/6 systolic ejection murmur, obscuring S2 Chest: CTAB anteriorly Abd: Obese, Soft, unable to palpate for HSM Ext: s/p R BKA. No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Cardiac cath: 1. Three vessel native coronary artery disease with ulcerated severe mid-LAD stenoses at the ridge of previously placed stent. 2. Patejnt SVG-OM and SVG-PDA and known occluded LIMA. 3. Normal systemic arterial blood pressure. 4. Left ventriculography was deferred. 5. Patient had hyperkalemia (6.6) and was given D50 and insulin. renal serviuce was contact[**Name (NI) **] and dialysis was requested. 6. Successful stenting of teh mid LAD with overlapping TAXUS DES. . Echo: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal to mid inferior segments. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. Mild to moderate ([**1-15**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild focal left ventricular systolic dysfunction. Moderate to severe aortic stenosis. Mild to moderate mitral regurgitation. Brief Hospital Course: On arrival to [**Hospital1 18**], she went directly to the cath lab. Cath revealed distal edge 80% re-stenosis of LAD stent -> received 2 Taxus stents. Transferred to CCU for dialysis post cath. Her hospital course was complicated by persistent demand-related ischemic chest pain in the setting of hypotension with dialysis, and during episodes of tachycardia. She underwent smaller-volume hemodialysis sessions more frequently to prevent this, and her beta blocker was titrated to prevent tachycardia. Prior to discharge she was breathing comfortably and did not appear volume overloaded. Medications on Admission: ASA Plavix 75mg daily Lopressor 25 mg qid Isordil 30 mg tid Lopid (gemfibrozil) Phoslo Renagel Epogen with dialysis Celexa Prilosec Regular Insulin (none this am) Immodium Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*3* 4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Insulin Please resume your regular insulin regimen as prescribed by your primary care [**Provider Number 51467**]. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Capsule(s)* Refills:*2* 8. Sevelamer Carbonate Oral 9. Sevelamer HCl 400 mg Tablet Sig: Three (3) Tablet PO with meals. Disp:*270 Tablet(s)* Refills:*2* 10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-15**] Sprays Nasal QID (4 times a day) as needed. Disp:*1 aerosol* Refills:*0* 11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-15**] Drops Ophthalmic PRN (as needed). Disp:*1 Bottle* Refills:*2* 12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual ASDIR (AS DIRECTED) as needed for CP. 13. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) 20,000 Injection once a week: With dialysis. 14. Lopid Please resume taking dose at home per your primary care physician; please clarify dose 15. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: 1. Non ST elevation myocardial infarction 2. End stage renal disease 3. Diabetes mellitus 4. Peripheral vascular disease 5. Aortic valve stenosis Discharge Condition: Stable, afebrile, saturating well on room air. Discharge Instructions: You were admitted to our hospital after being transferred for symptoms of chest pain and low blood pressure at the time of dialysis. During your stay, you underwent heart catheterization and two "BARE METAL" stents were placed. Your chest pain has improved and you are now ready to go back home Followup Instructions: Please follow up with your cardiologist within 1 week

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icd9cm

[ [ [] ] ]

[ "36.06", "88.56", "37.22", "00.40", "00.46", "00.66" ]

icd9pcs

[ [ [] ] ]

6798, 6804

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396, 498

6994, 7043

2766, 4300

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5142, 6775

6825, 6973

4945, 5119

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2181, 2747

339, 358

526, 1855

1877, 2009

2025, 2071

6,113

102,747

6388

Discharge summary

report

Admission Date: [**2136-5-24**] Discharge Date: [**2136-5-29**] Date of Birth: [**2068-11-24**] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 24666**] underwent aortic valve replacement and coronary artery bypass graft times two in [**4-24**] with sternal dehiscence and bilateral pectoral flap repair at that time. She has been followed by Dr. [**Last Name (STitle) 13797**] since she represented in [**1-26**] with sternal wound drainage and extruding suture. At that time she was brought to the Operating Room with removal of that suture and some removal of superficial pledgets and was discharged to home. She represented at this time with ongoing drainage from her sternum. PAST MEDICAL HISTORY: Aortic valve replacement and coronary artery bypass graft times two in [**4-24**] with pectoral flap status post dehiscence. Congestive heart failure. Cholelithiasis. Headaches. Osteoarthritis. Uterine fibroids. Psoriasis. Obesity. MEDICATIONS: 1. Metoprolol. 2. Aspirin. 3. Lisinopril. 4. Furosemide. 5. Lipitor. ALLERGIES: No known dietary or drug allergies. PHYSICAL EXAMINATION: Heart rate 80 and regular. Blood pressure 144/80. Height 4'9" tall, weight 200 pounds. General, obese elderly woman. Skin no obvious lesions. Well healed leg scars. HEENT pupils are equal, round, and reactive to light and accommodation. Nonicteric. Noninjected. Slight erythema in her oropharynx. Neck no jugular venous distension. Thick obese neck. Chest clear to auscultation bilaterally. Healed sternum with 1 cm opening at superior aspect. Heart regular rate and rhythm. S1 and S2. No murmur. Abdomen obese, nontender, nondistended. No costovertebral angle tenderness. Extremities obese, warm and well perfuse. Plus one bilateral pedal edema. Varicosities none noted. Neurological Cranial nerves II through XII grossly intact, nonfocal. Pulses plus 2 right and left femoral. Plus 1 right and left posterior tibial pulse. Plus 2 right radial. HOSPITAL COURSE: Mrs. [**Known lastname 24666**] was admitted on [**5-24**] and brought to the Operating Room with Dr. [**Last Name (STitle) 952**] and Dr. [**Last Name (STitle) 70**] with a diagnosis of draining sinus status post aortic valve replacement coronary artery bypass graft and pectoral flaps. At this time she underwent deep sternal exploration with sinus that extended to the anterior aorta where pledgets were involved and excised. She was transferred to the CSRU on Propofol and neo and she was extubated two hours after she left the Operating Room and she was weaned off of her intravenous drip medications at that time as well. On [**5-25**] she was transferred to the inpatient floor and had an uneventful hospital course. On [**5-27**] her sternal wound culture grew staph aureus. She was Vancomycin and on [**5-29**] she was discharged to home and plans for a two week course of Linezolid. CONDITION ON DISCHARGE: Alert and oriented times three, grossly intact. Cardiovascular normal sinus rhythm. Respirations clear to auscultation, room air O2 sat 93 percent. Abdomen soft, nontender, nondistended, positive bowel sounds. Wound sternal incision with clips, JP draining to bulb suction draining scant amount of serosanguinous drainage. LABORATORIES ON DISCHARGE: White blood cell 10.3, hematocrit 36.7, platelets 192, sodium 139, potassium 3.6, chloride 96, HCO3 30, BUN 22, creatinine 1.0, glucose 115, calcium 9.1, phos 4.0, magnesium 1.9. DISCHARGE STATUS: Mrs. [**Known lastname 24666**] is discharged to home with VNA in stable condition. DISCHARGE DIAGNOSES: Coronary artery disease status post aortic valve replacement coronary artery bypass graft ni [**4-24**] with pectoral flap status post dehiscence and now status post sternal wound exploration with removal of deep pledgets. Congestive heart failure. Obesity. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg q.d. 2. Lopressor 25 mg b.i.d. 3. Furosemide 40 mg po b.i.d. 4. Linezolid at 600 mg po b.i.d. for two weeks. FOLLOW UP: Dr. [**Last Name (STitle) 952**] in one week for removal of JP drain and assessment of wound. Dr. [**Last Name (STitle) 70**] in six weeks and visiting nurse at home with plans to check CBC q three days and fax results to Dr. [**Last Name (STitle) 952**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2136-5-30**] 11:23:16 T: [**2136-5-30**] 13:13:55 Job#: [**Job Number **]

[ "V45.81", "428.0", "V43.3", "998.4", "998.6" ]

icd9cm

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icd9pcs

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4042, 4562

1149, 2014

3311, 3595

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5342+5343+5344

Discharge summary

report+report+report

Admission Date: [**2152-9-28**] Discharge Date: [**2152-10-3**] Date of Birth: [**2092-4-12**] Sex: F Service: MEDICINE Allergies: Compazine / Droperidol / Sulfonamides / Gadolinium-Containing Agents / Demerol / Morphine / Haldol Attending:[**First Name3 (LF) 2817**] Chief Complaint: SOB, hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 60 female with h/o MCD, frequent admissions for flares, presents with fairly acute onset swelling, puruitis, tongue swelling and chest / abdominal pain. This started today while at her ophto appt. She was driving herself to the ED, and had to stop to give herself SC epinepherine. . She has felt unwell for the past several days, including vague abdominal pain and nausea without vomiting. She denies f/c/SOB prior to this episode. She has been compliant with her medications. . ED course: She was given 2mg IV dilauded x 3; benadryl 50mg IV x 1; solumedrol 125mg IV x 1; famotidine 20mg IV x 1; lorazepam 2mg IV x 1; hydroxyzine 25mg PO x 1; nebs. Her labs were unrevealing. She had a normal CXR and ECG. She is admitted to medicien for her MCD flare. . Review of Systems: As above. (+) flank pain, nausea, frequency, SOB, CP, abdominal pain. (-) fevers, chills, leg swelling, orthopnea. Past Medical History: - mast cell degranulation syndrome (MCDS): Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **] who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here by Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice. - Depression/anxiety/bipolar d/o, hx of SI - MI in [**2147**] after receiving cardiac arrest dose epi instead of anaphylactic dose epi - HTN - Erosive osteoarthritis - GERD, gastritis and esophagitis on recent EGD [**2151-1-8**] - Paradoxical Vocal Cord Dysfunction viewed on fiberoptic laryngoscopy - Anemia, iron studies c/w AOCD - Hemorrhoids - pt reports EGD demonstrated vegetable bezoar (?[**12-6**]). - Status post hysterectomy and oophorectomy - h/o MRSA infection (porthacath associated) - portacath placed [**3-7**] - d/c'd [**2-4**] MRSA infection - portacath placed [**2151-6-9**] Social History: Pt is divorced. Lives alone. She works as an ER tech in [**Hospital3 **]. No tobacco or EtOH or illicit drugs. Son is HCP [**Telephone/Fax (1) 21738**] Family History: Mother died of MI @ 76, Sister w/ breast cancer and bilateral mastectomy. Physical Exam: Vs- 98.1 160/90 98 18 97% ra Gen- Pleasant female uncomfortable due to pain, speaking quietly, NAD Heent- MMM, anicteric, OP clear, no tongue swelling on my exam Neck- supple, no LAD, no JVP Cor- Regular, tachy, flow murmur, no G/R Chest- Tight, roncherous, limited due to pain. Pos R>L CVAT. Right chest with port, C/D/I. Abd- obese, soft, tender to palpation in the epigastric area, no g/r, pos BS Ext- No c/c/e Neuro- AAO x 3, no focal findings, CN intact Skin- Thin skin, no rashes or lesions. Msk- Nodules on DIP and PIP joints bilaterally with some warmth and evidence of inflammatory arthritis on the right hand. Chest is non-tender to palpate. Pertinent Results: [**2152-9-27**] 06:12PM WBC-9.1 RBC-4.62 HGB-13.1 HCT-38.5 MCV-83 MCH-28.4 MCHC-34.1 RDW-16.1* [**2152-9-27**] 06:12PM NEUTS-71.9* LYMPHS-20.5 MONOS-5.6 EOS-1.6 BASOS-0.4 [**2152-9-27**] 06:12PM PLT COUNT-274 [**2152-9-27**] 06:12PM PT-11.1 PTT-23.1 INR(PT)-0.9 [**2152-9-27**] 06:12PM ALBUMIN-3.7 CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-2.2 [**2152-9-27**] 06:12PM CK-MB-NotDone proBNP-195 [**2152-9-27**] 06:12PM cTropnT-<0.01 [**2152-9-27**] 06:12PM LIPASE-30 [**2152-9-27**] 06:12PM ALT(SGPT)-25 AST(SGOT)-18 LD(LDH)-305* CK(CPK)-39 ALK PHOS-78 AMYLASE-45 TOT BILI-0.3 [**2152-9-27**] 06:12PM GLUCOSE-99 UREA N-12 CREAT-0.9 SODIUM-141 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-14 [**2152-9-28**] 12:52AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2152-9-28**] 04:41AM CK-MB-3 cTropnT-<0.01 [**2152-9-28**] 08:54PM CK-MB-3 cTropnT-<0.01 . Studies: CXR: There is a right-sided Port-A-Cath with distal lead tip in the proximal RA. Cardiac silhouette is upper limits of normal. There is some atelectasis at both lung bases. There remains a calcified left suprahilar lymph node. There are no signs for overt pulmonary edema or focal consolidation. . CT Spine: IMPRESSION: 1. No evidence of cervical, thoracic or lumbar vertebral body fracture. 2. Degenerative changes as outlined above . EKG: Sinus rhythm Borderline left axis deviation - possible left anterior fascicular block although is nondiagnostic Delayed R wave progression - is nonspecific Since previous tracing of the same date, sinus tachycardia rate slower but otherwise baseline artifact on previous tracing makes assessment difficult Brief Hospital Course: A/P: 60 yoF with mast cell degranulation with acute flare this afternoon unclear etiology . # MCD flare: The patient was admitted and treated aggressively with addition of IV Solumedrol, benadryl, in addition to her home medications. On multiple occasions she received anaphylactic dose epinephrine due to airway swelling, tongue swelling. She was treated aggressively for her chest and abdominal pain with IV Dialaudid and antiemetics. LFTs were within normal limits and she ruled out for MI with normal cardiac enzymes and no change on EKG. On discharge she had no further shortness of [**Month/Day/Year 1440**] and her pain improved significantly. She was not longer requiring epinephrine, she was tolerating po medications. . # HTN: She was continued on her home dose of diltiazem with stable blood pressure. . # OA: She has an unclear inflammatory osteoarthritis, for which she is on plaquenil. She was continued on this while in the hospital. . # Psych: Mood stable, though she has had increasing feelings of isolation / fear since the episodes are becoming more frequent. This may be related to vocal cord dysfunction, pt creating audible wheeze and stridor. It was recommended to her that speech therapy evaluation/treatment may be helpful for her as an outpatient for vocal cord retraining. Medications on Admission: - Cromolyn 100 mg/5 mL 100ml qid - Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release 24 qd - Diltiazem HCl 80 mg Capsule qd - Duloxetine 60 mg qd - Doxepin 50 mg qhs - Hydroxyzine HCl 25 mg qid - Hydroxychloroquine 200 mg qd - Montelukast 10 mg qd - Zolpidem 10 mg qhs prn - Ranitidine HCl 300 mg qd - Ferrous Sulfate 134 mg qd - Estradiol 0.05 mg/24 hr Patch Semiweekly - Fexofenadine 180 mg tid - Pantoprazole 40 mg qd - Butalbital-Acetaminophen-Caff 50-325-40 mg q6 prn - Prednisone 10 mg taper [FINISHED] - EpiPen 0.3 mg/0.3 mL prn - zofran 8mg PO prn - Dilaudid 2mg PO prn Discharge Medications: 1. Cromolyn 100 mg/5 mL Solution Sig: Three Hundred (300) mg PO QID (4 times a day). 2. Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 4. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. Hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO once a day. 9. Ferrous Sulfate 134 mg Tablet Sig: One (1) Tablet PO once a day. 10. Estradiol 0.05 mg/24 hr Patch Semiweekly Sig: One (1) patch Transdermal 2X per week. 11. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO three times a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 14. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 15. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 16. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day: on [**10-4**] then 3 tabs on [**10-20**] and 2 tabs on [**10-7**] and 1 tab on [**10-8**]. Disp:*12 Tablet(s)* Refills:*0* 17. Calcium 500 mg Tablet Sig: One (1) Tablet PO three times a day: with meals. 18. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day. 19. Doxepin 50 mg Capsule Sig: One (1) Capsule PO at bedtime. 20. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 21. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: 1.) Mast cell degranulation syndrome Secondary: 2.) Vocal cord dysfunction 3.) Gastroesophageal reflux disease 4.) Osteoarthritis Discharge Condition: Hemodynamically stable. Ambulatory. Discharge Instructions: You were admitted to the hospital because of shortness of [**Month/Day (4) 1440**] and flare of your mast cell degranulation syndrome. You were treated with IV steroids, epinephrine, benadryl and multiple antihistimine medications. You had a short stay in the intensive care unit. . Upon discharge you will have a short course of steroids to finish. Otherwise you should continue to take all medications as prescribed and keep all health care appointments. . We have added calcium and vitamin D to your medication regimen. You are at risk for osteoporosis as you have been on a long course of steroids. You should have a bone mineral density scan if you have not had one already. . If you have worsening shortness of [**Month/Day (4) 1440**], throat tightening, tongue swelling, chest pain, abdominal pain, or if your condition worsens in any way, seek immediate medical attention. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] as previously scheduled. You have the following previously scheduled health care appointments: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2152-10-10**] 1:20 Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2152-10-19**] 1:00 Admission Date: [**2152-10-8**] Discharge Date: [**2152-10-12**] Date of Birth: [**2092-4-12**] Sex: F Service: MEDICINE Allergies: Compazine / Droperidol / Sulfonamides / Gadolinium-Containing Agents / Demerol / Morphine / Haldol Attending:[**First Name3 (LF) 30**] Chief Complaint: CC: Chest pain, SOB Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 60 F c hx systemic mastocytosis and frequent admits for flares of this condition manifest by intermittent episodes of anaphylactic-like reaction who presents with similar symptoms. Reports that over the last several days has been having constant chest pain and shortness of [**First Name3 (LF) 1440**] that intermittently worsens. Describes her chest pain as a pressure over her sternum and over the epigastrium. Also has been taking regular benadryl but has had a few episodes of vomiting where she has been unable to keep benadryl down. This afternoon, patient had an episode of her usual symptoms (tightness breathing, chest discomfort, itchy tongue) and presented to the ED. Able to tolerate PO. . In the ED, dyspneac and tachypnea but not hypoxic and hemodynamically stable. Given combivent nebs, dilaudid, benadryl, solumedrol, ativan as is usual for her with some relief. . Came to floor and had another episode of anaphylaxis. Placed on monitor; 100% on RA. No wheeze detected on auscultation. Given benadryl, ativan, dilaudid, combivent nebs with relief of symptoms in 15-20 minutes. EKG done with no change from prior. Past Medical History: - mast cell degranulation syndrome (MCDS): Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **] who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here by Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice. - Depression/anxiety/bipolar d/o, hx of SI - MI in [**2147**] after receiving cardiac arrest dose epi instead of anaphylactic dose epi - HTN - Erosive osteoarthritis - GERD, gastritis and esophagitis on recent EGD [**2151-1-8**] - Paradoxical Vocal Cord Dysfunction viewed on fiberoptic laryngoscopy - Anemia, iron studies c/w AOCD - Hemorrhoids - pt reports EGD demonstrated vegetable bezoar (?[**12-6**]). - Status post hysterectomy and oophorectomy - h/o MRSA infection (porthacath associated) - portacath placed [**3-7**] - d/c'd [**2-4**] MRSA infection - portacath placed [**2151-6-9**] Social History: Pt is divorced. Lives alone. She works as an ER tech in [**Hospital3 **]. No tobacco or EtOH or illicit drugs. Son is HCP [**Telephone/Fax (1) 21738**] Family History: Mother died of MI @ 76, Sister w/ breast cancer and bilateral mastectomy. Physical Exam: Physical Exam: VS - 98.7, 156/92, 98, 100% 3l, rr 16-34 GEN - NAD presently; during episode, breathing shallow and clenching mouthpiece of nebulizer with eyes shut HEENT - no elevation of JVP, OP clear, MMM LUNGS - minimal air movement; no focal crackles. During episode, no wheeze detected HEART - RRR, S1, S2, no murmurs ABD - soft, ND, NT EXT - wwp, no edema. Pertinent Results: EKG: Sinus tach 100 bpm, LAD, aVL > 11 cm c/w LVH. No sig change from prior. Cardiac enzymes negative x 3. CXR: no acute CP process noted. . Urine Culture: >100,000 Klebsiella, pan-sensativive . C. diff - negative . Brief Hospital Course: In summary, Ms. [**Known lastname **] is a 60 yo female with a history of mast cell degranulation syndrome who presents with a typical flare characterized by chest pain, shortness of [**Known lastname 1440**], and pruritus. . Mast Cell Degranulation Syndrome. Patient is presenting with symptoms consistent with a flare of mast cell degranulation. She was treated with Diluadid IV 2 mg q 3 hours, Benadryl IV 25 mg q 4 hours, Solumedrol 125 mg IV followed by prednisone, Zofran PRN, albuterol nebs PRN. In addition, she was continued on home fexofenadine, gastrocrom, doxepin qhs, hydroxyzine, singulair, ranitidine. She was sent home on a prednisone taper. Epinephrine was not needed during the hospitalization. She continued to have numerous episodes of chest pain, shortness of [**Known lastname 1440**], and abdominal pain during the hospitalization that resolved with administration of benadryl and dilaudid. She was also started on asmanex upon discharged. She was also started on Ketotiften 1 mg [**Hospital1 **] and Zyletan 1 600mg tab QID as reccommended by Dr. [**Last Name (STitle) 79**]. . UTI. Urine cultures shows pan-sensitive Klebsiella. She was treated with 3 days of cipro. This may have served as a trigger for MCDS flare. . Chest Pain. Patient had numerous episodes of chest pain consistent with flares of MCDS that resolved with dilaudid, steroids, and bendaryl. Cardiac enzymes were negative and EKG remained unchanged. This chest pain did not appear to be cardiac in origin. . Steroid use. Patient has been on steroids for frequent flares. SHe was treated with Vitamin D for osteoporosis prevention and finger sticks were followed, but were not elevated. . Guiaic positive stool. Patinet was found to have guiac positive stool. Her hct has fallen from 37.7 to 31.3 during the admission. Patient had EGD in [**6-7**] that showed "Erythema of the antral mucosa with erosions in the body and fundus with stigmata of recent bleeding were noted in the fundus." Colonoscopy in [**1-8**] showed "Grade 1 internal & external hemorrhoids, Erythema in the mid rectum". . Medications on Admission: Meds: diltiazem CD 180mg qday atarax 25 QID Vivelle dot 0.05 twice per week ranitidine 300mg daily cymbalta 60mg qday plaquenil 200 [**Hospital1 **] adderal XR 25 fexofenadine 180 [**Hospital1 **] ambien 10 prn zofran 8 prn dilaudid 2 prn percocet prn fiorcet prn epi pen prn . Discharge Medications: 1. Doxepin 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 2. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 3. Cromolyn 100 mg/5 mL Solution Sig: One Hundred (100) ML PO qid (). 4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 5. Vivelle-Dot 0.05 mg/24 hr Patch Semiweekly Sig: One (1) Transdermal 2x week. 6. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 11. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours). 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 13. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for 5 days. Disp:*30 Tablet(s)* Refills:*0* 15. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for headache. 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Prednisone 20 mg Tablet Sig: as directed Tablet PO DAILY (Daily) for 6 days: Please take 2 tablets daily for three days, followed by 1 tablet daily for three days, then stop taking any more pills. Disp:*9 Tablet(s)* Refills:*0* 18. ketotiften Sig: One (1) mg twice a day. 19. zyletan Sig: One (1) 600 mg tablets four times a day. 20. Asmanex Twisthaler 220 mcg (120 doses) Aerosol Powdr [**Hospital1 **] Activated Sig: Two (2) puffs Inhalation twice a day. Disp:*1 inhaler* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Mast cell degranulation syndrome Urinary tract infection . Secondary diagnosis: Hypertension GERD Depression/ Anxiety CAD s/p MI Discharge Condition: fair Discharge Instructions: You were admitted for a flare of Mast Cell Degranulation Syndrome. You were treated with dilaudid, benadryl, steroids and anti-emetics. Your chest pain, abdominal pain, and shortness of [**Hospital1 1440**] improved with these interventions. . Please continue to take all medications that you were previously taking as prescribed with the following exceptions. Please stop taking your singulair inhaler, and instead take Zyletan four times a day. Please begin taking an Asmanex inhaler twice a day. Please take Zalidan twice a day as well. This prescription was phoned into America's Compounding Pharmacy at [**Telephone/Fax (1) 21741**]. In addition, please dilaudid as needed for pain. . Please call your physician of come to the emergency department if you develop chest pain, shortness of [**Telephone/Fax (1) 1440**], abdominal pain, lightheadedness, fevers, or any other concerning symptoms. . Followup Instructions: You have an appointment with Dr. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2152-10-19**] at 1PM. Phone:[**Telephone/Fax (1) 2226**]. . Please call Dr. [**Last Name (STitle) **] for a follow up appointment in [**1-4**] weeks ([**Telephone/Fax (1) 21735**]). . Please call Dr. [**Last Name (STitle) 79**] to set up a follow up appointment in [**1-4**] weeks. (([**Telephone/Fax (1) 21742**]). Admission Date: [**2152-10-13**] Discharge Date: [**2152-10-15**] Date of Birth: [**2092-4-12**] Sex: F Service: MEDICINE Allergies: Compazine / Droperidol / Sulfonamides / Gadolinium-Containing Agents / Demerol / Morphine / Haldol Attending:[**First Name3 (LF) 1973**] Chief Complaint: Chest Pain, SOB Major Surgical or Invasive Procedure: none History of Present Illness: 60 y/o F with hx of systemic mastocytosis and recurrent admission for this condition, recently d/c [**2152-10-12**] from [**Hospital1 18**] for similar episode. . Patient went home, the following day she had frequent episodes of diarrhea, with nasuea and vomit. Presents with acute onsent of chest pain, and shortness of [**Hospital1 1440**]. Given that she had nausea and vomit, she was unable to keep down his benadryl. He presented to the ED with simialr sympoms, shortness of [**Hospital1 1440**], chest pressusre and abdominal pain. . In the ED, VS: 98.6, HR 109, BP 170/82, Sats 100% RA. She received benadryl 50 mg IVx1, epinephrine, solumedrol 120mg ivx1, atarax 25 mg POx1, Dilauded 2 mf IV x3, albuterol nebs, Zofran 4 mg IV x1 Past Medical History: - mast cell degranulation syndrome (MCDS): Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **] who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here by Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice. - Depression/anxiety/bipolar d/o, hx of SI - MI in [**2147**] after receiving cardiac arrest dose epi instead of anaphylactic dose epi - HTN - Erosive osteoarthritis - GERD, gastritis and esophagitis on recent EGD [**2151-1-8**] - Paradoxical Vocal Cord Dysfunction viewed on fiberoptic laryngoscopy - Anemia, iron studies c/w AOCD - Hemorrhoids - pt reports EGD demonstrated vegetable bezoar (?[**12-6**]). - Status post hysterectomy and oophorectomy - h/o MRSA infection (porthacath associated) - portacath placed [**3-7**] - d/c'd [**2-4**] MRSA infection - portacath placed [**2151-6-9**] Social History: Pt is divorced. Lives alone. She works as an ER tech in [**Hospital3 **]. No tobacco or EtOH or illicit drugs. Son is HCP [**Telephone/Fax (1) 21738**] Family History: Mother died of MI @ 76, Sister w/ breast cancer and bilateral mastectomy. Physical Exam: VS - 98.4, 130/90, 107, 100% RA 20 GEN - NAD, talking full sentences HEENT - no elevation of JVP, OP clear, dyr oral mucose LUNGS - minimal air movement; no focal crackles. + wheezing. HEART - RRR, S1, S2, no murmurs ABD - soft, ND, NT EXT - wwp, no edema Pertinent Results: [**2152-10-12**] 05:33AM BLOOD WBC-9.3 RBC-3.69* Hgb-10.6* Hct-31.9* MCV-86 MCH-28.8 MCHC-33.3 RDW-16.4* Plt Ct-196 [**2152-10-15**] 04:49AM BLOOD WBC-5.9 RBC-3.99* Hgb-11.4* Hct-33.5* MCV-84 MCH-28.7 MCHC-34.1 RDW-16.5* Plt Ct-214 [**2152-10-13**] 10:00PM BLOOD Neuts-88.3* Lymphs-9.0* Monos-2.2 Eos-0.2 Baso-0.2 [**2152-10-12**] 05:33AM BLOOD Glucose-126* UreaN-13 Creat-0.7 Na-142 K-3.5 Cl-109* HCO3-27 AnGap-10 [**2152-10-15**] 04:49AM BLOOD Glucose-93 UreaN-8 Creat-0.7 Na-144 K-3.2* Cl-107 HCO3-31 AnGap-9 [**2152-10-13**] 10:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2152-10-14**] 05:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2152-10-15**] 04:49AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2152-10-12**] 05:33AM BLOOD Calcium-7.4* Phos-1.9* Mg-2.2 [**2152-10-13**] 10:00PM BLOOD Calcium-8.6 Phos-2.9 Mg-2.2 . CHEST (PORTABLE AP) [**2152-10-13**] 9:48 PM CHEST (PORTABLE AP) Reason: Please evaluate for cardiopulmonary process [**Hospital 93**] MEDICAL CONDITION: 60 y.o. female with systemic mastocytosis with multiple hospitalizations for exacerbations who presents now with acute onset of CP and SOB. REASON FOR THIS EXAMINATION: Please evaluate for cardiopulmonary process AP CHEST INDICATION: 60-year-old female with systemic mastocytosis. COMPARISON: Multiple previous studies, most recent dated [**10-8**], [**2152**]. FINDINGS: Cardiomediastinal silhouette is unchanged, with mild cardiac enlargement, predominantly left ventricular. Lung volumes are slightly improved. Again seen is a calcified left suprahilar node. There is no effusion, focal consolidation or pneumothorax. There is a right-sided Port-A- Cath with its tip in the proximal right atrium. Pulmonary vascularity is normal. IMPRESSION: No acute cardiopulmonary process, no significant change from [**2152-10-8**] . ECG Study Date of [**2152-10-13**] 9:04:48 PM Sinus tachycardia. Compared to prior tracing of [**2152-10-8**] no change. Brief Hospital Course: A/P: 60yo woman with h/o mast cell degranulation syndrome chest pain, shortness of [**Date Range 1440**] in the setting of her typical flare of MCDS. . # Chest Pain: patient with classic pressentation of her crisis. EKG did not show changes from baseline. her cardiac enzymes were negative. . #SOB: The patient had an acute episode of emotional upset and shortness of [**Date Range 1440**]. She reported having tight chest pain which was precipitating her dyspnea. Physical exam revealed adequate air movement and O2 sat was 100% on room air. Benadryl was adminstered without effect. The episode appeared similar to previous emotional episodes in which she reported dyspnea. The patient reported her symptoms are only responsive to dilaudid, because it eliminates her chest pain and allows her to breathe easier. She was administered dilaudid and the patient's dyspnea resolved. She did not have any further episodes of shortness of [**Date Range 1440**]. . # Mast Cell Degranulation Syndrome: Symptoms were consistent with similar flares. She was administered IV steroids in the ED and oral prednisone on the floor. She was also administered benadryl, dilaudid, and nebulizers. . # Benign Hypertension: patient was continued on her home dose of diltiazem. . # Depression/anxiety/bipolar/ADHD: continued on her outpatient dose of cymbalta. Medications on Admission: 1. Doxepin 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 2. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 3. Cromolyn 100 mg/5 mL Solution Sig: One Hundred (100) ML PO qid (). 4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 5. Vivelle-Dot 0.05 mg/24 hr Patch Semiweekly Sig: One (1) Transdermal 2x week. 6. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 11. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours). 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 13. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for 5 days. Disp:*30 Tablet(s)* Refills:*0* 15. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for headache. 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Prednisone 20 mg Tablet Sig: as directed Tablet PO DAILY (Daily) for 6 days: Please take 2 tablets daily for three days, followed by 1 tablet daily for three days, then stop taking any more pills. Disp:*9 Tablet(s)* Refills:*0* 18. ketotiften Sig: One (1) mg twice a day. 19. zyletan Sig: One (1) 600 mg tablets four times a day. 20. Asmanex Twisthaler 220 mcg (120 doses) Aerosol Powdr [**Date Range **] Activated Sig: Two (2) puffs Inhalation twice a day. Disp:*1 inhaler* Refills:*2* Discharge Medications: 1. Doxepin 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 2. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 3. Cromolyn 100 mg/5 mL Solution Sig: One (1) PO four times a day. 4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 10. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO every twelve (12) hours. 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 12. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 13. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for headache. 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Asmanex Twisthaler 220 mcg (120 doses) Aerosol Powdr [**Date Range **] Activated Sig: Two (2) Inhalation [**Hospital1 **] (2 times a day). 16. Prednisone 20 mg Tablet Sig: 1-3 Tablets PO once a day for 9 days: Beginning on [**2152-10-16**], Take 3 tablets (60mg) once a day, through [**2152-10-17**]. Beginning [**2152-10-18**] Take 2 tablets (40mg) once a day through [**2152-10-20**]. Beginning [**2152-10-21**] Take 1 tablet (20mg) once a day through [**2152-10-23**]. Then stop. Disp:*15 Tablet(s)* Refills:*0* 17. Vivelle-Dot 0.05 mg/24 hr Patch Semiweekly Sig: One (1) patch Transdermal 2X/week. Discharge Disposition: Home Discharge Diagnosis: Mast Cell Degranulation Syndrome crisis HTN Depression/anxiety Osteoarthritis Hypokalemia Discharge Condition: Good VS: T98.1 HR88 BP138/90 RR20 O2Sat97%RA Discharge Instructions: You were admitted to the hospital for management of chest pain, shortness of [**Month/Day/Year 1440**], and abdominal pain. EKG and lab tests showed that you did not suffer damage to your heart. Your chest x-ray was unremarkable. These symptoms were consistent with Mast Cell Degranulation Syndrome crisis that you have experienced in the past. In the ER you received benadryl, epinephrine, solumedrol, dilaudid, atarax, albuterol nebs, and Zofran. Your condition has improved. You will need to continue taking prednisone after discharge. Please contact your PCP or come directly to the ER if you experience shortness of [**Month/Day/Year 1440**], chest pain, fever, or increased abdominal pain. . Please follow-up as instructed below. Followup Instructions: Please contact your PCP [**First Name4 (NamePattern1) 3403**] [**Last Name (NamePattern1) 18252**] [**0-0-**] to make an appointment for follow-up in [**1-4**] weeks. Please contact your Allergist, Dr. [**Last Name (STitle) **], at [**Telephone/Fax (1) 21743**] to make an appointment for a follow-up. Please contact your Gastroenterologist, Dr. [**Last Name (STitle) 79**], at [**Telephone/Fax (1) 21732**] to make an appointment for a follow-up. . Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2152-10-19**] 1:00

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

29560, 29566

24278, 25625

20094, 20101

29700, 29751

22330, 23262

30537, 31140

21962, 22038

27653, 29537

23299, 23439

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1180, 1297

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23468, 24255

20129, 20869

18255, 18306

18175, 18234

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21791, 21946

24,560

154,385

15513

Discharge summary

report

Admission Date: [**2148-11-6**] Discharge Date: [**2148-12-2**] Date of Birth: [**2098-5-8**] Sex: M Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 50-year-old male transferred from an outside hospital in Bermuda for liver transplant evaluation. In early [**2148**], the patient's wife noted an increase in his abdominal girth, clumsiness, tremor, and skin color changes. Over the Summer, his symptoms rapidly progressed. At a hospital in Bermuda, cirrhosis was diagnosed by abnormal liver function tests and ultrasound. The patient was transferred to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Medical Center on [**2148-9-10**] where a workup revealed a negative workup for hepatitis C. Iron studies were negative. Normal anti-SM, RNP. Normal alpha-1 antitrypsin. Normal rapid plasma reagin. A magnetic resonance imaging revealed a 2.5-cm hepatic nodule, nonmalignant on ultrasound-guided fine-needle aspiration. An esophagogastroduodenoscopy revealed four large tortuous varices that were banded at that procedure as well as gastropathy. Serum ceruloplasmin was slightly low. The patient was subsequently seen by an ophthalmologist in Bermuda who noted Kayser-Fleischer rings. Upon return to Bermuda, penicillamine was started for a presumptive diagnosis of Wilson's disease. He was admitted to an outside hospital on [**2148-11-3**] with generalized weakness and falls. At that time, the penicillamine was held for concern of myasthenic reaction. The patient was then transferred to [**Hospital1 190**] for transplant evaluation. PAST MEDICAL HISTORY: 1. Cirrhosis (as above). 2. Pericarditis. 3. Viral syndrome with fevers, chills, cerebrovascular pain, and pericarditis. 4. Hand injury with a circular saw. MEDICATIONS ON ADMISSION: 1. Lactulose 30 cc p.o. six times per day. 2. Nadolol 40 mg p.o. q.d. 3. Furosemide 20 mg p.o. q.d. 4. Spironolactone 100 mg p.o. q.d. 5. Vitamin K 10 mg intravenously q.d. 6. Albumin 50 g intravenously q.d. 7. Ranitidine 50 mg intravenously q.12h. 8. Metronidazole 500 mg intravenously b.i.d. ALLERGIES: SOCIAL HISTORY: He is a welder. He has CCL4 exposure. He lives in Bermuda. He traveled to Batswana in [**2140**]. Trained with Bermuda armed forces in camp lives in [**Doctor First Name 5256**]. Vaccinated times three against hepatitis B virus. FAMILY HISTORY: Father died of a stroke at the age of 76. Mother and sister are alive and well. REVIEW OF SYSTEMS: Review of systems on this admission revealed no fevers or chills. Positive for nausea and vomiting. After starting penicillamine he admits to shortness of breath correlating with the increased abdominal girth. No chest pain. Positive abdominal discomfort and back pain. No dysuria. No stool passage for several days. No bleeding from nose, mouth, rectum, or noted in stools. He admits to difficulty swallowing. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed temperature was 95.5, blood pressure was 116/82, heart rate was 64, respiratory rate was 24, oxygen saturation was 93% to 94% on room air. In general, he was an ill-appearing and jaundiced, in no apparent distress. He had icteric sclerae. Pupils were 3 mm and reactive to light. Oral mucosa was dry. The neck was supple. Normal jugular venous distention. Lungs were clear to auscultation anteriorly. Heart had a regular rate and rhythm, normal sinus. Normal first heart sound and second heart sound. No murmurs, rubs, or gallops. The abdomen was tense, positive fluid wave, dullness to percussion. Extremities with 1 to 2+ pitting lower extremity edema bilaterally. Skins with spider angiomata and palmar erythema. Neurologically, he was alert. He responded to questions with blinks, thumbs up, and occasional whispers. He appeared to attend to questions well. Cranial nerves II through XII were intact. The patient would not maintain upward gaze long enough to assess fatigability. Perioral and facial muscles were weak. Deep tendon reflexes were 2+ in biceps, brachioradialis, 1+ quadriceps. Strength was [**4-26**], deltoids, biceps, and triceps bilaterally; 4-/5 in the left. Flexion extension was 3+/5 in the right, 3+ hip flexion bilaterally, [**4-26**] knee flexion, knee extension and ankle flexion and ankle extension bilaterally. Finger-to-nose was slow with fine intention tremor and possible fatigability. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories from the [**Hospital 44961**] hospital on [**1-5**] revealed white blood cell count was 7.5, hematocrit was 35.7, and platelets were 70. Sodium was 129, potassium was 3.9, chloride was 100, blood urea nitrogen was 26, creatinine was 0.8, and blood glucose was 95. ALT was 82, AST was 136, alkaline phosphatase was 176, total bilirubin was 4, direct bilirubin was 0.2. Total protein was 5.4. Pulmonary function tests showed no obstruction. CODE STATUS ON ADMISSION: Do not resuscitate/do not intubate (per patient). HOSPITAL COURSE: The patient was admitted for evaluation for possible liver transplant. In addition, a therapeutic paracentesis was recommended. He was continued on his nadolol and diuretics. Part of the workup for the liver transplant was to evaluate the diffuse muscle weakness as well as the possible fatigability. It was most likely thought to be a myesthetic syndrome secondary to penicillamine. Thus, the penicillamine was discontinued. Speech and Swallow was also consulted in order to evaluate the patient's ability to protect the airway due to his bulbar weakness. The patient failed the Speech and Swallow evaluation, and thus was recommended for an alternate nutrition source. In addition, due to the patient's progressive weakness, negative inspiratory forces were recorded to monitor the patient's ability to breathe, and to determine at what point he would need to be ventilated to be maintained. It was due to the concern over his respiratory status that the patient was admitted from the Medicine Service to the Medical Intensive Care Unit. The patient was managed supportively while the liver workup was in progress; which included multiple laboratory studies in addition to an Ophthalmology examination to again look for Kayser-Fleischer rings which were found bilaterally and superiorly. It was eventually determined on [**11-8**], given the uncertainty of his neuromuscular disorder and polyneuropathy, he was not a transplant patient candidate. During this time he was being maintained with nasogastric tube feedings in addition to CPAP to help with his respirations. Around this time, it was determined that he appeared to be fatiguing with respirations, and discussed with the family whether he would want to be intubated in order to continue potential aggressive care to see if the neuropathy resolved in order to make him a transplant candidate. Initially, the patient stated that he would only be intubated if it could be less than for 24 hours, which was not guaranteed. On [**11-9**], Mr. [**Known lastname 44962**] agreed to an elective intubation in order to maintain an aggressive level of care; i.e., nutrition and physical therapy in order to strengthen him to become a liver transplant candidate should his neurologic issues resolve. The patient was continued at this level of care and was also started on pyridostigmine as well as other neurologic agents in order to attempt to reverse his neuropathy. Even with the aggressive level of care, the patient was noted to have progressive weakness and was no longer able to communicate. Of note, during his stay in the Medical Intensive Care Unit, he also was hypotensive, requiring pressors to maintain blood pressure. On [**11-21**], the patient had a percutaneous tracheostomy performed without difficulty in order to better ventilate. Throughout his stay, the patient continued to have waxing and [**Doctor Last Name 688**] mental status, primarily unresponsive. In addition, he continued to have hypotensive episodes, requiring normal saline resuscitation in addition to pressors. On [**11-26**], the patient was noted to be hypotensive during the afternoon, and at around 6 p.m. vomited dark brown blood. An nasogastric tube was placed. The clinical situation was discussed with his wife who opted against emergent endoscopy and agreed to supportive measures; making the patient comfort measures only. He was transfused 500 cc of normal saline. A dopamine drip was increased. He was also started on Neo-Synephrine. He was also transfused packed red blood cells. On [**11-28**], the patient's wife made the decision to withdraw care and continue the comfort measures only for her husband. The patient was resting comfortably on a morphine drip and continued to receive suctioning. On [**11-30**], Mr. [**Known lastname 44962**] was transferred from the Medical Intensive Care Unit to the floor for continued comfort measures. He was given a morphine drip, Ativan as needed for agitation, and a scopoline patch as needed for secretions. In addition, continued communication with the wife and daughter was provided in order to support and provide some reassurance. On [**12-2**], at 4:15 a.m., the covering night float house officer was called to pronounce Mr. [**Known lastname 44962**]. Mrs. [**Known lastname 44962**] was present and agreed to an autopsy, at which time pathology was notified in order to take liver biopsy, nerve biopsies, and to obtain DNA samples in order to help determine not only the process which hastened Mr. [**Known lastname 44963**] demise but also to attempt to haplotype Mr. [**Known lastname 44962**] in order to screen the family. CONDITION AT DISCHARGE: The patient expired on [**12-2**] at 4:15 a.m. surrounded by family. DISCHARGE STATUS: To autopsy. DISCHARGE DIAGNOSES: 1. End-stage liver disease. 2. Likely Wilson's disease. 3. Progressive polyneuropathy of unknown etiology. 4. Possibly penicillamine-induced reaction. [**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**] Dictated By:[**Name8 (MD) 17134**] MEDQUIST36 D: [**2149-1-7**] 14:35 T: [**2149-1-9**] 20:31 JOB#: [**Job Number **]

[ "518.0", "275.1", "571.5", "572.2", "518.81", "789.5", "E933.8", "482.41", "358.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "03.31", "31.1", "96.6", "96.04", "54.91", "38.93" ]

icd9pcs

[ [ [] ] ]

2392, 2473

9846, 10274

1808, 2123

5034, 9708

9723, 9825

2494, 4949

165, 1598

4964, 5015

1620, 1782

2140, 2374

14,719

106,692

28995+57622

Discharge summary

report+addendum

Admission Date: [**2125-12-3**] Discharge Date: [**2125-12-14**] Service: VSU CHIEF COMPLAINT: Right carotid stenosis. HISTORY OF PRESENT ILLNESS: This is an 86-year-old gentleman who gives a history of a left TIA 1 year ago. Symptoms manifested as left upper extremity weakness. He was admitted [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital. He was found to have an 80% stenosis of the right coronary artery. The patient consulted Dr. [**Last Name (STitle) 1391**]. The patient denies a history of stroke or further transient ischemic attacks. The patient denies dizziness, memory loss, facial droop, speech changes, history of myocardial infarction. The patient is also known to have renal insufficiency, and is status post renal artery stenting in the past. The patient also has a history of gout, for which he is on allopurinol for. The patient now presents for elective right carotid endarterectomy and a renal angiogram with potential renal artery stenting. The patient also admits to claudication. He cannot walk further than 100 feet, with improvement in his symptoms with rest. He denies any rest pain. PAST MEDICAL HISTORY: Illnesses include hypertension, hyperlipidemia, gout, renal artery stenosis, status post angioplasty with stenting, peripheral vascular disease with claudication. PAST SURGICAL HISTORY: Right herniorrhaphy, remote. ALLERGIES: No known allergies. IBUPROFEN causes GI upset. MEDICATIONS: Include nifedipine 70 mg daily, Lipitor 40 mg daily, multivitamin daily, allopurinol 100 mg daily, metoprolol 50 mg b.i.d., Nexium 40 mg daily, Detrol long acting 4 mg daily, aspirin 81 mg daily, Catapres-2-TTS 1 q.72h.. SOCIAL HISTORY: The patient denies tobacco, alcohol or drug use. He has been a widow for the last 5 years. He lives alone. FAMILY HISTORY: Positive for coronary artery disease and diabetes. REVIEW OF SYSTEMS: Positive for claudication and difficulty with urination. PHYSICAL EXAMINATION: Vital signs are stable. General appearance is an alert, white male in no acute distress. HEENT exam is unremarkable. There is a carotid bruit on the right. Chest is clear to auscultation with old sternotomy scar incision. Heart is a regular rate and rhythm with a 2/6 systolic ejection murmur at the base. Abdomen is unremarkable. Extremities are without edema, ulcers or nail changes. Pulse exam shows radial pulses are palpable bilaterally. Femoral pulses are palpable bilaterally. Dorsalis pedis are absent bilaterally, and the posterior tibials are dopplerable signals bilaterally. Neurological exam reveals he is oriented. It is a nonfocal exam. Cranial nerves are intact. EOMs are intact. Pupils are equal, round and reactive to light and accommodation. Motor/sensory is intact. Strength is [**4-6**] upper and lower. There is no drift. HOSPITAL COURSE: The patient was admitted the night prior to anticipated surgery. He underwent a right carotid endarterectomy with Dacron patch angioplasty on [**2125-12-4**]. He tolerated the procedure well. He was extubated in the OR. He was neurologically intact. He was hemodynamically stable and was transferred to the PACU for continued monitoring and care. On the day of surgery, in the PACU, the patient was confused. He had a low urine output. He was fluid resuscitated with excellent results. His FENA was consistent with prerenal changes. The patient remained in the PACU until urine output improved. On postoperative day #1, his home medications were restarted. He diet was advanced. The arterial line was discontinued. He was weaned off the nitroglycerin for systolic hypertension. He was hydrated and given Mucomyst pre angio, and underwent an angio on [**2125-12-5**]. He had a renal artery stent stenosis angioplasty. He developed hypertension, requiring nitroglycerin. Cardiac enzymes were sent, which were negative. The day after angio, the patient desaturated to the low 90s. He required a 50% face mask. His chest x-ray showed congestive failure. His ABG on 4 liters nasal cannula showed an 86% saturation. His blood gas was 7.42/33/40. A Foley was placed. IV fluids were hep-locked. Placed on a nonrebreather. He was given Lasix 20 mg IV. The blood gases were repeated with improvement. Continued to monitor him during this period of time. He remained in the VICU. He required continued face mask on postoperative day #3 and continued diuresis. His BUN did bump during this period. Peaked at 2.1 from 1.6 with return to baseline. The patient was transferred to the ICU on [**2125-12-8**] because of persistent hypoxia. His white count went from 14 to 16. His hematocrit remained stable at 30. BUN was 97. Creatinine was 2.0. Diuresis was continued. He remained in the SICU. Neurologically, he remained intact. On postoperative day #5, enzymes demonstrated a peak CPK was 45, MBs were not done, troponins were 0.61 and 0.78. Cardiology was requested to see the patient in regards to the elevated troponins, in the setting of chronic renal insufficiency. Recommendations were that this was related to his myocardial demand and slow clearance of the troponin. An echo was obtained. Echo findings demonstrated moderate left atrial enlargement and a dilated right atrium. The left ventricle showed symmetric left ventricular hypertrophy with normal cavity size and systolic function with an EF of 55%. There was normal regional left ventricular systolic function. There was no resting LVOT gradient. The right ventricle was normal in chamber size and free wall motion. The aortic valve, there was a bioprosthetic aortic prosthesis. The AVR was well seeded. The leaflet disk motion and transvalvular gradients were within range. There was no aortic insufficiency. The mitral valve was mildly thickened. Mitral valve leaflets with moderate mitral valvular calcification with calcified tips of papillary muscles with mild-to- moderate mitral insufficiency. This could be worse. It is difficult to tell because of acoustic shadowing, and could be under estimated. The tricuspid valve was normal with mild regurgitation. Moderate pulmonary systolic hypertension. There was a trivial physiologic pericardial effusion. The patient was transferred to the VICU for continued monitoring and care on [**2125-12-9**] after obtaining the echo results. Gentle diuresis was continued with continued improvement in the patient's oxygenation. The patient was evaluated by physical therapy. The patient will require rehab to safely return to previous functional status, since he lives alone. On postoperative day #7, the patient remains in the VICU with intermittent episodes of confusion as to time and place. We will feel this is related to his prolonged hospitalization. Electrolytes and hematocrit are unremarkable. DISCHARGE DISPOSITION: The patient will be discharged to rehab once medically stable and bed is available. DISCHARGE DIAGNOSES: Include right carotid stenosis, symptomatic; restenosis of the renal artery stenting; status post angioplasty with a stent on [**2125-12-3**]; history of hypertension; history of gout; history of renal artery stenosis; status post angioplasty with stenting, remote; history of peripheral vascular disease with claudication; status post right inguinal hernia repair, remote; history of hyperlipidemia, on a statin; history of chronic renal insufficiency, baseline creatinine of 1.6; history of postoperative confusion; postoperative congestive heart failure, compensated. DISCHARGE MEDICATIONS: Include clonidine 0.2 mg per 24-hour patch weekly, q. Wednesday; tolterodine 2-mg tablets twice a day; allopurinol 100 mg daily; nifedipine 90 mg sustained release daily; Protonix 40 mg daily; atorvastatin 40 mg daily; aspirin 325 mg daily; Plavix 75 mg daily; hydralazine 25 mg q.6h.; Colace 100 mg b.i.d.; bisacodyl suppository 10 mg p.r.n.; metoprolol tartrate 50 mg b.i.d.. DISCHARGE INSTRUCTIONS: The patient should follow up with Dr. [**Last Name (STitle) 1391**] as directed once discharged from rehab. MAJOR SURGICAL OR INVASIVE PROCEDURES: Carotid endarterectomy with Dacron patch; angioplasty on [**2125-12-4**]; renal artery stent angioplasty on [**2125-12-5**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2125-12-11**] 11:58:05 T: [**2125-12-11**] 13:18:17 Job#: [**Job Number 69882**] Name: [**Known lastname 11887**],[**Known firstname 2197**] Unit No: [**Numeric Identifier 11888**] Admission Date: [**2125-12-3**] Discharge Date: [**2125-12-20**] Date of Birth: [**2039-3-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 231**] Addendum: [**2125-12-12**] POD#6 up all night and confused to place/time. started on seroquel@HS and prn Haldol without effect. Noted by nurses to have a change in character of his gait with leaning to right. CT head done, nondiagnositc secondary to artifact, recommend repeat when patient more cooperative. CBC and electolytes umremarkable. Being followed by Geratric Medicine. seroquel and haldol discontinued.Started zyprexa [**Hospital1 **] and additional prn doses 2/day. requiring NPT paste and IV antihypertensive medications to keep SBp <170. patient refusing po meds. IV hydration d/1/2NS @ 50cc /hr started. [**2125-12-13**] POD#7 continues to remain somulent. requires sitter. ziprexia converted to prn for agitation. Speech/Swallow requested to see patient for bedside evaluation for aspiration will return [**12-14**] to evaluate secondary to [**Hospital 1325**] clinic status. [**2125-12-14**] POD#8 less somultent and confused. Sitter discontinued. Re-evaluated by speech and swallow service since patient more coherent.No evidence of aspiration. Maintain aspiration precautions when patient is delerious. Not requiring zyprexia. Diureses for low urinary output.await reevaluation by physical thearphy. Bed search process continues. 1/13-1/18POD#[**7-15**] intermittent confusion zyprexia dose adjusted. haldol dose adjusted with gradually improvement of patient's mental status and sitters were discontinued [**2125-12-19**]. Patient has remained stable since. [**2125-12-20**] d/c to rehabe stable.Recommend zypreia dose decrease to 1.25mgm [**Hospital1 **] prn then d/c Discharge Disposition: Extended Care Facility: [**Hospital1 6463**] Health of [**Hospital3 7189**] - [**Location (un) 7190**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2125-12-20**]

[ "274.9", "996.74", "799.02", "414.8", "433.10", "428.0", "293.0", "585.9", "401.9", "440.21" ]

icd9cm

[ [ [] ] ]

[ "00.40", "88.42", "39.50", "00.44", "38.12", "88.45", "00.42" ]

icd9pcs

[ [ [] ] ]

10432, 10695

1836, 1888

6890, 7462

7486, 7865

2851, 6759

7890, 10409

1368, 1694

1989, 2833

1908, 1966

108, 133

162, 1157

1180, 1344

1711, 1819

54,613

168,310

50513

Discharge summary

report

Admission Date: [**2141-9-4**] Discharge Date: [**2141-9-5**] Date of Birth: [**2064-11-4**] Sex: M Service: MEDICINE Allergies: Lovenox / aspirin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Chest pain and Shortness of Breath Major Surgical or Invasive Procedure: Hemodialysis (Monday, Wednesday, Friday each week) History of Present Illness: History of Present Illness: 76 yo male history of anoxic brain injury s/p likely vfib arrest, ESRD on HD MWF, HTN, and DMII presenting from rehab with SOB. Per report, patient awoke with substernal chest pain and shortness of breath around 11:30 AM. In the ED, initial VS were: T97.4, HR87 BP190/87 RR22 satting 100% on NRB. Labs showed CBC with HCT of 39, otherwise rest of CBC WNL, pro BNP of [**Numeric Identifier **], Normal LFTs except for an AP of 135, and a CMP showing hyponatremia with Na of 129, hyperkalemia of 5.5, CL of 95, BUN 54, Cr of 6.9 and glucose of 251. Troponins were checked with a Trop of 0.34 with baseline in the 0.25 to 0.4 region. EKG performed showed sinus rhythm with peaked TW in the anterior leads, as well as TWI in AVL and V1. LVH present as well as LAE. No other ST/ischemic changes were noted. CXR showed bilateral infiltrates with superimposed fluid overload. Patient was provided with IV vancomycin and levofloxacin for empiric tx of PNA. In the ICU patient is complaining of [**8-8**] chest/belly pain Past Medical History: Anoxic brain injury s/p likely VF arrest in the setting of hyperkalemia CKD stage V, on HD MWF at [**Hospital **] hospital HTN DM II Severe peripheral neuropathy Glaucoma Depression Social History: Lives at [**Hospital3 537**] in JP. niece/HCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (3) 105203**] 043 - Tobacco: None - Alcohol: None - Illicits: None Family History: No history of cardiac disease, diabetes. Physical Exam: ADMIT EXAM: Vitals: T 97.6, HR 81, BP 196/93, RR 22, satting 99% ON 3L General: Alert, oriented, appears uncomfortable HEENT: Sclera anicteric, MMM, oropharynx clear with poor dentition, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, pansystolic murmur as well as [**4-4**] crescendo descrescendo murmur best auscultated parasternally. No rubs, gallops Lungs: Diffuse crackles with wheezes. Abdomen: soft, mild tenderness to palpation in epigastric region. Non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused,1+ pulses, no clubbing, cyanosis or edema. Fistula with palpable thrill and auscultated bruit in LUE. Neuro: Alert and oriented to person and place. CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 1+ reflexes bilaterally, gait deferred. DISCHARGE EXAM: Pertinent Results: IMAGING: CXR [**2141-9-4**] - FINDINGS: Diffuse parenchymal opacities with areas of increased interstitial markings are consistent with development of moderate pulmonary edema. No pneumothorax is seen. There is mild cardiomegaly. There may be small pleural effusions. Surgical clips are noted in the region of the gastroesophageal junction. MICRO/PATH: ADMIT LABS: [**2141-9-4**] 12:30AM BLOOD WBC-6.3 RBC-5.03 Hgb-11.4* Hct-39.0* MCV-78* MCH-22.7* MCHC-29.2* RDW-17.1* Plt Ct-176 [**2141-9-4**] 12:30AM BLOOD Neuts-77.2* Lymphs-15.2* Monos-5.5 Eos-1.7 Baso-0.4 [**2141-9-4**] 12:30AM BLOOD Plt Ct-176 [**2141-9-4**] 04:39AM BLOOD PT-10.1 PTT-32.5 INR(PT)-0.9 [**2141-9-4**] 12:30AM BLOOD Glucose-251* UreaN-54* Creat-6.9*# Na-129* K-5.5* Cl-95* HCO3-23 AnGap-17 [**2141-9-4**] 12:30AM BLOOD ALT-27 AST-27 AlkPhos-135* [**2141-9-4**] 12:30AM BLOOD proBNP-[**Numeric Identifier **]* [**2141-9-4**] 12:30AM BLOOD cTropnT-0.34* [**2141-9-4**] 12:30AM BLOOD Albumin-4.1 Calcium-9.1 Phos-4.5# Mg-2.7* [**2141-9-4**] 04:50AM BLOOD Type-[**Last Name (un) **] pO2-44* pCO2-52* pH-7.29* calTCO2-26 Base XS--1 [**2141-9-4**] 12:40AM BLOOD Lactate-0.8 K-5.3* RELEVENT LABS: [**2141-9-4**] 04:39AM BLOOD WBC-5.2 RBC-4.87 Hgb-11.1* Hct-37.9* MCV-78* MCH-22.9* MCHC-29.4* RDW-17.0* Plt Ct-155 [**2141-9-4**] 04:39AM BLOOD Plt Ct-155 [**2141-9-4**] 04:39AM BLOOD Glucose-314* UreaN-52* Creat-6.5* Na-129* K-5.1 Cl-96 HCO3-23 AnGap-15 Brief Hospital Course: 76 year old male with anoxic brain injury s/p likely vfib arrest, end stage renal disease on hemodialysis three times a week (monday, wednesday, friday), hypertension, and type two presenting from rehab with shortness of breath and chest pain. # Chest Pain: Intial chest xray shows bilateral multiple inflitrates concerning for fluid overload from flash pulmonary edema. While acute coronary syndrome was a concern, troponins were initially around baseline without evidence of EKG changes. While in the MICU he was treated with a nitroprusside drip given his hypertension to 220's systolic and underwent hemodialysis with the removal of 3.3 liters. His chest pain and shortness of breath resolved. Repeat EKG's and cardiac markers were unconcerning for a cardiac etiology. # Respiratory distress: Pt likely volume overloaded from renal failure and superimposed congestive heart failure exacerbation given elevated BNP, appearance of CXR, hypertension and history of similar episodes. His respiratory status improved with hemodialysis and nebulizers of albuterol and ipratropium. On day of discharge, he was dialyzed and 1.8L were removed. It appears that this is a recurrent process which may be related to inability to fully ultrafiltrate patient because BPs tend to fall. ****It is important that patient receive antihypertensives after dialysis sessions.**** [**Hospital1 **] Dialysis team will communicate with outpatient nephrologist. # End Stage Renal Disease: On hemodialysis monday, wednesday, and friday. While in the MICU we renally dosed his medication and treated him with Nephrocaps, calcium acetate, Vitamin D. On day of discharge, 1.9L were dialyzed off. For further comments see above. # Hypertension: Pt was hypertensive to systolic blood pressure of 220s on admission. Initially he was started on a nitroglycerin drip to drop pre-load and underwent dialysis for volume removal as above. He was continued on his home amlodipine, lisinopril, and carvedilol. His pulse pressure remained high, likely secondary to his fistula. # Coronary Artery Disease and Systolic Congestive Heart Failure: No evidence of acute coronary syndrome on EKG. Tropnin leak likely secondary to demand ischemia. He was constinued on his [**Last Name (un) **] medications one dialysis was complete. His BNP was elevated suggesting a acute CHF exacerbation. Unclear etiology. [**Month (only) 116**] be dietary indiscrestion or underlaying infection or inadequate fluid removal during dialysis. #Diabetes Mellitus: Chronic issue. Placed on insulin sliding scale. #Glaucoma: Chronic issue. Continued outpatient eyedrops. Transitional Issues: 1) Please check CBC on Wednseday [**9-6**] to follow up on mild leukopenia. 2) Please be sure to give antihypertensives after diaylsis sessions per renal recommendations. Medications on Admission: 1. Amlodipine 10 mg PO DAILY Hold for SBP<100 2. Omeprazole 20 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Nephrocaps 1 CAP PO DAILY 5. brimonidine *NF* 0.2 % OU [**Hospital1 **] 6. Senna 1 TAB PO BID 7. Levobunolol 0.25% 1 DROP BOTH EYES [**Hospital1 **] 8. Docusate Sodium 100 mg PO BID 9. Calcium Acetate 667 mg PO TID W/MEALS 10. Pilocarpine 1% 1 DROP RIGHT EYE QID 11. Acetaminophen 500 mg PO QOD HS 12. Gabapentin 400 mg PO HS 13. Carvedilol 12.5 mg PO BID Hold for SBP<100, HR<60 14. Lisinopril 40 mg PO DAILY Hold for SBP<100 15. Guaifenesin 20 mL PO TID cough 16. Loperamide 2 mg PO QID:PRN diarrhea 17. Polyethylene Glycol 17 g PO BID:PRN constipation 18. Epoetin Alfa 0.6 mL SC M,W,F AT HD 19. Lidocaine 5% Patch 1 PTCH TD DAILY 20. Isosorbide Mononitrate 30 mg PO QAM Hold for SBP<120 21. Loratadine *NF* 10 mg Oral qd itching, allergic rash 22. Vitamin D 50,000 UNIT PO 1X/WEEK (TU) 23. Glargine 5 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Nephrocaps 1 CAP PO DAILY 5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **] 6. Senna 1 TAB PO BID:PRN constipation 7. Levobunolol 0.25% 1 DROP BOTH EYES [**Hospital1 **] 8. Docusate Sodium 100 mg PO BID 9. Calcium Acetate 667 mg PO TID W/MEALS 10. Pilocarpine 1% 1 DROP RIGHT EYE Q6H 11. Acetaminophen 500 mg PO Q6H:PRN pain 12. Gabapentin 400 mg PO HS 13. Carvedilol 12.5 mg PO BID 14. Lisinopril 40 mg PO DAILY 15. Guaifenesin 20 mL PO TID cough 16. Epoetin Alfa 0.6 ml SC M,W,F AT HD 17. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 18. Lidocaine 5% Patch 1 PTCH TD DAILY 19. Loperamide 2 mg PO QID:PRN diarrhea 20. Loratadine *NF* 10 mg Oral qday:prn itching 21. Polyethylene Glycol 17 g PO BID:PRN constipation 22. Vitamin D 50,000 UNIT PO 1X/WEEK (TU) 23. Glargine 5 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Hypertensive urgency Pulmonary edema Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 1058**], You were admitted to the hospital when you were short of breath and had a high blood pressure. You required care in the intensive care unit for your blood pressure and you needed an extra course of dialysis to get fluid off of your lungs. It is unclear exactly why your blood pressure went so high. You were stable after this and are now safe to go back to your rehab facility. No medication changes were made **Your white blood cell count was a little low at the time of discharge and this will need to be rechecked at rehab on [**2141-9-6**]** Followup Instructions: Department: SURGICAL SPECIALTIES When: TUESDAY [**2141-10-17**] at 2:45 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 11307**], MD [**Telephone/Fax (1) 3752**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 1935**] CENTER When: THURSDAY [**2141-11-16**] at 1:45 PM With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "276.7", "V58.67", "411.89", "276.69", "585.6", "V45.11", "250.60", "357.2", "365.70", "583.81", "V12.53", "428.23", "414.01", "404.93", "311", "285.9", "348.1", "250.40", "288.50", "428.0", "365.9" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

9094, 9165

4288, 6904

318, 370

9246, 9246

2838, 4265

10033, 10816

1889, 1931

8116, 9071

9186, 9225

7123, 8093

9424, 10010

1946, 2801

2819, 2819

6925, 7097

244, 280

426, 1449

9261, 9400

1471, 1655

1671, 1873

48,409

136,465

47274

Discharge summary

report

Admission Date: [**2142-1-13**] Discharge Date: [**2142-1-18**] Date of Birth: [**2060-12-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: Unsteady gait Major Surgical or Invasive Procedure: Ultrasound-guided thoracentesis [**2142-1-14**] History of Present Illness: This is an 81-year-old female with a history of stage IV NSCLC diagnosed in [**5-/2140**], now getting palliative XRT, who presents today after she was unable to rise from a seated position on her bed. Patient states that she was sitting on her bed tonight and tried to get up to go to the comode, but felt "very imbalanced" and sat back on the bed. She subsequently was able to make her way to the toilet, but her husband was worried that she was so unsteady that he called 911. Patient reports noticable instability for the past few weeks; nothing acute, but increased trouble rising from a seated position and extra help needed with ADLs. She denies any falls in the past few weeks. Upon arrival in the ED, patient was found to be short of breath, with an 02 sat of 50-60% on room air. She immediately came up to 100% with a face mask. A CXR was done, which showed a significantly larger pleural effusion. Patient received a CTA over concern for PE, which was negative. EKG showed frequent PVCs, but no concerning ST changes. Troponin was 0.02 and patient received ASA. Initial vitals were: T: 98.0, HR 86, BP: 146/71, RR: 22. Vitals upon transfer were: HR: 103, BP: 160/83, RR: 25, SP02: 98% on 5 liters. Patient was more comfortable, though still breathing at 25 times/minute. ROS: Patient actually denies any trouble breathing, stating that she has had some DOE, but nothing at rest. She also denies any fever, "chest congestion," nausea, vomiting, diarrhea, chest pain, hemoptysis, dysuria, or other symptoms. Past Medical History: --NSCLC: Patient is followed closely by Dr. [**Last Name (STitle) 3274**] of heme/onc and Dr. [**Last Name (STitle) **] of rad-onc. A CT scan on [**12-25**] showed extensive disease (though slightly diminished from prior) with large right-sided tumor and metastatic spread to liver. Plan is for further review of cytology by pathology, and then possibly initiation of systemic chemotherapy. --Asthma as a child --Left knee replacement --Right hip fracture s/p ORIF [**2140**] --Hypertension --Amaurosis Fugax in [**2129**] --AAA repair [**2140**] --Tonsillectomy, adenoidectomy, mastoidectomy as a child --Appendicectomy --2 C-sections Social History: Patient is married and has 2 sons. [**Name (NI) **] husband is a psychiatrist, and one son is a neurologist in [**Name (NI) 760**]. She used to work at [**Hospital3 1810**] as a medical librarian. She is a longtime heavy smoker, [**1-20**] a pack per day from age 18, for an estimated total of 30 pack years. Occasional ETOH. Family History: Father with chronic leukemia and mother with HTN. Physical Exam: On admission Temp: 98.6 HR: 98 RR: 28 BP: 132/92 SP02: 96% on 5 liters General: Thin, no acute distress, tachypnic Chest: Diminished breath sounds on right, scattered crackles Cardiac: Regular rate and rhythm; normal S1 and S2; frequent PVCs Abdominal: Soft, non-tender, non-distended. +BS Extremities: Trace edema bilaterally; in pneumoboots Neuro: A&O x3, though initially thought it was [**2140**]. Easily re-directable. UE and LE motor exam grossly intact. Rectal tone deferred. Pertinent Results: CXR [**1-13**] Portable: Increased now large right effusion. Underlying consolidation not excluded. Right upper lobe mass,increased in size from [**2141-7-19**], but likely similar to CT [**2141-12-25**] . Additional lung findings and lymphadenopathy are better assessed on a prior CT. . NCHCT [**1-13**]: 1. No acute intracranial process. Please note limited sensitivity of non-contrast CT for intracranial metastases for which gadolinium-enhanced MRI is a better modality. 2. Moderate atrophy which may reflect age-associated involutional changes. 3. Chronic small vessel ischemic disease. . CTA chest [**1-13**]: 1. Overall worsening multiloculated right pleural effusion with interval increase in multiple necrotic masses, compatible with progression of metastatic lung cancer. 2. Multiple foci of air within the right pleural cavity admixed with associated pleural effusion, mildly increased since the prior study which may be due to necrosis but raises the possibility of a bronchopleural fistula. 3. Rounded 2.1 cm hepatic dome low-attenuation lesion (3:88), suboptimally characterized given arterial phase of imaging. This could represent a new metastasis or venous structure and attention on followup is recommended. CT Head [**1-16**] 1. Study significantly limited due to motion. 2. No CT evidence of large metastases, within the limitations. Pl. check the model and MR safety of aortic graft and if safe, consider MR [**Name13 (STitle) 430**] without and with contrast. 3. Unchanged moderate volume loss and chronic small vessel ischemic disease Brief Hospital Course: This is an 81-year-old female with a past medical history of NSCLC who presents from home with a 2-day history of worsening shortness of breath. . SHORTNESS OF BREATH: Shortness of breath most likely from increasing tumor burden and worsening pulmonary effusions. Other possibilities include infection, cardiac cause, or pulmonary embolus (though ruled out with CTA). Infection is unlikely given absence of fever, leukocytosis, or localizing symptoms. Cardiac cause is also lower on the differential given an absence of cardiac history. The patient continued to have an oxygen requirement following admission, and underwent an IR-guided thoracentesis after CT chest showed a loculated right-sided pleural effusion. 1.1 liters of exudative pleural fluid were removed, with subsequent improvement in oxygenation. The interventional pulmonology service were consulted regarding possible placement of pleurx catheter in right thorax given likely recurrence of malignant pleural effusion in setting stage IV non-small cell lung cancer. The patient was transferred to the MICU in anticipation of bronchoscopy. IP performed rigid bronchoscopy on [**1-17**] which was consistent with postobstructive pneumonia. Patient became progressively more hypoxic after this procedure despite supplemental oxygen and antibiotics. Patient underwent repeat bronchoscopy on [**1-18**] with additional removal of purulent material. Patient subsequently became bradycardic apneic and expired on [**1-18**]. DNR/I status was confimred with the patients husband and HCP prior to the patient's passing. . INSTABILITY/WEAKNESS: Ms. [**Known lastname 100083**] main complaint on arrival is instability and inability to get up off her bed without falling. Complaint is likely multifactorial, with etiologies including hypercalcemia, deconditioning, and poor appetite and intake. Patient also has a history of cervical spondylotic myelopathy, which could contribute to her weakness. Mild hypercalcemia was treated with IVF. TSH and cortisol were normal. The patient received physical therapy during her admission. . HYPERCALCEMIA: Patient with elevated calcium, espeically in light of low albumin. In addition to other etiologies, paraneoplastic syndrome were entertained in an individual with lung cancer (possibly squamous cell -> PTHrP). The patient received IVF initially during her hospital course, and calcium was monitored. Hydrochlorothiazide was held because of hypercalcemia. . LUNG CANCER: Patient with stage IV NSCLC. Patient was unable to tolerate chemotherapy after her initial diagnosis, and is currently being treated with palliative XRT. The plan is for further evaluation of her cytology, with the possibility of further systemic treatment. Her primary oncologist, Dr. [**Last Name (STitle) 3274**], suggested interventional pulmonology consultation as above. HTN: Held HCTZ. . HYPERCHOLESTEROLEMIA: Continued statin. . DECREASED ENERGY: Continued Ritalin 5 mg daily. Medications on Admission: Lipitor 10mg QD Epipen for bee stings Hctz 25mg QD hydrocodone-homatropine 5 mg-1.5 mg Tablet prn cough methylphenidate: 5 mg, 1 tablet [**Hospital1 **] as needed for fatigue Tylenol ASA 81mg Docusate Ergocalciferol Gucosamine-chondroitin Loperamide MV Senokot Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: lung cancer Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2142-1-19**]

[ "486", "518.81", "V87.41", "799.1", "401.9", "272.0", "V15.82", "V43.64", "511.81", "276.2", "518.0", "783.7", "519.19", "197.7", "721.1", "V15.3", "293.0", "275.42", "162.5" ]

icd9cm

[ [ [] ] ]

[ "33.23", "34.91", "96.05" ]

icd9pcs

[ [ [] ] ]

8407, 8416

5098, 8066

328, 377

8471, 8480

3513, 5075

8533, 8568

2943, 2994

8378, 8384

8437, 8450

8092, 8355

8504, 8510

3009, 3494

275, 290

405, 1924

1946, 2584

2600, 2927

20,865

152,825

25420

Discharge summary

report

Admission Date: [**2120-1-21**] Discharge Date: [**2120-1-29**] Date of Birth: [**2057-7-20**] Sex: M Service: MEDICINE Allergies: Meperidine / Demerol Attending:[**First Name3 (LF) 4393**] Chief Complaint: RUQ pain Major Surgical or Invasive Procedure: [**First Name3 (LF) **] Aspiration of Liver Abscess by Interventional Radiology History of Present Illness: The patient is a 62 yo man with h/o EtOH cirrhosis, s/p liver txp in [**2114**], complicated by hepatic artery stenosis, recurrent cholangitis over the past year. Went to OSH first, where he was foudn to be febrile to 103 with abdominal pain. Has been symptomatic for 1 day. F/N/V and was tachy to the 130s. Was given Levquin and Linezolid, and then Meropenem in the ED. 1 day h/o RUQ pain, fever, nausea, vomiting identical to prior. Tachycardic to 130s at OSH, s/p Levaquin, Linezolid. 103.6 on arrival, tachycardic, tachypneic. . In the ED, the patient's initial VS were T 103.6, P 129, BP 102/63, R 18, O2 98% on 2L. He was given Meropenem and 2 PIVs were placed. He was also given Dilaudid, Ibuprofen and Tylenol. He also had a RUQ U/S, and [**Year (4 digits) **] surgery was consulted. Hepatology was also C/S and [**Year (4 digits) **] was made aware. He then dropped his BP to the high-70s and and a RIJ was placed and he was started on Levophed. His VS at the time of admission were T 102, P 120, 95/49, R 19, O2 96% on 2L. Past Medical History: 1. h/o EtOH cirrhosis: -- c/b HCC, diuretic-resistant ascites, left hepatic hydrothorax, variceal hemorrhage s/p banding, encephalopathy, anemia -- s/p orthotopic liver [**Year (4 digits) **] - [**2115-2-21**] -- c/b renal failure [**1-10**] calcineurin toxicity, multiple episodes of biliary sludge & stones s/p repeat ERCPs (most recent [**2117-5-27**]), multiple episodes of acute cellular rejection ([**5-/2115**], [**8-/2115**], [**11/2115**]), delayed hepatic arterial thrombosis [**2115-10-9**] and resultant ischemic cholangiopathy and bile lakes 2. s/p Roux-en-Y hepaticojejunostomy [**2115-2-21**] at time of OLTx 3. CAD w/ MI s/p PTCA [**2099**] (LVEF >55% in [**1-18**]) 4. hypertension 5. dyslipidemia 6. osteoporosis 7. s/p bilateral inguinal hernia repairs 8. s/p umbilical hernia repair 9. s/p lipoma removal from left posterior neck Social History: Lives with wife. Denies current tob/etoh/drug use. The patient lives in [**Location 47**], MA with his wife. [**Name (NI) **] has a remote history of tobacco use (quit 35 years ago). He has a history of EtOH abuse, but has not had a drink for 6 years. Two children. Retired police officer. Denies illicit drugs. Family History: No family history of hereditary hemochromatosis, colon cancer or diabetes. No other family members with liver disease Physical Exam: On admission: Vitals: T: 99.4, HR 121, 109/43, 19, 99% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, except for diminished BS at bases R>L no wheezes, rales, ronchi CV: Tachy, Regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, distended, tender on RUQ/RLQ, + Hypoactive bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley-> dark yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. + 1 pitting edema bil up to knee Pertinent Results: ADMISSION LABS: [**2120-1-21**] 06:48AM WBC-5.3 RBC-4.44* HGB-9.7* HCT-30.2* MCV-68* MCH-21.9* MCHC-32.2 RDW-16.0* [**2120-1-21**] 06:48AM NEUTS-89* BANDS-10* LYMPHS-1* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2120-1-21**] 06:48AM PLT SMR-NORMAL PLT COUNT-176# [**2120-1-21**] 06:48AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-3+ POLYCHROM-NORMAL OVALOCYT-1+ [**2120-1-21**] 06:48AM GLUCOSE-182* UREA N-29* CREAT-1.4* SODIUM-141 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-20* ANION GAP-19 [**2120-1-21**] 06:48AM ALT(SGPT)-50* AST(SGOT)-59* LD(LDH)-194 ALK PHOS-352* TOT BILI-1.2 DIR BILI-1.1* INDIR BIL-0.1 [**2120-1-21**] 06:48AM LIPASE-30 [**2120-1-21**] 09:06AM LACTATE-1.9 [**2120-1-21**] 11:30AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2120-1-21**] 11:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG [**2120-1-21**] 11:30AM URINE RBC-0-2 WBC-[**5-17**]* BACTERIA-MOD YEAST-MOD EPI-0-2 [**2120-1-21**] 11:30AM URINE AMORPH-MOD [**2120-1-21**] 04:36PM rapamycin-8.0 [**2120-1-21**] 04:39PM PT-13.2 PTT-29.2 INR(PT)-1.1 Micro: [**2120-1-21**] 6:48 am BLOOD CULTURE **FINAL REPORT [**2120-1-26**]** Blood Culture, Routine (Final [**2120-1-26**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. DOXYCYCLINE Susceptibility testing requested by DR. [**Last Name (STitle) **] #[**Numeric Identifier 14013**] [**2120-1-25**]. SENSITIVE TO DOXYCYCLINE. DOXYCYCLINE sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. GRAM NEGATIVE ROD(S). COLONIAL MORPHOLOGY CONSISTENT WITH ORGANISM #1. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R Aerobic Bottle Gram Stain (Final [**2120-1-22**]): REPORTED BY PHONE TO DR. [**Known firstname **] [**Last Name (NamePattern1) 27395**] PAGER [**Numeric Identifier 63536**] @ 0240 ON [**2120-1-22**]. GRAM NEGATIVE ROD(S). . [**2120-1-21**] 6:50 am BLOOD CULTURE #2. **FINAL REPORT [**2120-1-25**]** Blood Culture, Routine (Final [**2120-1-25**]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 315-9829O [**2120-1-21**]. BACTEROIDES FRAGILIS GROUP. BETA LACTAMASE POSITIVE. Anaerobic Bottle Gram Stain (Final [**2120-1-22**]): GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final [**2120-1-22**]): GRAM NEGATIVE ROD(S).[**2120-1-21**] 11:30 am URINE **FINAL REPORT [**2120-1-22**]** URINE CULTURE (Final [**2120-1-22**]): <10,000 organisms/ml. . [**2120-1-21**] Urine Culture- No Growth [**2120-1-22**] Blood culture- No Growth [**2120-1-23**] BLOOD CULTURE Source: Line-cvl. **FINAL REPORT [**2120-1-29**]** Blood Culture, Routine (Final [**2120-1-29**]): BACTEROIDES FRAGILIS GROUP. BETA LACTAMASE POSITIVE. Anaerobic Bottle Gram Stain (Final [**2120-1-26**]): GRAM NEGATIVE ROD(S). [**2120-1-24**] BLOOD CULTURE x2 - No Growth [**2120-1-26**] ABSCESS Source: Liver aspiration. GRAM STAIN (Final [**2120-1-26**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). FLUID CULTURE (Final [**2120-1-29**]): ESCHERICHIA COLI. RARE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. . [**2120-1-26**] 9:25 am ABSCESS ANTERIOR RIGHT HEPATIC LOBE #2. GRAM STAIN (Final [**2120-1-26**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2120-1-29**]): ESCHERICHIA COLI. RARE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. ESCHERICHIA COLI. RARE GROWTH. SECOND MORPHOLOGY. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMIKACIN-------------- <=2 S <=2 S AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 16 I 16 I CEFAZOLIN------------- 8 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R =>16 R MEROPENEM-------------<=0.25 S <=0.25 S TOBRAMYCIN------------ 8 I 8 I TRIMETHOPRIM/SULFA---- =>16 R =>16 R ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. . Blood Cultures from [**1-26**], [**1-27**], [**1-28**] x2, [**1-29**] x2: No Growth To Date (PENDING) . STUDIES: [**2120-1-21**] Duplex Doppler U/S: 1. Multiple parenchymal abnormalities in the transplanted liver corresponding to the sites of previously demonstrated bilomas. Two dominant lesions in the right hepatic lobe are similar in size to [**2120-1-3**], though the more posterior shows new hypoechoic appearance. These may again represent abscesses or infected bilomas. 2. Multiple additional echogenic foci in the right hepatic lobe felt likely to relate to scarring from previous biloma cavities. 3. Patent hepatic vasculature with appropriate directionality of flow. . [**2120-1-21**] CXR: There is a right IJ line with tip in the SVC near the cavoatrial junction. The heart is moderately enlarged and there is pulmonary vascular redistribution. There are some hazy increased lung markings, but no focal infiltrate. There is no pneumothorax. . [**2120-1-24**] [**Month/Day/Year **]: Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla:The previously placed double pigtail and Cotton-[**Doctor Last Name **] biliary stents were noted at the major papilla. The stents were removed with a snare. Evidence of a previous sphincterotomy was noted in the major papilla. Cannulation: Cannulation of the biliary duct was performed with a balloon catheter using a free-hand technique. A straight tip guidewire was placed. Biliary Tree: The CBD was briefly opacified with contrast and a normal biliary anastomosis was noted. Balloon sweeps of the right and left hepatic ducts and CBD were performed with successful extraction of some sludge. Excellent drainage of contrast and bile was noted. Impression: The previously placed double pigtail and Cotton-[**Doctor Last Name **] biliary stents were noted at the major papilla. The stents were removed with a snare. Evidence of a previous sphincterotomy was noted in the major papilla. Cannulation of the biliary duct was performed with a balloon catheter using a free-hand technique The CBD was briefly opacified with contrast and a normal biliary anastomosis was noted. Balloon sweeps of the right and left hepatic ducts and CBD were performed with successful extraction of some sludge. Excellent drainage of contrast and bile was noted. . [**2120-1-25**] CXR: FINDINGS: PA and lateral views of the chest were obtained. The cardiac silhouette is stably enlarged. The lung volumes are low. Moderate pulmonary vascular congestion persists. There are moderate bilateral pleural effusions, right greater than left, which are slightly more prominent when compared to the prior study. Bibasilar atelectasis is noted. There is no pneumothorax. No acute osseous abnormalities are identified. . [**2120-1-29**] LIVER OR GALLBLADDER US (SINGLE ORGAN) FINDINGS: Again seen are three distinct predominantly hypoechoic lesions within the liver compatible with known abscesses. One in the left mid liver measuring 2.6 x 2.4 x 2.4 cm appears unchanged with a small amount of internal echogenicity. A second abscess is seen in the right superior liver measuring 3.0 x 3.0 x 2.7 cm also unchanged. A third lesion in the right inferior liver is overall stable in size measuring 5.9 x 4.6 x 4.3 cm. In the interval from the recent drainage the contents are slightly more echogenic and areas now present within the abscess. No new lesions are identified. A pocket of free fluid appears similar to prior examinations. No intrahepatic biliary dilation is seen. The gallbladder is not present. Normal arterial and venous waveforms are seen within the liver. The spleen is enlarged measuring 15 cm. IMPRESSION: 1. Stable size of known liver abscesses. Recently drained right inferior abscess now contains air and less fluid; however, overall unchanged in size. 2. Patent hepatic vasculature with appropriate flow. 3. Splenomegaly. . DISCHARGE LABS: [**2120-1-29**] 05:53AM BLOOD WBC-5.4# RBC-3.84* Hgb-8.6* Hct-27.4* MCV-71* MCH-22.5* MCHC-31.5 RDW-17.2* Plt Ct-95* [**2120-1-28**] 06:24AM BLOOD Neuts-72.8* Lymphs-16.3* Monos-9.0 Eos-1.6 Baso-0.3 [**2120-1-29**] 05:53AM BLOOD PT-14.4* PTT-27.6 INR(PT)-1.2* [**2120-1-29**] 05:53AM BLOOD Glucose-105* UreaN-12 Creat-0.9 Na-133 K-4.4 Cl-98 HCO3-28 AnGap-11 [**2120-1-29**] 05:53AM BLOOD ALT-53* AST-30 AlkPhos-169* TotBili-0.6 [**2120-1-29**] 05:53AM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.2 Mg-1.8 [**2120-1-28**] 06:24AM BLOOD calTIBC-160* Hapto-353* Ferritn-340 TRF-123* [**2120-1-29**] 05:53AM BLOOD Osmolal-274* [**2120-1-29**] 05:53AM BLOOD rapmycn-8.3 Brief Hospital Course: 62 yo man with h/o EtOH cirrhosis, s/p liver txp in [**2114**], complicated by hepatic artery stenosis, recurrent cholangitis over the past year who presents with sepsis. . # Sepsis: Patient was admitted to the MICU with temp of 103, chills and RUQ abd pain, hypotension. Given hx of ESBL bacterimia in blood in [**2119-11-8**], he was started on [**Last Name (un) **]; given h/o VRE, started on linezolid. The latter was d/c-ed when blood cultures returned with GNRs. Source of bacteremia felt most likely to be cholangitis; also with bilomas- discussed with ID whether would be wise to drain these; they were were undecided when patient was called out to the floor. GI was contact regarding [**Last Name (un) **] and stent placement, but it was felt this was not an emergent need and he would benefit from an infectious cool down. He was weaned off pressors and was called out to the floor for further management. . #. Recurrent Cholangitis/Infected Biloma: Patient is s/p liver [**Last Name (un) **] in [**2114**] complicated by hepatic artery stenosis. Pt now presenting with reccurent cholangitis. Was seen by [**Year (4 digits) **] and recommended non-emergency procedure as above. ID equivocal about drainage of bilomas given risk of reaccumulation and cross-infection. Was treated with meropenem and called out to the floor as above. On the floor blood cultures returned as E.Coli sensititive to ceftriaxone and bactereoides fragilis so started on ceftriaxone and flagyl. Had one culture growing out bacteroides even after starting antibiotics. He had an [**Year (4 digits) **] which did not show any biliary obstruction nor pus. Previously placed double pigtail and Cotton-[**Doctor Last Name **] biliary stents were removed. Pt had liver abscess drained by IR and fluid returned 2 species of E.Coli both sensitive to ceftriaxone. Follow-up ultrasound looked similar to ultrasound on admission without worsening abscess. Hepatology strongly recommends 6 weeks of IV antibiotics. ID recommended 3 weeks of IV antibiotics from last positive culture. The patient had a PICC placed and will follow-up with [**Doctor Last Name 1326**] hepatology and ID. . # Liver [**Doctor Last Name 1326**]: S/p liver [**Doctor Last Name **] in [**2114**] for ETOH cirrhosis. Currently on sirolimus 2.5mg daily in addition to bactrim prophylaxis. Given recurrent biliary stricture was placed back on [**Year (4 digits) **] list. Continued his home rapamycin level and trended his MELD. . # [**Last Name (un) **]: Pt p/w with elevation in creatine from baseline of 0.9->1.6. Likely due to pre-renal causes given poor PO intake in the few days and likely sepsis leading to hypoperfusion. Improved with IVF to baseline Cr. . # Anemia: The patient was anemic on admission near his baseline of 30 which trended down during his admission to a nadir of 24.4. No evidence of hemolysis on labs and iron labs consistent with chronic inflammation. He was transfused 1 unit of RBCs with an appropriate bump in his hct to 27.4 prior to discharge. . # Non-Anion Gap acidosis: Hyperchlorimic due to fluids (total of 6L of NS). Lactate not elevated. D/c-ed NS and bolused with LR as needed. On the floor, the patient did not have an anion gap. . # Hx of Coronary Artery Disease: Held ASA in anticipation of possible [**Last Name (un) **]. This was restartd along with his simvastatin. Held atenolol and linsinopril given septic picture. . # Code status: Full Code Medications on Admission: Alendronate 70 mg q Friday Atenolol 25 mg PO daily Doxycycline hyclate 100 mg PO BID Furosemide 20 mg PO daily Lisinopril 5 mg PO daily Omeprazole 20 mg PO qhs Simvastatin 20 mg PO qhs Sulfamethoxazole-trimethoprim 400-80 mg PO daily Ursodiol 600 mgqam Ursodiol 300 mg qhs Ambien 10 mg qhs Aspirin 325 mg PO daily Align 4 mg PO daily Caltrate-600 Plus Vitamin D3 PO BID Ferrous sulfate 300 mg TID MVI daily Rapamune 2.5 mg daily Discharge Medications: 1. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 2. ursodiol 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QFriday. 4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO at bedtime. 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 11. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 12. Align 4 mg Capsule Sig: One (1) Capsule PO once a day. 13. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 14. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 15. multivitamin Tablet Sig: One (1) Tablet PO once a day. 16. sirolimus 1 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 17. ceftriaxone 2 gram Recon Soln Sig: Two (2) gram Intravenous once a day for 19 days: to finish on [**2120-2-17**]. Disp:*19 doses* Refills:*0* 18. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 19 days: to finish [**2120-2-17**]. Disp:*57 Tablet(s)* Refills:*0* 19. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours for 1 weeks: do not drive while taking this medication. Disp:*25 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Home Solutions Discharge Diagnosis: Primary Diagnosis: Septick Shock, Cholangitis, Liver Abscess Secondary Diagnoses: Acute on Chronic Renal Failure, EtOH Cirrhosis status-post Orthotopic Liver [**Month/Day/Year 1326**]. 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 for a recurrence of the severe infections of your liver and biliary tree. You were treated with IV antibiotics and improved. An [**Month/Day/Year **] was performed and your stents were removed. You underwent a procedure by interventional radiology to drain an abscess in your liver. You had a PICC placed and will continue IV antibiotics as an outpatient to complete a [**2-11**] week course (Day 1 [**2120-1-26**]). . The following changes were made to your medications: START Ceftriaxone START Flagyl (Metronidazole) STOP doxycyline until Dr. [**Last Name (STitle) 724**] tells you otherwise. . It was a pleasure taking care of you. . Should your fevers worsen; you have chills, rigors, your pain worsens, changes in the coloration of your urine (darkening with [**First Name8 (NamePattern2) **] [**Location (un) 2452**] coloration) or anything else that concerns you please call Dr.[**Name (NI) 948**] office or come back to our emergency room. . You will need weekly labs drawn and results faxed to Dr. [**Last Name (STitle) 724**]. Followup Instructions: Dr.[**Name (NI) 6767**] office will call you to make an appointment in two weeks time, before you finish the antibiotics. If you do not hear from his office by tomorrow, then you should call and make an appointment at ([**Telephone/Fax (1) 4170**]. . Please call the liver [**Telephone/Fax (1) **] clinic at [**Telephone/Fax (1) 673**] for an appointment early next week. . Department: [**Telephone/Fax (1) **] When: WEDNESDAY [**2120-2-7**] at 11:00 AM With: [**Year (4 digits) **] [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: ENDO SUITES When: WEDNESDAY [**2120-3-20**] at 9:30 AM Department: DIGESTIVE DISEASE CENTER When: WEDNESDAY [**2120-3-20**] at 9:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]

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Discharge summary

report

Admission Date: [**2147-9-1**] Discharge Date: [**2147-9-5**] Date of Birth: [**2107-2-1**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Right middle lobe nodule Major Surgical or Invasive Procedure: [**2147-9-1**] Video-assisted thoracoscopic surgery, right middle lobectomy. History of Present Illness: Mrs [**Known lastname **] is known the Thoracic surgery service due to previous Left Vats with wedge resection of left lower lobe nodule in [**10-16**] and then another wedge resection of a nodule in left upper lobe in 9/[**2145**]. Both nodules were metastatic melanoma. In addition to the original resection of melanoma on the right cheek, she also had a resection of recurrence within the parotid gland which was resected as well. She has completed 13 cycles of GMCSF injections; and a repeat CT chest showed that there is a new lesion in the right middle lobe. Upon review, it looks like that lesion was there before but now it is bigger and more solid. She is being admitted following right video-assisted thoracoscopy with right middle lobectomy. Past Medical History: Melanoma GERD Anxiety Social History: has 3 children Family History: reviewed and is non-contributory Physical Exam: VS: T: 98.9 HR: 88 SR BP 100/64 Sats: 99% RA General: 40 year-old female in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR normal S1,S2 no murmur/gallop or rub Resp: decreased breath sounds on right otherwise clear bilateral GI: benign Extr: warm no edema Incision: R VATs site clean dry intact no erythema Neuro: awake, alert oriented Pertinent Results: [**2147-9-5**] WBC-3.3* RBC-3.28* Hgb-9.8* Hct-28.5 Plt Ct-150 [**2147-9-3**] WBC-4.8 RBC-3.50* Hgb-10.6* Hct-31.1 Plt Ct-128* [**2147-9-1**] WBC-8.8 RBC-3.88* Hgb-11.9* Hct-33.8 Plt Ct-169 [**2147-9-5**] Glucose-78 UreaN-5* Creat-0.6 Na-141 K-3.5 Cl-103 HCO3-31 [**2147-9-3**] Glucose-104* UreaN-4* Creat-0.7 Na-140 K-3.4 Cl-98 HCO3-34* [**2147-9-2**] Glucose-99 UreaN-8 Creat-0.7 Na-139 K-4.3 Cl-101 HCO3-30 [**2147-9-1**] Glucose-120* UreaN-10 Creat-0.7 Na-139 K-4.1 Cl-106 HCO3-28 [**2147-9-5**] Calcium-8.3* Phos-2.5* Mg-1.8 CXR: [**2147-9-4**]: A miniscule right apical pneumothorax could have been present on [**9-3**]. The moderate volume of subcutaneous emphysema in the right chest wall is unchanged. Small right pleural effusion is likely also unchanged. Right infrahilar atelectasis is worsened. Left lung is grossly clear. No left pneumothorax. Heart size normal. Generalized intestinal distention in the upper abdomen is unchanged. [**2147-9-3**]: Right-sided chest tube has been removed. There is a tiny residual right apical pneumothorax, less than 5%. Subcutaneous air tracks through the right chest wall. Left lung is relatively clear. Heart and mediastinum are within normal limits. [**2147-9-1**]: post surgical changes; small right apical pneumothorax. Brief Hospital Course: Mrs. [**Known lastname **] was admitted following Video-assisted thoracoscopic surgery, right middle lobectomy. She was extubated in the operating room, monitored in the PACU. While in the PACU postoperatively she experienced severe pain which was managed with Dilaudid, NSAIDs. She was transferred to the floor in stable condition blood pressure in the low 90's which is her baseline. On [**2147-9-3**] she became lethargic with respiratory depression and acidosis ABG pH 7.32/73/74 she was transferred to the ICU, BiPAP for 2.5 Hrs with improved oxygenation. Narcotics were discontinued, aggressive pulmonary toilet, incentive spirometer saturations 95% on room air. She transferred to the floor on [**2147-9-4**] without any further respiratory issues. Chest tube: Right [**Doctor Last Name 406**] drain with small persistent air leak remain on water-seal and was removed on [**2147-9-3**]. Chest films: serial chest films showed small right apical PTX which resolved. Right lower lobe atelectasis with small pleural effusion, left clear. Cardiac: sinus rhythm 70-80's Blood pressure 90-110 stable GI: PPI and bowel regime Nutrition: tolerated a regular diet. Renal: Foley was remove on POD1, she developed urinary retention Foley re-inserted with 1L out. Once narcotics were removed the Foley was removed and she voided. Pain: the acute pain service was consulted who recommend Lidoderm patch, Toradol, Gabapentin and Dilaudid initially. Following her respiratory acidosis her pain was well controlled with Toradol, Lidoderm patch and Vicodin prn. She was discharged with Motrin and her home dose Vicodin. Disposition: she continued to make steady progress and was discharged to home on [**2147-9-5**]. She will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Lexapro 20 mg daily, Bupropion 300 mg daily, Hydrocodone-Acetaminophen 5-325 prn, Motrin, Lorazepam 0.5 prn, Vit D, MVI, Ranidine 150 mg hs Discharge Medications: 1. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for reflux. 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q 12H (Every 12 Hours): 12 hrs on 12 hrs off. Disp:*5 Adhesive Patch, Medicated(s)* Refills:*0* 7. Motrin 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain: take with food and water. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: right middle lobe lung nodule Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or chest pain -Incision develops drainage -Chest tube site cover with a bandaid if you notice any drainage -You may shower. No tub bathing or swimming until all incisions healed -Walk 4-5 times a day for 10-15 minutes increasing to a goal of 30 minutes Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] [**0-0-**] [**9-21**] 3:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**] Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your appointment. Completed by:[**2147-9-5**]

[ "300.00", "338.18", "276.2", "197.0", "V10.82", "530.81" ]

icd9cm

[ [ [] ] ]

[ "32.30", "33.22" ]

icd9pcs

[ [ [] ] ]

5889, 5895

3072, 4870

343, 422

5969, 5969

1770, 3049

6544, 6832

1302, 1336

5060, 5866

5916, 5948

4896, 5037

6120, 6521

1351, 1751

279, 305

450, 1208

5984, 6096

1230, 1253

1269, 1286

6,901

198,044

16225

Discharge summary

report

Admission Date: [**2133-8-27**] Discharge Date: [**2133-9-3**] Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 64**] Chief Complaint: L hip OA Major Surgical or Invasive Procedure: L THR History of Present Illness: [**Age over 90 **]M with L hip OA Past Medical History: HTN GERD Sinus node dysfunction --> DDD pacer (v-paced at 70) Atrial fibrillation s/p cardioversion s/p ORIF "right leg" Cholecystectomy Cataract removal TURP Aortic stenosis s/p AVR (St. [**Male First Name (un) 923**] porcine valve, [**10-8**]) Carpal tunnel syndrome s/p release Allergic rhinitis Social History: Mr. [**Known lastname 46286**] is a retired window cleaner. He quit smoking 20 years ago and reports having smoked 1.5 packs per day for sixty years. He estimates drinking about 3 alcoholic drinks per month. He lives alone. Family History: Mr. [**Known lastname 46286**] [**Last Name (Titles) **] any contributory family history. Physical Exam: At the time of discharge: AVSS NAD wound c/d/i without erythema [**Last Name (un) 938**]/FHL/TA/GS intact SILT distally Pertinent Results: [**2133-9-3**] 06:25AM BLOOD WBC-6.5 RBC-3.35* Hgb-9.5* Hct-28.5* MCV-85 MCH-28.4 MCHC-33.3 RDW-16.3* Plt Ct-257 [**2133-9-2**] 06:35AM BLOOD WBC-6.7 RBC-3.26* Hgb-9.6* Hct-27.7* MCV-85 MCH-29.4 MCHC-34.6 RDW-16.0* Plt Ct-217 [**2133-9-1**] 07:00AM BLOOD WBC-6.5 RBC-3.17* Hgb-9.3* Hct-27.5* MCV-87 MCH-29.2 MCHC-33.8 RDW-16.1* Plt Ct-196 [**2133-8-31**] 04:36AM BLOOD WBC-7.1 RBC-3.15* Hgb-9.1* Hct-26.9* MCV-85 MCH-28.9 MCHC-33.9 RDW-15.9* Plt Ct-159 [**2133-8-30**] 09:30PM BLOOD Hct-27.7* [**2133-8-30**] 04:34AM BLOOD WBC-7.4 RBC-3.00* Hgb-8.5* Hct-25.9* MCV-86 MCH-28.5 MCHC-33.0 RDW-15.6* Plt Ct-130* [**2133-8-29**] 04:30AM BLOOD WBC-10.5 RBC-3.54* Hgb-10.0* Hct-30.4* MCV-86 MCH-28.1 MCHC-32.7 RDW-15.6* Plt Ct-158 [**2133-8-28**] 04:36AM BLOOD WBC-9.5# RBC-3.60*# Hgb-10.3*# Hct-31.1* MCV-86 MCH-28.7 MCHC-33.2 RDW-15.6* Plt Ct-159# [**2133-8-27**] 09:50PM BLOOD Hct-29.6*# [**2133-8-27**] 08:25PM BLOOD WBC-6.2# RBC-2.37*# Hgb-6.8*# Hct-20.8*# MCV-88 MCH-28.7 MCHC-32.8 RDW-15.5 Plt Ct-105* [**2133-8-27**] 04:03PM BLOOD WBC-12.8*# RBC-3.62* Hgb-10.3* Hct-31.3* MCV-86 MCH-28.4 MCHC-32.8 RDW-15.4 Plt Ct-163 [**2133-8-30**] 04:34AM BLOOD Neuts-79.9* Lymphs-10.8* Monos-5.8 Eos-3.3 Baso-0.2 [**2133-9-3**] 06:25AM BLOOD Plt Ct-257 [**2133-9-3**] 06:25AM BLOOD PT-33.3* PTT-38.4* INR(PT)-3.5* [**2133-9-2**] 06:35AM BLOOD Plt Ct-217 [**2133-9-2**] 06:35AM BLOOD PT-33.1* PTT-39.7* INR(PT)-3.5* [**2133-9-1**] 09:20PM BLOOD PT-33.0* PTT-43.2* INR(PT)-3.4* [**2133-9-1**] 07:00AM BLOOD Plt Ct-196 [**2133-8-31**] 04:36AM BLOOD Plt Ct-159 [**2133-9-1**] 09:20PM BLOOD PT-33.0* PTT-43.2* INR(PT)-3.4* [**2133-9-1**] 07:00AM BLOOD Plt Ct-196 [**2133-8-31**] 04:36AM BLOOD Plt Ct-159 [**2133-8-31**] 04:36AM BLOOD PT-19.8* PTT-36.0* INR(PT)-1.8* [**2133-8-30**] 04:34AM BLOOD Plt Ct-130* [**2133-8-30**] 04:34AM BLOOD PT-17.6* PTT-35.9* INR(PT)-1.6* [**2133-8-29**] 04:30AM BLOOD Plt Ct-158 [**2133-8-29**] 04:30AM BLOOD PT-16.3* INR(PT)-1.4* [**2133-8-28**] 04:36AM BLOOD Plt Ct-159# [**2133-8-28**] 04:36AM BLOOD PT-14.9* PTT-29.4 INR(PT)-1.3* [**2133-8-27**] 08:25PM BLOOD Plt Ct-105* [**2133-8-27**] 08:25PM BLOOD PT-16.3* PTT-35.1* INR(PT)-1.5* [**2133-8-27**] 04:03PM BLOOD Plt Ct-163 [**2133-9-3**] 06:25AM BLOOD Glucose-92 UreaN-15 Creat-0.9 Na-137 K-3.8 Cl-104 HCO3-26 AnGap-11 [**2133-9-2**] 06:35AM BLOOD Glucose-92 UreaN-17 Creat-0.8 Na-139 K-3.8 Cl-104 HCO3-25 AnGap-14 [**2133-9-1**] 07:00AM BLOOD Glucose-89 UreaN-18 Creat-0.7 Na-137 K-3.8 Cl-103 HCO3-26 AnGap-12 [**2133-8-31**] 04:36AM BLOOD Glucose-95 UreaN-23* Creat-0.8 Na-138 K-3.4 Cl-104 HCO3-27 AnGap-10 [**2133-8-30**] 04:34AM BLOOD Glucose-100 UreaN-25* Creat-0.8 Na-137 K-3.9 Cl-106 HCO3-28 AnGap-7* [**2133-8-29**] 04:30AM BLOOD Glucose-111* UreaN-22* Creat-0.8 Na-135 K-3.8 Cl-102 HCO3-29 AnGap-8 [**2133-8-28**] 04:36AM BLOOD Glucose-111* UreaN-23* Creat-0.9 Na-142 K-4.1 Cl-108 HCO3-25 AnGap-13 [**2133-8-27**] 08:25PM BLOOD Glucose-93 UreaN-20 Creat-0.9 Na-138 K-4.1 Cl-104 HCO3-26 AnGap-12 [**2133-8-27**] 04:03PM BLOOD Glucose-98 UreaN-23* Creat-1.0 Na-138 K-4.1 Cl-106 HCO3-25 AnGap-11 [**2133-8-28**] 04:36AM BLOOD CK(CPK)-418* [**2133-8-28**] 04:36AM BLOOD CK-MB-6 cTropnT-0.03* [**2133-8-27**] 08:25PM BLOOD CK-MB-5 cTropnT-0.02* [**2133-9-3**] 06:25AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.9 [**2133-9-2**] 06:35AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.8 [**2133-9-1**] 07:00AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.8 Iron-17* [**2133-8-31**] 04:36AM BLOOD Calcium-8.0* Phos-1.9* Mg-1.8 [**2133-8-30**] 04:34AM BLOOD Calcium-8.0* Phos-1.8* Mg-2.0 [**2133-8-29**] 04:30AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.0 [**2133-8-28**] 04:36AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0 [**2133-8-27**] 08:25PM BLOOD Calcium-8.2* Phos-3.2 Mg-1.7 [**2133-8-27**] 04:03PM BLOOD Calcium-8.2* Phos-3.3 Mg-2.1 [**2133-9-1**] 07:00AM BLOOD calTIBC-226* VitB12-338 Folate-11.0 Ferritn-197 TRF-174* Brief Hospital Course: The patient was admitted on [**2133-8-27**] and, later that day, was taken to the operating room by Dr. [**Last Name (STitle) **] for L THR without complication. Please see operative report for details. Postoperatively the patient was hypotensive in the PACU and unresponsive to fluid boluses, albumin and intermittent neo boluses. The patient was transferred to the ICU where he was maintained on a dopamine drip from [**2133-8-27**] until [**2133-8-30**]. He received a 1 unit transfusion on POD#1 for HCT 25.9. On [**2133-8-31**] the patient was deemed safe for transfer to the floor where he continued to do well. He received IV antibiotics for 24 hours postoperatively, as well as coumadin for DVT prophylaxis. He received a lovenox bridge until his INR became therapeutic. His INR was 3.5 on [**2133-9-2**] so his coumadin dose was reduced to 4mg daily (from his usual home dose of 8mg daily). The drain was removed without incident on POD#1. The Foley catheter was removed without incident on POD#5. The surgical dressing was removed on POD#2 and the surgical incision was found to be clean, dry, and intact without erythema or purulent drainage. While in the hospital, the patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was stable, and the patient's pain was adequately controlled on a PO regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient was discharged to rehabilitation in a stable condition. Medications on Admission: digoxin 125mcg qd, lasix 20 qd, lisinopril 2.5 qd, omeprazole 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. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous once a day for 3 weeks: To be followed by aspirin 325mg daily for 3 weeks. 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Target INR 2-2.5. INR to be followed by rehab physician while at rehab followed by PCP Dr [**Last Name (STitle) **] (phone [**Telephone/Fax (1) 1144**]) after discharge. 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as needed for insomnia. 15. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4-6H () as needed for breakthrough pain. 16. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days: Until [**2133-9-8**]. 17. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **] Discharge Diagnosis: L hip OA Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet experience severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your PCP regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not operate heavy machinery or drink alcohol when taking these medications. As your pain improves, please decrease the amount of pain medication. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (e.g., colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by a visiting nurse at 2 weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment at 4 weeks. 8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, advil, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg daily for an additional three weeks. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower after POD#5 but do not take a tub-bath or submerge your incision until 4 weeks after surgery. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by VNA in 2 weeks. If you are going to rehab, the rehab facility can remove the staples at 2 weeks. 11. ACTIVITY: Weight bearing as tolerated on the operative leg, and CPM machine advancing as tolerated. No strenuous exercise or heavy lifting until follow up appointment. 12. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at 2 weeks after surgery. Physical Therapy: WBAT Treatments Frequency: Wound checks. Physical therapy. VNA to remove staples at 2 weeks. Lovenox injections. Followup Instructions: Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2133-9-10**] 3:40 Provider: [**First Name8 (NamePattern2) 4599**] [**Last Name (NamePattern1) 9856**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2133-9-25**] 9:20 CC:[**Telephone/Fax (1) 46287**]

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icd9cm

[ [ [] ] ]

[ "38.93", "81.51" ]

icd9pcs

[ [ [] ] ]

8524, 8618

5043, 6732

272, 280

8671, 8680

1173, 5020

11350, 11682

927, 1018

6844, 8501

8639, 8650

6758, 6821

8704, 10402

1033, 1154

11213, 11218

11240, 11327

224, 234

10414, 11195

308, 343

365, 666

682, 911

50,561

174,086

42509

Discharge summary

report

Admission Date: [**2142-12-13**] Discharge Date: [**2142-12-21**] Date of Birth: [**2110-2-13**] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3006**] Chief Complaint: Left thumb amputation while at work Major Surgical or Invasive Procedure: -Left thumb replantation -Left thumb arterial anastamotic revision -Left thumb leech therapy -Left infra-clavicular pain catheter placement History of Present Illness: 32yo RHD male with left thumb amputation through the proximal phalanx. Occurred at work with a large press / cutting machine used to divide rubber. No LOC or other injuries. Tetanus UTD. Transferred from [**Hospital **] with distal tip on ice. Past Medical History: Anxiety Addiction Social History: Single, machinist, [**12-3**] ppd smoker, [**12-3**] EtOH'ic drinks/d, former opiate abuse, currently on suboxone, weekly marijuana Family History: Denies Physical Exam: Left thumb stump with moist gauze, no bleeding, sharp injury just proximal to IP joint.No injury to remainder of hand Pertinent Results: [**2142-12-14**] 03:49AM BLOOD WBC-5.9 RBC-2.95* Hgb-9.0* Hct-26.5* MCV-90 MCH-30.4 MCHC-33.9 RDW-12.2 Plt Ct-184 [**2142-12-14**] 11:28AM BLOOD WBC-8.5 RBC-2.74* Hgb-8.5* Hct-24.8* MCV-91 MCH-30.8 MCHC-34.1 RDW-12.2 Plt Ct-188 [**2142-12-14**] 07:46PM BLOOD WBC-7.4 RBC-2.14* Hgb-6.6* Hct-19.5* MCV-91 MCH-30.6 MCHC-33.7 RDW-12.1 Plt Ct-193 [**2142-12-15**] 01:38AM BLOOD Hct-22.6* [**2142-12-15**] 04:31AM BLOOD WBC-7.8 RBC-2.45* Hgb-7.5* Hct-21.4* MCV-87 MCH-30.7 MCHC-35.1* RDW-14.2 Plt Ct-115* [**2142-12-15**] 08:56AM BLOOD Hct-23.1* [**2142-12-15**] 02:46PM BLOOD WBC-7.2 RBC-2.63* Hgb-8.0* Hct-23.0* MCV-87 MCH-30.3 MCHC-34.7 RDW-14.3 Plt Ct-146* [**2142-12-15**] 10:05PM BLOOD Hct-22.0* [**2142-12-16**] 03:05AM BLOOD WBC-6.2 RBC-2.38* Hgb-7.3* Hct-21.0* MCV-88 MCH-30.5 MCHC-34.7 RDW-14.0 Plt Ct-153 [**2142-12-17**] 12:04AM BLOOD WBC-6.6 RBC-2.49* Hgb-7.4* Hct-21.8* MCV-88 MCH-29.9 MCHC-34.1 RDW-13.9 Plt Ct-154 [**2142-12-17**] 06:15AM BLOOD Hct-24.5* [**2142-12-18**] 05:00AM BLOOD WBC-8.2 RBC-2.87* Hgb-8.7* Hct-24.9* MCV-87 MCH-30.2 MCHC-34.9 RDW-14.7 Plt Ct-181 [**2142-12-20**] 05:23AM BLOOD WBC-9.7 RBC-2.79* Hgb-8.7* Hct-24.3* MCV-87 MCH-31.1 MCHC-35.6* RDW-14.8 Plt Ct-265 [**2142-12-14**] 03:49AM BLOOD PT-12.3 PTT-32.2 INR(PT)-1.1 [**2142-12-14**] 03:49AM BLOOD Plt Ct-184 [**2142-12-14**] 11:28AM BLOOD Plt Ct-188 [**2142-12-14**] 07:46PM BLOOD Plt Ct-193 [**2142-12-15**] 04:31AM BLOOD PT-13.4* PTT-27.3 INR(PT)-1.2* [**2142-12-15**] 04:31AM BLOOD Plt Ct-115* [**2142-12-15**] 02:46PM BLOOD PT-12.0 PTT-28.1 INR(PT)-1.1 [**2142-12-15**] 02:46PM BLOOD Plt Ct-146* [**2142-12-15**] 10:05PM BLOOD PTT-27.6 [**2142-12-16**] 03:05AM BLOOD PT-12.1 PTT-28.2 INR(PT)-1.1 [**2142-12-16**] 03:05AM BLOOD Plt Ct-153 [**2142-12-17**] 12:04AM BLOOD PT-11.8 PTT-33.4 INR(PT)-1.1 [**2142-12-17**] 12:04AM BLOOD Plt Ct-154 [**2142-12-18**] 05:00AM BLOOD Plt Ct-181 Brief Hospital Course: 32 yo RHD male with left thumb traumatic amputation at work and anxiety disorder that persisted as a problem for the entire hospital stay. [**2142-12-13**] - Admitted to OR (with left infraclavicular pain catheter in place) for left thumb replant. Post-op to PACU for observation, pain control, Subcutaneous heparin / toradol / ASA / heparin soaked sponge to nail bed. [**2142-12-14**] - Taken back to OR for left thumb arterial anastamotic revision. Post-op to PACU on same meds. Later changed to IV Heparin 500 units / hour. Began leech therapy to left thumb. HCT was 19.5. Ordered two units of PRBC to be transfused. Type and crossmatch was pending. Called to bedside later that evening for patient becoming unresponsive and hypotensive. Received fluid bolus, albumin, 1 dose of neosynephrine. Heparin IV changed to 250 units / hour. Leeches changed to Q6 hours. Received 4 units of PRBC. Doppler pulses stable. Pain control still an issue / Acute pain service on board. [**2142-12-15**] to [**2142-12-17**] - Transferred to SICU. Received two more units of PRBC. Stable. Held leech therapy for "venous stress test". Passed. Did not become congested and maintained doppler pulse. [**2142-12-18**] - Transferred to CC6. Pain catheter removed started on PO dilaudid, acute service signed off. Pain continues as uncontrolled. The acute pain service asked us to call the chronic pain service. [**2142-12-19**] - Leech therapy restarted for congested thumb. Thumb pinked up within an hour of the leech placement. Oozing persisted so Leeches changed to Q6 hours. Pain still an issue despite Dilaudid 14mg Q3hours pen. [**2142-12-20**]- Morning HCT stable @ 24.3. One more leech added then stopped again for "venous stress test" Called secondary to patient wanting to leave AMA. Team member spoke with the patient for an hour, he became calm. Pain service changed to Dilaudid 16 mg Q3 hours. [**2142-12-21**] - AF, VSS. Tol PO, ambulating independently, pain management regimen in place. Awaiting cast placement. Stable to be discharged. Medications on Admission: Clonidine, alprazolam Discharge Medications: 1. clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for anxiety / insomnia. 2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day as needed for anti-platelet / analgesia for 1 months. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for prophylaxis after leech therapy for 10 days. 5. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for infection prophylaxis following amputation for 10 days. 6. alprazolam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for anxiety. 7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) as needed for pain for 2 months. 8. hydromorphone 8 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 2 weeks. Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA Discharge Diagnosis: -Left thumb traumatic amputation -Status post left thumb replantation -Status post left thumb arterial anastamotic revision -Anxiety Disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. **FALL PRECAUTIONS** - Take extra care to protect thumb in uncontrolled environments (snow, ice, crowds, etc..) Discharge Instructions: -Keep left hand elevated on pillows -Keep left hand warm at all times -Wear left protective cast at all times, except for visiting nurse dressing changes. Keep clean and dry -Refrain from smoking, consuming caffeine (coffee, soda, tea, chocolate, etc..) -Dressing changes [**Hospital1 **]. Clean thumb gently with saline. Dress thumb loosely with xeroform strips longitudinally / gauze in the same manner leaving distal tip visible so that the patient can check capillary refill. Pad hand / forearm. Replace bivalved cast / splint. Patient may soak the thumb in warm water / peroxide (1:1 solution) as tolerated for 10 min to remove dried blood prn. Physical Therapy: -Out of bed w/ assist at least four times a day -Left upper extremity: Non weight bearing - Protect left thumb at all times by wearing splint / cast. Be cautious in uncontrolled environments (snow, ice, crowds, etc..) Treatments Frequency: Visiting Nurse - [**Hospital1 **] dressing changes to left thumb. Clean gently with saline, wrap thumb loosely with xeroform and gauze leaving distal tip exposed to check capillary refill. Pad hand / forearm. Replace splint / cast. Followup Instructions: -Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2142-12-28**] 3:00 -Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 25538**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2142-12-28**] 3:20 -Follow-up with the Chronic Pain Clinic, call [**Telephone/Fax (1) 1652**] for appointment -Follow-up with Dr. [**Last Name (STitle) 91987**]. Call him today upon returning home to set up plan. Ask him about starting "subutox" in place of suboxone. Completed by:[**2142-12-21**]

[ "998.11", "300.00", "285.1", "304.01", "305.20", "885.0", "305.1", "458.9" ]

icd9cm

[ [ [] ] ]

[ "39.31", "79.64", "84.21" ]

icd9pcs

[ [ [] ] ]

6161, 6212

3040, 5103

346, 488

6398, 6398

1142, 3017

7880, 8447

969, 977

5175, 6138

6233, 6377

5129, 5152

6701, 7360

992, 1123

7378, 7599

7621, 7857

271, 308

516, 763

6413, 6677

785, 804

820, 953

893

119,911

15623

Discharge summary

report

Admission Date: [**2197-10-16**] Discharge Date: [**2197-10-19**] Date of Birth: [**2140-1-30**] Sex: M Service: CARDIOTHOR HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 13781**] is a 57-year-old male who had an abnormal EKG which ultimately lead to work up including cardiac catheterization, transthoracic echocardiogram and a CT Scan ultimately showing a bicuspid aortic valve with aortic regurgitation and an ascending thoracic aneurysm with secondary left ventricular hypertrophy. Th[**Last Name (STitle) 1050**] has never had any chest pain, shortness of breath or dyspnea. No history of congestive heart failure or palpitations. No lower extremity edema. No prior history of MI or CVA. No diabetes in the past. Cardiac catheterization data was unavailable at initial presentation as a resultant fax to Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office. PAST MEDICAL HISTORY: 1. He has no prior surgical history. 2. He had a heart cath 18 years ago for a "congenital disease" which is not otherwise specified. 3. Benign heart murmur for which he gets prophylaxis with antibiotics over his lifetime. 4. No history of major depression and anxiety. 5. No hypertension. 6. He is on Accupril for his aortic insufficiency. 7. No history of coronary artery disease. He has clean coronaries by recent preoperative cardiac catheterization. 8. No history of gastroesophageal reflux disease. 9. No history of dyslipidemia or diabetes. OUTPATIENT MEDICATIONS: 1. Paxil 20 mg p.o. q. day. 2. Accupril 10 mg p.o. q. day. 3. Multivitamin occasionally. 4. He is not taking any aspirin. His cardiologist is Dr. [**Last Name (STitle) 45129**] at the [**State 28978**] [**Hospital1 107**] in [**Hospital1 1559**], [**State 350**]. Dr. [**Last Name (STitle) 45130**] is his PCP in the [**Name9 (PRE) 1559**] region. ALLERGIES: He has no known drug allergies except for just some seasonal allergies. Last dental exam was done on [**2197-9-21**] which showed no evidence of caries or risk. No need for tooth extraction. FAMILY HISTORY: He has a son who has a prior history of [**Name (NI) 1291**] repair with aortic aneurysm resection. His son has a history of congenital bicuspid aortic valve which related in aortic stenosis which required his procedure. SOCIAL HISTORY: Patient's occupation is a probation officer. He lives with his wife. [**Name (NI) **] has three grown children. Uses minimal alcohol. Only tobacco history was that of cigars. PHYSICAL EXAMINATION: In general well appearing, active, well-nourished, well-developed, age appropriate male. No rashes were present on the skin. Head, eyes, ears, nose and throat: Pupils are equal, round and reactive to light and accommodation. Extraocular muscles intact. No jugular venous distention, no bruit. No cervical lymphadenopathy. His precordium was quiet. Lungs were clear. Abdomen was soft. Extremities were unremarkable. Neurological is nonfocal. [**Last Name (STitle) 35700**]ese findings, he was sent for evaluation by Dr. [**Last Name (Prefixes) 411**] who deemed the patient an appropriate candidate for aortic valve replacement as well as resection of the ascending aortic aneurysm and the non-coronary sinuses. On [**2197-10-16**], the patient was admitted to the hospital and went to the Operating Room where he underwent an aortic valve repair with a 27 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial tissue valve. Also had resection of an ascending aortic aneurysm and of the non-coronary sinus. A 26 mm tube graft was accordingly placed. Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] was then attending surgeon with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21815**] being the assistant. The patient pericardium was left open with a right radial A line and Right IJ Swan-Ganz catheter, two ventricular and two atrial pacing wires. There was mediastinal and right pleural tubes that had been placed. He was in sinus rhythm. He came off the pump without any difficulty. Postoperatively he was rapidly extubated. He did well from a hemodynamic standpoint. He had excellent blood pressure control. Strips were weaned the following day and started on an oral regimen of Lopressor. He was diuresed accordingly. He otherwise is out of bed ambulating. He was transferred to the floor. His wires were removed. His Foley catheter had been discontinued. He is tolerating a diet ultimately by postoperative day #3. The patient passed a level 5 ambulatory status after having completed stairs without any assistance. The patient was eager to actually go home. Given the fact that he had done markedly well postoperative, his wounds looked excellent, lungs were clear, lower extremities were not edematous and the fact that he asked for analgesia and was ambulating up stairs without difficulty, it was thought that the patient was appropriate for discharge to home without service. MEDICATION ON DISCHARGE: 1. Paroxetine 20 mg p.o. q. day. 2. Percocet one to two tabs p.o. q. four to six p.r.n. 3. Ibuprofen p.r.n. 4. Tylenol as needed. 5. Aspirin 325 mg p.o. q. day. 6. Lasix 20 mg p.o. b.i.d. times seven days. 7. K-Dur 20 mEq p.o. b.i.d. to be taken for the seven days that he is on Lasix. 8. Lopressor 12.5 mg p.o. b.i.d. 9. Accupril will be held until he is seen by Dr. [**Last Name (STitle) 45129**] at follow up in the [**State 1558**]. 10. Continue his multivitamins. DISCHARGE DISPOSITION: Will be sent home without services. He did well postoperatively and had no other issues to speak of. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2197-10-19**] 10:29 T: [**2197-10-19**] 11:39 JOB#: [**Job Number 45131**] cc:[**Hospital3 45132**]

[ "300.00", "V11.1", "746.4", "429.3", "441.7" ]

icd9cm

[ [ [] ] ]

[ "88.72", "38.45", "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

5523, 5916

2093, 2316

1516, 2076

2535, 5006

5020, 5499

174, 911

933, 1492

2333, 2512

5,193

116,508

16135+16108

Discharge summary

report+report

Admission Date: [**2134-2-9**] Discharge Date: [**2134-2-18**] Date of Birth: [**2067-9-19**] Sex: F Service: PROCEDURE PERFORMED: Abdominal wall split thickness skin grafting, donor site left thigh. OVERT DIAGNOSES: 1. History of an aortic aneurysm rupture requiring multiple abdominal explorations for mesenteric and pancreatic ischemia. 2. She has also undergone a takedown of a colostomy in the past that developed a small dehiscence. 3. Ventral hernia repaired with Marlex. 4. She also has a cerebral aneurysm that has been coiled. 5. Atrial fibrillation. 6. Chronic kidney disease. 7. Hypertensive disease. 8. Coronary artery disease. HOSPITAL COURSE: Ms. [**Known lastname **] was admitted to the hospital where she underwent split thickness skin grafting on the 19th. A back dressing was placed on the wound. Her postoperative course was uneventful. On day 3, we took the vac dressing down. The skin graft had near 100% take, and we were able to at this point convert her management to bacitracin and adaptic. PLAN: She was discharged home on [**2134-2-12**] to followup with Dr. [**First Name (STitle) **] in one week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Dictated By:[**Last Name (NamePattern4) 3433**] MEDQUIST36 D: [**2134-6-15**] 18:52:31 T: [**2134-6-15**] 21:07:03 Job#: [**Job Number 46115**] Admission Date: [**2134-2-17**] Discharge Date: [**2134-2-20**] Date of Birth: [**2067-9-19**] Sex: F Service: MEDICINE Allergies: Codeine / Tape Attending:[**First Name3 (LF) 458**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization Intubation Temporary Pacer wire in right femoral vein History of Present Illness: The patient is a 66 y.o.f. with HTN, DM, hypercholestermia and h/o ruptured AAA who presented with chest pain this a.m. and was found to have an inferior STEMI with total occlusion of RCA. Of note, the patient was recently admitted from [**Date range (3) 46059**] for a anterior abdominal wall skin graft for a chronic abdominal wound (see below). Per the husband, the patient complained of intermittent chest discomfort throughout the day yesterday at rest, as well as occasional nausea. This a.m. she awoke her husband at 5:30 a.m. compaining of chest pain and nausea and he called EMS. Per husband, patient does not have chest pain normally, although she was uncomfortable over the last week in the abdominal area with occasional nausea s/p her surgery. However, because she 'never complains', he is not sure exactly how long the chest pain has been going on for. He states she has no orthopnea, PND, LE edema, palpitations. . Arrived to the ED at 06:45 a.m. with HR 40, 62/39, 23, 96% NRB. She received etomidate, succinate, versed, fentanyl and was intubated. She received 1 mg atropine, dopamine started, and total of 3L IVFs given. BP and HR responded with HR 90 and BP 180/69 (range in ED 83/47-180/69, 80-120). Also started on heparin, given aspirin 325 mg and plavix 600 mg. She developed and junctional rhythm at 7:27 and was transiently paced with good capture. . In the cath [**Date range (3) **] she was started on integrillin, continued on dopamine gtt. Cath showed mild left main and LAD diseaes, LCx nondominant and no disease, RCA occluded proximally with distal minor collarterals from the left. Lesion was crossed without difficulty and lesion was exported with good flow. Two overlapping bare metal stents were deployed in the proximal and mid RCA. There was a distal cut off in the PLB which was dottered with minimal success. LHC deomonstrated C.O. of 3.58, CI 1.75, RA 22/38 with EDP of 20 and PCWP of 14 but V wave of 20, concerning for RV infarct. During cath she developed episode of VT, but converted on her own. Cath ended at 8:41. Recieved 1750cc during procedure as well as nitro bolus and sodium bicarbonate. . On review of symptoms, husband 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. The husband denies recent fevers, chills or rigors. The husband denies exertional buttock or calf pain, although recently this has been difficult to assess due to her limited mobility in the setting of recent surgery. . Cardiac review of systems is notable for chest pain as above, but the absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: # h/o ruptured AAA. Course c/b the following: - repair of AAA rupture on [**2131-7-13**] - mesenteric ichemia resulting in exlap and ileocecotomy [**2131-7-14**] - necrotizing pancreatitis d/t hypertriglyceridemia s/p multiple debridements - ileostomy and mucocutaneous fistula [**2131-7-16**] - multiple abdominal washouts on [**8-11**], [**7-29**], [**8-4**], [**8-6**] - skin graft to the lower [**1-24**] abdominal wall on [**8-9**] - tracheostomy [**2131-8-2**] - left eye vision loss, felt to be d/t cerebral artery aneurysm (temporal artery biopsy negative) # Ventral hernia with component separation requiring attempt at colostomy closure and abdominal wall closure with marlex mesh on [**2133-1-13**] # Multiple hospitalizations for abdominal wound breakdown requiring VAC; currently undergoing abdominal wall mesh debridement and consideration of surgery with plastics, although patient deferring at this time # Type II DM # PNA # Hypertension # A Fib - periop, on coumadin until [**5-29**] and then off for unclear reasons # Hypercholestermia Social History: Lives in single family home w/husband. Social history is significant for the absence of current tobacco use. She drinks one screwdriver a night. Retired nurse Family History: Father died of an MI in his 60's, but no other family members with CAD. Physical Exam: VS: T 97.6, BP 125/72, HR 83 Vent: 550/20/0.8/5, 100% Gen: WDWN middle aged women intubated, comfortable, responds appropriately to questioning HEENT: NCAT. Sclera anicteric. pupils 3mm, sluggish on left with bilateral constriction with left light reflex, no light reflex on right Neck: Obese, unable to assess JVP, old trach site scar CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Intubated, CTAB anteriorly. Abd: Obese, soft, large ~10x10 cm scar periumbilcal with punctate areas of drainage surrounded by pink scar tissue. +BS, no HSM appreciated, NTND. Ext: No c/c/e. Warm. Dopplerable DP and PT pulses. No femoral bruits, no hematoma at groin site. Skin: Left thigh with 5x2cm skin graft, bandage C/D/I with xeroform overlying skin graft, moist. Large abdominal scar with wound as above. No stasis dermatitis or xanthomas. Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2134-2-17**] 06:58AM BLOOD WBC-9.3 RBC-3.02* Hgb-9.8* Hct-31.2* MCV-103* MCH-32.5* MCHC-31.5 RDW-12.6 Plt Ct-254 [**2134-2-17**] 07:50AM BLOOD WBC-13.6* RBC-2.83* Hgb-9.4* Hct-29.6* MCV-104* MCH-33.0* MCHC-31.7 RDW-12.5 Plt Ct-286 [**2134-2-17**] 11:28AM BLOOD WBC-6.0# RBC-2.49* Hgb-8.1* Hct-24.8* MCV-100* MCH-32.7* MCHC-32.8 RDW-12.8 Plt Ct-226 [**2134-2-18**] 03:26AM BLOOD WBC-6.6 RBC-2.80* Hgb-8.9* Hct-26.8* MCV-96 MCH-31.6 MCHC-33.0 RDW-15.4 Plt Ct-222 [**2134-2-20**] 05:30AM BLOOD WBC-4.9 RBC-2.80* Hgb-8.9* Hct-27.2* MCV-97 MCH-31.7 MCHC-32.7 RDW-14.6 Plt Ct-234 [**2134-2-19**] 07:30AM BLOOD PT-12.8 PTT-21.1* INR(PT)-1.1 [**2134-2-17**] 06:58AM BLOOD UreaN-32* Creat-1.4* [**2134-2-18**] 03:26AM BLOOD Glucose-122* UreaN-24* Creat-1.3* Na-142 K-4.4 Cl-109* HCO3-23 AnGap-14 [**2134-2-19**] 07:30AM BLOOD Glucose-165* UreaN-20 Creat-1.1 Na-140 K-4.4 Cl-103 HCO3-24 AnGap-17 [**2134-2-20**] 05:30AM BLOOD Glucose-109* UreaN-33* Creat-1.7* Na-142 K-4.5 Cl-106 HCO3-26 AnGap-15 [**2134-2-20**] 01:10PM BLOOD Glucose-124* UreaN-32* Creat-1.6* Na-140 K-4.2 Cl-105 HCO3-24 AnGap-15 [**2134-2-17**] 07:50AM BLOOD CK(CPK)-178* [**2134-2-18**] 03:26AM BLOOD CK(CPK)-595* [**2134-2-18**] 03:24PM BLOOD CK(CPK)-359* [**2134-2-17**] 07:50AM BLOOD CK-MB-13* MB Indx-7.3* [**2134-2-18**] 03:26AM BLOOD CK-MB-38* MB Indx-6.4* [**2134-2-18**] 03:24PM BLOOD CK-MB-19* MB Indx-5.3 [**2134-2-20**] 01:10PM BLOOD Calcium-8.5 Phos-4.5 Mg-2.0 [**2134-2-18**] 03:26AM BLOOD Triglyc-324* HDL-40 CHOL/HD-5.5 LDLcalc-116 LDLmeas-120 [**2134-2-18**] 03:26AM BLOOD TSH-0.82 [**2134-2-17**] 06:58AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2134-2-17**] 01:01PM BLOOD Glucose-139* Lactate-1.8 K-5.9* [**2134-2-17**] 07:25AM BLOOD Glucose-297* Lactate-3.2* Na-138 K-5.9* Cl-107 calHCO3-17* Cardiac Cath: 1. Coronary angiography in this right-dominant system revealed one-vessel disease: --the LMCA had mild disease. --the LAD had mild disease. --the LCX was a non-dominant vessel with no angiographically apparent disease. --the RCA was occluded proximally. Distal minor collaterals from the left were present. 2. Resting hemodynamics revealed elevated right-sided filling pressures, with RVEDP 24 mmHg. RA pressures were significantly elevated. There was mild pulmonary arterial systolic hypertension with PASP 45 mmHg. The PCWP was elevated, with a mean value of 24 mmhg. Cardiac output was depressed, with CI 1.8 L/min/m2. 3. The patient intermittently developed a junctional escape rhythm during the case with concomitant drop in SBP to 80s systolic. A temporary wire was placed via the femoral venous sheath. Brief pacing was performed, though the patient was able to maintain sinus rhythm afterwards with the pacemaker inactive and dopamine drip weaned off. 4. Successful stenting of the proximal and mid RCA with overlapping 2.5 x 28 mm Minivision stents at 14 and 22 ATM. Final angiography revealed no residual stenosis in the stents, a distal cutoff in the distal PLB, no dissection and TIMI III flow. (See PTCA comments) FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Elevated right-sided filling pressures. 3. Junctional rhythm with subsequent restoration of sinus rhythm, with RV transvenous temporary pacemaker in place. 4. Successful stenting of the proximal and mid RCA with BMS. Echo: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis/akinesis of the basal to mid inferior, inferolateral and inferior septal segments. Diastolic function could not be assessed. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderate focal left ventricular systolic dysfunction consistent with one vessel CAD. EF 30-35% The RV is not very well seen but probably has normal systolic function. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2133-1-19**], the wall motion abnormalities are new. Brief Hospital Course: # CAD: Patient had an acute STEMI with total occlusion of the RCA. This was opened with 2 overlapping BMS with good flow post intervention. She was initially on dopamine prior to intervention but was quickly weened off it after. She was also intubated prior to her intervention for hypoxia but was extubated within hours of her intervention with no complications. She was weened to room air within 12 hours of extubation. Just prior to her intervention, she developed junctional bradycardia which was paced using a temporary pacer wire in her R femoral vein. This was also removed within hours of her intervention and she had no further episodes of bradycardia. Her cardiac medication regimen was optimized to and increased dose of Toprol XL, lisinopril, a high dose statin, ASA, and Plavix. After extubation, she did note some mild R shoulder and anterior chest wall pain, reproducible on palpation. An EKG showed no changes and her cardiac enzymes continued to trend down. It was felt that this pain was either musculoskeletal based on positioning during the cath or referred pain from diaphragm irritation from the inferior MI. It markedly improved on discharge day with only Tylenol. She worked with physical therapy and was found fit for discharge home with home PT. She will follow up with Dr. [**Last Name (STitle) **] and her PCP # A.fib: The evening after her intervention she was found to be in atrial fibrillation with RVR. Her blood pressure remained steady. She was treated with IV metoprolol and an increased dose of PO metoprolol with conversion back to sinus rhythm and good rate control. The patient has a history of PAF surrounding surgeries but not at other times. In light of this, it was decided not to anticoagulate the patient at this time as this likely represents an isolated incident of atrial fibrillation. However, she will be discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to further monitor for other episodes of atrial fibrillation. This will be followed up by Dr. [**Last Name (STitle) **]. # Pump: Post catheterization echo showed a reduced EF of 30-35%. However, the patient showed no signs of volume overload or CHF during her admission. In fact, she required no diuretics and remained in negative fluid balance throughout her stay. She will likely need a repeat echo to assess for restoration of stunned myocardium in the future and evaluation of fluid status. She was discharged on Toprol XL and lisinopril. # Anemia - Her hemocrit dropped 4 points post catherization in the setting of a mild to moderate compressible R groin hematoma. Pressure was applied to the area with good effect and the hematoma did not recur. She did receive one unit of PRBCs with adequate improvement and subsequent stabilization of her hematocrit throughout her hospital stay. # Increased Cr.: On the day of discharge, her creatinine increased from a baseline of 1.3 to 1.7, in the setting of an increased lisinopril dose. She was given a 500cc bolus with subsequent improval of her creatinine. She was encouraged to drink liquids when she returns home. . # DM: Type II. Stage II CKD, likely d/t DM, HTN. HgA1C 6.1, unclear when diagnosed, not on home antihyperglycemics. Covered with HISS while in house with good effect. Should be discussed with PCP about starting antihyperglycemics. . # Abdominal wound: Complication of ruptured aortic aneurysm in [**2130**], chronic, followed by Dr. [**First Name (STitle) **] and plastics. S/P recent skin graft on [**2134-2-8**]. Currently stable. Pain controlled with propoxyphene, gabapentin, and dilaudid. . # FEN: Heart healthy diet. Continued pancreatic enzymes. . # Prophylaxis: heparin SQ, PPI, hold on bowel meds as usually has loose stools d/t pancreatic insufficiency, sertraline . # Code: Full but does not want a prolonged intubation. . # Communication: Husband [**Name (NI) 892**] [**Numeric Identifier 46060**] Medications on Admission: Pancrelipase [**1-24**] capsules once daily Zetia 10 mg daily Florinef 0.05 mg daily Neurontin 600 mg [**Hospital1 **] Ativan 1 mg QHS Ambien 5 mg QHS Toprol XL 25mg daily Darvon 65mg PO Q4h prn pain Sertraline 50 mg QHS Aspirin 81 mg PO daily Loperimide prn Metamucil prn MVI Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 3. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Propoxyphene 65 mg Capsule Sig: One (1) Capsule PO Q4H (every 4 hours) as needed. 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). [**Hospital1 **]:*60 Tablet Sustained Release 24 hr(s)* Refills:*2* 12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 14. Loperamide 2 mg Capsule Sig: One (1) Capsule PO three times a day as needed. Discharge Disposition: Home With Service Facility: VNA of [**Location (un) 1411**] Discharge Diagnosis: Acute ST elevation myocardial infarction Hypertension Paroxysmal Atrial fibrillation Discharge Condition: All vital signs stable. Chest pain free. Ambulatory. Discharge Instructions: You were admitted with a heart attack. You had a total blockage of your right coronary artery which was opened up with a stent. You will need to take a full strength aspirin and Plavix every day to prevent a clot in the stent. It is very important that you take these medications everyday. You also had an episode of atrial fibrillation. We have altered your dose of Toprol to better control this. We have also added a medication called lisinopril to better control your blood pressure. Please take all your medications as prescribed. Please be on time for your follow up appointments. Please call your doctor or return to the emergency room if you experience chest pain, worsening shortness of breath, fevers, chills, nausea, vomitting or any other symptom that concerns you. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2134-3-5**] 11:40 Please call Dr.[**Name (NI) 23247**] office at [**Telephone/Fax (1) 17753**] to set up a follow up appointment in the next 2-4 weeks

[ "998.12", "585.2", "410.41", "250.40", "785.51", "E879.0", "403.90", "427.31", "272.0", "427.1", "414.01" ]

icd9cm

[ [ [] ] ]

[ "37.78", "36.06", "00.17", "88.52", "00.66", "96.04", "00.40", "96.71", "99.20", "00.46", "99.04", "37.23", "88.56" ]

icd9pcs

[ [ [] ] ]

17205, 17267

11491, 15432

1699, 1779

17396, 17451

7052, 10116

18279, 18591

5875, 5949

15760, 17182

17288, 17375

15458, 15737

694, 1632

10133, 11468

17475, 18256

5964, 7033

1649, 1661

1807, 4602

4624, 5682

5698, 5859

73,546

155,695

44918

Discharge summary

report

Admission Date: [**2156-10-15**] Discharge Date: [**2156-10-22**] Date of Birth: [**2090-4-1**] Sex: F Service: NEUROSURGERY Allergies: Lipitor / Nsaids/Dietary Supplement Combinations Attending:[**First Name3 (LF) 1271**] Chief Complaint: nausea, vomiting Major Surgical or Invasive Procedure: [**2156-10-18**]: suboccipital craniotomy and resection of cerebellar mass History of Present Illness: Ms. [**Known lastname 96073**] is a 66 year old woman with a history of DM, HTN, metastatic rectal adenocarcinoma s/p resection, chemoradiation, who presented to the ER with severe nausea and vomiting. She stated that since she began her palliative spinal radiation (last dose 8/17), she has been very nauseous. For 3 days, she has been unable to keep anything down including, food, liquids, or pills. She stated that she is also lightheaded and sweaty but does not have any chest pain, tightness, but does have palpitations. Her ostomy has no output since day prior to admission. In the ER, she initially had a Blood glucose of 402 and an anion gap of 24, with a alkaline pH. After Zofran, infusion of 2L NS, 10 units IV insulin, and Novolog 10 units SC at 4am, her gap closed and her BG was downtrending. Past Medical History: ONCOLOGIC HISTORY: [**2153-11-14**]: presented with three months of constipation, BRBPR, weight loss. Colonoscopy on [**2153-11-21**] revealed adenocarcinoma, KRAS mutated. Rectal ultrasound [**2153-12-3**] revealed extension from posterior distal rectum down to the anorectal junction, with focal areas of extension beyond the muscularis propria. [**2153-12-15**]: Chemoradiation with capecitabine on [**2153-12-24**]. She received capecitabine instead of 5-FU because of insurance issues, and then started infusional fluorouracil on [**2154-1-16**] after her insurance changed. She completed chemoradiation on [**2154-1-31**]. [**2154-3-22**]: open abdominoperineal resection. She was found to have had a complete response to neoadjuvant chemoradiation. At the same time as the [**Month (only) **], she also underwent removal of multiple subserosal extramural leiomyomas measuring up to 7.5 cm. [**2154-5-15**]: began FOLFOX on [**2154-5-16**] and completed adjuvant therapy on [**2154-10-24**]; 6 cycles completed. Oxaliplatin was stopped during cycle 4 ([**2154-8-14**]) for foot neuropathy. [**2155-5-15**]: PET/CT [**2155-5-26**] shows pulmonary and C4 and T9 FDG avid lesions. [**2156-8-13**]: New back and left hip pain. CT torso with increase in size and number of pulmonary lesions, and osseous metastases involving T1, T5, G9, L1-L4, right second rib, right iliac bone. At L2, possible soft tissue extension causing canal narrowing also seen. [**2156-9-13**]: Pt will receive palliative dose of radiation to T8-T10 as well as from L1-S1 trying to prevent progression of soft tissue component into the thecal sac and trying to improve the level of pain. She will receive a dose of 30 Gy in 10 fractions to those areas DM, HTN, radiation-induced esophagitis [**9-/2156**] Social History: no EtOH or tobacco use Family History: Significant for unspecified cancer in maternal grandfather and prostate cancer in father. Diabetes in several family members. Physical Exam: On admission:PHYSICAL EXAMINATION: BP: 97.5 bp 155/73 HR 102 RR 18 SaO2 96 RA GENERAL: uncomfortable, rag over eyes, but interactive and alert HEENT: sclera anicteric, mucous membranes dry. Oropharynx clear without lesion. LYMPHATICS: No cervical lymphadenopathy HEART: regular tachycardia without murmur, rub, or gallop LUNGS: clear to auscultation bilaterally ABDOMEN: soft, nontender, nondistended, ostomy intact EXTREMITIES: warm, well perfused without clubbing, cyanosis, or edema NEURO: cranial nerves II-XII grossly intact. Strength 5/5 x4 extremities, sensation intact to light touch x4 extremities PSYCH: pleasant, cooperative Upon Discharge: Other than right dysmetria, she is neurologically intact. Pertinent Results: [**2156-10-15**] 03:25AM GLUCOSE-299* UREA N-9 CREAT-0.5 SODIUM-137 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [**2156-10-15**] 03:25AM TYPE-[**Last Name (un) **] PO2-48* PCO2-38 PH-7.42 TOTAL CO2-25 BASE XS-0 [**2156-10-15**] 03:25AM LACTATE-1.9 [**2156-10-15**] 03:25AM WBC-6.4 RBC-3.55* HGB-9.3* HCT-27.7* MCV-78* MCH-26.1* MCHC-33.5 RDW-16.6* [**2156-10-15**] 03:25AM NEUTS-85.6* LYMPHS-7.8* MONOS-4.9 EOS-1.7 BASOS-0.1 [**2156-10-15**] 03:25AM PLT COUNT-312 [**2156-10-15**] 01:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.029 [**2156-10-15**] 01:40AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-1000 KETONE-80 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2156-10-15**] 01:40AM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 [**2156-10-15**] 01:40AM URINE MUCOUS-RARE [**2156-10-15**] 12:44AM LACTATE-2.9* [**2156-10-15**] 12:40AM GLUCOSE-402* UREA N-11 CREAT-0.6 SODIUM-137 POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-23 ANION GAP-24* [**2156-10-15**] 12:40AM estGFR-Using this [**2156-10-15**] 12:40AM WBC-6.6# RBC-4.12* HGB-10.9* HCT-32.3* MCV-78* MCH-26.5* MCHC-33.9 RDW-16.4* [**2156-10-15**] 12:40AM NEUTS-87.5* LYMPHS-7.0* MONOS-4.0 EOS-1.1 BASOS-0.3 [**2156-10-15**] 12:40AM PLT COUNT-342# EKG: sinus tachycardia with TWI in precordial leads with no ST-T segment changes [**10-17**] CTA Chest- 1. No pulmonary embolism. 2. Increase in size of multiple pulmonary nodules, with interval development of bilateral moderate pleural effusions. 3. Diffuse osseous involvement, not significantly changed compared with [**2156-9-7**] [**10-17**] MRI Brain- IMPRESSION: Metastatic lesions as described, largest one being in the left cerebellum with significant perilesional edema and mass effect on the fourth ventricle. The findings were discussed with Dr. [**Last Name (STitle) **] via telephone at 3:45 p.m. on [**2156-10-17**]. [**2156-10-18**] CT Head: IMPRESSION: Expected post-surgical changes after left cerebellar mass resection. Markedly improved effacement of the fourth ventricle. [**2156-10-19**] MRI brain 1. Marginal enhancement along the left cerebellar surgical cavity is likely post-operative rather than related to residual tumor. However, recommend continued follow-up. 2. Decreased effacement of the fourth ventricle. The lateral and third ventricles remain normal in size. 3. Stable small metastases within the left frontal lobe and along the right superior vermis. [**2156-10-22**] Lower ext dopplers Negative for DVT Brief Hospital Course: Ms. [**Known lastname 96073**] is a 66 year old woman with history of metastatic rectal adenocarcinoma s/p resection, chemoradiation, currently receiving palliative spinal radiation presented to the ER with severe nausea and vomiting and Hyperosmolar Non-ketosis. This was thought to be secondary to radiation induced nausea and inability to take metformin. She was hydrated with NS. She was put on an insulin sliding scale. MI was ruled out. Zofran and Compazine wereg given as needed. Lisinopril was held in the setting of acute kidney injury secondary to hypovolemia She had brain imaging with the finding of cerebellar metastases. On [**10-17**] the patient was started on decadron after the finding of her cerebellar mass. She was transferred to the SICU on the neurosurgical service where she remained stable overnight. A discussion between surgery and medicine was held on [**10-18**] and it was decided to resect the cerebellar lesion. She underwent a suboccipital craniotomy without problem on [**10-18**]. She was transferred to the SICU and extubated post operatively there. Post op head CT revealed post op changes and no hemorrhage. On [**10-19**] he had a brain MRI which showed good resection of left cerebellar mass. She was trasnfered to the floor. Her foley catheter was discontinued. She was seen by Pt and they thought she needed rehab. She was discharged to a rehab facility in stable condition on [**2156-10-22**]. - pt scheduled to begin FOLFIRI [**2156-10-21**] Medications on Admission: Medications - Prescription AMITRIPTYLINE - 25 mg Tablet - 1 (One) Tablet(s) by mouth at bedtime Take 2 hours before bedtime FLUTICASONE [FLONASE] - (Prescribed by Other Provider) - Dosage uncertain LISINOPRIL - (Prescribed by Other Provider) - Dosage uncertain METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth twice a day OXYCODONE - 5 mg Tablet - [**2-15**] Tablet(s) by mouth every 4 to 6 hours as needed for pain Medications - OTC ACETAMINOPHEN [TYLENOL] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 2. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 5. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/temp: max 4g/24 hrs. 8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): hold for SBP<110. 11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 12. insulin glargine 100 unit/mL Solution Sig: Two (2) units Subcutaneous once a day: see sliding scale. 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily) as needed for nasal congestion. 16. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for insomnia. 17. dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO q12 () as needed for s/p crani for 2 days. 18. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q12 () as needed for s/p crani. Discharge Disposition: Extended Care Facility: [**Hospital 23095**] Rehabilitation & Nursing Center - [**Location 8391**] Discharge Diagnosis: Brain metastasis Metastatic rectal adenocarcinoma, Radiation gastritis Cerebral edema 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: Your metformin/glyburide and lisinopril were held upon admission due to your kidney function and hyperosmolar ketosis. 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 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 were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, do not resume taking these until cleared by your surgeon at your follow up. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: Follow-Up Appointment Instructions ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2156-10-25**] 2:00 . The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. Further care and follow up will be adressed at that time. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2156-10-22**]

[ "V44.3", "V10.06", "E879.2", "276.52", "787.01", "250.20", "198.5", "535.50", "198.3", "584.9", "348.4", "348.5", "401.9" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

10311, 10412

6531, 8023

331, 408

10542, 10542

3992, 5909

12041, 12671

3113, 3242

8622, 10288

10433, 10521

8049, 8599

10726, 12018

3257, 3257

3292, 3898

275, 293

3914, 3973

436, 1251

5918, 6508

3270, 3270

10557, 10702

1273, 3057

3073, 3097

1,344

190,827

2631

Discharge summary

report

Admission Date: [**2110-7-5**] Discharge Date: [**2110-7-16**] Service: CARDIOTHORACIC Allergies: Ciprofloxacin / Quinine Attending:[**First Name3 (LF) 1283**] Chief Complaint: SOB Major Surgical or Invasive Procedure: [**7-7**] pericardial window doxycycline pleurodesis History of Present Illness: 86 y/o woman w/known CAD, s/p PCI, known pleural and pericardial effusions previous pericardial window [**3-24**], still w/ symptomatic pericardial effusion. Past Medical History: 1. CAD (s/p cath [**2100**]: 2VD, prior PTCA in LPDA) 2. A fib: chronic, on coumadin 3. Breast Cancer s/p XRT and lumpectomy (6 years ago) 4. h/o CHF (EF reportedly normal on last echo) 5. HTN 6. Hyperchol 7. DM2 8. s/p CCY Social History: Lives w/ husband. [**Name (NI) 3003**] smoking hx: 30 pack years; quit 30 yrs ago. No EtOH or drug use. Family History: No Premature CAD Physical Exam: Breath sounds decreased bilat. bases Cor: irreg, w/holosystolic murmur 2+ ankle edema bilat otherwise unremarkable pre-op exam Pertinent Results: [**2110-7-16**] 05:55AM BLOOD Hct-34.9* [**2110-7-13**] 04:30AM BLOOD WBC-8.6 RBC-4.10* Hgb-11.9* Hct-34.5* MCV-84 MCH-29.0 MCHC-34.5 RDW-18.7* Plt Ct-241 [**2110-7-16**] 05:55AM BLOOD PT-21.8* INR(PT)-2.1* [**2110-7-15**] 05:50AM BLOOD PT-19.0* INR(PT)-1.8* [**2110-7-14**] 05:30AM BLOOD PT-17.2* INR(PT)-1.6* [**2110-7-16**] 05:55AM BLOOD K-4.1 [**2110-7-13**] 04:30AM BLOOD Glucose-64* UreaN-26* Creat-0.8 Na-135 K-4.2 Cl-95* HCO3-31 AnGap-13 Brief Hospital Course: Admitted to [**Hospital1 18**] on [**2110-7-5**] for heparinization/normalization of INR off Coumadin pre-op. She was taken tot he OR on [**2110-7-7**] for left thoracoscopic pericardial window. POst-op, she was taken to the CSRU, extubated & weaned of phenylephrine gtt by POD #1. Thoracic surgery consult was obtained on [**7-8**] for pleural effusion. On [**7-9**], she underwent doxycycline pleurodesis for her right pleural effusion. She was transferred to teh telemetry floor on [**2110-7-10**]. Her Coumadin was resumed, she began to progress with physical therapy and ambulation. Over the next few days, she continued to have a large amount of serous drainage from her chest tube, and re-dosing of doxycycline was considered. On [**6-2**], her drainage had decreased, and her chest tube was ultimately removed on [**7-14**]. Follow-up chest x-ray on [**7-15**] showed small, stable biapical pneumothoraces. She is ready to be discharged from the hospital, but still requiring assistance to ambulate. She will be sent to rehab to progress with physical therapy. Medications on Admission: Lasix, Atenolol, Digoxin, Crestor, Zetia, Arimidex, Leutien, Occivite, Actonel, Protonix, Detrol, Amitriptylline, Caltrate, vitamins, Metformin, Coumadin (alternating doses of 5mg w/2.5 mg) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day). 16. Warfarin 1 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily) for 2 days: then re-check INR and dose for INR 2-2.5. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**] TCU Discharge Diagnosis: Recurrent pericardial effusion CAD s/p PCI [**2100**] chronic afib HTN lipids DM2 breast ca s/p L partial mastectomy/chemo/XRT s/p pericardiocentesis [**11-23**] s/p pericardial window [**3-24**] Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (STitle) 9960**] 2 weeks Dr. [**Last Name (Prefixes) **] 3-4 weeks please call Dr.[**Doctor Last Name 4738**] office for follow-up appointment ([**Telephone/Fax (1) 4044**] Completed by:[**2110-7-16**]

[ "428.0", "511.9", "V58.61", "427.31", "V10.3", "414.01", "401.9", "423.9", "272.0", "250.00", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "37.12", "99.21", "34.92" ]

icd9pcs

[ [ [] ] ]

4296, 4400

1517, 2597

240, 295

4640, 4648

1047, 1494

867, 885

2837, 4273

4421, 4619

2623, 2814

4672, 4791

4842, 5063

900, 1028

197, 202

323, 482

504, 729

745, 851

14,359

111,289

20673

Discharge summary

report

Admission Date: [**2120-2-25**] Discharge Date: [**2120-2-28**] Date of Birth: [**2102-1-8**] Sex: M Service: Trauma [**Last Name (un) **] CHIEF COMPLAINT: Gunshot wound. HISTORY OF PRESENT ILLNESS: The patient is an 18-year-old male shot in the subxiphoid region at a convenient store and transferred from [**Hospital 1474**] Hospital where a right chest tube was placed and a CAT scan showed a liver injury. The patient's hematocrit was 42.7 at [**Hospital1 1474**]. PAST MEDICAL HISTORY: Asthma. PAST SURGICAL HISTORY: None. MEDICATIONS AT HOME: None. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient smokes one pack per day, unknown substance abuse. The patient lives with mother and stepfather in [**Name (NI) 1474**]. PHYSICAL EXAMINATION: Temperature 39.6 C. Heart rate was 80 to 100. Blood pressure 120/55. The patient's physical exam was limited secondary to direct admit to the operating room for exploratory laparotomy. The patient was intubated and sedated. Pupils were pin point. ET tube was in place. Chest had bilateral breath sounds with a right chest tube in place. Abdomen had a plus bullet hole, nondistended. Extremities were warm bilaterally with palpable pulses. The back examination showed no exit wound, no step-off. The patient's hematocrit on admission was 34.3. Coags and electrolytes were within normal limits. ALT was 328, AST was 314. HOSPITAL COURSE: The patient was transferred to the Intensive Care Unit postoperatively in stable condition with stable vital signs and good urine output. The patient is a status post exploratory laparotomy, an overshow of small bowel serosa, on [**2120-2-25**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please see op note for details. Findings in OR included an anterior and posterior wounds of the liver with the bleeding tract and serosal damage to ileum. The patient had perioperative antibiotics and had a unremarkable hospital course. The patient was transferred to the floor post extubation in stable condition with the chest tube to water seal and Dilaudid PCA for pain control. The patient's nasogastric tube was discontinued and the patient was started on a clear liquid diet and was advanced to regular diet without problems. On water seal the chest x-ray revealed a very small apical right pneumothorax for which the chest tube was placed vac to wall suction overnight. On the morning of [**2-27**] the chest tube was put back to water seal and a chest x-ray was obtained which showed no evidence of a pneumothorax or effusion. The chest tube was subsequently discontinued and the patient had good aeration and breath sounds bilaterally post discontinuation. Upon discharge the patient was afebrile with stable vital signs and no complaints. The patient had good aeration and lung sounds throughout both lung fields. The patient's abdomen was soft, nondistended with some incisional tenderness. The wound was clean, dry and intact. The patient had no edema, clubbing or cyanosis. The patient's hematocrit was stable upon discharge and the patient was tolerating a regular diet, and ambulating without problems. DISPOSITION: Home. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSIS: 1. Status post subxiphoid gunshot wound, anterior and posterior liver lacerations. 2. Small bowel serosal tear. 3. Small pneumothorax. The patient was to follow-up in Trauma Clinic times two to three weeks and to call the office for an appointment. The patient is status post exploratory laparotomy and small serosal tear [**2120-2-25**], and status post right chest tube placement at [**Hospital 1474**] Hospital on [**2120-2-25**]. DISCHARGE MEDICATIONS: Percocet 5/325 mg one to two tablets p.o. q.4-6h. p.r.n. pain. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Last Name (NamePattern1) 27744**] MEDQUIST36 D: [**2120-2-28**] 16:35 T: [**2120-2-29**] 08:16 JOB#: [**Job Number 55219**]

[ "493.90", "998.2", "864.15", "860.0", "E965.4", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "54.11", "46.73" ]

icd9pcs

[ [ [] ] ]

3277, 3286

637, 655

3770, 4116

3307, 3747

1478, 3255

575, 620

546, 553

829, 1460

174, 190

219, 491

513, 522

672, 806

30,907

119,152

33855

Discharge summary

report

Admission Date: [**2114-6-7**] Discharge Date: [**2114-8-31**] Date of Birth: [**2070-2-11**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: R hemiparesis Major Surgical or Invasive Procedure: None History of Present Illness: 44 year old male with few known details of previous medical history med flighted to [**Hospital1 18**] with left 6x6cm intracerebral hemorrhage. Per limited EMS reports the patient was walking down to his fishing boat and suddenly complained of headache and fell to the ground shouting "I need help." EMS was called and reported right sided weakness and "aphasia." His blood pressure at the scene was 190/120 per EMS records. The pt had a head CT at the OSH revealing large 6x6m intracerebral hemorrhage encompassing large region of basal ganglia and extending posteriorly towards the thalamus. Pt was intubated and medflighted to [**Hospital1 18**]. En route the pt was given phosphenytoin 1g IV, Fentanyl 600mg, Ativan 4mg IV and Propofol. ROS- unable to elicit Past Medical History: Possible hypertension, untreated Alchohol abuse, non addressed Social History: Portuguese speaking. Works as a fisherman. Lives in [**Location **]. Per family here on visiting visa, but this has not been confirmed. Family History: Non-contributory Physical Exam: Vitals: T 98, BP 138/83, Hr 72, Sat 100% on AC Gen- intubated and sedated, well nourished male. HEENT- NCAT, anicertic sclera, OP clear, no oral trauma Neck- no carotid bruits CV- RRR, no MRG Pulm- CTA B Abd- soft, nd, BS+ Extrem- no CCE Neurologic Exam: MS- intubated and sedated. not following commands. withdraws left arm to pain. CN- pupils 1mm, minimally reactive bilaterally. Unable to visualize fundi. Absent Dolls. Intact corneal reflexes bilaterally. Grimaces symmetrically to nasal tickle. Brisk gag reflex. Motor/Sensory- lifts left arm to noxious stimulation to right arm. No R arm movment. No movement of lower extremities bilaterally to noxious. Toes mute bilaterally. Reflexes: absent throughout. Pertinent Results: EKG Sinus rhythm. Left ventricular hypertrophy. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 71 156 100 440/459 40 19 -4 CT on admission: Large left basal ganglia hemorrhage with associated mass effect. No significant change from outside hospital study performed 2.5 hours earlier CT/CTA 5/1/8: HEAD CT: Again seen is a left basal ganglia hematoma with surrounding edema, unchanged from prior. There is a stable mass effect on the left lateral ventricle and rightward midline shift of approximately 5 mm. No new foci of hemorrhage seen. Ventricles have not increased in size. Continued prominence of the right lateral ventricle. HEAD AND NECK CTA: The circle of [**Location (un) 431**] appears normal, and there are no obvious aneurysms associated with the anterior, middle or posterior cerebral arteries. There is no convergence of vessels towards the site of hemorrhage to suggest AVM. Again seen is moderate mucosal thickening in the right maxillary sinus and right sphenoid sinuses. IMPRESSION: Essentially, no change compared to prior study with no CTA evidence for aneurysm or AVM. ECHO [**6-16**] and unchanged [**6-26**]: The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses are normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. No vegetation seen (cannot definitively exclude). MRI [**6-20**]: Again seen is a large intraparenchymal hemorrhage centered within the left basal ganglia which measures approximately 7.2 x 3.6 cm in its greatest transverse dimensions. There is surrounding vasogenic edema and there is left to right subfalcine herniation and effacement of the left ambient cistern as before. There are multiple scattered areas of slow diffusion involving both centrum semiovale as well as the corpus collosum, the left globus pallidus, the white matter and [**Doctor Last Name 352**] matter of the occipital lobes and right frontal lobe as well as the pons consistent with embolic infarcts. Seen on the post-gadolinium MP-RAGE images are two small foci of apparent enhancement involving either the cortex or the subarachnoid space of the left frontal and parietal lobes near the site of hemorrhage. This is of uncertain etiology and may represent dilated veins or enhancement related to the embolic infarcts. The visualized orbits and major flow voids appear normal. There is mucosal thickening within the right mastoid air cells as well as the sphenoid, ethmoid, and maxillary sinuses. No suspicious bony abnormalities are seen. IMPRESSION: 1. Large left basal ganglia intraparenchymal hemorrhage with surrounding vasogenic edema causing subfalcine herniation and compression of the ambient cistern on the left. 2. Multiple embolic infarcts as described above, both supra and infratentorially. 3. Two small foci of either cortical or subarachnoid enhancement adjacent to the hemorrhage which may represent dilated veins related to the hemorrhage or infarct-related enhancement. CT [**6-29**]: Interval evolution of left basal ganglia hemorrhage with decrease in size of the hematoma and decrease in mass effect. No new hemorrhage identified. No new hypodensities seen to suggest new focal abnormalities since the previous CT of [**2114-6-14**]. CT ABD: CT ABDOMEN WITH CONTRAST: The heart is normal in appearance without pericardial effusion. Aside from minimal dependent changes in the lung bases, no suspicious nodule, opacity, or effusion is detected. No arterially enhancing lesions are detected in the liver. The gallbladder is contracted and normal in appearance. The adrenal glands and kidneys are normal in appearance without focal lesion. There is no hydronephrosis. The spleen is normal in size and appearance. A percutaneous gastrostomy tube is noted within the stomach with adjacent foci of free air. The pancreas is normal in appearance without focal lesion or peripancreatic stranding. The visualized large and small bowel are normal in appearance. The appendix is well visualized without inflammatory stranding, which is filled with air and contrast. No pathologically enlarged lymph nodes are present within the mesentery or intraperitoneal locations with the largest lymph node along the lesser sac of the stomach (2:21) measuring 8 mm in short axis. There is no free fluid within the abdomen. CT PELVIS WITH CONTRAST: A Foley catheter is noted with balloon and tip in the bladder. There is a moderate-to-large amount of stool within the rectum which is otherwise unremarkable. The prostate gland, and large and small bowel within the pelvis appear normal. No adenopathy is detected. OSSEOUS STRUCTURES: Degenerative changes are noted in the lumbar spine with facet joint narrowing and sclerosis. No suspicious lytic or sclerotic lesions are identified. IMPRESSION: 1. No intra-abdominal abscess or inflammatory process detected to explain fever of unknown origin. 2. Moderate-to-large amount of stool within the rectum. 3. Degenerative changes within the lower lumbar spine. CT CHEST: CHEST: There is no thoracic adenopathy, pleural or pericardial effusion. The thoracic aortic caliber is normal, without dissection. The heart is mildly enlarged. Coronary artery calcifications are mild. There is no pleural or pericardial effusion. There are no filling defects within the pulmonary arteries. There is layering material within the right lower lobe bronchus (3, 46). Throughout the right lung, there are scattered vague foci of ground- glass opacity, slightly more confluent in the right lower lobe. The lungs are otherwise clear. The imaged upper abdominal viscera are unremarkable. OSSEOUS STRUCTURES: There are no suspicious lytic or blastic lesions. Mid thoracic endplate osteophytes are moderate in size. IMPRESSION: 1. No evidence of pulmonary embolus. 2. Scattered foci of ground-glass opacity in the right lung are most compatible with infection. 3. Layering secretions in the right lower lobe bronchus. Gastrograffin study [**2114-7-26**]: IMPRESSION: Gastrostomy tube tip is not visualized, however, contrast opacifies the distal stomach and duodenum, which likely confirms the intraluminal position of gastrostomy tube in the stomach. Brief Hospital Course: ICU COURSE Patient was admitted to the ICU. He was extubated for better clinical observation on D2, without respiratory difficulties. He was reintubated on Day 4 due to extreme agitation (and loss of IV access) in the setting of alcohol withdrawal, insufficient control with fixation and benzodiazepines. A central line was placed and he was overtreated with excessive benzodiazepines prolonging the need for intubation. On the other hand, when extubated was no longer withdrawing. He was treated for a ventilator associated PNA/hospital acquired PNA since he became febrile in between the two intubations - details below under "ID". His bloodpressure was managed with IV drips at first (hydralazine, nicardipine), but he was transitioned to oral medications by the time he arrived on the floor. He was briefly hypernatremic with hyperosmolalic therapy (sodium) for edema. FLOOR COURSE NEURO Exam remained stable thoughout his hospital course: Dense R hemiplegia, flaccid at the arm and hypertonic at the leg, complete global aphasia - with the help of interpreters he was assessed repeatedly throughout his stay, last time on the 20th of [**Month (only) 116**] with Speech/Swallow. His level of alertness and interaction markedly increased, but slowly over time. * His repeat CTs had shown scattered hypodensities like "satellite" lesions around the bleed, leading to an MRI, which showed scattered bilateral hemispheric as well as brainstem (R pons) and midbrain (L) embolic strokes. Interestingly, his exam had not changed significantly. An extensive workup did not reveal anyt signs of hypercoagulability, septic nor marantic endocarditis (>15 Cultures including continued surveillance Cx while on Abx all negative, TTE x2 normal while TEE failed due to biting on the tube, extensive labs, CT chest and abdomen to look for infectious source, tumor for maransis or paraneoplastic hypercoagulability), nor a cardiac, aortic or large vessel source for the emboli. Repeat CT further out in his hospital stay did not reveal evolution of the strokes nor new ones. One remote possibility would that the septic thrombophlebtitis of his arm has shed emboli, this is a rare complication and one would need to have a PFO. A PFO was not shown in him, but bubble studies were not done. CARDIOVASC EKG did not meet formal criteria of LVH, and there was no increased cardiothoracic index on CXR. TTE as outlined under "results". No significant cardiac issues during hospital stay. ID The bulk of his complications on the floor consisted of infections: Initially started spiking fevers [**6-11**] (up to 102.5), initally attributed to alcohol withdrawal, pan cultured (inital bld & ucx neg). On [**6-12**], urine cx >100K CoNS, and [**6-12**] sputum and BAL with SA & proteus mirabilis. Started on vanc and cipro [**Date range (1) 21717**]. Continued almost daily fevers to 100-101 on antibiotics. CXR showed some atalectatic changes in L base, but these resolved on further imaging. Had a TTE [**6-16**] which without vegetations. On [**6-16**] was switched to cefazolin when found to have clot in basilic and cephalic veins on R side on u/s, and chest imaging appeared to clear - not consistent with pna. Had MR of head which showed multiple supra and infratentorial embolic infarcts. CT chest [**6-19**] showed some ground glass opacity in R lung that could be consistent with infection. TTE [**6-26**] also showed no vegetations. CT abd and pelvis negative for intraabdominal process. cxr [**6-22**] no e/o infiltrate. On Empiric vanc and zosyn and continued to spike low grade temps to 100. Anibiotics were discontinued on a clinical decision-making basis and his white count came down spontaneously, his fever subsided. The clots in his R arm were treated conservatively with elevation and warmth. FEN Mild hypernatremia on floor, likely volume depletion with feeds on halt for studies, insuff IVF and loss with fever. Also was on low dose Lasix for edema of the arms, once this was discontinued sodium self-corrected. GI Signficant constipation will need to be further monitored and treated aggressively with a bowel regimen. G-tube in place. The patient eventually passed speech and swallow but continued to require tube feeds to maintain nutrition. During the month of [**Month (only) **], the patient's tube feeds were changed from continuous to overnight, as oral intake improved. His tube feed duration was shortened as the patient demonstrated increased ability to maintain oral intake. During [**Month (only) **] the PEG was slightly displaced and re-sutured by IR after gastrograffin study was performed. His insulin regime was re-adjusted and reduced due to hypoglycemia as his tube feeds were changed. HEME Anemia of chronic illness and repeated blooddraws. Trending towards more normal values by end of admision. Persistently elevated white count, as outlined above, also normalized. Hypercoag studies negative. SOC Family in [**Doctor Last Name **]. [**Doctor Last Name **] (only English speaking niece) [**Telephone/Fax (1) 78247**] contact person of family. Wife [**Telephone/Fax (1) 78248**] speaks only Portguese, she is HCP though. Relative infrequent visits due to absence of transportation and finances. At the current time, a physician at [**Name Initial (PRE) **] rehabilitation facility in [**Country 6257**] has accepted the patient, but will not return from vacation until [**9-7**]. He continues to work with physical, occupational, and speech therapy in an effort to improve his transfers and functional abilities. Medications on Admission: None Discharge Medications: 1. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 10. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. Disp:*1 MDI* Refills:*2* 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Disp:*1 bottle* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1 Left basal ganglia bleed 2 Multiple embolic strokes of unknown etiology 3 Alcohol withdrawal 4 Hypertension 5 Septic thrombophlebitis R arm Discharge Condition: Stable, dense R hemiparesis and global aphasia Discharge Instructions: Please take all your medications excactly as directed and please attend all your follow-up appointments. Please make sure that patient is drinking at least 6 cans of "Ensure Plus" per day, and that the family should give the patient the remainder of the cans through the PEG tube should he drink any less than 6 cans. Please report to the nearest ER or call 911 or your PCP immediately when you experience recurrence of weakness, numbness, tingling, problems with speech, language, walking, thinking, headache, or difficulties arousing, or any other signs or symptoms of concern Followup Instructions: Will be following up with doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 6257**]. If your return to [**Country 6257**] is delayed beyond 8 weeks from discharge, follow up with neurologist Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 2574**] [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2114-8-31**]

[ "599.0", "348.4", "434.11", "285.29", "451.82", "291.81", "482.41", "303.90", "431", "564.00", "999.2", "482.83", "276.0", "E879.8", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "38.91", "43.11", "96.04", "96.72", "96.71", "33.24" ]

icd9pcs

[ [ [] ] ]

15602, 15608

8705, 9633

328, 334

15794, 15843

2155, 2325

16472, 16859

1384, 1402

14312, 15579

15629, 15773

14283, 14289

9650, 14257

15867, 16449

1417, 1656

275, 290

362, 1128

2506, 8682

2339, 2497

1673, 2136

1150, 1214

1230, 1368

11,607

159,890

4054

Discharge summary

report

Admission Date: [**2137-3-29**] Discharge Date: [**2137-4-5**] Date of Birth: [**2082-8-27**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) / Codeine Attending:[**First Name3 (LF) 695**] Chief Complaint: Cholangiocarcinoma, HBV related cirrhosis, and HIV. Major Surgical or Invasive Procedure: [**2137-3-29**]; Left hepatic lobectomy, caudate lobe resection, cholecystectomy, common bile duct excision, Roux-en-Y hepaticojejunostomy to the right anterior/posterior hepatic duct (single anastomosis) over 5-French feeding tube, portal lymph node dissection, intraoperative ultrasound. History of Present Illness: 54 yo male with hx of HIV who presented [**2137-2-6**] with 3-4d of epigastric pain, n/v, jaundice, dark urine, pale stools. Workup with CT at that time showed a left lobe hepatic mass with no flow in the left hepatic vein and f/u CT revealed left common hepatic duct obstruction. He underwent ERCP with R CHD stenting during that admission, but the L sided system could not be accessed. His post-ERCP course was complicaed by asymptomatic pancreatitis.He was subsequently discharged home several days later and returned for completion of his work-up with PTC of the L sided biliary system and brushings along with liver biopsy which showed features consistent with chronic viral hepatitis B with cirrhosis. There was also evidence of a component of biliary obstruction. He subsequently developed fever and required admission for IV antibiotics; he received 2 weeks of Vanco and Ceftazadime via PICC line which has now been removed. He is admitted today following liver resection. Past Medical History: 1. HIV: dx [**2114**]- w/ history of Kaposi's sarcoma, anal cancer -medical regimens: ABC/3TC/NFV(1/99-5/01)->ABC/3TC/AZT/NVP-> ABC/3TC/TDF/NVP; CD4 nadir 130 [**7-8**](chemo for anal CA at this time) 2. anal CA s/p chemo and 6 wks XRT [**1-8**] 3. hypogonadism 4. ED 5. insomnia 6. B12 deficiency 7. Chronic HepB 8. Hairy cell leukoplakia 9. Kaposi's sarcoma Social History: Homosexual male who lives in [**Location 3615**]/[**Location (un) 86**] with his partner [**Name (NI) **]. [**Name2 (NI) **] is on disability. Reports minimal EtOH with no smoking hx and denies illicit substance use. Used intranasal cocaine in the remote past but no IVDU. Has multiple tatoos. Family History: Father died of an MI at age 56 and mother died of ovarian CA at age 59 Physical Exam: Post Op: VS: 97.4, 77, 128/69, 15, 97% 4L Neuro: A+Ox3, PERRLA, EOMI Card: RRR Lungs: CTA Bilaterally Abd: soft, appropriately tender, minimal distension Extr: No edema Incision: C/D/I Pertinent Results: Post Op [**2137-3-29**] WBC-4.7 RBC-3.01* Hgb-10.5* Hct-29.4* MCV-98 MCH-35.0* MCHC-35.8* RDW-15.4 Plt Ct-152 PT-14.4* PTT-27.8 INR(PT)-1.3* Fibrinogen-249 Glucose-148* UreaN-13 Creat-1.5* Na-139 K-4.4 Cl-109* HCO3-21* AnGap-13 ALT-142* AST-170* AlkPhos-113 TotBili-3.2* Calcium-8.7 Phos-3.9# Mg-1.5* Brief Hospital Course: Patient admitted following Left hepatic lobectomy, caudate lobe resection, cholecystectomy, common bile duct excision, Roux-en-Y hepaticojejunostomy. Please see the operative note for surgical details. In summary: "the patient was noted to have macronodular cirrhosis, but no evidence of portal hypertension or ascites. He had normal hepatic anatomy. The left lateral segment was smaller than normal. Intraoperative ultrasound demonstrated a mass involving the left hepatic duct, but was confined to the left lobe and did not extend into the right lobe. The tumor did extend down to the bifurcation and the common hepatic duct appeared abnormal by ultrasound. There were no pathologic lymph nodes noted. Frozen section of the distal common bile duct was negative for malignancy and frozen section of the right hepatic duct margin was also negative for malignancy." The patient was admitted post op to the surgical ICU with JP bulb drainage with serosanguinous drainage and the 2 PTC's previously in place. He used an epidural initially, this was d/c'd on POD 1. ALT and AST spiked on POD 2 into the 700's. An U/S of the liver was performed showing Normal right hepatic vascular waveforms. The following day the enzymes were trending back down and T Bili was down to 1.3 JP bulb drainage started to increase on POD3. On pod 6, a cholangiogram demonstrated patent ducts with slight narrowing of the anterior and posterior ducts at the anastomotic site likely representing postop edema. Both anterior and posterior right t tubes were capped. Patient was ambulating and was seen by PT who cleared him for home once medically stable. He was tolerating a regular diet and drinking enough fluid to keep up with the high output [**Doctor Last Name 406**] drain which was draining approximately one liter per day of serous fluid. He was sent home with empty t tube bags in the event that he should need to open the drains if febrile. Medications on Admission: Kaletra (Lopinavir-Ritonavir) 2 TABS'; Valtrex 500'; Tenofovir 300'; Epzicom (Abacavir 600/Lamivudine 300) 1 TAB'; Dapsone 100', Testosterone Inj 200 mg q week, HCTZ 25', Colace, Oxycodone Discharge Medications: 1. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for herpes labialis. 2. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while takiing pain medication. stop if diarrhea or loose stool. Disp:*60 Capsule(s)* Refills:*2* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): stop if diarrhea or loose/frequent stool. Disp:*30 Tablet(s)* Refills:*2* 6. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: HCC Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, drainage/redness/bleeding at JP or capped drain sites, increased abdominal pain or jaundice [**Month (only) 116**] shower, no heavy lifting, no driving while taking pain medication. Check drain sites for redness or drainage. Change dry gauze dressing once a day over drain sites. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 568**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2137-5-13**] 1:00 Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**] [**2137-4-8**] at 12:50 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2137-4-5**]

[ "155.0", "042", "070.32", "V10.06", "571.5", "575.11" ]

icd9cm

[ [ [] ] ]

[ "46.39", "88.79", "40.3", "50.22", "51.63", "51.37", "51.22", "50.69" ]

icd9pcs

[ [ [] ] ]

6176, 6182

2974, 4900

341, 633

6230, 6237

2649, 2951

6666, 7125

2356, 2428

5140, 6153

6203, 6209

4926, 5117

6261, 6643

2443, 2630

249, 303

661, 1644

1666, 2028

2044, 2340

79,242

136,849

37536

Discharge summary

report

Admission Date: [**2159-6-13**] Discharge Date: [**2159-6-21**] Date of Birth: [**2092-11-25**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4679**] Chief Complaint: Esophageal Cancer Major Surgical or Invasive Procedure: [**2159-6-15**] 1. [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy. 2. Buttressing of intrathoracic anastomosis with intercostal muscle. 3. Laparoscopic jejunostomy. 4. Therapeutic bronchoscopy. 5. Esophagoscopy. History of Present Illness: Mr. [**Known lastname 60411**] is a 66-year-old male who is morbidly obese with a BMI of 43. He has undergone chemoradiation therapy for locally advanced esophageal cancer of the GE junction. He is admitted for mimimal invasive esophagectomy. Past Medical History: Esophageal Cancer s/p Chemoradiation therapy Benign Hypertension Type 2 Diabetes Mellitus Hyperlipidemia Diverticulitis B/L Total Knee Replacements Biceps Reconstruction secondary to Trauma Social History: Ex-smoker (quit 35 years PTA), - ETOH, - Drugs, Married, Electrician (semi-retired) Family History: Non-Contributory Physical Exam: VS: 97.7 HR: 64 SR BP: 134/60 Sats: 95% RA at rest & activity FSBS: 114-150 General: well appearing gentleman in no apparent distress HEENT: nomocephalic, mucus membranes moist Neck:supple Card: RRR normal S1,S2 Resp: decreased breath sounds faint crackles at bases GI: obese, bowel sounds positive. J-tube in place site clean dry intact Incision: Right thoracotomy site clean dry intact no erythema, margins good approximation Neuro: non-focal Pertinent Results: [**2159-6-17**] WBC-7.6 RBC-3.65* Hgb-11.3* Hct-34.5 Plt Ct-205 [**2159-6-16**] WBC-9.4 RBC-3.60* Hgb-11.3* Hct-33.7 Plt Ct-194 [**2159-6-13**] WBC-11.1*# RBC-3.98* Hgb-12.1* Hct-37.0 Plt Ct-200 [**2159-6-21**] Glucose-120* UreaN-19 Creat-0.7 Na-135 K-4.9 Cl-98 HCO3-29 [**2159-6-20**] Glucose-151* UreaN-21* Creat-0.6 Na-137 K-4.1 Cl-101 HCO3-27 [**2159-6-17**] Glucose-128* UreaN-18 Creat-0.7 Na-143 K-3.8 Cl-105 HCO3-31 [**2159-6-14**] Glucose-135* UreaN-14 Creat-0.8 Na-137 K-4.2 Cl-104 HCO3-24 [**2159-6-13**] Glucose-137* UreaN-17 Creat-0.9 Na-139 K-4.3 Cl-107 HCO3-21 [**2159-6-20**] Mg-1.9; [**2159-6-21**] 1.8 CXR: [**2159-6-20**]: IMPRESSION: Mild interval increase in small right pleural effusion with stable moderate left effusion. A right apical pneumothorax is miniscule, if present. [**2159-6-18**]: The right-sided central venous catheter is unchanged. The chest tube on the right side is also stable. There is a small right apical pneumothorax which is unchanged since the prior study. There remains pleural parenchymal changes on the right side. There is also a left retrocardiac opacity and left-sided pleural effusion which is stable since the previous study. [**2159-6-14**]:Unchanged size of the cardiac silhouette with a minimal left pleural effusion and subsequent retrocardiac atelectasis. Unchanged minimal right basal atelectasis but no evidence of focal parenchymal opacities suggesting pneumonia. No evidence of pneumothorax. Esophagus: [**2159-6-19**]: Thin liquid barium was administered and there was free flow of contrast through the upper esophagus and through the esophagogastric anastomosis. There was no evidence of contrast holdup or leak. Final image demonstrates normal flow of contrast into the proximal duodenum and jejunum. IMPRESSION: no evidence of contrast leak or holdup at the anastomotic site. Contrast flows freely through the duodenum and the proximal jejunum. LENIS: LLE no DVT Brief Hospital Course: Mrs. [**Known lastname 60411**] was admitted following successful, [**Known lastname 12351**] [**Doctor Last Name **] esophagectomy, Buttressing of intrathoracic anastomosis with intercostal muscle. Laparoscopic jejunostomy. Therapeutic bronchoscopy, and Esophagoscopy. He was transferred to the SICU intubated. Respiratory: extubated [**2159-6-14**]. aggressive pulmonary toilet, chest PT and nebs were administered. His oxygen saturations were 95% RA with activity. Chest Films; serial chest films showed stable right tiny apical pneumothorax, bilateral lower lobe effusion and atelectasis. Chest-tube and JP drain was removed [**2159-6-19**] following esophagus study. Cardiac: he was continued on his beta-blocker. Amiodarone was restarted once tolerating POs, remained in sinus rhythm 70's and hemodynamically stable with blood-pressures 110-120. GI: bowel regime and PPI continued Nutrition: POD2 he was started on Replete with Beneprotein 21 gms and titrated to the Goal of 105 mL over 12 hrs. He was maintained on IV fluids initially. On [**2159-6-19**] the Esophagus study was negative for anastomic leak. He was started on Full liquid diabetic diet advanced to soft solids as an outpatient. Endocrine: fingerstick blood sugars were 114-150's. He was maintained on insulin sliding scale. He was sent home with a FreeStyle Lite Glucometer and instructed to restart his meformin once his blood sugars were consistenly elevated. Renal: the foley was removed on [**2159-6-19**], He voided without difficulty. Renal function remained within normal limits with good urine output. He was gently diuresed. His electrolytes were repleted as needed. Incision: Right thoracotomy site clean dry intact no erythema. Pain: Bupavicaine/Dilaudid epidural was placed preoperatively and required replacement [**2159-6-14**] by the acute pain service with adquate pain control. On [**2159-6-19**] the epidural was removed and he converted to PO pain medication. Prophylaxis: SQ heparin was administered. Extremities: left lower leg edema was noted. Left LENIS were negative for DVT. Neuro: non-focal Disposition: He was seen by physical therapy and deemed safe for home. He was discharged to home on [**2159-6-21**] with his wife and [**Name (NI) 269**]. He will follow-up with Dr. [**First Name (STitle) **] as an outpatient. Medications on Admission: lansoprazole 30 mg daily, amiodarone 200 mg [**Hospital1 **], lopressor 25 mg [**Hospital1 **] Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs PO Q3H PRN () as needed for pain. Disp:*450 ML(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Polyethylene Glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1) scoop PO DAILY (Daily) as needed for constipation. 8. Fenofibrate Nanocrystallized 145 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 9. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: start [**6-22**] if blood greater than 120. 10. Metformin 500 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day: take if blood sugars consistently greater than 120. 11. Aspirin 81 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day. 12. Centrum Silver Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day. 13. FreeStyle Lite Glucose Kit [**Month/Day (4) **]: One (1) Kit as directed. Disp:*1 * Refills:*0* 14. FreeStyle Lancets Misc [**Month/Day (4) **]: One (1) Miscellaneous twice a day. Disp:*100 lancets* Refills:*2* 15. FreeStyle Lite Test Strips [**Month/Day (4) **]: One (1) twice a day. Disp:*100 strips* Refills:*2* Discharge Disposition: Home With Service Facility: Physician's Home Care Discharge Diagnosis: Esosphageal Cancer Diabetes Mellitus type 2 Hypertension Hyperlipidemia Morbid obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Difficult or painful swallowing, nausea, vomiting, or diarrhea -Feeding tube fall out. Call immediately to have it replaced. -Keep head of the bed elevated 30 degress -Chest tube site cove with a bandaid until healed. -You may shower. No tub bathing or swimming for 4 weeks -No driving while taking narcotics. Take stool softners with narcotics Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] Date/Time:[**2159-7-5**] 3:00 on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]. Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your appointment Please call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] next week to let us know how you are doing. Completed by:[**2159-6-21**]

[ "272.4", "401.1", "427.31", "150.8", "530.81", "250.00", "V85.4", "278.01", "V15.3", "327.23", "V87.41", "562.10" ]

icd9cm

[ [ [] ] ]

[ "42.59", "42.23", "46.39", "96.6", "54.21", "42.42", "33.22", "03.90" ]

icd9pcs

[ [ [] ] ]

7899, 7951

3651, 5999

340, 587

8082, 8082

1693, 3628

8785, 9195

1190, 1208

6144, 7876

7972, 8061

6025, 6121

8233, 8762

1223, 1674

283, 302

615, 859

8097, 8209

881, 1072

1088, 1174

28,508

145,742

19620

Discharge summary

report

Admission Date: [**2158-11-28**] Discharge Date: [**2158-12-18**] Date of Birth: [**2102-1-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: left sided chest pain, fever, HONK Major Surgical or Invasive Procedure: Intubation Chest tube placement x3 by interventional pulmonology. History of Present Illness: Ms. [**Known lastname 110**] is a 56 y/o woman with PMH notable for insulin-dependent DM, ESRD on PD, and CAD s/p MI with stenting in [**2155**] who presents to the ED with two-day history of left-sided pleuritic chest pain, fever, and cough. The patient's husband served as the interpreter during our encounter. The patient noted left-sided lower rib pain about 2-3 days ago; she denies any other myalgias. She has had poor PO intake and today vomited twice, nonbloody. She has had fevers to 101.8 daily for the past three days. She is not producing sputum. She is having trouble lying flat to sleep due to left sided chest discomfort and dyspnea. She has been performing her PD as directed (her husband does this for her). Today, due to worsening pain and dyspnea as well as vomiting, the patient's husband brought her to the [**Name (NI) **] for evaulation. Vitals on presentation to the ED were T 99.1 BP 193/92, HR 100, 92% on RA. She was noted to have a left-sided retrocardiac infiltrate on cxr. She was treated with iv levofloxacin 750 gm X 1 and ceftriaxone 1 g IV X 1. She also received 1 g tylenol PR and 2 mg morphine. Due to elevated blood sugars and anion gap, she received 10 U regular insulin and was placed on an insulin gtt. She received a total of 2 L NS in the ED. Blood pressures improved to 150s/70s prior to transfer to the floor with pain control. On arrival to the ICU, the patient is sitting upright on bed. She is complaining of [**7-30**] left sided chest pain, at the inferior margin of the ribs, worse with inspiration. She denies any headache, dizziness, lightheadedness, nasal congestion, sore throat, difficulty swallowing, abdominal pain, or LE edema. She has not eaten much in the past 48 hours. She had a bowel movement yesterday but feels somewhat constipated. She denies any sick contacts. [**Name (NI) **] husband believes she got her flu shot this year. Past Medical History: PMH: * type II DM, now on insulin (lantus & humalog) * ESRD on PD ([**1-21**] to DM, followed at [**Last Name (un) **], on transplant list) * h/o anemia (intermittently given transfusions, on Epo) * eczema * hypertension * h/o CAD S/P bare metal stenting of her mid RCA and 4th obtuse marginal/left posterolateral branch on [**2156-11-22**] * recent h/o H pylori * h/o hemorrhoids Social History: Patient is Cantonese and Mandarin speaking only, married, with husband at bedside. Denies alcohol, tobacco, or drug use. Lives with husband who performs her PD and manages her medications (husband speaks english). Family History: Strong family history of Type II DM. Brother deceased of renal failure. Physical Exam: On presentation: PE: T: 99.1 BP: 158/64 HR: 101 RR: 24 O2 99% on 3 L NC Gen: Pleasant female, appears uncomfortable lying on right side HEENT: no scleral icterus, tongue slightly dry & midline NECK: supple, no LAD, no thyromegaly CV: slightly tachycardic but regular, no appreciable murmur, tender to palpation over left-sided inferior ribs under left breast but no rash at site LUNGS: crackles at left base with decreased breath sounds on that side ABD: distended but soft, + fluid wave, no rebound/guarding, nontender to palpation EXT: warm, no peripheral edema, wearing pneumoboots SKIN: no rashes, onychomycosis on toes NEURO: alert & interactive, appropriately responding to husband's questions, face symmetric, moving all extremities without difficulty Pertinent Results: ON ADMISSION [**2158-11-28**] 04:45PM PLT COUNT-337 [**2158-11-28**] 04:45PM NEUTS-80* BANDS-11* LYMPHS-3* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2158-11-28**] 04:45PM WBC-23.2*# RBC-3.21* HGB-10.2* HCT-30.7* MCV-96 MCH-31.7 MCHC-33.2 RDW-15.1 [**2158-11-28**] 04:45PM LIPASE-16 [**2158-11-28**] 04:45PM ALT(SGPT)-36 AST(SGOT)-58* CK(CPK)-2971* ALK PHOS-101 TOT BILI-0.2 [**2158-11-28**] 04:48PM HGB-11.2* calcHCT-34 [**11-28**] Blood Culture (2/2 bottles): STAPH AUREUS COAG + CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S PENICILLIN G---------- =>0.5 R TRIMETHOPRIM/SULFA---- <=0.5 S CXR [**2158-11-28**]: Left lower lobe retrocardiac opacity with associated left pleural effusion consistent with pneumonia. CT Abdomen/Pelvis [**12-1**] 1. Scattered foci of free air in the abdomen and pelvis along with free fluid. The presence of a peritoneal dialysis catheter and a recent peritoneal dialysis procedure being performed likely explains the presence of free air and free fluid. 2. Atrophic kidneys consistent with end-stage renal disease. 3. No evidence for bowel dilatation. 4. Areas of consolidation in the left lower lobe with small left pleural effusion concerning for pneumonia. Chest CT [**12-2**]: IMPRESSION: Cavitary lesion in the left lower lobe which was not present on prior chest x-rays from [**11-28**], [**2157**] concerning for pulmonary abscess. Hydropneumothorax on the left, possibly bronchopleural fistula. Left lower lobe pneumonia with areas of left lung atelectasis. Patchy airspace disease in the right lower lobe and right middle lobe, likely endobronchial spread of infection. Ascites. Nodule left lobe of thyroid. US recommended. [**12-12**] TEE: Conclusions No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). There are complex (>4mm) nonmobile atheroma in the descending thoracic aorta to 40cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is no pericardial effusion. Impression: No vegetation or abscess seen. ROMI: [**2158-11-28**] 04:45PM BLOOD CK-MB-6 cTropnT-0.03* [**2158-11-29**] 12:46AM BLOOD CK-MB-4 cTropnT-0.02* [**2158-11-28**] 04:45PM BLOOD CK(CPK)-2971* [**2158-11-29**] 12:46AM BLOOD CK(CPK)-[**2070**]* IRON STUDIES: [**2158-12-1**] 07:10AM BLOOD Iron-44 calTIBC-142* Ferritn-GREATER TH TRF-109* WBC/Hct TREND: [**2158-11-28**] WBC-23.2 Hct-30.7 [**2158-11-29**] WBC-19.5* Hct-26.2 [**2158-11-30**] WBC-15.6* Hct-23.0 [**2158-12-4**] WBC-25.3* Hct-22.4 [**2158-12-7**] WBC-17.5* Hct-22.5 [**2158-12-10**] WBC-13.0* Hct-26.5 [**2158-12-13**] WBC-13.4* Hct-26.1 [**2158-12-15**] WBC-14.9* Hct-33*# [**2158-12-17**] WBC-9.9 Hct-22.5* Brief Hospital Course: 56 y/o F with a history of type II DM, Chronic kidnye disease, on peritoneal dialysis who presents with left-sided infiltrate and anion-gap hyperglycemia. # PNEUMONIA/EMPYEMA: The patient was initially treated with levofloxacin for community-acquired pneumonia. She was initially on 5L oxygen by nasal cannula. Within 3-4 days, she no longer needed oxygen. DFA for influenza was negative. Urinary legionella antigen could not be obtained as patient does not void. Legionella culture from sputum and sputum cultures were pending. One blood culture from [**11-28**] grew MSSA, and patient was additionally given Nafcillin. She was treated with standing nebulizers, tessalon perles, and guaifennasin with codeine for cough. She complained of Left pleuritic rib pain, worse with cough or deep inspiration, and her WBC count continued to rise. Chest CT showed cavitary lesion in left lower lobe with air in the pleura, concerning for bronchopleural fistula. To investigate tuberculosis, PPD was negative and she had 3 induced sputums sent for AFB smear and culture that were negative. Interventional Pulmonary placed a pigtail catheter and subsequently a chest tube [**12-4**]. On transfer to MICU thoracics placed an additional 2 chest tubes [**12-6**]. The patient was intubated due to chest tube placement for decortication of empyema. Stopped flagyl [**12-7**] due successful chest tube placement and no culture data to suggest need for this antibiotic. All cultures grew MSSA - blood, BAL, sputum and pulmonary tissue. Patient remained intubated due to airway edema, (treated with prednisone) for 3 days, and was extubated on [**2158-12-9**]. The chest tube drained well for 48 hours, but then declined. Thoracic continued to follow, and instilled TPA in the chest tubes on [**12-5**] and [**12-15**]. The chest tubes were placed to water seal [**12-16**] and her husband was shown how to care for the chest tubes at home with help of VNA services. . She will continue on Nafcillin 2 grams IV q4 hours at discharge, to be continued until she meets up with Dr. [**Last Name (STitle) **]. She will follow up with Dr [**Last Name (STitle) **] (ID) [**2159-1-1**]; a repeat CT chest will be performed prior to this visit. . She will follow up with thoracic surgery for management of her chest tubes as well. . #Hypotension: The patient has a history of hypertension and is on metoprolol, valsartan and lasix at home. Her BP's in the hospital were persistantly 90-100s despite discontinuation of these medications. These medications may need to be restarted as an outpatient. . # Hypotension: Patient was hypotensive to the 70s/40s three days prior to discharge. This was likely due to hypovolemia as 7 L was removed over the prior 4 days. She responded well to fluid boluses and was not hypotensive for 2 days prior to discharge. She is to continue PD per renal as indicated below. . # Leukocytosis with bandemia: Likely related to above. However, given patient is on Peritoneal Dialysis, also checked Peritoneal fluid for peritonitis. Culture was negative. Three C. diff's were checked that were negative. . # Anion gap with hyperglycemia: Serum acetone negative, AG chronic and likely [**1-21**] renal failure, hyponatremic instead of DKA. Insulin ggt discontinued. Patient was hard to control and [**Last Name (un) **] was consulted. Patient during MICU stay was on lantus and insulin drip. [**Last Name (un) **] made adjustments to her insulin regimen throughout her stay; she is discharged on lantus with HISS as in med list. . # ESRD on PD: Patient has been performing dwells per her home regimen per husband while on floor. Upon transfer to the MICU patient was transitioned to q4hour dwells. Renal dialysis service followed along during this hospitalization. Patient while had NG tube was on calcium acetate instead of lanthanum. Patient was maintained on an aggressive bowel regimen to assist with peritoneal dialsis. . # Thyroid nodule: seen on Chest CT. Please follow up as an outpatient with US. Primary care physician was [**Name9 (PRE) 31142**] about this issue. Medications on Admission: MEDS: aspirin 81 mg daily lopressor 100 [**Hospital1 **] simvastatin 40 mg daily valsartan 80 mg daily lasix 80 mg [**Hospital1 **] renagel 1600 tid nephrocap daily lanthanum [**2149**] mg four times daily colace 100 [**Hospital1 **] bisacodyl 10 qhs fibercon 1250 mg daily epo 20,000 U weekly lantus 8 U qhs and sliding scale humalog clobetasol ointment anusol ointment pr prn Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Lanthanum 500 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO QID (4 times a day). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 7. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). Disp:*30 Lozenge(s)* Refills:*2* 8. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-[**Hospital1 2974**]). 9. Nafcillin 2 gram Recon Soln Sig: Two (2) grams Intravenous every four (4) hours: Continue through follow up with Infectious Disease [**2159-1-1**]; may need to continue for additional weeks beyond that appointment pending CT results. . Disp:*QS * Refills:*0* 10. PICC Care PICC Care per protocol 11. Outpatient Lab Work Please check a Chem 10, CBC with Diff, AST, ALT, Alk Phos and T BILI each week starting [**2158-12-19**]. Fax results to [**Last Name (LF) 4090**], [**Name8 (MD) 4102**] MD. Office phone: ([**Telephone/Fax (1) 817**], Dr [**Last Name (STitle) **] (office phone [**Telephone/Fax (1) 250**]) and to Dr [**Last Name (STitle) **] office phone ([**Telephone/Fax (1) 4170**]. 12. Hydrocortisone 2.5 % Cream Sig: One (1) application Topical twice a day. Disp:*30 gram* Refills:*0* 13. 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. 14. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. Disp:*1 bottle* Refills:*0* 16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 17. Bisacodyl Oral 18. Lantus 100 unit/mL Solution Sig: Sixteen (16) Units Subcutaneous at bedtime: Please take only 8 units the evening of discharge, [**12-18**], then resume 16 units at night. 19. Humalog 100 unit/mL Solution Sig: Per sliding scale units Subcutaneous three times a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. Community acquired pneumonia complicated by Left lower lobe empyema and bronchopleural fistula 2. MSSA bacteremia 3. Chronic kidney disease 4. Diabetes mellitus, type 2, uncontrolled 5. Hyponatremia, chronic 6. Anemia 7. Thyroid nodule Secondary diagnosis: Hypertension Coronary artery disease Discharge Condition: Stable, on room air, tolerating PO Discharge Instructions: You were admitted with pneumonia and bacteria in your bloodstream. You were closely monitored in the intensive care unit and treated with intravenous antibiotics. Your pneumonia developed into an abscess, which was drained with 3 chest tubes. . Your blood sugars were very high. The Diabetes Doctors [**First Name8 (NamePattern2) 767**] [**Name5 (PTitle) 4372**] were consulted and adjusted your insulin regimen. You were continued on peritoneal dialysis, and the kidney doctors [**Name5 (PTitle) 6349**] [**Name5 (PTitle) **] as well. . You will be discharged on IV antibiotics (nafcillin); you will continue taking these until discontinued by your ID doctor (Dr [**Last Name (STitle) **]. . The chest tubes will be in place at discharge as well; you will follow up with Dr [**First Name (STitle) **] as listed below for management of these tubes. . You were noted to have a nodule on your thyroid. You need to have an ultrasound performed as an outpatient. Your PCP will help you set this up. . Please seek medical care if you develop fevers, worsening cough, or chest pain, trouble with your chest tubes, lightheadedness, or any other concerning symptoms. Followup Instructions: Follow up with thoracic surgery for chest tube management: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2158-12-26**] 9:00. You should arrive to [**Hospital Ward Name 23**] 4 at 8:15 for a chest xray before your appointment with Dr [**First Name (STitle) **]. . You are scheduled for a CT scan of your chest on [**2158-12-28**] at 3:15 in [**Hospital Ward Name 23**] 4 ([**Hospital Ward Name 516**] of [**Hospital1 18**]). Do not have anything to eat or drink for 3 hours prior to this test. . Follow up with Dr [**Last Name (STitle) **] of Infectious Disease at [**Last Name (NamePattern1) **], Basement, Suite G, on [**2159-1-1**] at 3:30 PM. . You have an appointment with Dr. [**Last Name (STitle) **] on [**1-8**] at 8am. The clinic number is [**Telephone/Fax (1) 673**] . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7449**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2159-1-15**] 8:30 . Follow up with Dr [**Last Name (STitle) **] in the next few weeks. Call [**Telephone/Fax (1) 250**] for an appointment. You should discuss the thyroid nodule at this visit. . The diabetes doctors from the [**Name5 (PTitle) **] clinic will be contacting you regarding an upcoming follow up appointment. If you have questions, or if they do not contact you by [**2158-12-22**], please call ([**Telephone/Fax (1) 4847**]. Completed by:[**2158-12-19**]

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icd9cm

[ [ [] ] ]

[ "99.10", "34.06", "38.93", "34.09", "33.24", "96.72", "99.04", "99.07", "96.6" ]

icd9pcs

[ [ [] ] ]

13858, 13916

6969, 11054

352, 420

14258, 14295

3868, 6946

15508, 16966

2999, 3073

11483, 13835

13937, 14177

11080, 11460

14319, 15485

3088, 3849

278, 314

448, 2346

14198, 14237

2368, 2750

2766, 2983

12,153

188,067

27662

Discharge summary

report

Admission Date: [**2117-6-23**] Discharge Date: [**2117-7-1**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Asymptomatic with Aortic Stenosis Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x 2 (LIMA to LAD, SVG to Diag2) and Aortic Valve Replacement (21mm CE Magna pericardial tissue valve) on [**2117-6-24**] History of Present Illness: 85 y/o female with known Aortic Stenosis for several years(discovered after syncopal episode) who is currently asymptomatic. She has refused surgery in the past. She [**Date Range 1834**] a cardiac cath which not only confirmed AS but revealed coronary artery disease. She now wants to proceed with surgery. Past Medical History: Aortic Stenosis, Hyperlipidemia, Lyme Disease, Hard of hearing, Meniere's disease, Arthritis, Skin cancer s/p removal on face, Broken left wrist, s/p hysterectomy for cancer, s/p bilat cataract surgery, s/p right knee replacement Social History: Works as a volunteer. Denies tobacco, ETOH, or IVDA use. Family History: Non-contributory Physical Exam: VS: 90 25 111/44 5'6" 140# General: NAD Skin: Unremarkable Neck: Supple, FROM, -JVD HEENT: EOMI, PERRLA, OP benign Chest: CTAB -w/r/r Heart: RRR 3/6 SEM Abd: Soft NT/ND +BS Ext: Warm, well-perfused, -edema, superficial varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: Cath [**6-23**]: 1. Two vessel coronary artery disease. 2. Critical aortic stenosis. 3. Moderate diastolic ventricular dysfunction. 4. Moderate pulmonary hypertension. Carotid U/S [**6-24**]: Bilateral less than 40% carotid stenosis Echo [**6-24**]: There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal(LVEF>55%). There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. Mild to moderate ([**1-11**]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. The jet is central. Post Bypass: Biventricular systolic function is preserved. Bioprosthetic valve seen in the aortic position. Valve appears well seated and the leaflets move well. Trace aortic insufficiency present. Peak velocity at the level of the aortic valve was 1.7 m/sec. The mitral regurgitation is now 1+ which is significantly improved from pre bypass findings. CXR [**6-29**]: Small bilateral pleural effusions. [**2117-6-23**] 12:35PM BLOOD WBC-6.8 RBC-3.53* Hgb-10.8* Hct-31.6* MCV-90 MCH-30.5 MCHC-34.0 RDW-14.5 Plt Ct-290 [**2117-6-29**] 07:10AM BLOOD WBC-13.8* RBC-3.16* Hgb-9.9* Hct-28.4* MCV-90 MCH-31.3 MCHC-34.9 RDW-14.6 Plt Ct-211 [**2117-6-23**] 08:40AM BLOOD INR(PT)-0.9 [**2117-6-29**] 07:10AM BLOOD PT-13.1 INR(PT)-1.1 [**2117-6-23**] 12:35PM BLOOD Glucose-100 UreaN-11 Creat-0.6 Na-138 K-4.0 Cl-107 HCO3-22 AnGap-13 [**2117-6-29**] 07:10AM BLOOD Glucose-104 UreaN-15 Creat-0.7 Na-137 K-3.8 Cl-101 HCO3-28 AnGap-12 [**2117-6-28**] 02:26AM BLOOD Albumin-2.6* Calcium-7.9* Phos-3.6 Mg-2.0 [**2117-6-23**] 12:55PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2117-6-23**] 12:55PM URINE RBC-0-2 WBC-0 Bacteri-0 Yeast-NONE Epi-0 [**2030-6-26**] C. Diff Negative Brief Hospital Course: Ms. [**Known lastname **] [**Last Name (Titles) 1834**] cardiac cath on [**6-23**] which revealed severe AS and 2vd. She remained in the hospital and after pre-operative work-up and consent, she was brought to the operating room on [**6-24**]. She [**Month/Year (2) 1834**] a aortic valve replacement and coronary artery bypass graft x 2. Please see operative report for surgical details. She tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. Later on op day she was weaned from sedation, awoke neurologically intact and was extubated without incident. She did experience some post-op delirium which resolved with time and elimination of narcotics and further sedatives. Intermittent Haldol was required as was a patient observer to avoid self harm. She was started on Amiodarone for episodes of paroxsymal atrial fibrillation amd also given units of packed red blood cells to maintain hematocrit and optimize hemodynamics. Once her neurologic and hemodynamics stablized, she transferred to the SDU on postoperative day four. Over the next several days, her postop delirium completely resolved. Beta blockade was slowly advanced as tolerated while Amiodarone was continued. She maintained a normal sinus rhythm as no further episodes of PAF were noted. Overall, she continued to make clinical improvements with diuresis and mad steady progress with phsyical therapy. She was medically cleared for discharge on postoperative day seven. Medications on Admission: Aspiriin 81mg qd, Lescol 20mg qd, Ambien 5mg qhs, Vit. E, Tylenol prn, Vivelle 0.5mg patch biweekly Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Estradiol 0.05 mg/24 hr Patch Semiweekly Sig: One (1) Patch Semiweekly Transdermal biweekly (). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. 7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day) for 1 weeks. 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] for 5 days. Then 400mg qd for 7 days. Finally 200mg qd until stopped by cardiologist. 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 30191**] - [**Location (un) 22287**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2 Aortic Stenosis s/p Aortic Valve Replacement PMH: Hyperlipidemia, Lyme Disease, Hard of hearing, Meniere's disease, Arthritis, Skin cancer s/p removal on face, Broken left wrist, s/p hysterectomy for cancer, s/p bilat cataract surgery, s/p right knee replacement Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] take shower. Do not take bath. Do not apply lotions, creams, ointments or powders to incisions. Do not drive for 1 month. Do not lift greater than 10 pounds for 2 months. If you develop a fever or notice redness or drainage from incisions, please contact office immediately. Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks Dr. [**Last Name (STitle) 5310**] in [**2-12**] weeks Dr. [**Last Name (STitle) 67561**] in [**1-11**] weeks Completed by:[**2117-7-15**]

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icd9cm

[ [ [] ] ]

[ "36.11", "35.21", "88.53", "39.61", "99.04", "37.23", "36.15", "88.56", "89.60" ]

icd9pcs

[ [ [] ] ]

6068, 6144

3472, 4964

300, 451

6511, 6517

1447, 3449

6863, 7046

1131, 1149

5114, 6045

6165, 6490

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52052

Discharge summary

report

Admission Date: [**2164-10-13**] Discharge Date: [**2164-10-22**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2610**] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: [**Age over 90 **] y/o M with history of Afib, HTN, CVA's and severe dementia (nonverbal at baseline), with recent admission to [**Hospital1 18**] for respiratory failure, discharged two days ago, now presenting from [**Hospital 100**] rehab with respiratory failure. The patient was found on evening rounds to be hypoxic with O2 sats in the 70s on room air. He was given furosemide 80 mg via NG tube and morphine 2 mg SL x1, to treat presumed CHF exacerbation, without significant improvement. The patient vomited bilious emesis. Rehab facility documentation reports patient was having increased amounts of thick, white secretions. He was placed on a non-rebreather, and EMS was called to bring the patient to the ED. In the ED, initial VS were 118/50, 131, 33, 99% on BiPap. The patient was intubated with etomidate and succinylcholine, and sedated with fentanyl/midazolam. He was given vancomycin 1g and cefepime 2g for presumed HAP. He was also given acetaminophen 650 mg PR x1. Labs were notable for WBC 27.5, BNP 15K. He has been in afib with RVR to the 120s, which improved to the 100s with 3L NS and no rate control. BP was generally stable in the ED, with systolic BP readings between 95-125. Upon arrival to the MICU, the patient is afebrile with stable vital signs. He is intubated and sedated, not requiring hemodynamic support with vasopressors. Of note, the patient's recent admission to [**Hospital1 18**] featured respiratory failure and multifactorial (cardiogenic and septic) shock, with acute on chronic CHF and multifocal pneumonia. Several conversations were held between the MICU and floor teams, and the patient's brother [**Name (NI) 382**] and nieces, identifying what the patient's wishes would be in regards to his goals of care. According to the discharge summary from [**10-11**], the patient's brother and nieces all agreed to a code status of DNR/DNI and agreed he should not be reintubated if he failed extubation. Past Medical History: -Atrial Fibrillation -R MCA embolic stroke [**8-22**] -Cerebellar hemorrhage s/p craniotomy [**2126**] -Alzheimers dementia and nonverbal / PEG fed since stroke in [**2161**] -Colon CA stage III s/p resection -Coronary Artery Dementia -Hypertension -Mitral Regurg -Left Ventricular Hypertropy -Cervical radiculopathy/myelopathy -T12 compression fracture -Gastroesophageal Reflux -Liver hemangioma -Chronic Kidney Disease -BPH s/p TURP -History of bowel obstruction -History of multiple falls -History of ETOH abuse -Remote History of Pulmonary TB ([**2103**]'s) Social History: Immigrated from [**Country 532**] in [**2134**], at baseline speaks & understands limited English - translator needed. Positive h/o alcohol abuse, none for >1 yr. He does not smoke. Previously employed as a photographer. Brother states patient is a Holocaust survivor. Has lived in facility >1 yr. Nonverbal and fed by PEG. Family History: Both parents died in [**2095**] in the [**Location (un) 25508**] ghetto. Physical Exam: VS: Temp:99.8 BP:113/73 HR:109 (afib) RR:22 O2sat:100% Assist/control 500*16, FiO2 50%, PEEP 5 GEN: intubated, sedated, NAD, appears comfortable HEENT: Anisocoria with L > R pupil. Sluggish reactivity to light bilaterally, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, JVP at sternal notch, no carotid bruits, no thyromegaly RESP: Bilateral rhonchorous breath sounds with crackles, no wheeze CV: irregularly irregular. No m/r/g ABD: nd, NABSx4, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps RECTAL: Reportedly guaiac negative in ED. Pertinent Results: Initial Labs: [**2164-10-13**] 03:50AM WBC-27.5* RBC-4.20* HGB-10.4* HCT-33.7* MCV-80* MCH-24.9* MCHC-30.9* RDW-16.1* [**2164-10-13**] 03:50AM NEUTS-93.1* LYMPHS-2.6* MONOS-4.0 EOS-0.1 BASOS-0.2 [**2164-10-13**] 03:50AM PT-15.8* PTT-29.1 INR(PT)-1.4* [**2164-10-13**] 03:50AM PLT COUNT-428 [**2164-10-13**] 03:50AM FIBRINOGE-427* [**2164-10-13**] 03:50AM CALCIUM-8.7 PHOSPHATE-4.6* MAGNESIUM-2.7* [**2164-10-13**] 03:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2164-10-13**] 03:50AM LIPASE-81* [**2164-10-13**] 03:50AM cTropnT-0.04* [**2164-10-13**] 03:50AM proBNP-[**Numeric Identifier 107751**]* [**2164-10-13**] 04:05AM URINE BLOOD-TR NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2164-10-13**] 04:05AM URINE RBC-1 WBC-1 BACTERIA-MOD YEAST-NONE EPI-1 [**2164-10-13**] 04:05AM URINE HYALINE-[**5-24**]* [**2164-10-22**] 06:36AM BLOOD WBC-9.7 RBC-3.55* Hgb-9.0* Hct-29.2* MCV-82 MCH-25.4* MCHC-31.0 RDW-18.4* Plt Ct-193 [**2164-10-21**] 01:00PM BLOOD WBC-7.9 RBC-3.58* Hgb-9.0* Hct-29.3* MCV-82 MCH-25.2* MCHC-30.7* RDW-18.0* Plt Ct-245 [**2164-10-20**] 09:25AM BLOOD WBC-6.2 RBC-3.35* Hgb-8.4* Hct-27.9* MCV-83 MCH-25.2* MCHC-30.2* RDW-18.0* Plt Ct-242 [**2164-10-18**] 04:15AM BLOOD WBC-7.4 RBC-3.85* Hgb-9.3* Hct-30.6* MCV-79* MCH-24.1* MCHC-30.3* RDW-17.6* Plt Ct-264 [**2164-10-17**] 06:15AM BLOOD WBC-8.4 RBC-3.94* Hgb-9.9* Hct-31.9* MCV-81* MCH-25.0* MCHC-30.9* RDW-17.4* Plt Ct-368 [**2164-10-16**] 06:15AM BLOOD WBC-7.3 RBC-3.83* Hgb-9.7* Hct-31.4* MCV-82 MCH-25.3* MCHC-30.8* RDW-17.0* Plt Ct-356 [**2164-10-15**] 05:39AM BLOOD WBC-8.8 RBC-3.90* Hgb-9.7* Hct-31.6* MCV-81* MCH-25.0* MCHC-30.8* RDW-16.4* Plt Ct-331 [**2164-10-14**] 04:16AM BLOOD Neuts-75.4* Lymphs-12.0* Monos-3.1 Eos-8.9* Baso-0.6 [**2164-10-13**] 03:50AM BLOOD Neuts-93.1* Lymphs-2.6* Monos-4.0 Eos-0.1 Baso-0.2 [**2164-10-22**] 06:36AM BLOOD Glucose-111* UreaN-35* Creat-1.2 Na-141 K-4.8 Cl-105 HCO3-26 AnGap-15 [**2164-10-21**] 01:00PM BLOOD Glucose-102* UreaN-38* Creat-1.4* Na-141 K-4.8 Cl-105 HCO3-29 AnGap-12 [**2164-10-20**] 09:25AM BLOOD Glucose-125* UreaN-35* Creat-1.4* Na-147* K-4.4 Cl-111* HCO3-29 AnGap-11 [**2164-10-19**] 03:40AM BLOOD Glucose-122* UreaN-38* Creat-1.6* Na-147* K-3.6 Cl-109* HCO3-31 AnGap-11 [**2164-10-18**] 04:15AM BLOOD Glucose-108* UreaN-44* Creat-1.9* Na-146* K-3.6 Cl-108 HCO3-29 AnGap-13 [**2164-10-17**] 06:15AM BLOOD Glucose-110* UreaN-45* Creat-1.5* Na-149* K-4.7 Cl-114* HCO3-25 AnGap-15 [**2164-10-16**] 06:15AM BLOOD Glucose-108* UreaN-47* Creat-1.4* Na-147* K-4.7 Cl-113* HCO3-23 AnGap-16 [**2164-10-14**] 04:16AM BLOOD ALT-18 AST-27 LD(LDH)-227 AlkPhos-50 TotBili-0.5 [**2164-10-13**] 03:50AM BLOOD Lipase-81* [**2164-10-13**] 03:50AM BLOOD proBNP-[**Numeric Identifier 107751**]* [**2164-10-13**] 03:50AM BLOOD cTropnT-0.04* [**2164-10-22**] 06:36AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.2 [**2164-10-21**] 01:00PM BLOOD Calcium-8.3* Phos-3.7 Mg-2.3 [**2164-10-19**] 03:40AM BLOOD Calcium-8.4 Phos-3.1# Mg-2.2 [**2164-10-16**] 06:15AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.3 [**2164-10-15**] 05:39AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.3 [**2164-10-22**] 06:37AM BLOOD Vanco-17.4 [**2164-10-20**] 09:25AM BLOOD Vanco-20.6* [**2164-10-17**] 06:15AM BLOOD Vanco-25.0* [**2164-10-16**] 06:15AM BLOOD Vanco-17.7 [**2164-10-13**] 03:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2164-10-17**] 10:36AM BLOOD Type-ART pO2-108* pCO2-44 pH-7.40 calTCO2-28 Base XS-1 Intubat-NOT INTUBA [**2164-10-16**] 09:44PM BLOOD Type-ART pO2-78* pCO2-32* pH-7.44 calTCO2-22 Base XS-0 [**2164-10-13**] 06:07AM BLOOD Type-ART Temp-38.9 Tidal V-500 FiO2-100 pO2-302* pCO2-50* pH-7.41 calTCO2-33* Base XS-6 AADO2-378 REQ O2-65 -ASSIST/CON Intubat-INTUBATED [**2164-10-13**] 06:07AM BLOOD Glucose-122* Lactate-2.2* Na-142 K-3.9 Cl-102 [**2164-10-13**] 03:55AM BLOOD Glucose-115* Lactate-2.7* Na-145 K-4.9 Cl-101 calHCO3-31* Microbiology: [**10-3**]: GPC in clusters Imaging: [**10-13**]: CXR Mild pulmonary edema. Patchy airspace opacities bilaterally. ? Pulmonary edema, aspiration, or pneumonic infiltrates. . [**10-15**] KUB: Nonspecific gas pattern. Retrocardiac opacity better evaluated on recent chest x-ray. . [**10-16**] CXR: IMPRESSION: AP chest compared to [**10-10**] through [**10-14**]: Worsening opacification at the base of the right hemithorax could be due to increasing moderate pleural effusion alone or pleural fluid in association with lower lobe consolidation, a finding that would most readily be explained by aspiration. No endotracheal tube is seen below C7, the upper margin of this film and there is some tapering of the airway suggesting edema from a recent endotracheal tube. Left lower lobe opacification is persistent since [**10-14**], another focus of either atelectasis or pneumonia. Pulmonary vasculature is mildly engorged but there is no edema and mild-to-moderate cardiomegaly is unchanged. No pneumothorax. . [**10-17**] CXR: REASON FOR EXAM: Respiratory distress, status post flash pulmonary edema in setting of A-fib. Comparison is made with prior study performed a day earlier. There is stable mild-to-moderate cardiomegaly. Asymmetric opacities in the lungs, right greater than left could be due to asymmetric edema but aspiration is also a possibility. Left lower lobe retrocardiac opacities have improved consistent with improving atelectasis. Right lower lobe opacities consistent with atelectasis has increased. Small bilateral effusions are unchanged. Calcifications in the right upper lobe is again noted. . Brief Hospital Course: [**Age over 90 **] y/o nonverbal male with afib, CAD, htn, and recent admission for cardiogenic/septic shock [**1-17**] multifocal pneumonia, discharged to rehab on [**10-11**], presenting with worsening respiratory distress leading to intubation in ED. . # Goals of care: Conversations between care teams and patient's family members during last hospitalization well documented in discharge summary and other notes. Patient nonverbal at baseline and not able to speak for himself. Spoke with patient's brother over the phone, who stated that he wishes for patient to be intubated and wanted everything done but does not want his brother to undergo CPR. This was contiuously readdressed given the patient's very poor prognosis. He was ultimately made DNR/DNI. His nieces felt that the patient would be most appropriately CMO, but his brother did not agree. Palliative care was consulted and met with the brother who insisted on "everything to be done" without intubation. Given clinical improvement, pt was sent back to [**Hospital 100**] Rehab, should continue to hold discussion with brother regarding whether hospice care would be more appropriate in this setting given high potential for multiple readmissions without improvement in prognosis. . # Hypoxia/Respiratory distress: Pt was initially admitted to MICU for respiratory distress, intubated and quickly extubated. After transfer to floor on antibiotics for multifocal pneumonia, he had an episode of respiratory distress with tachypnea and labored breathing, the family was contact[**Name (NI) **] and brother reported that he wanted pt transferred back to the MICU. CXR most consistent with recurrent multifocal airspace disease or infection (Patient at high risk for aspiration of tube feeds). He was treated with 5 days of vancomycin and cefepime and then continued for total of 9 days on vanco and cipro, therefore completing his course for pneumonia. Pt had copious secretions which require regular suctioning. Prior to discharge, his O2 sats were 95% on RA, he was afebrile and no leukocytosis. His breathing improved after second discharge from MICU and was not labored. Clinically lungs still sound congested with coarse rhonchi, but no evidence of persistent pneumonia. . # Atrial fibrillation: Tachycardic to 110s on arrival, with improved rate after IVF resuscitation. No new ischemic changes on ECG. Possibly exacerbated by severe hypoxia. He was amiodarone loaded and continued on metoprolol. He intermittently had RVR requiring IV metoprolol, and his PO dose was uptitrated. After 4 days of amiodarone 450mg [**Hospital1 **], he was transitioned to 450mg daily. He was maintained on metoprolol 50mg [**Hospital1 **]. On discharge, HR was mostly in the 80s-90s. He was monitored on telemetry without significant events. . # Dementia/hx of CVA: During the MICU course, he was sometimes not responsive at all, other times tracking but usually not following commands or answering questions appropriately, even when [**Hospital1 595**]-speaking staff were talking to him. After second transfer to the floor, his mental status improved though he was still AOx1, he was more awake and followed commands, responded in 1-word answers. Tube feeds were continued for nutrition. . # Frank blood in Foley. Patient's Foley was irrigated because of poor UOP and revealed frank blood. Urology was consulted and help tamponade the bleeding. Prior to discharge, Foley was draining clear yellow urine with adequate urine output. . # Code status - DNR/DNI Contacts: HCP - brother, [**Name (NI) **] - [**Telephone/Fax (1) 107744**], [**Name2 (NI) **]es - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 107752**] [**Telephone/Fax (1) 107753**]; [**First Name8 (NamePattern2) 440**] [**Last Name (NamePattern1) 7016**] [**Numeric Identifier 107754**] Medications on Admission: -amiodarone 400 mg PO BID (Please take 400mg twice daily for 5 additional days until [**10-16**], then decrease your dose to 200mg daily until followup with a cardiologist) -docusate sodium PO BID -ipratropium bromide INH Q4 hrs PRN SOB, Wheezing -senna 8.6 mg PO BID PRN constipation -metoprolol tartrate 125 PO TID -nystatin Five ML PO QID PRN oral thrush -mirtazapine 30 mg PO HS -heparin 5,000 SC TID -brimonidine 0.15 % Drops Oc [**Hospital1 **] -latanoprost 0.005 % Drops OC QHS -bisacodyl 10 mg PR qM,W,F -acetaminophen 650 mg PR Q4H PRN pain -aspirin 325 mg PO daily -cholecalciferol (vitamin D3) 1,000 unit PO daily -Ativan 0.5 mg PO BID PRN -Ambien 5 mg PO QHS -sorbitol 70% Thirty ml PO daily -magnesium citrate 150 cc PO qM,W,F -Maalox PO Q6H PRN -albuterol sulfate neb Q4H PRN shortness of breath or wheezing -ipratropium bromide neb TID -omeprazole PO daily -Levsin/SL 0.25 mg Tablet, SL Q4H PRN -scopolamine Patch 72 hr [**Hospital1 **]: One patch Q72H -Tube feedings: Nutren 2.0 @ 35 or 55 mL/hr Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 2. brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime). 4. cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **]: 2.5 Tablets PO DAILY (Daily). 5. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) treatment Inhalation Q6H (every 6 hours). 6. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) treatment treatment Inhalation Q4H (every 4 hours). 8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO QID (4 times a day) as needed for abd pain. 10. acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a day). 11. metoprolol tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 12. amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 13. hyoscyamine sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1) Tablet, Sublingual Sublingual QID (4 times a day). 14. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1) PO DAILY (Daily). 15. morphine 2 mg/mL Syringe [**Last Name (STitle) **]: One (1) mg Injection Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Multifocal pneumonia . Secondary: atrial fibrillation Alzheimer's dementia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: You will follow-up with your PCP and providers at [**Hospital 100**] Rehab facility. Completed by:[**2164-10-22**]

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icd9cm

[ [ [] ] ]

[ "31.42", "97.02", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

16334, 16400

9749, 13574

285, 310

16528, 16528

4135, 9726

16704, 16821

3234, 3308

14637, 16311

16421, 16507

13600, 14614

3323, 4116

225, 247

338, 2290

16543, 16681

2312, 2876

2892, 3218

79,878

154,650

42767

Discharge summary

report

Admission Date: [**2156-12-24**] Discharge Date: [**2156-12-27**] Date of Birth: [**2093-10-14**] Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: STEMI, shock Major Surgical or Invasive Procedure: Cardiac catheterization and intra-aortic balloon pump placement (at [**Hospital6 3105**]). History of Present Illness: This is a 63 yo male with h/o CAD with MI in [**2149**] (s/p two stents to ?RCA), hiperlipidemia, tobacco abuse who presented to OSH with chest discomfort while shoveling snow earlier today. In teh OSH ER, the EKG showed ST elevations in II, III and AVF, c/w an inferior STEMI. Pt was given heparin, ticagrelor 180mg loading dose and ASA 325 in the ER. Morphine and zofran were also given for symptomatic relief. He was theen taken to the cath lab there for PCI. This was complicated by hypotension to SBP 50s. Of note, this episode occurred 5 min after administration of angiomax. Hypotension was then managed by starting neo gtt and placing a balloon pump. He became hemodynamically stable that time and PCI was performed. Per report, 4 stents were placed to the proximal RCA. PT rec'd total of 200 cc contrast and >[**2144**] cc IVF. Pt's pressor was changedc from neo gtt to dopamine gtt. Dopamine was noted to be infiltrated and thus was switched back to neo gtt. Pt was given regitine (alpha-adrenergic antagonist) for this and then transferred to [**Hospital1 18**] for further care. Of note, it was observed after the case that the patient was covered in an urticarial rash, was red and had periorbital edema. He was given pepcid and benadryl for concern for allergic reaction; he had no signs of symptoms of airway compromise at that time. For further characterization of presentation, patient was well until morning of [**2156-12-24**]. He had just been out shoveling snow, after which he went back into the house and developed chest pain which was very severe, compressive, in central chest area with no radiation. Associated symptoms were diaphoresis and dizziness. This prompted pt to call emergency team. He took aspirin and SL nitro (may have been expired) prior to being picked up by EMS. Of note, pt is not compliant with meds due to financial reasons. Pt admits to not taking any meds for the last 2 years. Pt does state that he has had a full cardiac workup recently, incl a stress test, which was all "negative". Upon arrival to teh floor, pt is lying comfortabley in bed. Pt has no complaints at this time. Denies chest pain, shortness of breath, dizziness, itching, tongue or lip swelling. Endorses difficulty urinating [**1-6**] BPH. Past Medical History: CAD s/p MI in [**2149**] had double stenting Hernia repair ~10 yrs ago Hx of colonic polyps in [**2151**] Tobacco abuse BPH Hematuria Elev PSA Social History: Retired state worker, currently smoking 1ppd x 28yrs, stopped drinking 30 years prior, no illicit drug use. Family History: Father died of an MI with CABGx3 @70 yrs old, was diabetic. Mother was diabetic, died from unkonwn cancer GF died of MI at 56 Brother with diabetes Physical Exam: Gen: NAD HEENT: xanthelasma present above both eyes, periorbital edema has resolved, oropharynx is clear CV: RRR s1/s2 -mrg R: CTA b/l -w/r/r Abd: +BS soft NTND Ext: -c/c/e Pertinent Results: [**2156-12-24**] 03:55PM BLOOD WBC-19.8* RBC-5.40 Hgb-16.3 Hct-46.0 MCV-85 MCH-30.2 MCHC-35.4* RDW-13.0 Plt Ct-256 [**2156-12-24**] 10:18PM BLOOD WBC-17.4* RBC-5.00 Hgb-15.0 Hct-42.3 MCV-84 MCH-30.0 MCHC-35.6* RDW-13.0 Plt Ct-190 [**2156-12-25**] 06:48AM BLOOD WBC-16.1* RBC-4.46* Hgb-13.6* Hct-37.8* MCV-85 MCH-30.4 MCHC-36.0* RDW-13.1 Plt Ct-157 [**2156-12-26**] 05:56AM BLOOD WBC-12.3* RBC-4.02* Hgb-12.0* Hct-34.0* MCV-85 MCH-29.8 MCHC-35.2* RDW-13.2 Plt Ct-132* [**2156-12-26**] 05:10PM BLOOD Hct-36.1* [**2156-12-27**] 07:25AM BLOOD WBC-10.4 RBC-4.19* Hgb-12.3* Hct-35.7* MCV-85 MCH-29.4 MCHC-34.4 RDW-13.4 Plt Ct-149* [**2156-12-26**] 05:56AM BLOOD Neuts-77.3* Lymphs-18.5 Monos-3.4 Eos-0.5 Baso-0.3 [**2156-12-27**] 07:25AM BLOOD PT-10.5 PTT-23.9* INR(PT)-1.0 [**2156-12-25**] 06:48AM BLOOD Glucose-122* UreaN-21* Creat-1.2 Na-138 K-4.8 Cl-106 HCO3-21* AnGap-16 [**2156-12-26**] 05:56AM BLOOD Glucose-95 UreaN-23* Creat-1.0 Na-140 K-4.2 Cl-107 HCO3-26 AnGap-11 [**2156-12-27**] 07:25AM BLOOD Glucose-98 UreaN-22* Creat-0.9 Na-138 K-4.3 Cl-104 HCO3-23 AnGap-15 [**2156-12-24**] 03:55PM BLOOD ALT-26 AST-75* LD(LDH)-448* CK(CPK)-849* AlkPhos-71 TotBili-0.5 [**2156-12-24**] 10:18PM BLOOD CK(CPK)-982* [**2156-12-25**] 06:48AM BLOOD ALT-22 AST-72* LD(LDH)-497* CK(CPK)-658* AlkPhos-56 TotBili-0.6 [**2156-12-26**] 05:56AM BLOOD CK(CPK)-155 [**2156-12-24**] 03:55PM BLOOD CK-MB-83* MB Indx-9.8* cTropnT-1.39* [**2156-12-24**] 10:18PM BLOOD CK-MB-77* MB Indx-7.8* [**2156-12-25**] 06:48AM BLOOD CK-MB-48* MB Indx-7.3* cTropnT-2.30* [**2156-12-26**] 05:56AM BLOOD CK-MB-8 cTropnT-0.96* [**2156-12-24**] 03:55PM BLOOD Triglyc-131 HDL-41 CHOL/HD-5.4 LDLcalc-154* LDLmeas-157* [**2156-12-24**] TTE: Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with inferior and inferolateral akinesis. The remaining segments contract normally (LVEF = 40%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. An eccentric, posteriorly-directed jet of mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild regional biventricular systolic dysfunction, c/w CAD. Mild eccentric mitral regurgitation, most c/w ischemic (tethering) mechanism. Brief Hospital Course: 63M hx CAD with MI in [**2149**] s/p 2 DES to RCA, HLP, tobacco abuse who is now transferred from OSH with STEMI s/p 4 DES to RCA and hypotension. . Shock: likely secondary to anaphylactic reaction to a medication used prior to episode (likely angiomax although also possibly ticagrelor). Concern initially was for cardiogenic shock in setting of large inferior STEMI (concern for RV infarct) however his right heart cath and other hemodynamic measurements strongly argued against cardiogenic shock (PCWP low, SVR ~500, CO ~8L) but rather supported some type of distributive vasodilatory shock. Upon arrival, he was weaned from dopamine fairly quickly. He did not have any urticaria upon arrival however his skin did have a sunburnt appearance and he did have periorbital edema. Angiomax has a known side effect of anaphylaxis in <1% of people, and the patient was stable until ~4-5 minutes after bolus with angiomax. Due to his hemodynamic measurements, ability to wean dopamine quickly after treatment for allergic reaction and clinical picture after cath (urticaria, periorbital edema) we felt that this was likely an anaphylactic reaction to angiomax or ticagrelor, and so treated with solumedrol, benadryl and pepcid ATC. His symptoms quickly abated after arrival, and the next morning his balloon pump was weaned and removed. While uncertain, we instructed the patient to note that he has an anaphylactic reaction to either bivalirudin or ticagrelor in the future. . STEMI: ST elevations in the inferior leads, cath showed occlusion in the location of his previous stents in the RCA. S/p 4 DES to RCA. He was hemodynamically stable after weaning treatment for anaphylaxis. He had no evidence for arrhythmia or other post-MI complications. Started on prasugrel here, changed to plavix upon discharge due to financial concerns. He was started on a beta blocker which was uptitrated to goal HR ~60, increased his statin to atorva 80 in spite of his history of muscle cramps on 80mg (with plan to decr to 40 as outpt), continued on full strength aspirin. We strongly encouraged smoking cessation and provided the patient with nicotine patches. . Systolic congestive heart failure: Inferior wall akinesis with EF 40%. Did not have issues with volume status during the admission. Was started on lisinopril which was titrated to blood pressure. Did not start spironolactone at this point in time, with plans to start as an outpatient if his repeat TTE in 8 weeks showed persistent depressed EF. . Medications on Admission: (Not taking any of the following but is prescribed) Aspirin 325 Simvastatin 20 Nicotine patch Atenolol 50 Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: ST-elevation myocardial infarction Anaphylactic shock due to either bivalirudin or ticagrelor Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]. You were transferred here after cardiac catheterization for a heart attack and shock. It is not clear what caused the shock, but it appears that one of a few medications might be the culprit. These medications include zofran, bivalirudin and ticagrelor. Your blood pressure dropped 4 minutes after getting bivalirudin, and anaphylactic shock is a known side effect. We cannot be certain though which of these medications was at fault. In the future, let any healthcare provider know that you have an allergy to either bivalirudin or ticagrelor, and the reaction is anaphylaxis. During your hospitalization, we stabilized you and put you on the appropriate medications for your condition. You will need to take some blood thinning medications, aspirin and plavix, for at the minimum of three months as you have four bare metal stents placed in your heart. Please note the following changes to your medications: Please START Aspirin 325mg by mouth once per day Plavix 75mg by mouth once per day Toprol XL 50mg by mouth once per day Atorvastatin 80mg by mouth once per day Lisinopril 5mg by mouth once per day Please STOP Atenolol Simvastatin Please stop smoking. This will provide you one of the biggest benefits for mortality. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 92408**] Location: [**Hospital1 **] FAMILY HEALTH CENTER Address: [**Location (un) **]., [**Hospital1 **],[**Numeric Identifier 66038**] Phone: [**Telephone/Fax (1) 63099**] ***The office requested that you attend their "walk-in" clinic this week to be seen for follow up post hospitalization. Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Address: [**Street Address(2) **]. [**Apartment Address(1) **], [**Location **],[**Numeric Identifier 21918**] Phone: [**Telephone/Fax (1) 63780**] Appt: [**1-26**] at 2pm ***The office is working on a sooner appt for you and have also placed you on the wait list. You will be called at home when a sooner appt becomes available.

[ "285.9", "790.29", "410.41", "E934.2", "305.1", "E932.0", "V12.72", "414.01", "V45.82", "272.4", "995.0", "600.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9302, 9308

5919, 8432

310, 402

9445, 9445

3379, 5896

10918, 11721

3021, 3171

8588, 9279

9329, 9424

8458, 8565

9595, 10545

3186, 3360

10575, 10895

258, 272

430, 2714

9460, 9571

2736, 2880

2896, 3005

236

182,562

25208

Discharge summary

report

Admission Date: [**2135-5-26**] Discharge Date: [**2135-5-28**] Date of Birth: [**2081-12-5**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 3127**] Chief Complaint: 52M s/p OLT and revision portal vein admitted after perc liver Bx for observation and Hct check with pRBC transfusion Major Surgical or Invasive Procedure: s/p perc liver biopsy Past Medical History: Hep C positive (Bx proven 4 years ago) HCC with RFA in [**4-5**] for lesions in segment V and VIII DVT cryoglobulinemia kidney stones depression lumbar spine laminectomy Left partial orchiectomy Social History: Lives with wife and 1 son in single family home smokes cigarettes No ETOH since [**2128**] Remote Hx IV heroin use Family History: Non-contributory Physical Exam: MS/NEURO: A/Ox3 HEENT: PERRLA, EOMI CVS: RRR Resp: CTA-B Abd: S/NT/ND/+BS Ext: No. P. Edema Inc: C/D/I Pertinent Results: [**2135-5-26**] 10:15PM WBC-10.2 RBC-3.85* HGB-11.2* HCT-33.1* MCV-86 MCH-29.1 MCHC-33.9 RDW-18.3* [**2135-5-26**] 10:15PM PLT COUNT-134* [**2135-5-26**] 04:20PM WBC-11.1* RBC-3.81* HGB-11.3* HCT-32.6* MCV-85 MCH-29.7 MCHC-34.7 RDW-18.2* [**2135-5-26**] 04:20PM PLT COUNT-139* [**2135-5-26**] 02:37PM WBC-12.6* RBC-3.63* HGB-10.6* HCT-31.0* MCV-85 MCH-29.1 MCHC-34.1 RDW-18.6* [**2135-5-26**] 02:37PM PLT COUNT-165 [**2135-5-26**] 11:00AM WBC-15.1* RBC-3.82* HGB-11.0* HCT-32.2* MCV-85 MCH-28.7 MCHC-34.0 RDW-19.2* [**2135-5-26**] 11:00AM PLT COUNT-205# [**2135-5-26**] 07:35AM GLUCOSE-91 UREA N-21* CREAT-0.8 SODIUM-138 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-23 ANION GAP-14 [**2135-5-26**] 07:35AM ALT(SGPT)-212* AST(SGOT)-186* ALK PHOS-233* TOT BILI-0.6 [**2135-5-26**] 07:35AM rapamycin-10.9 [**2135-5-26**] 07:35AM WBC-10.1 RBC-4.74 HGB-13.4* HCT-39.9* MCV-84 MCH-28.2 MCHC-33.6 RDW-19.2* [**2135-5-26**] 07:35AM PLT COUNT-95*# [**2135-5-26**] 07:35AM PT-10.9 INR(PT)-0.9 Brief Hospital Course: 53 male s/p perc liver biopsy s/p hypotensive episode (SBP 60s), drop Hct (39->32) after liver bx. Pt was dmitted to SICU on [**5-26**] for observation and monitoring. He was given 2u pRBCs. His follow-up Hct were stable at 33. On [**5-26**] U/S liver: (post-procedure) that showed no evidence of hematoma. He was tranferred back to the floor on [**5-27**]. Pt was stable and dicharged home on [**5-28**] with a HTC of 33. Medications on Admission: Metoprolol 50", Bactrim 80-400, FeSO4 325", RISS, MMF 1000", Sirolimus 3', Calcium 500''', Vit D 400', Zolpidem 5', Valganciclovir 450', Prednisone taper, Omeprazole 20' Discharge Medications: 1. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Mycophenolate Mofetil 250 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day). 3. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily). 10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: s/p perc liver biopsy for OLT Discharge Condition: stable Discharge Instructions: pt to call or return to Ed if he has any hypotensive episodes, fever, lightheadedness Followup Instructions: transplant coordinator to arrange follow-up Completed by:[**2135-5-28**]

[ "V12.51", "458.29", "V42.7", "273.2", "285.9", "070.54" ]

icd9cm

[ [ [] ] ]

[ "99.04", "50.11" ]

icd9pcs

[ [ [] ] ]

3492, 3498

1975, 2404

399, 423

3572, 3581

948, 1952

3715, 3790

791, 809

2625, 3469

3519, 3551

2430, 2602

3605, 3692

824, 929

241, 361

445, 642

658, 775

3,742

176,423

22440

Discharge summary

report

Admission Date: [**2186-5-8**] Discharge Date: [**2186-5-17**] Date of Birth: [**2137-6-22**] Sex: M Service: HEPATOBILIARY SURGERY HISTORY OF PRESENT ILLNESS: This is a 48-year-old male with stage IV colon cancer, status post a left colectomy with metastases to segments 5 and 8, who presents for hepatic segmentectomy. This patient also had a persistent pancreatic pseudocyst after his last colectomy, and his port has been recalled by the manufacturer. The patient presents for a right segment 5 and 8 hepatic segmentectomy as well as a cyst- gastrostomy and exchange of his port. PAST MEDICAL HISTORY: 1. Stage IV colon cancer. 2. Hypertension. 3. Depression. 4. Status post chemotherapy. MEDICATIONS ON ADMISSION: Include Lopressor 50 mg p.o. b.i.d. and Paxil 20 mg p.o. daily. HISTORY OF HOSPITAL COURSE: This pleasant 48-year-old male was admitted to hepatobiliary surgical service for routine postoperative care. Please see the operative note by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for further information in regards to operative technique and findings. Postoperatively, the patient did initially well. He made good urine output but was noted to have a low systolic blood pressure approximately in the 80s. For that reason, the patient was transferred to the SICU for closer monitoring. His blood pressure appropriately responded with some IV fluids, and a repeat hematocrit was stable. His serial hematocrits were stable and had no further complaints. The patient had a temperature on the evening on postoperative day 2 and simply monitored. Physical therapy was started. The patient was started on clears and hep-locked. Had decreased drainage in JP 1 which was the medial drain had output that was slightly bile-tinged, where as JP 2 put out predominantly serosanguineous to a lesser amount of approximately 70 to 90 cc per day as opposed to JP 1 which put out 360. The patient was advanced on his diet to solid food and continued to be monitored. He was encouraged to ambulate. On [**2186-5-13**] - postoperative day 5 - the patient spiked a temperature again overnight between postoperative days and 4 and 5. His central line was removed and cultured and his medial JP was removed. A review of his IVs were done, and there was no other infiltrative or phlebitic peripheral line. A chest x-ray was obtained which illustrated a retrocardiac pneumonia. His urinalysis was contaminated but repeat was negative. He was started on Levaquin. On [**2186-5-13**] the patient continued to spike, and after a discussion with ID broader spectrum antibiotics were added including vancomycin, azithromycin, aztreonam. Please note the patient has a history of an allergy to Zosyn, to which his reaction is hives, and therefore the recommendations were made by ID. The patient was continued on the antibiotics as well as the p.o. Levaquin and monitored. He was encouraged to use incentive spirometry and monitored. He was also noted to get a repeat a CT scan on the evening of the 14th to evaluate for a biloma or any other intraabdominal abscess. The CT scan failed to illustrate any intraabdominal process that might be contributing to this gentleman's postoperative fevers. Fortunately, at this point his cultures were all negative. On the 17th the patient continued to remain afebrile with stable vital signs, and he was continued on his IV antibiotics and simply monitored. On postoperative day 9, the patient was prepared to go home. His IV antibiotics were stopped. The patient was resumed on his p.o. Levaquin. Arranged for VNA services to help with drain assistance, and his staples were removed. He was restarted on his home p.o. medications; such as Paxil. The patient was started on a regular diet and had no complaints and had a clean incision on the day of discharge with no evidence of any erythema or drainage. DISCHARGE DIAGNOSES: 1. Status post segment 5 and segment 8 resection, status post cyst-gastrostomy, status post port change on [**2186-5-8**]. 2. History of hypertension. 3. History of colon cancer, status post left colectomy. 4. History of depression. 5. Postoperative pneumonia. 6. Postoperative fever. MEDICATIONS ON DISCHARGE: Include Percocet 1 to 2 tablets p.o. q.4-6h. (dispensed 30), Colace 100 mg p.o. b.i.d. (dispensed 60 to be taken while taking the Percocet), Paxil 20 mg p.o. daily, Lopressor 50 mg p.o. b.i.d., and Protonix 40 mg p.o. daily. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To home with services. DISCHARGE FOLLOWUP: The patient is to follow up with Dr. [**Last Name (STitle) **] in approximately 1 week, and is to record his drain output, and to call the office if he has any questions or concerns. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **] Dictated By:[**Doctor Last Name 22186**] MEDQUIST36 D: [**2186-5-17**] 11:18:59 T: [**2186-5-18**] 11:11:16 Job#: [**Job Number 58314**]

[ "780.6", "401.9", "998.89", "197.7", "V10.05", "997.3", "486", "427.31", "577.2" ]

icd9cm

[ [ [] ] ]

[ "50.22", "99.04", "38.93", "52.4" ]

icd9pcs

[ [ [] ] ]

4508, 4532

3909, 4199

4226, 4452

745, 821

839, 3888

4553, 5006

182, 607

629, 718

4477, 4484

17,190

106,415

5386

Discharge summary

report

Admission Date: [**2107-11-12**] Discharge Date: [**2107-12-21**] Date of Birth: [**2045-12-2**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 2763**] Chief Complaint: renal failure s/p CRT Major Surgical or Invasive Procedure: HD line placement History of Present Illness: 61M with history of ESRD s/p CRT [**2101**], hypertension, diabetes, diastolic CHF, admitted on [**2107-11-12**] with acute on chronic dyspnea, now s/p PEA arrest. He presented on [**11-12**] with 2 days of worsening dyspnea, cough, and fever/chills. Also with orthopnea, PND, and worsening edema in all 4 extremities. . Labs showed ARF with creatinine of 5.8 (up from 2.9). During hospital course on the floor, renal function continued to worsen and urine output was low even with furosemide (unclear etiology of ARF). Also noted to have intermittent somnolence but arousable and fully oriented. ABGs repeatedly with partially compensated respiratory acidosis (has also had this in the recent past), team unsure how reliable ABGs were given bilateral UE fistulas. . Patient was in angio having hemodialysis line placed when his arrest event occurred. He was placed in a lateral decubitus position due to difficulty lying flat due to shortness of breath. Towards the end of his line placement, he became more agitated and was pushing his facemask away. O2 sats were unable to be obtained. He was then placed in supine position for line suturing. He was then noted to be nonresponsive, code blue call. Then noted to be pulseless. CPR initiated and initial rhythm asystole/very slow PEA, subsequently faster PEA. Total pulseless time 13 minutes. Received total 2 mg epinephrine, 2 amps bicarb, 1 mg atropine, insulin/D50, IVFs via new HD line. Regained pulses with first SBP >180. Intubated. . In the MICU, patient seemed to be waking up some but with also evidence of extensor posturing in upper and lower extremities. Neuro consulted. Aline and CVL placed. . Review of systems: unable to obtain Past Medical History: - Renal cell carcinoma s/p resection [**2093**] - Severe obstructive sleep apnea,(not wearing CPAP at home) - ESRD s/p CRT [**2101**], complicated by transplant renal artery stenosis necessitating stent placement in [**2103**] - Resistant HTN - Diastolic congestive heart failure, TTE [**2107-8-18**]: Moderate diastolic LV dysfunction with elevated LVEDP. Mild pulmonary hypertension - Diabetes, type 2, on insulin - GERD - Barrett's Esophagus - s/p patella avulsion repair - history of hypercalcemia - hyperparathyroidism Social History: Married with seven children Employment: Employed as a chef at [**Hospital1 18**] Tobacco: No h/o Alcohol: No h/o Family History: Mother with kidney disease. Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Intubated; initially not sedated. Not opening eyes but moving all extremities to pain and initally spontaneously. ?myoclonic and posturing as below. HEENT: Sclera anicteric, pupils equal at 2 mm though minimal reactive. ETT in place. Neck: HD line in place. Obese neck, difficult to appreciate JVD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, loud systolic murmur best at RUSB and LUSB. Abdomen: soft, distended, appears non-tender, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. [**2-8**]+ bilateral LE edema, also +bilateral UE edema, ?right slightly greater than left Neuro: Moving some spontaneously and responsive to pain in the UEs, not much pain response in the LEs. Seems to be intermittently with extensor posturing (lasts 2-3 seconds at a time), sometimes associated with ?myoclonic movements of ankles. + significant bilateral ankle clonus. Pertinent Results: [**2107-11-12**] 8:10p . Other Urine Chemistry: UreaN:549 Creat:199 Na:<10 TotProt:53 Prot/Cr:0.3 Osmolal:347 . Color Yellow Appear Clear SpecGr 1.013 pH 5.0 Urobil Neg Bili Neg Leuk Tr Bld Neg Nitr Neg Prot 75 Glu Neg Ket Neg RBC 0-2 WBC [**6-15**] Bact None Yeast None Epi 0-2 Other Urine Counts RenalEp: 0-2 CastHy: 0-2 . [**2107-11-12**] 4:10p 138 103 72 ------------- 178 5.0 27 5.8 ∆ . Ca: 9.6 Mg: 2.6 P: 4.3 ∆ CK: 315 MB: 5 Trop-T: 0.08 . Alb: 2.9 proBNP: 1817 . .....8.4 5.5 ----- 212 .....26.8 N:68.5 L:21.8 M:6.9 E:2.4 Bas:0.5 . CXR [**2107-11-14**]: In comparison with the study of [**11-12**], there are lower lung volumes. Enlargement of the cardiac silhouette persists with mild vascular congestion suggested. . EKG: NSR at 94, NANI, low limb lead voltage, poor RWP (old); no significant change from prior. . TTE [**2107-11-14**]: The left atrium is moderately dilated. mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests 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 is mild pulmonary artery systolic hypertension. There is a very small circumferenital pericardial effusion. . Renal ultrasound [**11-13**]: No new findings. . CT Chest [**11-15**]: On CT, there is no evidence of air embolism. Cardiomegaly, mild axillary and mediastinal lymphadenopathy. Bilateral pleural effusions with areas of subsequent atelectasis, patchy lower lobe predominant parenchymal opacity is potentially suggestive of a combination of pneumonia and atelectasis. No pathologic air collection in the mediastinum and the lung interstitium. . CT Head [**11-15**]: 1. No acute intracranial hemorrhage or acute vascular territorial infarction. There is no hydrocephalus. 2. Opacification of sphenoid sinus, maxillary, ethmoid air cells and nasopharynx, most likely related to recent intubation. . CT Head [**11-17**]: 1. No acute intracranial hemorrhage or obvious major territorial acute infarct, mass effect, or hydrocephalus. If there is continued concern, MR of the head with diffusion-weighted imaging sequence is more sensitive in the detection of acute stroke. 2. Diffuse opacification of the sphenoid sinus, nasopharynx, the maxillary and the ethmoid air cells partly related to mucosal thickening, secretions from intubation. However, patient also had a left antrochoanal polyp in the past, which is incompletely assessed on the present study. 3. Discontinuous foci in the left parietal bone may relate to thinning of the bone, from arachnoid granulations or other etiology, to correlate with any history of surgery. However, this appearance is unchanged compared to the prior CT sinus study done on [**2102-10-19**]. . RUE US [**11-20**]: Although subclavian vein not evaluated, remainder of right upper extremity venous system appears normal with no evidence of DVT, and DVT would be likely in the subclavian vein given respiratory variation and normal appearance of remainder of the study. . MR [**Name13 (STitle) 430**] [**11-21**]: 1. Severely limited examination demonstrates changes of chronic microvascular white matter ischemic disease with old left frontal encephalomalacia without evidence for acute infarct. 2. Extensive paranasal sinus and mastoid air cell disease. . KUB [**11-25**]: 1. Severely limited examination demonstrates changes of chronic microvascular white matter ischemic disease with old left frontal encephalomalacia without evidence for acute infarct. 2. Extensive paranasal sinus and mastoid air cell disease. . KUB [**11-26**]: There is no evidence of free air. NG tube tip is in the stomach. Right femoral catheter remains in place. There is no evidence of bowel obstruction. There is nonspecific bowel gas pattern. . Portable Abdomen XR [**11-29**]: There is no evidence of ileus, small or large bowel obstruction. . Abdominal US [**12-6**]: Normal right upper quadrant ultrasound with no findings to suggest the cause of the patient's pain. . CT Abd/Pelvis [**12-6**]: 1. Small thrombus within the IVC and at the junction of the right common iliac vein and transplanted renal vein. 2. Diffuse mesenteric stranding with no small or large bowel pathology identified. . CT Head [**12-11**]: 1. . No acute intracranial abnormality. 2. Partial opacification of mastoid air cells bilaterally, maxillary, ethmoid and sphenoid sinuses, partly polypoidal. . CT Abd/Pelvis [**12-11**]: 1. Very large spontaneous hematoma involving a majority of the left hepatic lobe. A small amount of perihepatic hematoma and scattered areas of blood within the mesentery and along the left pericolic gutters tracking into the pelvis. No definite site of active extravasation identified. 2. Branches of left portal vein are attenuated and not well visualized in the midst of the hematoma but are patent. 3. No change in small 1.5 cm thrombus within the infrarenal IVC. Second separate smaller thrombus in the right common iliac vein near the transplant renal vein anastomosis on the prior study not definitely visualized and may have cleared with anticoagulation. 4. Atelectasis of both dependent lower lobes. 5. More confluent consolidative opacity of the superior right lower lobe could be explained with atelectasis but is concerning for possible area of aspiration or pneumonia. . CT Abdomen [**12-16**]: Limited study but no gross evidence of obstruction. . CXR [**12-19**]: There is interval development of vascular engorgement, perihilar opacities, and bibasilar opacities, left more than right, findings which might be consistent with interval progression of pulmonary edema. Evaluation after diuresis is recommended to exclude the possibility of underlying infectious process. Brief Hospital Course: 61M with ESRD s/p CRT, HTN, DM, admitted with dyspnea and ARF. During IR placement of an HD catheter he suffered a PEA arrest x 2. He was cooled using artic sun protocol. He slowly recovered, but his hospitalization was complicated by prolonged intubation leading to tacheostomy placement, Psuedomonas UTI, HAP, Stenotrophomonas PNA, aspiration PNA, acute on chronic kidney injury leading to loss of fuction of his transplanted kidney, IVC thombosis, spontaneous intrahepatic hemorrage during heparinization for his thrombus, gout flair, and altered mental status which has slowly improved. After more than a month in the hospital he has stabilized, is ambulating with assistance, speaking through a Passe Muir valve, and tolerating tube feeds. . # Aspiration: Patient had emesis [**2107-12-13**] and aspirated tube feeds. Developed aspiration pneumonitis vs. aspiration PNA. CXR showed no clear evidence of PNA but CT showed confluent consolidative opacity of superior RLL. Pt was febrile following aspiration event and ended up re-intubated. Now s/p 7-day course of vanc/zosyn for aspiration that ended on [**2107-12-18**]. Respiratory status has dramatically improved and he is now on trach mask only. He had a video swallow evaluation on [**2107-12-20**] which showed silent aspiration. It was suggested that he have a diet of nectar thick liquids and soft consistency solids. meds must be crushed in purees with Q6 hour oral care. He should have follow up with speech therapy at rehab with repeat video swallow if diet is to be advanced. . # Stenotrophomonas PNA: Diagnosed from repeated sputum cultures. On Bactrim x14 day course, day 1=[**12-16**] to d/c [**12-30**]. Note that Bactrim must be give FOLLOWING HD as it is dialyzed off. Intially diagnosed [**12-2**], but was inadquately treated as Bactrim was given prior to HD rather than after. . # Pseudomonas UTI: Had a long course of Cefepime for UCx positive for Pseudomonas x 2. . # Line infection: S/p Cefepime initially for UTI. Then Linezolid was added for purulent appearing CVL. His lines were exchanged and complicated by PEA arrest during procedure. His CVL grew out Micrococcus. According to ID, the Cefepime should have covered it. He received a 14d course of Cefepime and 9d course of Linezolid. A PICC line and new HD line were placed and have had no further complications. . # Labile blood pressures: Pt had been intermittently hypotensive (infectious source vs hypovolemia vs adrenal insufficiency). His infections were treated. He was given stress dose steroids. He was on pressors for hypotension. Ultimately this resolved and he became persistently hypertensive to the 190s to 220s. He was started on a labetalol drip as well as PRN hydralazine. He has been transitioned from Labetalol drip to PO Labetalol on [**12-9**], then switched to Labetalol PRN. On [**12-14**], Labetalol was d/c??????ed. Continue atenolol at 50mg daily. Continue lisinopril 10mg daily. . # Foot Pain: Likely gout, particularly given resolving hematoma and renal failure. Receiveing pulse steroids with Prednisone 40mg daily x5 days starting on [**2107-12-20**]. Will resume chronic Prednisone 5mg PO daily for maintenance of transplanted kidney thereafter. [**Month (only) 116**] need suppressive allopurinol in the future for his gout. . # DVT: Patient found to have venous thrombi in several vessels including his IVC. He was on a heparin drip, being bridged with coumadin. However, all anticoagulation stopped when liver hematoma developed (see helow). Hematology was consulted regarding whether it is appropriate to resume anticoagulation given the risk of bleed, and recommended SC Heparin tid until he follows up with Hematology and possibly vascular surgery regarding possible benefits vs. risks of an IVC filter placement. The patient should not be anti-coagulated with agents other than SC Heparin given his high risk of bleed. . # Abdominal Distension: Patient??????s abdomen became distended and tympanitic during this hospitalization. CT abdomen [**12-11**] showed large liver hematoma with scattered areas of perihepatic hematoma and scattered blood within the mesentery but without definite sites of active extravasation. Distension likely [**2-7**] chemical peritonitis which is resolving following reversal of anticoagulation vs. functional ileus/[**Last Name (un) **]??????s syndrome from infection/sepsis, intra-abdominal bleed, narcotic use, or respiratory failure. This is consistent with the patient??????s continued +bowel sounds and leukocytosis, but CT abdomen did not show dilated R side of colon and loops of bowel were read as WNL. Currently improved abdominal pain and minimally improved distension. Abd is much less tense than prior. Continue Reglan 2.5mg TID standing for treatment of presumed diabetic gastroparesis. Advancing diet as tolerated with tube feeds. . # Liver Hematoma: As above, CT showed hematoma of liver while on heparin drip for IVC thombus. IR consulted re: possible embolization, did not feel the bleed was acute (felt >48 hours old) and wished to preserve hepatic artery and liver function if possible, so recommended monitoring Hct. General surgery consulted re: possible relation to PEG placement, but did not believe this was [**2-7**] procedure based on the location of the hematoma. Recommended montoring q6h Hct and coags, transfusing as needed and keeping Hct >20. Received total of 3 unit pRBC after reversal of PTT with FFP. Awaiting hematology recommendation for long term anticoagulation given presence of IVC thombus but complication of hemorrhage. (Ultimately decided to hold all anticoagulation given severity of liver bleed.) . # Respiratory failure. Originally intubated in setting of arrest with hypoxia beforehand. Was very difficult to wean from vent due to persistent hypoxia, recurrent PNA, and altered mental status. Trach and PEG placed on [**12-2**]. Now stable on trach. Had aspiration even as above leading to short tern re-intubation. Now tolerating trach mask. Speaking with Passe Muir valve. . # Altered mental status s/p PEA arrest: S/p PEA arrest x 2. Underwent Artic Sun cooling protocol. Suring weaning of sedation was severely agitated. Ultimately was transitioned from fentanyl to methadone and then weaned on seroquel. He had a significant set back from his liver hematoma and aspiration PNA. Neuro was consulted and noted a staring spell that was concerning for seizures. He was monitored with continuous EEG, which showed epileptiform spikes but not outright seizure activity. Neuro recommended startingKeppra, with Keppra 500mg qday and an extra 250mg after HD. The patient has slowly improved and is not conversant, [**Location (un) 1131**], walking with assistance, and no longer agitated. He is alert and oriented. . # Acute on chronic renal failure. He is s/p CRT in [**2101**]. Etiology of ARF likely multifactorial due to hypotension from PEA, sepsis, contrast loads, and nephrotoxic drugs. Her the Renal Service, he will not recover renal function of his kidney. He will require HD henceforth. Continue prednisone 5mg PO daily for rejection as well as Renagel 800 tid, Sevelemer 800 tid. . # FEN: Speech and Swallow Recs - video swallow: silent aspiration seen on s/s for thin liquids. Recs: 1. Suggest a PO diet of nectar thick liquids and soft consistency solids. 2. PMV on for all POs. 3. Meds crushed with purees. 4. Monitor for nutritional intake. 5. Q6 oral care. 6. Follow up speech therapy in rehab s/p d/c Medications on Admission: -Amlodipine 10 mg [**Hospital1 **] -Calcitriol 0.25mcg QD -Cinacalcet 90 mg QD -Clonidine 0.1 mg [**Hospital1 **] -Lasix 120mg PO BID -Labetalol 600mg [**Hospital1 **] Lisinopril 10mg QHS -Minoxidil 10mg [**Hospital1 **] -Mycophenolate Mofetil 500mg [**Hospital1 **] -Prednisone 5mg QD Vardenafil 10mg PRN -Aspirin 81mg QD Insulin NPH & Regular Human Ten (10) units Subcutaneous qPM. Insulin NPH & Regular Human Twenty (20) Units Subcutaneous qAM. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**] units Injection PRN (as needed) as needed for line flush. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q6H (every 6 hours) as needed for fever, pain. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for constipation. 6. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-7**] Drops Ophthalmic PRN (as needed) as needed for irritation. 8. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day). 9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for renal transplant. 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Four (4) Tablet PO QHD (each hemodialysis): DC on [**12-29**].09. Give AFTER HD. 12. Metoclopramide 10 mg Tablet Sig: 2.5 mg PO BID (2 times a day). 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Increase as needed for persistent HTN. 14. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for dyspnea, wheeze. 17. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath, dyspnea. 18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 5 days: DC on [**2107-12-24**]. Please give IN ADDITION to standing prednisone 5mg PO daily for rejection. 19. 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. 20. Keppra 250 mg Tablet Sig: One (1) Tablet PO after HD: in addition to daily dose of Keppra 500mg PO BID. 21. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day. 22. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): For IVC thrombi until further evaluated by vascular surgery as outpatient. Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital Discharge Diagnosis: Primary: - Renal failure - Volume overload / acute on chronic CHF - PEA arrest - Altered mental status - Bacterial pneumonia - Ventilator associated pneumonia - Aspiration pneumonia - Urinary tract infection - Hypertensive urgency - Repiratory failure . Seconary: - Renal cell carcinoma s/p resection [**2093**] - Severe obstructive sleep apnea,(not wearing CPAP at home) - ESRD s/p CRT [**2101**], complicated by transplant renal artery stenosis necessitating stent placement in [**2103**] - Resistant HTN - Diastolic congestive heart failure, TTE [**2107-8-18**]: Moderate diastolic LV dysfunction with elevated LVEDP. Mild pulmonary hypertension - Diabetes, type 2, on insulin - GERD - Barrett's Esophagus - s/p patella avulsion repair - history of hypercalcemia - hyperparathyroidism Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted initially for volume overload and shortness of breath. You had a long and complicated hospitalization for treatment of this and various complications. You suffered a severe type of heart attack called a PEA arrest. You required life support from this event and were dependent on a breathing machine for several weeks. Due to this a tracheostomy (breathing tube in your neck) and feeding tube were placed. You had several infections including a urinary tract infection, blood infection, and pneumonias. You developed a clot in your veins and was placed on blood thinners. Unfortunately, you bled while on the blood thinners and these were stopped. Your kidney function worsened and your transplanted kidney stopped functioning. You were restarted on dialysis. . Please continue to take your medications as ordered. . Please attend your follow up appointments. . Followup Instructions: Appointment #1 MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Neurology Date/ Time: Wednesday, [**1-4**] at 1pm Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] bldg, [**Location (un) **] Phone number: [**Telephone/Fax (1) 44**] Appointment #2 MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Transplant Date/ Time: [**Last Name (LF) 766**], [**1-9**] at 3:20pm Location: [**Hospital Ward Name 517**], [**Hospital Ward Name **] Bldg, [**Last Name (NamePattern1) 439**], [**Location (un) 436**] Phone number: [**Telephone/Fax (1) 673**] Appointment #3 MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6944**] Specialty: Hematology Date/ Time: Wednesday, [**1-25**] at 1:40pm Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] bldg, [**Location (un) 436**] Phone number: [**Telephone/Fax (1) 6946**] During your appointment with Dr. [**Last Name (STitle) 6944**] (Hematology), please discuss whether you will need to be evaluated by vascular surgery regarding possible placement of an Inferior Vena Cava filter, and whether the benefits outweigh the risks, given your blood clots. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2107-12-21**]

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icd9pcs

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Discharge summary

report

Admission Date: [**2176-4-5**] Discharge Date: [**2176-4-7**] Date of Birth: [**2137-9-27**] Sex: F Service: MEDICINE Allergies: Bactrim / IV Dye, Iodine Containing Contrast Media / Shellfish / ibuprofen / Peanut / Latex Attending:[**First Name3 (LF) 613**] Chief Complaint: Throat tightness, pruritus Major Surgical or Invasive Procedure: None History of Present Illness: 38 yo W with anxiety/depression, asthma and multiple other allergies who presented to the ED from her dentist's office with concern for allergic reaction while undergoing a root canal. Pt. was in USOH until the afternoon of admission, when while having dental work done for an abcess in LL molar developed a sensation of heat, pruritis and throat tightness. As she was getting wheeled out of the office, she noted a sign re: informing staff if she had a latex allergy, thus thought she reacted to latex. On EMS arrival, she recieved epi pen x1 and 100mg of benadryl. In the ED, ini VS were 98.2 80 102/75 18 100%. She received 125mg IV solumedrol and 20mg of famotidine and was admitted to observation unit. At 4pm pt. noted to be SOB and found to be wheezy andreceived albuterol x3 stacked, improved. Pt. c/o of dental pain, tx with 15mg of Oxycodone with mild relief. At 21:45, triggered for throat closing, diffuse erythema (no tongue or lip swelling) and was found to be diffusely wheezy. Tx with w/ EPI pen, 125mg IV solumedrol, 50mg of benadryl and nebs x2. At time of transfer VS 114 128/75 24 96% on nebulizer. ED staff denied any exposures during observation. On arrival to the MICU, pt. appeared anxious and tachypneic. She has rapid speech, but no accessory m. use. C/o of left mandibular pain and tightness with swallowing. She notes that she is allergic to many foods and drugs and is uncertain if she has ever been exposed to latex. No other recent exposures. Notes that she was intubated 3mo ago for EtOH intoxication and asthma exacerbation. Past Medical History: 1. Polycystic Ovary Syndrome 2. Cholecystectomy due to Choledocholithiasis 3. Asthma 4. EtOH abuse 5. Multiple allergies Social History: Lives in a group home, currently attending AA and therapy for substance abuse. Unemployed. - Tobacco: 1/2ppd - Alcohol: denies, last drink 2mo ago - Illicits: cocaine, remote past Family History: Her sister has [**Name (NI) 4522**] Disease Atopy Physical Exam: Admission physical exam: Vitals: T:98.6 BP:130/80 P:112 R:22 18 O2: 96% 2LNC General: Alert, oriented, anxious appearing HEENT: Sclera anicteric, dMM, oropharynx clear Neck: supple, JVP not elevated. TTP along left cervical surface, no [**Doctor First Name **], no trismus, no meningismus, TTP along the left clavicle. No stridor, no angioedema. CV: RR, normal S1 + S2, no murmurs, rubs, gallops Lungs: scant wheezes b/l, normal air movement. Abdomen: soft, diffusely TTP, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, Skin: There is erythema on the anterior chest, blanching, lip w/ plaquelike lesion on lower vermilion border. Neuro: alert, awake, attentive, nl language. CN: R eye esotropia, VFF, 4-2mm b/l, symmetric face, tongue midline. UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/ nl tone and 5/5 strength. DTRs deferred [**Name2 (NI) **] b/l action tremor. Pertinent Results: Admission labs: [**2176-4-5**] 04:40PM WBC-6.2 RBC-3.65* HGB-12.8 HCT-39.3 MCV-108* MCH-35.0* MCHC-32.5 RDW-12.3 [**2176-4-5**] 04:40PM NEUTS-91.1* LYMPHS-8.1* MONOS-0.2* EOS-0.2 BASOS-0.4 [**2176-4-5**] 04:40PM PLT COUNT-337 [**2176-4-5**] 04:40PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2176-4-5**] 04:40PM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-1.5*# MAGNESIUM-1.9 [**2176-4-5**] 04:40PM cTropnT-<0.01 [**2176-4-5**] 04:40PM ALT(SGPT)-118* AST(SGOT)-78* ALK PHOS-70 TOT BILI-0.3 [**2176-4-5**] 04:40PM GLUCOSE-334* UREA N-8 CREAT-0.8 SODIUM-140 POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-18* ANION GAP-18 [**2176-4-6**] 03:35AM BLOOD WBC-13.2*# RBC-3.52* Hgb-12.2 Hct-37.6 MCV-107* MCH-34.7* MCHC-32.5 RDW-12.6 Plt Ct-292 [**2176-4-7**] 07:50AM BLOOD WBC-9.0 RBC-3.46* Hgb-12.1 Hct-37.2 MCV-108* MCH-34.9* MCHC-32.5 RDW-12.5 Plt Ct-328 . [**2176-4-6**] CXR: FINDINGS: The cardiac silhouette is normal. No pleural effusions. Normal appearance of the lung parenchyma, no evidence of pneumonia or pulmonary edema. No foreign bodies. . [**2176-4-6**] Neck, soft tissue: FINDINGS: On the frontal image, there is no evidence of foreign bodies and no evidence of other soft tissue abnormalities. The lateral image shows a normal air column of the upper trachea. The retropharyngeal space is not substantially widened. No safe evidence of prevertebral soft tissue swelling. However, if clinical suspicion persists, the neck should be evaluated using cross-sectional techniques such as CT or MRI, given the substantially increased sensitivity of this methods. . [**2176-4-6**] CT chest and neck: no acute process per wet read Brief Hospital Course: 38 yo W with anxiety/depression, asthma and multiple other allergies who presented to the ED from her dentist's office with concern for allergic reaction while undergoing a root canal. Pt. was in USOH until the afternoon of admission, when while having dental work done for an abcess in LL molar developed a sensation of heat, pruritis and throat tightness. . # Possible allergic reaction. Allergen uncertain, possibly latex, although multiple possibilities as exposed to multiple potential allergens while at the dentist. Even more unclear, is the reaction that occurred in the ED and again on the floor. As patient was tremulous, also monitored for EtOH withdrawal. Serum tox screen negative. Had similar brief symptoms in ICU, which resolved quickly with Benadryl. Patient given Benadryl, famotidine, prednisone, ipratropium. CT head, neck, and chest showed no acute process. Soft tissue X-ray of neck also negative for acute process. Allergy consulted: recommended steroid taper, [**Doctor First Name **] 180mg [**Hospital1 **], standing q6h benadryl. Patient had uneventful course on transfer to the floor where she would have "allergic reactions" which where marked by flushing, hyperventilation, and wheezing. These episodes responded to nebulizers and during these events her saturation never dropped below 97% on room air. There was a concern for malingering as patient has a known history of substance abuse and would frequently ask for IV benadryl. -Steroid taper per Allergy -Benadryl q6 and [**Doctor First Name 130**] -Follow up at [**Hospital1 2177**] for allergen testing . # Asthma: Appears to be at moderate-severe. However, it is difficult to assess the severity of her asthma as she would smoke cigarettes in the hallway bathroom. - Advair and ipratropium. . # Suspected tooth abcess. There is some suggestion of buccal/masticator space extension. There is no trismus or meningismus. Imaging not suggestive of abscess in pharyngeal or retropharyngeal space. Dental service was called--recommendation was that her tooth could be saved as outpatient if she goes to clinic on Monday. The patient was treated with oxycodone for management of her tooth pain. - Continue clindamycin. - Dental followup on [**2176-4-8**] . # Anxiety. - Continue sertraline, gabapendin, trazodone. Transitional Issues: 1. Smoking cessation: patient smoked in the hospital several times when confronted about smoking she denied smoking. 2. Allergen testing: Patient will have to discontinue her prednisone, [**Doctor First Name 130**], and benadryl prior to allergy testing for most accurate results. Medications on Admission: - Advair 250/50 [**Hospital1 **] - albuterol prn - trazodone 100mg nightly - Sertraline 50mg daily - Gabapentin 300mg [**Hospital1 **] Discharge Medications: 1. prednisone 10 mg Tablet Sig: As directed Tablet PO once a day for 8 days: 4tabx2day.3tabx2day.2tabx2day.1tabx2day. . Disp:*20 Tablet(s)* Refills:*0* 2. fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day) for 8 days. Disp:*48 Tablet(s)* Refills:*0* 3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 1 days. Disp:*6 Tablet(s)* Refills:*0* 4. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 8 days. Disp:*32 Capsule(s)* Refills:*0* 5. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 1 days. Disp:*8 Capsule(s)* Refills:*0* 7. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days. Disp:*20 Capsule(s)* Refills:*0* 11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. Discharge Disposition: Home Discharge Diagnosis: Allergic reaction, allergen undetermined Secondary diagnoses: chronic stable asthma EtOH abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 3825**], You were admitted for an allergic reaction to an unknown substance, possibly it was latex exposure. Please note that people who are allergic to latex are also allergic to kiwi, avocado, and banana. PLEASE note before you have allergy testing you cannot take any prednisone, [**Doctor First Name 130**], or benadryl before you have your testing for at least 5 days. If you have further questions about this please contact your primary care doctor. Fortunately, imaging obtained of your head, neck and airway showed that you have no swelling in your throat and your airway is patent. The oral surgeons saw you while you were in the hospital and recommended that you see your dentist on [**2176-4-8**] for your root canal surgery. Please resume your normal home medications. We are starting you on the following medications. 1. Prednisone please take 40mg for two days, then 30mg for two days, then 20mg for two days, and then 10mg for 2 days then you can stop taking the medication. 2. Please take Benadryl 25mg by mouth every six hours. 3. Please take [**Doctor First Name **] 180mg by mouth twice a day. 4. Oxycodone 5mg, 1-2 tabs every for to six hours for pain. 5. Please take Clindamycin for another day and please ask your dentist if you should continue to take clindamycin. 6. Please take ranitidine twice a day while you are taking prednisone. Please note that you must not drive or drink alcohol while you are taking oxycodone or benadryl. These medications make you drowsy and thus unsafe to operate a motor vehicle. Also, note that oxycodone can cause constipation. You may take an over the counter stoof softener such as colace to avoid constipation. Please remember to ask your PCP about stopping your anti-allergy medications before your Allergy appointment at [**Hospital3 9947**]. Please consider quitting smoking. It is very damaging to your lungs and will make your asthma worse. If you experience any of the following danger signs please call your PCP and come back to the emergency department. Followup Instructions: -Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for a follow up appointment next week. -Please [**Telephone/Fax (1) 79185**] for Allergy Department at [**Hospital1 2177**] to schedule a follow up appointment for allergy testing. -Please go to your dental appointment tommorow morning ([**2176-4-8**]) to get your root canal completed. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "305.03", "522.5", "311", "698.9", "305.1", "493.90", "300.00", "784.1" ]

icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2185-9-6**] Discharge Date: [**2185-9-8**] Date of Birth: [**2133-2-22**] Sex: F Service: MEDICINE Allergies: Morphine / Codeine / Nicotine Patch / Prednisone / Adhesive Tape / Amitriptyline / Prozac / Cyclobenzaprine / Moxifloxacin / Pneumococcal Vaccine / Influenza Virus Vaccine / Celecoxib / Pregabalin / Varenicline Attending:[**First Name3 (LF) 3326**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: [**9-6**] central venous line placed (removed on [**9-7**]) [**9-7**] PICC line placed History of Present Illness: [**Known firstname 87557**] [**Known lastname **] is a 52 yo female with h/o COPD, SLE in remission, chronic back pain r/t DJD and 2 recent admissions for cellulitis who presented to OSH with fevers and RUQ pain. She was found to have a mildly dilated CBD, but no LFT abnormalities or other son[**Name (NI) 493**] e/o cholecystitis. She was tranferred here for ERCP evaluation for possible cholangitis. On arrival to the ED a CXR and CT A/P were notable for a RLL PNA. She reports that her symptoms began Sunday night 2 days PTA. She noted fevers to 101.2 on Sunday night and pleuritic right axilalry CP and abdominal pain. She denied cough or SOB worse than baseline. She saw her pulmonologist on Monday AM and WBC was checked at 21.9. She was sent to [**Hospital3 3583**] and then transferred her as above. At [**Hospital3 **] she was febrile to 103 and was given ciprofloxacin and flagyl and dilaudid for pain. . In the ED, initial vs were: 98.3 106 91/51 16 96%ra. 98.9, She became hypotensive to the 70s in ED. She was given 5L of IVF and started on 0.6 of levofed with improvement in BP to 108/55. A right IJ was placed. She was given vancomycin, ciprofloxacin, tylenol and dilaudid in our ED. She spiked a fever to 102 in the ED and has been satting 98-99% on 2L. CVP 12, SVO2 of 62. . Of note, she has had 2 recent hospitalizations at [**Hospital1 **] this summer. In [**Month (only) **], she was treated for a possible MRSA cellulitis after a steroid injection into her back. More recently she was treated for a left lower leg cellulitis for 5 days and discharged on on bactrim on [**8-5**] to complete a 14 day course as an outpatient. . On the floor, she reports mild right upper quadrant pain but otherwise feels well. She is not in any distress. . Review of systems: (+) Per HPI and for headache associated with fevers, wheezing. reports pleuritic right axillary pain and for lumbar back pain. (-) Denies chills, night sweats, recent weight loss. Denies sinus tenderness, rhinorrhea or congestion. Denies chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias. Denies rashes or skin changes. Past Medical History: Medical: COPD - has home nebs but rarely uses. no home O2. Lung nodules/calcified granulomas - patient reports have several right lung nodules that are being evaluated for possible Lung Ca. SLE - in remission. pt reports history of pleurisy. ? h/o latent TB - s/p only 4 months of INH tx, self-d/c'ed (took INH from [**2185**]) fibromyalgia hypothyroidism perforated sigmoid diverticulitis s/p resection pyelonephritis neohrolithiasis MRSA cellulitis of back and legs s/p cortisone injection for back pain Back pain r/t DJD, disc herniation and sciatica. Osteoporosis at left hip and back. Surgical: sigmoid colectomy hysterectomy amputation of R 5th toe for arthritis h/o of lipoma in back s/p resection Social History: Lives in [**Location 17927**] and has custody of her 10 yo grandson. [**Name (NI) **] one son with substance abuse issues. Smokes [**2-24**] cigarettes per day, but used to smoke 2ppd. Denies EtOH/drugs. On disability. Family History: Mother with CHF. Father with DM. Physical Exam: ADMISSION: General: Alert, oriented, no acute distress HEENT: NCAT, EOMI, Sclera anicteric, MMM, oropharynx clear Neck: RIJ in place, 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, obese, NABS, non-distended, tender to palpation in RUQ no rebound tenderness or guarding, no organomegaly, neg [**Last Name (un) 87558**] GU: foley in place Back: midline healed scar. Ext: warm, well perfused, no clubbing, cyanosis or edema. 2+ DP & radial pulses bilat. Skin: LE with bilat scattered hyperpigmented healing scars/excoriations. DISCHARGE: General: Alert, oriented, no acute distress, breathing comfortably HEENT: NCAT, EOMI, Sclera anicteric, MMM, oropharynx clear Neck: 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, obese, NABS, non-distended, tender to palpation in RUQ no rebound tenderness or guarding, no organomegaly, neg [**Last Name (un) 87558**] Back: midline healed scar. Ext: warm, well perfused, no cyanosis or edema. 2+ DP & radial pulses bilat. Skin: LE with bilat scattered hyperpigmented healing scars/excoriations. Pertinent Results: Labs: [**2185-9-6**] 03:40AM BLOOD WBC-17.3* RBC-3.32* Hgb-10.5* Hct-29.7* MCV-89 MCH-31.5 MCHC-35.2* RDW-13.0 Plt Ct-252 [**2185-9-6**] 11:53AM BLOOD WBC-11.7* RBC-3.22* Hgb-10.0* Hct-30.2* MCV-94 MCH-31.1 MCHC-33.2 RDW-12.9 Plt Ct-223 [**2185-9-7**] 04:17AM BLOOD WBC-8.1 RBC-3.04* Hgb-9.5* Hct-28.1* MCV-93 MCH-31.4 MCHC-33.9 RDW-13.1 Plt Ct-208 [**2185-9-6**] 03:40AM BLOOD Glucose-124* UreaN-7 Creat-0.7 Na-137 K-4.3 Cl-104 HCO3-23 AnGap-14 [**2185-9-6**] 03:40AM BLOOD ALT-12 AST-17 AlkPhos-60 TotBili-0.3 [**2185-9-6**] 03:43AM BLOOD Lactate-0.8 Micro: [**9-6**] Ucx neg [**9-6**] Bcx pending [**9-6**] Bcx pending Imaging: [**2185-9-6**] CXR: Right basilar airspace opacification, for which differential includes infection or aspiration [**2185-9-6**] Abd/Pelvis CT w/o Contrast: 1. Right lower lobe airspace consolidation most compatible with infection. 2. No evidence of colitis or biliary dilatation. 3. Diverticulosis without evidence of diverticulitis. [**2185-9-7**] CXR: The examination is compared to [**2185-9-6**]. The right internal jugular vein catheter has been replaced by a right-sided PICC line. The line shows a normal course, the tip projects over the mid SVC. There is no evidence of complication, notably no pneumothorax. The described right medial cardiophrenic parenchymal opacity is visually less evident than on the previous radiograph, likely to reflect ongoing resolution of the parenchymal process. Newly occurred changes in the lung parenchyma. Unchanged borderline size of the cardiac silhouette without pulmonary edema. Brief Hospital Course: [**Known firstname 87557**] [**Known lastname **] is a 52 yo female with h/o COPD, SLE in remission, chronic back pain r/t DJD and 2 recent admissions for cellulitis who presented to OSH with fevers and RUQ pain found to have RLL PNA and hypotension. . Septic Shock - Patient with hypotension to 70s in ED. In the setting of radiologic/serologic evidence of an infection, it was believed that this was [**1-25**] to septic physiology. Other etiologies considered included cardigenic shock and PE. She received 5L of IVF and levofed infusion was initiated. Her SBP improved into the low 100s. She remained with good UOP and mental status. Her infection was treated as discussed below. Soon after her arrival in the [**Hospital Unit Name 153**], she tolerated weaning from levofed with SBPs in the high 90s and low 100s (her reported basline). At time of discharge, patient had been hemodynamically stable >24h. . Pneumonia, pleuritic RUQ pain/CP - Patient was admitted with leukocytosis and fever in setting of RUQ pain. On admission, consolidations c/w PNA observed on abdominal CT. Given multiple recent admissions to OSH for cellulitis (most recently 1 month ago), most likely [**Hospital Unit Name 10540**]. Given LFTs, amylase/lipase wnl, and no abdominal abnormalities noted on CT, less likely cholangitis, cholecystitis. PE less likely given radiologic findings and lack of tachycardia/hypoxia. Given concern for [**Name (NI) 10540**], pt was started on Vancomycin, Cefepime & Cipro. Cultures were obtained and remained negative at time of discharge. While in ICU, patient was afebrile and stable with no signs of respiratory distress. Pt did not want to remain in the hospital for further monitoring even though hospital management with monitoring of IV Abx would have been preferable. As a result a PICC was placed with a plan to have the patient on IV vanco, PO cefpodoxime, PO cipro for 7days. VNA infusion team was arranged and scheduled to meet the patient at her home at 2pm on the day of discharge. Follow-up was arranged with her PCP (Dr. [**Last Name (STitle) 85525**] on [**2185-9-14**]. Pt already has home VNA who was contact[**Name (NI) **] to perform a lab draw on [**2185-9-10**] with Vanco trough. Instructions were given given for VNA to fax results to PCP [**Name Initial (PRE) 3726**]. Dr.[**Name (NI) 87559**] office was contact[**Name (NI) **] at 12:15pm on [**2185-9-8**] and as Dr. [**Last Name (STitle) 85525**] was out of office her nurse was updated as to the clinical situation, pending labs, and follow-up appointment. D/C summary will be faxed to [**Telephone/Fax (1) 87560**] which is the office where Dr. [**Last Name (STitle) 85525**] will see Ms [**Known lastname **] in follow-up. . Back pain [**1-25**] Degenerative Joint Disease and osteoarthritis - Patient was continued on home pain regimen of baclofen and dilaudid, although she persistently asked for more pain medication. . HTN - Given low blood pressure on admission, antihypertensives were held on admission. Patient was instructed to continue to hold antihypertensives on discharge pending follow-up with her PCP. Medications on Admission: Advair 250/50 1 inhalation [**Hospital1 **] Albuterol MDI 2 puffs QID prn synthroid 150mcg daily zantac 150mg PO daily baclofen 10 mg PO TID simvastatin 20mg PO daily folic acid 1mg PO daily klonipin 1mg PO BID spironolactone 50mg PO daily - for HTN, pt no longer taking. prilosec 20mg PO daily furosemide 10mg PO daily doxepin 100mg PO daily dilaudid 2mg PO q4h Discharge Medications: 1. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 2. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Gram Intravenous Q 12H (Every 12 Hours) for 5 days. Disp:*10 Gram* Refills:*0* 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 6. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 8. Synthroid 150 mcg Tablet Sig: One (1) Tablet PO once a day. 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 14. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 15. Doxepin 150 mg Capsule Sig: One (1) Capsule PO at bedtime. 16. Outpatient Lab Work Please check CBC, CHEM 7 and VANCOMYCIN LEVEL in MORNING OF Saturday, [**2185-9-10**]. Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 36012**] Fax: [**Telephone/Fax (1) 17664**] 17. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Capsule Inhalation once a day. Disp:*30 capsules* Refills:*2* 18. Heparin Flush 10 unit/mL Kit Sig: Two (2) ML Intravenous four times a day as needed for LINE FLUSH for 5 days: PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. . Disp:*40 ML* Refills:*1* 19. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML Injection PRN (as needed) as needed for line flush: Flush with 10mL Normal Saline daily and PRN. Disp:*100 ML(s)* Refills:*1* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary: Pneumonia Sepsis/Hypotension Secondary: COPD Chronic back pain Depression/Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for right upper quadrant pain and fever which was due to a right lower lobe pneumonia. You were also found to low blood pressure. You were given fluids and strong antibiotics. You received a PICC line for antibiotic administration at home. . We made the following changes to your medications: -START VANCOMYCIN through your PICC line for 5 more days. -START CEFPODOXIME by mouth for 5 more days. -START CIPROFLOXACIN by mouth for 5 more days. -STOP LASIX and SPIRONOLACTONE until you see your primary care doctor. Please discuss restarting lasix at your next appointment. -START SPIRIVA for your breathing. . Please follow up with your PCP (appointment listed below). Followup Instructions: PRIMARY CARE Wednesday [**9-14**], at 11:15AM Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2801**] Location: [**Hospital3 **] MEDICAL CENTER Address: [**Street Address(2) 87561**], [**Location (un) **],[**Numeric Identifier 87562**] Phone: [**Telephone/Fax (1) 36012**] [**Hospital1 18**] [**Doctor Last Name **] PAIN CLINIC [**2185-9-16**] 8:30AM Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Location (un) 8170**] [**Location (un) **], MA ***Please call ([**Telephone/Fax (1) 80868**] before your appointment to speak with Registration.

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icd9cm

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icd9pcs

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24829

Discharge summary

report

Admission Date: [**2126-12-2**] Discharge Date: [**2126-12-12**] Date of Birth: [**2076-2-13**] Sex: F Service: MEDICINE Allergies: Depakote / Hydromorphone / Carbamazepine Derivatives Attending:[**First Name3 (LF) 6169**] Chief Complaint: R arm pain and febrile neutropenia Major Surgical or Invasive Procedure: Pericardial window CT guided lung bx Central line placement bone marrow bx lumbar puncture History of Present Illness: 50y/o F with relapsed Ph+ pre-B cell ALL presents with fever/neutropenia and chest pain. Pain started in her R arm (site of PICC). Pt states that chest pain began about 2 days ago, getting worse. Dull, all across chest, no radiation. No exacerbating or alleviating factors. No associated SOB, N/V, or diaphoresis. Not pleuritic. Has had this pain previously, when admitted to hospital. Pain now resolved with morphine. . Pt noticed rash on inner aspect of R arm, for the last few days, near PICC line. PICC being used for TPN and abx. Pt denies SOB, worsening cough, N/V, abdominal pain, diarrhea, dysuria, or fevers at home. No odynophagia or pain with chewing. . In [**Name (NI) **], pt rec'd cefepime 2g, vancomycin 1g, tylenol 1g, phenergan 12.5mg, anzemet 12.5mg, and morphine 12mg. Past Medical History: Onc Hx: Pt initially dx'ed in [**2-22**], s/p chemo - induction with doxorubicin, asparaginase, vincristine, cytoxan, and prednisone; s/p XRT cranial x12 fractions, and intrathecal MTX. Relaped in [**2-23**] while still rec'ing maintenance therapy. [**4-22**]: MTX, vincristine, prednisone. [**2126**]: ALL relapsed, rec'd chemo. [**Location (un) 5622**] chromosome positive. Now being Rx'ed with Gleevec, prednisone, and vincristine. . PMH: ALL as above pulmonary aspergillosis on lung bx [**9-23**] multiple sclerosis [**Month/Year (2) 862**] d/o (last [**Month/Year (2) 862**] 20 years ago) DVT [**12-22**] echo [**2126-11-5**] EF >55% Social History: Lives at home. Son [**Name (NI) **] is NOK and HCP (he is an only child). Husband died 22 years ago from ALL (at [**Hospital1 18**]). Family History: Non-contributory Physical Exam: VS: 97.3 133 112/70 24 100%on 4L Gen: ill appearing, alopecia, appears in respiratory distress. HEENT: PERRL, EOMI, MM dry, Neck: no LAD, no JVD CV: tachycardic, RRR nl S1-S2 Pulm: bibasilar crackles, R > L, otherwise CTAB Abd: soft, NT/ND, +BS, no masses Ext: R PICC with erythematous rash and mild skin breakdown more proximal;R arm warm, firm and painful, 1+ edema in LE bilaterally, symmetric; ppp Neuro: resting tremor, CN II-XII intact, strength and sensory grossly intact Perirectal area: no evidence of abscess Pertinent Results: [**2126-12-2**] 02:19AM BLOOD WBC-0.1* RBC-3.21* Hgb-9.9* Hct-28.6* MCV-89 MCH-30.9 MCHC-34.6 RDW-14.0 Plt Ct-20*# [**2126-12-9**] 04:15AM BLOOD WBC-0.3* RBC-3.29* Hgb-9.9* Hct-27.7* MCV-84 MCH-30.2 MCHC-35.9* RDW-16.7* Plt Ct-30* [**2126-12-3**] 07:20AM BLOOD Neuts-40* Bands-20* Lymphs-20 Monos-20* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2126-12-7**] 05:11PM BLOOD Neuts-43* Bands-43* Lymphs-0 Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-7* [**2126-12-2**] 02:19AM BLOOD PT-14.4* PTT-25.1 INR(PT)-1.4 [**2126-12-2**] 02:19AM BLOOD Plt Ct-20*# [**2126-12-9**] 04:15AM BLOOD Plt Ct-30* [**2126-12-9**] 04:15AM BLOOD PT-16.0* PTT-26.5 INR(PT)-1.8 [**2126-12-2**] 02:19AM BLOOD Gran Ct-50* [**2126-12-9**] 04:15AM BLOOD Gran Ct-230* [**2126-12-2**] 02:19AM BLOOD Glucose-130* UreaN-18 Creat-0.4 Na-135 K-4.0 Cl-103 HCO3-19* AnGap-17 [**2126-12-9**] 04:15AM BLOOD Glucose-79 UreaN-153* Creat-3.1* Na-148* K-3.8 Cl-112* HCO3-14* AnGap-26* [**2126-12-2**] 02:19AM BLOOD ALT-50* AST-20 CK(CPK)-4* AlkPhos-505* Amylase-8 TotBili-1.9* [**2126-12-9**] 04:15AM BLOOD ALT-23 AST-23 LD(LDH)-371* AlkPhos-308* TotBili-1.1 [**2126-12-2**] 02:19AM BLOOD Lipase-10 [**2126-12-2**] 02:19AM BLOOD CK-MB-NotDone [**2126-12-2**] 02:19AM BLOOD cTropnT-<0.01 [**2126-12-2**] 04:30PM BLOOD CK-MB-2 cTropnT-<0.01 [**2126-12-2**] 02:19AM BLOOD TotProt-5.2* Albumin-2.8* Globuln-2.4 Calcium-7.9* Phos-3.2 Mg-1.9 UricAcd-1.2* [**2126-12-9**] 04:15AM BLOOD Calcium-7.2* Phos-7.4* Mg-2.6 . [**12-2**] RUE U/S: No right upper extremity DVT. . [**12-2**] CXR: No acute cardiopulmonary process. Stable appearance of chest since [**2126-11-18**]. . [**12-2**] CTA Chest: 1. No evidence of pulmonary embolism. 2. Interval stable appearance of bilateral nodules, and patchy areas of consolidation within the lungs. 3. Previously noted mild splenomegaly is no longer appreciated, possibly related to slice selection. . [**12-4**] 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%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a moderate sized pericardial effusion. There is sustained right atrial collapse, consistent with low filling pressures or tamponade. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. No vegetation seen (cannot definitively exclude) Compared with the prior study (tape reviewed) of [**2126-11-5**], the pericardial effusion is now larger. . [**12-4**] Cath: 1. Limited resting hemodynamics demonstrated an elevated mean right filling pressure along with a magnified right atrial "x" descent along with an attenuated "y" descent. Additionally the mean right atrial pressure approatched the PCWP. The pericardial pressure and waveform matched the RA pressure and waveform. 2. Following pericardiocentesis (removal of over 320cc of non-bloody fluid) the pericardial pressure dropped to zero with no change in the right atrial pressure or cardiac output. FINAL DIAGNOSIS: 1. Moderate pericardial tamponade. . [**12-5**] CXR: The patient is status post pericardiocentesis. There is a catheter overlying the cardiac silhouette. There is continued bilateral multifocal opacity indicating invasive aspergillosis this patient with leukemia and neutropenia. The previously identified pulmonary edema has been slightly improving. There is continued small right pleural effusion. There is continued enlargement of the cardiac silhouette. No evidence of pneumothorax is identified. The right subclavian IV catheter remains in place. . [**12-5**] Abd U/S: No evidence of dilatation of the bile ducts. Unremarkable gallbladder. Echogenic right kidney suggestive of diffuse chronic parenchymal renal disease. . [**12-6**] KUB: A limited portable supine AP view of the abdomen at 22:15 hours show no evidence of dilated bowel loops to suggest intestinal obstruction. Small amount of gas is seen throughout the colon. . [**12-6**] MRI Brain: IMPRESSION: This examination is slightly limited by motion. Mild periventricular hyperintensities due to small vessel disease. No enhancing lesions seen. Findings discussed with Dr. [**First Name (STitle) 3640**]. MRV OF THE HEAD: Normal MRV of the head. IMPRESSION: Normal MRA of the head. . [**12-6**] CT head: No intracranial hemorrhage or mass effect. No change since [**2126-10-20**]. . [**12-6**] EEG: This is a markedly abnormal EEG due to the presence of abnormal background rhythms in predominantly the theta frequency range with superimposed delta and theta frequency slowing seen periodically in generalized bursts. No sharp or epileptiform features were associated with this slowing. The findings are most consistent with an encephalopathy. Common causes of encephalopathy include metabolic causes, medications, and infections. No focal or epileptiform features were seen. . [**12-6**] Echo: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 60%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is a small posterior pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2126-12-4**], a small consolidated effusion (posterior) is now evident. . [**12-7**] CXR: No significant change in bilateral parenchymal opacities related to pulmonary aspergillosis. . [**12-7**] KUB: A single supine portable abdominal film is compared to previous examination a day ago. The abdomen appears gasless with fecal material in left hemicolon. The linear lucencies in the splenic flexure and descending colon is felt to be intraluminal rather than within the wall of the colon. The tip of the NG tube is not visualized in distal esophagus and stomach. . [**12-7**] Renal U/S: No hydronephrosis or hydroureter bilaterally. Exam of the left kidney was technically limited. . [**12-9**] MR [**Name13 (STitle) 430**]: Unusual generalized focal FLAIR hyperintensities and possible coincident enhancement. Although motion artifact or possibly another unusual artifact may be responsible for the apparent sulcal enhancement, meningitis of infectious or neoplastic etiology should be considered in the given clinical scenario. . [**12-9**] Spinal fluid cytology: negative for malignant cells. . [**12-9**] Bone Marrow Bx: Bone marrow aspirate and core biopsy: Markedly hypocellular bone marrow with rare maturing erythroid precursors and interstitial eosinophilic material consistent with post-chemotherapy aplasia. MICROSCOPIC DESCRIPTION PERIPHERAL SMEAR Smear quality is acceptable. Red cells show anisopoikilocytosis with rare schistocyte. WBC count is decreased. A 42-cell count differential shows: 60% segmented neutrophils, 17% bands, 7% monocytes, 2% lymphocytes, 14% basophils. Platelet count appears decreased; giant forms are not present. ASPIRATE SMEARS: Inadequate for evaluation due to lack of spicules. CLOT SECTION AND BIOPSY SLIDES The marrow biopsy is virtually acellular (<5%) and contains only are small clusters populated by maturing erythroid precursors. Myeloid precursors and megakaryocytes are not seen. The remainder of the cellularity is composed of stromal cells, plasma cells, lymphocytes, and macrophages. No tumor, granuloma, lymphoma, lymphoid, or aggregate is seen. There is a small amount of interstitial eosinophilic material consistent with prior chemotherapy. Marrow clot section is not submitted. Touch prep is not submitted. SPECIAL STAINS Iron stain is inadequate for evaluation because it does not contain marrow spicules. Clinical: [**Location (un) 5622**] positive, ALL. Gross: The specimen is received in B+ Fixative labeled with "[**Known lastname 62516**], [**Known firstname **]", the medical record number and "MO5-659", and consists of a core biopsy of bone marrow measuring 1.7 cm in length. The specimen is entirely submitted in A. Brief Hospital Course: 50y/o F with ALL, fever/neutropenia, and R arm pain. . After treatment in the emergency department with cefepime and vancomycin for febrile neutropenia, the patient was admitted to the oncology service for further care. She was continued on cefepime and vancomycin, and the doses of her antifungal medication for known aspergillus infection were increased. The patient developed a new murmur and increased dyspnea and chest pain, and on [**12-4**] an echocardiogram revealed a pericardial effusion and tamponade physiology. She was transferred to the CCU for placement of a pericardial drain and for post-procedural care. 320cc of yellow fluid was removed via the pericardial drain. On [**12-5**] the patient developed renal failure. Her ambisome dose was therefore decreased and her voriconazole was changed to the PO formulation. On [**12-6**] the patien's mental status deteriorated and she became aphasic and less interactive. Neurology was consulted, and they were concerned for an intracranial process vs. toxic/metabolic etiology. A head CT without contrast was negative for any acute abnormality. EEG was consistent with encephalopathy. MRI was negative for acute infarct, and MRA was negative for any vascular abnormality. An LP was done which showed an opening pressure of 42; however, this was felt to be falsely elevated due to patient positioning. Laboratory studies were not consistent with infection, and cultures were negative. Not enough fluid was obtained to send for cytology. The patient was then transferred to the ICU for further care. Shortly thereafter, a family meeting was held in which the patient's code status was changed to DNR/DNI. A bone marrow biopsy was done on [**12-9**] to determine the status of the patient's leukemia. The marrow was hypocellular with no evidence of active leukemia. The patient's mental status did not improve, and so a repeat LP was done on [**12-9**] to confirm the opening pressure (which was again 40) and to obtain fluid for cytology. (CSF cytology was negative for malignant cells.) After the LP the patient was noted to be in severe respiratory distress and tachycardic to the 170s. EKG revealed sinus tachycardia with no ischemic changes. ABG at that time was 7.16/46/83/17. The patient's son was [**Name (NI) 653**], and he reiterated that he did not wish for his mother to be intubated. The patient's son and sister came to the bedside soon thereafter and requested that the patient be made comfortable. Her status was therefore changed to Comfort Measures Only and she was started on a morphine drip for comfort. On the morning of [**12-10**] the patient was noted to have [**Date Range 862**] activity. This was treated with ativan and resolved. The patient was then transferred out of the ICU to the floor for further care. On the BMT floor she was maintained on morphine and ativan drips that was titrated to her comfort. On the morning after transfer, she went into status epilepticus. This was terminated with 10mg of ativan given as 4mg, 4mg, and 2mg. She was again breathing comfortably after this intervention but expired 90minutes afterwards. The family was [**Date Range 653**] who professed gratitude with her care at [**Hospital1 18**] and refused autopsy. Medications on Admission: voriconazole 200mg IV bid prednisone ambisome 450mg IV MWF gleevec 400mg [**Hospital1 **] megace 400mg daily morphine sustained release 15mg [**Hospital1 **] morphine 15mg po q4-6hrprn zoloft 75mg daily levofloxacin 500mg po daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: ALL Multiple sclerosis Acute renal failure pericardial tamponade encephalopathy Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None

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Discharge summary

report

Admission Date: [**2137-4-11**] Discharge Date: [**2137-4-19**] Date of Birth: [**2058-10-27**] Sex: M Service: MEDICINE Allergies: Hydromorphone / Amoxicillin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: dyspnea, tachypnea Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: 78 M w/ ESRD on HD MWF, CAD s/p CABG (LIMA-->LAD, SVG-->OM1 and OM2) and St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] ([**12-12**]), sCHF w/ LVEF 30%, admitted from [**Hospital 100**] rehab today for sudden onset dyspnea, which began upon awakening this AM at 0900. Yesterday, he was in his USOH and underwent HD w/ removal 2.7 L fluid as well as HD on Monday where about 2-3L fluid was removed. RN noted that he was visibly short of breath this AM w/ RR 50s at the [**Hospital3 **] center where he has been living since his hospital d/c on [**3-19**]. He had been hospitalized from [**Date range (1) 89672**] for S.aureus and VRE bacteremia and decompensated sCHF w/ subsequent initiation of CVVH. . Today, the pt had been c/o dyspnea, which was worse with sitting up and improving somewhat while lying supine, with very mild midline substernal chest pressure. He was noted to have gained weight despite HD yesterday as he was 149 lbs on [**4-6**] and 159 lbs on [**4-8**] and [**4-9**]. His wife also reports increased facial "puffiness" and increased sacral and B/L UE edema. At rehab, he was given 5u insulin for FSBS 500, 2mg morphine and 40mg IV lasix for volume overload, although patient is anuric at baseline and has ESRD requiring HD 3x/ wk. Denies pleuritic pain, hemoptysis, cough, fevers, chills, or other complaints. In the ED, he appeared uncomfortable and was placed on supplemental O2. There he was noted to have a Troponin of 0.47, which is around his baseline and BNP of >70,000 and appeared volume overloaded on exam. He was evaluated by nephrology in the ED who recommended MICU admission for 2h ultrafiltration session followed by HD in the AM. . In the ED intial VS: 97.7 98 132/83 36 89% 2L NC. VS prior to transfer: 97 101/73 35 99% 2L NC . CXR was c/w volume overload although underlying RLL PNA could not be excluded, so he was given IV vancomycin and was written for levofloxacin and clindamycin. He was also given ASA and supplemental Oxygen. . In the MICU, pt appeared uncomfortable and tachypenic, with use of accessory muscles of respiration and complains of lethargy. His wife reports that he may have had sick contacts as he has been living at [**Hospital 100**] Rehab since his discharge from [**Hospital1 18**] on [**3-19**] when he was treated for dyspnea thought to be [**3-6**] volume overload and for VRE bacteremia w/ PO [**Month/Day (2) 11958**]/flagyl. During this admission, pt had been made CMO on HD9 due to multiple comorbidities; this was reversed HD13 as patient appeared more alert. . Patient states he had sudden onset of feeling weak, tired and short of breath this morning. He states he has had his "flu and pneumonia" shots. He denies chest pain, fevers/chills, nausea/vomiting, abdominal discomfort or diarrhea. He denies having had a cough or bringing up sputum although was intermittently coughing during the interview. All other ROS otherwise negative. Past Medical History: --chronic sCHF(EF 30%) --ESRD on HD --Chronic L-pleural effusion --Prior GI bleed - ?rectal ulcer --HLD --IDDM --chronic AF on coumadin --CVA with no residual neurologic deficits --Hypothyroidism --AS s/p [**Month/Day (2) 1291**] [**Hospital3 **] --Hyperparathyroidism --R-AVF --Rectal Ulcers: CMV positive --BCx during his prior hospitalization grew Aeromonas hydrophilia which was treated with 6wks cipro, last day [**2137-2-5**]. During this time he developed LGIB, colonscopy revealed rectal uclers which were cauterizated and biospy was CMV positive. Patient s/p 2 wks IV ganciclovir. Coumadin for afib held and was restarted the nigth prior to admission to [**Hospital1 18**]. --More recently on [**2-5**] at [**Hospital 100**] Rehab, due to persistent diarrhea, the patient was empirically started on Flagyl for cdiff colitis Social History: Married, former salesman, several children. His wife and children are very involved in his care. No tobacco, EtOH or illicits. Family History: Non-contributory Physical Exam: ADMISSION EXAM: VS: afebrile 77 144/113 SaO2 95% on 2L NC GEN: uncomfortable appearing elderly gentleman with plethoric face lying in bed getting hemodialysis coughing intermittently HEENT: EOMI, PERRLA CV: irregularly irregular rhythm, II/VI SEM LUNGS: bibasilar rales, worse on left than right side ABD: +BS soft NT ND, [**3-7**]+ sacral edema EXT: 1+ arm edema B/L, w/ hand edema, RUE AVF w/ palp thrill and audible bruit, trace LE edema, 1+ distal pulses SKIN: multiple areas of skin breakdown on UE, abrasions and excoriations. LLE lateral gastrocnemius area has cellulitic appearing wound w/ dressing c/d/i, good granulation tissue, scant serous drainage, debrided yesterday per wife NEURO: somewhat alert, but fatigued answering questions w/ only one or two words, knows that he is in a hospital, oriented x3. . DISCHARGE EXAM: VITALS: 97.8, 70, 132/56, 20, 98% on 3L NC GEN: Comfortable though tired-appearing, NAD HEENT: EOMI, PERRLA CV: irregularly irregular rhythm, II/VI SEM LUNGS: bibasilar rales, coarse breath sounds diffusely ABD: +BS, soft, NTND EXT: 1+ arm edema B/L, w/ hand edema, RUE AVF w/ palp thrill and audible bruit, trace LE edema, 1+ distal pulses SKIN: multiple areas of skin breakdown on UE, multiple bruises NEURO: A&Ox3, CNs grossly intact, strength and sensation grossly intact Pertinent Results: ADMISSION LABS: [**2137-4-11**] 11:30AM BLOOD WBC-15.5*# RBC-2.78* Hgb-9.0* Hct-27.0* MCV-97 MCH-32.5* MCHC-33.3 RDW-17.8* Plt Ct-291 [**2137-4-11**] 11:30AM BLOOD Neuts-89.7* Lymphs-5.7* Monos-3.2 Eos-1.0 Baso-0.4 [**2137-4-11**] 01:02PM BLOOD PT-35.4* PTT-36.7* INR(PT)-3.5* [**2137-4-11**] 11:30AM BLOOD Glucose-345* UreaN-63* Creat-2.5* Na-136 K-3.6 Cl-94* HCO3-29 AnGap-17 [**2137-4-11**] 03:32PM BLOOD ALT-8 AST-15 LD(LDH)-256* AlkPhos-95 TotBili-0.4 [**2137-4-11**] 08:38PM BLOOD CK(CPK)-18* [**2137-4-11**] 11:30AM BLOOD cTropnT-0.47* proBNP-GREATER TH [**2137-4-11**] 11:30AM BLOOD Calcium-11.1* Phos-2.1*# Mg-2.6 [**2137-4-11**] 03:32PM BLOOD Digoxin-2.0 . OTHER PERTINENT LABS: [**2137-4-11**] 03:32PM BLOOD HCV Ab-NEGATIVE [**2137-4-11**] 03:32PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [**2137-4-12**] PTH 467 . DISCHARGE LABS: [**2137-4-18**] WBC 12.3 HGB 7.9 HCT 23.9 PLT 141 [**2137-4-18**] Glucose 204 BUN 38 Creat 2.7 Na 134 K 3.8 Cl 94 HCO3 32 Ca [**36**].4 Phos 3.4 Mg 2.1. . MICRO: [**4-11**] flu swab: negative for Influenza A and B [**4-11**] blood cx: negative [**4-12**] blood cx: negative [**4-13**] blood cx: negative [**4-13**] stool cx: negative [**4-13**] c diff toxin: negative . IMAGING: [**4-11**] CXR: 1. Findings suggest fluid overload, possibly due to CHF with moderate pulmonary vascular congestion and right greater than left bilateral pleural effusions. Right base opacity may represent combination of layering fluid and atelectasis, given that the patient is semi-erect, however, underlying consolidation is also of concern. Additionally, patchy left base retrocardiacopacity is seen, which could be due to aspiration, infection, chronic atelectasis. 2. Left PICC line continues to be high riding. . ECHO [**2137-4-16**]: The left atrium is moderately dilated. The right atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded; the septum may be hypokinetic but is not fully visualized. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50%). The right ventricular cavity is mildly dilated with normal free wall contractility. A bileaflet aortic valve prosthesis is present and appears well-seated. The transaortic gradient is normal for this prosthesis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**2-3**]+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2137-3-4**], left ventricular systolic function now appears more vigorous, alhtough view are suboptimal for comparison. The right ventricle now appears dilated. . [**4-17**] CXR: In comparison with the study of [**4-16**], there is probably little change given the semierect rather than supine position. Again, there is enlargement of the cardiac silhouette with pulmonary vascular congestion and bilateral pleural effusions, worse on the right, with associated compressive atelectatic changes at the bases. Left PICC has its tip within the subclavian or proximal left brachiocephalic vein. Brief Hospital Course: 78 M w/ ESRD on HD (MWF), CAD s/p CABG and [**First Name8 (NamePattern2) **] [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**], systolic CHF (EF=30%), and AF on Coumadin, presents from [**Hospital1 10151**] with acute onset dyspnea and respiratory distress, likely in the setting of volume overload. . # DYSPNEA: Most likely secondary to volume overload given [**Hospital1 **] exam, BNP >70,000, known systolic CHF, and CXR findings. Patient initially started on broad spectrum antibiotics ([**Hospital1 11958**]/[**Last Name (un) 2830**]) given concern for possible HCAP, though these were later discontinued as the dyspnea was felt to be secondary to volume overload. Patient dialyzed with removal of fluid, and subsequent improvement in respiratory status. He was ruled out for flu, and the oseltamavir was discontinued. Cardiac meds were optomized to help decrease afterload and minimize the contribution of his mitral regurgitation on his pulmonary edema. Pt was also started on steroids out of concern for possible post-pericardotomy syndrome. These should be continued for one week post-discharge and then tapered. . # LEUKOCYTOSIS: Felt to be secondary to infectious etiology, and was concern for C. diff given recent infection and persistent diarrhea. PO flagyl switched to IV formulation, and stool sent for C. diff which was negative. Patient was also started on empiric antibiotics for treatment of possible PNA or bacteremia given history and dyspnea on presentation, and blood cultures sent. Was felt that acute presentation of dyspnea more likely secondary to volume overload, and as above antibiotics for pneumonia were discontinued. . # DIARRHEA: Per [**Hospital 100**] Rehab notes, pt having loose stools [**3-8**] x/day and continues on PO flagyl. Patient switched to IV flagyl for increased absorption. Stool sent for C. diff which was negative. 14 day course of flagyl was completed while in the hospital. . # ESRD on HD: Patient received CRRT w/ 2L removed on day of admission, and had several sessions of HD while in the hospital. Started on nephrocaps. Pts nephrologist, Dr [**Last Name (STitle) 118**], was involved in goals of care discussions. . # ATRIAL FIBRILLATION: Patient has previously been rate controlled with carvedilol and digoxin. Digoxin held on admission given high level, and patient not on beta blocker at present. Was rate controlled in sinus rhythm. Dig was restarted at a lower dose. On warfarin for anticoagulation, though this was initially held in setting of supratherapeutic INR, restarted on discharge. . # CAD s/p CABG/[**Last Name (STitle) 1291**]: Continued aspirin. Patient was CP free. . # IDDM: continued home lantus and humalog SS when pt is on TFs . # HYPOTHYROIDISM: ct home levothyroxine 75mcg daily . # DEPRESSION: Held home zoloft while pt on [**Last Name (STitle) 11958**] given risk of serotonin syndrome (although pt had been getting both at rehab). Zoloft was restarted prior to discharge. . # CELLULITIS: Patient has h/o left lateral leg cellulitis s/p debridement at bedside on day prior to admission. Dressing C/D/I, and wound appeared well-healed w/ granulation tissue and scant serous drainage on bandage. Patient had been receiving tx w/ irtapenem as outpatient. Wound care consulted, antibiotics held as described above as wound did not appear infected. . # COMMUNICATION: Patient, wife [**Name (NI) 4134**] cell-[**Telephone/Fax (1) 89673**] . # GOALS OF CARE: DNR/DNI/DNH, with plans to transition to hospice on discharge. These decisions were made in conjuction with Dr [**Last Name (STitle) 118**], the pt and the patients wife with the understanding that the patient's chronic renal failure and CHF contribute to a tenuous and difficult to manage volume status. Prior to discharge the patient was having significant discomfort with respirations and morphine was initiated for comfort. Medications on Admission: 1. Acetaminophen liquid 650mg q6h through G-tube (not to exceed 4g per day) 2. Albuterol nebs q12h 3. Digoxin 0.125mg daily 4. Fluticasone nasal spray 1 spray NU 5. Haldol 0.5mg PO BID 6. Imipenem/Cilastatin IV 250mh q12h @ 0400 and 1600 7. insulin glargine lantus 15u SC QHS 8. insulin lispro sliding scale 9. ipratropium bromide nebs 0.5mg q12h 10. levothyroxine 75 mcg daily 11. [**Last Name (STitle) 11958**] 600mg PO BID 12. flagyl 500mg PO BID 13. sertraline 25mg daily 14. Coumadin 2mg daily 15. loperamide 2mg TID PRN 16. morphine 2mg q4h SL PRN Discharge Medications: 1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain, fever. 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for sob, wheeze. 4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Nasal once a day. 6. ipratropium bromide 0.02 % Solution Sig: One (1) nep Inhalation twice a day: PRN SOB. 7. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. loperamide 2 mg Tablet Sig: One (1) Tablet PO three times a day as needed for diarrhea. 9. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for insomnia, anxiety. 10. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Take two tabs per day for 1 week, then 1 tab a day for 3 days, then [**2-3**] tab a day for 3 days. 11. hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours). 12. morphine 10 mg/5 mL Solution Sig: Five (5) mg PO Q1H (every hour) as needed for anxiety/sob. 13. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 100**] Rehab Facility MACU Discharge Diagnosis: Congestive heart failure Pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - independent. Discharge Instructions: Mr. [**Known lastname **], You were admitted with shortness of breath from an exacerbation of your heart failure. We removed fluid during dialysis and you are feeling better. It also seems that you may have developed a pneumonia during your hospitalization, so you were treated with antibiotics. During the hospitalization it was decided that you would be discharged with plans to shift the focus of care towards comfort. Your discharge medications were determined with this in mind but may be discontinued at the discretion of the admitting physician if the medications are no longer contributing to your comfort. . We made the following changes to your medications: - Digoxin was DECREASED to 0.0625 mg PO DAILY START THE FOLLOWING MEDS: -Prednisone. Please take 40 mg for 1 week, then 20 mg for 3 days, then 10 mg for 3 days, then stop. -olanzapine -morphine sulfate oral -hydralazine DISCONTINUE THE FOLLOWING MEDS: -Imipenem/Cilastatin -[**Known lastname 11958**] -flagyl -loperamide -haldol -insulin . You should weigh yourself every morning and call your doctor if your weight goes up more than 3 lbs. Followup Instructions: Please follow up with your primary care doctor Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 89674**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2137-4-19**]

[ "V58.67", "787.91", "V45.81", "428.22", "V43.3", "V45.11", "V58.61", "428.0", "414.00", "272.4", "285.21", "250.00", "V49.86", "V12.54", "486", "427.31", "585.6", "403.91", "244.9", "311", "511.9" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

15002, 15067

9228, 13121

315, 329

15146, 15146

5683, 5683

16435, 16709

4319, 4337

13725, 14979

15088, 15125

13147, 13702

15299, 15940

6535, 9205

4352, 5171

5187, 5664

15969, 16412

257, 277

357, 3302

5699, 6350

6372, 6519

15161, 15275

3324, 4158

4174, 4303

22,931

196,469

8811

Discharge summary

report

Admission Date: [**2195-2-23**] Discharge Date: [**2195-2-27**] Date of Birth: [**2132-7-21**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This is a 62-year-old white male with a history of recent onset of substernal chest pain and dyspnea on exertion. He went to [**Hospital1 190**] Emergency Room on [**2195-1-19**], with electrocardiogram changes. The patient was then taken to the catheterization laboratory which showed 3-vessel coronary artery disease with a pericardial effusion. No tamponade. Echocardiogram showed pericardial effusion, large 1-cm X 6-cm thrombin fibrin mass. Cardiac catheterization showed left anterior descending artery 60%, mid 50%, distal D1 of 80%, left circumflex 70%, right coronary artery 50%, ascending aorta was 4 cm, aortic insufficiency was 1+. PAST MEDICAL HISTORY: 1. Insulin-dependent diabetes mellitus. 2. Hypertension. PAST SURGICAL HISTORY: Status post previous surgery with appendectomy. MEDICATIONS ON ADMISSION: NPH 16 units q.p.m., Glucophage 500 mg p.o. b.i.d., glyburide 10 mg p.o. b.i.d., Levatol 20 mg p.o. b.i.d., Mavik 4 mg p.o. q.d. PHYSICAL EXAMINATION: HEENT was within normal limits. Chest was clear. Coronary examination revealed a regular rate and rhythm. No murmurs, rubs or gallops. Abdomen was benign. Extremities revealed no cyanosis, clubbing or edema. Good saphenous vein bilaterally. Neurologic examination was nonfocal. HOSPITAL COURSE: On [**2195-2-24**], the patient was taken to the operating room and had a coronary artery bypass graft surgery times two with a pericardial peel. Bypass was done left internal mammary artery to the left anterior descending artery, saphenous vein graft to the OM. The patient tolerated the procedure well and was transferred to the Cardiothoracic Intensive Care Unit in satisfactory and hemodynamically stable condition. After the initial postoperative period, the patient was extubated, and delined, and had his chest tubes discontinued as scheduled, and was transferred to the Far Six floor. He was up walking around with physical therapy. He was doing well. His appetite was good, and he was then stable enough to be discharged home on [**2195-2-27**]. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft surgery. 2. Status post cardiac catheterization. 3. History of insulin-dependent diabetes mellitus. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 20991**] MEDQUIST36 D: [**2195-3-24**] 09:15 T: [**2195-3-25**] 09:41 JOB#: [**Job Number 30758**]

[ "272.4", "414.01", "401.9", "423.9", "411.1", "250.01" ]

icd9cm

[ [ [] ] ]

[ "36.11", "36.15", "39.61", "37.31" ]

icd9pcs

[ [ [] ] ]

2312, 2723

1011, 1141

1467, 2239

935, 984

1164, 1449

2254, 2291

180, 828

850, 910

20,312

160,849

50282+59240

Discharge summary

report+addendum

Admission Date: [**2160-9-2**] Discharge Date: [**2160-9-6**] Date of Birth: [**2088-4-12**] Sex: M Service: UROLOGY Allergies: Codeine / Codeine Anhyd / Ambien Attending:[**First Name3 (LF) 824**] Chief Complaint: BPH Major Surgical or Invasive Procedure: [**9-2**] TURP History of Present Illness: 72M with multiple medical problems and BPH Past Medical History: Vascular Dementia HTN CVA Diabetes DVT: late [**2157-5-1**] s/p filter CKD baseline Cr around 3.5 peripheral neuropathy glaucoma with legal blindness skin grafts on B UE burns from automobile fire in [**2118**] hepatitis B and C anemia baseline Hct 26-32 history of alcohol and cocaine use a history of osteomyelitis - Left hip replacement joint infection. erectile dysfunction Social History: Currently lives with his wife who is the primary care taker. Previously was a construction worker retired 5 years ago. Daughter lives nearby. He was a smoker (15-20 pack year quit 5 years ago) in the past, h/o Etoh and cocaine abuse (no EtOH use since [**4-5**], no cocaine use since [**2138**]) Family History: Non contributory. Physical Exam: AVSS NAD Abd soft, nt/nd Pertinent Results: [**2160-9-2**] 05:19PM GLUCOSE-118* UREA N-75* CREAT-4.7* SODIUM-146* POTASSIUM-4.3 CHLORIDE-118* TOTAL CO2-18* ANION GAP-14 [**2160-9-2**] 05:19PM WBC-6.0 RBC-2.74* HGB-8.2* HCT-25.8* MCV-94 MCH-30.0 MCHC-31.9 RDW-15.0 Brief Hospital Course: Patient underwent a bipolar TURP on [**9-2**]. Please see operative report for further details. He was extubated in the OR but then reintubated due to tachypnea and poor respiratory effort. He was transferred to the ICU for overnight monitoring. ICU course: He was transferred to the ICU following reported respiratory distress following an elective TURP requiring reintubation. While in the ICU, his home anti-hypertensives other than Lisinopril were restarted. No anticoagulants were given. Due to concern of questionable prolonged PR interval on tele, 12 lead EKG was done which was slightly concerning for a questionable ST elevation in V2-V3. Cardio fellow was contact[**Name (NI) **] who felt it was most likely repolarization and was not concerned. appears old compared to EKG from 7/[**2159**]. He had Cath in [**2156**] which showed normal coronaries. The next day of ICU stay, he was extubated, and we restarted lantus, lasix, lisinopril, and called out to urology. The CBI was clamped at 4AM on POD2, and clear urine was noted inthe foley line without clots. The foley was removed and he was voiding without difficulty, and his pain was well controlled. He was tolerating a regular diet. At discharge, patient's pain well controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. He is given explicit instructions to call Dr. [**Last Name (STitle) 770**] for follow-up. Medications on Admission: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). 4. donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. isosorbide dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. pilocarpine HCl 4 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual As directed: every 5 minutes up to 3 times for chest pain, call 911 if chest pain continues 12. insulin glargine 100 unit/mL Solution Sig: 2-4 units Subcutaneous at bedtime. 13. insulin lispro 100 unit/mL Cartridge Sig: As directed Subcutaneous As directed: Please use as previously prescribed. 14. Lumigan 0.03 % Drops Sig: One (1) drops Ophthalmic As directed: 1 drop both eyes at bedtime 15. clotrimazole-betamethasone 1-0.05 % Cream Sig: One (1) Cream Topical As directed: apply to affected areas twice a day 16. Cosopt 2-0.5 % Drops Sig: One (1) Ophthalmic As directed: 1 drop both eyes three times a day 21. terbinafine 1 % Cream Sig: As directed Topical .: apply to affected area twice a day. 22. hydralazine 50 mg Tablet Sig: Three (3) Tablet PO three times a day. 24. lasix 40mg daily Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 2. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 3. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. pilocarpine HCl 4 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. hydralazine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 9. isosorbide dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. oxycodone 5 mg Tablet Sig: 1/2-1 Tablet PO every 4-6 hours as needed for pain. Disp:*12 Tablet(s)* Refills:*0* 12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: BPH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -No vigorous physical activity for 2 weeks. -Expect to see occasional blood in your urine and to experience urgency and frequecy over the next month. -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. Replace Tylenol with narcotic pain medication. Max daily Tylenol dose is 4gm, note that narcotic pain medication also contains Tylenol (acetaminophen) -Do not drive or drink alcohol while taking narcotics -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -Resume all of your home medications except for Aspirin. Resume aspirin on Monday [**9-8**] -Resume all of your home medications, but please avoid aspirin/advil for one week. -If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Followup Instructions: -Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office ([**Telephone/Fax (1) 7707**] ‎for follow-up AND if you have any questions (page Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] at [**Telephone/Fax (1) 2756**]). Completed by:[**2160-9-5**] Name: [**Known lastname 17013**],[**Known firstname 33**] L Unit No: [**Numeric Identifier 17014**] Admission Date: [**2160-9-2**] Discharge Date: [**2160-9-6**] Date of Birth: [**2088-4-12**] Sex: M Service: UROLOGY Allergies: Codeine / Codeine Anhyd / Ambien Attending:[**First Name3 (LF) 9906**] Addendum: Prior to d/c RN voiced concern that patient did not seem at usual baseline activity level versus preop. PT was asked to evaluate the patient and felt he was not in fact returned to baseline. He was kept in house overnight for repeat eval/session with PT, after which he was deemed fit for d/c home with VNA and home physical therapy to further rehabilitate him. Otherwise he spent an unremarkable night without events, complaints, fever, or other symptoms. At time of d/c voiding, pain controlled, tolerating usual diet. Will f/u with Dr. [**Last Name (STitle) **] and clinic and VNA/PT at home as above. Discharge Disposition: Home With Service Facility: [**Hospital 136**] Homecare [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9907**] MD [**MD Number(1) 9908**] Completed by:[**2160-9-6**]

[ "437.0", "290.40", "518.52", "250.00", "356.9", "585.9", "493.90", "600.01", "285.29" ]

icd9cm

[ [ [] ] ]

[ "60.29", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

8193, 8407

1441, 2899

293, 310

5730, 5730

1193, 1418

6887, 8170

1114, 1133

4579, 5601

5703, 5709

2925, 4556

5881, 6864

1148, 1174

250, 255

338, 383

5745, 5857

405, 784

800, 1098

11,944

142,622

6339

Discharge summary

report

Admission Date: [**2108-3-22**] Discharge Date: [**2108-4-13**] Date of Birth: [**2039-5-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: EGD Colonscopy Distal Ileocolic Artery embolization IVC filter placement EGD with ERCP History of Present Illness: HPI: 68 yo M with h/o MDS, thrombocythemia, HTN, COPD (fev1 62% pred, fvc 56% 11/06) p/w BRBPR. Yesterday PM pt had episode of large vol (not quantified) BRBPR, though no stool, associated with abd cramps. Pt has never had this in the past. Pt has had [**12-29**] similar episodes q 1 hour since that time. Denies n/v. Has also complained of mild cough and "spitting up" small amounts of blood-tinged sputum. Otherwise without complaints. Pt to ED today by cab. . In ED 97, hr 90, bp, 108/53, rr 18, sat 97% RA. Pt remained hemodynamically throughout. NGL attempted X 6 but attempts were unsuccessful and pt developed brisk nose bleed. 2 18 guage IVs placed. Hct in ED 25, INR 2.4. Vit K 10 mg po X1 given. Per report, no blood products immediately available by cross-match. GI consulted in ED, plan for EGD/[**Last Name (un) **] in MICU. Pt transferred to MICU for further management. . ROS: As above, also pt denies cp/sob/HA/vision/blance changes/joint or muscle pain or swelling/hematuria. . PROGRESS NOTE ON TRANSFER FROM MICU TO [**Hospital1 **]: 68 yo M with h/o MDS, thrombocythemia, HTN, COPD (fev1 62% pred, fvc 56% 11/06) who presented with BRBPR on [**3-22**]. He reported having a large volume of BRBPR without stool and associated with abdominal cramps. In the ED, he was hemodynamically stable, NGL attempted but not performed as pt developed nose bleed. Hct 25, INR 2.4, was given 10 mg vitamin K and admitted to the MICU. An EGD was unremarkable and and a colonscopy was significant for blood in the colon, sigomid diverticulosis, but no clear source of the bleeding. A SMA angiogram was significant for extravasation of contrast at the distal ileocolic branches, which was successfully embolized. He received a total of 10 U pRBC and 10 U FFP while in the MICU. Given his h/o thrombocythemia with clots and the fact that his anti-coagulation was held in the setting of GI bleed, LENIs were performed that showed a chronic appearing L superficial vein DVT. An IVC filter was placed. The pt then began to c/o nausea and increasing abdominal pain and LFTs were significant for an obstructive picture. A RUQ US showed a thick, edematous GB wall that was concerning for possible cholecystitis and surgery was consulted. A HIDA scan did not exclude the possibility of cholecystitis. He was started on cipro, flagyl, and unasyn and then underwent an ERCP in which a stone was removed from the biliary tree, a sphincterotomy was performed, and the CBD was noted to be dilated to 12 mm. Past Medical History: 1. DVT RLE ([**2105**]) hospitalized 2. Aortic Regurg ([**7-/2101**]) ECHO TTE: The left atrium is normal in size. There is moderate concentric left ventricular hypertrophy. The left ventricle cavity is normal in size. Overall left ventricular systolic function is normal (LVEF 60-65%). Normal right ventricular chamber size and systolic function. The aortic root is mildly dilated. The ascending aorta is moderately dilated. The aortic valve leaflets are mildly thickened/sclerotic, but move well. Mild aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no pericardial effusion. 3. Influenza A--> "coma" for 21 days ([**2100**]) Pt admitted to [**Hospital1 **] for respiratory distress. Dignosed w/ influenza or PNA. pt was intubated. cultured MRSA. RUQ ultrasound showed a hypoechoic pancreas and sludge in the gallbladder. He was subsequently extubated and did better. He received antibiotics. Incidentally was diagnosed with Anemia and manocytosis so got Bone Marrow Biopsy. 4. Anemia/ Manocytosis (myelodysplastic syndrome): [**2-/2100**] Bone Marrow Biopsy: Cellularity is 60% overall which is hypercellular for the patient's age. Myeloid: erythroid ratio estimate is normal. Megakaryocytes are adequate in number and normal in distribution. No abnormal localization of immature precursors is found. No carcinoma, lymphoma, or granulomas are seen. Note: The high MCV, hypercellular marrow and subtle [**Hospital1 **]-lineage anomalies can be seen in an evolving myelodysplastic syndrome. Follow-up is suggested. [**2-16**] Path report: peripheral blood for immunophenotyping flow cytometry phenotyping: impression: clonal lymphocytosis. Recommend T cell receptor gene rearrangement study by polymerase chain reaction to rule-out a T/NK cell lymphoproliferative disorder. 4. hemochromocytosis or sideroblastic anemia? [**2100**]: The patient was noted on admission to have a hematocrit of 41 with an MCV of 119. His folate, B12 and TSH levels all were normal. His iron studies revealed an iron of 113, total iron binding capacity of 135, ferritin of greater than 1000 and a TRF of 104. His iron to total iron binding capacity ratio was 83%. 5. Pancreatitis: [**2100-1-15**] during ICU admission. 6. HTN: well controlled with Tiazadone 7. Gout: controlled with Allopurinal 300 daily 8. COPD "breathing much improved since stopped smoking 9 months ago". 9. Scarlet fever as child. Social History: 1-2 packs per day for > 50 years (began whe he was 9 and just stopped 9 months ago). Pt has positive alcohol history: claims to have stopped or greatly reduced drinking, but did report in [**2100**] drinking [**2-18**] six- packs per day on the weekends, 2-3 beers a day during the week. Family History: Mother died in 80s not sure what from. His father has hypertension- died in his 60s from heart attack?. 2 siblings are alive and in good health. Son has asthma. Physical Exam: Temp 96.8 BP 105/69 Pulse 77 Resp 14 O2 sat 99 % 2 l NC Gen - Alert, no acute distress HEENT - extraocular motions intact, anicteric, mucous membranes dry Neck - no JVD, no cervical lymphadenopathy Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, no murmurs appreciated Abd - Soft, nontender, mild distended, with normoactive bowel sounds Extr - No edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3 Skin - No rash Pertinent Results: LABS ON ADMISSION: [**2108-3-22**] 10:35AM WBC-8.6 RBC-2.06* HGB-8.3* HCT-25.2* MCV-122* MCH-40.1* MCHC-32.8 RDW-25.1* [**2108-3-22**] 10:35AM NEUTS-56 BANDS-3 LYMPHS-7* MONOS-32* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* OTHER-1* [**2108-3-22**] 10:35AM PLT SMR-NORMAL PLT COUNT-428 PLTCLM-1+ [**2108-3-22**] 10:35AM PT-24.1* PTT-51.4* INR(PT)-2.4* [**2108-3-22**] 10:35AM GLUCOSE-130* UREA N-32* CREAT-1.3* SODIUM-133 POTASSIUM-5.7* CHLORIDE-99 TOTAL CO2-24 ANION GAP-16 [**2108-3-22**] 12:45PM HCT-21.3* [**2108-3-22**] 08:02PM HCT-22.5* [**2108-3-22**] 09:27PM POTASSIUM-3.8 . EKG-nsr@79 bpm, twi I/avl (old) . IMAGING: CXR [**3-22**] - The cardiac silhouette is enlarged, but stable in size. The aorta is tortuous. Pulmonary vascularity is within normal limits. Hazy opacities in the lower lung regions may be due to crowding of vasculature related to low lung volumes, but it is difficult to exclude peribronchiolar infection or aspiration. PA and lateral chest radiograph with improved inspiratory volumes may be helpful for more complete assessment of these regions. . EGD [**3-22**]: Normal EGD to duodenum. . Colonscopy [**3-23**]: Blood in the whole colon. Diverticulosis of the sigmoid colon . SMA Angiogram [**3-23**]: SMA angiogram demonstrates extravasation of contrast from the distal ileocolic branches. Successful coil embolization of distal feeding branches of the ileocolic artery. . LENI [**3-26**]: Long segment left superficial femoral vein DVT. Wall thickening of the left common femoral vein suggestive of sequela of prior DVT. Combined with the patient's history, these findings likely represent a chronic DVT. . [**3-27**]: Successful placement of Bard recoverable G2 filter in the infrarenal inferior vena cava. . RUQ US [**3-27**] - 1. Echogenic liver and splenomegaly consistent with intrinsic liver disease. 2. Thickened, edematous gallbladder wall. The gallbladder is not particularly distended and this appearance may be related to liver disease or fluid resuscitation. It is unlikely to represent acute cholecystitis; however, if there is clinical concern for this, a HIDA scan could be performed. 3. Re-demonstration of nonobstructing left renal stone. . CXR [**3-27**] - Compared with [**2108-3-27**], there is now right perihilar haziness, with a more symmetric appearance of the pulmonary edema. There is persistent cardiomegaly. There are no pleural effusions, consolidations, or pneumothorax. Mediastinal and hilar contours are unchanged. IMPRESSION: Progressed pulmonary edema. . HIDA [**3-29**] - Findings suggest hepatocellular dysfunction. This study neither confirms nor excludes cholecystitis. . CT abd/pelvis c contrast [**3-29**] - 1. Patchy opacities at bilateral lung bases, which may represent atelectasis versus early pneumonia. 2. No evidence of cholecystitis, colitis or diverticulitis, however multiple mildly enlarged retroperitoneal and root of mesentery lymph nodes are seen which is a nonspecific finding. However, may be associated with an inflammatory or infectious process. . ERCP [**3-30**] - 1. Cannulation of the biliary duct was performed with a sphincterotome 2. A dilation was seen at the biliary tree with the CBD measuring 12mm. 3. A single stone was seen at the biliary tree. 4. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome. 5. The stone was extracted successfully using a balloon catheter. . Renal US c doppler [**4-2**] - The right kidney measures 12.7 cm. The left kidney measures 12.3 cm. There are small echogenic foci peripherally located in the mid pole of the left kidney, which may represent crystals within a caliceal diverticulum. There is no evidence of hydronephrosis or mass. The renal arteries and veins are patent bilaterally. Foley catheter is observed in the decompressed bladder. IMPRESSION: Small echogenic foci within the periphery of the mid pole of the left kidney, which could represent crystals within a caliceal diverticulum. Otherwise, normal renal ultrasound. . CT abd/pelvis without contrast [**4-2**] - 1. No evidence of retroperitoneal hematoma following ERCP. 2. Questionable areas of inflammatory stranding immediately beneath the pancreatic neck. The assessment is limited by dense contrast in the hepatic flexure, causing beam hardening artifact. Findings could indicate mild post-ERCP pancreatitis. Correlate with amylase/lipase levels. 3. Potential DVT in right common and superficial femoral veins. Compared to the ultrasound from [**2108-3-26**], this would be a new finding. An IVC filter is already present. If determining whether there is DVT in the right lower extremity is of clinical significance, this could be confirmed with Doppler son[**Name (NI) 1417**]. 4. Nonobstructing 2-mm stone in mid pole, left kidney. 5. Unchanged non-pathologically enlarged mesenteric and retroperitoneal lymph nodes. . RLE LENI [**4-3**] - 1. New right lower extremity DVT extending from the CFV/GSV junction to the popliteal vein. 2. Redemonstration of left superficial femoral vein DVT . [**4-5**] ECHO: INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root. Moderately dilated ascending aorta. Focal calcifications in ascending aorta. Mildly dilated aortic arch. Focal calcifications in aortic arch. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Minimally increased gradient c/w minimal AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal tricuspid valve supporting structures. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . CXR [**4-11**]: Right-sided PICC line is again noted and although is difficult to evaluate the exact location of the tip, it is likely unchanged. Cardiomediastinal contours are unchanged. Left retrocardiac opacity is again seen, however, there may be some slight improvement with better visualization of the hemidiaphragm. Left basilar atelectasis is also noted. Blunting of the costophrenic angles is noted posteriorly which may contain a small amount of fluid. Old healed left-sided rib fractures are noted. IMPRESSION: Perhaps mild improvement of left retrocardiac opacity. . LABS ON DISCHARGE: WBC 12.9 HGB 7.3 HCT 22.1 PLT 299 NA 133 K 4.2 HCO3 27 BUN 39 CR 1.4 PT 25.1 INR 2.5 ALT 20 AST 22 Total Bili 0.9 Brief Hospital Course: 68 yo M with h/o MDS, thrombocythemia, HTN, COPD who initially presented with BRBPR. . #) BRBPR: The patient had an egd and colonoscopy which failed to find the source of bleeding. The patient underwent an SMA angiogram which showed bleeding at the distal ileocolic branches, which underwent successful embolization. The patient's hematocrit was then followed throughout his stay and was stable at 21-23 on discharge. His hematocrits are also unresponsive to blood transfusions presumably due to difficult crossmatching. This was reported to the blood bank prior to the patient's discharge. The patient continued to have intermittent guiac positive stool, but his hematocrit remained stable. The guaiac positivity was discussed with IR prior to discharge, but no further diagnostic intervention was felt possible on their part unless he bled briskly. He was discharged with plan to observe for any evidence of acute bleeding or decrease from his baseline hct of 22. . #) Cholethiasis: The patient was found to have increasing LFTs with abdominal pain. An EGD was performed with ERCP. ERCP resulted in successful removal of a stone and a sphincterotomy. His LFTs were monitored thereafter and decreased to normal. The patient should be scheduled for cholecystectomy with [**First Name8 (NamePattern2) **] [**Name8 (MD) 468**], MD in the next month ([**Telephone/Fax (1) 476**] or [**Telephone/Fax (1) 2835**]). His office was called regarding this. . #) DVT: Prior to admission, the patient had been on chronic coumadin anticoagulation therapy for history of DVT and splenic vein thrombosis. On admission with GI bleed, his INR was reversed with 10 mg of vitamin K. A lower extremity ultrasound demonstrated a chronic left superficial femoral vein thrombosis, and an IVC filter was placed to prevent PE - in the setting of his bleed and having to stop his anticoagulation as well as his antiplatelet agents. During this hospitalization, on a CT of his abdomen to look for ? GIB after his ERCP, he was found to have an incidental DVT on his RLE. The patient was bridged with heparin and restarted on coumadin. On discharge he was therapeutic (goal INR 2.0-3.0) on coumadin. Given his current antibiotic regimen, his INR needs to be closely followed in the short term, and he is being discharged currently on 5 mg coumadin every day. In the long term, it is expected that he will return to his coumadin regimen prior to this hospitalization of 10 mg every MON,WED,FRI and 5 mg every TUES, THURS, SAT, SUN. . #) Acute renal failure: The patient developed acute renal failure during his stay and renal consult suspected it was secondary to contrast dye. It resolved over the course of the stay. His baseline creatinine level is 1.0. . #) Anemia: The patient has myelodysplastic syndrome - from which anemia is the primary manifestation. He requires intermittent transfusions. He required transfusions to upkeep his Hct while in house. The patient's iron studies are consistent with anemia of chronic disease. The patient's last iron level checked on [**4-10**] was normal at 139. The patient was continued on epogen as directed by [**Month/Year (2) 1978**]. THE PATIENT IS A DIFFICULT CROSS MATCH FOR BLOOD BANK DUE TO KNOWN ANTIBODIES. PLEASE CALL THE [**Hospital **] BLOOD BANK AT ([**Telephone/Fax (1) 24530**] IF YOU HAVE QUESTIONS IN THIS REGARD. . #) Leukocytosis - The patient periodically had increased WBC during his stay. He was treated for pneumonia with a 10 day course of levofloxacin. He continued to have elevated WBC and a nonspecific retrocardiac opacity on CXR. He was started on a course of ceftriaxone and azithromycin and discharged to complete 7 more days of these medications. He has been afebrile and his most recent urine culture was negative for infection. He has not had any positive blood cultures. He has a PICC line which does not appear infected. His PICC line should be removed once he has finished his 7 day course of IV ceftriaxone and may be used for lab draws in the interim. His WBC count started to trend downward on discharge. from 18->12. . #) Hypoxia: The patient required small amounts of nasal cannula oxygen intermittently after his ICU course, likely secondary to volume overload and atelectasis. He also has a history of COPD. On discharge his pulse ox on room air was 88% and on 2L was 97%. He should be weaned from oxygen as tolerated as he undergoes rehabilitation. The patient may need lasix on a PRN basis (20 mg IV is suitable dose) if he appears fluid overloaded on exam. . #) Myelodysplastic syndrome: Stable. Likely the cause of many of the patient's hematologic abnormalities. PLEASE ENSURE THAT THE PATIENT ATTENDS HIS FOLLOW-UP [**Telephone/Fax (1) **] APPOINTMENT WITH Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2108-4-19**] at the [**Hospital1 1170**], [**Telephone/Fax (1) 22**]. . #) Essential thrombocythemia - Patient has history of multiple thromboses due to this disorder. He was admitted on aspirin and anagrelide, both anti-platelet medications. These were discontinued on admission because of his need for procedures. It is expected that the patient will need to have a cholecystectomy within the next month, with Dr. [**First Name (STitle) **] [**Name (STitle) 24531**]. In preparation for this, the patient's aspirin and anegrilide were not restarted on discharge and need to be held until he is done with his Cholecystectomy. His hydroxyurea was continued to treat this disorder. . #) HTN: - atenolol and diltiazem. . #) COPD: Not active. Continue nebs prn. . #) Gout: Restart allopurinol 100 mg qdaily as taking pos. . #) Access: R PICC line placed on [**3-30**]. Please remove after no more need for IV antibiotics (7 days). . #) Fluids, electrolytes, nutrition: heart healthy diet, replete lytes prn . #) ppx: pneumoboots, ppi as above . #) FULL CODE, confirmed with patient . #)Contact: [**Name (NI) 4489**] [**Name (NI) 24532**] - home phone- [**Telephone/Fax (1) 24533**], cp [**Telephone/Fax (1) 24534**]. Medications on Admission: Atenolol 25 mg QD Anagrelide 1 mg am/1.5 mg pm Diltiazem SR 180 mg QD Aspirin 81 mg QD MVI 1 tab QD hydroxyurea 500 mg daily allopurinol 100 mg daily coumadin 10 mg mwf/5mg trfss hctz 25 mg QD atrovent albuterol ibuprofen (usually takes one 200 mg tab daily) Discharge Medications: 1. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for cough. 2. Diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 3. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please switch to regimen of 10 mg on MWF and 5 mg on SSTuTh after patient has finished 7 day course of azithromycin. . 6. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 7 days. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) g Intravenous Q24H (every 24 hours) for 7 days. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 15. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 16. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 17. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital 4316**] Rehab and [**Hospital **] Care Center Discharge Diagnosis: Primary Diagnosis: GI Bleeding Cholelithiasis DVT Essential thrombocytosis MDS Discharge Condition: Stable Needs assistance with ambulation Discharge Instructions: You were admitted for GI bleeding and had your distal ileocolic artery embolized, or clotted off. During the hospital course, you also developed an infection of your biliary tract and had a procedure in which a gallstone was removed. You will need to have your gallbladder taken out surgically in the future. You should call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] at [**Telephone/Fax (1) 476**] or [**Telephone/Fax (1) 2835**] to schedule this. Please take all medications as prescribed. You were started on two antibiotics, called ciprofloxacin and flagyl, for treatment of a biliary tract infection. Call your doctor or return to the emergency room if you experience any of the following: fever > 101, shortness of breath, Followup Instructions: Provider: [**Name10 (NameIs) 8848**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9 Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2108-4-19**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2108-4-19**] 1:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2108-6-4**] 2:00 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**] Completed by:[**2108-4-13**]

[ "459.0", "238.75", "274.9", "287.5", "303.01", "285.1", "571.3", "424.1", "496", "453.41", "569.85", "574.51", "584.9", "401.9", "577.0", "593.89", "799.02", "428.0", "562.10", "518.0", "562.12" ]

icd9cm

[ [ [] ] ]

[ "99.04", "88.47", "99.15", "45.13", "51.88", "39.79", "38.7", "45.23", "51.85", "38.93" ]

icd9pcs

[ [ [] ] ]

22314, 22398

14189, 20206

342, 430

22521, 22563

6372, 6377

23361, 23991

5730, 5892

20515, 22291

22419, 22419

20232, 20492

22587, 23338

5907, 6353

275, 304

14050, 14166

458, 2955

22438, 22500

6392, 14031

2977, 5408

5424, 5714

2,840

153,227

10099

Discharge summary

report

Admission Date: [**2152-1-28**] Discharge Date: [**2152-2-8**] Date of Birth: [**2079-11-5**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 72 year-old male with a history of mycosis fungoides, metastatic malignant melanoma who was admitted on [**2152-1-28**] for excision of a left upper lobe mass. The mass was noted on a routine chest x-ray and was thought to represent a metastasis of his melanoma. PAST MEDICAL HISTORY: 1. Mycosis fungoides status post PUVA therapy. 2. Metastatic melanoma, with positive cervical lymph node biopsy for metastatic disease. 3. Coronary artery disease. 4. Depression. ADMISSION MEDICATIONS: 1. Ambien 10 milligrams q day. 2. Zyrtec 10 milligrams q day. 3. Atenolol 50 milligrams q day. 4. Norvasc 10 milligrams q day. 5. Lipitor 10 milligrams q day. 6. Ritalin 5 milligrams q day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Denies tobacco, quit alcohol 10 years ago. FAMILY HISTORY: The patient's mother died of leukemia. PHYSICAL EXAMINATION: On admission temperature 99.3 F, blood pressure 140/78, heart rate 82, respirations 15, saturation 95% on four liters nasal cannula. Lungs are clear to auscultation bilaterally. Heart - regular rate and rhythm, no murmurs, rubs, or gallops. Abdomen - obese, positive bowel sounds, soft, nontender, nondistended. HOSPITAL COURSE: As noted above the patient was admitted for wedge resection of his upper lobe mass on [**2152-1-28**]. The resection went without incident and the patient was transferred to the floor. However on the next day he was found to be obtunded with decreased right sided movement. The patient was suspected to have a CVA. MRI / MRA on [**2152-1-30**] showed acute infarction of the left corona radiata of the [**Doctor First Name **] ganglia. It also showed moderate to high grade stenosis of the left ICA. The patient was transferred to the Intensive Care Unit and was intubated for a 24 hour period of time. Subsequent carotid doppler showed a left 80 to 99% stenosis and a right 60 to 99% stenosis. The patient did well after transfer to the ICU. He extubated after 24 hours regaining much of his right sided movement almost back to baseline levels. His mental status also cleared. The patient was transferred back to the medical floor to [**2152-2-2**]. The patient's outpatient oncologist, Dr. [**Last Name (STitle) 1729**], was consulted on the case. Pathology of his left upper resection showed a metastatic melanoma. Given this his oncologist felt that no further treatment would be helpful at this time. The patient's multiple cutaneous malignancies were thought to preclude any benefit of further chemotherapy. The patient was treated while in house with emollients and topic steroids for his mycosis fungoides. It was also decided that pursuing carotid endarterectomies for his bilateral carotid stenosis would not be helpful given his anticipated survival of 6 to 12 months. After transfer to the floor the patient developed dysuria and urinary obstruction after his Foley catheter was removed. After it was replaced he was found to have a clots irrigated from his bladder. A three way Foley was inserted with some difficulty. However after that the patient had no difficulty passing urine from the Foley. A final plan on his catheter was pending at the time of this dictation summary. DISCHARGE CONDITION: The patient was discharged to rehabilitation in stable condition. DISCHARGE MEDICATIONS: 1. Aspirin 81 milligrams po q day. 2. Triamcinolone ointment [**Hospital1 **] (1%). 3. Erythromycin eye ointment to both eyes [**Hospital1 **]. 4. Zantac. 5. Aquaphor Cream to affected area prn. 6. Lopressor 50 milligrams po tid. 7. Albuterol nebulizers prn. 8. Lac-Hydrin ointment to skin prn. 9. Levofloxacin for planned three day total course for UTI 250 milligrams po q day. DISCHARGE DIAGNOSIS: 1. Metastatic malignant melanoma. 2. Mycosis fungoides. 3. Status post CVA. DR.[**Last Name (STitle) **],[**First Name3 (LF) 1730**] 12-209 Dictated By:[**Name8 (MD) 2061**] MEDQUIST36 D: [**2152-2-7**] 13:47 T: [**2152-2-7**] 13:51 JOB#: [**Job Number 33736**]

[ "197.0", "434.11", "202.10", "599.6", "599.0", "997.02", "918.1", "518.5", "V10.82" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "32.29" ]

icd9pcs

[ [ [] ] ]

3404, 3471

981, 1021

3494, 3883

3904, 4206

1376, 3382

669, 903

1044, 1358

158, 440

462, 646

920, 964

21,534

145,090

4324

Discharge summary

report

Admission Date: [**2175-5-13**] Discharge Date: [**2175-5-26**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: found minimally responsive in bed by family Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] yo Russian speaking woman with afib and CHF on coumadin who was last seen well at 12 noon by her grandson, who was then later found at 3pm minimally responsive laying on her bed, thus EMS was called. Nursing noticed patient was neglecting the right side (staring to the left) and thus a code stroke was called at 3:57pm. Patient seen immediately as examiner was in the ED tending to another code stroke. NIHSS 20 - mute, not following commands, right dense neglect with fixed gaze, right facial droop, right hemiparesis. CT 4:16pm shows left frontal hypodensity, old right occipital infarct. Labs pending. No prior h/o strokes, was feeling well earlier today. At baseline, dresses herself but requires help with other activities. Cannot walk down stairs on her own. Lives with family. FULL CODE. Past Medical History: 1. Congestive heart failure with an ejection fraction of 40 to 45% with last echocardiogram in [**2167-9-8**]. 2. Chronic atrial fibrillation on anticoagulation. 3. Hypertension. 4. Status post total abdominal hysterectomy. 5. Status post appendectomy. 6. Arthritis of the knees. 7. Bilateral cataract surgeries 8. CRI with baseline ~1.7 . Echo ([**9-/2167**]): Dilated right atrium and left atrium, normal ventricular chamber sizes. Mild concentric left ventricular hypertrophy. Mildly depressed left ventricular function due to focal inferior-basal hypokinesis to akinesis. Mildly thickened 3 leaflet aortic valve with moderate aortic insufficiency. Mildly thickened mitral valve with moderate mitral regurgitation. Normal tricuspid valve with moderate tricuspid regurgitation and top normal pulmonary artery pressure. Small pericardial effusion. Social History: lives with extended family, patient actually has no children, former kindergarten teacher, no tob/etoh/drugs ever. Russian speaking. FULL CODE. Family History: No family history of diabetes, coronary artery disease or hypertension. Physical Exam: Vitals: 138/78, 64, 100% NRB -> 96% RA GEN: elderly woman in NAD laying in stretcher looking to the left HEENT: NC/AT, anicteric sclera, mmm NECK: supple, no carotid bruits CHEST: CTA bilat anteriorly CV: irregular irreg rhythm without mur (difficult to appreciate murmurs in the ED) ABD: soft, NT/ND EXTREM: no edema Pertinent Results: [**2175-5-12**] 04:16PM WBC-9.0 RBC-4.17* HGB-13.6 HCT-39.2 MCV-94 MCH-32.6* MCHC-34.6 RDW-14.3 [**2175-5-12**] 04:16PM CK-MB-2 cTropnT-<0.01 [**2175-5-12**] 04:45PM PT-24.3* PTT-30.3 INR(PT)-2.4* [**2175-5-13**] 08:35AM cTropnT-<0.01 [**2175-5-25**] 04:12AM BLOOD WBC-16.3* RBC-3.20* Hgb-10.2* Hct-30.4* MCV-95 MCH-31.9 MCHC-33.6 RDW-14.4 Plt Ct-505* [**2175-5-22**] 02:54AM BLOOD Neuts-83.2* Lymphs-9.5* Monos-5.3 Eos-1.1 Baso-0.9 [**2175-5-16**] 03:32AM BLOOD Macrocy-1+ [**2175-5-25**] 04:12AM BLOOD Plt Ct-505* [**2175-5-22**] 02:54AM BLOOD Fibrino-638*# [**2175-5-25**] 04:12AM BLOOD Glucose-144* UreaN-40* Creat-1.1 Na-140 K-3.7 Cl-108 HCO3-24 AnGap-12 [**2175-5-23**] 03:00AM BLOOD ALT-22 AST-21 AlkPhos-75 TotBili-0.2 [**2175-5-16**] 03:32AM BLOOD Lipase-20 [**2175-5-16**] 03:32AM BLOOD proBNP-3313* [**2175-5-25**] 04:12AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.2 [**2175-5-13**] 08:35AM BLOOD %HbA1c-6.2* [Hgb]-DONE [A1c]-DONE [**2175-5-15**] 05:45AM BLOOD Triglyc-92 [**2175-5-16**] 03:32AM BLOOD TSH-2.4 [**2175-5-16**] 03:32AM BLOOD Digoxin-0.6* [**2175-5-12**] 04:16PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-26.8* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2175-5-24**] 04:31AM BLOOD Type-ART pO2-144* pCO2-42 pH-7.44 calHCO3-29 Base XS-4 [**2175-5-23**] 03:58AM BLOOD Type-[**Last Name (un) **] Temp-38.6 O2 Flow-4 pO2-134* pCO2-46* pH-7.34* calHCO3-26 Base XS--1 Intubat-NOT INTUBA [**2175-5-16**] 02:06AM BLOOD Type-ART pO2-82* pCO2-32* pH-7.43 calHCO3-22 Base XS--1 [**2175-5-17**] 01:22PM BLOOD Type-ART Temp-37.2 PEEP-5 FiO2-40 pO2-153* pCO2-32* pH-7.42 calHCO3-21 Base XS--2 Intubat-INTUBATED [**2175-5-23**] 03:58AM BLOOD Lactate-2.4* [**2175-5-16**] 03:58AM BLOOD Lactate-1.4 [**2175-5-12**] 04:16PM BLOOD Lactate-1.6 [**2175-5-17**] 01:22PM BLOOD freeCa-1.18 . [**5-14**] Head CT: IMPRESSION: 1. Interval evolution of left MCA territorial infarct demonstrated by loss of left frontal lobe [**Doctor Last Name 352**]-white differentiation, local edema with minimal mass effect. 2. Stable chronic ischemic changes as described above. . [**5-12**] Head CT: IMPRESSION: 1. Limited study due to motion artifact. If there is clinical suspicion for acute ischemia, an MRI is recommended. 2. Stable chronic ischemic changes as described. . Carotid doppler: IMPRESSION: Less than 40% stenosis in the bilateral extracranial internal carotid arteries. Brief Hospital Course: AA/P: 93 Russian-Speaking female s/p large L MCA territory stroke intubated due to respiratory distress and increased work of breathing likely caused by aspiration pneumonia. . 1. Stroke: The patient was noted to have a grossly abnormal neurologic exam in the ED and was admitted to the neurology service for stroke. Head CT ultimately revealed a large L MCA stroke. This was a suspected cardioembolic source given the A-fib, although she was therapeutic on coumadin. Carotid dopplers were negative. Her mental status and neuro exam remained stable over the admission, although she did remain confused, unable to communicate with providers. She was awake, alert moving her extremities. She failed speech/swallow [**Last Name (LF) **], [**First Name3 (LF) **] NG tube was placed. neurologically, she remained stable for the duration of the admission. She was transferred to the MICU for respiratory distress on [**5-15**]. Shw will follow up with neurology as an outpatient, per the discharge paperwork. . 2. Respiratory Distress; On [**5-15**] the patient was noted to be tachypneic and in respiratory distress on the neuro floor. She was transferred to the MICU and intubated. She had a presumed aspiration pneumonia, given the stroke and failed swallow study. No organism obtained on sputum. She was treated with a course of vanc/levoflox/flagyl for 7 days. She was extubated successfully at 1200 on [**5-19**]. Although she continued having a lot of secretions, needing frequent deep suctioning, noted to have poor gag. . 3. Afib: She has permanent AF, with episodes of RVR. The dig was stopped. Rate control was continued with metoprolol. Anticoagulation was continued with coumadin, although she required a dose of vitamin K to reverse a supratherapeutic INR, after which coumadin was resumed. . 4. HTN: BP meds were titrated daily to acheive target bp 120-130/80s. Metoprolol, captopril, isosorbide were used. Lasix as well for diuresis for CHF. . 5. CHF, EF 45-50%: There was a component of overload to the respiratory distress. She was diuresed with lasix. . FEN: Tube feeds were used given the aspiration risk. For long term, will need dobhoff tube or pediatric NGT. The family was opposed to PEG. . PPX: IV PPI, pneumoboots, on coumadin . Dispo: MICU for now, ? d/c to rehab where frequent suctioning could be performed. . Code: DNR, no escalation of care, no CPR, no pressors. DO NOT re-intubate. No trach, no PEG. continue current level of care. work toward rehab. Medications on Admission: Meds on transfer: IV levoflox 500q24 IV flagyl 500q8h ASA 81 qd Digoxin 0.125qd Imdur 120 po qd Metop 50 po tid IV Heparin Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. insulin per sliding scale to be arranged by accepting MD 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 7. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QODHS (every other day (at bedtime)). 12. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day) as needed for afib. 13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 15. 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: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: stroke atrial fibrillation respiratory failure Discharge Condition: stable, requiring periodic suctioning of respiratory secretions Discharge Instructions: please note that your medication regimen has been changed. You now have a new blood pressure regimen as well as a new coumadin dose. We have stopped the digoxin. You need your INR checked frequently for goal INR 2-2.5. Please check C. difficile stool studies and repeat WBC count. Consider flagyl therapy if positive. Followup Instructions: Please call to establish Neurology follow-up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] within 6-8 weeks. ([**Telephone/Fax (1) 7394**] . Please call your primary care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment witin 1-2 weeks. [**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 4606**] [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "428.0", "403.91", "427.31", "507.0", "434.11", "427.69", "585.9", "715.96", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.04" ]

icd9pcs

[ [ [] ] ]

9013, 9086

5034, 7514

307, 314

9177, 9243

2649, 4441

9610, 10105

2219, 2292

7687, 8990

9107, 9156

7540, 7540

9267, 9587

2307, 2630

224, 269

342, 1168

4723, 5011

1190, 2040

2056, 2203

7558, 7664

81,857

171,064

52741

Discharge summary

report

Admission Date: [**2170-2-2**] Discharge Date: [**2170-2-9**] Date of Birth: [**2100-12-14**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Left lower lobe effusion Major Surgical or Invasive Procedure: [**2170-2-2**]: Flexible bronchoscopy with bronchoalveolar lavage, left video-assisted thoracic surgery, decortication and pleurectomy. History of Present Illness: Mr. [**Known lastname 38492**] is a 69-year-old gentleman who has been having dyspnea and was found to have recurrent effusions with a rind suggestive of hypothorax. He has previously had radiation and also had undergone open heart surgery (coronary artery bypass graft). Past Medical History: 1. Aortic stenosis.Moderate AS (AoVA 1.0-1.2cm2) 2. Hypertension. 3. Dyspnea. 4. History of coronary artery disease status post CABG in [**2160**] (LIMA to LAD, SVG to OM1, SVG to RCA to PDA). 5. Hyperlipidemia 6. Hodgins' disease s/p radiation and chemotherapy currently in remission 7. Bilateral total knee replacement Cardiac History: CABG, in [**2160**] anatomy as follows: History of (LIMA to LAD, SVG to OM1, SVG to RCA to PDA). 8. Congestive Heart Failure, Dystolic, EF 55% Social History: Recently married. Lives with wife in [**Name (NI) 7188**], RI. One daughter who is healthy. He is a never smoker. Drinks occasional wine, but no EtOH in 2 months. He owns a Marine construction company building bridges. Family History: Mother - died of MI at 85 Father - died of MI at 59 Brother - died of [**Name (NI) 1932**] disease Brother - died of rectal cancer Physical Exam: VS: T 98.6 HR: 98 SR BP: 122/64 Sats: 94 RA General: no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple, no lymphadenopathy Card: RRR Resp: decreased breath sounds L>R faint crackles at bases GI: benign Extr: no edema, warm Incision: Left VATs site clean dry intact, Pneumostat site clean, no erythema Neuro: non-focal Pertinent Results: [**2170-2-9**] WBC-9.6# RBC-3.54* Hgb-10.7* Hct-30.5* Plt Ct-336 [**2170-2-7**] WBC-6.2 RBC-3.37* Hgb-10.2* Hct-29.2* Plt Ct-272 [**2170-2-2**] WBC-15.1*# RBC-4.18* Hgb-12.6* Hct-36.6* Plt Ct-298 [**2170-2-7**] Glucose-119* UreaN-14 Creat-0.9 Na-138 K-4.2 Cl-99 HCO3-31 [**2170-2-5**] Glucose-116* UreaN-13 Creat-0.9 Na-134 K-4.3 Cl-101 HCO3-29 [**2170-2-2**] Glucose-122* UreaN-23* Creat-1.0 Na-141 K-4.2 Cl-105 HCO3-29 CXR: [**2170-2-8**]: Left pleural tube unchanged in position at the base of the hemithorax. No definite pneumothorax. Persistent small left pleural effusion or thickening and left lower lobe atelectasis. Subcutaneous emphysema is still present in the left axilla and chest wall, not fully imaged. Right lung grossly clear. [**2170-2-4**]: The position of the two left chest tubes is unchanged. No pneumothorax is identified. Extensive subcutaneous emphysema is present. Extensive atelectasis of left lung again noted. [**2170-2-2**]: Left basal pneumothorax, no evidence of tension pneumothorax. Pathology: [**2170-2-2**]: DIAGNOSIS: Left parietal pleura, excision (A-C): Pleural fibrosis with acute and chronic inflammation. 2. Pleura, left lung rind, excision (D-E): Pleural fibrosis with chronic inflammation. Lung parenchyma with fibroelastotic scar. 3. Diaphragm, excision (F):Pleural fibrosis. Cytology [**2170-2-2**]: Pleural Fluid, left: NEGATIVE FOR MALIGNANT CELLS. Brief Hospital Course: Mr. [**Known lastname 38492**] was admitted on [**2170-2-2**] and taken to the operating room for Flexible bronchoscopy with bronchoalveolar lavage, left video-assisted thoracic surgery, decortication and pleurectomy. He was extubated in the operating room and transferred to the PACU for monitoring. While in the PACU he became hypotensive likely secondary to fluid loss requiring pressors and fluid. He was transferred to the SICU. The 2 chest-tube were placed to low-wall suction x 72 hrs with moderate serosanguinous drainage and moderate respiratory variation. He was followed with serial chest-films which showed a small stable pneumothorax and atelectasis. His pain was managed via an Bupicaine/Dilaudid Epidural with good control. On POD1 his volume status improved, wean from pressors and transferred to the floor. His diet was advanced as tolerated. On POD2-3 his home medications were restarted as tolerated. He was seen by physical therapy who deemed him safe for home. On POD4 the chest-tube were placed to water-seal and follow-up chest film confirmed stable small apical pneumothorax. The epidural was removed and his pain was well controlled with PO pain medication. The foley was d/c'd and he voided without difficulty. On POD5 the apical chest tube was removed. Follow-up chest film was stable subcutaneous emphysema, left atelectasis, consolidation, and fluid. On POD6 the basilar chest-tube remained on water-seal with moderate serosanguinous drainage. On POD7 the chest-tube drainage subsided and was converted to pneumostat. The discharge chest-film showed stable small left apical pneumothorax and atelectasis. He and his wife were instructed on pneumostat care and he was discharged to home. He will follow-up with Dr. [**Last Name (STitle) **] as an outpatient next week. Medications on Admission: lasix 40mg daily, spiriva daily, pravastatin 40mg daily, toprol 50 mg daily, protonix 40mg [**Hospital1 **], aspirin 81mg daily Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Left lower effusion Aortic stenosis Hypertension/Hyperlipidemia Dyspnea [**Last Name (un) 108792**] disease s/p radiation/chemotherapy currently in remission CAD s/p SABG [**2160**] Bilateral total knee replacement Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Incision develops drainage. -Pneumostat: drain daily. Keep record of drainage. Change dressing daily. -You may shower. Cover site. No tub bathing or swimming. -No driving while taking narcotics. -Take stool softners with narcotics. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] Date/Time:[**2170-2-15**] 3:30pm on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]. Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4249**]. [**Telephone/Fax (1) 18645**] Completed by:[**2170-2-9**]

[ "428.0", "512.1", "458.29", "511.0", "428.32", "V17.3", "V43.65", "424.1", "401.9", "V15.3", "V45.81", "272.4", "201.90" ]

icd9cm

[ [ [] ] ]

[ "34.52", "33.24" ]

icd9pcs

[ [ [] ] ]

6258, 6264

3495, 5306

345, 484

6523, 6532

2066, 3472

6991, 7434

1546, 1679

5484, 6235

6285, 6502

5332, 5461

6556, 6968

1694, 2047

281, 307

512, 787

809, 1293

1309, 1530

82,312

102,911

38698

Discharge summary

report

Admission Date: [**2103-4-20**] Discharge Date: [**2103-4-26**] Date of Birth: [**2018-2-14**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: Renal Cell carcinoma Major Surgical or Invasive Procedure: [**2103-4-20**]: Left laparoscopic radical nephrectomy and Laparoscopic paraaortic lymph node dissection with Dr [**Last Name (STitle) 3748**] Caval thrombectomy and reconstruction with Dr [**Last Name (STitle) 816**] History of Present Illness: This patient currently lives in [**Location 4194**] and presented several weeks ago with left testicular swelling. Ultrasound eventually led to an abdominal ultrasound, which showed a large left renal mass and a tumor thrombus into the cava, but below the hepatic veins. Per outpatient note, he denied hematuria, frequency, nocturia, or dysuria. He denies weight loss, night sweats, chills, change in appetite. He has fairly chronic constipation, but is able to move his bowels. He also complains of some vague chronic right shoulder pain, right knee pain. He will be admitted following surgery to be done by Dr [**Last Name (STitle) 3748**] and Dr [**Last Name (STitle) 816**]. Past Medical History: Radical prostatectomy 10 years ago, hypertension controlled with medications, cataract surgery [**07**] years ago, left hernia repair 20 years ago Social History: Live is [**Country 4194**], He is a retired IRS tax collector from [**Country 4194**]. No tobacco, social alcohol, no drug use. He exercises and performs yoga three times per week. He walks 20 minutes on a treadmill several times per week. Family History: negative for prostate, kidney, or bladder cancer. Physical Exam: VS: 98.7, 94, 110/47, 12, 96% 4L (post op) General: Alert, responsive Card: RRR Lungs: CTA bilaterally Abd: Soft, non-distended, appropriately tender to plapation, incisions/dressings; C/D/I Extr: No edema Pertinent Results: On Admission: [**2103-4-20**] WBC-6.6 RBC-3.60* Hgb-10.3* Hct-31.0* MCV-86 MCH-28.6 MCHC-33.2 RDW-13.6 Plt Ct-302 PT-12.9 PTT-26.9 INR(PT)-1.1 Glucose-143* UreaN-27* Creat-1.7* Na-139 K-4.3 Cl-111* HCO3-22 AnGap-10 ALT-52* AST-136* AlkPhos-50 TotBili-0.3 Calcium-8.3* Phos-4.0 Mg-2.5 On Discharge: [**2103-4-26**] WBC-7.2 RBC-3.53* Hgb-10.1* Hct-30.3* MCV-86 MCH-28.6 MCHC-33.4 RDW-13.8 Plt Ct-320 Glucose-96 UreaN-46* Creat-2.0* Na-140 K-3.7 Cl-107 HCO3-22 AnGap-15 ALT-26 AST-72* AlkPhos-58 TotBili-0.5 Calcium-7.6* Phos-2.8 Mg-2.2 Brief Hospital Course: 85 y/o male who underwent Left laparoscopic radical nephrectomy and laparoscopic para-aortic lymph node dissection with Dr [**Last Name (STitle) 3748**] and Caval thrombectomy and reconstruction with Dr [**Last Name (STitle) 816**] for Renal cell carcinoma with tumor extension into the left renal vein and inferior vena cava. During the surgery, the large left renal tumor was seen emanating out of the left retroperitoneum. The renal vein which contained the tumor thrombus as it coursed over the aorta was removed. As well, an adrenalectomy was performed. Once the kidney was removed, Dr [**Last Name (STitle) 816**] was able to remove the tumor thrombus by transecting the left renal vein. It was removed in its entirety in one piece. Please see both operative notes for surgical detail. The patient tolerated the procedure without complication. He was transferred to the SICU. The patient had a mild ileus, with emesis, and a KUB showing dilated loops of bowel. NGT was placed with 700 cc removed. However on POD 3 he self d/c'd the NGT, but it was not replaced as his abdominal exam had improved greatly. Sips were started and diet advanced slowly with good tolerance. He had an initally lower urine output, this improved daily, 1 - 1.5 liters daily. He did have fever to 101.4 on POD 3. Urine culture was no growth. Blood culture remained pending on day of discharge but was no growth to date. The patient was transferred to [**Hospital Ward Name 121**] 10, and he remained on Dr [**Last Name (STitle) 15283**] service, and followed by urology team. He was evaluated by PT who thought he should be discharged with home PT. Follow up appointments have been arranged. Medications on Admission: MVI,ASA,Metamuzil,Prilosec,Propafenonine,Rhythmol Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Propafenone 150 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 3. Propafenone 150 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Prilosec 10 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Micardis 80 mg Tablet Sig: One (1) Tablet PO QD (). 9. Psyllium Packet Sig: One (1) Packet PO QOD (). Discharge Disposition: Home Discharge Diagnosis: Left Renal cell cancer with tumor extension into the left renal vein and inferior vena cava. Discharge Condition: Stable/Good A+Ox3 Ambulatory with PT/assistive devices Discharge Instructions: Please call Dr [**Last Name (STitle) 15283**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, diarrhea, increased abdominal pain, inability to take or keep down food, fluids or medications. Monitor the incision for redness, drainage or bleeding You will also be following up with Dr [**Last Name (STitle) 18846**] office No heavy lifting Drink enough fluids to keep the urine light yellow in color Followup Instructions: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2103-5-3**] 9:30; [**Hospital **] Medical Office Building, [**Last Name (NamePattern1) **] DR. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3752**] Date/Time:[**2103-5-10**] 2:15. [**Hospital Ward Name 516**] Completed by:[**2103-4-27**]

[ "593.9", "458.29", "E878.6", "189.0", "403.90", "997.4", "585.9", "560.1", "780.62", "198.89" ]

icd9cm

[ [ [] ] ]

[ "40.3", "07.22", "55.51" ]

icd9pcs

[ [ [] ] ]

5108, 5114

2563, 4241

335, 555

5251, 5308

2005, 2005

5781, 6179

1712, 1764

4341, 5085

5135, 5230

4267, 4318

5332, 5758

1779, 1986

2303, 2540

275, 297

583, 1266

2019, 2289

1288, 1436

1452, 1696

47,912

182,705

42121

Discharge summary

report

Admission Date: [**2179-10-27**] Discharge Date: [**2179-11-4**] Service: MEDICINE Allergies: albuterol / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 3256**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: central line placement History of Present Illness: 87F history of C. difficile colitis since [**2179-8-9**] currently in rehabilitation facility receiving p.o. vancomycin and Flagyl who presents with hypotension. Per patient, she had increased bowel movements this past weekend (had actually been improving in frequency last week) and was found to have systolics in the 80s at the rehabilitation facility. Denies fevers. She states her abdominal pain as being constant and has not changed and her during the last few days. Patient has been compliant on her vancomycin/Flagyl regimen. She states she hasn't been staying hydrated. . Also of note, per daughter, at rehab she had an asthma exacerbation last week and received 5 days of solumedrol taper, which stopped 2-3 days ago. She states the physcians that started the steroids verified with ID that this would not exacerbate C diff. . In the ED, initial VS were: T 97.5 HR 96 BP 70/50 Pox 97% ra. She has a chronic indwelling foley and had a UA that showed large leuk, many WBC, many bacteria and was given ceftriaxone. KUB was done, which did not show toxic megacolon or dilated loops of bowel. Labs were significant for lactate 3.4, Na 127, BUN 59, Cr 1.9 , WBC 12.6 with 13% bands, INR 6.5. Got 4L IVF in ER-->systolics high 90's-100's, though of note BP's usually 130's 140's. Close to time of transfer, systolic BP's dropped to 80's. She was asymptomatic, but the ER wanted to place a CVL and start pressor. Pt refused femoral CVL and remarked she wants to be DNR/DNI. She also reports she has met with palliative care in the previous weeks. She did agree to levophed being run through her existing PICC line. On transfer, VS: HR 111, RR 19-20, Pox 98% RA, BP 92-102/30's-40's. Access is 18g EJ and a R PICC. Unclear why she has a R PICC line. . On arrival to the MICU, pt states "this is too much." She reports abdominal pain and diarrhea. She is conversive and confirms she is DNR/DNI. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, abdominal pain. Denies rashes or skin changes. Past Medical History: afib on coumadin, per daughter had been on amiodarone HTN [**Name (NI) 2091**] baseline Cr 1.3-1.5 hypothyroidism Cdiff colitis Diabetes Asthma Social History: - Tobacco: Distant - Alcohol: Occasional - Illicits: Denies Came from [**Hospital 100**] Rehab MACU, previously independent prior to hospitalization Family History: sister with diabetes, sister with throat cancer (smoker) Physical Exam: On admission: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL Neck: supple, JVP low, no LAD CV: irreg irreg Lungs: occ wheeze Abdomen: soft, + BS, mild TTP, distended GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: Labs on admission: [**2179-10-27**] 07:39PM GLUCOSE-163* UREA N-56* CREAT-1.8* SODIUM-130* POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-20* ANION GAP-18 [**2179-10-27**] 08:08PM LACTATE-2.8* [**2179-10-27**] 07:39PM CALCIUM-6.9* PHOSPHATE-4.5 MAGNESIUM-2.3 [**2179-10-27**] 12:45PM PT-59.7* PTT-59.2* INR(PT)-6.5* Micro: [**2179-11-3**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2179-11-3**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [**2179-11-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2179-11-1**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL INPATIENT [**2179-11-1**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2179-10-31**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2179-10-31**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2179-10-30**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2179-10-30**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2179-10-29**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2179-10-29**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2179-10-29**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2179-10-28**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [**2179-10-28**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [**2179-10-27**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2179-10-27**] BLOOD CULTURE Blood Culture, Routine-FINAL {KLEBSIELLA PNEUMONIAE, ENTEROCOCCUS FAECIUM}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] [**2179-10-27**] BLOOD CULTURE Blood Culture, Routine-FINAL {ENTEROCOCCUS FAECIUM}; Aerobic Bottle Gram Stain-FINAL SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | ENTEROCOCCUS FAECIUM | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- 16 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S LINEZOLID------------- 2 S MEROPENEM-------------<=0.25 S PENICILLIN G---------- =>64 R PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ =>32 R Reports: ct a/p IMPRESSION: 1. Findings consistent with colitis. 2. Cholelithiasis. 3. Substantial pleural effusions. 4. Small quantity of ascites. 5. Macrolobulation of the hepatic contour in some areas of uncertain significance although underlying liver disease could be considered as a possibility clinically. cxr [**11-3**] Extensive bilateral pleural effusions with subsequent areas of basal atelectasis Brief Hospital Course: Ms [**Known lastname **] is an 87yo F with w/ h/o afib on coumadin, recent extended course at rehab for severe C dificil who presented with septic shock. Originally, this was thought to be secondary to recurrence of severe C dificile, but she subsequently was found to have polymicrobial bacteremia, likely secondary to gut translocation/microperforation. Her bloodstream organisms (as above) were quite resistant, and she was treated with meropenem and daptomycin, as well as IV flagyl/PO vancomycin for C difficile. Upon initial presentation, she required aggressive volume resuscitation and two pressors. While she was able to wean off of pressors, she ultimately was >20L positive for the hospitalization. On [**2179-11-3**] she was started on lasix gtt and diuril [**Hospital1 **] for diuresis, but with only minimal accomplishment. The next step to improve her volume status would likely have been CVVH, which were not in line with the patient's goals of care. Ms. [**Known lastname **] [**Last Name (Titles) 91371**] that if she could not achieve a functional status where she was home and independent, as she was prior to hospitalization, she would not want to continue maximal medical care. It was [**Last Name (Titles) 91371**] to her that this goal of independence seemed fairly unlikely. She and her family requested palliative care consult with plans to discuss her discharge and goal to not be rehospitalized. During that meeting, decision was made to move towards comfort measures only and all antibiotics and supportive care were discontinued (she continued only on lasix gtt for comfort). She passed away on [**2179-11-4**] with her family at the bedside. Medications on Admission: amiodarone (per rehab notes, loaded over weekend, now continuing on amiodarone but not noted in med list) cholestyramine 4g daily Cyanocobalamin 500mcg once a day Insulin humalog sliding scale (on glipizide and januvia at home) Ipratropium [**Last Name (un) **] [**Hospital1 **] standing Lactobacillus, 2 tabs [**Hospital1 **] Levalbuterol 0.63mg Q12 hrs standing Coumadin being held in setting of INR 3.6 on [**10-26**] Flagyl Lopressor 12.5mg TID Mirtazapine 7.5mg QHS Omerazole 20mg daily Vancomycin 250mg QID Tylenol 650mg Q4hrs PRN Zofran 4mg Q8H PRN Miconazole Dyazide being held at rehab Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Clostridium difficile colitis VRE bacteremia Septic Shock Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

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icd9cm

[ [ [] ] ]

[ "38.91", "96.6", "38.97" ]

icd9pcs

[ [ [] ] ]

8778, 8787

6424, 8099

264, 288

8888, 8897

3461, 3466

8953, 8963

2910, 2969

8746, 8755

8808, 8867

8125, 8723

8921, 8930

2984, 2984

2231, 2556

213, 226

316, 2212

3481, 6401

2578, 2724

2740, 2894

3,914

160,191

6536

Discharge summary

report

Admission Date: [**2197-9-17**] Discharge Date: [**2197-10-9**] Date of Birth: [**2121-10-27**] Sex: M Service: CSU This is a history and physical preoperatively. HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old male, who was admitted to [**Hospital3 7362**] early a.m. on [**2197-9-17**] with the complaints of chest tightness and shortness of breath. He was then transferred to [**Hospital1 18**] for further care, catheterization, and possible surgery. He has known coronary artery disease in the past. He has had a PTCA with stent to his left LAD in [**2195**], which was complicated by acute renal failure with a creatinine in between 2.5 and 4.0. He also has critical aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.6 centimeter squared in [**2195**]. He was referred to Cardiac Surgery for a possible aortic valve replacement plus or minus CABG. PAST MEDICAL HISTORY: His past medical history is as follows: Coronary artery disease status post MI in [**2195**] and PCI/stent to the LAD; aortic stenosis, [**Location (un) 109**] of 0.6 centimeter squared in [**2195**]; hypertension; acute renal failure after PCI in [**2195**], he was on dialysis, but not presently, with a creatinine of 2.5 to 4.0; hypercholesterolemia; prostate cancer status post radical prostatectomy and radiation treatment; anemia, the patient is on Epogen; COPD. Also, the patient is status post a GI bleed (secondary to infection as per wife). He is also status post MRSA UTI. The patient has diabetes mellitus. PAST SURGICAL HISTORY: The patient is status post cholecystectomy, status post right THR x2, status post urinary tract revision with sphincter. CURRENT MEDICATIONS: The patient's current medications are: 1. Zocor. 2. Norvasc. 3. Lopressor 5 mg q.d. 4. Allopurinol 150 mg q.d. 5. Casodex 150 mg q.d. 6. Felodipine 5 mg q.d. 7. Epogen every week. 8. Humulin 70/30 25 units q.a.m. and NPH 20 units at dinner. 9. Ceftriaxone. 10. Zithromax. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: He does not drink alcohol. He quit smoking 40 years ago. PHYSICAL EXAMINATION: Neurologically, he is grossly intact. Alert and oriented x3. Pulmonary: His lungs are clear to auscultation. His heart has regular rate and rhythm, with a 4/6 systolic ejection murmur. His abdomen is soft, nontender, and nondistended with bowel sounds. His extremities are warm with positive pulses, no clubbing, no cyanosis or edema. His carotid arteries have bilateral murmurs from the heart that radiate up. LABORATORY DATA: His chest x-ray was negative for any cardiopulmonary abnormalities. VQ scan was negative. UA was negative. His white blood count was 9.5 and hematocrit 27.6. Platelets 128,000. Sodium 139, potassium 4.2, chloride 104, bicarbonate 22, BUN 57, creatinine 2.7, glucose 178, CPK 463, and troponin T is 1.3. PT 12.7, PTT 34.1, and INR 1. IMPRESSION AND PLAN: So, once again, the plan for this patient: This is a 75-year-old male with multiple medical problems, which he currently has a fever, and the plan was to follow up on his cultures that were taken a day before. We will get a Panorex x-ray and Dental consult, have cardiac catheterization, an echocardiogram, and a carotid study, and also have an ID consult to rule out infectious source of his fever and a Hematology/Oncology consult to evaluate his anemia and a possible metastatic workup for his prostate CA. Carotid ultrasounds revealed no significant hemodynamic lesion in either the left or right carotid artery. Cardiac catheterization was performed on [**2197-9-19**], which showed the following results: LMCA was normal. His LAD had a mid 70 percent stenosis, the left circumflex with moderate diffuse disease mid 50 percent, distal 70 percent. The right RCA demonstrated mild luminal irregularities. The patient had [**First Name8 (NamePattern2) **] [**Location (un) 109**] gradient of 0.627 meter squared. FINAL DIAGNOSES: Severe and progressive aortic stenosis, moderate two-vessel coronary artery disease with left anterior descending stent, and severely elevated left-side filling pressures. HOSPITAL COURSE: Echocardiogram performed on [**2197-9-19**] showed the following results: Severe aortic stenosis, mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction, mild aortic regurgitation, at least mild mitral regurgitation. There was no regurgitation present in any other valves. So, on hospital day number 2, the patient was seen by Infectious Disease for a possible source of infection secondary to increased hematuria and fever, and Cardiac Surgery continued to follow up until given consent was okayed for surgery. On hospital stay day number 3, the patient had a bilateral lower limb ultrasound Doppler to rule out any DVT for source of fever and possible asymmetry of his calves. There were no DVTs found on the Doppler examination, no evidence of abnormality, and the day earlier, the patient was seen by Dental and was cleared for surgery as per Dental. On hospital day number 9, which was [**2197-9-26**], the patient appeared to be ready for his CABG and AVR in the near future. Following a Urology consult, the patient will need a suprapubic tube placed as a urethral catheter could cause erosion of urethra and also need recommendations from Urology to comment on when full authorization for cardiopulmonary bypass is safe status post a placement of the suprapubic catheter. Throughout the last nine days of the [**Hospital 228**] hospital stay, he has been followed by Medicine, Cardiology, Nephrology, Infectious Disease, Physical Therapy, and Hematology/Oncology in the need to find any source of infection following his renal status and following his CHF status and his anemia. The patient has also received several blood transfusions secondary to a decreased hematocrit during the last week. On [**2197-9-28**], which was hospital day number 11, the patient had a Foley inserted with the help of cystoscopy and pelvic ultrasound guidance, and was planned for surgery the next day, which would be [**2197-9-29**]. Cardiac Surgery had done this. On [**2197-9-29**], the patient was brought into the operating room for cardiac surgery. The surgeon was Dr. [**First Name (STitle) **] [**Name (STitle) **]. The procedure was coronary artery bypass graft x2. The grafts were LIMA to LAD and saphenous vein graft to OM. The patient also received aortic valve replacement with a 21-mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial tissue valve. The patient tolerated the procedure well. The cardiopulmonary bypass time was 108 minutes. Cross-clamp time was 88 minutes. The patient's condition on transfer to the CSIU is as follows: He had a rate of 80 beats per minute in normal sinus rhythm, mean arterial pressure of 67, CVP of 5, PA diastolic of 13, and PA mean of 21. He was receiving epinephrine drip of 0.02 mcg/kg per minute, nitroglycerin at 0.5 mg, insulin at 2 units per hour, and propofol 20 mg en route to the CSIU. On postoperative day number 1, the patient was still receiving the following drips: Insulin of 1 unit, milrinone of 0.5 mg, Natrecor of 0.01 mg, and propofol of 25 mg. The patient had a specifically low cardiac index. Examination-wise, the patient was in no acute distress. His heart rate was regular rate and rhythm. His lungs were clear. His wounds were clear, dry, and intact. His temperature was 99.7 degrees F., 94 normal sinus rhythm heart rate, BP 106/45, and respirations 14. His white blood count was 11.3, hematocrit was 29.2, and platelet count was 84,000, which was down from 113,000. His hematocrit, I guess, was 29.2, which was down from 37. The plan was to start Lasix t.i.d., get a hepatic panel with possible decrease in milrinone, and extubate the patient as soon as the patient was tolerable. On postoperative day number 2, the patient was still receiving milrinone at 0.3 mg now, which was down from 0.5 mg, insulin of 4 units, Natrecor of 0.01 mg, and he was on 40 mg of Lasix intravenously. The patient was extubated. He had received 1 unit of packed red blood cells secondary to a decrease in his hematocrit, and we have been slowing weaning his milrinone. Hemodynamically, he was stable. His hematocrit now was 31.2. His heart rate was a little tachycardic at 100. On physical examination, he was unremarkable, and his milrinone was decreased to 0.2 mg. On postoperative day number 3, the patient was still receiving insulin drip before milrinone of 0.2 mg and Natrecor of 0.01 mg. Following his removal of his chest tubes, there appeared to be a small apical pneumothorax, and 5:30 a.m. this morning, which was [**2197-10-2**], the patient developed a subcutaneous emphysema. Urology recommended to remove his Foley today, which was done so, and a condom catheter with artificial sphincter in the open position was in place. Hemodynamically, he was tachycardic at 106, BP 129/54, and oxygen saturation was 94 percent. Hematocrit was 32.7, white blood count was 10.3, his BUN was 46, creatinine 2.8, which was down from 2.9. The plan was to recheck a x-ray to see if there was any expansion, which was not of his pneumothorax, and to wean his milrinone and to check the hepatic panel. On postoperative day number 4, which was hospital day number 12, the patient was transferred to the Inpatient Telemetry floor, and his milrinone was weaned off. He was still receiving Natrecor at 0.1 mg and Lasix at 40 mg t.i.d. He was on aspirin. Hemodynamically, his BP was 152/63, temperature of 99 degrees F., heart rate of 99, and his oxygen saturation was 96 percent. White blood count was down to 7.8, hematocrit was stable at 32.6, and his platelet count was down to 60,000 from 67,000. The plan was to discontinue his Natrecor, start Lopressor, and remove his epicardial pacing wires. On postoperative day number 6, the patient was complaining to have troubled breathing overnight, but improved with morning. The patient reported troubled breathing secondary to pain. Currently, he was hemodynamically very stable. Heart rate was 76, sinus rhythm. BP 126/63, temperature of 99.3 degrees F. The patient was alert and oriented x3. He was weak, but intact with no focal deficits. He had rhonchorous breath sounds bilaterally with a productive cough and yellow sputum. His extremities revealed 1 plus edema. The plan was to increase his Lopressor to 50 mg b.i.d., decrease his Lasix to 40 mg b.i.d., continue monitoring of his creatinine, and have Rehab Physical Therapy screen the patient in Cardiac Intensive Care. The patient had been ambulating with PT and OT. The patient was also being seen by physicians from [**Last Name (un) **] secondary to his blood glucose and diabetes management better under control. On postoperative day number 7, the patient appears to be doing well. His creatinine continually lowered. Today, it was at 2.2 down from 2.5, which shows a continual improvement. His white blood count was now 5.9, his hematocrit is 34.4, and his platelets are 114,000. Physical examination was unremarkable besides [**1-6**] plus edema on his extremities. His sternum was stable, and incision was clear, dry, and intact. Lasix was changed to p.o., and the plan was to have Urology consulted to see the patient again secondary to the urinary sphincter, and now that the patient was on p.o. Lasix, it was probable to remove as long as the patient continues to do well and ambulating and getting out of bed and meets the criteria for discharge. The patient will be seen by PT until he does so. On postoperative day number 8, which is hospital day number 20, the patient had no events overnight. He appears to be doing well. The BP was slightly elevated at 153/69, and his respiratory rate was elevated at 24. His oxygen saturation was 99 percent on room air. His physical examination was unremarkable. The patient continued to get out of bed and slowly attempted stairs. His Lopressor was increased to 75 mg p.o. b.i.d. On [**2197-10-9**], the patient continued to appear doing well. This is hospital day number 22. The [**Hospital 228**] hospital course was complicated secondary to multiple medical problems when admitted to the hospital, fever, CHF, multiple medical issues that the patient had in the past like chronic renal insufficiency, anemia, and the patient needed to be worked up for all those prior to cardiac surgery. Following cardiac surgery, his course improved dramatically, and he was discharged postoperatively from cardiac surgery on day number 10. His physical examination on discharge: Neurologically, he was grossly intact. His lungs were clear to auscultation with decrease at the left lower base. His heart rate was regular rate and rhythm, positive S1 and S2, with a 2/6 systolic ejection murmur. His sternum was stable. Steri- Strips were intact and clean and dry without erythema or drainage. His right calf incision with the saphenectomy site had Steri-Strips intact and was clean, dry, and intact. His extremities had trace edema. His temperature was 99.3 degrees F., pulse of 78 and sinus rhythm, respiratory rate of 20, BP of 107/54, and oxygen saturation of 96 percent. His weight was 79 kg; preoperatively, he was 78 kg. On the physical therapy standpoint, he was doing well, ambulating, going up stairs and out of bed, and was ready to be discharged to home today. CONDITION ON DISCHARGE: The patient was discharged to home in good condition with VNA services. DISCHARGE DIAGNOSES: His discharge diagnoses are as follows: His coronary artery disease status post coronary artery bypass graft x2, aortic stenosis status post aortic valve replacement with 21-mm pericardial tissue valve, hypertension, hypercholesterolemia, chronic obstructive pulmonary disease, chronic renal insufficiency, prostate cancer status post radical prostatectomy and radiation treatment, anemia, and the patient is on Epogen, urinary tract revision with sphincter. RECOMMENDATIONS: The patient was recommended a follow-up with Dr. [**Last Name (STitle) **] in two to three weeks, Dr. [**Last Name (STitle) 25059**] in two to three weeks, and Dr. [**Last Name (STitle) **] in four weeks. DISCHARGE MEDICATIONS: Discharge medications are as follows: 1. Calcium chloride 10-mEq capsules, two capsules q.12h. 2. Lasix 40 mg one tablet b.i.d. 3. Colace 100 mg one p.o. b.i.d. 4. Aspirin 325 mg one p.o. q.d. 5. Lopressor 25 mg three p.o. b.i.d. 6. Pantoprazole 40 mg one p.o. q.24h. 7. Hydromorphone 2 mg p.o. q.4h. p.r.n. 8. Insulin 70/30 units per millimeter suspension. The patient was told to take 32 units subcutaneously once a day, and insulin NPH, the patient is told to take 18 units subcutaneous at bedtime. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) 25060**] MEDQUIST36 D: [**2197-11-3**] 09:16:57 T: [**2197-11-4**] 06:16:21 Job#: [**Job Number 25061**]

[ "211.3", "410.71", "585", "424.1", "V10.46", "531.90", "250.40", "428.0", "780.6", "285.21", "414.01" ]

icd9cm

[ [ [] ] ]

[ "45.42", "00.13", "36.15", "57.94", "35.21", "39.61", "88.56", "37.23", "45.16", "36.11", "99.04" ]

icd9pcs

[ [ [] ] ]

13611, 14295

14319, 15074

4202, 12674

1597, 1719

4011, 4184

2173, 3993

12689, 13491

1741, 2074

214, 926

949, 1573

2091, 2150

13516, 13589

56,307

166,321

50931

Discharge summary

report

Admission Date: [**2200-12-23**] Discharge Date: [**2200-12-30**] Date of Birth: [**2143-10-19**] Sex: F Service: MEDICINE Allergies: All drug allergies previously recorded have been deleted Attending:[**First Name3 (LF) 1242**] Chief Complaint: Vomiting Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: This is a 57 yo woman with borderline mental retardation, DMII, ?gastroparesis, who was seen in clinic today with a complaint of vomiting since Sunday. In the clinic, the patient was noted to be hypotensive with SBPs in the 80s. She was subequently sent to the ED for further evaluation. In the ED, the patient was noted to have a temp of 99.6, BP 128/82, HR 102, RR 19 and o2 sat 100% on RA. She was given a PO challenge of water but was was noted to be spitting up anything she attempted to drink. She was given 2 liters of normal saline and admitted to medicine. . On arrival to the floor, the patinet reports difficulty swollowing for several years. She has not noted any specific progression of her symptoms. Starting saturday night, however, the patient reports a fever to 104 and an inability to take anything by mouth without it coming back up. She has difficulty describing her vomiting, as she say the at times she vomits food, but most of the time, she is spitting up "foam". She reports that the food feels as though it is getting stuck in her throat. She denies esophageal pain, per se, but endorces a discomfort in the region of her lower throat. Besides the reported fever to 104, the patient denies any additional symptoms including chills, nausea, diarrhea, abdominal pain. She denies sick contacts. . Review of systems is otherwise negative for dizziness, changes in bowel or urinary habits, chest pain. She endorces weight gain over the last year (30lbs) as well as chronic joint pains and headache. She states she believes she had a partial seizure 2 days ago (leg shaking) but has had seizures/neurologic symptoms otherwise. All other ROS is negative. Past Medical History: - Mild mental retardation - DM, onset age 51 (poorly controlled, does not check FS; A1c [**10-18**] 9.7%) - neuropathy - dysphagia - hx of [**Doctor Last Name **] with spontaneous remission - PVD, angioplasty of R femoral in [**2198**] - Seizure disorder (per pt focal, partial) - Lower Back pain s/p fall, followed in chronic pain clinic - posterior mediastinal mass since [**2182**], stable (likely neurofibroma). - Hyperlipidemia - Urinary Incontinance - Pneumonia ([**2198**]) - ? gastroparesis- normal gastric emptying, no reflux in [**1-/2200**] Endoscopy with ? [**Last Name (un) **]; biopsy negative. . Surgical History - Angioplasty as above ([**2198**]) - Appendectomy . Psychiatric History: Patient reports going up in state care. She has a history of an impulse control disorder. She reports that she is not currently not seeing any psychiatrists. She has discontinued her use of amitriptyline. Social History: The patient lives alone. She is disabled and on [**Social Security Number 105853**]social security. DMR caseworker [**Doctor First Name **] (Phone #[**Telephone/Fax (1) 105853**]) . Sister [**Name (NI) 717**] [**Telephone/Fax (1) 105854**]. Gets Home services from [**Location (un) 1465**] Elder Services through Case Worker [**Doctor First Name **] [**Telephone/Fax (1) 105855**] Tobacco: Smoker since the age of 3, 2 packs per day. Quit [**2198**] Etoh/Drugs: None Family History: Ovarian Cancer, Diabetes in mother and grandmother Physical Exam: T=98.7 BP=130/60 HR=95 RR=20 O2=100% . PHYSICAL EXAM GENERAL: Thin, dissheveled appearing, Pleasant woman in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. Dentures in place OP clear. Neck Supple, No LAD, No thyromegaly or erythema. Tender to palpation over thyroid/cricoid cartilage. CARDIAC: Regular rhythm, mildly tachycardic. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. NO appreciable JVD LUNGS: CTAB, good air movement biaterally. ABDOMEN: Old midline scar. NABS. Soft, NT, Mildly distended. No HSM EXTREMITIES: No edema or calf pain, 1+ dorsalis pedis/ posterior tibial pulses. 2+Radial pulses SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. 1+ reflexes, equal BL. Normal coordination. Normal Gait. PSYCH: Increased prosity of speach, tangential but directable. Otherwise, listens and responds to questions appropriately. Pertinent Results: [**2200-12-23**] 12:00PM PLT COUNT-269 NEUTS-71.3* LYMPHS-22.4 MONOS-3.8 EOS-1.2 BASOS-1.3 WBC-7.8 RBC-4.95 HGB-15.2 HCT-40.5 MCV-82 MCH-30.6 MCHC-37.5* RDW-12.7 %HbA1c-9.2* ALBUMIN-4.4 CALCIUM-9.8 PHOSPHATE-3.5 MAGNESIUM-1.9 ALT(SGPT)-16 AST(SGOT)-16 LD(LDH)-216 ALK PHOS-98 TOT BILI-0.6 GLUCOSE-154* UREA N-25* CREAT-0.8 SODIUM-142 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-25 ANION GAP-19 . VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2200-12-25**] 1:11 PM PA AND LATERAL CHEST, [**2200-12-23**] AT 13:47 HOURS HISTORY: History of gastroparesis and inability now to tolerate p.o. COMPARISON: Multiple priors, the most recent dated [**2200-2-6**]. FINDINGS: The lungs remain hyperexpanded. No focal consolidation or superimposed edema is seen. Mild tortuosity is noted at the aortic arch. A small hiatal hernia is evident. Otherwise, the mediastinum is unremarkable with no radiographic findings suggestive of pneumomediastinum. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is noted. Mild degenerative changes are noted in the mid and lower thoracic spine. IMPRESSION: No acute pulmonary process. . [**2200-12-23**] Radiology ABDOMEN (SUPINE & ERECT) SUPINE AND UPRIGHT ABDOMEN, [**2200-12-23**] AT 1359 HOURS. COMPARISON: Multiple priors, the most recent dated [**2200-2-6**]. FINDINGS: No free intraperitoneal air is identified. There is a nonobstructive bowel gas pattern in the small bowel. Extensive stool is seen throughout the colon including the rectum. The stomach is nondilated. There are no radiographic findings of ascites or organomegaly. A small hiatal hernia is incidentally noted. IMPRESSION: Small hiatal hernia with extensive stool throughout the colon. Non-obstructive bowel gas pattern with no free air. Incidental note is made of surgical clips grouped and projecting over the right hip. CT NECK W/CONTRAST (EG:PAROTIDS) Study Date of [**2200-12-24**] 4:33 PM IMPRESSION: No mass or evidence of airway obstruction. NOTE ADDED AT ATTENDING REVIEW: I agree with the above, but note that the mid esophagus is distended, with material within it. For evaluation of dysphagia, a barium swallow may be helpful. VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2200-12-25**] 1:11 PM SUMMARY: Pt presents with normal oropharyngeal swallow function without aspiration. Etiology of her intolerance of PO appears to be below the level of the upper esophageal sphincter. Immediately following this evaluation, pt was taken for barium swallow study to further evaluate the esophageal phase of the swallow. Please refer to radiologist's report, filed separately, for results of that evaluation. This swallowing pattern correlates to a Dysphagia Outcome Severity Scale (DOSS) rating of 7, WNL. RECOMMENDATIONS: 1. Further esophageal work up prior to re-initiating PO. 2. Once esophageal phase issues are resolved, pt will likely tolerate return to full oral diet. . ESOPHAGUS Study Date of [**2200-12-25**] 1:47 PM IMPRESSION: Markedly narrowed long segment of the distal esophagus, concerning for neoplasm, with filling defect more proximally and markedly dilated esophagus, which raises the concern for neoplasm versus retained food. . Brief Hospital Course: The patient is a 57 yo woman with a PMH of DMII, borderline MR and seizure disorder who presents with a 3 day history of vomiting and inability to maintain oral intake. . #. Vomiting/Esophageal Obstruction: The patient reported continued vomiting with all attempted oral intake. After further discussion, it appeared that her inability to take oral nutrition wa related to feelings of dysphagia and rather than actual vomiting. A speech and swallow consult evaluation was conducted. She was found have a normal orpharyngeal response on both bedside and video swallow. However, she was noted to have an apparent blockage in the upper esophagus. A barium swallow again was consistant with a proximal esophageal obstruction and the gastroenterology service was consulted for EGD. An EGD was performed while the patient was in the ICU which showed retained food and esophageal ulcerations. She was placed on a clear liquid diet and transferred to the floor. Her diet was slowly advanced to purees. The patient was discharged with instructions to continue a twice a day PPI and a pureed diet. She was scheduled for a repeat endoscopy in 2 weeks. . #. Diabetes: The patient does not check fingersticks at home due to an inability to handle sliding scale. On the morning of hospital day 2, the patient was noted to be hypoglycemic with a blood sugars in the 40s. Her lantus was held. Over the next 48 hours, her blood sugars were stable in the 100s-200s. She recieved PRN insulin but no lantus as she was NPO. On HD#4, the patient's bicarbonate was noted to be 10 (an acute drop from the previous AM value of 21). Venous blood gas was notable for a pH of 7.14. The patient was started on D5 with bicarb and an endocrine consult was called. It was felt that the patient's presentation was consistant with diabetic ketoacidosis and she was transferred to the ICU for closer monitoring. In the ICU the patient's blood sugars were much better controlled. Her non-gap and gap acidosis resolved with fluid resuscitation of D5NS and insulin therapy. The patient was discharged on a lower dose of lantus (22units every morning) and was instructed to follow up with her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Per the endocrine consult team, it was felt that the patient may have type I diabetes and may benefit from antibody studies in the future. . #. Seizure disorder: Per pt; these have been a life-long issue. The patient reported not taking carbamezapine regularly but PRN. There was no evidence of seizure while hospitalized. . #. Peripheral Neuropathy: The patient reported a history of lower extremity neuropathy for which she took nortriptyline. According to the patient, she continued to have intense, burning pain in her legs daily, especially at night. Given a noted allergy to neurontin, the patient was given a prescription for cymbalta on discharge and instructed to follow up with her PCP. . #. Hyperlipidemia: The patient was continued on simvastatin. Medications on Admission: 1. Clonazepam 0.5 mg PO TID 2. Simvastatin 40 mg PO HS 3. Ibuprofen 400 mg Tablet 1-2 Tablets [**Hospital1 **] 4. Omeprazole 20 mg Capsule QD 5. CLOTRIMAZOLE - 1 % Cream - apply [**Hospital1 **] for 1 week; repeat prn 6. Insulin Aspart [NOVOLOG FLEXPEN] 6 units w/meals TID 7. Insulin Glargine [LANTUS] 22 units QAM 8. Trazodone - 50 mg Tablet QHS 10. Loratadine - 10MG Tablet PRN ALLERGIES 11. GLUCERNA- Liquid - 1 can by mouth twice a day 12. Tegratol 200mg (per patient, taking PRN) Discharge Medications: 1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q12 () as needed. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day for 3 weeks. Disp:*42 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 5. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 6. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. 9. Glucerna Shake Liquid Sig: One (1) PO twice a day. 10. Cymbalta 30 mg Capsule, Delayed Release(E.C.) Sig: [**12-12**] Capsule, Delayed Release(E.C.)s PO once a day: Please take 1 capsule per day (30mg) for 1 week then 2 capsules (60mg) per day thereafter. Disp:*90 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 11. Insulin Aspart 100 unit/mL Insulin Pen Sig: Six (6) units Subcutaneous with each Meal. 12. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous qAM. Discharge Disposition: Home Discharge Diagnosis: Esophageal impaction Diabetes Diabetic Ketoacidosis Peripheral Neuropathy Discharge Condition: The patient was hemodynamically stable, afebrile and without pain at the time of admission. Discharge Instructions: You were admitted for evaluation and treatment of vomiting and throat pain. You were found to have food stuck in your esophagus and this was removed by endoscopy. A study of your throat showed that you have a possible narrowing of your esophagus and you will need a repeat endoscopy in 2 weeks. It is recommended that you continue to eat a modified diet consisting of ground up food to avoid having food get stuck again. Please be sure to chew all food well and to eat slowly. . The food stuck in your esophagus caused irriation and you will need to take a medication (omeprazole) for the next 3 weeks to help your esophagus heal. . During this hospitalization, you were noted to have low blood sugars and you required a short stay in the intensive care unit while we corrected your blood sugars. You were seen by the endocrinologists who felt your symptoms were due to your inability to eat and changes to your insulin regimen during your illness. The have recommended that you take the following insulin at home: 22units Lantus in the morning 6 units of NOVOLOG with each meal . Because of the pain in your legs, we are discharging you with a new medication called Cymbalta. . Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] next week. In the meantime, please call your doctor or seek immediate medical attention if you develop a fever, inability to swallow, shortness of breath, chest pain, nausea, vomiting or any other symptom of concern. . Followup Instructions: ENDOSCOPY APPOINTMENT: Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2201-1-13**] 12:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2201-1-13**] 12:30 Gastroenterology Follow Up Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2201-1-27**] 10:30 . Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: Monday [**3-23**], 9am [**Telephone/Fax (1) 250**] . Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2201-4-17**] 10:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2201-4-17**] 11:15 Completed by:[**2201-1-1**]

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icd9cm

[ [ [] ] ]

[ "98.02", "45.13" ]

icd9pcs

[ [ [] ] ]

12562, 12568

7767, 10773

329, 341

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46722

Discharge summary

report

Admission Date: [**2111-2-24**] Discharge Date: [**2111-3-5**] Date of Birth: [**2057-4-5**] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 3444**] is a 53-year-old female with a multitude of medical problems who was admitted on [**2111-2-24**] to [**Hospital1 69**] with MRSA and VRE bacteremia. Patient was just recently discharged from [**Hospital1 69**] at the pneumonia and pleural effusion as well as mental status changes. Upon her discharge to [**Location 6065**], she was noted to have urinary tract infection with Klebsiella for which she received a full course of antibiotics namely amikacin and Cipro which ended on [**2111-2-18**]. Her repeat urine cultures grew Klebsiella, Staph, and Enterococcus. Her blood cultures drawn revealed MRSA and VRE for which the Center. Upon arrival at [**Hospital1 69**], she began her treatment with Vancomycin for MRSA bacteremia. Initially, she was started on linazolid for VRE, however, following ID evaluation, that was thought to be colonization. No other cultures drawn at [**Hospital1 346**] confirmed VRE. The patient underwent an echocardiogram which revealed an ejection fraction of 75% and no vegetations, as well as spine films to evaluate for osteomyelitis which were negative. On [**2111-3-3**], the patient was noted to have increased oxygen requirement as well as shortness of breath and mental status changes. To maintain her saturations of 90%, she required a nonrebreather mask and due to the mental status changes was evaluated for Medical Intensive Care Unit admission. At the time of being evaluated by the MICU team, the patient was confused and was not able to provide any history. She was using accessory muscles of ventilation and was pulling off her nonrebreather mask. An arterial blood gas was drawn which revealed a pH of 7.37, pCO2 of 24, and pO2 of 60. Patient was changed to BiPAP mask and transferred to Medical Intensive Care Unit. SOCIAL HISTORY: Patient is a Jehovahs Witness. She had a 35 pack year smoking history, quit in [**2094**]. She denied any alcohol. Healthcare proxy was [**Name (NI) 449**] [**Name (NI) **], [**Telephone/Fax (1) 99170**]. FAMILY HISTORY: Noncontributory. PAST MEDICAL HISTORY: 1. Congestive obstructive pulmonary disease with 35 pack year smoking history on 2 liters home O2, no CO2 retention per prior blood gases. 2. Obstructive-sleep apnea on CPAP - patient is poorly compliant. 3. Diabetes mellitus type 2. 4. Adrenal insufficiency secondary to steroid use on chronic steroids. 5. AVM malformation of the gut status post gastrointestinal bleeding. 6. History of HIT-antibody positivity. 7. History of liver failure of unknown etiology. Full workup was undertaken on prior admissions and was negative. Two leading etiologies are alcohol and NASH. 8. Status post cholecystectomy. 9. Status post total abdominal hysterectomy. 10. Status post left total knee replacement. PHYSICAL EXAMINATION ON ADMISSION TO MICU: Temperature is 98.6 rectally, blood pressure 105/70, respiratory rate 20, heart rate 88, O2 saturation 99% on BiPAP mask [**10-18**] with 60% FIO2. Generally, the patient was an elderly female with moderate respiratory distress using her accessory muscles of ventilation. She was somnolent and not oriented. HEENT: She had scleral icterus. Pupils are equal and reactive to light. Extraocular movements are intact. Oropharynx was clear. Could not assess jugular venous pressure due to the body habitus. Heart was regular, rate, and rhythm, no murmurs, rubs, or gallops were appreciated. Lungs were with decreased breath sounds on the left base. Abdomen was soft, obese. Could not assess for ascites or hepatosplenomegaly. Extremities were edematous with 3+ pitting edema. There is no cyanosis noted. LABORATORY FINDINGS ON ADMISSION TO MICU: White count 20.9 which is up from 14, hematocrit 27.8, platelet count 118, MCV 107. Sodium 143, potassium 4.1, chloride 115, bicarbonate 15, BUN 17, creatinine 2.0, glucose 81. Calcium was 8.5, phosphorus 5.3, magnesium 1.8. Her INR was 2.5, PTT was 43.6. Vancomycin level was 20.2. Her last LFTs done on [**2111-2-25**] showed an ALT and AST of 41 and 46, alkaline phosphatase of 152, T bilirubin of 6.6. Her arterial blood gas drawn on BiPAP of [**10-18**] at 60% of FIO2 showed a pH of 7.27, pCO2 of 30, pO2 of 92. Blood cultures drawn on 14th and [**3-3**] no growth to date. Blood cultures drawn on [**2-25**] had 2/4 bottles growing VRE linazolid sensitive. The [**3-17**] blood cultures drawn on [**2-24**] showed MRSA. Her urine cultures have been negative throughout the whole hospitalization with exception of culture drawn on [**2-28**], which revealed more than 100,000 of yeast. CHEST X-RAY: On [**2111-3-2**] showed a PICC line in the brachiocephalic vein, increased left pleural effusion, continuous left lower lobe collapsed consolidation. Echocardiogram performed on [**2111-3-2**] showed hyperdynamic left ventricle with an ejection fraction of 75%, moderate pulmonary hypertension. HOSPITAL COURSE: In summary, the patient is a 53-year-old female with liver failure of unknown etiology as well as renal failure with MRSA bacteremia. Admitted to MICU for acute respiratory decompensation. During this hospitalization, the patient's issues included: 1. MRSA bacteremia. The patient was continued on Vancomycin. For the presumed left lower lobe pneumonia, she was started on levofloxacin and Flagyl. Linezolid was d/c'd as per ID recommendations. 2. Hypoxia. The patient had enlarged AA gradient that was most likely due to combination of her pulmonary hypertension, pneumonia, and congestive obstructive pulmonary disease. She was not able to tolerate BiPAP due to the mental status changes and required intubation on [**2111-3-3**]. 3. Acute renal failure. The patient was thought to be prerenal, however, throughout her MICU stay, she was aggressively hydrated with normal saline and Lactated ringers with improvement in her creatinine and minimal urine output. 4. Liver failure. Patient's INR remained elevated. Her albumin was 2.0. She was presumed to be encephalopathic and an OG tube was placed for lactulose delivery. 5. Patient has a history of HIT antibody positivity. She did not receive any Heparin during this hospitalization. 6. Adrenal insufficiency. The patient was continued on high dose hydrocortisone for possible congestive obstructive pulmonary disease exacerbation as well as for adrenal insufficiency. 7. Diabetes. The patient was maintained on sliding scale and her glucose was monitored. 8. Access. PICC line and A-line which was placed on [**2111-3-3**]. Upon extensive discussion with the family, with the light of the patient becoming hypotensive, a decision was made to concentrate on patient's comfort. Patient's severe acidosis continued to progress and she passed away on [**2111-3-5**] at 1:28 pm. Family was at the bedside. Request for autopsy was denied. IMMEDIATE CAUSE OF DEATH: 1. Hypertension. 2. Acidosis. CHIEF CAUSE OF DEATH: Liver, kidney, and pulmonary failure. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) 1762**] MEDQUIST36 D: [**2111-3-5**] 14:43 T: [**2111-3-6**] 05:29 JOB#: [**Job Number **]

[ "112.2", "276.2", "038.11", "518.81", "255.4", "491.21", "486", "572.2", "584.5" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.04", "96.71", "00.14" ]

icd9pcs

[ [ [] ] ]

2212, 2230

5082, 7366

159, 1969

2252, 5064

1986, 2195